The Ophthalmic Complications of Bariatric Surgery: The Role of Vitamin A Deficiency

Background

The role of vitamin A-associated organic compounds such as retinol and retinoic acid in retinal photoreceptor metabolism is well understood. Vitamin A plays an important role for corneal and conjunctival development, prevention of xerophthalmia, and central nervous system function. Further properties of vitamin A and its metabolism are still unclear and subject to research [1]. Uptake from food sources and distribution is dependent of intact fat absorption mechanisms and cofactors such as retinol-binding protein [2]. Deficiency of vitamin A is the most common preventable cause of blindness in children and is associated with high mortality and morbidity in developing countries where the WHO is committed to treatment and prevention programs [3]. In industrialized countries, bariatric surgery has become an established treatment for obesity. Most of these procedures lead to the malabsorption of micro- and macronutrients and regular control, and substitution of vitamins and substrates is mandatory. However, a lack of regular substitution (i.e., when patients are non-adherent to treatment or lost to follow-up) can lead to severe vitamin deficiency states as shown in the following two case reports.

• References

• 1 McLaren DS, Kraemer K. Vitamin A in health. World Rev Nutr Diet 2012; 103: 33-51
• 2 Blomhoff R, Green MH, Green JB. et al. Vitamin A metabolism: new perspectives on absorption, transport, and storage. Physiol Rev 1991; 71: 951-990
• 3 World Health Organization. Global prevalence of vitamin A deficiency in populations at risk 1995–2005: WHO global database on vitamin A deficiency. 2009. Available at: https://apps.who.int/iris/bitstream/handle/10665/44110/9789241598019_eng.pdf Accessed 2009
• 4 Mollan SP, Ali F, Hassan-Smith G. et al. Evolving evidence in adult idiopathic intracranial hypertension: pathophysiology and management. J Neurol Neurosurg Psychiatry 2016; 87: 982-992
• 5 Moss HE. Bariatric Surgery and the Neuro-Ophthalmologist. J Neuroophthalmol 2016; 36: 78-84
• 6 Panozzo G, Babighian S, Bonora A. Association of xerophthalmia, flecked retina, and pseudotumor cerebri caused by hypovitaminosis A. Am J Ophthalmol 1998; 125: 708-710
• 7 Sadun A. Acquired mitochondrial impairment as a cause of optic nerve disease. Trans Am Ophthalmol Soc 1998; 96: 881-923
• 8 Chisholm JT, Abou-Jaoude MM, Hessler AB. et al. Pseudotumor Cerebri Syndrome with Resolution After Discontinuing High Vitamin A Containing Dietary Supplement: Case Report and Review. Neuroophthalmology 2017; 42: 169-175
• 9 Thompson DA, Fujinami K, Perlman I. et al. ISCEV extended protocol for the dark-adapted red flash ERG. Doc Ophthalmol 2018; 136: 191-197 doi:10.1007/s10633-018-9644-z
• 10 Saker S, Morales M, Jhittay H. et al. Electrophysiological and microperimetry changes in vitamin A deficiency retinopathy. Doc Ophthalmol 2015; 130: 231-240
• 11 Pereira S, Saboya C, Ramalho A. Impact of different protocols of nutritional supplements on the status of vitamin A in class III obese patients after Roux-en-Y gastric bypass. Obes Surg 2013; 23: 1244-1251