Night blindness

Nyctalopia

{
Endro Pranoto
FK Unizar Mataram
NIGHT-BLINDNESS
NYCTALOPIA /nktlopi/ = from Greek :
-, nykt- night
, alaos blind, not seeing
and , ops eye

not an eye disease or disorder.

actually a symptom or indication of an

underlying problem in which some may be

serious.
 Historical usage
Aulus Cornelius Celsus, writing ca. 30 AD,

described night blindness

recommended an effective dietary supplement:

There is besides a weakness of the eyes, owing to

which people see well enough indeed in the daytime

but not at all at night; .
also known as moonblink,

temporary night blindness believed to be caused

by sleeping in moonlight in the tropics.

 . People with nyctalopia
able to see normally in the day

have poor vision in the darkness

difficult or impossible to see in relatively low light

unable to distinguish images in low levels of

illumination
in night time, they become blind

insufficient adaptation to darkness

Normal Night Vision Night blindness Vision
 The opposite problem,
the inability to see in bright light,
known as hemeralopia and is much rarer.
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Since the outer area of the retina is made up of more
rods than cones, loss of peripheral vision often
results in night blindness.
Individuals suffering from night blindness

see poorly at night,

require extra time for their eyes to adjust from brightly lit
areas to dim ones.
Contrast vision may also be greatly reduced.
 Rods contain a receptor-protein called rhodopsin
When light falls on rhodopsin,
generating electrical signals
carried to the brain via the optic nerve.
In the absence of light, rhodopsin is regenerated.

The body synthesizes rhodopsin from vitamin A,

which is why a deficiency in vitamin A causes poor night
vision.
 Causes :
- acquired
- congenital
---

Acquired causes:
Cataracts
the lens start to become unclear and cloudy. blocks and
distorts light entering the eyes.
Common signs of cataracts are blurriness, night blindness and
halos.
people with cataracts often have difficulty in : reading,
driving a car especially at night and seeing facial
expressions.
 Myopia (nearsightedness):
night blindness can be a sign of untreated myopia.

Another general cause is

uncorrected nearsightedness (myopia).

Even with vision correction, nearsighted people

may find their nearsightedness worsen when their

pupils dilate at night

Use of certain drugs:

some glaucoma medications cause constriction

of the pupils, which can make it difficult to see at

night.
Diabetes
Diabetes is a known cause for reduced night
vision.
Over time, high blood sugar damage the
retinai blood vessels
leakage and damage the retina
(retinopathy).
Two early signs of retinopathy from diabetes :
are poor night vision and taking a long time to
see normally after coming indoors from bright
light outside.
 Vitamin A Deficiency
Night blindness is one of the first signs of vitamin A

deficiency, which is commonly associated with malnutrition.

The vitamin A deficiency often develops in malnourished
children who are too young to recognize a problem with
their night vision or report avision problem
A common cause of night blindness in developing countries.
Vitamin A is a crucial ingredient in keeping your retina healthy.
The lack of it causes your retina not being able to function
properly and results in reduced night vision.

Zinc Deficiency
Zinc works in the eye as a partner to vitamin A.
Without zinc, the vitamin A that's present may not be as
effective, and nyctalopia could result.
 LASIK Complications
Complications of LASIK are fairly common.
One common complaint of patient is distorted night vision in form of
glare and halos around objects.
surgery (especially PRK with the complication of "haze")

may rarely cause a reduction in best night-time acuity

due to the impairment of contrast sensitivity function (CSF)
resulting from surgical intervention in the natural structural
integrity of the cornea

which is induced by intraocular light-scatter

resulting from surgical intervention in the natural structural integrity of the
cornea.

Dry Eyes
Dry eye syndrome reduces the quality and quantity of tear film.
This can affect the condition of the cornea thus affecting the quality of vision,
especially night vision.
 Liver conditions.
impairs vitamin A metabolism.

Xerophthalmia.
This condition is characterized by dryness of the

conjunctiva cornea, light sensitivity, and night
blindness.
It is caused by vitamin A deficiency.

Macular degeneration .

Degeneration of the macula retinae - a specialized

region of the retina - can cause night blindness.

 Congenital causes:
X- linked Congenital Stationary Night Blindness with or
without myopia:
This stands for a group of genetically heterogeneous
(mutation in gene) disorders.
One type of congenital stationary night blindness
(choroideremia) affects only males; females are carriers
of the gene but do not have symptoms.
but the condition doesn't get worse
Usher syndrome:
This syndrome is characterized by hearing loss and
retinitis pigmentosa, which, as noted above, can cause
night blindness
 Retinitis pigmentosa:
uncommon genetic disorder

Recent genetic studies have identified mutations related to

retinitis pigmentosa on human chromosome 19.
frequently diagnosed in early childhood cones and
rods in the retina to deteriorate gradually lose their
ability to respond to the light
It can cause permanent vision loss.
Worsening night vision is often the earliest symptom.

Affected persons may have decreased vision at night or in low light.

have progressive nyctalopia
daytime vision may also be affected
May also have problems with central and peripheral vision.
Vitamin A Deficiency (VAD)

VAD affects vision

by inhibiting the production of rhodopsin,
the eye pigment responsible for sensing low light
situations.
Rhodopsin is found in the retina and is composed of
retinal (an active form of vitamin A)

and opsin (a protein).

The body cannot create retinal in sufficient amounts,

a diet low in vitamin A will lead to a decreased amount of

rhodopsin in the eye,

as there is inadequate retinal to bind with opsin.

Night blindness results.

 Night blindness caused by VAD :
associated with the loss of goblet cells in the

conjunctiva,
Goblet cells are responsible for secretion
of mucus,
and their absence results in xerophthalmia,

a condition where the eyes fail to produce tears.

Dead epithelial and microbial cells accumulate on

the conjunctiva
and form debris that can lead to infection

possibly blindness.
 Vitamin A (retinoid)
known as retinol
strengthening immunity against infections
helping vision in dim light
maintaining cell growth in some parts of the body
There are two types of Vitamin A.
Retinoids : the active form of vitamin A come
from animal products.
Carotenoids (Beta-carotene) is among the
second type of vitamin A come from plants.
 Most people get enough vitamin A from their diets.
Vitamin A deficiencies suggested vitamin A

supplements
those with certain diseases (such as digestive
disorders)
very poor diets.
 Vitamin A doses :
Men need 0.7mg a day,
Women need 0.6mg a day,
get all the vitamin A from a healthy diets

Having a total of 1.5mg or less of vitamin A per

day, on average, from diet and supplements
cause harm.
Higher doses used to treat vitamin A deficiencies,
 Vitamin A food sources
Good food sources of retinoid vitamin A include:
Eggs Cheese - Yoghurt

Plant sources of vitamin A (from beta-carotene)

include carrots, spinach, and apricots.

Vitamin A supplement information

in the form of beta-carotene,
is standard in multivitamins (it is omitted
from pregnancy multivitamins).
as a prescription cream.
keep in a cool, dry place,

away from humidity and direct sunlight.

 There are two types of photoreceptors
Rods and Cones.

Rod Cone
100 million 3 million
Black and white Colors.
Detect motion and Vision in bright
provide peripheral vision. light.
Vision in dim light Only in the
Spread throughout center of the
the retina, retina.
 Vision in dim light or darkness is blurry
Each rod must share this connection to the brain with
several other rods the brain does not know exactly
which rod produced the signal.
Vision in bright light is sharp
because each cone has its own connection to the
brain the brain can determine exactly where on
the retina the signal originated.
 Another feature of rods must adapt to darkness.
This is best exemplified by walking into a dark

movie theater.
At first, see very little. With time, vision

improves and one is able to discern objects.

This dark adaptation process occurs because of the

chemical nature of rhodopsin.

Rhodopsin is decomposed in bright light, making

the rods nonfunctional.

In darkness, rhodopsin is regenerated faster than

it can be decomposed.
 Full dark adaptation takes about 15-30 minutes
and, when complete, increases light sensitivity by
about 100,000 times.

Persons with night blindness should not drive

during the evening or at night.
Vitamin A warnings

Side-effects.
Symptoms of vitamin A toxicity include
dry skin,
joint pain,

vomiting,

headaches and confusion.

Interactions.
Vitamin A supplements interact with some oral
contraceptives, blood thinners, acne medicines, cancer
treatments and many other drugs.
 Vitamin A deficiency (VAD) or hypovitaminosis
A is a lack of vitamin A in blood and tissues.
It is common in poorer countries but rarely seen in
more developed countries.
Nyctalopia (night blindness) is one of the first signs of
VAD.
Can cause :

Xerophthalmia,
keratomalacia
complete blindness Vitamin A has a major role
in phototransduction.
 Vitamin A deficiency
the leading cause of

preventable childhood blindness

and is critical to achieving Millennium
Development Goal 4 to reduce child mortality.
Approximately 250,000 to 500,000 malnourished
children in the developing world go blind each year
from a deficiency of vitamin A,
approximately half of whom die within a year

of becoming blind.
The United Nations Special Session on Children in
2002 set a goal of the elimination of VAD by 2010.
 The prevalence of night blindness due to VAD
high among pregnant women in many developing

countries.

VAD also
contributes to maternal mortality and other poor

outcomes in pregnancy and lactation

diminishes the ability to fight infections.
 In countries where children are not immunized
infectious diseases like measles have higher fatality
rates.
As elucidated by Alfred Sommer
even mild, subclinical deficiency can also be a

problem,
as it may increase children's risk of

developing respiratory

diarrheal infections,

decrease growth rate,

slow bone development,

decrease likelihood of survival from serious

illness
 VAD is estimated to affect

approximately one third of children under the age of

five around the world.[6]
It is estimated to claim the lives of 670,000 children

under five annually.[7]

Approximately

250,000500,000 children in developing countries

become blind each year owing to VAD,
with the highest prevalence in Southeast Asia and
Africa.
 According to the World Health Organization (WHO),
VAD is under control in the United States,
but, in developing countries, VAD is a significant
concern.
Globally,
65% of all children aged 6 to 59 months received two
doses of vitamin A in 2013, fully protecting them
against VAD (80% in the least developed countries).[1]
 Signs and symptoms
VAD The common cause of blindness in developing countries is.
The WHO estimates :
13.8 million children to have some degree of visual loss related to
VAD.[8]
Night blindness and xerophthalmia,
are markers of VAD,
as it can also lead to
impaired immune function,
cancer,
and birth defects.
Bitot's spots, Collections of keratin in the conjunctiva.
Imtiaz's sign is the earliest ocular sign of VAD.
Conjunctival epithelial defects occur around lateral aspect of
the limbus in subclinical stage of VAD.
These conjunctival epithelial defects are
not even visible on a biomicroscope,
but they take up black stain and become readily visible after instillation
of kajal (surma); this is called "Imtiaz's sign".
 Causes
In addition to dietary problems, there are other causes of
VAD.
Iron deficiency affect vitamin A uptake.

Excess alcohol consumption deplete vitamin A,

Stressed liver more susceptible to vitamin A toxicity.

inadequate intake,

liver disorders

fat malabsorption,

pancreatitis,

cystic fibrosis,

tropical sprue

biliary obstruction
Infection rates
Along with poor diet
there is a large amount of infection and disease present in
many developing communities.
The vitamin A deficit
more susceptible to infection (Combs, 1991);
severe VAD susceptibility to disease increased nine times
(Dole 2009
increased documentation of xerophthalmia
after an outbreak of measles
and the varying stages of xerophthalmia become a good
reference point for the extent of deficiency (with mortality
increasing with severity of the eye disease).
 in VAD increased infection rate populations
is due to :
the T-killer cells require retinoids to proliferate correctly
(Athanassiades1981).
Retinoic acid binds the promoter region of specific genes and
so activates the transcription process and therefore cell
replication (Baron 1981).
A vitamin A deficient diet
will have a very limited surplus of retinol
cell proliferation and replication will be suppressed,
reduced number of T-cells and lymphocytes.

lack of immune reaction if pathogens become

present in the body and consequently a greater

susceptibility to incubation of disease.
 VAD and infections
aggravate each other
with infection the vitamin A levels are depleted
which in turn reduces intestinal absorption of vitamin A
(WHO 1982).

VAD often found together with is protein

energy malnutrition (PEM).
With PEM
the synthesis of retinol binding protein (RBP) is
decreased
the uptake of retinol is reduced (Combs, 1991).
inability to utilise any vitamin A present as the RBP is
absent
and so the retinol cannot be transported to the liver
maximising the VAD (Ikekpeazu 2010).
 Decreasing night blindness
requires the improvement of vitamin A status in at-

risk populations.
Supplements and fortification of food have been
shown to be effective interventions.
Supplement treatment for night blindness includes
high doses of vitamin A (200,000 IU) in the form
of retinyl palmitate to be taken by mouth, which is
administered two to four times a year.
Intramuscular injections
are poorly absorbed

and are ineffective in delivering sufficient bio-

available vitamin A.
Fortification of food with vitamin A is costly, but can
be done in wheat, sugar, and milk.
Bulan Vitamin-A
Februari dan
Agustus
 Preventing Injury Due to Night Blindness
 According to the National Safety Council, traffic
death rates are three times greater at night than
during the day.
avoid driving at night and drive only during the

day.
Driving at night is dangerous because a drivers
ability to react depends on vision, and normal
vision is severely limited at night
People with night blindness have difficulty
driving even in a well-lit city.
 Older drivers have even greater difficulty
seeing at night.
A fifty-year-old driver may need twice as much
light to see as well as a thirty-year old.

If must go out at night, take steps to

protect yourself.
Increase your visibility by cleaning your car
windows and headlights,
slow down to give yourself more time to react to
any unexpected hazards.