The world through tinted glasses

• Published in: The Lancet (British edition) Vol. 364; no. 9431; p. 388
• Main Authors: Bennett, David LH, Webster, George JM, Molyneux, Paul, Descamps, Marjanne JL, Plant, Gordon T, Pereira, Stephen P, Reilly, Mary M
• Format: Journal Article
• Language: English
• Published: London Elsevier Ltd 24.07.2004; Lancet; Elsevier Limited
• Subjects: Abdomen; Biological and medical sciences; Biopsy; Carotenoids; Case reports; Celiac Disease - complications; Endoscopy; Eyes & eyesight; General aspects; Gluten; Humans; Male; Medical diagnosis; Medical disorders; Medical sciences; Middle Aged; Night Blindness - diagnosis; Night Blindness - etiology; Night Blindness - therapy; Pancreatitis; Pancreatitis, Alcoholic - complications; Physical examinations; Vitamin A; Vitamin A Deficiency - diagnosis; Vitamin A Deficiency - etiology; Vitamin A Deficiency - therapy; Vitamin D; Vitamin E; Vitamins; World; Medicine; Public health; Glass; International
• ISSN: 0140-6736; 1474-547X
• DOI: 10.1016/S0140-6736(04)16731-7

A 45-year-old man presented in August, 1996, with deteriorating night vision over 5 months. He described being blind when he woke at night and had been investigated for transient ischaemic attacks. By day he reported that he seemed to be looking through a yellow filter when he looked at a blue sky. 7 years previously, he had had an extensive ileal resection following a compound volvulus. More recently he had suffered from weight loss and intermittent diarrhoea with pale stools. On examination, visual acuity was 6/9 (right eye) and 6/9+2 (left). Colour vision was normal (17/17 Ishihara plates). The Goldman visual fields were restricted more on the left than the right. We observed bilateral conjunctival xerosis and Bitot's spots (figure). On fundoscopy the right foveal reflex was altered and a right para-macular haemorrhage was present. No rod or blue cone responses were seen on ERG. He was deficient in the fat soluble vitamins: vitamin A: 0.1 mmol/L (1.05-2.27), 25 hydroxy-vitamin D: 10 nmol/L(40-195), vitamin E: 0.5 mmol/L(11.5-46.4) and vitamin K as shown by coagulopathy (INR: 3.98, APTTR: 1.43). Serum zinc was low at 7.7 mmol/L (10.7-22.9). He had anti-gliadin and anti-endomysial antibodies and a duodenal biopsy showed sub-total villous atrophy. He was eventually diagnosed with malabsorption secondary to a previous ileal resection and coeliac disease. He was treated with parenteral vitamins A, D, E, and K, and started on a gluten-free diet. His night blindness improved rapidly and his ERG returned to the lower limit of normal. When last seen in August, 2003, he had no visual signs or symptoms.