DISCOLORATION FROM A DIFFERENT CONDITION?

This letter is in reference to the Online Photo Diagnosis column by Tom Arnold, OD, that appeared in the April edition of Contact Lens Spectrum. My first impression of the photo was that of a Kayser-Fleischer ring resulting from the deposition of copper in Descemet’s membrane of the cornea, which is indicative of liver disease and, in particular, Wilson’s disease. Upon reviewing the references accompanying the photo, I could find no mention of any corneal findings associated with hypervitaminosis A. An admittedly cursory online Google search of this condition also produced no results regarding corneal findings in cases of hypervitaminosis A.

While signs of this condition may include dry skin and lips, hair loss, and brittle nails, hypervitaminosis A may also result in heart valve calcification, hypercalcemia, increased intracranial pressure and liver damage (Saljoughian, 2021). Given the findings in the photo and the patient’s history of “using large amounts of supplements on a regular basis,” I believe a further medical evaluation is indicated.

John E. Crews, OD
Danville, VA

Dr. Arnold’s Response

Thank you, Dr. Crews, for your interest in the Online Photo column and, in particular, of my photo of yellow discoloration of the limbus. I apologize for my poor documentation of the literature regarding this finding. For your interest, I would refer you to this article:

Eller AW, Gorovoy IR, Mayercik VA. Yellow corneal ring associated with vitamin supplementation for age-related macular degeneration. Ophthalmology. 2012 May; 119:1011-1016.

In that study, the authors document four patients who took vitamin supplements for age-related macular degeneration (ARMD) between January 2010 and April 2011. They note that “each patient had circumferential yellow peripheral corneal rings and exhibited subtle yellowing of the skin most notable on the palms. Serum carotene levels were normal in two of the three cases and markedly elevated in the last case in which it was measured.”

Further, the authors noted that “the propinquity of the limbal circulation and its clarity predisposes the peripheral cornea to the deposition of pigment from the systemic circulation.”

Their conclusion: “We report the occurrence of a yellow peripheral corneal ring that we believe is secondary to the carotenoids found in vitamin supplementation for the treatment of age-related macular degeneration….”

You are correct, of course, that a number of systemic diseases may also result in discoloration. However, this patient and her physician husband, confirmed the use of a large amount of vitamin supplementation.

References

1. Saljoughian M. Hypervitaminosis: A Global Concern. US Pharm. 2021 Oct 15;46:47-50.