PREVALENCE OF REFRACTIVE ERRORS AND STRABISMUS

AMONG THE CHILDREN’S OF SPECIAL EDUCATION

COMPLEX, PESHAWAR

“A thesis submitted by”

BISMA SALEEM

Master Scholar in Public Health

Institute of Public Health and Social Sciences

Supervised by
DR AYAZ AYUB
MBBS,M.P.H
Assistant Professor
Institute of Public health and Social Sciences,KMU

KHYBER MEDICAL UNIVERSITY, PESHAWAR

Session 2015-17
 Declaration
By Scholar:

I certify that this thesis titled “Prevalence of refractive errors and strabismus among the
children’s of special education complex, Peshawar” is based on my own independent work,
except where acknowledged in the text by reference. No part of this work has been submitted for
a degree or diploma to this or any other university.

_________________________________________
BISMA SALEEM
Master Scholar in Public Health
Institute of Public Health and Social Sciencs
Khyber Medical University Peshawar

By Supervisor:

I hereby, certify that Bisma Saleem having KMU Registration Number:, has been working under
my direct supervision with effect from: February 20, 2017 to date in the Institute of Public
Health and Social Sciences, of Khyber Medical University, Peshawar. The enclosed thesis titled:
“Prevalence of refractive errors and strabismus among the children’s of special education
complex Peshawar” was prepared according to the thesis guidelines of KMU under my direct
supervision. I have read the thesis and have found it satisfactory for further submission and
review / viva by external examiners.

_________________________________________
Dr Ayaz Ayub
Dr Hamid Hussian
Dedication:

This research was dedicated to my parents; teachers and friends always supported
me in my educational career.
Acknowledgement:

All praise is to Allah Almighty, The Omnipotent, Omnipresent and Omniscient

who enabled us to undertake and successfully complete this tremendous task.

Thanks to Dr.Ayaz Ayub and Dr Hamid Hussian for their guidance, valuable
suggestion, wise counsel and very nice attitude while completing this research.

I thanks to all the individuals who have contributed in this research and special
thanks to Special Education Complex director, who is very supportive and also the
staff members.
I thanks to my parents and family members because without their encouragement
and guidance I would not have been possible to complete this task.
 Abbreviations:

KPK: Khyber Pakhtunkhwa

KMU: Khyber Medical University
WHO: World Health Organization
ASRB: Advance Studies and Research Board
IOL: Intra Ocular Lens
PRK: Photorefractive Keratectomy
Lasik: Laser Assisted Stromal in Situ Keratomileusis
ADL: Activities of Daily Life
NPC: Near point of convergence
Chapter 1
Introduction
BACKGROUND:

Visual impairment which is not corrected is a major public health problem.

Worldwide prevalence of myopia and presbyopia are dramatically increased. (1)
Low vision is the main cause of visual impairment and the second leading cause of
Blindness.(2) Worldwide 285 million people live with visually impaired.
Approximately 39 million people are blind and 246 were low vision.(3)

Children which are school going may have many vision related problems, one on
four school age children have vision problems according to Prevent Blindness
American and if it is not treated than is will affect personality, learning ability and
adjustment in school. Some of the school going children may take part in many
recreational activities that require sharp and good vision.(4)

Children with special educational needs are more likely to have refractive errors
and visual impairment than children without special educational needs.(5)

All children who are disabled may also need some special education and also have
a right to education. The main function to provide proper education to these special
children as applies to all children. Education is about to develop in all these aspects
including, cognitive, moral, spiritual, imaginative, mentally, social, emotional,
aesthetic, and physical.(6)
Ocular and visual disorders such as refractive errors, strabismus, nystagmus,
cataract, reduced visual acuity(VA) and poor accommodation are found to be more
common in children with intellectual disabilities than in typically developing
children.(7)

Consanguineous marriage together with environmental factors and maternal

infections have high incidence for developmental/ congenital abnormalities in
children. Other causes include trauma, nutritional factors of childhood blindness.
Vitamin A deficiency, corneal scaring, trachoma and ophthalmia neonatrum and
use of harmful traditions practice can occur in poor countries of the world.(8)

REFRACTIVE ERRORS:
Refractive errors occur when the light is not directly focus on the retina so it causes
blurring of vision. The size and length of the eyeball (longer or shorter) ,aging of
the lens, change in the shape of cornea all causes refractive errors.

HYPEROPIA:
Hyperopia also called Farsightedness when the light is focus behind the retina. In
hyperopia people will see near objects blur and distant objects clear.
Many of the children including babies tend to have no blurry vision with mild
hyperopia. Both distance and near vision is clear because their eyes can focus,
gradually when the person get older it losses ability to focus(9)

MYOPIA:
Myopia also called Nearsightedness when the light is focus in front of the retina
and it causes blurring of vision. In myopia near objects become clear while the
distant objects appear to be blurring.
Myopia can run in family and it is inherited, if myopia is present in parents than
definitely you will suffer from myopia. 8 to 12 age of children were often
diagnosed with myopia and if their bodies grow the myopia become more worsen.
Myopia changes very little between the ages of 20 and 40. Low myopia is called
mild myopia while high myopia is called severe myopia. Detached retina can occur
in the children or persons who may have high myopia, and it cause blindness
because it is a severe eye problem.

ASTIGAMATISM:
Astigmatism is also called distorted vision it may blur or distorts vision for both
distant and close up objects. When the eyes were not perfectly round like a ball
than it cause astigmatism. Myopia and hyperopia is occurring along with
astigmatism.

PRESBYOPIA:
Presbyopia can occur when there is difficulty in reading near objects. It usually
begins after 40. If the person is myopic, hyperopic, astigmatism also presbyopia
can occur when the person reach at 40’s. (10)

WHO IS AT RISK OF REFRACTIVE ERRORS?

The adult’s whose age is over 35 most affected by presbyopia. Adult and children
both affect by refractive errors. Refractive errors which are present in parents may
be more likely to be run in their family.
SIGNS AND SYMPTOMS OF REFRACTIVE ERRORS:
The most common symptom which is occurring in all refractive errors are blurred
vision. Other symptoms may include headache, eye strain, diplopia, glare,
squinting and haziness.(11)

DIAGNOSIS OF REFRACTIVE ERRORS:

Refractive errors can be diagnosed by optometrist of ophthalmologist with the help
of different machines including retinoscope, retino box/ refraction box. One by one
lens from the refraction box is placed in front of the patient eye to evaluate, or trial
of eyeglasses prescriptions. And the patient tells the optometrist that which one
lens is clearer to him/her. The patients like children, mentally retard or special
children who are not cooperated with these lenses, than go through for
retinoscopy.(12)

TREATMENT OF REFRACTIVE ERRORS:

Refractive errors can be treated by lenses, concave and convex lenses. In myopic
correction contact lenses can use. Surgery is also done that include
Keratorefractive, minus phakic IOL, for high myopia clear lens extraction,
intracorneal rings for low degree. Excimer laser was also done like PRK or
LASIK.(13)

STRABISMUS:
It is also known as squint. Crossing or misalignment of two eye is called
strabismus.
By direction the strabismus can b classify in different types including
Esotropia an inward deviation of eyes
Exotropia an outward deviation of eyes
Hypertropia upward deviation of the eyes
Hypotropia downward deviation of the eyes
The squint may be present for all the time that is called constant or when it is
present for sometimes it is intermittent. The tropia is present if the affected eye
turns when the eye is open and phoria is present if the affected eye shut or
close.(14)

CAUSE OF STRABISMUS:
Poorly control of neuromuscular eye movement is the result of strabismus.
A problem with the actual eye muscle causes less commonly strabismus.

STRABISMUS RELATED TO POOR VISION:

Amblyopia is the major reason of developing poor vision in children. The brain
can receive two images when the eyes are oriented in different directions. The
crossed or misaligned eye can ignore the image from the brain to avoid double
vision which resulting in poor vision.

DEVELOPMENT OF STRABISMUS IN CHILDREN:

The normal children may develop strabismus, but some other disorders that may
affect the brain such as Down syndrome, hydrocephalus, cerebral palsy, and brain
tumor may develop strabismus.

DISORDERS OF ADULT CAUSES STRABISMUS:

The leading cause of strabismus in adults is stroke. Some other causes of
strabismus in adult are neurological problems, trauma, and Graves’s disease.(15)

SYMPTOMS OF STRABISMUS:
The eye is not straight is one of the main symptom. Those children whose eyes are
squint with one eye in bright sunlight or sometime focus on something may tilt
their head for clear vision.

DIAGNOSIS OF STRABISMUS:
An eye examination can be done for the diagnosis of strabismus. The
ophthalmologist, optometrist and family doctor may check strabismus before the
age of four years in children. The ophthalmologist can check the vision of the child
before the age of three years when there is positive history of squint and
amblyopia. The true and false strabismus can also identify by ophthalmologist.

TREATMENT OF STRABISMUS:
Complete examination of eyes an ophthalmologist may recommend treatment for
strabismus that works to straighten the eyes, to preserve vision, and to restore
binocular vision. The most common treatment for strabismus is to provide glasses
or advise patching in some cases if the vision of one eye is very poor. And
sometimes surgery may do to correct the unbalanced eye muscles.(16)

DISTRIBUTION OF SPECIAL EDUCATION SCHOOLS IN KP:

In Khyber Pakhtunkhwa there are 39 functional governments’ special education

schools. There are 15% male, 4% female and 83% are co education. Primary
schools are 63%, middle/high 37%. 2225 students enrolled in government special
education centers. By gender there are 73% male, 27% are female. Total schools
are 39 in which 17 are working in government building and 22 are in rented
building. Visually handicapped are 14%, mentally retard and physically
handicapped centers are 26% and deaf and dumb are 60%.(17)
Research objective:
 To determine the prevalence of refractive errors among students of special
education complex.
 To determine the prevalence of strabismus among students of special
education complex.
Operational definitions:
Refractive errors: can be measured with Auto refractor or Retinoscope.

Myopia: Mild: -0.25 to -3.00 Diopters

Moderate: -3.00 to 6.00 Diopters
High: over -6.00 Diopters.(18)
Hyperopic: Low: +0.25 to+3 Diopter
Medium: +3.25 to +5 Diopter
High :> +5 Diopters.(19)
Astigmatism: Low: up to 3.0 Diopters
Medium: from 3.0 to 6.0 Diopters
High: over 6.0 Diopters.(20)
Strabismus:
Hirschberg test is used to identify the squint.
1mm decentration of the corneal light reflection approximately 7 degrees or 15
prisms.
Reflex at pupillary margin is about 2mm from the pupillary center approximately
15 degrees or 30 prisms.
Reflex in the mid iris region is about 4mm from the pupillary center approximately
30 degrees or 60 prism.
Reflex at limbus is about 45 degrees or 90 prism.(21)

Special Education:
It refers a range of educational and social services that is provided by public and
other educational institutions to individuals with disabilities with the age between 3
and 21 years.(22)

Summary of Chapter 1:
From discussion it is clear that refractive errors are the major public health
problem. If refractive errors were not correctly identified especially in children it
may become more severe. So it is also necessary to identified any of eye disorder
in special education children. If not treated on time than is cause many symptoms
like amblyopia, headache, diplopia and many more.
In the next chapter a detail literature will be discussed which is taken all around the
literature of the world.
Chapter 2
Literature review
Introduction of literature review:
The aim of literature review is to show individuals that you have good grasp of
literature to addition of new knowledge and address the uncovered gaps.
This chapter includes review of past researches on refractive and strabismus in
special education schools.
Objective of literature review:
The objective of objective review was that to identify existing research,
information and gaps in the literature that need to be addressed.
Literature search:
Find the articles that are most relevant to research objectives and research question.
Research question:
To determine the prevalence of refractive errors and strabismus among the students
of special education complex, Khyber Pakhtunkhwa, Pakistan
Inclusion criteria:
 Original articles
 Abstract
 Systematic reviews
Exclusion criteria:
 Non English articles
 Editorial
  Case report
 Duplication of articles

Searching the relevant literature:

Pubmed, Google scholer, Science direct, Springer link were the main literature
search engines to fine the relevant articles or topics.
Search terms:
The following search words were used to find the relevant topic or articles.
 Refractive errors
 Strabismus
 Refractive errors and strabismus in children
 Refractive errors and strabismus in special education schools

BURDEN OF PREVALENCE OF REFRACTIVE ERRORS AND

STRABISMUS AMONG THE WORLD:

A study was done in special education schools in Wales, UK to identify the visual
status and ocular disorders. The study is divided in to three phases. In 1st phase
they send questionnaire to 44 special schools in Wales. The questionnaire is about
to what information school has according to vision or vision problem. Those who
did not response to questionnaire than telephone interview carried out. So this is
the screening test. Out of 44 schools 5 schools has reported that the vision is not
well so they have decided to have two optometrists who are specialized in
assessment of these special children. A full eye examination can be carried out by
these optometrists. If the children diagnosed with any problem than advice for
further treatment or prescribed glasses. In phase 3 feedbacks was taken from all the
schools who has participated in this and also from the parents whose children
identify with any refractive error. From this study it show that the five schools
presented with refractive errors and low vision. (5)

Another study was conducted in Osan state of Nigeria. This study is about the
cause’s enrolment of children in special schools and ocular health status of those
children. A cross sectional study done in 8 schools in which 6 primary schools and
2 secondary schools, total number of children including in this study was 472. In
this study the person with low income more affected by ocular diseases. 4.7 %
were blind, and 9.9% of students seen with abnormal ocular findings. This is a
good study because the common eye diseases can easily prevented.(23)

Visual impairment is due to refractive errors and this risk is increased if the
students suffer from cognitive impairment. In Hualien the city of Taiwan a study
was conducted in special schools. 241 students from the special school were
examined of their various eye conditions. Total numbers of children which suffer
from refractive errors were 35.4%. 34.8% children need glasses. In this study it
show that the higher prevalence of ocular disorders are more common in multiple
disability than the simple intellectual disability group.(24)

In India, Pune a study was conducted in 11 special schools of learning disabilities.

The eye examination was done by ophthalmologist, optometrist but also parents
and teachers note any of the following like squint, the child sit close to television,
reading books very close to eye or sit very close to blackboard. Drooping of upper
lids, rubbing of eyes, red eyes, itching, white spot in the eye, history of night
blindness. This is the best study that was done because it include previous medical
history of the mother related to details of birth and other medical history is related
to child including down syndrome, cerebral palsy, epilepsy etc. Detail external
ocular examinations were carried out with flashlight or diffuse illumination.
Abnormal head posture, ocular mortality, and facial anomalies were noted. Hisrch
berg test perform on the children which suffer from strabismus. Cycloplegic
refraction was done in children which are not cooperative or inability to talk. Half
of the children suffer from refractive errors and one fourth had their vision
improved.(25)

One of the major health issues which affect the quality of life is hearing disorder.
One such study was done in Iran that children with hearing impairment compare
with different eye problems. In deaf children or people vision is one of the
important senses that communicate. Cross sectional study was done in two groups
of people one is deaf children and the other is non deaf children and compared
these two groups in terms of eye problems including refractive errors, strabismus
and amblyopia. The examination was done in proper lighting and done cycloplegic
refraction in children those are not cooperative. Refraction was done with
refraction box and retinoscope, cover test is performing for squint children. This
study simply shows that the deaf children have significantly more eye problems as
compared to normal children, and the possible relation found between deafness and
eye problems. If proper treatment and attention is pay to these children than these
eye problems can easily be cured.(26)
Joshi RS and Somani AAK carried out one study that is related to ocular disorders
in mentally retard children. It was understood that vision or ocular disorders are
neglected in mentally retard children. So this study was done in India to identify
the eye problems and their relationship with degree of retardation. Diagnostic and
Statistical Manual of Mental Disorders diagnostic criteria was used for the
diagnosis of mental level and Binet Kamat was used to assessed Intelligence
quotient. A detail medical or previously history was taken. Eyes checkup
optometrist or ophthalmology, children which are cooperative using C chart,
children which are not cooperative using pictures or done objective refraction with
the help of retinoscope. The study show that 124 children suffer from ocular
disorders with mental retardation. The children with any disability have higher risk
of ocular disorders so annually checkup of these children will help them in their
future life activities.(8)

A strong relationship is found between functions of various organs of sensation

especially in ears and eyes. One such study was done in Nepal deaf school. It was a
cross sectional study and check on 87 students. Ophthalmologist, optometrist,
technicians, eye worker, ophthalmic assistants were carried out. The deaf children
responded the vision in their sign language. Children those are not cooperative can
be assessed bye cycloplegic refractive or objective refraction. Children with severe
abnormalities further refer to hospital, or children who are identifying with
refractive errors prescription will be prescribed. Refractive errors found in deaf
children are 14.94%. The refractive errors are common in deaf children as
compared with normal children.(27)

Another study on hearing impairment is done in blind school of Nigeria. Many

previous studies demonstrated that vision impairment and hearing influence the
Activities of daily living (ADL). Hearing and visual impairment increase the risk
of fear of falling, fall, feeling unsafe, reduced social participation, dependency and
also the main difficulty in daily life activities. The survey of blind school was done
in Kaduna, Nigeria. Basic ear examination, family history of hearing loss, duration
of hearing impairment, causes of ear disease and audiometric data was utilized by
WHO ear and Hearing disorders survey protocol is used. Eye examination was
done by ophthalmoscope and ear examination was done by audiometricians.58
students were recruited for the study in which 17.2% students were deaf. Efforts
are needed towards promoting aural hygiene practices, introducing sustainable
rehabilitative access for hearing aids, strengthening hearing screening for blind
school or persons with dual disability.(28)

A screening was done in deaf school of Nigeria for ophthalmic problems.

Incidence of visual problems is higher in deaf children as compared to normal
children. Ocular examination was done by optometrist, ophthalmologist with the
help of bright penlight and visual acuity was carried out by Snellen chart. Perkins
tonometer was used to measure the intraocular pressure. In this study significant
causes of low vision, ptosis, squint, ptergyium, and pale cupped disc were seen.
This study show that significant vision problems seen in deaf children.(29)

Visual disorders such as poor accommodation, refractive errors, nystagmus, squint,

reduced visual acuity, cataract are more common in children having certain
disabilities than in normal children. In developed countries there has been great
progress in the field of vision problems for children with intellectual disabilities.
One such study was done in special schools of Nepal to identify the children with
any eye problem. This was done in seven schools of Kathmandu valley. Visual
acuity was assessed by using Snellen’s visual acuity chart, those children unable to
cooperate or participate using Kays pictures and Keeler Acuity Test. Strabismus
was measured by Krimsky Test or Hisrchberg Test. For contrast sensitivity Hiding
Heidi was used. In this study commonest visual disorders were Refractive errors
and strabismus. Other ocular findings include blepharitis, conjunctivitis, ectropion
and chalazion. (7)

Aden the city of Yemen conducted a study on deaf and dumb students having
ocular abnormalities. The visual acuity was assessed by using snellen visual acuity
chart. Ocular mortality, anterior segment examination, alternate cover test,
pupillary evaluation conducted with the help of slit lamp. The leading abnormality
was refractive errors, Warrdenburg syndrome and pigment epithelium patches
were seen in this study. (30)

Ovenseri-Ogbomo G, Abraham C carried out a study of ocular findings and visual

impairment among hearing and deaf impaired children. It was a cross sectional
study. At the time of admission these children was examined by otolaryngologist to
identify that the child was hearing impaired or deaf. No previous eye examination
was done in these children. The eye examination was carried out by trained
optometrist, check out the detail eye examination including refraction, cover test,
near point of convergence test (NPC), with the help of direct ophthalmoscope and
pen torch internal and external eye examination was done. A refractive error with
the astigmatism is the commonest form of refractive error in this study. (31)

Burden of Prevalence of refractive errors and strabismus in Pakistan:

Prevalence of refractive errors and strabismus is a major public health issue in
Pakistan. Literature search showed no specific work on prevalence of refractive
errors and strabismus in special education schools in Pakistan. Although literature
is available regarding prevalence of refractive errors and strabismus in others
schools. Due to lack of awareness these special children need extra need, attention
and care if these children are not observed at early age than they lead to severe eye
problems. In Khyber Pakhtunkhwa there are many special education schools but no
one else focus on these schools.

Various studies were done on prevalence of refractive errors in Pakistan. A cross

sectional study was conducted in Lahore. High schools children taken from class
6th to 10th. Visual acuity of all children was checked. Retinoscopy and refraction
was done on those children identify with refractive error. The result shows that
myopia and astigmatism was more common in children than hypermetropia. The
positive family history was found between closely watching on television, wearing
glasses, studying in dim light and close study. It was recommended that preschool
examination of children was mandatory and also examination of children was
carried out annually. (32)

Another study was done in Rawalpindi, it was a cross sectional study on risk
factors related for refractive errors in school going children. Convenient sampling
was done using a structured questionnaire to assess the risk factors associated with
refractive errors. In this studies students was grouped in different categories i.e.
dietary habit, daily routine, ocular hygiene and personal hygiene. If all these
categories of students are maintained than there is no chance of refractive errors. A
student with good daily routine was less likely to exhibit refractive errors. (33)

Z.Atta and A.Arif carried out the cross sectional study in Madrassa students of
Haripur district. The reason for selecting these madrassa students is that they
continuously work on reciting, memorizing and reading the Holy Quran. Few
madrassas provide basic health care services to these students but majority was
neglected. Refraction was done these students including wet and dry retinoscopy.
Jack cross cylinder and blur test was used. This study shows that the myopia is
more common in children than hyperopia and astigmatism. As continue reading
increase the chances of myopia, so encourage children to take break between
readings and read at further distance.(34)

Chapter 3
Methodology
INTRODUCTION:
This chapter describes the methodology of the study in detail. It explains study
population, study design, study duration, inclusion and exclusion criteria, data
collection instrument, data collection procedure, ethical consideration, and data
entry and data analysis.

Study design and type:

This study was cross sectional study design which is a type of analytical study.

Study setting:
Peshawar:
Peshawar is the capital of Khyber Pakhtunkhwa, it is the largest city of KP
province. It is most populous city in Pakistan. In 2014 the total population of
Peshawar is 1.755 million and the area is 1,257 km2. There are 39 functional
government special schools in KP. Special education complex is only one having
categories of deaf, mentally retard, physically handicap and blind. Data was
collected from this special education complex.

Study duration:
6 months.

Sampling technique:
Census was followed.
Inclusion criteria:
All the students registered in daily attendance sheet of special education complex
of Peshawar.

Exclusion criteria:
Those students who are blind.
Those students absent on the day of data collection.
Those who are unwilling to participate in the study.

Data collection procedure:

Data was collected after synopsis was approved by Graduate Committee,
Advanced Scientific Research Board (ASRB) of Khyber Medical University.
Than visit social welfare department of Khyber Pakhtunkhwa for approval to
conduct the study in special education complex registered with them. The
researcher will visit the complex on respective dates after the inform consent by
parents of students, students and teachers. The next day researcher and team will
visit again for detail examination which include relevant history regarding the type
of disability, etc was recorded. Ocular examination was carried out with
retinoscope, ophthalmoscope and flash light. Snellen’s E chart, Kay symbols were
used for assessing the visual acuity in children who could read and co operate.
The questionnaire will be filled to obtain the objectives of the study.

Data analysis procedure:

  Descriptive statistics: For scale variables i.e. age (in years) mean and
standard deviation will be calculated while for categorical variables i.e.
gender frequencies and percentages will be calculated.
 Chi square test will be used for association between variables like gender,
strabismus and refractive errors.
 Independent t test will be used for association of age with strabismus.

Technical and Ethical Approval:

As per rules of the university, approval of the study was granted by the
Advanced Studies Research Board in the 49th meeting held on 8/5/2017
(Annexure No ). The approval/permission was obtained from Khyber Medical
University Research and Ethics board in the meeting held on 4/7/2017
(Annexure No )

Summary:
In the summary, was cross sectional study and the sampling technique was census,
conducted in Peshawar, KP. Prevalence of refractive errors and strabismus were
including in this study. Technical approval was taken from Graduate Committee
and ASRB. The approval was obtained from KMU research and ethics board.
For data analysis SPSS version 20 was used. Mean and standard deviation were
calculated while for categorical variables i.e. gender frequencies and percentages
were calculated. Chi square test was used for association between variables like
gender, strabismus and refractive errors. Independent t test was used for
association of age with strabismus.
The next chapter includes the result and analysis of this study.
Snellen visual acuity chart
Child responded by sign language
Examination of eyes
Examination of eye with the help of Retinoscope
Child with Down syndrome
The child with one eye having micro cornea and ptergyium
Chapter 4
Results
Descriptive Statistics:
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