Serial ERG monitoring of response to therapy in vitamin A deficiency related night blindness.

Two male patients with known systemic disorders who presented with complaints of nyctalopia underwent a complete ophthalmic examination including electrophysiological evaluation and serum vitamin A (retinol) levels. A significant vitamin A deficiency was detected, supplementation started and repeat electroretinogram (ERG) testing was carried out to monitor the timeline of recovery. Restoration of rod and generalised cone function was rapid within the first week of receiving treatment and near normal recovery was seen after 1 month of supplementation. Serial monitoring of ERG changes in vitamin A deficiency (VAD) associated night blindness plays an important role to demonstrate functional recovery post-treatment. The different effects of VAD on rod and cone function, and their rate of recovery, may reflect differences in the visual cycle between the two photoreceptors. We report the serial ERG changes in VAD related night blindness secondary to intestinal lipofuscinosis and liver cirrhosis in two patients.

Case Report: Vitamin A Deficiency and Nyctalopia in a Patient with Chronic Pancreatitis.

SIGNIFICANCE: Vitamin A deficiency is a known concern in developing countries, but it is often overlooked in developed regions. A history of conditions causing alimentary malabsorption should be considered when patients present with complaints of nyctalopia. PURPOSE: A case of vitamin A deficiency with nyctalopia in a patient with chronic pancreatitis including pertinent diagnostic testing, treatment, and management is presented. The intent is to draw attention to the condition as a differential diagnosis for nyctalopia due to increased prevalence of conditions causing malabsorption. CASE REPORT: A patient with a history of chronic pancreatitis and pancreatic tumor presented with symptoms of nyctalopia and xerophthalmia. Given his systemic history, testing was ordered to determine serum vitamin A levels and retinal function. After results had confirmed depleted vitamin A levels and diminished retinal function, treatment with both oral and intramuscular vitamin A supplementation was initiated to normalize vitamin A levels and improve retinal photoreceptor function. Subjective improvement in symptoms was reported shortly after beginning supplementation, and ultimately, vitamin A levels and retinal function showed improvement after intramuscular treatment. CONCLUSIONS: Detailed case history and a careful review of systems along with serum vitamin A testing and, if available, electroretinography to assess retinal function can help to make a definitive diagnosis. With appropriate comanagement with the patient's primary care physician, it is possible for those with nyctalopia to begin vitamin A supplementation and regain retinal function.

A Mixture of U.S. Food and Drug Administration-Approved Monoaminergic Drugs Protects the Retina From Light Damage in Diverse Models of Night Blindness.

Purpose: The purpose of this study was to test the extent of light damage in different models of night blindness and apply these paradigms in testing the therapeutic efficacy of combination therapy by drugs acting on the Gi, Gs, and Gq protein-coupled receptors. Methods: Acute bright light exposure was used to test susceptibility to light damage in mice lacking the following crucial phototransduction proteins: rod transducin (GNAT1), cone transducin (GNAT2), visual arrestin 1 (ARR1), and rhodopsin kinase 1 (GRK1). Mice were intraperitoneally injected with either vehicle or drug combination consisting of metoprolol (ß1-receptor antagonist), bromocriptine (dopamine family-2 receptor agonist) and tamsulosin (α1-receptor antagonist) before bright light exposure. Light damage was primarily assessed with optical coherence tomography and inspection of cone population in retinal whole mounts. Retinal inflammation was assessed in a subset of experiments using autofluorescence imaging by scanning laser ophthalmoscopy and by postmortem inspection of microglia and astrocyte activity. Results: The Gnat1-/- mice showed slightly increased susceptibility to rod light damage, whereas the Gnat2-/- mice were very resistant. The Arr1-/- and Grk1-/- mice were sensitive for both rod and cone light damage and showed robust retinal inflammation 7 days after bright light exposure. Pretreatment with metoprolol + bromocriptine + tamsulosin rescued the retina in all genetic backgrounds, starting at doses of 0.2 mg/kg metoprolol, 0.02 mg/kg bromocriptine, and 0.01 mg/kg tamsulosin in the Gnat1-/- mice. The therapeutic drug doses increased in parallel with light-damage severity. Conclusions: Our results suggest that congenital stationary night blindness and Oguchi disease patients can be at an elevated risk of the toxic effects of bright light. Furthermore, systems pharmacology drug regimens that stimulate Gi signaling and attenuate Gs and Gq signaling present a promising disease-modifying therapy for photoreceptor degenerative diseases.

Case Report: Delayed Vitamin A Retinopathy Secondary to Bariatric Surgery.

SIGNIFICANCE: Although rare, vitamin A retinopathy should be considered by the clinicians in their differentials for conditions that can lead to nyctalopia, especially in those patients who have undergone bariatric surgery. Patients must be educated on this potential delayed adverse effect of the surgery and possible lifelong vitamin A supplementation. PURPOSE: The purpose of this study was to report a rare case of delayed vitamin A retinopathy that occurred because of vitamin A malabsorption secondary to bariatric surgery. CASE REPORT: A 55-year-old woman presented with nyctalopia and dark adaptation problems. The patient had a history of gastric bypass surgery 22 years earlier. Fundus examination revealed a large number of small white dots in the midperiphery of both eyes. Electrophysiology testing revealed flat-lined scotopic responses. Vitamin A levels were found to be severely reduced. Subsequent vitamin A supplementation resulted in the reversal of all signs and symptoms. CONCLUSIONS: This case report demonstrates the importance of considering vitamin A deficiency in patients who present with symptoms of nyctalopia with a history of bariatric surgery. Clinicians should be aware of a possible delayed onset and refer for appropriate testing and treatment, as vitamin A retinopathy has been shown to be reversible. Because other conditions can present with nyctalopia and retinal white spots, clinicians also need to consider the appropriate differential diagnoses. Lifelong monitoring is indicated because reoccurrences have been reported.

Treatment of vitamin A deficiency retinopathy with sublingual vitamin A palmitate.

PURPOSE: To report treatment of vitamin A deficiency retinopathy with sublingual vitamin A drops. METHODS: Case report with review of the literature. RESULTS: A 69-year-old Caucasian woman with a history of small bowel resection presented with progressive symptoms of bilateral nyctalopia and decreased visual acuity. Ophthalmic examination revealed bilateral conjunctival xerosis and fine white granular deposits in the midperipheral retina suggestive of vitamin A deficiency. Full-field electroretinogram (ERG), multifocal ERG (mfERG), and two-color dark adaptometry revealed significant impairment of rod and cone photoreceptor function. Kinetic perimetry demonstrated depressed macular sensitivity with constriction of the finer isopters. After 5 months of treatment with sublingual vitamin A drops, the patient's vision, ERG, mfERG, dark adaptometry, and perimetry normalized. A review of the literature summarizing the electrophysiologic testing in vitamin A deficiency is also discussed. CONCLUSIONS: This case highlights novel observations on the effects of sublingual vitamin A supplementation for acquired vitamin A deficiency retinopathy. Sublingual vitamin A may represent a viable and efficacious treatment modality for vitamin A deficiency.

Vitamin A supplementation during pregnancy for maternal and newborn outcomes.

BACKGROUND: The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin A deficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection.   OBJECTIVES: To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 March 2015) and reference lists of retrieved studies. SELECTION CRITERIA: All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: We reviewed 106 reports of 35 trials, published between 1931 and 2015. We included 19 trials including over 310,000 women, excluded 15 trials and one is ongoing. Overall, seven trials were judged to be of low risk of bias, three were high risk of bias and for nine it was unclear. 1) Vitamin A alone versus placebo or no treatmentOverall, when trial results are pooled, vitamin A supplementation does not affect the risk of maternal mortality (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.65 to 1.20; four trials Ghana, Nepal, Bangladesh, UK, high quality evidence), perinatal mortality (RR 1.01, 95% CI 0.95 to 1.07; one study, high quality evidence), neonatal mortality, stillbirth, neonatal anaemia, preterm birth (RR 0.98, 95% CI 0.94 to 1.01, five studies, high quality evidence), or the risk of having a low birthweight baby.Vitamin A supplementation reduces the risk of maternal night blindness (RR 0.79, 95% CI 0.64 to 0.98; two trials). There is evidence that vitamin A supplements may reduce maternal clinical infection (RR 0.45, 95% CI 0.20 to 0.99, five trials; South Africa, Nepal, Indonesia, Tanzania, UK, low quality evidence) and maternal anaemia (RR 0.64, 95% CI 0.43 to 0.94; three studies, moderate quality evidence). 2) Vitamin A alone versus micronutrient supplements without vitamin AVitamin A alone compared to micronutrient supplements without vitamin A does not decrease maternal clinical infection (RR 0.99, 95% CI 0.83 to 1.18, two trials, 591 women). No other primary or secondary outcomes were reported 3) Vitamin A with other micronutrients versus micronutrient supplements without vitamin AVitamin A supplementation (with other micronutrients) does not decrease perinatal mortality (RR 0.51, 95% CI 0.10 to 2.69; one study, low quality evidence), maternal anaemia (RR 0.86, 95% CI 0.68 to 1.09; three studies, low quality evidence), maternal clinical infection (RR 0.95, 95% CI 0.80 to 1.13; I² = 45%, two studies, low quality evidence) or preterm birth (RR 0.39, 95% CI 0.08 to 1.93; one study, low quality evidence).In HIV-positive women vitamin A supplementation given with other micronutrients was associated with fewer low birthweight babies (< 2.5 kg) in the supplemented group in one study (RR 0.67, 95% CI 0.47 to 0.96; one study, 594 women). AUTHORS' CONCLUSIONS: The pooled results of three large trials in Nepal, Ghana and Bangladesh (with over 153,500 women) do not currently suggest a role for antenatal vitamin A supplementation to reduce maternal or perinatal mortality. However, the populations studied were probably different with regard to baseline vitamin A status and there were problems with follow-up of women. There is good evidence that antenatal vitamin A supplementation reduces maternal night blindness, maternal anaemia for women who live in areas where vitamin A deficiency is common or who are HIV-positive. In addition the available evidence suggests a reduction in maternal infection, but these data are not of a high quality.

Electrophysiological and microperimetry changes in vitamin A deficiency retinopathy.

PURPOSE: To describe a follow-up case of vitamin A deficiency (VAD)-related retinopathy with macular involvement monitored with electroretinography and microperimetry. METHODS: Flash (ERG), pattern (PERG), and multifocal (mfERG) electroretinography were recorded in parallel with microperimetry before and during 7-month follow-up of vitamin A treatment on a 65-year-old man presented with a 1-year history of night blindness. The patient had undergone ileostomy procedure for Crohn's disease 14 years ago. His best corrected visual acuity was 6/6 in each eye. Fundus examination revealed macular and mid-peripheral yellow-white lesions compatible with drusen. RESULTS: Before treatment, PERG was reduced, and mfERG was reduced and delayed, worse in responses from the central rings. These results revealed evidence of bilateral macular and central cone dysfunction. The flash ERG showed reduced dark-adapted 0.01 ERG (rod response); a-wave of dark-adapted 3.0 and 10.0 ERG was normal but b-wave was reduced (negative configuration); light-adapted 3.0 ERG was slightly reduced. The flash ERG revealed evidence of bilateral generalised retinal dysfunction affecting the rod more than cone system. Microperimetry showed deep reduction in retinal sensitivity. Fixation stability was unstable with eccentric locus. During treatment, ERG and microperimetry demonstrated significant improvements. Fixation stability reached normal values after the third treatment week. CONCLUSIONS: This case illustrates the importance of electrophysiological investigation in early VAD-related retinopathy detection correlated with microperimetry. Our findings indicate a more delayed central cone function recovery than that of generalised rod and cone function. There was a marked correlation between ERG and microperimetric changes.

Impact of different protocols of nutritional supplements on the status of vitamin A in class III obese patients after Roux-en-Y gastric bypass.

BACKGROUND: This study aims to investigate the nutritional status of vitamin A (VA) using biochemical and functional indicators in subjects with class III obesity, before and after RYGB, supplemented with three protocols. METHODS: The sample comprised 90 patients, with BMI ≥40 kg/m(2), divided into three groups: G1 that received routine supplementation containing 5,000 IU of retinol daily; G2 that received 10,000 IU of retinol daily; and G3 that received routine supplementation plus complementary of 50,000 IU of retinol intramuscularly every month. The status of VA was evaluated before (T0), 30 days (T1), and 180 days (T2) after surgery. RESULTS: The vitamin A deficiency (VAD) in G1, G2, and G3 was respectively 20.7, 21.2, and 20.2 % as regards retinol and 37.8, 63.3, and 40 % as regards ß-carotene in T0; 26.7, 10, and 23.4 % as regards retinol and 68, 37, and 32 % as regards ß-carotene in T1; and 21, 8.7, and 20.2 % as regards retinol and 63.3, 20, and 32 % as regards ß-carotene in T2. A reduction of retinol and ß-carotene with increasing BMI and waist circumference was observed in T0. The prevalence of night blindness (XN) in groups 1, 2, and 3 was respectively 23.3, 26.7, and 16.7 % in T0; 56.7, 40, and 60 % in T1; and 70, 43, and 63.3 % in T2. CONCLUSION: The study showed high prevalence of VAD. Among the supplementation protocols used, the one containing 10,000 IU of retinol showed the best impact. However, in cases of more severe VAD, intramuscular supplementation should be considered. The prevalence of XN, justifies attention to this segment of population.

Phrynoderma: a rare dermatologic complication of bariatric surgery.

Biliopancreatic diversion is a predominantly malabsorptive bariatric procedure that can lead to the development of several nutrition complications, including fat-soluble vitamin deficiencies. Routine supplementation with vitamins and trace elements and a strict medical follow-up are essential to prevent these nutrition risks. Vitamin A deficiency is common after bariatric surgery but rarely causes clinical symptoms. Case reports have described ophthalmological and fetal complications associated with vitamin A deficiency after malabsorptive bariatric surgery. Phrynoderma is a type of follicular hyperkeratosis located on the extensor surfaces of the extremities whose main cause is vitamin A deficiency. The simultaneous occurrence of phrynoderma and ocular symptoms secondary to hypovitaminosis A after bariatric surgery is exceptional. The authors describe a man who presented follicular hyperkeratosis with nyctalopia and xerophthalmia that had appeared 1 year after biliopancreatic diversion. He admitted poor compliance with diet and daily supplementation of vitamins and oligoelements. Serum vitamin A levels were decreased. Treatment with high doses of vitamin A was associated with a clear improvement of cutaneous and ocular lesions with complete resolution after 2 months. The patient was readmitted 2 years later because of the reappearance of cutaneous lesions and micronutrient deficiency. Revisional bariatric surgery was performed. The authors review and discuss the relationship between phrynoderma, malnutrition, and vitamin A deficiency.

Night blindness in a teenager with cystic fibrosis.

This article describes the case of a 16-year-old boy with cystic fibrosis who presented with difficulty seeing in the dark. He had a history of bowel surgery at birth, and he developed cystic fibrosis liver disease and osteopenia during his teenage years. He always had good lung function. When his serum vitamin A level was checked, it was undetectable in sample. He was diagnosed with night blindness and commenced on high-dose vitamin A. His symptoms resolved within 3 days. However, it took over 1 year for his vitamin A level to return to normal. This case emphasizes the importance of monitoring vitamin levels in cystic fibrosis to detect deficiency and prevent long-term consequences, and it highlights the challenges encountered during the course of night blindness treatment.

Reduction of vitamin A deficiency and anemia in pregnancy after implementing proposed prenatal nutritional assistance / Reducción de avitaminosis A y anemia en el embarazo después de la implementación propuesta de asistencia nutricional prenatal

Introduction: Micronutrient deficiency is an unquestionable public health problem, specially anemia and vitamin A deficiency (VAD). This is due to the collective dimension of these carencies, which reflects on morbimortality rates in the maternal and infant group. Objective: to evaluate the impact of a proposal for prenatal nutritional assistance, comparing the prevalence of anemia and VAD, in pre-intervention (GI) and intervention(GII) groups. Methods: this is a prospective intervention study in a cohort of pregnant women. The GI group was made up of 225 the GII group of 208 pregnant adults and their respective newborns, attended a Public Maternity Wardin Rio de Janeiro, Brazil. Concentration of hemoglobin was used to diagnose anemia and a standardized interview to diagnose night blindness (XN) .Results and conclusion: after adjusting for confounding variables, through logistic regression, the protective effect of intervention at the on set of anemia (OR = 0.420;IC 95% = 0.251-0.702), with a significant reduction in prevalence, of 28.4% in the GI to 16.8% in the GII, also observed at the on set of XN (OR = 0.377; IC95% = 0.187-0.759), with a reduction in prevalence of 18.7 % in the GIto 6.2% in the GII. Nutritional intervention has a beneficial effect on maternal health, reducing nutritional deficiencies most prevalent during pregnancy and the impact of these on the obstetric ailment (AU)

Introducción: La deficiencia de micronutrientes es un problema de indudable de salud pública, especialmente la anemia y deficiencia de vitamina A (DVA). Esto es debido a la dimensión colectiva de estos carencies, que se refleja en las tasas de morbi-mortalidad en el grupo materno infantil. Objetivo: Evaluar el impacto de un proyecto de atención nutricional prenatal, comparando la prevalencia de anemia y DVA, en la pre-intervención (GI) y la intervención (GII).Métodos: se trata de una intervención prospectiva de un grupo de mujeres embarazadas. El GI consistió de 225 mujeres en el posparto y GII en 208 mujeres embarazadas y sus recién nacidos inscritos en una maternidad pública de Rio de Janeiro, Brasil. Se utilizó la concentración de hemoglobina en el diagnóstico de la anemia durante el embarazo y la entrevista estandarizada para diagnosticar la ceguera nocturna (XN). Resultados y conclusión: Tras ajustar por variables de confusión, por la regresión logística, se verificó el efecto protector de la intervención sobre la anemia (OR = 0,420,95% CI = 0.251-0.702), con reducción significativa en la prevalencia, 28,4 en el GI y 16,8% en el GII, que también se observó en los resultados XN (OR = 0,377, IC del 95%desde 0,187 hasta 0,759), con una reducción en la prevalencia, el 18,7% al 6,2% en el GI y GII. La intervención dietética tiene efectos beneficiosos sobre la salud materna, reducir las deficiencias nutricionales más prevalentes durante el embarazo y el impacto de estos sobre el resultado del embarazo (AU)

Effects of vitamin A or beta carotene supplementation on pregnancy-related mortality and infant mortality in rural Bangladesh: a cluster randomized trial.

CONTEXT: Maternal vitamin A deficiency is a public health concern in the developing world. Its prevention may improve maternal and infant survival. OBJECTIVE: To assess efficacy of maternal vitamin A or beta carotene supplementation in reducing pregnancy-related and infant mortality. DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized, double-masked, placebo-controlled trial among pregnant women 13 to 45 years of age and their live-born infants to 12 weeks (84 days) postpartum in rural northern Bangladesh between 2001 and 2007. Interventions Five hundred ninety-six community clusters (study sectors) were randomized for pregnant women to receive weekly, from the first trimester through 12 weeks postpartum, 7000 µg of retinol equivalents as retinyl palmitate, 42 mg of all-trans beta carotene, or placebo. Married women (n = 125,257) underwent 5-week surveillance for pregnancy, ascertained by a history of amenorrhea and confirmed by urine test. Blood samples were obtained from participants in 32 sectors (5%) for biochemical studies. MAIN OUTCOME MEASURES: All-cause mortality of women related to pregnancy, stillbirth, and infant mortality to 12 weeks (84 days) following pregnancy outcome. RESULTS: Groups were comparable across risk factors. For the mortality outcomes, neither of the supplement group outcomes was significantly different from the placebo group outcomes. The numbers of deaths and all-cause, pregnancy-related mortality rates (per 100,000 pregnancies) were 41 and 206 (95% confidence interval [CI], 140-273) in the placebo group, 47 and 237 (95% CI, 166-309) in the vitamin A group, and 50 and 250 (95% CI, 177-323) in the beta carotene group. Relative risks for mortality in the vitamin A and beta carotene groups were 1.15 (95% CI, 0.75-1.76) and 1.21 (95% CI, 0.81-1.81), respectively. In the placebo, vitamin A, and beta carotene groups the rates of stillbirth and infant mortality were 47.9 (95% CI, 44.3-51.5), 45.6 (95% CI, 42.1-49.2), and 51.8 (95% CI, 48.0-55.6) per 1000 births and 68.1 (95% CI, 63.7-72.5), 65.0 (95% CI, 60.7-69.4), and 69.8 (95% CI, 65.4-72.3) per 1000 live births, respectively. Vitamin A compared with either placebo or beta carotene supplementation increased plasma retinol concentrations by end of study (1.46 [95% CI, 1.42-1.50] µmol/L vs 1.13 [95% CI, 1.09-1.17] µmol/L and 1.18 [95% CI, 1.14-1.22] µmol/L, respectively; P < .001) and reduced, but did not eliminate, gestational night blindness (7.1% for vitamin A vs 9.2% for placebo and 8.9% for beta carotene [P < .001 for both]). CONCLUSION: Use of weekly vitamin A or beta carotene in pregnant women in Bangladesh, compared with placebo, did not reduce all-cause maternal, fetal, or infant mortality. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00198822.

Improvement in S-cone-mediated visual fields and rod function after correction of vitamin A deficiency.

PURPOSE: To evaluate S-cone-mediated visual fields and full-field electroretinograms (ERGs) in a patient with vitamin A deficiency. METHODS: A 65-year-old woman diagnosed with primary sclerosing cholangitis reported experiencing night blindness. The patient underwent comprehensive ophthalmic examination, including funduscopy, ERGs, Humphrey standard automated perimetry (SAP), and short-wavelength automated perimetry (SWAP). Serum vitamin A concentrations were measured. RESULTS: The patient's best-corrected visual acuity was 1.2 in both eyes. The ERG results showed no rod b-waves, reduced combined rod-plus-cone responses (negative type), and normal cone and 30-Hz flicker responses. Serum vitamin A concentration was 18 IU/dL (normal range 97-316 IU/dL). The SAP mean deviation (MD) values were -1.09 dB (OD) and -0.97 dB (OS), whereas the SWAP MD values were -10.10 dB (OD) and -10.50 dB (OS). The rate of sensitivity decreased with increasing eccentricity in SWAP. Four months after starting oral administration of vitamin A, all ERG values were normalized, and SWAP MD values were greatly improved (OD -3.47 dB, OS -4.10 dB) compared with changes in SAP MD values (OD +0.67 dB, OS +0.41 dB). Rod dysfunction and impaired S-cone-mediated pathways were preferentially observed and found to be reversed after the treatment. CONCLUSIONS: The findings in this patient suggest that rods and S cones are more susceptible to vitamin A deficiency than L and M cones. Vitamin A deficiency visual impairment may therefore be reversible with appropriate therapy.

Prevalence of vitamin A deficiency and its determinants among the rural pre-school children of Madhya Pradesh, India.

BACKGROUND: Vitamin A deficiency (VAD) continues to be a major public health nutritional problem in India, even though the National Vitamin A Prophylaxis Programme has been in operation for more than three decades. AIM: To assess the prevalence of vitamin A deficiency among rural pre-school children. SUBJECTS AND METHODS: A community-based cross-sectional study was carried out in rural Madhya Pradesh. A total of 8777 pre-school children were clinically examined for VAD and blood vitamin A levels were estimated in a sub-sample by dried blood spot method. RESULTS: Prevalence of night blindness and Bitot's spot, an objective sign of VAD, was 0.8% and 1.4%, respectively, and prevalence increased significantly (p < 0.001) with age. The proportion of children with blood vitamin A deficiency ( < 20 µg/dL) was 88% (95% CI: 84.8-91.2).The prevalence of Bitot's spot was significantly (p < 0.001) higher among children of lower socio-economic communities, 3-5-year age group and those of illiterate mothers. CONCLUSIONS: VAD is a major public health problem among rural children of Madhya Pradesh. Children of 3-5 years and those belonging to lower socio-economic communities are at high risk of VAD. Therefore, appropriate intervention measures are to be initiated to improve the vitamin A status of children.

Vitamin A supplementation during pregnancy for maternal and newborn outcomes.

BACKGROUND: The World Health Organization recommends routine vitamin A supplementation during pregnancy or lactation in areas with endemic vitamin A deficiency (where night blindness occurs), based on the expectation that supplementation will improve maternal and newborn outcomes including mortality, morbidity and prevention of anaemia or infection.   OBJECTIVES: To review the effects of supplementation of vitamin A, or one of its derivatives, during pregnancy, alone or in combination with other vitamins and micronutrients, on maternal and newborn clinical outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (15 July 2010). SELECTION CRITERIA: All randomised or quasi-randomised trials, including cluster-randomised trials, evaluating the effect of vitamin A supplementation in pregnant women. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed all studies for inclusion and resolved any disagreement through discussion with a third person. We used pre-prepared data extraction sheets. MAIN RESULTS: We examined 88 reports of 31 trials, published between 1931 and 2010, for inclusion in this review. We included 16 trials, excluded 14, and one is awaiting assessment.Overall when trial results are pooled, Vitamin A supplementation does not affect the risk of maternal mortality (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.55 to 1.10, 3 studies, Nepal, Ghana,UK ), perinatal mortality, neonatal mortality, stillbirth, neonatal anaemia, preterm birth or the risk of having a low birthweight baby. Vitamin A supplementation reduces the risk of maternal night blindness (risk ratio (RR) 0.70, 95% CI 0.60 to 0.82, 1 trial Nepal). In vitamin A deficient populations and HIV-positive women, vitamin A supplementation reduces maternal anaemia (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.43 to 0.94, 3 trials, Indonesia, Nepal,Tanzania ). There is evidence that vitamin A supplements may reduce maternal clinical infection (RR 0.37, 95% CI 0.18 to 0.77, 3 trials, South Africa, Nepal and UK).In HIV-positive women vitamin A supplementation given with other micronutrients was associated with fewer low birthweight babies (< 2.5 kg) in the supplemented group in one study (RR 0.67, CI 0.47 to 0.96). AUTHORS' CONCLUSIONS: The pooled results of two large trials in Nepal and Ghana (with almost 95,000 women) do not currently suggest a role for antenatal vitamin A supplementation to reduce maternal or perinatal mortality. However the populations studied were probably different with regard to baseline vitamin A status and there were problems with follow-up of women. There is good evidence that antenatal vitamin A supplementation reduces maternal anaemia for women who live in areas where vitamin A deficiency is common or who are HIV-positive. In addition the available evidence suggests a reduction in maternal infection, but these data are not of a high quality.

Nyctalopia: the sequelae of hypovitaminosis A.

We present a case of night blindness due to vitamin A deficiency in a gentleman who had previously undergone a pancreaticoduodenostomy 10 years ago. The deficiency was attributed self-cessation of his pancreatic supplements without being aware of the possible consequences. The diagnosis and management of this patient is presented here, along with a discussion of similar cases in the literature.

Molecular medicine in ophthalmic care.

BACKGROUND: Lipofuscin is the most consistent and phylogenically constant morphologic marker of cellular aging. Autofluorescence of the A2E fluorophore within retinal pigment epithelial (RPE) lipofuscin affords the opportunity for noninvasive evaluation of age- and disease-related pathophysiological changes in the human retina. It is being used in National Eye Institute/Age-Related Eye Disease Study II to evaluate age-related macular degeneration (AMD) geographic atrophy expansion. Experiments show lipofuscin can be reversed in cell culture and animal models in heart, brain, spinal cord, and retinal tissues, using an array of antioxidants and iron chelators. METHODS: An 80-year-old man with a gastric resection presented with complaints of unremitting night driving difficulty despite treatment with lutein and omega III fatty acids. Notable parafoveal deposition of retinal lipofuscin by 50 degrees fundus auto-fluorescence (580 nm excitation/660 barrier filters) and concurrent abnormalities in non-Snellen measures of visual function-Contrast Sensitivity Function, 6.5 degrees large field tritan threshold, 10 degrees threshold visual fields, and deficits in the National Institutes of Health/National Eye Institute Visual Function Questionnaire (VFQ) 25 subjective night driving/mental health subscale questionnaire were obtained. The patient was placed on an over-the-counter daily oral polyphenolic mixture containing resveratrol and re-evaluated 5 months later. RESULTS: The data reveal improvements in all measures of visual function, subjective improvement in vision and mental functioning on the VFQ 25, and visible clearing of RPE lipofuscin. CONCLUSION: To our knowledge, we believe this to be the first reported human clinical case of lipofuscin reversal in the human eye correlated with measured clinical and subjective improvement in visual and mental function after nutraceutical intervention.

Fundus white spots and acquired night blindness due to vitamin A deficiency.

To report a successfully treated case of acquired night blindness associated with fundus white spots secondary to vitamin A deficiency. An ocular examination, electrophysiologic testing, as well as visual field and OCT examinations were obtained on a 61-year-old man with vitamin A deficiency who had previously undergone gastric bypass surgery. The patient had a re-evaluation after treatment with high doses of oral vitamin A. The patient was observed to have numerous white spots in the retina of each eye. Best-corrected visual acuity was initially 20/80 in each eye, which improved to 20/40-1 OU after oral vitamin A therapy for 2 months. Full field electroretinogram (ERG) testing, showed non-detectable rod function and a 34 and 41% reduction for 32-Hz flicker and single flash cone responses, respectively, below the lower limits of normal. Both rod and cone functions markedly improved after initiation of vitamin A therapy. Vitamin A deficiency needs to be considered in a patient with white spots of the retina in the presence of poor night vision.