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Prevalence of Manifest Hyperopia among High School Students in a Ghanaian

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Jacobs Journal of Ophthalmology

Research Article

Prevalence of Manifest Hyperopia among High School Students in a Ghanaian

Metropolis: A Population-Based Cross-Sectional Study
David Ben Kumah1*, Dominic Owusu1, Eugene Appenteng Osae1, Emmanuel Ankamah1, Reynolds Kwame Ablordeppey1
Department of Optometry and Visual Science, Kwame Nkrumah University of Science and Technology, Private Mail Bag, University Post
1

Office, Kumasi, Ghana

*Corresponding author: David Ben Kumah, Department of Optometry and Visual Science, Kwame Nkrumah University of Science and
Technology, Private Mail Bag, University Post Office, Kumasi, Ghana, Email: ben56kay@gmail.com
Received: 11-29-2015
Accepted: 08-08-2016
Published: 11-03-2016
Copyright: © 2016 David Ben Kumah

Abstract

Purpose: The aim of this study was to determine the prevalence of manifest hyperopia in a population of Ghanaian high school
students.

Methods: A total of 662 students from 12 different high schools were examined (344 males and 318 males, aged 15-19years,
mean age 16.9±3.5) in this population-based cross-sectional study. The examination comprised measurement of distance visual
acuity (VA) with a Snellen chart, non cycloplegic retinoscopy, subjective refraction and the use of interviewer administered
questionnaire to record oculo-visual symptoms experienced by the participants. Manifest hyperopia was defined as the spherical
equivalent of at least +0.75 D. Data was analysed using GraphPad Prism version 6. Descriptive statistics was employed. Pearson
correlation coefficient and chi test were performed: p – values of < 0.05 were considered statistically significant.

Results: The overall prevalence of manifest hyperopia was ≈26.0%. A negative correlation was found between age and prevalence
of manifest hyperopia [r (3) = -0.07, p >0.05]. We detected no significant difference between gender groups and the prevalence
of manifest hyperopia (p >0.05). Oculo-visual symptoms reported among the subjects include tearing, blurred distant vision
and headache. Headache was widely reported among the hyperopic subjects (62.8%). We observed that only 4% of the study
participants wore spectacle correction.

Conclusion: The prevalence of manifest hyperopia was high in the population studied.

Keywords: Manifest Hyperopia; Prevalence; Refractive Error; High School; Students

Introduction “hyperopes”) have a better distance than near visual acuity

[1,2].
Hyperopia synonymous to “hypermetropia” and
“farsightedness” is an anomalous refractive condition of the There are divergent views on the classification of hyperopia.
eye in which light rays entering the eye converge at a point Hyperopia however may exist as Latent, Manifest, Facultative
behind the retina, with accommodation fully relaxed. In other and Absolute Hyperopia. Latent hyperopia is where all or part
words, images of objects are not brought to a sharp focus on the of a patient’s hyperopia is compensated for by a process called
retina but behind the retina. This invariably leads to blurred accommodation. For example, if a routine objective refraction
vision. In some cases, persons suffering from hyperopia (called reveals a 4.00 dioptre (D) of hyperopia in a patient but the
Cite this article: David Ben Kumah et al. Prevalence of Manifest Hyperopia among High School Students in a Ghanaian Metropolis: A Population-Based Cross-Sectional Study.
J J Ophthalmol. 2016, 2(2): 021.
Jacobs Publishers
a subjective refraction reports on 2.00 D of hyperopia, the
2.00 D revealed in subjective refraction represents manifest
hyperopia. The other 2.00D which was (hidden) compensated
for by accommodation represents the latent hyperopia [1,3].
Absolute hyperopia is that hyperopia that cannot be
compensated for by accommodation. If a person has 5.00D
of hyperopia and 2.00 D of accommodation, the 3.00 D of
hyperopia that cannot be overcome by accommodation
represents absolute hyperopia and the other dioptre of
hyperopia (3.00D) that can be overcome by accommodation is
the facultative hyperopia [1-3].
Generally, hyperopia is common in children and young
adults. The trend in prevalence could change with age, with
the process of emmetropization and also the refraction
technique employed [4]. The same population could have
different prevalence values if study subjects are made to
undergo cycloplegic refraction at one time and non-cycloplegic
refraction at another time. Studies done in different populations
have reported differences in the prevalence and distribution of
hyperopia [5-7].
Clinically uncorrected hyperopia could come with a myriad
of oculo-visual signs and or symptoms. Hyperopia could
be significant enough to cause visuomotor and sensory
complications for individuals. Apart from the frequently
reported blurred vision, hyperopic individuals could show
accommodative esotropia and may show head turn. Hyperopia
that is left uncorrected from childhood may lead to amblyopia.
Other commonly reported signs and symptoms among
hyperopes include red or tearing eyes, facial contortions
while reading, asthenopia, frequent blinking, focusing
problems, decreased binocularity and eye-hand coordination,
and difficulty with or aversion to reading. The effects of
uncorrected hyperopia could vary depending on the magnitude
of hyperopia, the age of the individual and the status of the
accommodative - convergence system [1,8-11].
Some reports show that hyperopia has an association with
lower literacy standards in children [12]. Lower intelligence
quotient scores in the UK have been reported hyperopic
subjects than in myopic patients [13]. The complications of
uncorrected hyperopia including but not limited to strabismus
and amblyopia especially in young people can be prevented by
early detection and subsequent correction of hyperopia with
spectacles, contact lenses and or surgery [1, 14-16].
This study was an attempt to determine the prevalence of
manifest hyperopia (MHyp), oculo-visual symptoms and the
coverage of hyperopic spectacle correction among some high
school students in a Ghanaian metropolis.
Methods
Sampling
Cite this article: David Ben Kumah et al. Prevalence of Manifest Hyperopia among High School Students in a Ghanaian Metropolis: A Population-Based Cross-Sectional Study.
J J Ophthalmol. 2016, 2(2): 021.
2
This was a population-based cross-sectional study in which 12
of out of the total of 23 senior high schools in the metropolis
were randomly selected. Two classes were randomly selected
in each of these 12 schools and the students in those particular
classes examined.
Data collection/ Procedures
Participants were guided by one of the investigators to answer
an interviewer – administered questionnaire which focused on
gathering information on their demographic profile and ocular
history (specifically oculo – visual symptoms detailed on the
questionnaire) and the use of spectacle correction. Participants
were free to report about their own known medical conditions.
Distance visual acuity was assessed for each participant using
a Snellen chart at six (6) meters backlit with luminance of
160cd/m2. We performed non-cycloplegic objective refraction
(retinoscopy) in a dark room using a Welch Allyn Elite (streak)
retinoscope. Subjective refraction was performed on all the
participants. Plus 1 blur test was incorporated in the subjective
refinement of dioptre values of the refractive error detected.
Participants were diagnosed as hyperopic if they had manifest
hyperopia of a spherical equivalent of at least +0.75 D in either
of the eyes.
Ethical consideration
The entire study and the involved procedures were explained
to all participants. Informed consent was sought from some
participants (aged ≥ 18years) and from parents of some
participants aged below 18 years. Permission to carry out
the investigations in the selected schools was obtained from
the Directorate of Education in the Metropolis and the head
teachers of those schools. The study obeyed the tenets of the
Declaration of Helsinki
Data Analysis
Data collected were analysed using GraphPad Prism version
6 (GraphPad Software, Inc., California USA). Continuous
variables were expressed as mean ± standard deviation
(M±SD). Descriptive statistics, Chi-square tests and Pearson
correlation coefficient were performed to find significant
differences between comparable categorical groups. A p-value
<0.05 was considered significant.
Results
Patients’ characteristics
A total of 662 students (52.0% males and 48% females)
were examined during the study. The mean of these study
respondents 16.9 ± 0.9 years: with an age range of 15 – 19
years. The age and sex distribution of the students is displayed
in Table 1.
Jacobs Publishers 3
Gender Amounts of MHyp(D)
Age (yrs.) Male Female Total Age(yrs)
+0.75 +1.00 +1.25

15 11 11 22 15 3 1 0

16 91 105 196 16 38 16 0

17 55 17 2
17 153 141 294
18 23 8 0
18 67 48 115
19 7 2 0

19 22 13 35 Total 126 (19.0%) 44 (6.6%) 2 (0.3%)

Total 344 (52.0%) 318 (48.0%) 662 (100.0%) Table 3. Distribution of MHyp per age of participants.

Coverage of refractive correction of respondents.

Table 1. Age and sex distribution of the students.
Prevalence and distribution of manifest hyperopia (MHyp)
among study respondents.
The overall prevalence of MHyp recorded was ≈ 26.0% (male
prevalence was 12.6% and female prevalence 13.4%). We did
not detect a significant difference in the prevalence of MHhyp
between sex groups (p<0.05). Table 2 shows the distribution
of hyperopia among male and female respondents.
Gender of participants
Amount of MHyp (D)
Male Female
+0.75 59 67
+1.00 22 22
+1.25 2 0
Total 83 (48.3%) 89 (51.7%)
Table 2. Distribution of MHyp by gender.
Regarding the distribution of MHyp per age of the study
respondents, those aged 17 years recorded the highest
percentage of 11.2%, followed by those aged 16 years. The
least per age category were those aged 15 years (0.6%).
Pearson correlation coefficient revealed a negative correlation
between age and the prevalence of MHyp [r (3) = -0.07, p-
>0.05]. Table 3 summarizes the distribution of MHyp per age
of the participants.
Oculo-visual symptoms reported by the respondents.
In all, the most widely reported symptom was headache
(62.8%). This was followed by teary (watery) eyes (47.1%)
with the least reported symptom being blurred vision (31.4%).
Some of the hyperopes in the study reported of more than one
of these symptoms.
Cite this article: David Ben Kumah et al. Prevalence of Manifest Hyperopia among High School Students in a Ghanaian Metropolis: A Population-Based Cross-Sectional Study.
The overall coverage of hyperopic refractive correction was
low. Only 4% of the total with MHyp wore spectacle corrections.
The other (96%) hyperopes had their hyperopia uncorrected
(unmanaged).
Discussion
Globally, there have been extensive studies on the prevalence of
refractive errors (including hyperopia) in different populations
and across different span of ages [5,7,17,18]. Many studies
Total focused on younger children but our study was concerned with
studying high school students who in their middle (15years) to
late (19years) teenage years. This was done as an attempt to
126 gain some insight into the trend of hyperopia in that particular
span of ages in the Ghanaian population.
44
The overall prevalence of MHyp for this study was relatively
2
higher than what has been reported in other studies conducted
172 (100.0%) elsewhere in Ghana and South Africa (≈26% versus 1.6%
and 5%) which also employed non-cycloplegic refraction
technique [19,20]. On one hand, our reported prevalence value
was lower than what was reported (≈26.0% versus 73.1%) in a
study which also used non-cycloplegic [21]. Other comparable
studies reported prevalence values that are close to what we
recorded (≈26.0% versus 22.6%, ≈26.0% versus 27.3%) [22,
23].
It suffices to say that the prevalence value of hyperopia differs
from one study to the other. This could be due to differences
in population characteristics, sample size, age and sex of
participants [20-22]. Another possible factor that could
account for the differences in prevalence value is the refraction
technique employed. Prevalence values have been observed to
be different for studies employing cycloplegic technique and
non-cycloplegic technique [5, 24, 25].
While we detected a negative and insignificant relationship
J J Ophthalmol. 2016, 2(2): 021.
Jacobs Publishers
between the prevalence of MHyp and age, other studies have
reported otherwise. A Polish study [5] recorded a positive and
significant correlation (p< 0.001) between the prevalence of
hyperopia and age. For that study, hyperopia increased between
the ages of 7 -8 years. Difference in prevalence between male
respondents (12.6%) and females (13.4%) was insignificant
(p->0.05). Other studies, have reported significant differences
in prevalence of hyperopia between sex age groups. Hyperopia
has also been found to have association with age and gender
[1,2,26,27].
We would like to mention that, readers should consider the
findings from this study in the light of some limitations to
our study design. For example, the nature of our study sites
did not allow for cycloplegic refraction; we thus are reporting
only dioptric values of hyperopia from dry refraction (Manifest
hyperopia) ranging from +0.75D to +1.25D. Even though these
values are comparable to what is reported in other studies, it
would be wrong to interpret our findings as the whole picture
of hyperopia among the population studied. The latency
of hyperopia common among young people would provide
different results should we have employed cycloplegic/
refraction (1, 3, 28-30). Studies that employed cycloplegia to
unmask latent hyperopia have reported values ranging from
+1.00D to >+3.00D [5,24,27,31].
Some of these participants with MHyp reported more than one
oculo - visual symptom. Headache was the most frequently
reported symptom (62.8%). Blur vision and watery eyes were
also reported. Even though we did not focus on studying how
MHyp associated with these symptoms, it is important the
stress accommodative stress placed on the visual system of
persons with uncorrected could be significant to trigger general
asthenopia – which comprise but not limited to pain in the eye,
redness, headaches, blur and sometimes double vision [1-3].
It is these unpleasant visual experiences that warrant early
detection and subsequent correction of hyperopia. We also did
not assess how hyperopia impacted academic performances
of our study respondents but some studies have reported
low literacy standards and lower intelligent quotients among
hyperopes [12,13]. Reading and writing require good vision
and where refractive anomalies exist proficiency in these skills
could be reduced.
It was found in our study that, only 4% of the participants with
MHyp wore spectacle correction. This indicates a low coverage
of refractive correction in the population studied. One study
reported a similarly low coverage (1.69%) of refractive
correction among study subjects [32]. On one hand, a different
study reported a higher coverage of refractive correction
among children with refractive error [22]. While we neither
knew nor investigated what accounts for the low coverage of
refractive correction, it is reasonable to assume that many of
the hyperopes did not wear a spectacle correction for reasons
that may include cost, lack of awareness (and or knowledge)
of their refractive status and or other personal reasons.
Cite this article: David Ben Kumah et al. Prevalence of Manifest Hyperopia among High School Students in a Ghanaian Metropolis: A Population-Based Cross-Sectional Study.
J J Ophthalmol. 2016, 2(2): 021.
4
Socioeconomic challenges have been a barrier to uptake of
refractive services in most places across the world. People may
not wear a spectacle correction (or assess any form of health
care) because of financial constraints or social stigma attached
to wearing spectacle – spectacle wearers in certain Ghanaian
communities are often tagged as having “bad eyes” [31, 33-38].
Conclusion
The study has attempted to provide an insight into the
prevalence of manifest hyperopia among some high school
population in Ghana. The overall prevalence (26.0%) is
relatively high compared to what other studies have been
reported. There was a low coverage of refractive correction;
this suggests that the participants and other people at their age
in Ghana will benefit from refractive screening and correction
services. The Ghana Education Service could thus implement
a policy on rolling basis to help screen, detect and correct
hyperopia and other forms of ametropia in students.
Recommendation
We recommend future investigation in population of ages
similar to the participants in this study to employ cycloplegic
refraction to allow for better comparison and to give a standard
picture of the hyperopia situation among people of such ages
in Ghana. We have only reported on manifest hyperopia which
does not provide a perfect representation of hyperopia in the
study population.
Conflicts of Interests
The authors declare that they have no conflicting interests.
Financial Disclosure
The authors have no financial relationships to disclose.
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Cite this article: David Ben Kumah et al. Prevalence of Manifest Hyperopia among High School Students in a Ghanaian Metropolis: A Population-Based Cross-Sectional Study.
J J Ophthalmol. 2016, 2(2): 021.

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