Purpose:
To demonstrate use of sutureless amniotic membrane in healing bilateral corneal ulcers caused by severe vitamin A deficiency in an autistic child
Methods:
Interventional case report
Results:
A 14-year-old severely autistic boy with a history of a self-restricted diet consisting of only Pringles and Wheat Thins presented to the emergency department at Children’s Hospital Colorado with a 5-day history of severe photophobia and recent falls. Four days prior he was evaluated for altered mental status and trouble ambulating, but his eye condition went unnoticed. Examination under sedation demonstrated bilateral corneal ulcers, keratinization of the conjunctiva, and descemetocele of the left eye (figure 1A, 1B). He was started on hourly topical antibiotics. Vitamin A level was undetectable and retinol binding protein was 0.9mg/dl (nl 3-9.2). A nasogastric tube was used to administer vitamin A. On day 4, sutureless amniotic membrane (ProKera, Bio-Tissue, Inc, Miami, Fl) was placed in the left eye. Repeat exam on day 11 showed improvement and ProKera was placed in both eyes. On day 24 the left cornea was glued after it was found to be Seidel positive. By day 31, the ulcer was sealed and both corneas were fully epithelialized. Three months later, there was corneal scar on the right, complete opacification of the left cornea, and dramatic improvement in conjunctival keratinization (figure1C,1D). The patient is now able to see well enough to grab objects and ambulate without assistance.
Conclusions:
Xerophthalmia is an extremely rare occurrence in the United States. It has been reported in patients with self-restricted diets and malabsorptive diseases. It is not uncommon for children with autism to have eating disorders including food faddism. This is the second reported, and most severe, case of bilateral corneal ulcers in an autistic child with vitamin A deficiency due to a self-restricted diet and the first report of the use of ProKera in this setting. This case is a reminder that vitamin A deficiency can cause irreversible blindness and the diagnosis can be missed in this at-risk population due to difficulty obtaining a reliable exam.
Keywords: vitamin A deficiency • keratitis • cornea: tears/tear film/dry eye