Download EVALUATION PREVALENCE OF EYE DISEASES AMONG

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PREVALENCE OF EYE DISEASES AMONG SCHOOL CHILDREN IN A RURAL SOUTH EASTERN
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NIGERIAN COMMUNITY. (Original Research)
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Dr Obiekwe Okoye*, FMCOph
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University of Nigeria Teaching Hospital, Enugu, Nigeria
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Mobile phone +2348037007163
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E- mail: [email protected]
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Professor (Mrs) Rich Umeh, FMCOph
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University of Nigeria Teaching Hospital, Enugu, Nigeria
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Mobile phone +2348033324691
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E- mail: [email protected]
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Professor Felix Ezepue, FMCOph
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University of Nigeria Teaching Hospital, Enugu, Nigeria
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Mobile phone +2348036766673
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E- mail: [email protected]
Contribution to manuscript: concept, data collection, data analysis, literature search, writing of
manuscript.
A registered member of Rural and Remote Health Journal
Contribution to manuscript: literature search, data analysis, writing of manuscript, review of
manuscript
Not registered with Rural Remote Health Journal
Contribution to manuscript: literature search, data analysis, writing of manuscript, review of
manuscript
Not registered with Rural Remote Health Journal
* Corresponding
Author
This research was funded by the Federal Ministry of Health Of Nigeria.
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ABSTRACT
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Introduction
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Vision plays an essential role in development and visual deficit constitutes a risk factor not only
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for visio-sensory development, but also for overall socio-economic enhancement. Timely
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screening for the early detection of eye and vision problems in children is vital to avoid lifelong
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visual impairment. Early detection provides the best opportunity for effective treatment. There
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is paucity of data regarding causes of eye diseases among rural children in Nigeria. The aim of
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this study is to determine the prevalence and causes of eye diseases among children residing in
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rural communities in Nigeria.
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Methods
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A cross sectional survey to determine the prevalence and common causes of ocular morbidities
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in primary school children in Abagana - a rural community in Njikoka Local Government Area of
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Anambra State South East of Nigeria. The available children in all the 8 existing primary schools
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in the community who are aged between 6 and 16 years were registered, interviewed and their
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eyes examined. Data were analyzed for age, sex, types of ocular disorders and causes of visual
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impairment. Frequency and
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parametric method.
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Results
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The
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females, a male female ratio of 1.07/1 .Ocular disorders were found in 127(6.1%) of the
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population. The most common ocular disorder in this community were vernal conjunctivitis
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61(2.9%) followed by refractive error 14(0.7%)(.
percentages
were calculated with univariate analysis and
census population consisted of 2092 children, 1081(51.7%) males and 1011(48.3%)
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Conclusion
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The commonest cause of eye disease among rural children surveyed is vernal conjunctivitis
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followed by refractive error. Findings in this study indicate that most of the causes of visual
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impairment were due to amblyiopia which is avoidable. Early detection through early eye
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screening, health education and provision of access to adequate eye care facility will reduce the
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burden of eye disease and blindness among rural Nigerian children.
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Key Words; Children, Eye disease, Nigeria, Rural, school.
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Introduction
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The prevalence of blindness in children varies from approximately 0.3/1,000 children in
wealthy regions of the world, to 1.2/1,000 in the poorer countries/regions[1].
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Blindness among children is more common in the poor region of the world for three
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main reasons[2]: First, there are diseases which can lead to blindness from causes which are no
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longer prevalent in industrialized countries but are still prevalent in poor regions of the world,
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such as measles, vitamin A deficiency, and ophthalmia neonatorum. Second, there are fewer
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well equipped facilities and personnel trained in managing treatable causes of blindness in the
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poorer countries. Third, is the contribution of ignorance, poverty and superstition to the
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disease causation, propagation, treatment and prevention in the rural areas. These factors
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collectively impact negatively on perception of eye diseases and encourages use of harmful
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traditional eye medications which in turn can result to avoidable blindness.
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Incidence data are very difficult to obtain, but it has been estimated that there are 8 new
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blind children for every 100,000 children each year in industrialized countries[2].In the
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developing countries, approximately 500,000 children become blind every year – one every
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minute and about half of them die within one or two years of becoming blind[3]. Available data
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indicate that the prevalence of childhood blindness varies from 1.2/1000 children in very low
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income region of the world to 0.3/1000 children in high income region[4].
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The high number of blind years resulting from blindness during childhood is one of the
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reasons why the control of childhood blindness is a priority of the World Health
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Organization/International Agency for Prevention of Blindness (WHO/IAPB) Vision 2020: The
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Right to Sight Programme[5].
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Children who are blind have to overcome a lifetime of emotional, social and economic
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difficulties, which affect the child, the family and the society[6]. Loss of vision in children
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influences their education, employment and social life[6]. Childhood blindness is second only to
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adult cataract as a cause of blind-person years. Approximately 70 million blind-person years
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are caused by childhood blindness worldwide[7].
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Vision plays an essential role in development and visual deficit constitutes a risk factor
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not only for visio-sensory development, but also for overall development[8]. Timely screening
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for the early detection of eye and vision problems in children is vital to avoid lifelong visual
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impairment. Early detection provides the best opportunity for effective treatment[9].
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It has been recognized world wide even in developed economies that there is great vision
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benefit from regular eye screening of children. This should include a comprehensive eye
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examination. Depending on the findings, early institution of corrective measures will go a long
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way in reducing the current magnitude of childhood blindness and morbidity. In a study among
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school children in Oman[10], 28,765 (6.9%) of the 416,157 children examined were found to
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have defective vision. Abdul Rasheed Qamar advocated for a regular eye screening of
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children[11]. Out of total of 38575 schoolchildren examined 2065 (5.3%) were found to have
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refractive errors. Early treatment will reduce the incidence of avoidable childhood visual
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impairment and blindness.
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School-age children (6 –15 years) represent 20 – 30% of the total population of most
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third world countries[12]. For Nigeria this translates to an estimated 20 – 30 million children.
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In some states in southern Nigeria, 80% of the children are in school and can best be reached
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there for any health care program[13].
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target group, which could be screened adequately for early detection of eye diseases and
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prevention of blindness[14].
Therefore, school children form an important large
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Not all ocular conditions result in visual impairment. In Pakistan, the prevalence of non-
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vision-impairing conditions (NVIC) is 14.6%[15]. Although NVIC are non-vision impairing,
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affected individuals may have need for frequent clinic visit with the attendant impact on their
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academic performance. Sufferers of allergic conjunctivitis tend to experience quality of life
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reduction in general health[16]. More worrisome in the rural setting is the potential use of
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harmful traditional eye medication and improper use of proprietary medications such as
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steroids for vernal keratoconjuctivitis and the like, which may result in vision impairing
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complications.
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There is paucity of data regarding causes of ocular morbidity in children residing in rural
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communities in Nigeria. This study targets primary school children in a rural community of
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Anambra state of Nigeria. The aim is to determine the prevalence of ocular disorders and their
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common causes in order to propose a modality for applying the findings in the prevention of
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blindness programmes.
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Abagana is one of the rural communities of Anambra state of Nigeria. It has 8 primary schools
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with 2,336 pupils and 128 teaching staff.
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There is one community health center and a comprehensive health center of the University of
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Nigeria Teaching Hospital with only a nurse with ophthalmic training. There is no
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ophthalmologist or optometrist in the entire community. However, there are 25 consultant
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ophthalmologists and 10 optometrists practicing at both private and public hospital in the
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urban city of Enugu about 100 kilometers from rural Abagana. Jones et al[17] observed that
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following work force and work load issues, financial factors emerge as the biggest threat to
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rural practice viability. This is same in Nigeria as no financial incentives are currently offered to
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healthcare personnel working in rural areas. While there is currently no policy in place in
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Nigeria, several studies[11,18] effectively utilized the teachers for purpose of initial eye
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screening of school children as a way of solving the personnel shortage challenges. In a study in
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Tanzania[18], simple screening by teachers correctly identified 80% of the pupils who were
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found to have bilateral poor eyesight by the eye team, with 91% specificity. Currently in Nigeria
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school health services provide immunization services through the National immunization
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scheme, general health education and minimal routine eye screening programme.
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Methods
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This was a cross sectional study. After obtaining verbal informed consent from parents and
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school heads all the available and eligible children in the 8 primary schools in Abagana, aged 6
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years but below 16 years totaling 2092 were interviewed and examined.
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The visual acuity was measured outdoors for each child by an ophthalmic assistant using
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the standard Snellens’ chart placed at 6 meters. When visual acuity was less than 6/9, a pinhole
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was used to test again. Recorded visual acuities were further crosschecked by the author to
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ensure validity of findings.
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Using the Modified WHO/PBL eye examination record, a trained assistant collected the
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required information on personal data and ophthalmic history. The section on visual
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assessment and ocular examination were completed by the author.
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The external eye examination was done with the aid of a pen torch and a simple
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magnifying head loupe. A direct ophthalmoscope was used to examine the posterior segment
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and where necessary for example if the visual acuity was less than 6/18 and did not improve
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with pin hole, with no obvious identifiable causative factor, dilated fundoscopy was done using
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short acting dilating eye drops (0.5% Tropicamide). Ocular alignment was evaluated with
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corneal reflex text and cover-uncover tests.
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Refractive error was considered when subnormal visual acuity improved with a pin hole test.
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Amblyopia was also considered in a child with subnormal visual acuity in the absence of
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external eye, anterior and posterior segment pathology.
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Children with minor eye problems were treated while those with major eye conditions were
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referred to the University of Nigeria Teaching Hospital for further evaluation and management.
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The data were analyzed using the statistical package for social sciences (SPSS-11 IBM, Armonk,
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New York, USA). Univariate analysis and the parametric method were used to calculate
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frequency, percentage, and 95% confidence intervals (CI). Comparison of percentages was done
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using Chi- square test.
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Ethics approval
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Ethical clearance for the study was obtained from the Health Research Ethics committee
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(HREC) of the University of Nigeria Teaching Hospital, Enugu. Study was adequately explained
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and refusal of participation by the parents, teachers and the children were allowed.
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Results
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Out of 2336 primary school pupils, 2092 aged 6 - 16 years were examined. Out of the
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244 not examined 62 though eligible were absent from school on the day of visit, while 182
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were excluded because of ineligibility due to age. More males 1081(51.7%) than females
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1011(48.3%) constituted the census population giving a male/female ratio of 1.07 to 1.
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In table 1 the 6 - 10 years age group constitutes 52.7% of the subject population
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Refractive error and corneal scar were the main causes of subnormal vision (Table 2). Bilateral
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low vision was seen in 6/2092 (0.3%) caused mainly by amblyopia which was diagnosed in 3 out
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of the 6 children who have low vision. No child was found to be blind according to WHO
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classification. However, monocular blindness was found in 4/2092 (0.2%) of children. These
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were due to chorioretinal scars, congenital glaucoma, traumatic cataract and traumatic optic
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neuropathy respectively and hence contribute 25% each of causes of monocular blindness.
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Of the 2092 school children seen a total of 6.1 %(CI 0.03-0.13) had ocular disorders of various
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types (Table3) some occurring bilaterally. Vernal conjunctivitis was the commonest disorder
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making up 48.0% of all ocular disorders followed by refractive error 11.01% and subconjuctival
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haemorhage, 7.1%.
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Discussion
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Most of the children were found to have normal vision in this study. This may be
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attributed to the absence of environmental factors known to cause blindness in children for
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example vitamin A deficiency and the positive impact of the sustained rural immunization
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program against measles by the federal ministry of health.
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The age group with the lowest number of school children was 14 to 16 years comprising
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3.7% of the population studied. In a similar study by Oragwu[19], this age group constituted the
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lowest number of the children studied making up 5.2% of the census population studied.
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However these numbers are high because this age group ought to be in the secondary school.
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This could be as a result of the fact that both studies were carried out in rural setting where
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poverty, ignorance and altered priorities may result in late entry of the children into formal
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schools. There is slight male preponderance of the total number of children studied. Though
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there are more females than males at the entry age group level of 6-9 years, more males tends
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to dominate as age group increased with academic class level. This a reflection of the socio-
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cultural gender bias of the Igbo tribe that make up the south eastern Nigeria where this study
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was done[20]. The male gender is preferred and most parents prefer to give education to the
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male child in the face of limited financial resources. The result is gender inequality of access to
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formal education and consequent socio-economic limitation of the girl child. Massive education
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aimed at encouraging the education of the girl child and provision of free education especially
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in rural areas is highly indicated.
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The 0.5% prevalence of visual impairment found in this study is lower than findings in
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other studies by Nkanga[21] (0.72%), Yoloye[22] (7.4%), Onyekwe[23] (4.1%), Mohammed
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(18%)[24]. The different results from the various studies mentioned may be due to the different
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study areas, different age groups and the definition of visual impairment in each study.
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Onyekwe combined both primary and secondary school subjects in their study while Yoloye’s
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definition of visual impairment as visual acuity of 6/9 to 3/60 will tend to produce a higher
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prevalence of visual impairment when compared with this study.
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By World Health Organization definition, no case of blindness was found in this study as
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in a similar study in Ethiopia[24]. In Nkanga”s[12] study, the prevalence of blindness was
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0.05%. This low prevalence is in keeping with the global low prevalence of blindness in
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children[25]. Other possible reason for the absence of blind children in this study is the fact that
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most blind children will be in schools for the blind. Also some of the blind children may be
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hidden at home as a result of stigma and ignorance of the fact that the child can be helped.
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However, in this study 4(0.2%) out of the 2092 children examined had visual acuity of
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<3/60 in one eye, which corresponds to monocular blindness. These were caused by congenital
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glaucoma, traumatic cataract, optic neuropathy resulting from blunt trauma to the brow, and
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macular chorioretinal scar, each contributing a case. In Oragwu’s[19] study, 3(0.18%) cases of
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monocular blindness were due to traumatic cataract, phthisis bulbi and squint. Trauma was
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responsible for 50% of the cases in this study and 100% of the cases in Oragwu’s[19] study. This
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suggests that simple preventive measures that reduce the occurrence of ocular injuries may
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significantly reduce the prevalence of monocular blindness in childhood in the area studied.
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This study found ocular disorders to have a prevalence of 6.1%. The prevalence of ocular
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disorders found in this study is lower than that obtained in the previous studies by Nkanga[12],
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Yoloye[22], Bhar and Abiose[26]. This may be due to the difference in study areas and the
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period of study as some ocular disorders have seasonal variability. It may also be a reflection of
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improved health care delivery over time.
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The commonest ocular disorders identified were vernal conjunctivitis, followed by
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refractive error. Refractive error was the commonest in a similar study[12] in Enugu Nigeria,
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while trachoma ranked the highest in similar studies in Ethiopia[24], and India[27]. This
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variation may be attributed to the difference in study areas and study population. The
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Ethiopian and Indian studies were done in trachoma endemic communities. Though vernal
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conjunctivitis is the major cause of morbidity in this study, it rarely causes visual impairment
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except in cases of use of harmful traditional eye medication as may be seen in a rural setting in
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Nigeria. However, in this study refractive was the cause of subnormal vision in 70% of the
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children presenting with reduced visual acuity. This is slightly higher than that found in a study
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by Naidoo et al[28] where refractive error accounted for 63.4% of causes of reduced vision in
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191 eyes. While this study was school based involving 2092 children, the study by Naidoo et al
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was community based involving a total of 5,599 children. In addition in this study subnormal
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vision was defined as visual acuity less than 6/9 while Naidoo et al used a visual acuity of less
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than 6/12 as subnormal vision. This will tend to result in higher number of children with
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subnormal vision in this study. Overall, this underscores the importance of regular eye
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screening of children as early vision correction is necessary to prevent amblyopia.
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Most of the curable and preventable ocular disorders were due to factors for which
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interventional programmes could be applied. For instance the monocular blindness from
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traumatic cataract, is curable surgically (if the lens is the only structure affected) while
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amblyopia could be prevented by early detection and treatment. This could be made possible
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by regular vision screening of children, intensive eye health education of children, parents and
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teachers, and provision of human and infrastructural resources to cater for eye health
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especially in rural areas.
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A major limitation of this study is its being a school-based study which may not totally reflect
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the real clinical condition in the community as a significant number of children in the
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community may not be in school due to poverty.
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Conclusion
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This study found a prevalence of 6.1% of ocular disorders amongst the primary school
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children in Abagana and also showed that most cases of visual impairment are avoidable being
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either curable or preventable. The commonest cause of visual impairment was amblyopia,
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which is preventable. Vernal conjuctivities was the commonest ocular disorder found followed
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by refractive error. None of these contributed to visual impairment.
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Infective disorders did not feature as important causes of ocular morbidity in this area.
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Since most of the disorders could be attributable to preventable and curable causes, effective
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preventable measures put in place as well as prompt and appropriate attention to curable
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causes will drastically reduce ocular morbidity and blindness in children in rural Nigeria. There
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should be in place a system that encourages eye care workers to work in rural areas with
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provision of modern facilities to guarantee the viability of rural practice. This will ensure
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equitable access to quality eye care services which in turn will significantly reduce the burden of
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eye diseases and blindness among the rural Nigerian children.
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Acknowledgement:
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The education secretary of Njikoka local government area and the school heads of the 8
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primary schools in Abagana are hereby thanked for their cooperation and permission to
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undertake this study. Many thanks to the Federal Ministry of Health Nigeria which funded this
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research through the management of University of Nigeria Teaching Hospital, Enugu.
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Table 1. Age and Sex Distribution of the study subject (n=2092)
Age group(years)
Sex
Male
500
533
48
1081
6-9
10-13
14-16
Total
Total
Female
600
382
29
1011
1100
915
77
2092
407
408
409
410
411
412
413
414
(n = 2092)
700
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
Number of pupils
600
Male
500
Female
400
300
200
100
0
6 to 9
10 to 13
14 to 16
22
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
Table 2 Causes of bilateral subnormal, low vision and unilateral blindness among school children aged 6-16
years old.
Causes
Subnormal vision
Visual
Unilateral
% Total cases
(%) (VA <6/9-6/18)
impairment(VA
blindness(VA<3/60)
(n=2092)
<6/18->3/60)
Refractive error
14(70%)
14 (0.7%)
Corneal scar
3(15%)
3 (0.1%)
Amblyopia
3(15%)
3 (50%)
6 (0.3%)
Macular scar
1 (16.7%)
1 (25%)
2 (0.1%)
Albinism
1 (16.7%)
1 (0.05%)
Congenital glaucoma 1 (16.7%)
1 (25%)
2 (0.1%)
Traumatic cataract
1 (25%)
1 (0.05%)
Traumatic Optic
1 (25%)
1 (0.05%)
neuropathy
Total
20 (100%)
6 (100%)
4 (100%)
27 (1.5%)
23
467
Table 3 Distribution of ocular disorders (n = 127)
Age
Total (%)
6 – 9(%)
10 –13(%)
27 (21.3)
31 (24.4)
3 (2.4)
61(48.1)
Refractive error
6(4.7)
6(4.7)
2(1.5)
14(11.0)
Subconjunctival haemorrhage
7(5.6)
2(1.5)
-
9(7.1)
Amblyopia
5(3.9)
1(0.8)
2(1.5)
8(6.2)
Hordeolum externa
1(0.8)
5(3.9)
-
6(4.7)
Miscellaneous
4(3.1)
1(0.8)
-
5(3.9)
8(6.2)
15(11.8)
1(0.8)
24(18.9)
58(45.8)
61(48)
8(6.2)
127(100)
Ocular disorders
Vernal conjunctivitis
14 -16(%
Ptosis
Total
468
469
470