A 50-year-old man underwent a Scopinaro biliopancreatic diversion in January 2004 due to morbid obesity. The patient presents with hepatic steatosis and malabsorptive syndrome. He is being treated with vitamin B12 for chronic anaemia and vitamin K for decreased prothrombin activity.
In January 2006 he underwent pyeloinfundibulonephrolithotomy with postoperative urinary fistula.
In April 2006, the patient was referred to the ophthalmology department for night blindness progressive over 3 months. The patient also reported a foreign body sensation and red eye. On examination the visual acuity was unity in both eyes. Slit lamp examination showed a very decreased BUT, conjunctival xerosis and Bitot spots in both eyes. Fine corneal conjunctival epithelial stippling could also be seen on fluorescein staining. In the Schirmer I test under anaesthesia, values greater than 15 mm were observed. Ophthalmoscopically, there was whitish mottling in the mid-periphery without macular involvement. The plasma retinol level was 0.07 mg/l (normal level 0.30-0.8 mg/l).

Given the potential severity of the condition, oral treatment with vitamin A and pancreatic enzymes was started to promote its absorption while awaiting intramuscular treatment, with little improvement.
Concomitantly, due to complicated nephrolithiasis (intrarenal abscess), the patient underwent a nephrectomy with severe bleeding, requiring five red blood cell concentrates. After this procedure, the patient reported a slight improvement in his symptoms, despite having stopped oral treatment due to post-surgical fasting.
Finally, 300,000 IU of intramuscular vitamin A was administered, achieving an immediate improvement in the subjective symptoms, although the ophthalmoscopic manifestations took three months to disappear.