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International Ophthalmology (2005) 26:121125 DOI 10.

1007/s10792-005-4836-4

Springer 2007

Prevalence and causes of blindness and visual impairment among school children in south-western Nigeria
A. I. Ajaiyeoba1, M. A. Isawumi2, A. O. Adeoye2 & T. S. Oluleye1
1

Department of Ophthalmology, University College Hospital, Ibadan, Nigeria; 2Ophthalmology Unit, Surgery Department, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria

Received 21 September 2004; accepted 23 October 2005

Key words: blindness, causes, prevalence, treatable, visual impairment

Abstract The aim of the study was to assess the prevalence and identify the causes of blindness and visual impairment in school children of Ilesa-East Local Government Area of Osun State, Nigeria. A total of 1144 school children in primary and secondary schools were selected using a 2-stage random sampling method and examined to determine the prevalence and causes of blindness and visual impairment.A total of 17 (1.48%) children were blind or visually impaired. These comprised of 11 (0.96%) children who were visually impaired and 4 (0.3%) who were severely visually impaired. Only 2 (0.15%) school children were blind. The causes of visual impairment were refractive error 10 (0.87%) and immature cataract 1 (0.08%), causes of severe visual impairment included corneal opacities 2 (0.2%), amblyopia leading to squint 1 (0.08%) and 1 cataract 1 (0.08%). The causes of blindness in school children were corneal scars presumed to be due to vitamin A deciency 1 (0.08%) and keratoconus 1 (0.08%).Causes of blindness and visual impairment in children attending regular schools in Nigeria were treatable. Prevention, early recognition and prompt treatment of these diseases by regular screening of school children would denitely reduce unnecessary visual handicap in Nigerian school children so that they can attain their full potential in the course of their education. Also, information from this study is relevant for the purpose of planning eye care programmes for the prevention of blindness in Nigerian school children. This will go a long way in the prevention of unnecessary blindness and visual impairment in school children.

Introduction Vision is said to be impaired when the function of the visual pathway is altered. Visual acuity is used as the standard test for determining the level of blindness and visual impairment. According to the World Health Organization [1], visual acuity of more than 6/18 classied as normal vision, less than 6/18 but more than 6/60, as visual impairment, and less than 6/60 but more than 3/60 as severe visual impairment. Best corrected visual acuity in the better eye of less than 3/60 is dened [2] as blindness. The age group 519 years constitutes [3] about 37.78% of the total population of Nigeria. This age

group is very important since they form the growing population whose potentials dictate the countrys future economy. Disability Adjusted Life Years (DALY) has been described [1] as a measure of the time lived with a disability and the economic loss incurred during the years. DALY is very important in children considering the fact that the magnitude of economic loss is associated with it and is measured in dollars per blind year. While some causes of blindness in children like cataract are treatable, majority like trachoma and vitamin A deciency are largely preventable [4, 5]. The initial years of early development make the child particularly vulnerable to visual disorders, especially if the normal development of the eye

122 was aected by the occurrence of disease which has been documented by various authors [6, 7]. This may have a devastating impact on the childs psychological and physical development and his ability to learn. Children with poor vision may be considered by their teachers to be poor students and both teachers and parents may subsequently reduce their expectation on the childs performance. Newcomb and Marshall [8] observed that this impaired ability may also aect the childs behaviour. Information about the causes of blindness and visual impairment is scarce in this part of the country. This study was therefore designed to supply information about the causes of visual impairment in Ilesa-East Local Government Area of Osun state in Nigeria. This information will also be utilised to plan strategies to prevent unnecessary blindness and visual impairment in school children so that they can attain their full potential in life with corresponding economic benets to the country. Pre-survey activities Teachers were trained and tested by the authors to obtain demographic data and perform visual acuity testing on the school children. A 2-stage random sampling technique was used to select 1144 children from six primary and three secondary schools (selected using the Epi-table) in Ilesa-east local government area. The 1st stage sampling was done using the numbered list of schools obtained from the Local Inspector of Education (LIE) of the local government using the EPITABLE calculator. This led to the selection of six primary schools and three secondary schools. In the 2nd stage, the pupils and students to be examined were selected by random sampling using the class register. The numbers of each student in the class register were written on pieces of paper, rolled and put in a basket. The desired number for each class were then picked randomly until the desired number has been picked. Pilot study Materials and methods The study was a school-based eld survey to assess the prevalence and identify the causes of blindness and visual impairment among school children in Ilesa-east local government area, in south-western Nigeria. The survey was conducted during the months of February and April 2002. A 2-stage random sampling technique was used to select 1144 children from six primary and three secondary schools (selected using the Epi-table) in Ilesa-east local government area. A pilot study was carried out in a primary and secondary school not selected for the study after obtaining ethical approval from the Obafemi Awolowo Teaching Hospital Complex Ethical Approval Committee. The survey Every pupil or student selected at the 2nd stage random sampling was registered for the study. Their demographic data was obtained and recorded by the trained teachers. Information obtained included name, date of examination, name of school, age, sex, class and fathers occupation. Snellens literate and an Illiterate E chart placed at 6 m in a well-illuminated area were used with and without a pinhole as appropriate. The visual acuity was tested for all the children registered for the study by the trained teachers and ophthalmic nurses separately for each eye. Near vision was assessed in both eyes using the Sussex Vision Test Type. The visual acuities of 25% of visual acuity results were cross-checked by one of the authors (IMA). Any child who failed to read the 6/6 VA line had VA was also cross-checked who also examined all children with visual acuity of less than 6/18. Those children who improved with

Ethical approval Approval for conducting the study was obtained from the Ethical Committee of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. Informed consent Informed consent from the parents of school children was obtained with the assistance of school heads through their class teachers.

123 pinhole had refraction done by the optometrist at the base hospital. Those children who did not improve with pinhole were invited to the base hospital for more detailed assessment. The pupils of such students were dilated with mydriacyl for detailed slit-lamp examination and funduscopy. Ocular examination of all children was performed by one of the authors (IMA) using a pen torch and an ophthalmoscope. However, more detailed examinations and investigations were also conducted in some of these cases at the Eye clinic of the base hospital where necessary. The parents of children with blindness and visual impairment were invited for interview where necessary in order to accurately determine the aetiology. All data were entered into a predesigned data collection form that was used to obtain data. Data management Specially designed computer software EpiData 2.0 was used to enter data, carryout checks and rechecks to ensure validity. Data was analysed using computer software Epi Info version 6. Analysis included frequency distribution for the variables of interest and stratication by age groups, sex, schools and fathers occupation. p-Values for test of signicance were determined. cataract 1 (0.08%), causes of severe visual impairment included corneal opacities 2 (0.2%), amblyopia leading to squint 1 (0.08%) and 1 cataract 1 (0.08%). The causes of blindness in school children were corneal scars presumed to be due to vitamin A deciency 1 (0.08%) and keratoconus 1 (0.08%). Three children had corneal opacity giving a prevalence of (0.3%). There was one (0.1%) case each of anterior staphyloma and bilateral keratoconus complicated with corneal opacities. There were two (0.2%) children with cataract. One had bilateral immature cataract associated with visual impairment while the other had a unilateral mature cataract with blindness. Three children had squint (0.3%). Esotropia at 45 secondary to traumatic corneal opacity and two children with exotropias at 30 and 45 associated with refractive error. Overall, 11 children had visual impairment due to refractive error in 10 and cataract in 1. Four children had severe visual impairment due to corneal opacity (two), cataract (one) and squint (one). Two children were blind; one from bilateral corneal opacities and the other from bilateral keratoconus.

Discussion In this study, prevalence of 1.5% of blindness and visual impairment in children attending regular schools is very surprising. However, in the Jos Plateau [9] of Nigeria, prevalence of visual impairment alone of 4.1% was found among school children. In Ibadan, which is in the same geo-political zone with Ilesa where our study was conducted, other workers [10] found a prevalence of 7.4% among school children. Also in our study, the causes of visual impairment and blindness were refractive errors, corneal cataract. This is similar to the experience of other workers in Nigeria. The commonest causes in the Jos plateau [9] were refractive errors and corneal opacity, whereas in Kaduna other workers [11] found treatable causes such as conjunctivitis, refractive errors and muscle imbalance as the common causes in post-primary institutions. Refractive error There were many newly diagnosed refractive errors as was also the experience of some authors

Results A total of 1144 school children were examined. These comprised of 617 (54%) children in six primary schools and 527 (46%) in three secondary schools. Of these 504 (44.1%) of them were males while 640 (55%) were females. Their ages ranged between 4 and 24 years. The mean age was 11.89 years3.52 SD. The 1014 years and the 59 years age group were the largest groups of school children examined. A total of 17 (1.48%) children were blind or visually impaired. The ages of children with visual loss were on the average not dierent form the population of children without any visual loss, i.e. 11.5: 11.6 years These comprised of 11 (0.96%) children who were visually impaired and 4 (0.3%) who were severely visually impaired. Only 2 (0.15%) school children were blind. The causes of visual impairment were refractive error 10 (0.87%) and immature

124 [12]. However, from our study only two children previously diagnosed were wearing corrective glasses. Poor vision and inability to read clearly the materials written on the board can have a serious impact on the childs participation and learning in class. This can therefore adversely aect the childs education, occupation and socioeconomic status of life as observed by some authors [13]. Poor economic status of parents had been identied [14] as a main constraint and barrier preventing the children from wearing glasses. This therefore calls for a lot of eort and work to be done by professionals about public health education towards the use of spectacle correction among school children. Corneal diseases From our study, corneal diseases were the major cause of blindness and severe visual impairment. These were from keratoconus and bilateral corneal opacities that complicated vernal ulcers. Kaimpo and Kaimbo [15] suggested that heredity and environmental factors may contribute to the aetiology of keratoconus and corneal hydrops in Congolese children. In our study, it was however surprising that corneal opacity due to measles keratitis was not found. It could have however co-existed with some other type of infective keratitis, like bacterial. This only conrmed the impression of other workers [16, 17] that in developing countries corneal diseases are still the major cause of blindness, which is avoidable. However, a change in the trend is being noticed, especially in areas of higher environmental awareness, availability of ophthalmologist, eye hospital, and higher social standards. For example, a study [18] in a blind school in Lagos, showed that retinal dystrophy, followed by lens disorders constituted the major anatomical causes. Unilateral causes of blindness were due to corneal opacity following trauma and cataract. Comparatively, other workers [17] in a retrospective hospital-based study found trauma and measles to be the commonest causes of corneal disease resulting in childhood blindness. Trauma In our study, there was a case of unilateral blindness from post-traumatic corneal opacity. Comparatively, other workers [17] in a retrospective hospital-based study, found trauma and measles to be the commonest causes of corneal disease resulting in childhood blindness. Many authors [1921] showed that school children and students of post-primary institutions were particularly vulnerable to trauma especially while at play. Many authors [21 23] have also observed that visual outcome depends on the type and extent of injuries, time of presentation at the hospital for special treatment and sophistication of instrument available to treat the injury type. In Turkey, ocular trauma had been found [24] to be the leading cause of non-congenital unilateral blindness in children under 20, as more than (80%) resulted in perforating eye injury. Unfortunately since it is almost always uniocular, it is therefore not always featured in blindness prevalence data [1]. Ocular injuries continue to cause visual impairment and or blindness; therefore the need for adult supervision of children at play, and putting in place preventive or control measures has been emphasised by various authors [1921]. Ocular injuries continue to cause [5] visual impairment and or blindness, therefore the need for adult supervision of children at play, and putting in place and prevention or control measures, cannot be over emphasised. The global pattern [25] of eye injuries and their consequences emerging from several reviews undertaken for planning purposes in the prevention of blindness programme, indicate that approximately 1.6 million are blind from injuries and another 2.3 million with bilateral low vision. Further epidemiological studies are needed to permit more accurate planning of prevention and management measures. A standardised international template for reporting on eye injuries might be useful to this eect especially along the lines of reporting, occurring through the US Eye Injury Register. Squint Only one case of squint was found in our study, which was due to amblyopia from uncorrected refractive error. Comparatively a slightly lower gure was found in Enugu [7], while other workers [10, 12] recorded higher gures in Lagos and Ibadan. All these studies conrm a very low prevalence of squint in our environment as compared to studies done in developed countries, which usually have higher prevalence. In the

125 Belfast study [26], among British school children born either with very low birth weight or normal weight, the prevalence of squint was relatively higher. Conclusion and recommendation Ocular diseases leading to visual impairment and blindness are still rampant amongst school children in Nigeria. Since most of these diseases are largely preventable, avoidable or treatable early recognition and prompt treatment of these diseases by regular screening of school children would denitely reduce unnecessary visual impairment and blindness in children so that they can attain their full potential in the course of their education. Information from this study is relevant for the purpose of planning eye care programmes for the prevention of blindness in Nigerian school children. Information obtained from the study will assist government in planning and facilitating the incorporation of primary eye care into the existing primary health care structure of the state. Acknowledgements We are grateful to the Local Government Inspector of Education [L.I.E], principals, head-teachers, sta and school children of the schools involved in this study. We are also thankful to Mr Lasisi and Mr Ajala for their assistance during the examination.
7. Nkanga DG, Dolin P. School vision screening programme in Enugu, Nigeria: Assessment of referral criteria for refractive error. Nig J Ophthamol 1997; 5(1): 3440. 8. Newcomb RD Marshall EC. New York National Society for Prevention of Blindness. Vision problems in the U.S. 1990: 5370. 9. Onyekwe LO, Ajaiyeoba AI, Malu KN. Visual impairment among school children and adolescents on Jos Plateau Nigeria. Nig J Ophthamol 1998; 6(1): 15. 10. Yoloye MO. Patterns of visual defects and eye diseases among primary school children in Ibadan, Nigeria (dissertation) (National Postgraduate Medical College in Ophthalmology: Lagos, 1991). 11. Abiose A, Allanson DBO. Ocular health status of post primary school children in Kaduna, Nigeria. Report of a survey. J Paediatr Ophthamol Strab 1980; 17: 337340. 12. Balogun BG. Vision screening among primary school children in Mainland Local Govt. area of Lagos State (dissertation). Lagos. National Postgraduate Medical College in Ophthalmology, 1999. 13. Taylor HR. Refractive errors: magnitude of the need. J Com Eye Health 2000; 13(33): 12. 14. Faderin MA, Ajaiyeoba AI. Barriers to wearing glasses among primary school children in Lagos, Nigeria. Nig J Ophthamol 2001; 1(1): 1519. 15. Kaimpo WA, Kaimbo D. A case report of a 10-year-old with corneal hydrops associated with vernal conjunctivitis. Bull Soc Belge Ophthamol 2002; 283: 2933. 16. Rabiu MM, Kyari F. Vitamin A deciency in Nigeria. Nig J Med 2002; 11(1): 68. 17. Magulike NO, Ezepue UF. Corneal disease and childhood blindness: a retrospective hospital based study. Br J Ophthamol 2003; 2: 7579. 18. Akinsola FB, Ajaiyeoba AI. Causes of low vision and blindness in a blind school in Lagos, Nigeria. West Afr J Med 2002; 2(1): 6365. 19. Ajaiyeoba AI. Ocular injuries in Ibadan, Nigeria. N J Ophthalmol 1995; 2(3): 18. 20. Umeh RE, Umeh CO. Causes of visual outcome of childhood eye injuries. Eye 1997; 11: 489495. 21. Kyari F, Alhassan MB, Abiose A. Pattern and outcome of paediatric ocular trauma-A 3-year review at National Eye Centre, Kaduna. Nig J Ophthamol 2000; 8(1): 1116. 22. Akinsola FB. Eye injuries in children: guiness Eye Centre, Lagos University hospital experience. Nig J Surg 1996; 3(1): 1216. 23. Adeoye AO. Eye injuries in the young. N J Med 2002; 11(1): 69. 24. Arituk N. The evaluation of ocular trauma in children between ages 012 years. Turk J Paediatr 1999; 41(1): 4352. 25. Negrel AD, Thylefors B. Global impact of eye injuries. Ophthamol Epid 1998; 5(3): 143169. 26. McGinnity F, Bryars JH. Controlled study of ocular morbidity in school children born pre-term. Br J Ophthamol 1992; 76: 520524. Address for correspondence: Department of Ophthalmology, University College Hospital, Ibadan, Nigeria Phone: +234-2-2413922; Fax: +234-2-2411768; E-mail: ayotundeajaiyeoba@ yahoo.co.uk

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