Comparison of Outcomes of Vision and Eye Screening of Children of Four Orphanages and School Children of Riyadh.

PURPOSE: The purpose was to compare vision and ocular disease among orphans to age-matched school children and determine the barriers they faced for ophthalmic care in Riyadh, Saudi Arabia.
METHODS: Children of four orphanages of Riyadh (Gr1) were screened for vision refractive error (RE) and eye ailment on "World Sight Day-2019." They were compared to age-matched school children (comparison group; Gr2). The rates of RE, strabismus, amblyopia, and allergic conjunctivitis were estimated in two groups. The coverage of existing eye services for orphan children was reviewed.
RESULTS: We screened 53 children of Gr1 and 106 school children of Gr2. The risk of RE was statistically significantly higher in school children compared to orphan children (odds ratio [OR] = 2.4 [95% confidence interval (CI) 1.2; 4.8] P = 0.01). The coverage of refractive services for Gr1 was significantly lower than for Gr2 (OR = 0.09 [95% CI 0.02; 0.4] P = 0.001). In Gr1, blurry vision (12 children), red eye (2), and itchy eyes (1) were the main symptoms. In Gr2, no child had eye complaints. In Gr1, amblyopia (1), strabismus (1), history of ocular trauma and surgery (1), eye medications needed (2), and systemic health problems were noted in 9 children. In Gr2, amblyopia (4), strabismus (4), and history of ocular surgery were noted in 2 children.
CONCLUSION: Orphan children had less rate of myopia compared to school children. However, unattended ocular pathologies were detected during the screening campaign. The coverage of refractive services was low in these underprivileged children compared to school children. Copyright:

Introduction

The United Nations (UN) and World Health Organization (WHO) recommend that their member countries adopt the “Universal Health” declaration.[12] Goal 3 (”Good Health and Wellbeing”) and Goal 10 (”Reduce Inequalities”) from this declaration should be linked to achieving Sustainable Development Goals.[3] Thus, in addition to providing universal eye health, it is important that there is a concerted effort to address marginalized communities in society.

Underprivileged children such as refugees, orphans, and street children have a higher risk of health problems including ocular diseases compared to age-matched school children and children living with their parents.[45678910]

In Arab countries, there are a number of vision and eye screening initiatives that address ocular problems in school children.[1112131415] However, to the best of our knowledge, there is no peer-reviewed literature on the ocular health of orphans in the Middle East. The Kingdom of Saudi Arabia has a Gross Domestic Product per capita of US $ 23,418.[16] The capital city, Riyadh, has a population of 6 million and 4 orphanages.

A comparison of vision and ocular disease among orphans to a cohort of age-matched healthy children will help determine the barriers faced by orphans and aid in the development of ophthalmic care initiatives for this at-risk population.

Methods

In this retrospective cohort study, we compared the vision and ocular disease among a group of age-matched orphan and healthy children in Riyadh, Saudi Arabia. The Institutional Research Board (2305-P) of King Khaled Eye Specialist Hospital approved this study. The study was conducted in adherence to the guidelines of the Declaration of Helsinki. Data were collected on vision and ocular assessment of children from four orphanages (Group 1) in Riyadh. Ophthalmologists and optometrists from King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia performed the examinations in October 2019 as part of the “World Sight Day” activities. Children with impaired vision were further assessed by pediatric ophthalmologists to determine the cause and pathology. An age-matched group of Saudi children enrolled in kindergarten and government schools were included in the present study as a comparison group (Group 2)

To calculate the sample size for this retrospective cohort study, we assumed a 70% prevalence of refractive error (RE) and other eye ailments among orphan children and 45% in healthy school children.[17] To achieve 95% confidence interval (CI) and 80% power to the study with a 1: 2 ratio, at least 50 children were required in Group 1 and at least 100 in Group 2. Open Epi Statcalc was used for calculating the sample size(Rollin School of Pblic Health, Emory university, USA).[18]

In 2018, medical students visited Saudi preparatory and secondary schools in Riyadh to perform vision and RE screening (1633-P).[17] The data from this screening were used to collect randomly selected healthy children for Group 2 to review vision, RE, and ocular diseases. These groups also included data of another research project for reviewing vision and ocular disease among children in kindergarten (1633-P).[19] RE was first evaluated using a spot screener (autorefractor) and subsequently confirmed by manual refraction and subjective correction by an ophthalmologist in the schools. The ophthalmologist confirmed amblyopia and other ocular pathologies.

In the current study, data were collected on age, gender, and the orphanage center where the child was enrolled. The vision was tested using a Snellen chart at 6 m distance using projection. The uncorrected and best-corrected visual acuity for each eye was documented. Cycloplegic refraction was performed and spectacles were prescribed based on subjective correction 1 week after the initial visit to the eye clinic. The vision and refraction of the worse eye was used to grade vision impairment and RE. The vision was graded as follows: vision >20/60 in the worse eye was considered as “functional normal vision;” vision from 20/60 to 20/200 was considered as moderate visual impairment; vision from 20/200 to 20/400 was considered as severe visual impairment; and vision <20/400 was considered “WHO–Blind.”[20]

Refraction was graded as follows: refraction ≥ 0.75 D without esotropia was considered as hyperopia requiring intervention; ±0.5 D RE was considered emmetropia; mild myopia was defined as a refraction <−0.5 D to −3.0 D; moderate myopia was defined as <−3.0 D to −6.0 D; and RE >−6.0 D was defined as high myopia.[21] If astigmatism was more than ± 1.5D cylindrical, we considered it as high astigmatism. Amblyopia was defined as a 1-line difference in BCVA between eyes.[22]

The data for both groups were entered into an Access® spreadsheet (Microsoft Corp., Redmond, WA, USA) and then transferred to Statistical Package for the Social Studies (SPSS-25; IBM Corp., Armonk, NY, USA). The qualitative data were presented as frequencies and percentage proportions. The mean and standard deviation were calculated for quantitative variables with a normal distribution. If the data were not distributed normally, we estimated the median and interquartile range. The outcomes of both groups were compared as the difference of percentage proportion, the 95% CI, and a two-sided P value. A comparison of continuous variables involved estimation of the difference of mean, the 95% CI, and a two-sided P value. P < 0.05 was considered statistically significant.

Results

The study sample was comprised of 53 children in Group 1 and 106 school children in Group 2. The proportion of boys in Group 1 was marginally greater than in Group 2 (P = 0.09). The distribution of children by age between groups was not statistically different (Chi-square = 2, df = 3, P = 0.2).

In Group 1, there were 37 emmetropes and 16 children with RE (7 hyperopes, 6 with mild myopia and 2 with moderate myopia, and 1 high astigmatism). In Group 2, there were 57 emmetropes and 49 with RE (11 hyperopes, 31 mild myopes, and 7 moderate myopes) [Figure 1]. The risk of RE was statistically significantly higher in Group 2 compared to Group 1 (odds ratio [OR] = 2.4 [95% CI 1.2; 4.8] P = 0.01).

Figure 1

Distribution of refractive error among orphan and school children in Riyadh Saudi Arabia. Emmetropia: <±0.5D spherical equivalent in both eyes. Hyperopia: >+0.5D spherical equivalent in the worse eye. Mild myopia: >−0.5D to −3.0D spherical equivalent in the worse eye. Moderate myopia: >3.0D to −6.0D spherical equivalent in the worse eye. Severe myopia: >−6.0D and more spherical equivalent. High astigmatism: more than 1.5 D cylindrical in the worse eye

Of the 16 children with RE in Group 1, only 2 (12.5%) were previously prescribed spectacles. Of the 49 children with RE in Group 2, 6 (5.7%) were using contact lens and 26 (61.9%) were using spectacles. The coverage of refractive services for Group 1 was significantly lower than for Group 2 (OR = 0.09 [95% CI 0.02; 0.4] P = 0.001).

In Group 1, the main ocular symptoms were 12 children with blurry vision, 2 with red eye, 1 child with itchy eyes. In Group 2, none of the children presented with eye complaints, and this group was part of the vision and refractive screening campaign in 2018.

In Group 1, there was 1 child diagnosed with amblyopia, 1 with strabismus, 1 child had a history of ocular trauma and ocular surgery, 2 children were given eye medications, and 9 children had systemic health problems. In Group 2, 4 children had amblyopia, 4 had strabismus, and there was a history of ocular surgery in 2 children.

Discussion

In the present study, there was a lower prevalence of RE among children from orphanages compared to age-matched school children in Riyadh, the capital city of Saudi Arabia. On ocular examination, children from the orphanages had more complaints and symptoms and there was lower coverage of refractive services compared to school children.

Orphan children worldwide are underprivileged and have less access to health care compared to children living with their parents.[23] These observations are magnified in children who have experienced civil conflict, war, or HIV epidemics that affected young parents.[2425] In these children, there is a high prevalence of diseases related to the malnutrition and poor hygiene.[2627] To the best of our knowledge, this is the first peer-reviewed study in the literature addressing the issue of eye health among orphans in an urban area of an affluent country compared to the children of a similar age group living with their parents and attending school.

In our study, RE, mainly myopia, was less prevalent among orphan children compared to school children. Myopia is linked to the near work activities such as reading, writing, and working on computers and smartphones.[2829] The orphan children have limited availability of digital devices compared to the school children, and this may be protective against the development of myopia. Interestingly, no orphan child had moderate and high myopia. High myopia in early childhood has a genetic etiology; however, acquired factors also have an effect on the development of myopia.[30] Hence, children in both groups should be periodically assessed for disabling RE that may affect early childhood development.

In the absence of periodic vision and eye screening initiative of school children, the coverage of refractive services in Riyadh by professionals at optical shops or eye hospitals is reasonably high but warrants improvement. In contrast, orphan children seem to face barriers to accessing refractive services that require resolution by national eye health services and administrators at orphanages.

Compared to school children, orphan children had a number of unaddressed eye diseases. This observation is likely explained by the fact that parents of school children are presumably more vigilant and actively seek out eye care for their children. This difference could be addressed by a system of prompt referral and periodic vision assessment and ocular health assessment by trained nurses or mid-level eye care providers by visiting children at orphanages.

There are some limitations to our study. The vision and ocular health screening of orphans was performed at an eye hospital, whereas school children were examined at schools. In the former eye examination and refraction, testing was performed in a clinical setting. In the school, it was using a spot screener first, followed by a detailed assessment by an ophthalmologist. The validity of RE detection even in young children is very high.[1731] Therefore, the outcomes are comparable between groups. Ophthalmologists examined all children with ocular disease/pathology. Hence, the differing RE and ocular disease between groups were not likely due to the different locales of the participants. The sample size calculation was based on the high prevalence of RE in children of orphanage compared to school children. However, the final results of the present study revealed lower prevalence of RE in orphan children than school children. This could have introduced error in the present study and therefore should be interpreted with caution before comparing them to other studies.

Conclusion

Our study shows that orphan children in a large city in Saudi Arabia have unattended ocular pathology. The pathologies were detected during a screening campaign (”World Sight Day”). All children were brought to an eye hospital to undergo vision and eye examination. Such initiatives should be done more frequently and at the national level to cover orphan children throughout the country. In addition, periodic eye screening should be organized and those with the ocular disease should be offered care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.