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A 44-year-old woman was referred for evaluation of peripheral corneal rings. At the time of presentation, her best-corrected visual acuity was OD 20/30 and OS 20/25. Intraocular pressure was normal OU, and pupils were round and reactive bilaterally. On exam, the anterior segment was normal except for bilateral, golden yellow-orange-coloured rings in the cornea at the limbus (figure 1A). The material was deposited in the deep stroma and Descemet membrane (figure 1B). No pigmentation of the conjunctiva or lens capsule was noted. The dilated fundus exam was normal. General physical examination revealed an orange skin tone. When asked about her current medications, the patient admitted to taking more than 40 different vitamin supplement pills daily but was unable to recall the names or the amounts of supplements ingested. Regarding her skin, she stated that she was using a daily tanning colour lotion. A laboratory evaluation was performed in order to determine the aetiology of the deposited material. Her blood count, metabolic panel, serum liver function tests, heavy metals (gold, silver, arsenic, lead, mercury), ceruloplasmin, vitamins A and D, and inflammatory markers were normal. The serum carotene was found to be elevated at 255 μg/dl (range 6–77 μg/dl), α-carotene was 69 μg/dl (range 9–101 μg/l), β-carotene was 995 μg/l (range 42–373 μg/l), lutein was 1690 μg/dl (range 50–250 μg/l), zeaxanthin was 100 μg/dl (range 8–80 μg/l), vitamin A was 39 μg/dl (range 38–98 μg/l), and a diagnosis of hypercarotenaemia was made.
The patient provided a list of her vitamin supplements. In total, she ingested 38 different supplement pills daily. Her total daily β-carotene intake was 12 879 retinol activity equivalent (RAE) (equals 42 500 IU), …