Microsoft Word - A Rasheed Qamar

Original Article

Eye Screening in School Children: A Rapid
Way

Abdul Rasheed Qamar

Pak J Ophthalmol 2006, Vol. 22 No. 2

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
See end of article for
authors affiliations

…..………………………..

Corrrespondence to:
Abdul Rasheed Qamar
Associate Professor
Deptt. of Ophthalmology,
University College of Medicine
1 Km Raiwind Road, Lahore

Received for publication
November’ 2004
…..………………………..

Purpose: A screening program was carried out in different school in Punjab to
detect the children with refractive errors and refer them to nearest hospitals for
treatment.

Materials and Methods: The screening program was carried out through the
Sight First Program of Lion’s Club International. 38575 school children in
different school were screened in 3 years from 2002 to 2004. A maximum
participation of the teachers and volunteer paramedical staff made it possible
to screen this huge number of schoolchildren.

Results. Out of total 38575 schoolchildren 2069 (5.4%) were found to have
refractive errors.

Conclusion: The protocol described in this paper can be used to screen a large
number of children in less time and with minimal involvement of the
ophthalmologist(s).

arly detection of refractive errors in children is
very important. It prevents the development of
amblyopia and increases the potential for more

effective learning1. The early treatment of amblyopia
leads to better visual outcome2.

In a trial on 177 children, conducted in
Department of Ophthalmology, School of Neuro-
biology, Neurology and Psychiatry, University of
Newcastle upon type, it was observed that delay in
treatment until the age of 5 years did not seem to
influence effectiveness3. Age over 6 years is less likely
to achieve successful outcome4. This shows the
importance of school health service. In France a 23
years experience of involving the Mother and Child
Welfare Services with School Health Services has
shown better results5. Unluckily both these services
are rudimentary in Pakistan.

In this paper a protocol has been described which
was used by author in screening school children

through Sight First Program of Lion’s Club
International.

MATERIALS AND METHODS
The Sight First Program is run on noncommercial
basis exclusively by the vonlunteers. The eye
screening program was done in 3 steps.
Step 1. Teaching the Teachers.
On the day of screening the first step was to brief the
teachers about the signs which they can themselves
detect in the children with refractive errors. I have
found that when these signs are discussed with the
teachers, most of them had already noted them in
some of students in their class not knowing their
significance. After the discussion, the teachers were
asked to go to their classes and note carefully these
signs in all of their students. This did not waste any
time of the students because these signs could be
noted during their routine teaching.
The signs were:

1. Placing the book very close to the eyes when
reading.

2. Squinting: The teachers very readily learned the
Hirschburg test

3. Closing or covering one eye.
4. Excessive blinking.
5. Frequent “day dreaming”.
6. “Learning disabled or “ trouble makers” when

they otherwise had good IQ.
7. Children already using glasses.

I have noted that the students which had been
isolated by the teachers on the basis of these signs
were almost always “positive “, in the sense that they
did have a problem. The “negative” cases (not
detected by the teachers) were covered by giving the
students an option to go to step 2 if they felt any
problem.

Step 2: Eyesight Testing
In step 2 the children were taken to the eyesight
testing area. These children were from two sources:
1. The children isolated by the teachers in Step 1.
2. The children who themselves felt that they had

defective vision.
The eyesight testing area consisted of a square marked
on the floor of a hall or in the playground. Each side of
the square was 12 meters so that when “vision box”
was placed in the center, it was about 6 meters from
each side (Fig 1).

The children stand on the middle part of each side
and by occluding each eye one by one read the chart.
Those who could read whole of the chart with each
eye had normal eyesight and were sent back to the
classes.

The trained paramedical staff was present in the
eyesight testing area to guide the children. They also
sent the children, according to their age, to the side of
the vision box with E chart, pictures or letters.

Fig 1: Eyesight testing area consists of a square 12 m x
12 m. The vision box which is in the center is 6
m from each side. The children stand on the
middle part of each side (shown as the darker
part). The children stand, according to their age,
to the side of the vision box with E chart,
pictures or letters.

In this method the turn over was very fast because

every 5 minutes about 20 to 40 children could check
their eyesight depending on the efficiency of the
paramedical staff. It must be noted that most of the
children were checking their eyesight themselves.
Only very young children needed help. Most of the
children were normal. They either wanted to confirm
their eyesight of just came for fun sake. They were not
discouraged.

The paramedical staff recorded the eyesight of
only those children who had defective vision and
referred them for step 3.

Step 3. Final Disposal
In the step 3 the children referred from step 2 were
examined by an ophthalmologist. Their eyesight was
rechecked and a pinhole test was done to confirm the
refractive errors. They were advised treatment if time
and facilities permitted otherwise they were referred
to the nearest hospitals with their concurrence.

Table 1: Number of children detected in different

Steps of screening programs n (%)

Children detected in step 1 1647 (4.3)

Confirmed in step 2 1288 (78.2)

Final confirmation in step 3 1130 (68.6)

Children detected directly in step 2 954 (2.5)

Cinfirmed in step 3 939 (98.4)

Total children in step 3 2069 (5.4)

RESULTS
The screening program was conducted in 18 schools in
Punjab. 38575 school children from KG to Class 10
were screened during 3 years from 2002 to 2004.

A total number of 2069 (5.4%) children were
detected to have refractive errors. In step 1, 1647
children were detected and referred for step 2. Out of
these 1647 children 1288 were found to have decreased
vision. When these children were referred to step 3 for
confirmation 1130 children were confirmed to have
refractive errors. Out of the children directly reporting
in step 2, 954 were found to have decreased vision.
From this group 939 children were confirmed to have
refractive errors. The children diagnosed in different
steps of screening programs are shown in (Table 1).
DISCUSSION
The importance of the eye screening in children cannot
be overestimated considering the value of prevention
of permanent amblyopia. The magnitude of the
problem can be assessed by a study conducted in
Muscat, Sultanate of Oman. In this study 416,157
school children were evaluated for their visual status
and it was found that 28,765 (6.9 %) students had
defective vision6.

Our result showed 5.4% of schoolchildren having
refractive errors. It may be that some cases were
missed in these rapid screening programs. It is
recommended that, to be more effective, such
screening programs should be repeated at regular
intervals by different organizations.

In Birmingham, UK a study has shown the
efficacy of optometric profession7 for this purpose. In
Pakistan the qualified optometrists are not available
for screening programs. So we mostly depend upon
the ophthalmologists for these programs. The
screening programs are very time consuming,
exhausting and difficult to run especially on
noncommercial volunteer basis.

Considering these difficulties and limitations I
have always been trying to make the Eye Screening
Program more effective with minimum wastage of
time and convenient both of the school children and
the screening team. The protocol presented is in fact

the product of the process of evolution of a number of
procedures tried and rejected. It involves the teachers
and paramedical staff for eye screening, although
every one is working under the direct supervision of
the ophthalmologist(s).

CONCLUSION
The protocol is useful economical and easy to perform
for those interested in eye screening programs for the
children. The real benefit of the eye screening
programs is when they are repeated at regular. A
mandatory eye examination or health evaluation at the
time of admission in school will gradually reduce the
need for such big exercises.

Author’s affiliation
Dr. Abdul Rasheed Qamar
Associate Professor of Ophthalmology,
University College of Medicine
1 Km Raiwind Road, Lahore

REFERENCE
1. Krumholtz I. Results from a pediatric vision screening and its

ability to predict academic performance. Optometry. 2000; 71:
426-30.

2. Williams C, Northstone K, Harrad RA, et al. Amblyopia
treatment outcomes after screening before or at age 3 years:
follow up from randomised trial. Br J Ophthalmol. 2002; 324:
1549.

3. Clarke MP, Wright CM, Hrisos S, et al. Randomised
controlled trial of treatment of unilateral visual impairment
detected at preschool vision screening. BMJ. 2003; 327:1251.

4. Hussein MA, Coats DK, Muthialu A, et al. Risk factors for
treatment failure of anisometropic amblyopia. JAAPOS. 2004;
8: 429-34.

5. Speeg-Schatz C, Lobstein Y, Burget M, et al. A review of
preschool vision screening for strabismus and amblyopia in
France: 23 years experience in the Alsace region. Binocul Vis
Strabismus Q ; 19: 151-8.

6. Khandekar RB, Abdu-Helmi S. Magnitude and determinants
of refractive error in Omani school children. Saudi Med J 2004;
25:1388-93.

7. Logan NS, Gilmartin B. School vision screening, ages 5-16
years: the evidence-base for content, provision and efficacy.
Ophthalmic Physiol Opt. 2004; 24: 481-92.