A Rare Cause of Bilateral Corneal Ulcers: Vitamin A Deficiency in the Setting of Chronic Alcoholism

Abstract

Vitamin A deficiency is rarely encountered in the western world. When encountered, vitamin A deficiency is seen as a component of the malabsorption spectrum of disease. Given the infrequency of nutritional deficits in the developed world, vitamin A-associated ophthalmologic disease is rarely encountered. We report a case of a 56-year-old male with severe vitamin A deficiency in the setting of alcoholic liver cirrhosis. This case emphasizes two important points. First, it considers vitamin A deficiency as a cause of corneal ulceration in patients with chronic alcoholism. Second, it raises awareness of hepatotoxicity that can result after the supplementation of vitamin A in patients with chronic alcoholism. Although an uncommon diagnosis, it should be considered when other causes, such as infectious and autoimmune conditions, are ruled out.

Vitamin A Deficiency Screening in Patients With Chronic Alcohol-Associated Liver Disease: Implications for Liver Transplant Candidates

“…12 Chronic liver disease can be associated with a severe form of VAD because of 3 mechanisms: low dietary intake, malabsorption, and loss of hepatocytes. 13 Alcohol-associated cirrhosis may be more commonly associated with VAD than other etiologies such as viralassociated cirrhosis because of poor dietary intake and malabsorption. 14,15 Sohal et al 13 previously reported a patient with corneal ulcers secondary to alcohol-associated cirrhosis-induced VAD; however, they were unable to track corneal ulcer progression in response to vitamin A supplementation.…”

“…13 Alcohol-associated cirrhosis may be more commonly associated with VAD than other etiologies such as viralassociated cirrhosis because of poor dietary intake and malabsorption. 14,15 Sohal et al 13 previously reported a patient with corneal ulcers secondary to alcohol-associated cirrhosis-induced VAD; however, they were unable to track corneal ulcer progression in response to vitamin A supplementation. Patients with advanced fibrosis and cirrhosis may experience a significant decrease in the number of hepatocytes responsible for the primary storage of vitamin A, leading to possible acute/ subacute VAD.…”

Ocular manifestations of liver disease: an important diagnostic aid

“…Chronic alcohol intake results in decreased oral retinoid intake while also increasing retinol breakdown by inducing enzyme activity [ 12 ]. In patients with cirrhosis, decreased oral intake of vitamin A along with decreased intestinal absorption of vitamin A results in vitamin deficiency that can cause ocular symptoms [ 13 ]. Bitot spots are one such manifestation, presenting as keratinous accumulations on the cornea usually preceded by ocular xerosis and ultimately leading to keratoconjunctivitis.…”

“…Bitot spots are one such manifestation, presenting as keratinous accumulations on the cornea usually preceded by ocular xerosis and ultimately leading to keratoconjunctivitis. If extensive, a vitamin A deficiency in cirrhotic patients can even lead to corneal necrosis [ 13 ].…”