Bitot’s Spots 

What Are Bitot’s Spots?

[dropcap]B[/dropcap]itot’s spots are superficial foamy patches that develop on the exposed bulbar conjunctiva (white of the eye) as a manifestation of advanced vitamin A deficiency.

This painless eye disorder is reversible only with vitamin A therapy. It is named after Charles Bitot, who first described it.

Q: What makes up these foamy alterations of the conjunctiva?

A: Bitot’s spots are composed of epithelial debris (dead surface cells) and secretions.¹

Bitot’s spots may develop in malnutrition, reduced intake including alcoholism, medication adverse effect, old age, low stomach acid, and disease causing vitamin A deficiency such as celiac disease, Crohn’s disease, pancreatic insufficiency, and short bowel syndrome.  Other conditions associated with vitamin A deficiency may include disordered transport (Abetalipoprotenemia, a genetic disorder) and reduced liver storage caused by liver disease.

What Are Bitot’s Spots In Celiac Disease and/or Gluten Sensitivity?

• Bitot’s spots is an eye disorder associated with celiac disease that develops from inadequate vitamin A and protein caused by malabsorption.

How Prevalent Are Bitot’s Spots In Celiac Disease and/or Gluten Sensitivity?

Bitot’s spots has increased occurrence in patients with untreated celiac disease.

A Dutch study investigating prevalence found 7.5% of patients in 80 patients at diagnosis showed deficient levels of vitamin A.²

What Are The Symptoms Of Bitot’s Spots?

• Bitot’s spots is marked by painless, superficial triangular shiny gray spots and foamy spots on the exposed conjunctiva of the eyeball.

How Do Bitot’s Spots Develop In Celiac Disease and/or Gluten Sensitivity?

• Bitot’s spots results from vitamin A and protein deficiency due to malabsorption in celiac disease.

Do Bitot’s Spots Respond To Gluten-Free Diet?

Yes. Celiac disease-related Bitot’s spots resolve on gluten free diet with vitamin A supplementation.

6 Steps To Improve Bitot’s Spots In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both eye and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.³
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory). [box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁴
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁴
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁴.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁴
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁴
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁴[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

 

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4[/dropcap] Manage Your Medications Safely:

[box type=”shadow” ] Certain prescription drugs can cause nutritional deficiencies that increase risk for Bitot’s Spots. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

This is not a complete listing.

WEIGHT LOSS DRUGS THAT BIND FAT also interfere with absorption of some nutrients.

• Zenicol (Orlistat®) depletes Vitamin A.

CHOLESTEROL DRUGS

• Colestid® and Quetran® deplete Vitamin A, and others.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Vitamin A, and others.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Vitamin A, and others.[/box]

• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.
• Vitamin A as prescribed following a blood test for vitamin A status.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort. Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps: Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Bitot’s Spots In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients.” This study aiming to assess the nutritional and vitamin/mineral status of current “early diagnosed” untreated adult celiac disease patients in the Netherlands found that vitamin/mineral deficiencies are still common in newly “early diagnosed” celiac disease patients, including vitamin A.

Eighty newly diagnosed adult celiac disease patients were included and a comparable sample of 24 healthy Dutch subjects was added to compare vitamin concentrations. Nutritional status and serum concentrations of  various nutrients including vitamin A were assessed before prescribing gluten free diet.

Almost all celiac disease patients (87%) had at least one value below the lower limit of reference. Specifically, for vitamin A, 7.5% of patients showed deficient levels. Overall, 17% were malnourished (>10% undesired weight loss), 22% of the women were underweight (Body Mass Index (BMI) < 18.5), and 29% of the patients were overweight (BMI less than 25). Vitamin deficiencies were barely seen in healthy controls, with the exception of vitamin B₁₂. Vitamin/mineral deficiencies were counter-intuitively not associated with a (higher) grade of histological intestinal damage or (impaired) nutritional status. Extensive nutritional assessments seem warranted to guide nutritional advices and follow-up in celiac disease treatment.⁵

“Corneal manifestations in Vitamin A deficiency.” This study investigating alterations in the anterior segmant of the eye demonstrated vitamin A deficiency can be the reason for bilateral conjunctiva manifestations.⁶

CASE REPORTS

“Bitot’s Spots: Look at the Gut.” This case report describes vitamin A deficiency presenting as Bitot’s spots in a 10-year-old boy and eventual diagnosis of celiac disease. The child presented with diarrhea since 1 year, passing multiple stools in a day. He also complained of decreased vision in low lighting. The child was malnourished, had pallor and height for age and weight for age were lower than the 3rd percentile. He was eldest of the three siblings and belonged to a poor rural family. He also had superficial, irregularly-shaped, white lesions on the conjunctiva in both eyes. Mild pitting edema of the feet was noted and systemic examination was normal.

Evaluation revealed low hemoglobin of 8 mg/dL (Normal 12-16 mg/dL), microcytes in peripheral smear and a mean corpuscular volume of 71 mm3, normal leukocyte count and thrombocytosis (5 lakh/mm3). The patient had low serum albumin (2.8 g/dL, Normal: 3.5-5 g/dL) and mild transaminitis (Alanine transaminase – 71 U/L, Normal: 0-35 U/L, aspartate transaminases AST- 75 U/L, 7-41 U/L) with a normal level of bilirubin. Upper gastoduodenoscopy showed grooving and scalloping in second part of duodenum. Duodenal biopsy revealed subtotal villous atrophy. Immunoglobulin A (IgA) tissue transglutaminase was 213 U/mL (Normal: 0-8 U/mL).⁷

*PHOTO CREDIT: Sommer A: Nutritional Blindness: Xerophthalmia and Keratomalacia. New York, Oxford University Press, 1982.

Sources:

1. Sadowski B, Rohrback JM, Steuhl KP, Weidle EG, Castrillon-Obendorfer WL. Corneal manifestations in Vitamin A deficiency. Klinische Monatsblatter fur Augenheilkunde. Aug 1994;205(2)76-85. [↩]
2. Wierdsma NJ, van Bokhorst-de van der Schueren MA, Berkenpas M, Mulder CJ, van Bodegraven AA. Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients. Nutrients. 2013 Sep 30;5(10):3975-92. doi: 10.3390/nu5103975. [↩]
3. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
4. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
5. Wierdsma NJ, van Bokhorst-de van der Schueren MA, Berkenpas M, Mulder CJ, van Bodegraven AA. Vitamin and mineral deficiencies are highly prevalent in newly diagnosed celiac disease patients. Nutrients. 2013 Sep 30;5(10):3975-92. doi: 10.3390/nu5103975. [↩]
6. Sadowski B, Rohrback JM, Steuhl KP, Weidle EG, Castrillon-Obendorfer WL. Corneal manifestations in Vitamin A deficiency. Klinische Monatsblatter fur Augenheilkunde. Aug 1994;205(2)76-85. [↩]
7. Sharma A, Aggarwal S, Sharma V. Bitot’s Spots: Look at the Gut. Int J Prev Med. 2014 Aug;5(8):1058-9. [↩]