Xerophthalmia secondary to bowel malabsorption after Roux-en-Y gastric bypass

Vitamin A is a fat-soluble vitamin, obtained through diet. Vitamin A deficiency is the leading cause of preventable blindness in children in developing countries due to impaired intake (Phanachet et al. 2018). Nevertheless, it is uncommon in the developed world where malabsorption takes a prominent role.

A fifty-one-year-old female presented complaining of foreign body sensation, pain, tearing, fluctuating visual acuity, nyctalopia, diarrhea, polyphagia and weight loss. She had history of Roux-en-Y gastro-jejunal bypass, Lynch syndrome and right hemicolectomy with ileo-colonic anastomosis, she also referred to an additional unspecified bowel resection. In the ophthalmologic examination, best corrected visual acuity was 20/30, intraocular pressure was 11 mmHg in both eyes. Anterior segment biomicroscopy revealed a dry and thickened conjunctiva with wrinkles, multiple grey-white small, round, confluent, foamy lesions in the interpalpebral conjunctiva of both eyes, compatible with Bitot's spots, and superficial punctate keratitis.

The rise of bariatric surgery, inflammatory bowel disease and end stage liver disease has led to an increase in cases of malabsorption syndrome and nutrient deficiencies in the developed world. Retinoids are essential for corneal and conjunctival epithelial cells differentiation and its deficiency is associated with a wide spectrum of ocular surface manifestations known as xerophthalmia. In this case, a gastric bypass and another unspecified bowel resection should raise the suspicion of malabsorption and nutrient deficiencies. In our patient, the diagnosis was made early and appropriate treatment was implemented before irreversible damage arose, however, vitamin A deficiency can be easily overlooked.

In patients with xerophthalmia, interrogation should include previous history of gastrointestinal surgery, especially since bariatric surgery has become a popular technique. This is, to our knowledge, the first case report of xerophthalmia in a patient with Lynch syndrome.