Eye Diseases in African Children.

SIRs,-The comment of Rodger (1958) on the ocular manifestations of malnutrition in the West African child are a timely reminder that, not only in Africa but also in many other parts of the tropics, the blinding effects of dietary deficiency continue to be of great importance. However, his views on vitamin A deficiency cannot be allowed to pass unchallenged. That the status of Bitot's spot is still uncertain is exemplified on the one hand by Rodger's paper, where it is stated, although evidence is not given, that it is "irreversible" and unrelated to vitamin A deficiency, and on the other by the equally recent work of Roels, Debeir, and Trout (1958), also from Africa (Ruanda-Urundi), where a close correlation is claimed between Bitot's spots and serum carotene and vitamin A levels. In both papers photographs are reproduced of what the authors regard as typical Bitot's spots, and it would appear that they are talking about the same condition. They closely resemble the lesions I saw accompanied by xerosis conjunctivae in India in school-age children and in young adults, which were usually, but not always, responsive to prolonged vitamin A therapy. Most mucous membrane and skin signs associated with defective diet have been shown to be non-specific and of multiple aetiology, and various kinds of local trauma also play a constant but ill-defined part. Such lesions of the conjunctiva are usually confined to or maximal in the interpalpebral fissure; for example, pigmentation, wrinkling, Bitot's spot, conjunctival injection, pinguecula, and pterygium, and in this unique area of the body, where transparent epithelial structures are exposed to both light and air, trauma and nutrient deficiency may be closely related. In my view, it would be as difficult to justify the decision of Debeir to take Bitot's spot as the sole clinical sign of vitamin A deficiency because it is "reputedly very specific" as it is to agree with Rodger on the "irreversible" nature (length of treatment not stated) of his admittedly "very few" cases. My own opinion, based upon personal experience of xerophthalmia over a number of years in South India, Indonesia, and East Africa, is that no single conjunctival change or group of changes can be regarded as being specific for vitamin A deficiency. When one turns to the advanced stages, going by the names of xerophthalmia and keratomalacia, it has been repeatedly shown by others, and is also my own experience …