Purpose: To describe ocular problems seen and treatments provided to the children attending a tertiary level eye care facility in western Nepal.

Material and Methods: In the hospital based retrospective study, all children coming to the pediatric department of Lumbini Eye Institute during October and November, 2013 were reviewed. Out of 1295 new children, 1061children in age of 0-15 years were included in the study. Data on age at presentation, sex and diagnosis were collected from clinical charts and analyzed. Patients were grouped into four age groups (0-1 years, 2-5 years, 6-10 years and 11-15 years) and grouped in terms of clinical diagnoses.

Results: Among 1061 children examined, male: female ratio of 1.43:1, the most common group was children aged 11-15 years (35.5%). Conjunctival diseases were the most common disorder 235 (22.1%) in children followed by refractive errors (19.8%) and disorders of lacrimal drainage system (15.7%). 70.6% children needed medical treatment, 21.5% required glasses, 5.5% required surgery and 1% required orthoptic treatment. 56 % were Nepalese children.

Conclusion: Conjuctival disorder and refractive errors were the most common occurring disorder. Males were more affected than females. Most children needed medical treatment followed by optical correction.

Rai Salma KC, Hari T, Malla BA, Kabindra B (2015) Clinical Profile of Pediatric Ocular Morbidity in a Tertiary Eye Care Centre in Western Region of Nepal. Ann Pediatr Child Health 3(5): 1070.

•    Children
•    Ocular morbidity
Nepal

Eye diseases in children are important causes of medical consultation and require prompt attention because of their impact on a child’s development, education, future work and quality of life. Children have unique problems in terms of ocular morbidities, not only due to their inability to express their problems, but also because of the potential to develop amblyopia. Although most

ocular lesions are preventable but due to ignorance and carelessness, they cause impairment of vision or even blindness. Childhood blindness is second only to cataract in terms of “blind years” [1]. Hence strategies to manage paediatric ophthalmic disorders must be initiated as early as possible, with interventions at all the three levels of primary, secondary and tertiary eye care centres. Possible measures include optical, orthoptic, medical and surgical interventions [2].

The present study was conducted with the objective to determine the pattern of ocular morbidity in children less than 16 years of age children presenting in the outpatient department (OPD) of Pediatric Ophthalmology Unit of a tertiary care hospital of Western Region of Nepal.

Medical records of all new patients aged 15 years and younger, who presented to the outpatient department of pediatric Ophthalmology unit of Lumbini Eye Institute ophthalmology in October and November, 2013 were retrospectively reviewed. Informed consent was taken from Institutional board. Refraction was performed when required under cycloplegia by an Optometrist. Anterior segment examination was done with torch and slit lamp. Posterior segment examination was performed after dilating the pupil using direct and indirect ophthalmoscope by two pediatric Ophthalmologists.

The age at presentation, sex and clinical diagnosis were determined from records. The clinical diagnosis was grouped as appropriate diseases. Patients were grouped by age into four age groups (0-1 years, 2-5 years, 6-10 years and 11-15 years). The data were recorded and analyzed using SPSS statistics program.

A total of 1061 new children attended at Pediatric Ophthalmology Department, Lumbini Eye Institute were included in the study. The mean age was 7.8 years with standard deviation ±4.8. Their ages ranged between one month and 15 years. Majority (59%) of the children were males with a male to female ratio of 1.43: 1. The 11-15 years age group had the largest proportion with 35.5% of children; followed by the 6-10 years age group (28.3%).

For the main presenting complaint, 257 (24.2%) children complained of watering followed by poor distance vision (21.9%), redness (18.9%) and (0.6%) complained of night blindness.

The commonest eye diseases were of the conjuctiva (conjunctivitis, subconjunctival hemorrhages etc) in 235(22.1%) children followed by refractive error (19.8%), lacrimal drainage system (15.7%), and cornea and sclera (12.4%). 1.6% of children involved posterior segment disease (retina and optic nerve disease).

Among the children, 55.9% could achieve a distance visual acuity of 6/60 or better after receiving the correct spectacles. 32 (3%) children already had spectacles at the time of presentation.

Among the children with conjunctival diseases, allergic conjunctivitis accounted for 56.2% followed by subconjunctival haemorrage, 18.7%.

Among the corneal and sclera diseases, 36.4% were presented with keratitis followed by corneal scar, 29.6% and bitot’s spot 15.5%.

Medication was advised on 749(70.6%) children followed by optical correction (21.5%), surgical (5.5%), and orthoptic exercise (1%)

In our study, 59% were male and 41% were female. These findings were quite similar to study done by Sethi S et al at Khyber Teaching Hospital, Peshawar where 60.6% were male and 39.1% were female [2]. The higher frequency of the consultation was seen in the older age group of 11-15 years (35.5%) that was similar to a study done by Onakpoya et al [1]. Chandana Chakraborti et al found a higher frequency of the consultation in the age of 6-10 years (38.87%) [3].

Diseases of conjunctiva were the most common disorder (22.1%) with conjunctivitis being the most common disease. This may be due to low socio economic and poor literacy rate of the catchment area. Among them allergic conjunctivitis accounted for 56.2% and infective conjunctivitis 6.8%. Various studies reported allergic conjunctivitis as the most common surface disorder. Dusty polluted environment, rural living may contribute to development of chronic allergic conjunctivitis. Proper management can bring relief to the conditions.

In this study, refractive errors were present in 210 (19.8%) children with myopia, hypermetropia and astigmatism. Refractive errors were found to be more in older age group (11- 15yrs). Onakpoya et al reported 14.3%, Sethi et al found 12.7 % [1,2]. Various studies have quoted the refractive error prevalence to be between 12 to 31%. The incidence of refractive error may have been underestimated as it was a hospital based study. Globally, uncorrected refractive errors are the main cause of visual impairment in children aged 5-15 years [4].

It was reported that the blind schools in Pakistan and India where corneal diseases accounted for 12% and 26.4% respectively of all children with severe visual impairment/blindness [5,6]. In our study, corneal and sclera diseases accounted for only 12.4%. The most common cause of corneal scar was found to be vitamin A deficiency. The government of Nepal has incorporated the vitamin A capsule distribution to all children aged 6 months to 5 years in Nepal twice a year. It has contributed for reduction in vitamin A deficiency cases seen in hospital in recent years [4].

In our study, ocular motility was affected in 3.1%. Sethi et al reported 8.06% [2]. Tanzania showed the prevalence of squint was 0.5% and South of Kavadi of Pakistan showed prevalence of squint as 0.6% [7]. A study at Katmandu reported the prevalence of squint was 1.6% [8]. Determinants of strabismus diagnosis are important because of the amblyogenic nature of certain concurrent squint [9]. Esotropia is also more likely to be amblyogenic than exotropia [10,11]. The high occurrence of squint in our study (3.1%) may be due to the presence of a well established strabismology set up with a qualified paediatric ophthalmologist with special interest in strabismology available.

Signs of Vitamin A deficiency were seen in 23 children (2.2%) in the form of Bitot’s spot (21 children), conjunctival xerosis (1 child) and keratomalacia (1 child) that was similar to a study done by Sethi et al reported 2.09% vitamin A deficiency [2]. Lower prevalence of xerophthalmia may be due to the widespread coverage of vitamin A prophylaxis programme in Nepal and India.

Table 1: Distribution of eye diseases at different age group in children.

Table 2: Distance visual acuity in children.

Table 3: Distribution of conjunctival diseases among the children.

Table 5: Methods of treatment at different age group.

The most common eye problem was conjuctival disorder. Refractive errors presented the second most common causes of paediatric ophthalmic disorder. There should be routine refraction of the children and provision of the spectacles at low cost.

We are extremely thankful to Dr Ken Bassett, SEVA, Canada for his valuable suggestion.

1. Onakpoya OH, Adeoye AO. Childhood eye diseases in southwestern Nigeria: a tertiary hospital study. Clinics (Sao Paulo). 2009; 64: 947- 952.

2. Sethi S, Sethi M J, Iqbal R, Khan T. Pattern of common eye diseases in children attending outpatient eye department, Khyber Teaching hospital, Peshawar. J Med Sci. 2008; 16: 99- 101.

3. Chandana Chakraborti, Malay Mondal, Krittika Pal, Choudhury et al. Clinical Profile of Paediatric Ocular Morbidity in a Tertiary Eye Care Centre in West Bengal: Bengal Ophthalmic Journal. 2012; 30-33.

4. Nepal Netra Jyoti Sangh. Strategic Plan for the Eye Care Services. Nepal 2013-2020.

5. Afghani T. Causes of childhood blindness and severe visual impairment survey of blind children from rural population and school for blind in urban area. Pak J Ophthalmol. 2003; 19: 4-25.

6. Rahi JS, Sripathi S, Gilbert CE, Foster A. Childhood blindness in India: causes in 1318 blind school students in nine states. Eye (Lond). 1995; 9 : 545-550.

7. Wedner SH, Ross DA, Balira R, Kaji L, Foster A. Prevalence of eye diseases in primary school children in a rural area of Tanzania. Br J Ophthalmol. 2000; 84: 1291-1297.

8. Nepal BP, Koirala S, Adhikary S, Sharma AK. Ocular morbidity in schoolchildren in Kathmandu. Br J Ophthalmol. 2003; 87: 531-534.

9. Robaei D, Rose KA, Ojaimi E, Kifley A, Martin FJ, Mitchell P. Causes and associations of amblyopia in a population-based sample of 6-year-old Australian children. Arch Ophthalmol. 2006; 124: 878-884.

10. Mohney BG. Common forms of childhood esotropia. Ophthalmology. 2001; 108: 805-809.

11. Mohney BG, Huffaker RK. Common forms of childhood exotropia. Ophthalmology. 2003; 110: 2093-2096.