Xerophthalmia: Symptoms, Types, Causes and Treatment

Xerophthalmia is a significant global eye health issue, particularly in regions where nutrition is poor or access to vitamin-rich foods is limited. This condition, most commonly triggered by vitamin A deficiency, can lead to irreversible blindness if left untreated. Understanding the symptoms, various types, underlying causes, and modern treatment options is crucial for prevention and effective management. This article will guide you through each aspect, highlighting the latest research and expert consensus.

Symptoms of Xerophthalmia

Recognizing xerophthalmia early is vital, as timely intervention can prevent progressive vision loss and blindness. The symptoms often begin subtly but can escalate quickly, especially in vulnerable populations like children.

Symptom	Description	Severity Progression	Source(s)
Night Blindness	Difficulty seeing in low light or at night	Early	1 4 5 7
Dryness	Dry, gritty sensation in the eyes	Early to Moderate	1 5 8
Bitot’s Spots	Foamy, white patches on conjunctiva	Moderate	1 4 7
Conjunctival Xerosis	Dull, dry appearance of the conjunctiva	Early to Moderate	1 5 8
Corneal Xerosis	Dry, hazy, or rough cornea	Moderate to Severe	1 4 5
Keratomalacia	Softening and ulceration of the cornea	Severe, sight-threatening	1 5 8
Photophobia	Sensitivity to light	Early	5
Redness & Secretion	Red eyes with mild discharge	Early	5

Table 1: Key Symptoms

Understanding the Symptoms

Night Blindness (Nyctalopia)

One of the earliest and most characteristic symptoms is night blindness—difficulty seeing in dim light. This occurs due to impaired regeneration of rhodopsin, a light-sensitive pigment in the retina dependent on vitamin A. Night blindness often presents first, sometimes even before visible eye changes develop 1 4 5 7.

Dryness and Early Ocular Changes

Patients commonly report a gritty or dry feeling in their eyes, sometimes accompanied by mild redness and a slight secretion. These symptoms reflect the early stages of conjunctival and corneal xerosis, where the ocular surfaces lose their normal moist appearance and become dull or rough 1 5 8.

Bitot’s Spots

Bitot’s spots are distinctive, foamy, whitish patches on the conjunctiva—typically at the temporal side. These lesions are formed by keratinized epithelial cells and are highly suggestive of vitamin A deficiency 1 4 7.

Progression to Corneal Involvement

If not treated, xerophthalmia can progress to corneal xerosis and ultimately keratomalacia—a softening and ulceration of the cornea that can lead to blindness. This stage is a medical emergency and requires immediate intervention 1 5 8.

Photophobia and Redness

Children may also develop photophobia (light sensitivity) and mildly red eyes, which can be mistaken for conjunctivitis in the early stages 5.

Types of Xerophthalmia

Xerophthalmia is not a single-stage disease but rather a spectrum of ocular changes associated with vitamin A deficiency. Each type reflects a progressively worsening state of eye health, underlining the importance of early detection and intervention.

Type	Defining Feature	Typical Stage	Source(s)
Night Blindness	Poor vision in low light	Earliest	1 4 5 7
Conjunctival Xerosis	Dry, lustreless conjunctiva	Early	1 5 8
Bitot’s Spots	Foamy, white conjunctival plaques	Early to Moderate	1 4 7
Corneal Xerosis	Dry, rough, hazy cornea	Moderate	1 5 8
Keratomalacia	Corneal softening/ulceration	Severe	1 5 8
Dystrophia Alipogenetica	Malnutrition-linked degenerative changes	Associated	5

Table 2: Types of Xerophthalmia

A Closer Look at the Types

Night Blindness

This is the earliest and most reversible manifestation. It is often the first warning sign, especially in children and pregnant women 1 4 5 7.

Conjunctival Xerosis

At this stage, the conjunctiva—the thin membrane covering the white of the eye—becomes dry and loses its normal shine. This dryness is due to the depletion of mucous-secreting goblet cells, which rely on vitamin A to function 1 5 8.

Bitot’s Spots

These classic lesions are pathognomonic for xerophthalmia and are easily identified on eye examination. Their presence indicates a moderate deficiency and warrants urgent dietary intervention 1 4 7.

Corneal Xerosis and Keratomalacia

When the deficiency progresses, the cornea becomes dry (corneal xerosis), then softens and may ulcerate (keratomalacia). This stage can rapidly lead to irreversible blindness if not treated immediately 1 5 8.

Dystrophia Alipogenetica

This term describes degenerative changes in infants and young children due to fat-soluble vitamin deficiencies, particularly vitamin A. It is associated with general malnutrition, stunted growth, and increased susceptibility to infections 5.

Causes of Xerophthalmia

Understanding the root causes of xerophthalmia is critical for both prevention and treatment. While vitamin A deficiency is the direct cause, several underlying factors contribute to its development, especially in vulnerable populations.

Cause Type	Example/Description	At-Risk Population	Source(s)
Nutritional	Low vitamin A/protein intake, poor diet	Children, poor families	4 5 7 8
Malabsorption	Liver disease, alcoholism, chronic GI illness	Adults, alcoholics	1 8
Infection	Measles, local ocular infections	Children	4 7 8
Socioeconomic	Poverty, rural residence, maternal illiteracy	Children	4 5 7
Dietary Practices	Maize-based diet, reduced animal fat intake	Rural populations	4 5 7
Cultural Factors	Boiling milk excessively, food export	Specific regions	5

Table 3: Main Causes of Xerophthalmia

Exploring the Causes

Nutritional Deficiency

The fundamental cause is insufficient intake of vitamin A, often compounded by a lack of dietary fats and proteins needed for absorption and metabolism. Diets based predominantly on cereals like maize, with little animal produce or leafy vegetables, place children at high risk 4 5 7 8.

Malabsorption and Associated Diseases

Adults may develop xerophthalmia due to chronic conditions that impair nutrient absorption—such as liver cirrhosis, chronic alcoholism, or gastrointestinal diseases. Alcohol-induced malnutrition, for example, is a recognized cause, especially in developed countries where overt dietary deficiency is less common 1 8.

Infection as a Catalyst

Infections, particularly measles, can precipitate or worsen vitamin A deficiency by increasing the body's demand for the vitamin and reducing its absorption. Measles is a notorious catalyst for xerophthalmia-related blindness in children, especially in malnourished populations 4 7 8.

Socioeconomic and Cultural Factors

Poverty, rural living, and maternal illiteracy are significant risk factors, primarily by limiting access to nutritious foods. Cultural practices such as excessive boiling of milk (destroying fat-soluble vitamins) or exporting local dairy produce can also deplete local vitamin A availability 4 5.

Dietary and Environmental Contributors

Children fed on artificial diets lacking in whole milk or essential fats, or those whose diets rely heavily on processed or starchy foods, are especially vulnerable. Seasonal variations, such as the scarcity of vitamin-rich foods in spring, can also play a role 5 7.

Treatment of Xerophthalmia

Effective treatment of xerophthalmia hinges on rapid restoration of vitamin A levels, management of ocular symptoms, and addressing underlying nutritional or medical issues. Both immediate and long-term interventions are key.

Treatment	Application/Method	Benefits	Source(s)
Oral Vitamin A	High-dose supplementation	Rapid reversal of symptoms	11 12
Intramuscular Vitamin A	Injection for severe cases	Equally effective to oral	11
Dietary Modification	Protein, beta-carotene-rich foods	Sustainable recovery, prevention	5 9 12
Artificial Tears	Lubricating eye drops	Symptom relief	1 2 10
Topical Therapies	Sodium hyaluronate, rhEGF	Reduces dryness/inflammation	2
Acupuncture	10-session therapy	Longer-lasting symptom relief	10
Treat Underlying Disease	Manage malnutrition, infections	Prevents recurrence	1 8 12

Table 4: Treatment Options for Xerophthalmia

Approaches to Treatment

Vitamin A Supplementation

High-dose oral vitamin A is the cornerstone of treatment. Studies show that oral administration is as effective as intramuscular injections, even in children with malnutrition or diarrhea 11. In severe cases, a repeated dosing schedule may be required. Intramuscular injections are reserved for cases where oral therapy is not feasible 11.

Dietary Interventions

Long-term management focuses on improving the diet. Introducing foods rich in vitamin A (e.g., liver, eggs, dairy, green leafy vegetables, orange fruits) and protein can reverse mild to moderate xerophthalmia and prevent recurrence 5 9 12. Locally available sources—such as the buriti fruit in Brazil—have proven effective 9. Nutrition rehabilitation centers have demonstrated success using affordable, locally sourced foods 12.

Ocular and Supportive Therapies

Artificial tears and lubricating eye drops, such as those containing carboxymethylcellulose or sodium hyaluronate, provide symptomatic relief for dryness and discomfort 1 2 10. Recent evidence supports the addition of recombinant human epidermal growth factor (rhEGF) to sodium hyaluronate for enhanced reduction of inflammation and improved ocular surface health after cataract surgery 2.

Acupuncture and Alternative Therapies

Acupuncture has shown promise for longer-lasting relief of symptoms compared to artificial tears, though it should be considered adjunctive rather than primary therapy 10.

Managing Underlying Conditions

Treating associated malnutrition, infections (especially measles), and chronic diseases is essential to prevent recurrence and further complications 1 8 12.

Conclusion

Xerophthalmia remains a leading cause of preventable blindness worldwide, particularly among children in low-resource settings. Early recognition and prompt intervention are crucial to averting permanent vision loss. Addressing both the immediate deficiency and underlying causes through a combination of supplementation, dietary improvement, and supportive therapies offers the best chance for recovery and prevention.

Key Takeaways:

• Symptoms: Progress from night blindness and dryness to Bitot’s spots, corneal xerosis, and potentially blinding keratomalacia 1 4 5 7 8.
• Types: Represent a spectrum, from early functional changes to severe, structural damage 1 5 7.
• Causes: Most commonly due to vitamin A deficiency from poor diet, malabsorption, infections, and socioeconomic factors 1 4 5 7 8.
• Treatment: Combines high-dose vitamin A, dietary correction, artificial tears, and management of underlying illnesses. Oral therapy is often as effective as injections 1 2 5 9 10 11 12.
• Prevention: Rests on improving nutrition, public health education, and timely management of childhood infections.

By increasing awareness and access to effective interventions, we can move closer to eradicating this preventable cause of blindness.