ORIGINAL RESEARCH

Prevalence of eye diseases among school children in a

rural south-eastern Nigerian community
O Okoye, RE Umeh, FU Ezepue
Department of Ophthalmology, University of Nigeria Teaching Hospital, Enugu, Nigeria

Submitted: 18 September 2012; Revised: 25 March 2013; Accepted: 26 April 2013; Published: 29 September 2013
Okoye O, Umeh RE, Ezepue FU

Prevalence of eye diseases among school children in a rural south-eastern Nigerian community
Rural and Remote Health 13: 2357. (Online) 2013

Available: http://www.rrh.org.au

ABSTRACT

Introduction: Vision has an essential role in a child’s development, and visual deficit is a risk factor not only for altered visio-
sensory development, but also for overall socioeconomic status throughout life. Early detection provides the best opportunity for
effective treatment of eye and vision problems in children. Therefore, timely screening is vital to avoid lifelong visual impairment.
There is a paucity of data regarding the causes of eye disease among rural children in Nigeria. The aim of this study was to determine
the prevalence and causes of eye disease among children residing in rural communities in Nigeria.
Methods: A cross-sectional survey was conducted to determine the prevalence and common causes of ocular morbidities in
primary school children in Abagana, a rural community in Njikoka Local Government Area of Anambra State, South-East Nigeria.
Children aged 6–16 years in all 8 primary schools were registered, interviewed and their eyes examined. Data were analyzed
according to age, sex, type of ocular disorder and causes of visual impairment. Frequency and percentages were calculated with
univariate analysis and parametric method.
Results: The census population consisted of 2092 children, 1081 (51.7%) males, with a male to female ratio of 1.07:1. Ocular
disorders were found in 127 (6.1%) of the population. The most common ocular disorders in this community were vernal
conjunctivitis 61 (2.9%) followed by refractive error 14 (0.7%). Amblyiopia, which is avoidable, was the most common cause of
visual impairment.
Conclusion: Study findings indicated that early detection through early eye screening; health education and access to a quality eye
care facility will reduce the burden of eye disease and blindness among rural Nigerian children.

Key words: eye disease, Nigeria, rural children, school health.

© O Okoye, RE Umeh, FU Ezepue, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au
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Introduction Vision has an essential role in a child’s development, and a
visual deficit is a risk factor not only for altered visio-sensory
development, but also for overall socioeconomic status
The prevalence of blindness in children varies from
throughout life7. Timely screening for the early detection of
approximately 0.3 per 1000 children in wealthy regions of
eye and vision problems in children is vital to avoid lifelong
the world, to 1.2/1000 in the poorer countries or regions1.
visual impairment. Early detection provides the best
There are three main reasons for this2. First, diseases that can
opportunity for effective treatment6.
lead to blindness such as measles, vitamin A deficiency, and
ophthalmia neonatorum are still prevalent in poor regions of
The benefits of regular eye screening in children that includes
the world. Second, there are fewer well equipped facilities
a comprehensive eye examination has been recognized
and personnel trained in managing treatable causes of
worldwide, including in developed economies8. Early
blindness in poorer countries. Third, in rural areas ignorance,
corrective measures for deficits detected would greatly assist
poverty and superstition contribute to disease causation and
in reducing childhood blindness and related morbidity. In a
propagation, and work against treatment and prevention.
study among school children in Oman, 28 765 (6.9%) of the
These factors collectively impact negatively on the perception
416 157 children examined were found to have defective
of eye diseases and encourage the use of harmful traditional
vision9. In Pakistan, of a total of 38 575 schoolchildren, 2065
eye medications which can result in avoidable blindness.
(5.3%) were found to have refractive errors. Early treatment
reduces the incidence of avoidable childhood visual
Incidence data are very difficult to obtain, but it has been
impairment and blindness.
estimated that there are 8 new blind children for every
100 000 children each year in industrialized countries2. In
School-age children (6-15 years) represent 20–30% of the
developing countries, approximately 500 000 children
total population in most low income countries10. For Nigeria
become blind every year – one every minute – and
this translates to 20–30 million children. In some states in
approximately half of these children die in one to two years3.
Southern Nigeria, 80% of children attend school and can
Available data indicate that the prevalence of childhood
therefore be reached by healthcare programs11. Therefore,
blindness varies from 1.2/1000 children in very low income
school children are an important, large target group for early
world regions to 0.3/1000 children in high income regions4.
detection of eye diseases and prevention of blindness12.

The high number of blind years resulting from childhood

Not all ocular conditions result in visual impairment. In
blindness was one reason for the control of childhood
Pakistan, the prevalence of non-vision-impairing conditions is
blindness to become a priority for the World Health
14.6%13; however, affected individuals may need frequent
Organization/International Agency for Prevention of
clinic visits which may impact on academic
Blindness (WHO/IAPB) Vision 2020: The Right to Sight
performance. Sufferers of allergic conjunctivitis tend to
Programme5. Children who are blind must overcome a
experience quality of life reduction related to general
lifetime of emotional, social and economic difficulties, which
health14. Of more concern in rural settings is the potential use
also affect the family and society1. Loss of vision in children
of harmful traditional eye medication and improper use of
influences their education, employment and social activities1.
proprietary medications such as steroids for vernal
Childhood blindness is second only to adult cataracts as a
keratoconjuctivitis and other conditions, which may result in
cause of blind person years. Approximately 70 million blind
vision impairing complications.
person years are due to childhood blindness worldwide6.

© O Okoye, RE Umeh, FU Ezepue, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au
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Aim were interviewed and examined for this cross-sectional
study.
There are little data on the causes of ocular morbidity in
children in rural communities in Nigeria. This study targeted Visual acuity was measured outdoors for each child by an
primary school children in a rural community of Anambra ophthalmic assistant using the standard Snellen eye-test chart
State, Nigeria, with the aim of determining the prevalence of placed at 6 m. When visual acuity was <6/9, a pinhole was
ocular disorders and their common causes, and applying these used to re-test. Recorded visual acuities were further cross-
findings to prevention of blindness programs. checked by an author to ensure validity.

Context Using the Modified WHO/PBL eye examination record, a

trained assistant collected the required personal data and
Abagana is a rural community in Anambra State, Nigeria. It ophthalmic history. The sections on visual assessment and
has 8 primary schools with 2336 pupils and 128 teaching ocular examination were completed by an author who is a
staff. There is one community health center and a consultant ophthalmologist.
comprehensive health center of the University of Nigeria
Teaching Hospital with only a nurse who has ophthalmic External eye examination was performed using a pen torch
training. There is no ophthalmologist or optometrist in the and a simple magnifying head loupe. A direct
community. However, there are 25 consultant ophthalmoscope was used to examine the posterior segment
ophthalmologists and 10 optometrists practicing at both of the eye. Where necessary (eg visual acuity < 6/18 and did
private and public hospitals in the urban city of Enugu, not improve with pinhole test, with no obvious identifiable
approximately 100 km from rural Abagana. causative factor), dilated fundoscopy was performed using
short-acting dilating eye drops (0.5% Tropicamide®). Ocular
It has been observed that after work force and work load alignment was evaluated with corneal reflex text and cover-
issues, financial factors are the greatest threat to rural uncover tests.
practice viability15. In Nigeria no financial incentives are
offered to healthcare personnel working in rural areas. Refractive error was considered when subnormal visual
Several studies have reported the effective use of teachers for acuity improved with a pinhole test. Amblyopia was also
initial eye screening of school children as a way of resolving considered in a child with subnormal visual acuity in the
health personnel shortage challenges8,16. In a study in absence of external eye, anterior and posterior segment
Tanzania, a simple screening by teachers correctly identified pathology.
80% of pupils with bilateral poor eyesight, with 91%
specificity16. Currently in Nigeria school health services Children with minor eye problems were treated, while those
provide immunization services through the national with major eye conditions were referred to the University of
immunization scheme, general health education and minimal Nigeria Teaching Hospital for further evaluation and
routine eye screening programs. management.

Methods Data were analyzed using Statistical Package for Social

Sciences (www.spss.com). Univariate analysis and the
parametric method were used to calculate frequency,
After obtaining verbal informed consent from parents and percentage, and 95% confidence intervals (CI). Comparison
school heads, all available and eligible children aged 6 years to of percentages was by χ2 test.
under 16 years (n=2092) in the 8 primary schools in Abagana

© O Okoye, RE Umeh, FU Ezepue, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au
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Ethics approval sustained rural immunization program against measles by the
Federal Ministry of Health. This could be strengthened by the
Ethical clearance for the study was obtained from the Health deployment of adequate human resources and the provision
Research Ethics Committee (HREC) of the University of of an affordable and accessible eye care facility for the rural
Nigeria Teaching Hospital, Enugu (approval numbers not populace to eliminate childhood blindness.
issued). The study was adequately explained, and refusal of
participation by parents, teachers or children was respected. The age group with the lowest number of school children was 14–
16 years (3.7% of the population studied) which was similar to
Results 5.2% in a rural study by Oragwu17. However these numbers are
relatively high because this age group should be in secondary
school, and may be the result of poverty, ignorance and altered
Of 2336 primary school pupils, 2274 reported for
priorities in rural communities delaying the entry of children into
participation but only 2092 were examined. Of the 244 not
formal schooling. The slight preponderance of males in the total
examined, 62 were eligible but absent from school on the day
number of children studied despite more females at the entry level
of visit, while 182 were excluded due to age. There were
age-group (6–9 years) was due to the retention of males as age-
more males (n=1081; 51.7%) than females, giving a male to
groups and academic class levels increased. This reflects the socio-
female ratio of 1.07:1. The 6–10 years age group constituted
cultural gender bias of the Igbo tribe in South-Eastern Nigeria18,
52.7% of the subject population (Table 1).
among whom male gender is preferred and limited financial
resources are directed to boys' education. This gender bias leads to
Refractive error and corneal scar were the main causes of
socioeconomic limitations for girls. Increased education to
subnormal vision (Table 2). Bilateral low vision was seen in
encourage female participation in education, and the provision of
6/2092 (0.3%), caused mainly by amblyopia which was
free education, especially in rural areas, is indicated.
diagnosed in 3 out of the 6 children who had low vision. No
child was found to be blind according to WHO classification.
The 0.5% prevalence of visual impairment found in this study
However, monocular blindness was found in 4/2092 (0.2%)
is lower than findings in other studies by Nkanga19 (0.72%),
of children, due to chorioretinal scars, congenital glaucoma,
Yoloye20 (7.4%), Onyekwe21 (4.1%) and Mohammed22
traumatic cataract and traumatic optic neuropathy,
(18%). These differing results may be due to differences in
contributing 25% each to the causes of monocular blindness.
study areas, age groupings and definitions of visual
impairment. For instance, the study of Onyekwe et al
Of the 2092 school children seen, a total of 6.1% (CI 0.03-
combined both primary and secondary school subjects, while
0.13) had ocular disorders of various types (Table 3), some
Yoloye’s definition of visual impairment as visual acuity of
occurring bilaterally. Vernal conjunctivitis was the
6/9 to 3/60 would tend to produce a higher prevalence of
commonest disorder at 48% of all ocular disorders, followed
visual impairment when compared with the present study.
by 11.01% refractive error and 7.1% subconjunctival
hemorrhage.
According to the WHO definition, no case of blindness was
found in this study, as in a similar study in Ethiopia22. In
Discussion Nkanga and Dolin’s study, the prevalence of blindness
was 0.05%10. This low prevalence is consistent with a low
Most of the children in this study were found to have normal global prevalence of blindness in children23. In addition, most
vision. This may be attributed to the absence of blind children would be in schools for the blind, and some
environmental factors known to cause blindness in children blind children would be concealed at home due to stigma and
(eg vitamin A deficiency) and the positive impact of the ignorance of the fact that the child could be helped.

© O Okoye, RE Umeh, FU Ezepue, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au
4
 Table 1: Age and sex distribution of the study subject

Age group Sex Total

(years) Male Female
6-9 500 600 1100
10-13 533 382 915
14-16 48 29 77
Total 1081 1011 2092

Table 2: Causes of bilateral subnormal, low vision and unilateral blindness among school children aged
6–16 years old

Cause Vision – n (%) Total

Subnormal Visual impairment Unilateral (N=2092)
(VA <6/9- (VA <6/18->3/60) blindness n (%)
6/18) (VA<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)
VA, Visual acuity.

Table 3: Distribution of ocular disorders according to age

Ocular disorder Age (years) – n (%) Total

6-9 10-13 14 -16 n (%)
Vernal conjunctivitis 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 7 (5.6) 2 (1.5) - 9 (7.1)
haemorrhage
Ptosis 5 (3.9) 1 (0.8) 2 (1.5) 8 (6.2)
Amblyopia 1 (0.8) 5 (3.9) - 6 (4.7)
Hordeolum externa 4 (3.1) 1 (0.8) - 5 (3.9)
Miscellaneous 8( 6.2) 15 (11.8) 1 (0.8) 24 (18.9)
Total 58 (45.8) 61 (48) 8 (6.2) 127 (100)

© O Okoye, RE Umeh, FU Ezepue, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au
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However, in this study 4 (0.2%) of the 2092 children used in the present study would result in a higher number of
examined had visual acuity of <3/60 in one eye, which children diagnosed with subnormal vision. Overall, this
corresponds to monocular blindness. The four contributing underscores the importance of regular eye screening of
causes were congenital glaucoma, traumatic cataract, optic children because early correction of vision is necessary to
neuropathy resulting from blunt trauma to the brow, and prevent amblyopia.
macular chorioretinal scar. In Oragwu’s study17, the 3
(0.18%) cases of monocular blindness were due to traumatic Most of the curable and preventable ocular disorders found
cataract, phthisis bulbi and squint. That trauma was were due to factors for which there are intervention
responsible for 50% of the present cases and 100% of programs. For instance monocular blindness from traumatic
Oragwu’s suggests that simple preventive measures to reduce cataract is curable surgically (if the lens is the only structure
the occurrence of ocular injuries may significantly reduce the affected), while amblyopia can be prevented by early
prevalence of monocular blindness in childhood in this study detection and treatment. Such interventions can be enabled
area. by regular vision screening of children; intensive eye health
education of children, parents and teachers; and the provision
This study found a 6.1% prevalence of ocular disorders, of human and infrastructural resources to cater for eye
which is lower than in the studies of Nkanga and Dolin10, health, especially in rural areas.
Yoloye20, and Bhar and Abiose24. This may be due to
differences in the study areas and the period of study as some Limitations
ocular disorders have seasonal variability. It may also be a
reflection of improved healthcare delivery over time. A major limitation of this study is that it was school based,
which may not reflect the clinical conditions in this
The commonest ocular disorders identified were vernal community where a significant number of children may not
conjunctivitis, followed by refractive error. Refractive error attend school due to poverty. Also, due to the logistical
was commonest in a similar study in Enugu Nigeria10, while challenges of a daytime study, it was difficult to recognize and
trachoma ranked highest in similar studies in Ethiopia22, and diagnose night blindness. The study did not evaluate
India25. This variation may be attributed to differences in diagnoses recognized and reported by the child,
study areas and populations, with the Ethiopian and Indian parent/guardian or teachers.
studies performed in trachoma-endemic communities.
Although vernal conjunctivitis was the major cause of Conclusion
morbidity in this study, it rarely causes visual impairment,
except where harmful traditional eye medication is used, as is
This study found a prevalence of 6.1% of ocular disorders
common in rural Nigeria. However, in this study refractive
among the primary school children in Abagana, Nigeria. The
error was the cause of subnormal vision in 70% of the
commonest cause of visual impairment was amblyopia, which
children presenting with reduced visual acuity. This is slightly
is preventable, and most cases of visual impairment were
higher than was found in a study by Naidoo et al26, where
either curable or preventable. Vernal conjuctivitis was the
refractive error accounted for 63.4% of causes of reduced
commonest ocular disorder, followed by refractive error,
vision in 191 eyes. While this study was school-based
neither of which contributed to visual impairment. Infective
involving 2092 children, the study by Naidoo et al was
disorders did not feature as important causes of ocular
community-based involving 5599 children. In addition, in this
morbidity. Access to preventative strategies and programs, as
study subnormal vision was defined as visual acuity <6/9,
well as prompt and appropriate attention to curable causes
while in Naidoo et al’s study it was <6/12. The definition

© O Okoye, RE Umeh, FU Ezepue, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au
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will drastically reduce ocular morbidity and blindness among 7. Fazzi E, Signorini S, Bova S, Ondei P, Bianchi PE. Early
children in rural Nigeria. To achieve this, eye care workers intervention in visually impaired children. International Congress
must be encouraged to work in rural areas with the provision Series 2005; 1282: 117-121.
of modern facilities to guarantee viability of rural practice.
Only then will equitable access to quality eye care services 8. Qamar AR. Eye screening in school children: A rapid way.
significantly reduce the burden of eye diseases and blindness Pakistan Journal of Ophthalmology 2006; 22(2): 79-81.
among rural Nigerian children.
9. Khandekar RB, Abdu-Helmi S. Magnitude and determinants of
Acknowledgement refractive error in Oman school children. Saudi Medical Journal
2004; 25: 1388-1393.

The education secretary of Njikoka local government area

10. Nkanga DN, Dolin P. School Vision Screening programme in
and the school heads of the 8 primary schools in Abagana are
Enugu, Nigeria: Assessment of referral criteria for error of
thanked for their cooperation and permission to undertake
refraction. Nigerian Journal of Ophthalmology 1997; 5(1): 34-40.
this study. The authors also thank the Federal Ministry of
Health Nigeria which funded this research through the
11. Abubakar S, Ajaiyeoba A.I Screening for Eye disease in
management of University of Nigeria Teaching Hospital,
Nigerian school children. Nigerian Journal of Ophthalmology 2000;
Enugu.
9(1): 6-9.

References 12. Desai S, Desai R, Desai N, Lohiya S. School eye health

appraisal. Indian Journal of Ophthalmology 1989; 37(4): 173-175.
1. Gilbert C, Foster A. Childhood blindness in the context of vision
2020. The Right to sight. Bulletin WHO 2001; 79: 227-232. 13. Hussain A, Awam H, khan MD. Prevalence of non-vision
impairing condition in a village in Chekwal district, Punjab,
2. Gilbert C. New issues in childhood Blindness. Community Eye Pakistan. Ophthalmic Epidemiology 2004; 11(5): 413-426.
Health Journal 2001; 14(40): 53-56.
14. Smith A, Rodruiguez A, Alio J, Marti N, Teus M, Guillen S et
3. David Y. The Global Initiative VISION 2020: The Right to sight. al. The economic and quality of life impact of seasonal allergic
Childhood Blindness. Community Eye Health Journal 1999; 12(31): conjuctivitis in a Spanish setting. Strabismus 2000; 8(4): 283-285.
44-45.
15. Jones JA, Humphreys JS, Adena MA. Doctors’ perspectives on the
4. Gilbert C. Changing challenges in the control of blindness in viability of rural practice. Rural and Remote Health 4: 305. (Online) 2004.
children. Eye 2007; 21(10): 1338-1343. Available: www.rrh.org.au (Accessed 8 August 2013).

5. WHO. Global Initiative for the Elimination of Avoidable Blindness. 16. Wedner SH, Ross DA, Balira R, Kaji L, Foster A. Prevalence of
Geneva: WHO, 1997. eye diseases in primary school children in a rural area of Tanzania.
British Journal of Ophthalmology 2000; 84: 1291-1297.
6. Shamanna B, Muralikrishnan R. Childhood cataract: magnitude,
management, Economics and Impact. Community Eye Health Journal 17. Oragwu UCI. Survey of Eye Health Status of Primary School
2004; 17(50): 17-18. Children in Nkanu West local Government Area of Enugu State of
Nigeria. Dissertation, National Postgraduate Medical College in
Ophthalmology, Lagos, Nigeria, 2002.

© O Okoye, RE Umeh, FU Ezepue, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au
7
18. Ndu AC, Uzuchukwu BSC. Child gender preference in an 23. Foster A. Worldwide blindness increasing but avoidable.
urban and rural community in Enugu, Eastern Nigeria. Journal of Seminars in Ophthalmology 1993; 8: 166-170.
College of Medicine (University of Nigeria) 2011; 16(1): 24-29.
24. Abiose A, Bhar LS. The ocular health status of Post Primary
19. Nkanga DG, Dolin P. Blindness and visual impairment in Schools in Kaduna. Journal of Paediatric Ophthalmology and Strabismus
primary school children in Enugu State, Nigeria. East African Medical 1980; 17: 337-340.
Journal 1998; 75(8): 478-481.
25. Nazia U, Santhosh K, Khaja BM, Mohammed AZ, Reddy DV.
20. Yoloye MO. Patterns of visual defects and eye disease among A comparative clinical survey of the prevalence of refractive errors
primary school children in Ibadan. Dissertation, National and eye diseases in urban and rural school children. Canadian Journal
Postgraduate Medical College in Ophthalmology, Lagos, Nigeria, of Ophthalmology 2009; 44: 328-333
1990.
26. Naidoo KS, Ragbunandan A, Mashige PK, Govender P,
21. Onyekwe LO, Ajaiyeoba AI, Malu KN. Visual impairment Holden BA, Pokharel GP et al. Refractive error and visual
amongst school-children and adolescents in Jos, Nigeria. Nigerian impairment in African Children in South Africa. Investigative
Journal of Ophthalmology 1998; 6(1): 1-5. Ophthalmology and Visual Sciences 2003; 44(9): 3764-3770.

22. Mohammed S, Abebe B. Common eye diseases in children of

rural community in Goro district, Central Ethiopia. Ethiopian
Journal of Health Development 2005; 19(2): 148-152.

© O Okoye, RE Umeh, FU Ezepue, 2013. A licence to publish this material has been given to James Cook University, http://www.rrh.org.au
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