Hindawi

Journal of Ophthalmology
Volume 2020, Article ID 6934013, 6 pages
https://doi.org/10.1155/2020/6934013

Research Article
Visual Impairment among Primary School Children in Gondar
Town, Northwest Ethiopia

Ayanaw Tsega Ferede ,1 Destaye Shiferaw Alemu,1 Alemayehu Desalegn Gudeta,1

Haile Woretaw Alemu,1 and Mulusew Asferaw Melese2
1
University of Gondar, College of Medicine and Health Sciences, Department of Optometry, Northwest Ethiopia,
Amhara National Regional State, Gondar, Ethiopia
2
University of Gondar, College of Medicine and Health Sciences, Department of Ophthalmology, Northwest Ethiopia,
Amhara National Regional State, Gondar, Ethiopia

Correspondence should be addressed to Ayanaw Tsega Ferede; ayanaopto@yahoo.com

Received 20 February 2020; Revised 1 June 2020; Accepted 28 July 2020; Published 24 August 2020

Academic Editor: Marı́a J. González-Garcı́a

Copyright © 2020 Ayanaw Tsega Ferede et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Background. An impairment of the visual system at or shortly after birth adversely affects educational performance of children
which typically occurs through vision. Limited evidence on the magnitude and causes of visual impairment is one of the reasons
for the low priority given to eye care in low-income countries. Objectives. To estimate the prevalence and determine the causes of
visual impairment in primary school children in Gondar town, Northwest Ethiopia. Materials and Methods. A descriptive cross-
sectional study was conducted among 1289 children aged 5–15 years who were randomly selected in 9 primary schools
(government and private) from May to June 2016. Visual acuity was measured at 6 m using Snellen’s chart, and children with an
acuity of less than 6/18 in the better eye underwent refraction and a detailed eye examination. A cause of their impairment was
determined. Data were recorded using pretested tools. . Statistical Package for Social Sciences version 16 was used to enter and
analyze the data using 95% confidence intervals. Results. The prevalence of visual impairment was 1.8%. Refractive errors (nearly
70%) followed by strabismus and cataract, each contributing 4.3%, were the most frequent causes of visual impairment in the
study population. Majority (87%) of the children had moderate degree of vision impairment, and 10–15-year age groups are the
more affected ones. Children of age fifteen and above showed statistically significant association with visual impairment
(p � 0.005). Conclusion. The magnitude of visual impairment in primary school children in the study area is significant. School
screening programme is recommended to minimize the burden of visual impairment in the study area.

1. Background have been either prevented or has yet to be addressed.

According to the World Health Organization (WHO) 2010
Visual impairment is defined as a functional limitation of the reports, approximately 19 million children below 15 years of
eye(s) or the visual system and can manifest as reduced age are estimated to be visually impaired worldwide [2, 3]. The
visual acuity or contrast sensitivity, visual field loss, pho- WHO estimated that 80% of blindness is preventable, but still
tophobia, diplopia, visual distortion, visual perceptual dif- there are more than 419,000 blind children in Africa and
ficulties, or any combination of the above. Vision many more with visual impairments, most of which could
impairment ranges in severity from mild visual loss to total have been prevented [4]. Research studies in Africa showed
absence of light perception [1, 2]. that prevalence of visual impairment in children varies from
Recently, world report on vision showed that at least 2.2 1.2% to 29.4% [5–8]. In Ethiopia, the proportion of school
billion people have a vision impairment or blindness globally children with vision impairment ranges from 1.75% to 8%
and at least 1 billion of whom have a condition which could [9–12], whereas the proportion with uncorrected refractive
2 Journal of Ophthalmology

error varies from 4% to 10.2% [13, 14]. Uncorrected refractive 2. Materials and Methods
error accounts for 77.3% of visual impairment in children [9].
An impairment of the visual system at or shortly after 2.1. Study Design, Setting, and Population. A cross-sectional
birth adversely affects educational performance which study design was employed to determine the prevalence and
typically occurs through vision. Children who got visual causes of visual impairment in primary school children in
impairment early will have longer life of suffering with the Gondar town from May to June 2016. One thousand two
condition [4]. It can also affect areas of gross and fine hundred eighty nine (1289) children aged 5–15 were ran-
motor skills, visual perception, and reading at the domly selected from 9 primary schools (6 government and 3
chalkboard or overhead projection, with inability to private) using multistage stratified random sampling tech-
discriminate colors which have a significant impact on nique. Data on the total number of private and government
child’s quality of life. More obvious signs of visual im- primary schools (n � 58) and of students registered (61,560)
pairment include squinting, sitting very close to the in the new academic year were obtained from the Gondar
chalkboard or screens, messy work, or difficulty of seeing town district educational office. First, nine schools out of 58
things clearly [15–17]. were determined by chance. Then, the total sample size
According to the 2019 world report on vision among (n � 1289), which was determined using the formula for a
children, the causes of vision impairment vary consid- single population proportion, was proportionally allocated
erably across countries. For example, in low-income to the selected schools. Finally, using a systematic sampling
countries, congenital cataract is a leading cause, whereas technique (sampling fraction, K � N/n), children were in-
in high-income countries, it is more likely to be reti- cluded from each school until proportionally allocated
nopathy of prematurity [2]. In Africa, a report on child eye sample is achieved. The first child in the class was randomly
health indicated that the major causes of child blindness selected using the lottery method, and the next child was
and visual impairment are diverse and context-specific. included by keeping the sampling fraction. Children whose
The most common causes are corneal scaring from consent/assent were obtained and attended their class on the
measles, vitamin A deficiency, the use of harmful tradi- date of data collection were included. Children in night
tional eye remedies, and swelling of child’s eyelids due to schools and attended school for different reasons were
infection [4, 18]. excluded.
The literature reviewed in school- and community-
based studies across different countries in African and 2.2. Data Collection Tool and Instruments. Data were col-
Asian regions also showed factors associated with visual lected by qualified optometrists using standardized check list
impairment. For example, vitamin A deficiency [18, 19], and physical examinations. Optometrists measured visual
refractive errors [20], corneal abnormalities [7, 21, 22], lens acuity including pinhole vision by Snellen’s charts and
and optic nerve disorders [7, 21–23], ocular trauma [24], performed the refraction using trail sets and retinoscope. .
and congenital cataract [25] were reported as causes of Children with a visual acuity of less than 6/18 in one or both
visual impairment. eyes underwent ocular examination. Refraction was un-
There are different strategies or interventions at dif- dertaken in a class room with appropriate illumination.
ferent levels of visual conditions to reduce the impact of Torchlight, direct ophthalmoscope, and handheld slit lamp
visual impairment on the child. Some are among the most bio-microscope were used to examine anterior and posterior
feasible and cost-effective ones to implement. For example, ocular structures by an ophthalmologist.
the uncorrected refractive error can be corrected with
glasses, while surgery for cataract and eye patching for
amblyopia are best interventions to restore vision. Vision 2.2.1. Operational Definitions
rehabilitation services are also effective in improving Visual impairment was considered as a presenting
function of people with irreversible vision impairment [2]. distance visual acuity of less than 6/18 in the better eye
Academically and socially, many of them appear to be quite measured by Snellen’s chart at 6 meters
successful [16].
Despite all these reasons and hopes for restoring vision, Refractive error was defined if a child has myopia of
there are limited data about magnitude visual impairment <0.50 D, hyperopia of >+1.00 D, and/or astigmatism
in school children in Ethiopia. Particularly in the study (>1.00 DC) in subjective refraction
area, there is only one previously published study focused
on the prevalence of refractive error among all age groups 2.2.2. Data Management and Analysis. Coded data were
of students and it does not show the magnitude of visual entered into SPSS version 16 for analysis. Descriptive sta-
impairment in school children. In addition, the results will tistics was used to analyze the result. Results were presented
be important to prioritize resource allocations, to see re- using tables and texts.
gional variations, as compared with the reported preva-
lence of visual impairment in studies performed in 3. Results
Ethiopia in different zones at community level. Therefore,
this study was aimed to generate evidence by determining 3.1. Sociodemographic Characteristics of Study Population.
the burden of visual impairment in school children in A total of 1289 primary school children (55.2% are females)
Gondar town. from nine primary schools were included in the study, i.e.,
Journal of Ophthalmology 3

response rate of 100%. The mean age was 10.83 (SD ± 2.44, prevalence of visual impairment and this is true that there is
range 5–15) years. The majority of the children were aged 10 high chance of detecting children with the condition at
to 15 years. The majority (85.7%) of children are from community level.
government schools. Using the definition of the better eye’s vision or either
eye's vision less than 6/18, this result is found to be higher
than that in Addis Ababa. Arada subcity reported results of
3.2. Prevalence and Degree of Visual Impairment. The 0.53% and 1.1% [9] and one population-based study in the
prevalence of bilateral visual impairment in the study southwest, Sekuro district, showed results of 0.062% [25].
population was 1.8%, while the prevalence of uniocular The difference might be the sample size selection criteria;
visual impairment was found to be 3.7% using vision <6/18 that is, the latter study showed that children included were
in either eye definition. Twelve (52%) male children were already either blind or with severe visually impaired or just
bilaterally visually impaired though not statistically signif- undergone for examination to identify the causes, but in the
icant (p > 0.05). The majority (98.2%) of children have current study, there was no predetermined selection of
normal-to-mild vision impairment (6/6–6/18), followed by children, i.e., chance was given to all. The reason could be the
moderate visual impairment in 1.6% (<6/18–6/60). There characteristics of population differences for eye care services.
was no severe visual impairment in the study population. However, the prevalence in the study area was lower than
Among students with moderate visual impairment, females other study reports of developed countries such as Egypt
accounted for about 55%. There were 47 eyes (3.65%) that (29.4%) [27], Northern Ireland (3.6%) [21], Nepal (9.1%)
are visually impaired among school children (see Table 1). [22], Brazil (2.67% and 4.82%) [28, 29], two regions of China
(6.37% and 7.7%) [30, 31], and Australia (6.4%) [32]. This is
3.3. Causes and Proportion of Visual Impairment. The most probably due to variation in the measurement of visual
frequent cause of uniocular and bilateral visual impairment impairment, where in this study, children presenting with a
in the study population is refractive error (Table 2). More visual acuity of <6/18 in the better eye were considered as
than two-thirds of proportion of both uniocular and bilateral visually impaired, whereas majority of the above used
visual impairments were due to refractive errors. There were children presenting with a visual acuity of less than or equal
three blind children enrolled with normal sight but use to 6/12 and specifically, vision ≤6/9 was used in Egypt. In
Braille and other techniques to learn and cope with friends. addition, the discrepancy could also be attributed to the
Children’s age was the sociodemographic variable that difference in age of children included in the studies, in which
showed statistically significant association with visual im- some studies included children up to age of 18 years since
pairment (p � .0.044). Children of age fifteen and above increasing age is an important predictor of visual impair-
showed statistically significant association with visual im- ment. Some of the studies are population-based house-to-
pairment (p � 0.005). Without taking other variables into house studies which may include preschoolers and children
account, children of age 15 and above were more than 6 dropped out school for various undetected ocular
times (COR: 6.18, 95% CI, 1.75–21.9) to be visually impaired conditions.
than those children in the age between 5 to 10 years. There Majority (87%) of the school children in the current
was no statistically significant difference in visual impair- study were with moderate visual impairment, and age
ment between males and females (p � 0.47). groups of 10–15 years were the more affected ones. This
implies that vision recovery could be possible if refractive
4. Discussion errors are detected and treated early. In Egypt, the pro-
portion of moderate visual impairment was 2%. However, in
Globally, visual impairment and blindness are among the the current study, there were no children with severe visual
major public health issues especially in developing countries impairment and only 3 (0.2%) children were found to be
such as Ethiopia. Knowing the magnitude and causes of the bilaterally blind. In contrast, a study performed in schools
disease will help to plan action to reduce the impact at for the blind in Eastern Africa reported that about 65.2%
individual, community, and national levels through evi- them are with severe visual impairment or blind [7]. It can be
dence-based implementation of treatment and prevention understood here that children in schools for the blind are
strategies for avoidable causes. already identified as having visual impairment and enrolled
As a result, this study was conducted in Gondar town in separate schools, while children found visually impaired
among children and found that the prevalence of visual in this study and other studies are expected to have healthy
impairment was 1.8%. This result is in agreement with the and normal vision.
study performed in the southern part of Ethiopia, Goro Reviewed studies conducted at different time points and
district (1.75%) [10]. The probable reason could be the towns in Ethiopia showed the prevalence of refractive errors as
similar age group of population. On the other hand, this 4%, 9.3%, and 10.2% [13, 14, 33]. The ocular condition is still
finding is much lower to studies in other parts of Ethiopia. common in some parts of the world. For instance, prevalence
For example, in Amhara regional state, Bahir dar city, and data were reported as 4.4% in Nigeria, 19.2% in Vietnam, and
Sekela district, visual impairment was reported to be 8.7% 20.69% in China [5, 30, 34]. It can be said that the magnitude is
and 8%, respectively [12, 26], and in the capital city, Addis significant in countries with reported data, and the possible
Ababa, two studies showed 5.8% and 7.24% [9, 11]. In explanation could be that environmental factors will contribute
addition, the two studies in Amhara region reported higher to the development of refractive errors especially at school age
4 Journal of Ophthalmology

Table 1: Proportion and degree of visual impairment in terms of sociodemographic variables among visually impaired children in Gondar
town.
Uniocular visual impairment Bilateral moderate and severe VI (<6/18–3/60) Blind
Characteristics
(n � 47, 3.65%) (n � 23) (<3/60)
Male 17 (36.2%) 9 (39.1%) 3 (13.1%)
Sex
Female 30 (63.8%) 11 (47.8%) 0%
5–10 years 12 (25.5%) 5 (13.1%) 2 (8.7%)
Age group
10–15 years 35 (74.5%) 15 (73.9%) 1 (4.3%)
Right 24 (1.9%) 20 (1.6%) 3 (0.2%)
Laterality
Left 23 (1.8%)

Table 2: Cause-specific proportion of visual impairment among visually impaired children in Gondar town.
Unilateral visual impairment/ Bilateral visual impairment/
Ocular condition blindness (n � 47) blindness (n � 23)
N Percentage N Percentage
Refractive error 33 70.1 18 78.3
Strabismus 1 2.1 0 0
Cataract 3 6.4 1 4.3
Corneal opacity and cataract 2 4.3 1 4.3
Glaucoma 2 4.3 0 0
Retinal disorders 1 2.1 0 0
Corneal trauma 2 4.3 0 0
Unconfirmed 3 6.4 3 13
Total 47 100 23 100

and spending more time indoors and excessive near work will disorders such as optic nerve lesions and retinopathy are
lead to myopia onset [35]. Specifically, the probable scientific commonly found in developed countries, but corneal
reason for high prevalence in China could be the genetic in- opacities from infections disease and xerophthalmia are less
fluences and geographical variations. common in developed countries.
Uncorrected refractive errors are found to be the main The odds of being visually impaired with age above 15
cause for 70% of visual impairment in children in this study. years was 6 times more likely than the counterparts with a
This is supported by reports in Addis Ababa, Ethiopia crude odds ratio of (COR) 6.18 (95% CI, 1.75–21.9). A single
(70.3% and 77.3%), Sudan (36%), Vietnam (92.7%), Nepal study in Ethiopia similarly reported that children of age 10
(93.3%), China (86%), and Australia (69%) and above are almost 3 to 4 times more likely to be affected
[8, 9, 11, 22, 31, 32, 34]. In addition, the 2019 WHO report by visual impairment [11]. This finding supported and
indicated that refractive error still remains the number one strengthened the previous fact that visual impairment will be
cause of visual impairment in the world. This may be due to more with increasing age as frequent evidence was presented
lack of awareness about the symptoms and use of eye glasses and reported by the WHO and IAPB. However, no statis-
for correction. Besides, uncorrected refractive error is tically significant gender difference was shown with visual
painless visual condition and children with it may live impairment in this study.
without complain to parents and may not seek eye care as One of the limitations of this study is that the findings
compared with children with infectious eye disease. Despite might not show the causal relationship between visual
variations discussed in the above-reported prevalence of impairment and other independent variables because of the
visual impairment and refractive errors, majority of the nature of the method used. Recently, vision of 6/12 in either
findings indicate the need to focus on reducing uncorrected eye is used as the cutoff point for definition of visual im-
refractive errors and then visual impairment by taking child pairment and refractive error. But this study reported vision
eye health as public health agenda. less than 6/18 in the better eye as the cutoff point, and
In addition to refractive errors, strabismus (unilateral therefore, there might be underreporting of both visual
visual impairment) and cataract were second and third impairment and refractive errors in children. Also, the result
causes of visual impairment. Cataract is reported as the main may not be generalized to children who do not have access to
cause in African countries [8, 36] and is reported in small school due to different reasons, and the result may not show
percentage in developed countries. However, in other the real picture of the problem at community level.
studies, amblyopia [9, 29, 31, 34] becomes the second leading
cause of visual impairment in school children followed by 5. Conclusion
retinal disorders. This variation could be attributed to
variations in distribution of ocular problems across different Visual impairment in the study area is a significant public
countries based on socioeconomic development. Retinal health problem in school children. Refractive errors are the
Journal of Ophthalmology 5

major causes of the problem. Hence, priority should be given Birnin Kebbi, North West, Nigeria,” Sahel Medical Journal,
to start school vision screening in primary school children in vol. 18, no. 2, 61 pages, 2015.
the study area. [6] E. E Anne, K. S. Naidoo, and P. Govender, “Prevalence of
vision impairment and refractive error in school learners in
Calabar, Nigeria,” African Vision and Eye Health, vol. 78,
Data Availability no. 1, 2019.
[7] M. M. G. Njuguna, B. Shilio, C. Tumwesigye, P. Court right,
The data in which this result finding is based are available in and S. Lewallen, “Causes of Severe Visual Impairment and
soft copy with the corresponding author. Any query related Blindness in Children in Schools for the Blind in Eastern
to data can be deciphered by contacting the corresponding Africa,” Ophthalmic Epidemiology, vol. 16, no. 3, pp. 151–155,
author (e-mail: ayanaopto@gmail.com). 2009.
[8] Z. D. Mohamed, K. H. Binnawi, and M. Abdu, “Prevalence
Ethical Approval and causes of childhood blindness and visual impairment in
quranic boarding schools in Al-gazira state of Sudan,”
Ethical clearance was obtained from the research ethical Sudanese Journal of Ophthalmology, vol. 9, pp. 44–49, 2018.
review committee of the University of Gondar. [9] H. F. Darge, G. Shibru, A. Mulugeta, and Y. M. Dagnachew,
“The prevalence of visual acuity impairment among school
children at Arada subcity Primary Schools in Addis Ababa,
Consent Ethiopia,” Journal of Ophthalmology, vol. 2017, pp. 1–7, 2017.
[10] J. G. A. Kedir, “Prevalence of refractive error and visual
Verbal consent was obtained from each school head. Written
impairment among rural school-age children of Goro District,
consent was obtained from guardians/parents and assent Gurage Zone, Ethiopia,” Ethiopian Journal of Health Science,
was obtained from children. Confidentiality was kept vol. 24, no. 4, pp. 353–358, 2014.
through coding personal identity. Children with ocular [11] T. W. A. Lidiya Bezabih and R. O. Fite, “Prevalence and
abnormalities were referred to the University of Gondar factors associated with childhood visual impairment in
tertiary eye care center for further ocular evaluation, and Ethiopia,” Clinical Ophthalmology, vol. 11, pp. 1941–1948,
treatment was given. 2017.
[12] Y. A. Mengistu Zelalem and Y. Adamu, “Tewodros Getinet
prevalence of visual impariment amng three primary schools
Conflicts of Interest of sekela woreda ,Amhara regional state,” Northwest Ethiopia
The authors declare that they have no conflicts of interest. SAGE Open Medicine, vol. 7, pp. 1–8, 2019.
[13] S. Aweke Sewu, K. K. Aredo, and M. Gedefew, “Uncorrected
refractive error and associated factors among primary school
Authors’ Contributions children in debre markos district, Northwest Ethiopia,” BMC
Ophthalmology, vol. 14, no. 1, 2014.
AT initiated the concept and wrote the proposal of the paper. [14] A. W. Tefera and S. W. Tigist, “Refractive errors among school
AD reviewed the proposal and entered data. DS analyzed, children in Addis Ababa, Ethiopia,” Journal of Ophthalmology
interpreted, and wrote the manuscript. HW papered the of Eastern Central and Southern Africa, 2015.
manuscript. MA reviewed the manuscript. All authors read [15] H. A. Bakke, W. A. Cavalcante, I. Santos De Oliveira,
and approved the final manuscript. S. W. Sarinho, and M. T. Cattuzzo, “Assessment of motor
skills in children with visual impairment: a systematic and
Acknowledgments integrative review,” Clinical Medicine Insights: Pediatrics,
vol. 13, pp. 1–10, 2019.
The authors would like to thank the University of Gondar for [16] Lombardi P.. Understanding and Supporting Learners with
its financial support to carry out the research. Disabilities: Visual Impairments/Blindness https://granite.
pressbooks.pub/understanding-and-supporting-learners-
with-disabilities.
References [17] S. P. Mariotti, Global Facts on Blindness and Visual Impair-
ment, World Health Organization, Geneva, Switzerland, 2010.
[1] American Optometric Association, Optometric Clinical [18] IAPB International, Agency for Prevention of Blindness Re-
Practice Guideline: Care of the Patient with Visual Impair- port,2012 November.IAPB International, England, UK, 2010.
ment, American Optometric Association, St.Louis, MO, [19] A. S. W. J. Pai, C. Samarawickrama, G. Burlutsky, K. A. Rose,
1USA, 2014. and R. Varma, “Prevalence and risk factors for visual im-
[2] World Health Organization, Visual Impairment and Blind- pairment in preschool children,” American Ophthalmology
ness, WHO, Geneva, Switzerland, 2020, https://www.who.int/ Academy, vol. 118, no. 8, pp. 1495–1500, 2011.
en/news-room/fact-sheets/detail/blindness-and-visual- [20] J. H. M. Muecke, Y. Y. Aung, S. Warrier, A. Kong, and
impairment. A. Morse, “A survey of visual impairment and blindness in
[3] D. Pascolini and S. P. Mariotti, “Global estimates of visual children attending seven schools for the blind in Myanmar,”
impairment: 2010,” British Journal Ophthalmology, vol. 96, Ophthalmic Epidemiology, vol. 16, no. 6, pp. 370–377, 2009.
no. 5, pp. 614–618, 2012. [21] M. F. DnoghueL, N. S. Logan, A. R. Rudnicka, C. G. Owen,
[4] B. Y. M. Annalies, O. Lene, and D. Reshma, “Child’s Eye and K. J. Saunders, “Refractive error and visual impairment in
Health in Africa,” The African Child Policy Forum, Addis school children in Northern Ireland,” British Journal of
Ababa, Ethiopia, 2013. Ophthalmology, vol. 94, no. 9, pp. 1155–1159, 2010.
[5] H. B. Aliyu, A. Ibrahim, and A. Asmau, “Vision screening to
detect refractive errors in three selected secondary schools in
6 Journal of Ophthalmology

[22] Y. D. Sapkota, B. N. Adhikari, G. P. Pokharel, B. K. Poudyal,

and L. B. Ellwein, “The prevalence of visual impairment in
school children of upper-middle socioeconomic status in
Kathmandu,” Nepal Ophthalmic Epidemiology, vol. 15, no. 1,
p. 17, 2008.
[23] C. Mhina, “Magnitude and causes of visual impairment and
blindness among children attending paediatric eye clinic at
muhimbili national hospital,” Journal of Evolution of Medical
and Dental Sciences, vol. 11, 2010.
[24] A. Kingo and B. T. Ndawi, “Prevalence and causes of low
vision among school children in Kibaha district,” Tanzania
Journal of Health Researc, vol. 11, no. 3, pp. 111–115, 2009.
[25] B. S. Demissie and A. W. Solomon, “Magnitude and causes of
childhood blindness and severe visual impairment in Sekuro
district, southwest Ethiopia,” Royal society for Tropical
medicine and visual science, vol. 105, no. 9, pp. 507–511, 2011.
[26] Y. A. Merrie, M. M. Tegegne, M. B. Munaw, and H. W. Alemu,
“Prevalence and associated factors of visual impairment
among school-age children in BahirDar city, northwest
Ethiopia,” Clinical Optometry, vol. 11, pp. 135–143, 2019.
[27] G. Yamamah, A. Talaat, A. A. Alim, Y. Mustafa, R. Ahmed,
and A. M. Mahmud, “Prevalence of visual impairment and
refractive errors in children of south Sinai, Egypt,” Oph-
thalmic Epidemiology, vol. 22, no. 4, pp. 246–252, 2015.
[28] S. R. C. R. Salomão, A. Berezovsky, L. Mendieta et al.,
“Prevalence and causes of visual impairment in low-middle
income schoolchildren in Sao Paulo, Brazil,” Inves-
tigativeOphthalmology Visual Sciences, vol. 49, no. 10,
pp. 4308–4313, 2008.
[29] R. S Solange, M. R. K. H. Mitsuhiro, and R. Belfort Jr, “Visual
impairment and blindness, an overview of prevalence and
causes in Brazil,” Annals of the Brazilian Academy of Sciences,
vol. 81, no. 3, pp. 539–549, 2009.
[30] R. Vishnuprasad JB, K. Madhanraj, R. P. Hannah, Z. Singh,
K. S. Abel, and T. Muthukumar, “Visual impairment among
10–14-year school children in Puducherry: a cross-sectional
study,” Jouranl of Family Medicine and Priary Care, vol. 6,
no. 1, pp. 58–62, 2017.
[31] L. H. C. L. Pi, Q. Liu, N. Ke et al., “Prevalence of eye diseases
and causes of visual impairment in school-aged children in
western China,” Journal of Epidemiology, vol. 22, no. 1,
pp. 37–44, 2012.
[32] S. P. J. J. Amy, S. Chameen, B. George et al., “Prevalence and
risk factors for visual impairment in preschool children the
sydney paediatric eye disease study,” Journal of Ophthal-
mology :American Academy of Ophthalmology, vol. 118, no. 8,
pp. 1495–1500, 2011.
[33] A. W. B. Yared, S. Destaye, T. Ayanaw, E. Zelalem, and
T. Ayanaw, “Prevalence of refractive errors among school
children in Gondar town, northwest Ethiopia,” Middle East
African Journal of Ophthalmology, vol. 19, no. 4, pp. 372–376,
2012.
[34] P. H. P. Prakash, R. Prasidh, M. H. Suit et al., “Prevalence of
vision impairment and refractive error in school children in
Ba Ria–vung Tau province, Vietnam,” Clinical and Experi-
mental Ophthalmology, vol. 42, pp. 217–226, 2014.
[35] World Health Organization BHVI, “The impact of myopia
and high myopia,” in Global Scientific Meeting on Myopia,
World Health Organization, Geneva, Swizerland, 2016.
[36] M. M. Maake and O. A. Oduntan, “Prevalence and causes of
visual impairment in patients seen at Nkhensani Hospital Eye
Clinic, South Africa,” African Journal of Primary Health Care,
vol. 7, no. 1, pp. 728–734, 2015.