Microsoft Word - Zareen Mahdi 145 Original Article Pattern of Eye Diseases in Children at Secondary Level Eye Department in Karachi Zareen Mahdi, Shahnawaz Munami, Ziauddin Ahmed Shaikh, Haroon Awan, Shahid Wahab Pak J Ophthalmol 2005, Vol. 22 No.3 . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …………….……………….. Corrrespondence to: Zareen Mahdi Community Ophthalmologist, Prevention & control of Blindness Cell, Eye OPD, Civil Hospital, Karachi. Received for publication July’ 2005 …………….……………….. Purpose: To asses the pattern of common eye diseases in children of 0-15 years of age attending an out patient eye department, Sindh government hospital, new Karachi. Material and Methods: A modified WHO/PBL eye examination proforma in respect of each child was filled in for recording of personal history, examination results and treatment required. The pattern of eye diseases affecting the children of new Karachi causing blindness and visual impairment according to age and sex were assessed. Results: A total of 520 children of which 57.1% were male and 42.9 % female were examined and recorded squint 17.7% was the most common ocular morbidity followed by bacterial conjunctivitis 14.8%, Vernal Catarrh 12.1%, trauma 9.6%, blephritis 7.9%, vitamin A deficiency 7.5%, lid problems 7.5% (chalazion, stye), Corneal ulcers and Corneal opacity accounted for 9.4% ,nasolacrimal duct block 3.7%, trachoma 2.3%, and Cataract 1.4%. Out of 520, 334 children in age group 7-15 i.e. 64.2% were examined for refractive errors and 56.8 %found to be visually impaired. Others causes were less than 1%. Conclusion: The distribution of male and female children was similar in different age groups. The number of eye disease was highest in children age group 7-15 i.e. 64% followed by age group 1-6, i.e. 27.5%, and children less than 1 year were 8.3%. ccording to a recently concluded population census in 1998, Pakistan has an estimated population of 142 million in 2003. It is estimated that 40% of the population is below 16 years of age. The prevalence of blindness in children in Pakistan is estimated to be about 10 per 10,000 children, which means there are about 60,000 blind children. A further 100,000 to 180,000 children are estimated to have low vision1. The high incidences of consanguineous marriages together with maternal infections and environmental factors are responsible for the significant proportion of congenital/developmental abnormalities in these children. Other causes of childhood blindness include nutritional factors and trauma2. In poor countries of the world corneal scarring due to vitamin A deficiency, ophthalmia neonatrum trachoma and use of harmful traditional practices (TP) predominates3. Increasingly, refractive errors is being recognized as an important cause of visual impairment in both children and adults, the type and magnitude of refractive errors clearly changes with advancing age and also appears to be changing overtime , with recent A 146 cohort having higher prevalence than earlier one . Visual acuity is the most appropriate screening test to identify individual with visual impairment due to uncorrected refractive errors5. MATERIAL AND METHODS This was a hospital-based study; and cross sectional in term of time and orientation and descriptive in methodological design. All children 0-15 years attending outpatient at eye OPD in Sindh Government Hospital New Karachi, were included in study. The survey thus commenced on 1st July and extended to 10th August 2002 i.e. 36 days. Logistics and ethical considerations were discussed before the start of the study with the medical superintendent and Head of the ophthalmology department of Sindh Government Hospital New Karachi and they extended full cooperation and the required equipment during the entire survey period. Against the estimated 540 children, a total of 520 children were examined. The subjects were children in the age group 0-15 attending outpatient in Eye Department of Sindh Government Hospital, New Karachi. On an average 12 children attended the said OPD daily from 9a.m to 1p.m daily. All children examined were found to have single ocular problems while a few children had more than one ocular problem. During the study, a detailed history of each child, father’s occupation, immunization, was asked. Children of 0-3 years were examined with a magnifying loop. The visual acuity of all children from age group 0-6 years was excluded, due to time limitation and technique. All children of age group 7- 15 were examined on slit lamp and visual acuity checked with illiterate snellen E chart directly and with pinhole. Children who showed improvement with pinhole were referred, with findings on an outpatient slip, for refraction to the head of ophthalmology department and children who showed no improvement were also referred to the ophthalmologist for direct and indirect ophthalmo- scopy, to exclude any pathology. On anatomical basis the disorders were divided into the diseases affecting the lid, whole globe, cornea, lens, uvea, retina, optic nerve. Data was entered daily in the evening on the computer using Epi Info 2000 version. The data was cleaned, analyzed using the same software, results were drawn and recommendations were suggested. RESULT A total of children 520 of which 57.1% were male and 42.9% female were examined and recorded (Table 1). Few of all children examined had one or more ocular problems. 30 % consanguinity was found, in all examined subjects. One child was mentally retarded and two were found to be physically handicapped. The proportion of diseases as shown in (Table 2) were squint both convergent and divergent i.e. 17.7% Table 1: Distribution of children 0-15 years by age & sex Age (Yrs) Male n (%) Female n (%) Total n (%) < 1 23 (7.7) 20 (8.9) 43 (8.3) 1 – 6 86 (29) 57 (25.6) 143 (27.5) 7 – 15 188 (63.3) 146 (65.5) 334 (64.2) Total 297 (100) 223 (100) 520 (100) Table 2: Proportion of children (0-15) with diseases Diseases Male n (%) Female n (%) Total n (%) Squint 58 (19.5) 34 (15.2) 92 (17.7) Bacterial conjunctivitis 42 (14.1) 35 (15.7) 77 (14.8) Vernal catarrh 51 (17.2) 12 (5.4) 63 (12.1) Trauma 34 (11.4) 16 (7.2) 50 (9.6) Blepharitis 7 (2.4) 34 (15.2) 41 (7.9) Vitamin. A deficiency 31 (10.4) 8 (3.6) 39 (7.5) Lid problem (chalazion, stye) 10 (3.4) 29 (13) 39 (7.5) Corneal ulcer 23 (7.7) 5 (2.2) 28 (5.3) Corneal 13 (4.4) 8 (3.6) 21 (4.1) 147 opacity Nasolacrimal duct block 4 (1.3) 15 (6.7) 19 (3.7) Trachoma 5 (1.7) 7 (3.2) 12 (2.3) Cataract 4 (1.4) 3 (1.4) 7 (1.4) Other <1% 15 (5.1) 17 (7.6) 32 (6.1) Total 297 (100) 223 (100) 520 (100) was the most common ocular morbidity followed by bacterial conjunctivitis 14.8%, vernal catarrh 12.1 %, trauma 9.6 %, the etiology (Table 3) of the trauma in this study was 50% due to foreign bodies, (like Iron particle, plastic, glass piece, paint, glue, tyre burst) 10% due to lime burn, 10% stick injury, and 30 % occurred at home (by rubber bands, needles, fire crackers, while playing with others). Blepharitis 7.9 %, vitamin A deficiency 7.5 % and it was mainly due to malnourishment, poverty and large family sizes. Lid problems (chalazion, stye) 7.5%, Corneal ulcers and corneal opacity accounted for 5.3% and 4.1% respectively, additionally corneal ulceration and scar were due to bacterial conjunctivitis, viral (herpes) conjunctivitis, presence of foreign bodies and trauma, exact details for these few cases in terms of frequencies and percentages is not presented in this document. Naso lacrimal duct block cases 3.6%, trachoma 2.3%, cataract 1.4% and other miscellaneous disease less than 2%, among them few important one include, a case of panophthalmitis, drooping of eyelid, oclusio pupillae, nystagmus, macular degeneration and conjunctival cyst and retinoblastoma. The frequency of eye diseases was highest in children age group 7-15 years in 334 i.e. 64.2%, followed by age group1-6 years 143 i.e. 27.5% and < I year 43 i.e. 8.3 % (Table 4). Out of 520, children 334 in the age group 7-15 only were examined for refractive error, and the frequency was 56.8%. Of the total refractive errors 50% were found to be myopic and 50% were hypermetropic (Fig. 1). Refractive error was found predominately in male children i.e. 70% and 30% in female children (Fig 2). Medication (eye drops) were provided to all who needed it. Children suffering from vitamin A deficiency were provided vitamin A capsules but no one turned up for follow up. All children of cataract and refractive error were referred to ophthalmologist for further evaluation1. DISCUSSION Total children 520 were examined, of which 57.1% males and 42.9% were females children. All of them had eye diseases; number of children had more than one ocular problem. Consanguinity was found in 30 %of cases. Squint was registered among highest number of children 17.7% and followed by bacterial conjunctivitis i.e. 14.8%. The leading cause of monocular blindness was trauma. 148 Table 3: Major causes of trauma Causes Male n (%) Female n (%) Total n (%) Foreign bodies 20 (40) 5 (10) 25 (50) Home injuries 8 (16) 7 (14) 15 (30) Lime burn 2 (4) 3 (6) 5 (10) Stick injury 4 (8) 1 (2) 5 (10) Total 34 (68) 16 (32) 50 (100) Table 4: Distribution of disease in different age group Disease < 1 (y) n (%) 1-6 (y) n (%) 7-15 (y) n (%) Total n (%) Squint 2 (4.7) 10(7) 80 (24) 92 (17.7) Bacterial conjuncti- vitis 16 (37) 31(21.6) 30 (9) 77 (14.8) Vernal catarrh 0 (0) 14(9.8) 49 (14.7) 63 (12.1) Trauma 4 (9.3) 12(8.4) 34 (10.2) 50 (9.6) Blephritis 0 (0) 1(.7) 40 (11.9) 41 (7.9) Vitamin a deficiency 0 (0) 29(20.2) 10 (3) 39 (7.5) Lid prob- lem(chala zion,stye) 2 (4.7) 11(7.7) 26 (7.8) 39 (7.5) Corneal Ulcer 3 (7) 9(6.3) 16 (4.8) 28 (5.3) Corneal opacity 0 (0) 4(2.8) 17 (5) 21 (4.1) Naso lacri- mal duct block 8 (18.6) 9(6.3) 2 (6) 19 (3.7) Trachoma 0 (0) 2(1.4) 10 (3) 12 (2.3) Cataract 2 (4.7) 1(.7) 4 (7) 7 (1.4) Others < 1% 6 (14) 10(7.1) 16 (4.8) 32(6.1) Total 43 (100) 143(100) 334 (100) 520 (100) 50% 50% Myopia Hypermatropia Fig. 1: Types of refractive errors age 7-15 years Total = 190 70% 39% 0% 10% 20% 30% 40% 50% 60% 70% Male Female Male Female Fig. 2: Refractive errors in age group (7-15) years by sex. Total children =334 Both convergent and divergent squints were discovered in 92 i.e 17.7 % children. Squints are common all over the world but do not have any special association with developing countries or tropical environments6. There are many possible causes of squint. Squints develop in children where there is no obvious defect or refractive error in the eye. Convergent squints were more common than divergent squints. Most of them had convergent squint associated with refractive errors. Out of total, there were 24% squints in age group (7-15years), associated with refractive errors, 75 % children had convergent squints whereas 25 % were having divergent squint. Children with Squint were referred to the hospital Ophthalmologist for further evaluation. Hyper- 149 matropic squints were found to be 80 % in age group 0-15 years i.e. 520 and 50% hypermatropic were of total refractive errors i.e. 190, the reason is that hypermetropes were ignored due to illiteracy and squint occurred whereas myopic were noticed by others, so parents seek early treatment. In our study, 80% were hypermetropes; this is also emphasized by Abrahamasson et al where the patient with convergent squint had a pronounced hyper- metropia7. This relation of esotropia to hypermetropia has also been reported by Duke–Elder8. The proportion of squint in our study is similar to study by Chaturved S found, the apparent/latent squint was 7.4%9. In our study squints were almost same proportion in both sexes i.e. 19.5% in male and 15.2% in female children. Futhur studies will be needed to find out reason and mechanism identified so these children can be detected early. It was observed that squints were due to illiteracy and uncorrected refractive errors in children, whose parents cannot afford glasses. The Government/ NGOs should provide literacy and spectacles to young children, who have refractive errors, so they do not develop squint. Squints managed by glasses may need corrective surgery as well. In this study the bacterial conjunctivitis was found in patients 77 (14.8%), the second highest peadiatric ophthalmic disorder. Bacterial conjunctivitis was diagnosed on the presence of purulent discharge in eye. The same results were obtained by Awan and Usman i.e. 34.18%10. In our study 37 % were