COVID-19 Update - This is to inform you that the Government of India has announced a complete lockdown in India 22nd March 2020 to 14th April 2020. As a result, our offices will now be closed till 14th April 2020 and all our employees will be working from home. Office telephones will not be answered, and therefore you are requested to direct all your queries related to manuscript submission, review process, publication etc. at below mentioned details. editor@innovativepublication.com, rakesh.its@gmail.com, Mob. 8826373757, 8826859373, 9910947804


Print ISSN:-2395-1443

Online ISSN:-2395-1451

CODEN : IJCEKF

Current Issue

Year 2020

Volume: 6 , Issue: 1

  • Article highlights
  • Article tables
  • Article images

Article view: 146

Article download: 88


Srivastava, Kumar, Kapoor, and Mishra: Childhood blindness - Etiological risk factors as evaluated by blind schools survey in Prayagraj and surrounding districts


Introduction

Blindness specially in children is a global problem which markedly influences social and mental development of a child. Approximately 30% of India’s blind loose their eye sight before the age of 20 years and many of them are under five years when they become blind.1 Child hood blindness, thus should be a priority area for any nation because a child has to live with blindness for quite a long time. Children born and brought up in developing countries are more prone to blindness as compared to developed nations. Incidentally almost half of all blindness in children in the developing countries of Africa and Asia are due to avoidable causes which are poorly managed specially at primary eye care level.

Thus obviously we require meticulous data for effective planning and monitoring the out come of preventive and curative services for children including planning special health education and low vision services.

The causes of blindness and their risk factors exhibits changing scenario with time due to improved health facilities by trained and specialized medical personnel. Previously the most common cause for blindness was ocular and other infections. Most of them were treated by harmful traditional medications with sequelae. It has been observed that due to improvement of health and socio-economic status, nutritional and infective causes of blindness shows declining trend while hereditary and congenital factors have become the major causes in children. There is appreciable regional variation in causes of blindness usually nutritional and infective causes in developing while in developed country lesions of CNS predominate. In middle income group countries picture is mixed with Retinopathy of prematurity emerging as an important treatable cause of blindness. Globally cataract, retinal diseases, and congenital abnormalities affecting whole globe are important cause of blindness.

Although various studies have been done in blind schools to know the prevalence of avoidable causes of congenital and acquired blindness but a glimpse of variations and incoherence is always there. More or less some authors are of clear cut opinion about changing scenario of cause of blindness. Use of Teratogenic medications along with X-Ray and other exposures during pregnancy is still prevailing, specially in rural areas due to lack of qualified gynecologists and pediatricians. Surprisingly sometimes with a ppropriate optical or surgical interventions many children improved their vision so much so that they can do their major tasks comfortably yet admitted in blind schools. Thus this retrospective study is done to evaluate the avoidable cause of childhood blindness, Ocular morbidity status and identify etiologies that triggered blindness in children of various blind schools in Prayagraj and its neighbouring districts of Prayagraj namely, Fatehpur, Koushambi and Pratapgarh.

Infact we find that study in these blind schools is not a real estimate of magnitude of childhood blindness as they represent only a very small proportion of total blind ness in the society in comparision to population based study. Blind Children from rural area, low socio-economic group, with associated disability are usually under represented. But since population based survey requires larger sample size and are very costly so in Indians cenario most of the statistics usually comes from blind school survey.

Materials and Methods

The study was conducted in f our School for the blinds in Prayagraj and in the four accelerated learning camps situated in three neighbouring districts namely Fatehpur, Koushambi and Pratapgarh. In cross sectional study total 159 students were examined. List of these blind schools and accelerated learning camps was obtained from District Magistrate office of corresponding districts. An examination date was fixed separately for each blind school and accelerated camp in consultation with principal of the school. Parents of children were also called on the same date just to obtain history, income and various incidents and happenings responsible for blindness to extract out etiological risk factors.

The study included all the students of blind school irrespective of their age. Basic informations were gathered from student himself, class teacher and parents (wherever possible), by reviewing school official and medical records of student. A meticulous history pertaining to time, duration and mode of vision loss was obtained. Careful prenatal, natal and post natal history was obtained. Any fever, acute illness, harmful medications, X-ray exposure during pregnancy was en quired. During childhood h/o diarrhoea, measles, trauma, infections in eye was also noted. Family history specially about involvement of other member in family, Consanguineous marriage also recorded. Additional disability like mental retardation, epilepsy, hearing problems and any other were recorded.

Figure 1
https://s3-us-west-2.amazonaws.com/typeset-media-server/3d8c3930-340d-417e-a806-bcd950f0349aimage1.png

An ophthalmologist and an ophthalmic assistant examined the children at school premises. Vision assessment was done using snellen’s illiterate E chart or broken rings. If vision was less then 3/60, each eye was tested for ability to perceive light. Pinhole examination was carried out and those who improved were subjected under proper cycloplegic refraction. Student who failed to co-operate with these traditional tests were watched by their behaviour while walking, talking, moving head etc. Anterior segment examination was done with torchlight, simple magnifying loupe (x 2.5). Fundus was examined (in appropriate case) by direct ophthalmoscopy (Indirect ophthalmoscopy if required) after fully dilating the pupil.

The a natomical cause of visual loss i.e blindness / SVI was assessed by clinical examination. We tried to ascertain most probable aetiological risk factors responsible for blindness / SVI with the help of clinical evaluation, history by child himself/herself or sometimes by making relevant enquires by parents of child. In spite of our best efforts in some children exact aetiological risk factors could not be ascertained. A list of students requiring any sort of therapeutic intervention (optical, medical or surgical) was prepared in duplicate. These students were either called to our R.I.O or related to nearby secondary/ tertiary ophthalmic institution. One list of these students was handed over to principal of school and a fixed day/date was told for further examination and management at our R.I.O.

Data collected was entered into an IBF compatible computer, from where frequency charts and distributions were generated. The cause of SVI/BL were documented.

The study was conducted in total 159 students of four school of the blind in Prayagraj and in four accelerated learning camps of three neighboring districts of Prayagraj.

Table 1
Name of School Total No.of Student Male Female
Accelerated Learning Camp in Prayagraj. 38 18 20
Accelerated Learning Camp in Fatehpur. 30 20 10
Accelerated Learning Camp in Kaushambi. 17 8 9
Accelerated Learning Camp in Pratapgarh. 5 3 2
Raj Andh Vidyalaya, Prayagraj. 33 18 15
Arunima Blind School, Prayagraj. 21 12 9
The School and home for the blind, Naini Prayagraj. 10 9 1
Bachpan Day Care Center, S.R.N. Hospital Road, Prayagraj. 5 3 2
159 91 68
57.6% 36.4%

Number of students examined in each blind school is as follows.

Graph 1

Distribution of students in blind schools by gender (in percentage)

https://s3-us-west-2.amazonaws.com/typeset-media-server/3d8c3930-340d-417e-a806-bcd950f0349aimage2.png

Table 2
No. of Students %
Urban 34 21.38
Rural 125 78.61
Total 159 100

Distribution of students in blind schools by area of residence (Urban or Rural)

Table 3
Class Per capita per month income No. of Students %
I 5156 and above 12 7.54
II 2578 to 5155 27 16.98
III 1547 to 2577 21 13.33
IV 773 to 1546 46 28.93
V Below 773 53 33.33
Total 159 100

Distribution of students in blind schools by socio economic status according to modified B.J, Prasad Classification:-

Table 4
WHO Visual Category VISION (Better eye) No. of Students Percentage
Blind PL-VE (NPL) 34 21.38
Blind <3/60-PL 110 69.18
SVI <6/60-3/60 11 6.91
VI <6/18-6/60 0 0
No impairment 6/18 or better 4 2.51
Total 159 100

Visual Acuity in better eye in blind school students

Table 5
Anatomical site No. Percentage (%) Causes No. Percentage (%)
Whole globe 83 54.44 Microphthalmos 55 34.59
Anophthalmos 23 14.46
Buphthalmos/Glaucoma** 5 3.14
Others (Cryptophthalmos etc) 4 2.51
Corea 43 24.45 Staphyloma* 3 1.88
Corneal Scar* 35 22.01
Others 0 0
Uvea 1 1.11 Coloboma 2 1.25
Others 0 0
Retina 3 3.33 Dystrophy 4 2.51
Albinism 0 0
Retinopathy of Prematurity** 0 0
others (Retinal Detachment etc.) 2 1.25
Optic Nerve 6 6.67 Optic Nerve Atrophy 10 6.28
159 100

The main course of Blindness and Severe visual impairment in better eye among blind school students.

[i] *Preventable cause of blindness **Treatable cause of blindness.

Results

  1. There was male ponderance (57.6%) as compared to female students (Table 1)

  2. Number of students from rural background (125-78.6%) was significantly higher as compare to urban background. (Table 2)

  3. 99(62.22%) students were belonging to lower socio-economic income group i.e. class 4 and 5 as per modified B.J. Prasad classification. (Table 3)

  4. 143 (approximately 90%) students were blind as per proposed criteria by WHO in 1972 with visual acuity. < 3/60 by snellen's or its equivalent. (Table 4)

  5. 4(2.51%) students were having visual accuity 6/18 or better hence not requiring admission. (Table 4)

  6. Approximately 80 students were blind due to whole globe (Microphthalmos, Anopthalmos, Bupthalmos) plus corneal (staphyloma, scarring etc) abnormalities. (Table 5)

Majority of causes of blindness among blind school children were avoidable i.e. preventable or treatable. Meticulous antenatal, natal and postnatal care, genetic studies, avoiding use of harmful traditional medications, nutritional care, anti infective and effective immunization measures may reduces incidence of childhood blindness considerably.

Discussion

WHO in 1972 proposed a uniform criteria to define blindness as visual acuity less than 3/60 (snellen) or its equivalent. In order to ensure the screening of students by less specialized person and that too with less co -operation, in the absence of appropriate vision charts, the WHO in 1979 added the "inability to count fingers in a day light at a distance of 3 meters" to indicate vision less than 3/60 or its equivalent.

It is very difficult to obtain prevalence of blindness in children as it is not possible to have desired sample size in a population based survey for blindness in children. More or less usually blind schools do not admit children below 5 years of age and children with multiple disabilities. Apart from this, villagers specially from poor community may not having proper information about blind schools. Thus representation from every sphere may not be uniform. However we tried to achieve some clue about blindness and its causes from examining blind children in blind schools.

It has already been observed that in developing countries only 10% of the blind children attend blind school. So as in our previous study we did not focus much upon exact incidence of blindness in children. We tried to examine and analyze various causes of blindness and their aetiological risk factors in this study. Blindness in children is not as common as blindness in adults. Still most causes of blindness in children is either preventable or treatable. More or less timely appropriate interventions against various risk factors as belonging to nutrition, infections, antenatal, natal and postnatal care, immunization, may be avoided.

We found that out of 159 students 78.61% (125 students) were admitted from rural back ground in various blind schools. This does not mean that awareness for admission in blind school is more in rural area. Aetiological risk factors causing childhood blindness are more prevalent in rural area as poverty, lack of education, infections, and less awareness to avail opportunities of government and social policies are some factors causing more blindness in rural area as compared to urban population. Of course, government is facilitating rehabilitation of rural blind children by opening accelerated learning centers in rural areas yet more emphasis is required for health education and awareness programmes to prevailing government programmes regarding prevention of various nutritional and infective diseases. Unfortunately the present study clearly reveals that in developing nations blindness occurring in preschool age group could have been prevented just by simple care at primary level. So preventive aspects at CHC level is required to be strengthened still more.

In our study majority of students, 90% were having visual acuity in the better eye to the level of critically defined blindness i.e. below 3/60. This parameter very strongly advocates incorporation of various facilities in blind schools as promoting training and education for blind children as upgradation of Braille system. Some of blind schools were not having trained teachers for this valuable technology. Government should intend to train and provide job opportunities for these children. Surprisingly 4(2.5%) students were having equal or more than 6/18 vision in better eye. These students may not require admission and would have continued their lives at home. We recommended a regular and meticulous examination by a board of specialist constituted by C.M.O. apart from at time of admission, parents of every student is required to submit a certificate of blindness or SVI as provided by this board at the time of admission. Apart from this there should be a provision of regular examination to assess visual status of every child and any student found to be having vision 6/18 or better must be encouraged to hire and grow at home with parents which definitely provide much better environment.

The chief concern of present study is to discuss about avoidable i.e. preventable and treatable causes of blindness. Approximately two third students were blind due to diseases which could have either been prevented or treated by specific specialist.

Approximately 25% of students were blind due to potentially preventable causes of blindness. Vitamin A deficiency, measles, trauma, use of harmful and teratogenic medication remedies and X-rays exposure and TORCH Infection. This clearly suggests importance of primary prevention as maternal and child health care, immunization, nutrition, control of endemic disease and good treatment of common conditions.

Cataract (10%), glaucoma (2.7%) and retinopathy of prematurity are among some treatable conditions. Congenital cataract and glaucoma are most important treatable causes of childhood blindness in blind schools. These diseases required early intervention by experienced ophthalmologist. There should be provision for long term follow up and management. Government should take all care to establish and promote pediatric ophthalmology unit with experienced and trained ophthalmologists specially in north India. Children with ROP deserves special attention in well equipped neonatal intensive care. A super specialist having ample knowledge and experience in Retina and lens are to be posted to treat these children.

Presence of 4 students having vision better than 6/18 led us to think about regular check up and treatment of various conditions including proper refraction and provision of low vision services among students having aphakia, microphthalmos, coloboma, pathological myopia and other such condition requiring provision of spectacles and low vision aids. Vijay Lakshmi et al have also recommended that children with vision better than CF should undergo refraction and BCVA with appropriate correction in blind schools time to time.

We are of the opinion that in previous comparison corneal diseases (24.25%) declined as a cause of childhood blindness. Beyond doubt, safe water supply, improved nutrition, better awareness for infections and an effective expanded programme on immunization (EPI) may have resulted this. However Cornea is one of the most vital part of eye and should be taken care of for long term. Village level practitioners should be advised to institute Vit. A in children having long standing diarrhoea and measles. There should be no instillation of steroid drops in simple conjunctival and corneal infections in children as being done by some general practitioners and as directly provided by some medical store owners in villages. Government should take action time to time in villages so that medical store owners may not provide medicines directly to patients.

Although we could encounter visual status of every students meticulously as majority (156) of students in our study were having age, six years or above and they could easily responded by simple vision examination. However this may be drawback as health care facilities instituted 6-8 years prior to examination were of no use for analysis. These type of discussions require understanding of recent health care policies. Usually blind schools do not admit preschool children or those with multiple disabilities. So accurate blindness status in children is usually underestimated even by a most meticulous survey and some times we have to study upon a logical and rough estimates.

Conclusion

Conclusion of our study is that almost half of students were having blindness due to abnormalities (microphthalmos, anophthalmos, corneal dystrophy and coloboma etc.) present since birth. It becomes very difficult to obtain meticulous history to decide exact aetiogolical risk factor for these blinding diseases. However exposure to X -Rays, injudicious use of various medicines during antenatal period by family itself or quack or some genetic factors may have influences. Madgula (2009)8 also observed 41.3% blindness in children due to globe anomalies. Community health centre's specialists and city based medical associations are supposed to teach village level practitioners to avoid unnecessary exposure of X -rays and medicines during antenatal period. Otherwise specific attentions is needed to establish genetic studies at RIO level throughout country. Thus proper care of mother and foetus in ante natal period specially in Ist trimester, the time for or ganogenesis, is very essential. Safe delivery and meticulous postnatal care specially in neonatal period may prove to be an important factor in avoiding incidence of childhood blindness. Obviously this may be achieved by a combined, joint and sincere efforts by primary level worker, gynaecologist and pediatrician. Government should focus on proper training and monitoring of these specialists at every level.

Source of Funding

None.

Conflict of Interest

None.

References

  1. Gupta M., Chauhan A., Bharwaj-Ocular morbidity prevalance among school children in Shimla, Himanchal, North India. Indian J Ophthalmol 2009;57(2);133-138.

  2. Danish Assistance to National Programme for control of blindness. New Delhi, India : 1996, Vision screening in school children. Training module 1.

  3. Rahi J.S, Gilbert CE, Fuster A, Minassion D. Measuring the burden of childhood blindness. Br J Ophthalmol 1999;83:387-388.

  4. Global initiative for the elimination of avoidable blindness. Geneva : WHO; 1997 WHO; pp 1-2 (WHO/PBL/97.61)

  5. Preventing blindness in children:Report of a WHO/IAPB Scientific of meeting. WHO/PBL/00.71. Geneva; 2000.

  6. MC Chirambo and D Banezra- Causes of blindness among students in blind school institutions in a developing country. Br J ophthalmol 1976;60(9):665-668.

  7. A.B. Kello, C. Gilbert, causes of severe visual impairment and blindness in children in schools for blinds in Ethiopia. Br J Ophthalmol 2003;87:526-530.

  8. Madgula I, childhood blindness in India-Regional variations. J Clin Diagn Res 2009;1255-1260.

  9. Gilbert C, Fustera, Childhood blindness in the context of vision 2020- the Right to Sight. Bull World Health Organ 2001;79:227-232.

  10. Sushank A. Bhalerao. visual impairment and blindness among the students of blind schools in Allahabad and its vicinity-A causal assessment. Indian J Ophthalmol 2015;63:254-258.

  11. R. Jose and Sandeep Sachdeva, school eye screening and National Program for control of blindness-Indian Pediatrics volume 46- March 17, 2009.

  12. H Bhattacharjee, K Das, RR Borah, K Guha, P Gogate, S Purakayastha et al. Causes of childhood blindness in the North-Eastern states of India. Indian J Ophthalmol 2008;495-499.



jats-html.xsl

© 2019 Published by Innovative Publication. This is an open access article under the CC BY-NC-ND license (creativecommons.org)