Research Article

Prevalence of refractive error among school-going

children of Imphal, Manipur
K Sathish Kumar1, Brogen Singh Akoijam2
1
Department of Community Medicine, Karpaga Vinayaga Institute of Medical Sciences, Madurantakam, Kanchipuram, Tamil Nadu, India.
2
Department of Community Medicine, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, India.
Correspondence to: K Sathish Kumar, E-mail: kumarsathish16@gmail.com

Received October 11, 2015. Accepted October 19, 2015

Abstract

Background: Uncorrected refractive error is the leading cause of eye problem and the second cause of blindness worldwide.
Among children aged 5–15 years, 12.8 million are visually impaired because of refractive errors.
Objective: To assess the magnitude of refractive error among school-going children of Imphal, Manipur, India, and to
determine the association between refractive error and variables such as sex, dietary habits, family history, and daily
activities such as watching television and using computers.
Materials and Methods: This was a cross-sectional study conducted among upper primary school students (students
of classes six and seven) of Imphal from June 21, 2014 to July 8, 2014. Sample size was calculated to be 267. Cluster
sampling method was used to select the study participants. Snellen chart, Roman test type chart, and pinhole were used
to detect refractive error. Analysis was done using χ2-test and Fisher’s exact test. P value of <0.05 was taken as significant.
Result: Total number of respondents was 302. Prevalence of refractive error was 29.14% and among them only 20.5%
were already wearing glasses for correction. Prevalence of refractive error was significantly associated with watching
television sitting nearby, using computers, positive family history, problem while reading the blackboard in the class, and
problem while watching TV, computer, or playing video games.
Conclusion: Students, parents, and teachers must be educated about the early detection of refractive error and correction
with spectacles to prevent progression of visual impairment.
KEY WORDS: Refractive error, prevalence, uncorrected, school students

Introduction 1.8 billion have access to adequate eye examination and

affordable corrections leaving behind 500 million people,
Refractive error is an optical defect intrinsic to the eye, mostly in developing countries, with uncorrected error causing
which prevents the light from being brought to a single focus either blindness or impaired vision.[3] Among children aged
on the retina; thus, reducing normal vision.[1] Uncorrected 5–15 years, 12.8 million are visually impaired because of
refractive error is the leading cause of eye problem worldwide refractive errors representing a prevalence of 0.97% with higher
and the second cause of blindness.[2] It is estimated that about prevalence reported in China and urban areas of Southeast
2.3 billion people worldwide have refractive errors; of which Asia.[4] Refractive errors are usually present in the childhood
and continue to the adult life.[5,6] Undetected and uncorrected
Access this article online refractive errors are particularly a significant problem in school
Website: http://www.ijmsph.com Quick Response Code: children.[3] As children are not mature enough to point out the
deficiency at an early stage or the parents have no idea on
DOI: 10.5455/ijmsph.2016.11102015203 the gradually developing vision problem, uncorrected refrac-
tive error can have a dramatic impact on learning process
and educational capacity.[7] Most of the children with such
diseases are apparent and hence, screening helps in early
detection and correction with spectacles.[8] In the global initiative,

International Journal of Medical Science and Public Health Online 2016. © 2016 K Sathish Kumar. This is an Open Access article distributed under the terms of the
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1364 International Journal of Medical Science and Public Health | 2016 | Vol 5 | Issue 07
 Kumar and Akoijam: Prevalence of refractive error among school-going children

Vision 2020, for the elimination of avoidable blindness, refrac- Data collected were checked for completeness and
tive error has been emphasized.[9] As the treatment of refractive consistency, and those were entered in IBM SPSS version 20
errors is perhaps the simplest and effective forms of eye care, software. Descriptive statistics such as mean and percentages
blindness because of refractive error can be prevented. This were used. Analysis was done using χ 2-test and Fisher’s
study was conducted to assess the magnitude of refractive exact test. P value of < 0.05 was taken as significant.
error among school-going children of Imphal, Manipur, India,
and to determine the association between refractive error and
variables such as sex, dietary habits, family history, and daily
Result
activities such as watching television and using computers.
Total number of respondents was 302. Mean age of the
respondents was 12.4 ± 1.03 years with a range of 10 to
Materials and Methods 17 years. Table 1 shows that about two-thirds of the respond-
ents were boys and majority of them were Hindus.
This was a cross-sectional study conducted among upper Prevalence of refractive error was 29.14%. Myopia was
primary school students (students of classes six and seven) the most common type of refractive error constituting 27.15%
of Imphal, the capital city of Manipur from June 21, 2014 to of the participants whereas 1.3% had both myopia and
July 8, 2014. Taking prevalence as 50%, with an absolute hypermetropia [Figure 1].
precision of 7.5% at 5% significance level, sample size was Figure 2 shows that of those who were having refractive
calculated to be 177. With a design effect of 1.5, the final error, only 20.5% of them were already wearing glasses for
sample size was estimated to be 267. Hence, approximately correction.
300 students were targeted for data collection. Six schools Table 2 shows that about 16.9% of the respondents had
were randomly selected with probability proportionate to size, an eye checkup in the past.
and students in each school were selected by simple random Prevalence of refractive error was greater among those
sampling. The number of students selected from each school who had problem when reading the blackboard in the class
was proportionate to the strength of the school. Those who and when viewing the television, using computer, or playing
were absent on the day of data collection were excluded from video games, and was found to be statistically significant.
the study. The study tools used were a structured interview Prevalence of refractive error was significantly higher among
schedule, Snellen chart, Roman test type chart, measuring those who watch television sitting nearby and those who use
tape, eye shield, torch light, and pinhole. computers. Refractory error was significantly associated with
Data were collected by interns posted in Community family history of wearing glasses because of refractory error
Medicine Department of Regional Institute of Medical Sciences either among parents or siblings [Table 3].
(RIMS), Imphal, who were trained to conduct interviews and
ophthalmic examination. In a well-lighted room, Snellen chart Table 1: Sociodemographic characteristics of the respondents
was fixed on a wall at eye level. After interviewing the Sociodemographic characteristics Number %
respondents, visual acuity was tested for far vision with Snellen Type of school
chart at a distance of 6 m for each student, one at a time.
Government 140 46.4
Near vision was tested with Roman test type chart kept at a
Private 162 53.6
distance of 30 cm from the eyes of the subjects. One eye was
tested first with the other eye covered with an eye shield. Gender
After 2 min, the other eye was tested similarly. Any other eye Male 200 66.2
problems were also checked. Students having visual acuity Female 102 33.8
≤6/9 for far vision and <N5 for near vision were tested with the Religion
pinhole. Students who had improvement in the visual acuity Hindu 280 93.0
after pinhole testing were considered to be having refractive Christian 12 4.0
error. Students found to have refractive error and other eye
Others 9 3.0
problems were referred to Ophthalmology Outpatient Depart-
Class
ment, RIMS. Ethical approval was obtained from institutional
ethics committee, RIMS before the initiation of the study. Class VI 167 55.3
Informed consent was obtained from school principals and Class VII 135 44.7
verbal assent or consent was taken from students. Steps
were taken up to maintain confidentiality. Table 2: History of having an eye checkup in the past
The following operational definitions were used: Did you have any Refractive Refractive Total
●● Myopia: Visual acuity ≤6/9 in any eye for far vision, if eye checkup error present error absent
improved after pinhole testing, was taken as myopia n (%) n (%) n (%)
●● Hypermetropia: Visual acuity <N5 in any eye for near
Yes 27 (45.5) 34 (25.2) 51 (16.9)
vision, if improved after pinhole testing, was taken as
No 61 (54.5) 180 (74.8) 251 (83.1)
hypermetropia

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 Kumar and Akoijam: Prevalence of refractive error among school-going children

Table 3: Association of refractive error with selected variables

Characteristics Refractive Refractive P-value
error present error absent Total
n (%) n (%) n (%)
Type of school
Government 34 (24.3) 106 (75.7) 140 (46.4) 0.08
Private 54 (33.3) 108 (66.7) 162 (53.6)
Sex
Male 25 (24.5) 77 (75.5) 102 (66.2) 0.21
Female 63 (14.0) 137 (68.5) 200 (33.8)
Number of study hours per day
<4 35 (14.4) 208 (85.6) 243 (80.4) 0.44
>4 6 (10.1) 53 (89.9) 59 (19.6)
Anyproblem while reading a book
Yes 28 (42.4) 38 (57.6) 66 (21.9) 0.28
No 60 (25.4) 176 (74.6) 236 (78.1)
Any problem while reading the blackboard in class
Yes 51 (54.3) 43 (45.4) 94 (31.1) 0.00
No 43 (17.8) 171 (82.2) 208 (68.9)
Watching television
Yes 82 (29.4) 197 (70.6) 279 (92.4) 0.74
No 6 (26.1) 17 (73.9) 23 (7.8)
Duration of watching TV in a day
Upto 2 hours 61 (27.2) 163 (86.8) 224 (74.2) 0.11
>2 hours 21 (38.2) 34 (61.8) 55 (25.8)
Distance of watching TV
Near (≤1 metre) 40 (38.1) 65 (61.9) 105 (37.6) 0.01
Far (>1 metre) 42 (24.1) 132 (75.9) 174 (62.4)
Using computer
Yes 34 (41.0) 49 (59.0) 83 (27.5) 0.02
No 54 (24.8) 165 (75.2) 219 (72.5)
Duration of using computer
Upto 2 hours 27 (36.0) 47 (64.0) 74 (89.2) 0.03
>2 hours 7 (77.8) 2 (22.2) 9 (10.8)
Playing video games
Yes 18 (32.1) 38 (67.9) 56 (18.9) 0.55
No 69 (28.2) 176 (71.8) 245 (81.1)
Duration of playing video games
Upto 2 hours 18 (34.6) 34 (65.4) 52 (92.9) 0.45*
>2 hours 2 (50.0) 2 (50.0) 4 (7.1)
Problem when watching TV, computer, or playing video games
Yes 41 (36.3) 72 (63.8) 113 (37.4) 0.03
No 47 (24.9) 142 (75.1) 189 (62.6)
Daily intake of green leafy vegetables
Yes 13 (41.9) 18 (58.1) 31 (10.2) 0.10
No 75 (27.7) 196 (72.3) 271 (89.8)
Daily intake of fruits
Yes 7 (15.5) 8 (53.3) 15 (5.0) 0.13
No 81 (28.1) 206 (71.8) 287 (95.0)
Family history of refractive error
Present 78 (42.2) 107 (57.8) 185 (61.2) 0.00
Absent 30 (25.6) 87 (74.4) 117 (38.8)
*Analysis done by Fisher’s exact test.

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 Kumar and Akoijam: Prevalence of refractive error among school-going children

be seen from the finding that only 16.9% of the participants

had an eye checkup in the past. Ogbomo GOO et al.[14]
reported a similar finding in Ghana where only 13.3% of the
respondents had an eye checkup in the past.
There was no difference in the prevalence of refractive
10(3.3%) error between boys and girls but in some studies[10,12,13,15] girls
82(27.2%) 4(1.3%)
showed higher prevalence. Rahman et al.,[11] Niroula and
Sahal,[16] and Sun et al.,[18] reported higher prevalence among
boys. Prevalence of refractive error was significantly higher
among those who had problem in reading blackboard in the
Myopia class. El-Bayoumy et al.[12] reported a similar finding where the
Hypermetropia prevalence of refractive error was higher among those who
had problem in seeing distant objects. Presence of refractive
Figure 1: Prevalence of refractory error (88/302 = 29.1%).
error was significantly associated with a positive family history
as seen in other studies.[10,15,18] Prevalence of refractive error
was significantly high among those watching television sitting
nearby and those who use computers. A similar finding was
70(79.5%) reported in some studies[13,15,21,23,24] where refractive error was
significantly associated with close work or near activity such
as prolonged study hours, watching computers/television, and
so on. Prevalence of refractive error was high among those
who do not eat fruits and vegetables daily but it is not statis-
tically significant. The most worrying finding is that very few
students consume fruits and vegetables daily because there
18(20.5%) are evidences to suggest that daily intake of fruits and vege-
tables can prevent refractive error.[25,26]
The strength of this study was that sample size was
Not wearing glasses adequate. The limitation of this study was that as refractory
Wearing glasses error was diagnosed by pinhole testing and not by retinoscopy
or subjective refraction; the prevalence of astigmatism could
Figure 2: Wearing glasses for correction among students with refractive
not be estimated and is misclassified as either myopia or
error.
hypermetropia. As this was a school-based study non-school-
going children were left out from the sampling frame.
Discussion
Conclusion
This study shows that the prevalence of refractive error
was 29.3%, which was more than most of the studies con- We can conclude that refractive error was a significant
ducted around the world.[10–16] Studies conducted in China,[17] cause of visual impairment among school children. Students
Japan,[18] Hong Kong,[19] Taiwan,[20] and Srinagar[21] showed must be educated to avoid unhealthy practices, such as
higher prevalence whereas one study in Kancheepuram[22] watching television sitting nearby and indiscriminate use of
showed prevalence similar to our study. These variations in computers and video games, to prevent the development of
prevalence could have been due to differences in demographic refractive error. Prevalence of uncorrected refractive error
factors and different operational definitions for refractive error. was also very high. Students, parents, and teachers must
The possibility of differences in ethnic background and differ- be educated about the early detection of refractive error and
ences in environment and socioeconomic conditions causing correction with spectacles to prevent progression of visual
varying prevalence rates should also be considered. Among impairment. The existing school health services should be
the refractive errors, myopia was common, which is similar strengthened and implemented effectively for regular screen-
to the findings seen in other studies.[10–13,15,18,21] This finding ing and to provide affordable corrective services.
is contrast to that seen in some studies where prevalence of
hypermetropia was higher.[14,17] Prevalence of uncorrected
refractive error was higher as seen in some other studies in Acknowledgments
India.[11,17,22] But in studies conducted outside India such as
China[12] and Egypt,[18] a higher proportion (95% and 43%, We thank all the participants for their cooperation and all
respectively) of children with refractive error were already the school authorities for giving permission to conduct this
wearing glasses. This higher prevalence of refractive error study. We also acknowledge the commitment of the interns in
may be due to poor utilization of eye care services, which can the data collection.

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 Kumar and Akoijam: Prevalence of refractive error among school-going children

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