The psychomotor and emotional development of a child is largely dependent on normal vision. Visual impairment in pediatric age group is a global issue. Several causes of visual impairment are either treatable or preventable. Globally 1.4 million(3%) are blind. However, these children suffer from a lifetime misery ahead of them, which is second only after cataract.1 Around half of all causes of childhood blindness can be prevented by taking cost effective measures.2 Visual impairment can negatively affect a child’s school performance and overall quality of life. Furthermore, conditions such as strabismus and amblyopia can cause permanent visual loss.3
Common eye problems are prevalent in
primary school children irrespective of their
socioeconomic status. Teachers, medical students
and ophthalmic technicians when trained can be
an asset in the screening these children.
The prevalence of childhood blindness greatly varies from different parts of the world on the basis of under five mortality rate and socioeconomic development. Prevalence is reports to be 1.5 per 1000 children in low income countries and in high under-5 mortality rate and as low as 0.3 per 1000 children in higher income countries.4 Usually children are unaware of their visual impairment and adapt to their environment by sitting in the front row of the class, copying work from the fellow student, squinting to see the board clearly or holding books very close to the eyes. They eventually fail to meet educational targets which demand concentration and finally lose interest in class room activities. Visual screening programs should become a part of regular care during the schooling years.5 Primary school children represent aa vulnerable age group where uncorrected refractive errors may lead to an immense decline in learning ability.6 Eye screening can pick up who children who need referral to the ophthalmologist for further management. Refractive error is the major cause of visual impairment and causes significant morbidity.It is estimated that uncorrected refractive errors account for visual impairment in 12.8 million children in the age range 5-15 years worldwide.7 In one study it was estimated that blindness due to refractive errors resulted on an average of 30 years of blindness for each person as compared to 5 years of blindness due to untreated cataract for each person.8 A new approach to screening for common eye problems is required in order to maximize utilization of human resources such as training teachers in visual screening.9
MATERIAL AND METHOD
Children from two private primary schools of Hayatabad, Peshawar were selected for this cross-sectional study. This accounted for 2400 school children in total from the age of 3 to 12 years. Of these children, 1320 (55%) were male and 1080 (45%) were female. All children from ages 3 to 12 years with or without pre-diagnosed eye conditions were included in this study. Children falling outside of the inclusion criteria were not included. Data was collected over a period of 1 month. 10 teachers,4 community health workers (CHWs), 4 medical students, 2 ophthalmic technicians, 1 medical officer, 1 refractionist and 1 consultant ophthalmologist from a tertiary care hospital participated in this study. A memorandum of understanding (MOU) was signed between the school administrations headed by the school head mistresses and the Eye Department of Hayatabad Medical Complex, Peshawar. Subsequently, 5 teachers from each school were selected to undergo training. The teachers, medical students and community health workers were trained at the hospital by the consultant in two groups. The respective groups received training in screening of common eye diseases with the aid of interactive presentations and visual acuity testing in the eye clinic. Each member of the team was provided with the following: 1 pen torch, 1 snellen’s chart, antibiotic eye ointment, first aid material and a register for recording findings. The schools had five working days per week. There were 1200 students in each school. The duration of the screening was one month. Twenty two days were allocated to screening. In each school fifty to fifty five students were screened per day. Screening started from junior classes. Members of the team examined children with the supervision of ophthalmic technicians. Children with vision < 6/12, squint, ptosis, amblyopia, red eye or other ocular abnormalities were referred to the eye department and either identified as normal or affected. They were prescribed ocular medications by the consultant and were refracted by the refractionist. After the affected children had received treatment, the consultant ophthalmologist revisited both schools to check the patients’ performance with their prescribed treatments and found it to be highly effective.
A total of 2400 childrenbetween the ages of 3 to 12 years with a mean age of 7.5 years were selected for screening who participated in the screening test. Table 1 and fig. 1 shows the number of children screened according to age distribution In the 3-5 years age group there were 600(25%) students, in the 6to9years age group there were 1320(55%)students, and in the 10to12years age group there were 480(20%) students.
Table 2 and Fig 2 show the gender distribution of the total screened and affected children. Among these there were 1320 males (55%) and 1080(45%) females.
A total of 228 (9.5%) children were screened positive for eye problems. Of these, 110 (48.2%) were male and 118 (51.75%) were female. The affected children were referred to HMC eye department in Peshawar and examined by the consultant ophthalmologist. After examination, 20 (8.7%) children were found to be normal. The remaining 208 (91.22%) were diagnosed with one of the eye problems and treated accordingly. 99 (4.13%) patients were diagnosed with refractive error and the remaining 109 (4.50%) with other ocular abnormalities. In this study we found Vernal catarrah in 27(11.84%) patients, Blepharitis in 24 (0.11%) patients, other cases of conjunctivitis in 20 (8.77%) patients, squint in 10 (4.39%) patients, amblyopia in 9 (3.95%), trachoma in 8 (3.51%), and other problems such as ptosis and Bitot spots in seven and four patients respectively. Table 3 and fig 3 shows the disease distribution in the referred students
The consultant ophthalmologist revisited both schools on a specific date and found that 18 children screened positive for eye problems that were missed in the initial visit. The screened children referred to the ophthalmology unit of Hayatabad medical complexwere examined by the consultant and it was found that 20 (8.77%) were normal, which were false positive and those found affected were 208(91.22%), true positive. The false negatives were 18 (0.75%) patients who were missed during screening.
The sensitivity and specificity of this screening were calculated to be 92% and 99% respectively.
Two primary schools from the private sector were selected for screening of common ocular abnormalities by medical students, teachers, ophthalmic technicians and community health workers. The schools are located in phase 2 of Hayatabad, Peshawar. The well to do community sends their children to these schools, and almost all parents were educated and were supposed to be aware of the importance of health care screening. The purpose was to find about the disease distribution in the educated community and practical application of the parents awareness of the primary eye care. The medical students were selected from three different medical colleges, and they were in the fourth and final year of MBBS. The teachers were selected based on their background knowledge of biology and the will to participate. The ophthalmic technicians and community health care workers belonged to the Hayatabad Medical Complex and had their training obtained from the Pakistan Institute of Ophthalmology, Peshawar. The basic knowledge provided to them can be of use in future programs that such screening are carried out regularly. Our study was both community and hospital oriented. The screened children labeled as affected were brought to the hospital. That is why our results are comparable to any study. Several disorders result in significant visual impairment which remain asymptomatic in young children and thus are easily missed by caregivers. Screening programs for such ‘silent’ disorders are required in order to provide timely medical attention. The ocular morbidity in our study was 8.67% which is comparable to the reports by Ghulam and Ahla who reported an ocular morbidity of 7.6%.10 Ntim-Amponsah and Ofosu- Amaahreportedan ocular morbidity of 8.67 % from Ghana, Africa which is exactly similar to our statistics11.Khalil reported a high ocular morbidity of 22.84% in school going children of Distt. Lasbella, Balochistan.12 BT Kamath and GM Bengalorkar reported an ocular morbidity of 10.33% in private school children in Karnataka, South India.13 Ocular morbidity in primary school children in Turkey was recorded to be 10%.14 A female preponderance was noted and we found 51.92 % of the females and 48.08 %of the males to have the ocular morbidity. Farrukh S and Atif M.A. reported almost similar statistics from Bahawalpur.15 In a study conducted in Himachal NIndia 52.08% of the male children in school had eye problems which is contrary to our study.16 Refractive error is a public health issue worldwide.17 Uncorrected refractive errors can adversely affect school performance.18 The most common ocular morbidity we noted in our study was refractive error . Its prevalence was 4.13%. This is similar to the prevalence reported by Ghulam and Ahla which is 3.9%.10The south East Asia estimated pool prevalence of all refractive errors is 16.9%.19 Of the 12.8 million children with uncorrected refractive errors worldwide, the highest prevalence is reported to be in developed areas of South-East Asia and China.20 The study by Sethi et al “Pattern of common eye diseases in children attending outpatient eye department Khyber Teaching Hospital” shows a higher than expected value of 12.8% of refractive errors21. Muhammad Zahid Latif found a prevalence of 24.4% of refractive errors in public high schools of Lahore.22 Our study shows that 96% children had no ocular morbidity. It is possible that some children with visual acuity of 6/6 and astigmatism may have been missed in the screening program. The second ocular morbidity was vernal catarrh. There were 27 cases (1.13%). This is acommon condition in our climate. The screening was done in January and February while vernal catarrah cases are more common in spring and summer season. A study from Jordan reported a prevalence of 1.76% of vernal catarrah.23 Sethi et al reported a higher prevalence of 35.6% which can be attributed to the study being conducted at the hospital with all patients presenting with disease.21 Baig et al noted it to be 19.2% in school children in Karachi.24 Allergic diseases are increasing globally and it is theorized to be due to climatic changes. Environmental degradation in urban cities in developing countries is especially responsible for the rise.25 It remains the most common ocular surface disorder in agriculture laborers and rural communities. Medical screening can drastically reduce permanent complications of blindness by early detection and treatment. We found that amblyopia was 0.38% and strabismus was 0.42%. Rajavi et al reported a prevalence of 2.3% of amblyopia in primary school children in Tehran.26 Trachoma is endemic in developing countries with poor sanitation. Our study revealed a prevalence of 0.33% which is quite low than a study by Khokhar who reported 1.91% of active cases of trachoma in children in Dera Ghazi Khan27. This may be due to different areas of study with low socio economic status. The effectiveness of our screening program was assessed by the true positive and false positive rates. The true positive rate was 91.22%. The false positive rate in our study was 8.7%. This is a measure of over-referrals or false diagnoses. A high false positive rate can increase the burden on the ophthalmology department and inadvertently increase cost and time which is contrary to the purpose of screening programs. This may also increase parents’ stress levels and decrease their trust in screening programs. The over-referrals may be due to teachers attempting to avoid missing any children who may require medical attention. The high true positive rate in our study indicates that teachers, medical students and ophthalmic technicians were of utmost importance in the accurate diagnosis of ocular morbidities. This can be further increased by improving the quality of training given to teachers and other volunteers.
Common eye problems are prevalent in primary school children irrespective of their socioeconomic status. Teachers, medical students and ophthalmic technicians when trained can be an asset in the screening of the eye problems.
1. Facial Synkinesis (Marin-Amat Syndrome)
A young boy com¬plained of involuntary clo¬sure of his right eye when he smiled. He suffered Bells palsy a year ago, with complete resolution. The ocular exam was otherwise normal, and his visual acuity was 20/20 in both eyes. Marin-Amat syndrome specifically refers to a rare form of facial synkinesis in which the orbicularis oculi muscle is activated with the voluntary movement of the lower facial muscles while smiling. It is thought to be caused by aberrant seventh nerve regener¬ation after trauma or as a result of Bells’ palsy. Botulinum toxin injections was planned for the future.
Sumana S. Kommana, MD, Upneet K. Bains, MD, Temple University Hospital, Philadelphia.