1. 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  

2. 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

3. 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

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

5. 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

6. 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

7. 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.

8. 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

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%

10. 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

11. 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

12. 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

13. 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%  year: 1.2%
Myopia: 5-7 year: 12.8%  year: 18.1%
18.1%
1.2%
6.9%

14. 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.

15. 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

16. 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

17. Thank You