a 50-year - old male reported to the ophthalmic outpatient 
 department ( opd ) with complaints of inability to see with the 
 left eye for the past three months and with the right eye for the 
 past one month . he gave history of difficulty in seeing after sunset 
 for the past few years . he gave history of chronic diarrhea , especially following 
 meals , associated with marked weight loss for the past four 
 years . he denied history of ocular 
 trauma , fever , cough , hemoptysis , chest pain , breathlessness 
 or any systemic medication . patient belonged to poor socioeconomic strata and his diet 
 consisted of only rice with occasional curry . there was dry keratinization of the palpebral 
 conjunctiva with a corrugated appearance akin to skin . the visual acuity was reduced in each eye to perception of light 
 with accurate projection of rays . the cornea of the right eye was reduced to a thin 
 opaque membrane seen in parts only and was covered with 
 mucopurulent strands . the entire iridocorneal mass 
 was protuberant with a whitish / pinkish - appearing patch in 
 the center [ figure 3 ] the cornea of the left eye was shrunken to about 6 mm 
 in diameter , opaque , thinned out and flattened with nasal 
 vascularization . rest of the details of the anterior chamber 
 could not be made out [ figure 4 ] . patient was provisionally diagnosed as keratomalacia right 
 eye and atrophic bulbi with xerophthalmia left eye . he was 
 evaluated to determine any contributory causes for loss of 
 weight and chronic diarrhea . blood sugar , 
 serum electrolytes , stool examination , renal and liver function 
 tests and chest x - ray were normal . hbsag and c - reactive 
 protein were negative , electrocardiogram showed sinus 
 bradycardia and abdominal ultrasound showed splenomegaly . he was given intramuscular injection of vitamin a 200,000 
 iu on the day of admission , the next day and then after one 
 week . in addition he was treated with topical antibiotics and 
 artificial tears . within a week of the treatment there was a 
 reversal of all changes of conjunctival xerosis and keratinization 
 and the conjunctiva became pink and velvety [ figure 5 ] . 
 however , there was no change in the corneal condition . the 
 patient sought discharge against medical advice despite being 
 advised about his condition . aids caused by hiv is characterized by the deficiency of t 
 helper ( cd4 ) lymphocytes , leading to an inability to combat 
 opportunistic infections . a provisional diagnosis of aids was made based on the 
 world health organization criteria2 which , was subsequently 
 confirmed in accordance with the national aids control 
 organization guidelines.3 besides two major features , weight 
 loss and chronic diarrhea , and one minor feature in the form 
 of generalized lymphadenopathy , the patient was serologically 
 positive too , established by positive elisa . the diagnosis of 
 keratomalacia was based on the findings of a melted cornea 
 in a relatively quiet eye associated with clinical features of 
 xerophthalmia with reversal of the conjunctival signs on 
 parenteral vitamin a therapy . the patient could not afford 
 serum retinol levels and cd4 cell count or plasma viral load 
 estimation . hypovitaminosis a is well documented in children , especially 
 following severe measles where vitamin a stores are rapidly 
 depleted due to increased metabolism.4 active corneal 
 xerophthalmia is extremely rare in older children and adults , 
 except in severe famines . they are a medical emergency 
 and require urgent treatment by high - dose vitamin a 
 supplementation.5 retinol deficiency is quite frequent in the 
 population of hiv - infected individuals . serum retinol levels of 
 less than 1.05 micromol / l determine a 3.5 to five times higher 
 death risk.6 the recommended treatment for hiv - positive 
 individuals is similar to their hiv - negative peers.5 liang et al . , have found that hypovitaminosis a , e , 
 and b12 accelerated the development of aids , whereas 
 their normalization retarded the development of immune 
 dysfunction.7 in ethiopia , vitamin a deficiency is recognized as a serious 
 public health problem among patients with chronic diarrhea , 
 with or without hiv infection . micromol / l ) was observed in 52.7% and 
 45.5% of diarrheic patients with and without hiv co - infection , 
 respectively . about 13% of healthy controls and 29.3% of 
 asymptomatic hiv - infected blood donors were deficient in 
 vitamin a.8 though hypovitaminosis a is well documented in patients 
 with hiv infection and is aggravated by the associated 
 diarrhea , keratomalacia as presenting ocular manifestation of 
 aids was not found on a medline search of literature . this 
 case is being reported on account of the unusual presenting 
 ocular manifestation of aids .
a 50-year - old male who presented with bilateral keratomalacia 
 and on subsequent evaluation was found to be human 
 immunodeficiency virus ( hiv ) positive is being reported . 
 a medline search of the literature did not reveal any report of 
 keratomalacia as the initial presenting feature of hiv/ acquired 
 immune deficiency syndrome .