Paediatric Refractive Error among Hospital Attending Population in the Maldives Rajendra Gyawali Consultant optometrist, Male’ Eye Clinic Maldives Lecturer Optometrist, Asmara College of Health Sciences, Eritrea Fathimath Nestha Mohamed Nabin Paudel Department of Optometry and Vision Science, University of Auckland, New Zealand Asmara College of Health Sciences, Eritrea Email: gyawali.rajendra@gmail.com  

INTRODUCTION Uncorrected refractive error as a global public health problem 12.8 M visually impaired children with prevalence of 0.97%(WH0) Significant and large geographic differences in prevalence of refractive error in children(RESC) WHO blindness estimation Maldives  0.8% Causes Cataract, refractive error and childhood blindness(V2020 MALDIVES) Higher prevalence in China and urban areas of south east Asia4. No population based surveys on blindness, disease pattern and management available from Maldives

INTRODUCTION Maldives Eye Care Population of 319,000, 1,190 coral islands (90,000 Km2) Only 200 are inhabited Capital  Male’ (2/3rd population) Eye Care 6 regional hospital eye departments Eye care services concentrated in capital Male’ Lack of evidence based information Local optometrist: 1, Local ophthalmologist: 4, Expat optometrist: 7, Expat Ophthalmologist: 2 (all in Male’) In Male’: Two tertiary hospital eye departments, Seven eye clinics, Several optical outlets Other Islands: Government and private outreach programs, Eye clinic in one island only (Addu), Few optical outlets

OBJECTIVES Assess the prevalence of refractive errors among hospital attending children Observe the association of different types of refractive errors with age and gender

METHODOLOGY Study design Participants Cross sectional hospital based All the consecutive children aged 5 to 15 years Ophthalmology out patient department of IGMH from April 2010 to September 2011. Exclusion: Infectious anterior segment disorders Ocular injuries

CLINICAL EXAMINATION Distance Visual Acuity Refractions Projected Snellen letter or a pictorial chart at 3 meter Refractions Retinoscopy Subjective refraction Cycloplegic refraction in indicated cases Anterior and Posterior segment evaluation Slit lamp examination Fundus examination Visual acuity: Presenting, uncorrected and best corrected VA

DEFINITIONS Myopia: >-0.50D Spherical equivalent (SE) error Hyperopia: > +1.00D SE Astigmatism: >0.75D or more in either eye. Anisometropia: >1.0D difference of SE error in between two eyes. Statistical Analysis Prevalence rates and 95% confidence intervals (CI) have been presented. Multiple regression logistic analysis was used to assess the effect of age and gender on refractive errors. A p value <0.05 was considered statistically significant.

RESULTS 4448 children 7.6% of the estimated mid-year population for age group 5-15 years in 2010 (Maldives Year book 2011) Representative sample* Age Group (years) Female % Male 5-7 598 13.4 8-10* 295 6.6 370 8.3 11-13 704 15.8 558 12.6 14-15 722 16.3 603 13.6 Total 2319 52.1 2129 47.9

RESULTS 1221 (27.5%) Spectacle coverage: 74.28% China (0.43%); Chile (3.3%); Nepal (0.44%); rural India (0.78%); urban India (0.81%); Iran (0.2%). Causes: Amblyopia (41.6%), Retinal causes (35.1%), corneal disorders (12.9%), cataract (5.2%) Spectacle coverage: 74.28% Distribution of Uncorrected, Presenting and best corrected visual acuity in better eye (N=4436) Visual acuity No. (%) with uncorrected VA No. (%) with presenting VA No. (%) with best corrected VA 6/6->6/9 3215 (72.48) 4107 (92.58) 4177 (94.16) 6/9->6/18 795 (17.92) 213 (4.80) 182 (4.10) 6/18->3/60 401 (9.04) 107 (2.41) 73 (1.65) ≤3/60 25 (0.56) 9 (0.21) 4 (0.09) 1221 (27.5%) 2.62% 1.74%

REFRACTIVE ERROR Refractive Error 28.0% SE Myopia 21.3% SE Hyperopia 1.6% Astigmatism* 5.1% Astigmatism: Children who had spherical error emmetropia but had significant amount of astigmatism Mean refractive error -1.64D±2.5 Male -1.66D Female -1.62D

MYOPIA 21.3% ↑Age = ↑Myopia Prevalence (fluctuation) Pakistan (3.7%) Nepal (1.2%), rural India (4.1%), Chile (6.8%), urban India (7.4%) and Iran (4.3%) China (16.2%), Hongkong (36.7%) ↑Age = ↑Myopia Prevalence (fluctuation) Higher prevalence in male (all the age except for 7 years) 21.3% Gender wise difference in myopia prevalence Temporal differences in development between7

HYPEROPIA 1.6% 5.8% in Pakistan Rural India (0.8%) and Nepal (1.4%) China (3.5%), Iran (5.4%), Chile (7.7%) and urban India (16.3%) A higher prevalence of hyperopia was observed in children of lower age cohorts

RESULTS -0.85D -2.20D -1.06D -2.22D -0.71D -2.19D 12.8% 18.1% 1.2% Female: Reduction in the mean refractive error from the age 7 years (mean error -1.06D) to 11 years (mean error -0.41D)  At the age of 12 years this error increases to -2.22D and stabilises afterwards. Male: The mean error increases with rather small fluctuation, starting at -0.71D at 5 years to reach -2.19D at 15 years of age. Overall myopia progresses from -0.85D±2.7 at 5 years to -2.20D±2.4 at 15 years of age while considering both genders. A trend of increase in prevalence of myopia can be observed in both the gender with a significant differences and fluctuations over the age; while hyperopia shows consistent decrease. Hyperopia: 5-7 year: 6.9%  14-15 year: 1.2% Myopia: 5-7 year: 12.8%  14-15 year: 18.1% 18.1% 1.2% 6.9%

ASTIGMATISM 17.6% of eyes WTR 86.9%; ATR 8.9%; OA 4.1% Iran (11.5%), China (15%) and Chile (19%); Lower than Singapore (28.3%) Higher than Nepal (2.2%), rural India (2.8%) and urban India (5.4%) WTR 86.9%; ATR 8.9%; OA 4.1% No gender difference WTR astigmatism decreased and ATR astigmatism increased with age. Prevalence and amount was associated with younger age but not with the gender. 2.06DC at 5 years  0.86DC at 15 years >2D 6.6% of the eyes. Higher than China (1.7%)7, rural India (0.7%)10, urban India (1.3%)11 Significantly lower than that in Chile (11.9%)8 and America (20.2%)16.

ANISOMETROPIA 3.3% of the children Mean anisometropia 1.94±1.16D Comparable with 3.8% in Iran Less than Hong Kong (9.2%) and Australia (9.0%) Mean anisometropia 1.94±1.16D No age (p=0.4) and gender (p=0.9) differences More in myopic children than hyperopic No age (p=0.4) and gender (p=0.9) differences  agreement with the works of Fan et al14 and Dobson17 More in myopic children than hyperopic consistent with the previous studies18, 19 but Opposite to Deng and co-worker20

CONCLUSION Refractive errors, myopia and astigmatism in particular, are common in school-age children in Maldives. Refractive error characteristics vary with age and gender Prevalence of all forms of visual impairment is considerably high Almost one fourth of the children who need spectacles are not wearing them

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