ACG Case Reports Journal · 5 authors, 3 centres
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Two liver transplant candidates with alcohol-associated cirrhosis presented with nonhealing central corneal epithelial defects and low serum vitamin A levels (10.7 and 14.9 ug/dL). High-dose vitamin A supplementation led to corneal healing within days to weeks. The authors recommend routine VAD screening in all liver transplant candidates to prevent severe ocular sequelae.
**Background:** Chronic liver disease, particularly alcohol-associated cirrhosis, can impair vitamin A absorption, storage, and distribution due to hepatocyte loss and malabsorption. Vitamin A is essential for ocular surface health, and deficiency can lead to corneal epithelial defects, ulcers, and xerophthalmia. This case report highlights two liver transplant candidates with VAD-related corneal ulcers and their response to supplementation.
**Methods:** Two patients with alcohol-associated cirrhosis and scleral icterus were evaluated by ophthalmology for unilateral corneal ulcers. Patient 1 was a 31-year-old man with a large central corneal epithelial defect in the left eye; Patient 2 was a 28-year-old man with a central epithelial defect in the right eye and punctate epitheliopathy in the left. Both had no identifiable risk factors (e.g., contact lens use) and denied night blindness. Serum vitamin A levels were measured, and liver function tests were performed. Both received high-dose vitamin A supplementation (100,000 units/3 days, 50,000 units/14 days, then 10,000–20,000 units daily for up to 2 months).
**Key Results:** Serum vitamin A levels were significantly low: 10.7 ug/dL (Patient 1) and 14.9 ug/dL (Patient 2) (normal range: 20.1–62.0 ug/dL). Liver function tests showed elevated bilirubin (32.6 and 31.6 mg/dL), low albumin (2.3 and 3.0 g/dL), and low total protein (4.3 and 3.6 g/dL). Patient 1's corneal ulcer healed after several weeks with subepithelial haze, complicated by exposure keratopathy and prolonged ICU stay post-transplant. Patient 2's epithelial defect healed within 1 week of starting vitamin A.
**Clinical Implications:** VAD is common in liver transplant candidates (70% prevalence) and can present with acute, nonclassical ocular findings like corneal epithelial defects without xerosis or Bitot spots. Early screening and high-dose vitamin A supplementation (preferably parenteral due to malabsorption) can prevent severe sequelae such as corneal perforation and visual loss. The authors recommend routine VAD screening in all liver transplant candidates, even before ocular symptoms appear, using a cost-effective scoring system based on symptoms, history, and eye exam.