Prevalence of Refractive Error… Jafer K et al 353

ORIGINAL ARTICLE

PREVALENCE OF REFRACTIVE ERROR AND VISUAL

IMPAIRMENT AMONG RURAL SCHOOL-AGE CHILDREN OF
GORO DISTRICT, GURAGE ZONE, ETHIOPIA
Jafer Kedir1, Abonesh Girma2
ABSTRACT

BACKGROUND: Refractive error is one of the major causes of blindness and visual impairment in
children; but community based studies are scarce especially in rural parts of Ethiopia. So, this study aims
to assess the prevalence of refractive error and its magnitude as a cause of visual impairment among
school-age children of rural community.
METHODS: This community-based cross-sectional descriptive study was conducted from March 1 to
April 30, 2009 in rural villages of Goro district of Gurage Zone, found south west of Addis Ababa, the
capital of Ethiopia. A multistage cluster sampling method was used with simple random selection of
representative villages in the district. Chi-Square and t-tests were used in the data analysis.
RESULTS: A total of 570 school-age children (age 7-15) were evaluated, 54% boys and 46% girls. The
prevalence of refractive error was 3.5% (myopia 2.6% and hyperopia 0.9%). Refractive error was the
major cause of visual impairment accounting for 54% of all causes in the study group. No child was
found wearing corrective spectacles during the study period.
CONCLUSIONS: Refractive error was the commonest cause of visual impairment in children of the
district, but no measures were taken to reduce the burden in the community. So, large scale community
level screening for refractive error should be conducted and integrated with regular school eye screening
programs. Effective strategies need to be devised to provide low cost corrective spectacles in the rural
community.
KEYWORDS: Refractive error, visual acuity, visual impairment, children

DOI: http://dx.doi.org/10.4314/ejhs.v24i4.11

INTRODUCTION is caused by refractive errors and as much as 4%

of the population sees less than 6/18 because of
Refractive error is one of the most common causes this condition (2).
of visual impairment. Recent data suggests that a Refractive error as a cause of blindness has
large number of people are blind in different parts not received much attention because many
of the world due to high refractive error because definitions of blindness have been based on best
they are not using appropriate refractive corrected visual acuity (BCVA). However, in
corrections (1). many parts of the world, refractive error would
The global magnitude of refractive error is become the second largest cause of treatable
not reliably known, as there is great variation in blindness if blindness were defined on the basis of
groupings according to age, definitions of presenting distance visual acuity (3). This fact is
blindness, and examination methods. Reports further strengthened by the recent report of global
suggest that 5-25% of blindness in some countries meta-analysis released by WHO in 2008.
1
Department of Ophthalmology, Jimma University, Ethiopia
2
Department of Ophthalmology, Addis Ababa University Medical Faculty, Ethiopia
Corresponding Author: Jafer Kedir, Email: [email protected]
354 Ethiop J Health Sci. Vol. 20, No. 3 November 2010

According to this report, a total of 153 million located at about 150 km southwest of Addis
people in the world are estimated to be visually Ababa, was selected for this study taking cost,
impaired from uncorrected refractive errors, of manpower and time in to consideration. Goro
whom 8 million are blind. This cause of visual district had a total population of 169,000. About
impairment has been overlooked in previous 45% of the population comprises of children under
estimates that were based on best corrected vision. 15 years of age and about 20% of the total
This revealed that uncorrected refractive error is (33,800) are in the age range of 7-15 years (7).
the main cause of low vision and the second cause Taking in to account the proportion of refractive
of blindness (4). error in the past related studies in the region
According to the report from the ‘National (6.3%), margin of error 2.5%, and the design
Survey on Blindness, Low Vision and Trachoma effect 1.5, the calculated sample size was 544
in Ethiopia’, that was conducted in the year 2005- children.
2006, the prevalence of blindness in Ethiopia was Multistage cluster sampling was used to
1.6% and that of low vision (vision<6/18) was select the study population. The district was
3.7%. But in this survey, emphasis was not given geographically classified in to peasant associations
for burden of refractive error in children even (PAs), which is taken as 1st stage cluster. There
though they were included in the general were 64 PAs in the district. Six PAs were selected
population (5). Special attention should be given by lottery method from the total list of 64. In the
to children because visual impairment in children district, PAs were further divided into villages that
restricts their education and general performance, have an average of 50 households each. Villages
personality development, future quality of life and were chosen as second level clusters and 2 villages
career opportunities which affect their success were selected by simple random selection (lottery
lifelong (6). method) from each of the 6 peasant associations.
There are various ways of assessment of So, 12 villages were selected as the final cluster of
refractive error in children. The two most common the study populations. Since the average
ways are community vision screening approach household size in Ethiopia was estimated to be 5
and school vision screening approach. In during the study period, each household was
developing countries like Ethiopia, not all children expected to have an average of one child in the
start schools on time, and impaired vision due to age group of 7-15 and every household in the
refractive error may even be the reason not to village was visited (8).
attend schools. So, screening based on schools fail All children whose ages were 7-15 years
to reach these children and community vision living in these villages were registered by the data
screening may be the best way to include these collectors and included in the study. This resulted
children. in the involvement of 570 children, which is
Only few studies are done on this issue in slightly higher than the calculated sample size.
Ethiopia in some schools. Based on these facts, Then, all of them were examined at their
our study was done with an objective of respective villages after informed consent was
determining the prevalence of refractive error and obtained from the parents.
its contribution to childhood visual impairments in For each eligible child, general information
the school age children of rural community. Other like name, age, gender and years of schooling
causes of visual impairment were also determined were recorded before ophthalmic evaluation. The
in this study. ophthalmic examinations include distance visual
acuity measurement, subjective refraction, ocular
MATERIALS AND METHODS alignment and motility evaluation, and, anterior
segment and fundus examination.
A community-based, cross-sectional, descriptive Visual acuity was measured in bright sunlight
study was done from March 1 to April 30, 2009, in by Snellen’s E-chart at 6m. For children with
children aged 7-15 years living in rural uncorrected vision of 6/12 or worse, visual acuity
community of Goro District, Gurage Zone of was repeated with pinhole. For children who
southern Ethiopia. There were 15 districts in showed improvement with pinhole, subjective
Gurage Zone. From these districts, Goro, which is refraction was done using standard refraction trial
 Prevalence of Refractive Error… Jafer K et al 355

set. For the children with uncorrected vision of RESULTS

6/12 or worse, but no improvement of vision with
pinhole, further evaluation was done which During the study period, 592 children aged 7-15
includes: ocular alignment at 0.5 m and 4m (for years were registered and 570 of them participated
near and distance vision respectively), ocular in the study, accounting for 96 % response rate.
motility, anterior segment evaluation using torch Out of these, 54% were boys. A total of 375
light and magnifying loupe, and posterior segment children (65.8%) were in the age range of 7-10
evaluation using direct ophthalmoscope after and the remaining 195 (34.2%) were 11-15 years
pupillary dilation by 1% tropicamide eye drop. old (Table 1).
Finally, subjective refraction was done for those
children with retinal finding suggestive of high Table 1: Age and sex distribution of the school-
myopia but no improvement with pinhole. The age children in rural Gurage Zone; Mar 1- April
principal cause of uncorrected vision of 6/12 or 30, 2009.
worse was recorded after completion of the ocular
examination. The causes were categorized into Sex Total
refractive error, corneal opacity due to any cause, Age group F M
cataract, retinal disorders, amblyopia and other 7-9 yrs 115 135 250(43.9%)
causes. 10-12 yrs 106 137 243(42.6%)
In this study, subnormal vision was defined 13-14 yrs 41 36 77(13.5%)
as vision of 6/9 or worse in the better eye; visual Total 262 308 570(100%)
impairment was defined as vision worse than 6/18
in the better eye. Myopia was considered in Among the children, the majority (71.6%) were in
refractive error requiring a minus sphere of 0.50 grade 1-3. A total of 34 children (6%) did not start
Diopter or more for correction and hyperopia if schooling (Table 2).
they need a plus sphere of 1.00 Diopter or more.
Amblyopia was diagnosed in children with poor Table 2: Distribution of school grade among the
vision which does not improve with refraction and rural children of Gurage Zone (Age 7-15 years);
no pathology causing the visual loss. Mar 1–Apr 30, 2009.
All data were entered into computers using
SPSS software version 16 and processed.
School Sex Total
Statistical tests of significance were conducted Grade F M
using x2tests or two tailed t- tests as appropriate
and p-values less than 0.05 were considered Didn’t start 16 18 34(6.0%)
significant. The study was done after approval by 1–6 243 283 526(92.3%)
Research and Publication Committee of the 7-9 3 7 10(1.7%)
Department of Ophthalmology, Medical Faculty Total 262(46%) 308(54%) 570(100%)
of Addis Ababa University. Permission was also
obtained from appropriate administrative bodies
and stakeholders of the local area. Informed A total of 533 children (93.5%) had presenting
consent was obtained from parents of each child vision of 6/9 or better in both eyes. The remaining
after explaining the procedure and the purpose of 37 children (6.5%) had presenting vision of 6/12
the study. or worse in one or both eyes. Of these, 20 (3.5%
of the total) had vision of 6/12 or worse in both
eyes. A total of 10 children (1.75%) had
presenting vision worse than 6/18 (Table 3).
356 Ethiop J Health Sci. Vol. 24, No. 4 October 2014

Table 3: Distribution of presenting and BCVA* in rural school-age children of Gurage Zone; Mar 1-Apr 30,
2009

VA groups Frequency of Frequency of

Presenting Visual Acuity BCVA*(%)
Number (%)
>6/9 in both eyes 533(93.5) 546(95.8)
>6/9 in the better eye 17(3.0) 13(2.3)
6/12-6/18 in the better eye 10 (1.8) 3(0.5)
<6/18-3/60 in the better eye 10 [1.8] 8(1.4)
<3/60 in the better eye 0 0
Total 570(100) 570(100)
* Best Corrected Visual Acuity

When the best corrected visual acuity (BCVA) was Refractive error was the most common cause of both
assessed, 546 children (95.8%) had vision of 6/9 or unilateral and bilateral low vision. Out of the 37
better. Only 24 children (4.2%) had BCVA of 6/12 children with either unilateral or bilateral low vision,
or worse in one or both eyes; 11 of them (1.8% of 20 (54%) had refractive error. Among the 20
total) in both eyes and 13 of them (2.4%) in one eye. Children with refractive error, 13 had bilateral
There was no bilaterally blind child according to involvement. The other major causes of either
WHO criteria, but there were 3 children with unilateral or bilateral subnormal visual acuity were
unilateral blindness. The distribution of presenting retinal causes, corneal opacity, and strabismic
visual acuity did not differ significantly between amblyopia with proportion of 10.8%, 8.1% and 5.4%
boys (M = 0.89, SD = 0.18) and girls (M= 0.86, SD respectively. The cause of poor visual acuity was
= 0.16) (t = 0.58, p-value = 0.56 for the right eye, t- unexplained in 5 children (13.5%), but amblyopia
test). There was also no statistically significant was the most likely factor because of absence of any
difference in the mean presenting vision between detectable pathology even though it doesn’t fulfill
children who didn’t start schools (M = 0.90, SD = the stated criteria to diagnose amblyopia. The causes
0.18) and those who were at schools in the same age the unilateral blindness in three children in this study
group (M = 0.89, SD = 0.19) (t= 0.17, p-value = were: congenital cataract, enucleation after trauma,
0.87, right eye, t-test). and phthisis bulbi of unknown cause each involving
one eye of the three children (Table 4).

Table 4: Causes of low vision, defined as visual acuity of 6/12 or worse, among rural school-age children of
Gurage Zone. Mar 1-Apr 30, 2009

No. of eyes with No. of children Prevalence of VA

VA of <6/12 (%) With VA of <6/12 <6/12 in one or
Causes OD OS in one or both eyes (%) both eyes (%)
Refractive Error* 16(51.7) 17(65.7) 20(54.0) 3.51
Retinal abn. 4(12.9) 3(11.5) 4(10.8) 0.70
Corneal Opacity 3(9.7) 2(7.7) 3(8.1) 0.53
Strab. Amblyopia** 1(3.2) 1(3.8) 2(5.4) 0.35
Phthisic eye 1(3.2) - 1(2.7) 0.18
enucleated 1(3.2) - 1(2.7) 0.18
cataract 1(3.2) - 1(2.7) 0.18
Undefined 4(12.9) 3(11.5) 5(13.5) 0.88
Total 31(100) 26(100) 37(100) - 6.50
* 2 children have bilateral amblyopia due to high myopia, ** strabismic amblyopia
 Prevalence of Refractive Error… Jafer K et al 357

Among the children with refractive error, 15 (75%) males. Females tend to be more myopic but the
were myopic and 5 (25%) of them were hyperopic. difference was not statistically significant (p-
Among these children, the mean value refractive value=0.48). The overall prevalence of myopia
error in the right eye was -1.16 D & the left eye - among the children was 2.6% and hyperopia 0.9%
0.90D. The difference between the two eyes was not (Fig 1). No child was wearing corrective spectacles
statistically significant. In the same children with during the study period.
refractive error, the mean value in the right eye was -
1.88D (SD=3.31) in females and -0.69 (SD=3.83) in

DISCUSSION (14-15). In another study in rural India, prevalence

of low vision was 2.7% which is slightly lower than
The distribution of refractive error varies in different ours (15).The major cause of both unilateral and
parts of the world; moreover, there is no uniformly bilateral visual impairment in our study was
accepted standard way of assessing and reporting the refractive error. This is similar to most studies done
problem until recently. To address this issue, there is in other countries. The percentage of refractive error
a standard protocol set currently, called “Refractive from total causes visual impairment ranges from
Error Study in Children” (RESC) and carried out in 53% in Indian studies to 87% in Iran and 90% in
few countries like China, Nepal, Chile, India, Tanzanian children of the same age group
Malaysia and South Africa. These studies have (10,15,18).
shown promising comparable results (4). However, it The prevalence of refractive error among the
is difficult to carry out such extensive study in rural total number of children in our study was 3.5 %.
community of all countries uniformly because of This value is very low compared to the study in
limited resources and manpower especially in Uganda, which shows 11.6% among school children
developing countries like Ethiopia. Our study was aged 6-9 years (19). It is also lower than that of Iran
less extensive but similar to studies done by RESC (6.13% in age groups 7-15 years) (8). But it is higher
protocol. than similar studies in South Africa (1.82%), India
The prevalence of visual impairment in this (1.9%), and Tanzania (1%) (15,17,18).This great
study (i.e presenting vision < 6/18) was 1.8%. This is variability maybe due to racial/ ethnic variations,
comparable but slightly lower than that of previous different lifestyles, or living conditions in different
similar study at a school in the district 5 years back countries as supported by various prior studies that
which shows visual impairment rate of 2.2% (9). show significant association between refractive error
The prevalence of low vision in our study (i.e. 3.5%) and these factors (20 - 22).
is comparable to that of Iran (3.8%) but significantly The predominant type of refractive error in our
lower than results of studies in Malaysia (17.1%), study was myopia, accounting for 75% of the cases.
Chile (15.8%), China (12.8%), urban India (9.0%), The overall rate of myopia was 2.6% and hyperopia
and to some extent, rural India (5.0%) (10-15). 0.90%. The prevalence of myopia is lower than the
However, it is higher than the studies done in other result reported from China (16.2%), urban India
countries like Nepal (2.9%) and South Africa (2.7%) (New Delhi=7.4%), rural India (4.1%), and Iran
358 Ethiop J Health Sci. Vol. 24, No. 4 October 2014

(3.4%) (10, 13-15), but it is higher than that of Nepal central Ethiopia. Ethiopian Journal of Health
(1.2%) and Tanzania (0.7%) (14,16). Our result is Dev. 2005;19(2): 148-152.
similar to that found in South Africa (2.9%) and 10. Akbar F, Hassan H, Mehdi K et.al. The
Uganda (2.7%) (17,19). prevalence of refractive errors among
The predominance of types of refractive error schoolchildren in Dezful, Iran. Br. J.
varies from study to study. In general, objective Ophthalmol. 2007; 91:287-292.
refraction in children usually shows large 11. Goh P, Abqariyah Y, Pokharel GP, Leon B.
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