Graefes Arch Clin Exp Ophthalmol (2015) 253:655661
DOI 10.1007/s00417-015-2943-0
PEDIATRICS
Refractive errors, visual impairment, and the use of low-vision
devices in albinism in Malawi
M. Schulze Schwering & N. Kumar & D. Bohrmann &
G. Msukwa & K. Kalua & P. Kayange & M. S. Spitzer
Received: 23 October 2014 / Revised: 13 January 2015 / Accepted: 14 January 2015 / Published online: 12 February 2015
# Springer-Verlag Berlin Heidelberg 2015
Abstract
Background This study focuses on the refractive implications
of albinism in Malawi, which is mostly associated with the
burden of visual impairment. The main goal was to describe
the refractive errors and to analyze whether patients with al-
binism in Malawi, Sub-Saharan Africa, benefit from
refraction.
Methods Age, sex, refractive data, uncorrected and best-
corrected visual acuity (UCVA, BCVA), colour vision, con-
trast sensitivity, and the prescription of sunglasses and low
vision devices were collected for a group of 120 albino indi-
viduals with oculocutaneous albinism (OCA). Refractive er-
rors were evaluated objectively and subjectively by retinosco-
py, and followed by cycloplegic refraction to reconfirm the
results. Best-corrected visual acuity (BCVA) was also
assessed binocularly.
Results One hundred and twenty albino subjects were exam-
ined, ranging in age from 4 to 25 years (median 12 years), 71
(59 %) boys and 49 (41 %) girls. All exhibited horizontal
pendular nystagmus. Mean visual acuity improved from
M. Schulze Schwering (*) : K. Kalua : P. Kayange : M. S. Spitzer
c/o College of Medicine, University of Malawi, P Bag 360, Blantyre
3, Blantyre, Malawi
e-mail: mssoculus@web.de
M. Schulze Schwering : M. S. Spitzer
University Eye Hospital Tbingen, Schleichstr. 1216,
72076 Tbingen, Germany
N. Kumar : G. Msukwa : K. Kalua
Lions Sight First Eye Hospital, Post dot net, Blantyre 3, PO Box E
180, Blantyre, Malawi
D. Bohrmann
Mechanical and Automotive Engineering, Trier University of
Applied Sciences, Trier, Germany
0.98 (0.33) logMAR to 0.77 (0.15) logMAR after refraction
(p<0.001). The best improvement of VA was achieved in pa-
tients with mild to moderate myopia. Patients with albinism
who were hyperopic more than +1.5 D hardly improved from
refraction. With the rule (WTR) astigmatism was more present
(37.5 %) than against the rule (ATR) astigmatism (3.8 %).
Patients with astigmatism less than 1.5 D improved in 15/32
of cases (47 %) by 2 lines or more. Patients with astigmatism
equal to or more than 1.5 D in any axis improved in 26/54 of
cases (48 %) by 2 lines or more.
Conclusions Refraction improves visual acuity of children
with oculocutaneous albinism in a Sub-Saharan African pop-
ulation in Malawi. The mean improvement was 2 logMAR
units.
Keywords Albinism . Refractive error . Visual acuity .
Low vision . Sub-Saharan Africa
Introduction
Albinism refers to a heterogenous group of hypopigmentation
disorders; more than 100 genes influence the pigmentation of
hair, skin, and eyes of mice, and it is at least as likely that as
many genes are involved in humans [1]. The
hypopigmentation disorder is only classified as albinism in
humans if there is reduced vision, nystagmus, iris translucen-
cy, macular hypoplasia, and anomalous optic chiasm. The
albino retina has less cone axons in the central retina than that
in normal pigmented individuals [24]. In Sub-Saharan Africa
(SSA), the most common form of albinism is the tyrosinase-
positive form, oculocutaneous albinism type II (OCA 2) (12).
Especially in SSA, the hypopigmentary phenotype distin-
guishes the affected individuals as different in a black
656
population, sometimes resulting in problems of acceptance
and integration as reported from various African countries
[57]. Another distinguishing feature has recently been de-
scribed by Kiprono and colleagues in northern Tanzania: in-
dividuals affected by albinism have a higher number of
colony-forming units, which is associated with sun-damaged
skin [8].
Numerous previous studies showed a wide range of refrac-
tive errors in patients with albinism [912]. The goal of our
study was to describe the refractive errors and the benefit of
refraction for Sub-Saharan patients in Malawi, and to compare
our results with previous international data. It adds to the
scientific knowledge in the field of ophthalmology by study-
ing refractive errors in the largest sample of SSA albino pa-
tients so far. Moreover, it should be clarified whether refrac-
tion and the prescription of glasses improves visual acuity
(VA) in this underserved patient population.
Material and methods
The project was funded by the Malawian Ministry of Educa-
tion under the MIEP (Ministry of Education Programme) pro-
gramme. The target group was government primary school
children. The programme was initiated by choosing itinerary
teachers. These are teachers trained at Montfort University,
Malawi on special needs from the southern & central region
of Malawi. They are trained on measuring visual acuity,
briefed on ocular diseases leading to low vision, and trained
on different types of low vision devices (LVDs) and usage.
Ethical approval was obtained from the College of Medi-
cine Research Committee (COMREC). The study adhered to
the tenets of the Declaration of Helsinki. All the albino chil-
dren were informed about the program well in advance at their
respective schools, with the consent of parents and the respec-
tive head teachers specifically for the project, and were given
an appointment for the examination of their eyes. Some par-
ents accompanied their children for the examination of their
eyes to the respective schools on the appointment day. The
majority of the children were being examined for the first
time; some had been examined a few years before and given
corrective spectacles, but the children were not using them
because they were damaged or were broken.
All identified children during the period 2010 to 2012 with
visual defects at each school were given an appointment with
our team for assessment. The team was allowed to assess a
maximum of only ten children per day for quality assessment.
A well-ventilated room with curtains for altering the room
lighting conditions was identified in all the respective schools
for assessment and the team used Bailey Lovie flip charts
consisting of E, numeric, and alphabetic and picture types
at 4 m distance for distance visual acuity assessment under
Graefes Arch Clin Exp Ophthalmol (2015) 253:655661
normal room lighting conditions. Distance visual acuity was
measured and recorded first binocularly then uniocularly.
Unaided visual acuity was followed by objective examina-
tion of the refractive conditions by dry (undilated) retinoscopy
performed under diminished room lighting conditions by clos-
ing the window curtains. Results of retinoscopy were refined
by subjective correction, and the VA in each eye was mea-
sured with best correction possible.
Dry retinoscopy was followed by measuring and prescrib-
ing of telescopes over best correction of refractive error for the
best eye; the target vision for prescribing telescopes for the
best eye was set as 6/12 Snellens notation or 0.3 LogMAR.
Vision less than 6/18 (<0.5 logMAR) with best correction in
the best eye was graded as a low-vision child (low vision).
In order to standardize data on the causes of blindness in
children, we used a classification system with standard defi-
nitions and methodology developed by the International Cen-
tre for Eye Health (ICEH) in collaboration with WHO [13].
This was followed by a near-vision function test (unaided;
first uniocularly and then binocularly), and the readings were
recorded using the Bailey Lovie near-vision charts (E, num-
ber, and alphabetic and picture types); the distance between
the patients eye and the reading chart was measured using a
simple ruler, and the readings were recorded. This was follow-
ed by measuring the uniocular and binocular near vision with
best correction, and readings were recorded. For near-vision
anomalies, an appropriate optical device (magnifiers etc.) and
nonoptical devices (large print, felt-tip pen etc.) were
prescribed.
A simple colour vision test was performed under normal
room lighting conditions by using a set of four primary colour
pencils consisting of red, green, yellow, and blue colours, two
of them each, and one colour pencil out of eight was given to
the child to match the same colour out of the remaining seven
pencils, and repeated with each colour to identify the matching
colour. This test was aimed to rule out the basic colour vision
functionality of albino children.
The colour vision test followed by contrast sensitivity as-
sessment witha Lea picture chart at 1.6 m distance holding the
chart vertically under normal room lighting conditions, and
the readings were recorded.
Contrast sensitivity was followed by recording the inter-
pupillary distance for each child. This was followed by dilat-
ing the childs eyes using cyclopentolate eye drops for
cycloplegic refraction. Finally, cycloplegic refraction was per-
formed to compare the dry retinoscopy and subjective
correcting results, and the final spectacle prescription was
given.
The screening ended with training the child on spectacle
and LVD usage. All identified children were given a free pair
of LVDs and spectacles. A file containing recommendations
for parents and teachers of each child with low vision was
handed over to the respective school head teacher for safe-
Graefes Arch Clin Exp Ophthalmol (2015) 253:655661 657

Table 1 Age, sex, pupillary distance (PD) with standard deviation, SD Table 3 Influence of refraction correlated to the age of the children

Male: n (%) Female: n (%) Total: n (%) Subjects (n in group) Age (years) Difference uncorrected/corrected
VA log MAR (average, BE)
Sex 71 (59 %) 49 (41 %) 120 (100 %)
Mean age (years) 12.7 (4.0) 12.2 (3.2) _ 4 6 0.15
PD (SD) 60.1 (4.4) 60.1 (4.3) _ 3 7 0.20
10 8 0.27
SD standard deviation 6 9 0.12
12 10 0.23
keeping. These children are being followed up every year on 15 11 0.18
the usage and condition of the LVDs. In addition, their perfor- 11 12 0.24
mance at school is followed up by the head teacher producing 11 13 0.09
each childs file that was given for safekeeping, and the team 9 14 0.11
recording the follow-up measurements in the same file. 8 15 0.33
Regression analysis was performed for the correlation of 10 16 0.33
right and left eyes, visual acuity, and refractive error. The 6 17 0.38
relative difference between the VA before and after was
6 18 0.08
analysed with ANOVA using JMP statistical software (version
3 19 0.15
10.0, SAS Institute Inc, Cary, NC, USA). A p<0.05 was con-
1 22 0.30
sidered to indicate a statistically significant difference.
One hundred and twenty albino subjects were examined, Average improvement ranged from 0.11 to 0.38 logMAR units (age 6 to
ranging in age from 4 to 25 years (median 12 years). All 22 years). There was no clear age-dependency of refraction-associated
exhibited horizontal pendular nystagmus. They were attend- VA improvement
ing schools covering a wide range of communities in southern
and central Malawi including Blantyre urban, Blantyre rural, Results
Zomba, Machinga, Balaka, Salima, Lilongwe urban and Li-
longwe rural. Results are shown in Tables 1, 2, 3, 4, and 5, and Figs. 1, 2, 3,
Refractive errors and visual acuity data were collected for 4, 5, and 6.
both eyes of most subjects, although nystagmus and/or age One hundred and twenty albino subjects were examined,
limitations precluded complete sets of data being obtained ranging in age from 4 to 25 years (median 12 years), 71 boys
for five subjects. (59 %) and 49 girls (41 %). All exhibited horizontal pendular
Visual acuity was measured using a black-on-white Bailey nystagmus. Mean pupillary distance was 60.1 mm in boys and
Lovie chart following standard procedure and recorded in girls. Colour vision was tested in 98 children, of whom none
logMAR format. Uncorrected visual acuity (UCVA) was tak- had deficiencies. Contrast sensitivity of 1.25 at 50 cm was
en in both eyes and in each eye as well as binocular BCVA. present in 98 children. Tinted glasses were prescribed for
106 of 120 children (88.3 %). The children of whom neither
colour vision, nor contrast sensitivity tests was taken were
either not cooperative taking it or were too young to under-
Table 2 Visual acuity data and refractive error with standard deviation, stand the test. Low-vision devices were prescribed for 114
SD

Eyes N logMAR (SD)

Table 4 Astigmatism (104/120): with the rule (WTR), against the rule
VA BE uncorrected 94/120 (78 %) 0.98 (0.33) (ATR)
BE corrected 94/120 (78 %) 0.77 (0.15)
N Percentage
Eyes N D (SD)
Refractive error, R 120 4.54 (5.77) WTR 39 37.5
best sphere ATR 4 3.8
L 120 4.37 (5.47) No astigmatism 61 58.7
Refractive R 120 1.09 (1.43) Total 104 100
astigmatism
L 120 1.23 (1.40) With the rule (WTR) astigmatism was more present (37.5 %) than against
Refractive error, R 120 4.09 (5.72) the rule (ATR) astigmatism (3.8 %). We considered each patient astigmatic
Equivalent sphere only if he had simple myopic or hyperopic astigmatism. All the com-
L 120 3.87 (5.36) pound myopic and hyperopic astigmatism we have taken as spherical
equivalent and assumed as spherical correction
658
Table 5 Prescription of
LVDs in Malawian Magnification Prescriptions (n=115)
patients with albinism
2 11
3 45
4 55
115/120 albino patients 5 4
received telescopes
children: 11 with twofold magnification, 45 with threefold, 55
with fourfold and three with fivefold.
Refraction
Of 120 patients (n=240 eyes) with albinism, 71 were male and
49 female. The mean average sphere was 3.26 D, median
1.5 D, with a range from 30.00 D to + 16 D. The mean
average cylinder was 0.99, median 1.0 D, with a range from
6 D to + 3.5 D. The pupillary distance (n=120) ranged from
52 to 70 mm (median 60 mm). The uncorrected visual acuity
(UCVA) of both eyes (n=120) ranged from 0.2 to 2.0 (median
0.9 0.3). The best-corrected visual acuity (BCVA) of both
eyes (n=120) ranged from 0.1 to 1.2 (median 0.8 0.16).
VA improvement after correcting for refractive errors was
as follows: 23/94 (24 %) showed no benefit from refraction;
30/94 (32 %) improved by 1 line (VA measured in logMAR
units), 18/94 (20 %) by 2 lines, and 23/94 (24 %) patients
improved by 3 lines or more. Significant improvement was
achieved in some patients with myopia and astigmatism
higher than 1.5 D in any axis. Patients with high to mild
myopia (range 19.5 to 1.0 D) improved by 2 lines or more,
patients with astigmatism less than 1.5 D improved in 15/32 of
cases (47 %) by 2 lines or more. Patients with astigmatism
equal to or more than 1.5 D in any axis improved in 26/54 of
cases (48 %) by 2 lines or more. Most mild hyperopic patients
did not improve, or only up to 1 line.
LVDs were given with the target vision of 6/12 with tele-
scopes. E.g. if a patient improved to 6/36 with best spectacle
correction in the best eye, as our target vision for the child was
Fig. 1 Refractive error relationship between right and left eye.
Refractive errors of the right and the left eye of the same patient
correlated highly with each other (correlation coefficient of 0.90)
Graefes Arch Clin Exp Ophthalmol (2015) 253:655661
Fig. 2 Correlation of visual acuity (logMAR) and spherical equivalent of
the right eye (RE). Spherical equivalent and uncorrected visual acuity do
not correlate with each other (correlation coefficient of 0.4)
6/12 with LVDs we divided the best-corrected vision by target
vision to get the desired telescope magnification, 36/12 = 3x
telescope (36 derives from 6/36 best corrected vision and 12
from the target vision with LVDs). Likewise with 6/60: then
the target telescope power was 60/12=5x tele.
Discussion
In our study of a Sub-Saharan African (SSA) albino popula-
tion in Malawi, we retrospectively analysed the refractive er-
rors of 120 patients with the inherited form of oculocutaneous
albinism (OCA). To our knowledge, this is the first study ever
in this region on refractive errors in children with albinism.
We examined 120 patients, which means that this is one of the
largest groups of albinos worldwide ever examined for refrac-
tive errors. The main outcome is that that refraction is improv-
ing visual acuity of children with oculocutaneous albinism in
Malawi. The biggest improvement was achieved in patients
whowere myopic between 1 and 7.5 diopters.
These findings are almost in line with those of Anderson
and colleagues [9]: They examined 35 patients, and the mean
binocular VA at distance was 20/80.9 (0.6 logMAR) corrected
and 20/107.6 (0.7 logMAR) uncorrected (p<0.001). Wildsoet
and colleagues described the same finding, with all subjects
(n=25) showing a reduced visual acuity with a mean of 0.9
logMAR units [12]. They emphasized that the higher the re-
fractive error, the more their patients tended to show poorer
Fig. 3 Best eye with emmetropia, myopia, hyperopia (sum=120) or
astigmatism 1.5 D
Graefes Arch Clin Exp Ophthalmol (2015) 253:655661
Fig. 4 Improvement in lines as a function of refraction VA taken (n=
94/120, 78 %). This diagram shows the improvement in lines after
refraction. The biggest improvement could be achieved in patients who
visual acuities. We were nopt able to observe this phenome-
non, as BCVA improved at least by 1 line after refraction in
most of our patients.
In our study, we were able to show that the benefit of
refraction might even be higher, and found a mean improve-
ment by two logMAR units: mean visual acuity improved
from 0.98 (0.33) logMAR to 0.77 (0.15) logMAR after refrac-
tion (p<0.001).
Our findings are in contrast to the findings of Eball and
colleagues from Cameroon, who examined the biggest SSA
group of patients with albinism so far [14]. They retrospec-
tively analysed the refraction of 35 patients by automatic re-
fraction. They concluded that the degree of refractive error did
not influence the corrected visual acuity. However, we found
significant improvement in myopic patients, especially in
those with mild to moderate myopia. The Cameroonian col-
leagues also concluded that astigmatic patients did not dem-
onstrate improvement regardless of the type of astigmatism.
In contrast to this, we found that patients with astigmatism less
than 1.5 D improved in 47 % by 2 lines or more. Patients with
astigmatism equal to or more than 1.5 D in any axis improved
in 48 % by 2 lines or more (Fig. 5). We, like others, also
observed that with the rule (WTR) astigmatism was more
commonly present (37.5 %) than against the rule (ATR) astig-
matism (3.8 %) (Table 3).
We found refractive errors of all entities, of which myopia
was the most commonly encountered refractive error
Fig. 5 Improvement in lines as a
function of astigmatism VA
taken (n=94/120, 78 %. Patients
with astigmatism less than +1.5 D
improved in 15/32 of cases
(47 %) by 2 lines or more.
Patients with astigmatism equal to
or more than +1.5 D in any axis
improved in 26/54 of cases
(48 %) by 2 lines or more
659
were myopic between 7.5 and 1 diopters. The VA in patients with
albinism who were hyperopic more than +1.5 D did almost not improve
after refraction
(58.3 %). The mean refractive error in spherical equivalent
for the right eye was 4.09 D (5.72 SD), for the left eye
3.87 D (5.36 SD) (Table 2). The strong correlation of both
eyes of the respective patient is shown in Fig. 1. The observa-
tion that myopia was encountered most frequently is one in-
teresting result of our study, as myopia can be regarded as a
phenomenon of more urban and postmodern societies than in
the one investigated by us, in which children spend many
hours every day outdoors. Guo and colleagues examined
681 children in China. They concluded that less outdoor
activity, more indoor studying, older age, maternal myopia,
and urban region of habitation were associated with longer
ocular axial length and myopia in primary school children in
Greater Beijing. They also emphasized that remaining out-
doors for a longer time (e.g., during school) may reduce the
high prevalence of myopia in the young generation in Beijing
[15]. This stands in contrast to our children, who are coming
from rural African settings with many outdoor activities and
only few reading opportunities. The broader myopic range has
also been described by other study groups such as Yaholam
et al. in Israel [16]. They found that among OCA II patients
with albinism mean values were: hypermetropia 3.2 2.5 D;
myopia 3.8 4.5 D and astigmatism 1.8 1.0 D. In their
study, the mean best-corrected visual acuity (BCVA) was
0.48 0.2 logMAR units. According to the WHO guidelines
[13] this means mild or no visual impairment (VI). W were
unable to find such a mild degree in our Malawian patients,
660
Fig. 6 Overall distribution of improvement in lines. (0=zero lines; 1=1
line; 2 = 2 lines; 3 = 3 lines). VA was improved by refraction in
approximately 75 % of patients
who all had to be classified as visually impaired (VI) regard-
less of whether they were uncorrected or with best-corrected
visual acuity.
Mvogo and colleagues from Cameroon examined 42 albi-
no patients in 1999 [17]. The highest visual acuity reported by
them in OCA II was 0.3 (decimal), corresponding to 0.6 to 0.5
logMAR units which was above the average VA values we
found in our study. Albinism can also be associated with syn-
dromes. The rarest syndromic forms of albinism, affecting
the normal function of other organs, can be grouped into the
HermanskyPudlak syndrome (HPS1-9) and the Chediak
Higashi syndrome (CHS1) [18, 19]. We did not observe
any of these in our patients.
Furthermore, we observed that correcting for refractive er-
rors resulted in VA improvement in the majority of patients at
any age. There was no clear age-dependency of refraction-
associated VA improvement. Our findings support recommen-
dations by Lynch and Lund that appropriate measures for im-
proving VA should be put in place immediately to alleviate the
visual impairment of children who are looking white in a
black population [20].
In conclusion, refraction is useful for improving visual acu-
ity of children with oculocutaneous albinism in Malawi as
soon as possible, because early correction should avoid further
amblyopia.. Although the average visual acuity improvement
of 2 log MAR units was rather mild, around 25 % gained more
than 3 lines of VA. Thus, refraction should be performed in
albino patients in resource-limited areas such as in Malawi
where patients often present infrequently and late in life to
health-care providers.
Acknowledgments We thank Sight Savers (SS) for supporting refrac-
tive and low-vision care for patients with albinism in Malawi. We thank
Else KrnerFresenius Stiftung for supporting the College of Medicine,
Blantyre, Malawi. We thank Professor. Dr. Peter Knig, Mechanical and
Automotive Engineering, Trier University of Applied Sciences, for the
statistical support.
Graefes Arch Clin Exp Ophthalmol (2015) 253:655661
Conflict of interest All authors certify that they have NO affiliations
with or involvement in any organization or entity with any financial
interest (such as honoraria; educational grants; participation in speakers
bureaus; membership, employment, consultancies, stock ownership, or
other equity interest; and expert testimony or patent-licensing arrange-
ments), or non-financial interest (such as personal or professional rela-
tionships, affiliations, knowledge or beliefs) in the subject matter or ma-
terials discussed in this manuscript.
Authorship according to ICMJE guidelines M Schulze Schwering,
N Kumar, K Kalua, and P Kayange: designed study
M Schulze Schwering, N Kumar, and K Kalua: collected data
M Schulze Schwering, N Kumar, D. Bohrmann, M Spitzer, and P
Kayange: did study analysis
M Schulze Schwering, M Spitzer, and P Kayange: edited manuscript
for submission.
M Schulze Schwering, N Kumar, D Bohrmann, G Msukwa, K Kalua,
M Spitzer, and P Kayange: Reviewed manuscript before submission
M Schulze Schwering, N Kumar, G Msukwa, M Spitzer, K Kalua, and
P Kayange: agreed to manuscript being published.
Competing interests None.
References
1. Bennett DC, Lamoreux ML (2003) The color loci of micea genetic
century. Pigment Cell Res 16(4):333344
2. Naumann GOH, Lerche W, Schroeder W (1976) Foveolar aplasia in
tyrosinase-positive oculocutaneous albinisim. Albrecht von Graefes
Arch Klin Exp Ophthalmol 200(1):3950, German
3. Fulton AB, Albert DM, Craft JL (1978) Human albinism. Light and
electron microscopy study. Arch Ophthalmol 96(2):305310
4. Abadi RV, Cox MJ (1992) The distribution of macular pigment in
human albinos. Invest Ophthalmol Vis Sci 33(3):494497
5. Ezeilo BN (1989) Psychological aspects of albinism: an exploratory
study with Nigerian (Igbo) albino subjects. Soc Sci Med 29(9):1129
1131
6. Hong ES, Zeeb H, Repacholi MH (2006) Albinism in Africa as a
public health issue. BMC Public Health 17(6):212
7. Lund PM, Gaigher RA (2002) A health intervention programme for
children with albinism at a special school in South Africa. Health
Educ Res 17:365372
8. Kiprono SK, Masenga JE, Chaula BM, Naafs B (2012) Skin flora:
differences between people affected by albinism and those with nor-
mally pigmented skin in Northern Tanzaniacross sectional study.
BMC Dermatol 12:12. doi:10.1186/1471-5945-12-12
9. Anderson J, Lavoie J, Merrill K, King RA, Summers CG (2004)
Efficacy of spectacles in persons with albinism. J AAPOS 8(6):
515520
10. Ksmann B, Ruprecht KW (1996) Might the refractive state in
oculocutaneous albino patients be a clue for distinguishing between
tyrosinase-positive and tyrosinasenegative forms of oculocutaneous
albinism? Ger J Ophthalmol 5(6):422427
11. Sampath V, Bedell HE (2002) Distribution of refractive errors in
albinos and persons with idiopathic congenital nystagmus. Optom
Vis Sci 79(5):292299
12. Wildsoet CF, Oswald PJ, Clark S (2000) Albinism: its impli-
cations for refractive development. Invest Ophthalmol Vis Sci
41(1):17
13. Gilbert C, Foster A, Negrel AD, Thylefors B (1993) Childhood blind-
ness: a new form for recording causes of visual loss in children. Bull
World Health Organ 71(5):485489
Graefes Arch Clin Exp Ophthalmol (2015) 253:655661
14. Eball AO, Mvogo CE, Noche C, Zoua ME, Dohvoma AV (2013)
Refractive errors in Cameroonians diagnosed with complete
oculocutaneous albinism. Clin Ophthalmol 7:14911495
15. Guo Y, Liu LJ, Xu L, Lv YY, Tang P, Feng Y, Meng M, Jonas JB
(2013) Outdoor activity and myopia among primary students in
rural and urban regions of Beijing. Ophthalmology 120(2):277
283
16. Yahalom C, Tzur V, Blumenfeld A, Greifner G, Eli D, Rosenmann A,
Glanzer S, Anteby I (2012) Refractive profile in oculocutaneous al-
binism and its correlation with final visual outcome. Br J Ophthalmol
96(4):537539
661
17. Mvogo CE, Bella-Hiag AL, Ellong A, Mbarga BM (1999) Visual
problems in albinos: a hospital study carried out at the Douala
General Hospital. Sant 9(2):8991
18. Mrtinez-Garca M, Montoliu L (2013) Albinism in Europe. J
Dermatol 40(5):319324
19. Schneier AJ, Fulton AB (2013) The HermanskyPudlak syndrome:
clinical features and imperatives from an ophthalmic perspective.
Semin Ophthalmol 28(56):387391
20. Lynch P, Lund P (2011) Education of children and young people with
albinism in Malawi. Ministry of Education, Science, and Technology
Malawi. Final report. Commonwealth Secretariat, London, pp. 56
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.