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Early detection key to reversing ocular complications after gastric bypass, surgeon says
Lack of compliance with vitamin A supplementation after bariatric surgery can lead to serious ocular complications.
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WASHINGTON – When W. Barry Lee, MD, began his presentation on complications associated with bariatric surgery at the World Cornea Congress here, he assured the audience of ophthalmic surgeons that he was at the right conference.
Dr. Lee’s presentation was prompted, he said, by his concern that an increasing number of patients may experience serious ocular complications after gastric bypass surgery. The risk of ocular complications may rise with the volume of the surgical procedure, which is performed to correct extreme obesity, he said.
“It’s a very interesting topic, and I’m trying to get the word out on it now because it’s easy to misdiagnose with dry eyes,” Dr. Lee said in a telephone interview.
Dr. Lee’s presentation at the World Cornea Congress concerned an unusual case that had puzzled him and his colleagues until the connection with gastric bypass surgery was made. The case report was subsequently published in Ophthalmology.
A difficult evaluation
A 39-year-old woman had seen four eye care professionals over the course of a year before she was referred to Dr. Lee and his colleagues with chronic dry eyes.
Images: Lee WB |
“Apparently, the year before I saw her, her vision was 20/20,” Dr. Lee said.
By the time she came to his office, he said, her visual acuity had declined to 20/400.
“She was totally blind in both eyes,” he said. “Slowly, she said, every month she had lost a little more vision. Her eyes felt very dry, and she said she couldn’t get enough moisture in them.”
The patient’s evaluation revealed that she had Bitot’s spots in a prominent pattern that is common with xerophthalmia, a drying of the conjunctiva and cornea commonly due to a vitamin A deficiency.
“Whenever you see those two things together you immediately have to think it’s a vitamin A deficiency,” he said. “The most common cause of vitamin A deficiency would be malnutrition, but we don’t see that often here in the United States.”
Dr. Lee performed a full medical evaluation and inquired about the patient’s history, but she assured him that she had not had any surgeries.
“I was puzzled. I asked her about liver disease, but she didn’t have any problem there. I asked her about other systemic disorders that can do that, but she denied everything,” he said. “I walked out of the room to get medicine, and when I came back in she said she forgot to tell me that she had a gastric bypass done 3 years ago.”
That was when the light went on.
Reduced vitamin absorption
“When you have a gastric bypass surgery, they actually alter the part of your small intestine that absorbs vitamin A,” he said. “That’s when I started research. I pulled a lot of articles on this and realized it had not really been described before.”
Dr. Lee tested the patient’s vitamin A level and found that it was almost zero. Over the course of 3 years, the patient had gone from 395 pounds to 150 pounds, but after a while she had stopped taking the vitamin supplements prescribed by her surgeon.
Her vision had declined after she stopped taking the supplements.
“We don’t get it from our body, so you actually have to eat vitamin A, whether it’s through a supplement or vegetables,” Dr. Lee said. “With gastric bypass surgery, your stomach is about the size of three quarters. So a lot of these patients quit eating and quit drinking nutrition, and that’s how they lose all the weight.”
Dr. Lee said the patient told him that she was advised by her surgeon to take vitamin supplements, but the importance of taking them for the rest of her life had not been stressed to her.
“This needs to be known,” Dr. Lee said. “Once you have a gastric bypass surgery, it’s essential that you take these vitamins that they recommend, probably in a liquid form so they can be tolerated better. She got so sick from taking the vitamin supplements, which is what is recommended with gastric bypass, that she stopped taking them.”
A reversible condition
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Dr. Lee immediately prescribed a daily regimen of liquid vitamin A and multivitamins, and this quickly turned around the patient’s condition.
“It’s definitely reversible, but if you don’t catch it in time, there is no way to save it,” he said.
When the patient first came to visit Dr. Lee, her visual acuity was 20/400. After following the vitamin regimen for 14 months, her acuity had improved to 20/20.
The recommended daily allowance of vitamin A is 4,000 to 5,000 IU, Dr. Lee said. For this patient, he doubled the dose to 10,000 IU for the first 3 months.
“Once her vision started to normalize, we got her back down to a normal regimen,” he said. “She takes her vitamins religiously now. … You can’t even tell that she had anything wrong, and her eyes look completely normal now.”
Bound to increase
Dr. Lee said he knows of only one other case of xerophthalmia caused by lack of vitamin supplementation after gastric bypass surgery, and that patient also improved under a high-dose vitamin A regimen.
“It’s tough to pick up because it does look a lot like dry eye syndrome, and that’s where four people had misdiagnosed her before,” he said. “I only know about two cases, but I find it hard to believe that there aren’t more.”
From 1992 to 2004, Dr. Lee said, there was a 10-fold increase in the volume of gastric bypass surgery in the United States. There were 140,000 gastric bypass surgeries last year alone, he said.
A recent study estimated that 69% of patients who have had some type of gastric bypass surgery will be vitamin A deficient, even if they are on vitamin supplements, Dr. Lee said.
“There have got to be more of these patients out there,” he said.
During his World Cornea Congress presentation, Dr. Lee said, “The rising incidence of obesity and gastric bypass surgery has the potential to create an epidemic syndrome.”
Identifying cases
“Taking a really good medical history and surgical history is important, and that is going to let you know which patients are at risk for this,” Dr. Lee said. “Although, as I told you from my patient, sometimes they may not tell you the whole story. I think some people may be a little embarrassed about having gastric bypass.”
A complete examination of the ocular surface should reveal whether or not the patient has Bitot’s spots and xerophthalmia, he said.
“The first test you should do if you are concerned is to check their vitamin A level, and that will tell you the facts,” he said.
For Your Information:Reference:
- W. Barry Lee, MD, can be reached at Eye Consultants of Atlanta, 95 Collier Road, Suite 3000, Atlanta, GA 30309; 404-351-2220, ext. 1375; fax: 404-351-7070; e-mail: lee0003@aol.com.
- Lee WB, Hamilton SM, Harris JP, Schwab IR. Ocular complications of hypovitaminosis A after bariatric surgery. Ophthalmology. 2005;112(6):1031-1034.
- Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology.