Refractive Error and Visual Impairment Among School Children: Result of a South-Eastern Nigerian Regional Survey.

PURPOSE: To determine the prevalence refractive errors and causes of visual impairment in school children in the south-eastern region of Nigeria. METHODS: School-based cross-sectional samples of children 5 to 15 of age in both urban and rural areas were profiled through cluster sampling. The main outcome measures were presenting, uncorrected, and best-corrected visual acuity using the Refractive Error in School-age Children (RESC) protocol. RESULTS: A total of 5723 children were examined during the study period comprising 2686 (46.9%) males and 3037 (53.1%) females; (M:F ratio 0.9:1) and aged 10.49±2.74SD of mean (range, 5 to 15 years). The age group 12 to <13 accounted for the highest 776 (13.6%) number of the study participants. The uncorrected visual acuity (VA) of <20/40 (6/12) was seen in 188 (3.4%) of the study participants while the presenting and best-corrected visual acuity of <20/40 (6/12) were noted in 182 (3.4%) children and 14 (0.2%) children, respectively. Refractive error was the principal cause of visual impairment. CONCLUSION: Prevalence of refractive error is low. Myopia is the principal cause of refractive error occurring more in females and in urban schools. The main cause of visual impairment is refractive error, and most children that need spectacle correction did not have them. Program to identify children with refractive error in addition to providing free or affordable optical services remains the key to preventing visual impairment from refractive error particularly in resource-poor settings.

Using Key Informant Method to Determine the Prevalence and Causes of Childhood Blindness in South-Eastern Nigeria.

PURPOSE: To determine the prevalence and causes of childhood blindness in an underserved community in south-eastern Nigeria using the key informant method. METHODS: This was a descriptive cross-sectional study. Key informants (KI) appointed by their respective communities received 1-day training on identification of blind children in their communities. Two weeks later, the research team visited the agreed sites within the community and examined the identified children. The World Health Organization eye examination record for blind children was used for data collection. Data entry and analysis were done with the Statistical Package for Social Sciences (SPSS) version 17.0. RESULTS: Fifteen blind or severely visually impaired children (age range 3 months to 15 years) were identified in this community; nine of these were brought by the KIs. The prevalence of childhood blindness/severe visual impairment (BL/SVI) was 0.12 per 1000 children. By anatomical classification, operable cataract in 6 (40.0%) was the leading cause of BL/SVI in the series; followed by optic nerve lesions (atrophy/hypoplasia) in 3 (20.0%). The etiology of BL/SVI is unknown for the majority of the children (66.7%). It was presumed hereditary in four children (26.7%). Sixty percent of the blindness was judged avoidable. Only three children (20.0%) were enrolled in the Special Education Centre for the Blind. CONCLUSION: The prevalence of childhood BL/SVI in our study population is low but over half of the blindness is avoidable. There may be a significant backlog of operable childhood cataract in south-eastern Nigeria. The KI method is a practical method for case finding of blind children in rural communities.

Dry Eye Disease: Concordance Between the Diagnostic Tests in African Eyes.

OBJECTIVE: To assess the concordance between the diagnostic tests for dry eye disease (DED) in a Nigerian hospital population. METHODS: The study was a hospital-based cross-sectional survey of adults (≥18 years) presenting at the eye clinic of the University of Nigeria Teaching Hospital (UNTH), Enugu; September-December, 2011. Participants' socio-demographic data were collected. Each subject was assessed for DED using the "Ocular Surface Disease Index" (OSDI) questionnaire, tear-film breakup time (TBUT), and Schirmer test. The intertest concordance was assessed using kappa statistic, correlation, and regression coefficients. RESULTS: The participants (n=402; men: 193) were aged 50.1±19.1 standard deviation years (range: 18-94 years). Dry eye disease was diagnosed in 203 by TBUT, 170 by Schirmer test, and 295 by OSDI; the concordance between the tests were OSDI versus TBUT (Kappa, κ=-0.194); OSDI versus Schirmer (κ=-0.276); and TBUT versus Schirmer (κ=0.082). Ocular Surface Disease Index was inversely correlated with Schirmer test (Spearman ρ=-0.231, P<0.001) and TBUT (ρ=-0.237, P<0.001). In the linear regression model, OSDI was poorly predicted by TBUT (ß=-0.09; 95% confidence interval (CI): -0.26 to -0.03, P=0.14) and Schirmer test (ß=-0.35, 95% CI: -0.53 to -0.18, P=0.18). CONCLUSION: At UNTH, there is poor agreement, and almost equal correlation, between the subjective and objective tests for DED. Therefore, the selection of diagnostic test for DED should be informed by cost-effectiveness and diagnostic resource availability, not diagnostic efficiency or utility.

Eye Injuries Among Primary School Children in Enugu, Nigeria: Rural vs Urban.

A cross-sectional survey of the prevalence of eye injuries among primary school children in two noncontiguous local government areas of Enugu State of Nigeria was undertaken. One of the local government areas was urban, while the other one was rural. Children who were <15 years in two randomly selected primary schools in the urban area and three randomly selected schools in the rural area were interviewed and examined with Snellen chart, pen torch, head loupe, and direct ophthalmoscope. The findings were recorded using a semi-structured questionnaire and the World Health Organization Programme for Prevention of Blindness (WHO/PBL) eye examination form. Training on visual acuity measurement was done for each of the class teachers. A total of 1,236 children <15 years of age were studied and analyzed. Slightly more females, 652 (52.8%), than males, 584 (47.2%), constituted the sample population giving a female/male ratio of 1.1:1. A total of 98 (7.93%) children had evidence of injury to the eye or its adnexa. Eyelid scar was the commonest (5.34%) followed by eyebrow scar (2.10%). Canthal scar was the next (0.32%). Two girls had monocular blindness from eye trauma (0.16%). One had leucoma, while the other had a dislocated lens. All the monocular blind children of this study were from the urban area. The home was the commonest environment for an eye injury (69.39%) followed by the school (20.41%). The farm was next in frequency (7.14%), especially among boys in the rural area. The church and the road/street constituted the remainder. Regarding persons causing the injury, the child's playmate was the commonest (55.10%) followed by self (27.55%). Parents and guardians were the next (9.18%). These were injuries associated with corporal punishment. Corporal punishment-related eye injury, according to this study, appears to be common in the rural area and affects boys predominantly. Other human intermediary agents that cause an eye injury include passersby (2.04%), RTA (2.04%), siblings (2.04%), and others (1.02%). The primary agents that caused an eye injury were sticks/wood, 29 (29.60%); stone, 21 (21.43%); pieces of metal, 19 (19.39%); fall, 10 (10.20%); fight/fist blow, 9 (9.918%); plastic, 2 (2.04%); fingernails, 2 (2.04%); farm tools/fruits, 2 (2.04%); and RTA, glass, and headbutt, each 1.02%. Farm implements/fruits as well as fingernails appear to be fairly common primary agents that cause an eye injury in the rural Enugu, Nigeria. In terms of prevalence, there was no significant difference between the urban and rural areas. The findings from this study showed a high prevalence of eye injury among primary school children. In terms of treatment, 58.16% of the children with an eye injury had no form of treatment for it. The children from this study with monocular blindness did not receive adequate medical treatment. Treatment of an eye injury, according to this study, was sought from chemists (19.39%), at hospital/health centers (16.33%), at home (3.06%), and from traditional healers (3.06%). The persons who treated an eye injury, as observed from this study, were doctors (14.29%), nurses (4.08%), chemists (17.35%), and traditional healers and fathers (3.06% each). The frequency of noninjury-related diagnosis made in this study was refractive error, 4.85%; allergic conjunctivitis, 1.94%; oculocutaneous albinism, 0.24%; prepapillary vascular loops, 0.40%; and then ptosis, exotropia, stye, corneal opacity, and retinitis pigmentosa, 0.08% each. The annual incidence of an eye injury according to this study was 3.48%. The majority of the causes of an eye injury, as per this study, were preventable. Appropriate promotion of preventive eye care among children may go a long way in reducing the burden of blindness from eye injuries.

Prevalence of presbyopia in a rural African community.

INTRODUCTION: When presbyopia (loss of accommodation of the crystalline lens with increasing age) sets in, doing near work becomes associated with headache and eye strain. Reading and writing become a challenge. Literacy levels may be low in rural communities; nevertheless some work other than reading, like sewing, sorting stone from grain and operating mobile phones, is done with dissatisfaction. This study aims to determine the prevalence of presbyopia, the unmet presbyopia need and the presbyopia correction coverage in a rural African community. METHODS: A population-based cross-sectional study was carried out in a rural population aged 35 years and greater, selected by cluster random sampling. Information was sought on biodata of the participants and they were subsequently examined. Distance visual acuity for each participant was determined. Anterior and posterior segments of the eyes were examined. Objective refraction with subjective refinement was done on all subjects with distant visual acuity less than 6/6. Near visual acuity was assessed at 40 cm with distant correction in place if required. Presbyopia was defined as inability to read N8 at 40 cm or requiring an addition of at least +1.00DS to improve near vision to at least N8. Questionnaires were administered to those identified as presbyopic on source of procurement of spectacles (if they had one) and on reasons for non-procurement of presbyopic spectacles. They were also asked to rate their difficulty with various listed near work. Data entry and analysis were done using Statistical Package for the Social Sciences v16.0 and Program for Epidemiologist v4.01 software. RESULTS: A total of 585 subjects (participation rate 81.1%) aged 35 years and greater were interviewed and examined. The prevalence of presbyopia was 63.4% (95% confidence interval (CI) 62.6-64.2%). There was increasing prevalence with increasing age. The met presbyopia need was 17.6%, unmet need was 45.8% and presbyopic correction coverage was 27.8%. The commonest reasons for not procuring presbyopic correction were 'not a priority' (21.5%) and 'cost' (21.2%). CONCLUSIONS: The prevalence of presbyopia in this rural African community is high. Many who need presbyopic correction do not have corrective spectacles.

Dry eye disease: prevalence, distribution and determinants in a hospital-based population.

OBJECTIVES: To determine the prevalence, distribution and risk factors for dry eye disease (DED) in a tertiary ophthalmic outpatient population. METHODS: The study was a cross-sectional descriptive hospital-based survey conducted at the Eye clinic of the University of Nigeria Teaching Hospital (UNTH), Enugu, between September and December, 2011. The participants comprised adult ophthalmic outpatients aged 18 years or older. Participants' sociodemographic data were obtained. Dry eye disease was assessed subjectively with the Ocular Surface Disease Index (OSDI) questionnaire; and objectively with Schirmer's test and Tear-film Break-up Time (TBUT). An OSDI score of ≥ 50 with a TBUT of <10s or Schirmer's test reading of <10mm was considered diagnostic of DED. Descriptive and analytical statistics were performed. In all comparisons, a p<0.05 was considered statistically significant. RESULTS: The participants (n=402) comprised 193 males and 209 females who were aged 50.1 ± 19.06 SD years (range 18-94 years). The majorities of the participants were married - 74.1%, possessed formal education - 86.0% and were civil servants - 33.6%. The prevalence of DED was 19.2%. Dry eye disease was significantly associated with age>40 years (OR 1.88, 95% CI 1.06-3.35, p=0.0004), non-possession of formal education (OR 0.40, 95% CI 0.21-0.74, p=0.001) but not gender (OR 1.48, 95% CI 0.89-2.46, p=0.158). CONCLUSION: The prevalence of DED among ophthalmic outpatients at UNTH, Enugu, is comparatively high. Older age and illiteracy are predictors of DED. There is need for high index of diagnostic suspicion to prevent sight-threatening complications of DED.

Unmet visual needs of children with Down syndrome in an African population: implications for visual and cognitive development.

PURPOSE: To determine the magnitude and types of ocular disorders in children with Down syndrome in an African population and to assess to what extent these visual needs have been met.
 METHODS: This is a cross-sectional study of children with Down syndrome attending a school for the mentally challenged in Southeastern Nigeria. Visual acuity, ocular examination, and cycloplegic refraction were done on all cooperative participants. Information was sought from parents/caregivers to ascertain previous ocular treatment/spectacle usage. 
 RESULTS: A total of 30 children with Down syndrome aged 5-15 years were examined. Uncorrected refractive errors were detected in 76.4% of them. Other lesions included mongoloid slant (53.5%), strabismus (33.3%), ptosis (33.3%), nystagmus (13.3%), and cataract (3.3%). None of the children with refractive errors had ever worn spectacles.
 CONCLUSIONS: Refractive error is a common finding in this population. There is a high unmet visual need in these children. This may have implications for visual and cognitive development. Early screening for ocular disorders in Down syndrome is recommended to detect and treat them.

Challenges in the management of paediatric cataract in a developing country.

AIM: To review the management of cataract in children in a tertiary hospital in a developing country, and to highlight the challenges therein. METHODS: The hospital records of children aged 15 years or less that had cataract surgery at University of Nigeria Teaching Hospital, Enugu from 2005 to 2008 were reviewed retrospectively. Information was obtained on bio-data, pre- and post-operative visual acuity (VA), biometry, and type of surgery, use of intraocular lens (IOL) and presence of co-morbidity. SPSS was used for data entry and analysis. RESULTS: The hospital records of 21 children (26 eyes) were analyzed. There were 12 males (57.1%) and 9 females (42.9%). Pre-operative VA could not be assessed in 11 eyes (42.3%), 14 eyes (53.9%) had VA <3/60 and 1 eye (3.8%) had VA 6/60. Biometry was done in only 5 eyes (19.2%). All eyes had standard extracapsular cataract extraction without primary posterior capsulectomy; 12 eyes (46.2%) had posterior chamber intraocular lens (PC-IOL) implant while 13 eyes (50.0%) had no IOL. After 12 weeks of follow up, vision assessment was available in only 15 eyes. With best correction, VA of 6/18 or better was achieved in only 5 eyes (33.3%). CONCLUSION: Inadequate facilities and inadequate follow up after surgery are some of the challenges in managing paediatric cataract in the developing countries. If these challenges are not addressed, cataract will remain a major cause of childhood blindness and low vision in Africa for many years. There should be collaboration between Paediatric Ophthalmology Centres in industrialized and developing countries to enhance skill transfer. Governmental and International Non-governmental Organizations can go a long way to facilitate this exchange.

An overview of management of pterygium in Nigeria / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To review the management of pterygium in Nigeria.METHODS: The medical records of patients who had pterygium excisions over a four year period (January 1999-December 2002) were reviewed. These patients were seen at University of Nigeria Teaching Hospital and Ebrans Clinic both in Enugu, Nigeria. The analysis of patients' bio-data, clinical presentation, surgical management and post-operative complications were carried out using EPI-INFO version 6.1. Three surgical techniques were employed: bare sclera procedure only (60 eyes); bare sclera with adjuvant 5-fluorouracil (42 eyes)and bare sclera with mitomycin-C, MMC, (22 eyes).RESULTS: One hundred and twenty-four eyes of 72 patients had pterygium excisions and were followed up for a least one year post-operatively. There were 41 males (56.9%) and 31 females (43.1%) giving a male to female rario of 1 :0.8. The mean age was 42.8 years while the range was 20-69 years. Recurrence was highest is stage Ⅲ (55.6%) and lowest in stage Ⅰ (22.2%). Concerning the 3surgical techniques, the recurrence rates were 65.0%, 52%and L3.6% respectively.CONCLUSION: In the management of pterygium in a developing country, early excision with use of intraoperative MMC is advocated. It is safe, affordable, technically easier and less invasive.