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Review Article

The Status of Childhood Blindness and Functional Low Vision in the Eastern Mediterranean Region in 2012

Rajiv Khandekar, H. Kishore1, Rabiu M. Mansu2, Haroon Awan3

ABSTRACT Access this article online Website: Childhood blindness and (CBVI) are major disabilities that compromise www.meajo.org the normal development of children. Health resources and practices to prevent CBVI are DOI: suboptimal in most countries in the Eastern Mediterranean Region (EMR). We reviewed the 10.4103/0974-9233.142273 magnitude and the etiologies of childhood visual disabilities based on the estimates using Quick Response Code: socioeconomic proxy indicators such as gross domestic product (GDP) per capita and <5‑year mortality rates. The result of these findings will facilitate novel concepts in addressing and developing services to effectively reduce CBVI in this region. The current study determined the rates of bilateral blindness (defined as Best corrected (BCVA)) less than 3/60 in the better eye or a visual field of 10° surrounding central fixation) and functional low vision (FLV) (visual impairment for which no treatment or refractive correction can improve the vision up to >6/18 in a better eye) in children <15 years old. We used the 2011 population projections, <5‑year mortality rates and GDP per capita of 23 countries (collectively grouped as EMR). Based on the GDP, we divided the countries into three groups; high, middle‑ and low‑income nations. By applying the bilateral blindness and FLV rates to high, middle‑ and low‑income countries from the global literature to the population of children <15 years, we estimated that there could be 238,500 children with bilateral blindness (rate 1.2/1,000) in the region. In addition, there could be approximately 417,725 children with FLV (rate of 2.1/1,000) in the region. The causes of visual disability in the three groups are also discussed based on the available data. As our estimates are based on hospital and blind school studies in the past, they could have serious limitations for projecting the present magnitude and causes of visual disabilities in children of EMR. An effective approach to eye health care and screening for children within primary health care and with the available resources are discussed. The objectives, strategies, and operating procedures for child eye‑care are presented. Variables impacting proper screening are discussed. To reach the targets, we recommend urgent implementation of new approaches to low vision and rehabilitation of children.

Key words: Childhood Blindness, Eastern Mediterranean Region, Functional Low Vision, Visual Disability

INTRODUCTION illness and subsequent rehabilitation. It also includes the right of children with any kind of disability to special care and n 1989, the United Nations adopted a convention on the support.1 In 2009, a 20‑year review of the CRC identified Irights of the child (CRC). A major article of this convention various challenges facing member states in the implementation is the right of children to have access to the highest attainable of this article. It determined that the limited allocation of standard of health and to the facilities for the treatment of resources to be a significant factor in hampering optimal

Department of Research, King Khalid Eye Specialist Hospital, 2Middle East Africa and IMPACT NGO, Riyadh, Saudi Arabia, 1Department of Pediatric Ophthalmology, Al Nahdhah Hospital, Ministry of Health, Oman, 3Avicenna Consulting Pvt Ltd., Islamabad, Pakistan Corresponding Author: Dr. Rajiv Khandekar, Department of Research, King Khaled Eye Specialist Hospital, POB: 7191, Riyadh 11462, Saudi Arabia. E‑mail: [email protected]

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Khandekar, et al.: Childhood Blindness in EMR Region

physical and mental development of children in many parts As an example, gross domestic product (GDP) per capita and of world.2 mortality rates of children < 5‑year of age have been shown to be reliable proxy indicators to determine the magnitude of Childhood blindness and visual impairment (CBVI) has a childhood blindness. 11 These are reliable indicators due to the significant effect on the physical, mental, and social development intimate relationship between some causes of blindness (measles, of a child. Therefore, childhood blindness remains a priority , ophthalmia neonatorum, rubella, disease of the global initiative for the elimination of avoidable etc.) and diseases with high morbidity and mortality in blindness by the year 2020: “VISION 2020 ‑ The Right to developing countries. Developing countries have a low level of the Sight”.3 All 23 countries of the Eastern Mediterranean socioeconomic development and suboptimal health resources Region (EMR) were signatories to the CRC and World Health to prevent or treat these conditions. To estimate the number Organization (WHO) resolutions on the VISION 2020 and of children with bilateral blindness in each EMR country on Millennium Developmental Goals. 4 Measures to address the basis of socioeconomic indices such as GDP and under 5‑year rights of children unfortunately have not been adequately or of age mortality rate, we grouped the 23 EMR countries into uniformly implemented. In order to identify effective methods 3 categories using the data from the 2011 annual report of the to provide optimal child eye heath care within a comprehensive Regional Director of WHO EMR.12 Countries with GDP over health delivery system, we assessed the magnitude and causes of US$15,000 were classified as Group 1, countries with GDP of CBVI in children in the EMR. CBVI mainly includes bilateral US$1,500-US$15,000 were classified in Group 2 and countries blindness and functional low vision (FLV). Bilateral blindness with GDP < US$1,500 were classified in Group 3. We also is defined as the best‑corrected visual acuity (BCVA) of less grouped the countries into three sets based on the childhood than 3/60 in the better eye or field of vision restricted to 10° mortality rates of under 5‑year of age: Set 1 included children around central fixation. FLV is defined as visual impairment for with a mortality rate of < 20/1,000 live births; Set 2 with a which no treatment or refractive correction can improve the mortality rate between 20 and 50/1,000 live births and; Set 3 vision up to >6/18 in a better eye. Our previous publication countries with a mortality rate > 50/1,000 live births [Figure 1]. covered important aspects of visual disabilities in children in We determined that this classification coincided well with the EMR.5 However, civil conflicts have affected the economy of GDP grouping of countries. many middle eastern countries in the previous 5‑year.6 Children, as the highest at‑risk population, are often the most affected For each group, we applied a blindness prevalence rate obtained in these conflicts. Due to new conflicts arising in the area, it is from countries with similar GDP. Thus, for Group 1 countries, likely that factors affecting visual disabilities in children might the rate was tabulated to be 0.3/1,000, for Group 2, it was 11 have changed, thus warranting a re‑examination of this issue 0.9/1,000, and for Group 3, it was 1.5/1,000. These data were and a new analysis for the regional countries. used to calculate the number of children with bilateral blindness

MAGNITUDE OF THE PROBLEM Somalia 180 Afghanistan 655 Evidence‑based information on the magnitude of certain health Pakistan 840 issues is vital for an appropriately enhanced approach in the Yemen 926 Djibouti 1031 7 public health sector. Elimination of preventable childhood Sudan 1353 blindness is one of the priorities of the “VISION 2020 ‑ The Palastine 1804 Right to the Sight” initiative in the subcontinent. Estimates show Syria 1804 that there are 1.4 million blind children living in the middle‑ and Egypt 1949 low‑income countries. Of these blind children, 200,000 were Morocco 2707 8 Jordan 3257 projected to be blind in member countries of the WHO EMR. Iraq 3524 The report further states that every year, an additional 50,000 Tunisia 3796 9 children go blind in worldwide. Iran 5070 Labanon 7659 Community‑based prevalence surveys for childhood blindness Libya 14846 are essential in creating roadmaps to manage this health issue. Saudi Arabia 18603 Oman 19102 However, they require a large sample and are costly. Therefore, Bahrain 27943 conducting these surveys is a major challenge in developing Kuwait 40485 countries where there are competing demands for financial United Arab Emirates 64009 resources.10 In such circumstances, creation of alternative Qatar 88990

methods to estimate the magnitude and identify causes of Figure 1: Gross domestic product in US$ and <5 mortality per 1000 live births in childhood blindness must be considered. member countries of Eastern Mediterranean Region of the World Health Organization

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Khandekar, et al.: Childhood Blindness in EMR Region

in an individual EMR country [Table 1]. We determined that Table 1: Estimated bilateral blindness and FLV in children aged the bilateral blindness rate in the EMR region was 1.2/1,000 15‑year or younger in member countries of EMR of the WHO children < 15‑year of age. This translates to a 238,500 bilateral Countries Population Bilateral FLV** blind children across the entire EMR countries. Two‑thirds were <15 children blind* distributed in seven countries in Group 3 (with low GDP and Group 1 (GDP >15,000 US$ and <5 mortality rate <20/1,000 live births) high mortality rates among < 5‑year‑old children). Bahrain 262,633 80 250 UAE 1,674,708 500 1,450 We also calculated the number of children with FLV. We used Kuwait 781,534 250 650 data from a multicenter study of schoolchildren across countries Qatar 245,018 100 250 KSA 9,195,186 2,750 7,850 based on their level of their GDPs already grouped into 1-3 Oman 1,124,596 350 1,000 from low to high. In Group 1, for countries with highest GDP, Group 2 (GDP 5,000-15,000 US$ we used the FLV rate (0.3/1000) in South Africa with GDP of and <5 mortality rate 20-50/1,000 13,14 live births) US$11,273 in 2010. In Group 2, the FLV rate was projected Egypt 26,101,729 23,500 49,000 to be 1.87 as reported for Nepal with GDP of US$1,388/capita). Iran 17,311,053 15,580 32,500 In Group 3, the rate was assumed to be 2.5/1,000 children Iraq 13,755,978 12,380 25,750 as reported in India with a GDP US$1,455 in 2010. Table 1 Jordan 2,330,312 2,100 4,350 Lebanon 1,068,623 950 2,000 presents the FLV of 23 countries. The FLV rate was 2.1/1,000 Libya 1,858,143 1,675 3,500 children under 15‑year of age, and 417,725 children had FLV Morocco 9,453,912 8,500 17,700 in the EMR region. As our estimates are based on the hospital Palestine 1,733,120 1,550 3,250 Syria 8,054,581 7,250 15,100 and blind school studies in the past, they could have serious Tunisia 2,532,614 2,300 4,750 limitations for projecting the magnitude and causes of visual Group 3 (GDP <5,000 US$ and <5 disabilities in children in EMR. Community‑based prevalence mortality rate >50/1,000 live births) data would be more accurate for national public health planning. Afghanistan 12,506,940 18,760 31,275 Pakistan 60,393,579 90,600 151,000 Yemen 9,991,717 15,000 8,500 CAUSES OF CHILDHOOD BLINDNESS Somalia 3,962,322 5,950 10,000 AND VISUAL IMPAIRMENT South Sudan 4,305,533 6,450 11,000 North Sudan 14,307,546 21,450 35,800 Djibouti 316,355 475 800 Studies have been conducted to review the anatomical and Total 203,267,732 238,500 417,725 etiological causes of BCVI in children in the EMR.15‑20 These The bilateral blindness rate in<15 children was assumed to be 1.5/1000 in are mostly institution based studies, undertaken in schools for Group 3, 0.9/1000 in Group 2 and 0.3/1000 in Group 1 countries. The FLV rate in <15 children was assumed to be 2.5/1000 in Group 3, 1.87/1000 in Group 2 special needs children or schools for the blind. Other studies and 0.85/1000 in Group 1 countries. FLV: Functional low vision, EMR: Eastern were hospital and community‑based21‑25 [Table 2]. However, mediterranean region, WHO: World health organization, GDP: Gross domestic product, KSA: Kingdom of Saudi Arabia, *Bilateral blind =BCVA <3/60 in better valid data on the true causes of overall FLV among children in eye or field of vision restricted to 10 degrees around fixation, ** Functional the EMR are scarce. low vision (FLV) = BCVA ≤6/18 in better eye after correction of refraction and treatment In industrialized countries, central visual function defects due to perinatal and hereditary causes (in USA, Europe and improvements have resulted in an increase in the rate of ROP Western pacific countries), retinal dystrophies, and and its severity at presentation.34 These factors have resulted in of prematurity (ROP) are the leading causes of childhood a steady rise of central visual deficits and birth defects with ROP blindness.26 In contrast, infection, , trauma, and as the more common causes of visual deficits and uncorrected , and un‑operated cataract are declining rates of infectious and nutritional causes in Group 1 leading causes of visual disabilities in developing countries.27 and 2 countries.35 In Group 3 countries, corneal blindness due In developing countries, the majority of these conditions are to Vitamin A deficiencies, infections, and war‑related injuries avoidable or treatable with improved access to medical care, remain the primary etiology of visual deficits.36 routine visual screening and the appropriate action of care.28 In the emerging EMR market‑nations, a combination of various MEASURES TO ADDRESS THE PROBLEM causes of FLV is noted. Additional factors contributing to the intricacy of FLV in children are the high rate of consanguineous In a recent study, Limburg et al. reported that 36.4% of childhood marriages, unacceptable therapeutic abortions, and the high blindness were due to uncorrected refractive error in developing birth rates.29‑33 Improved access to health care and improved countries. Among children at blind schools, one‑fourth of visual delivery of health care especially related to maternal and child disability was ‑or corneal‑related.37 The study showed health care in most of the aforementioned countries have that many childhood visual disabilities are preventable, and the resulted in better survival of preterm children. However, these rest may be addressed through rehabilitation to improve vision

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Khandekar, et al.: Childhood Blindness in EMR Region

related quality‑of‑life. The needed intervention is dependent on implementation of these programs through the national eye the available infrastructure for primary health care and eye‑care health care programs of Group 1 and 2 countries. within a country. Furthermore, we advise direct management of other ocular Preventive measures conditions like retinal dystrophies, ROP, , To properly design appropriate and relevant measures to congenital , , , etc., to be done address the optimal public health approaches in reducing the vis‑a‑vis pediatric ophthalmologists or general ophthalmologists CBVI will be a complex and an immense undertaking due to oriented in pediatric ophthalmology. New ophthalmology centers the diverse causes of childhood blindness in the EMR. The of excellence providing direct access to health‑care professionals EMR countries have committed themselves in reaching the within the already existing secondary/tertiary pediatric eye Millennium Development Goals.4 With specific public health hospitals would ultimately establish the gold‑standard approach initiatives, a number of preventive measures could be introduced in management of conditions leading to childhood blindness. and reinforced to address nutritional, childhood infection, and injury‑related eye problems in children. Integrating primary Late interventions often compromise the outcomes of ocular pediatric eye‑care screening with the preexisting primary pathologies leading to childhood blindness. However, following health care delivery in school settings and community‑based the intervention, the child can utilize the residual vision and use outreach programs will allow for an early detection of disabling low vision aids to improve his/her quality‑of‑life.46 As a result, eye diseases in children.38,39 This will enable eye care providers for disabled children especially in Group 3 countries, maximum to detect and prevent blinding eye conditions at early stages, efforts should be dedicated to allocate proper resources in that is, , blindness secondary to measles, rubella, identifying treatable blindness even if such conditions present and ocular trauma. This could also be a channel for advocacy in the late stages or are initially detected at an older age. for healthy eye practices, providing first aid for eye emergencies and guiding children with visual disabilities for rehabilitation. The following lists are the suggested goals for managing some Close collaboration of all stakeholders responsible for children’s of the common causes of visual impairment and blindness in overall health like pediatricians, sociologists, parents, family children: physicians, community support groups, etc., could further • The goal of managing a child with congenital cataract: enhance a better eye care screening, delivery, and treatment of • Significant visual impairment due to cataract should diseases for all children. undergo timely surgery using age appropriate and evidence‑based surgical techniques Curative measures • To stimulate further development of the Refractive error is a major cause of the slow rise in ocular by enabling clear images in both eyes morbidity in the EMR. The prevalence was 13.7% in Saudi • To offer functional vision to a child with cataract, children, and 22.1% in Egypt.40,41 Mid‑level eye care personnel provide low vision rehabilitation services in time and can manage refractive error in children and could provide monitor changes in quality of life and maintain visual aids at an affordable cost.42 Screening for • The goal of managing a child with ROP: in 3-5‑year‑old children, vision‑screening for all • To arrest the progression of ROP. preterm infants regardless of their previous ROP status, as • To monitor short and long‑term outcomes of ROP well as vision‑screening programs for all school age children management for refractive errors, have been found to be cost‑effective • To offer refraction, low vision care and if needed, measures in the literature.43‑45 At the minimum, we recommend rehabilitation

Table 2: Different studies in EMR highlighting the causes of childhood blindness Author Country Year Sample Causes Reference Source Al‑Wadani KSA 2012 61 Hereditary 56%, glaucoma, cataract 15 School for the blind Kazmi Pakistan 2007 50 Posttrauma phthisis, RP, OA 16 Mirdehghan Iran 2005 362 Cataract, OA, CO, glaucoma 17 Khandekar Oman 2011 47 Congenital disorder 55% 18 Kotb KSA 2006 217 Congenital disorder 19 Sight savers international Pakistan 2003 1000 Retinal problem 51.2%, 20.3% 20 Elder Palestine 1993 205 Retina, OA, glaucoma, cataract 21 Hospital Tabbara KSA 2005 5,217 OA, retinal dystrophy and cataract 22 Al‑Merjan Kuwait 2005 412 Congenital malformation, OA, ROP 23 Register for blind Razavi Iran 2010 123 Retina, globe 24 Community Bamashmus Yemen 2010 45 Cataract, glaucoma, retinal disorder 25 Hospital KSA: Kingdom of Saudi Arabia, RP: pigmentosa, ROP: Retinopathy of prematurity, OA: Optic atrophy, CO: Corneal opacities, EMR: Eastern mediterranean region

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• The goal of managing a child with strabismus: of 10 million people, we will need a minimum of 60 pediatric • To determine the underlying cause of strabismus. ophthalmologists in EMR region.55 The WHO recommended • To treat amblyopia and refractive correction as needed. ratio of one optometrist to every 50,000 population cohort • To ensure cosmesis by proper use of spectacles and might be a suitable basis for good eye‑care.56 However, local surgery as needed optometrists require training for providing child eye‑care. The • To optimize binocularity. time required for training is nearly 2-3 years. However, more optometrists (more than 1,200) will be required by the time Low vision services the training is complete due to the continual increase in the Despite the best preventive and curative measures, some children younger population in the region. In addition, a skilled work will continue to remain visually impaired. In such cases, low force (of optometrists) is found mainly in the urban areas while vision rehabilitation services are warranted to ensure that these the rural population with more childhood blindness has difficult children live a near normal life. There is a major emphasis on access to health care services. If the doctors work with other integrating low vision care within VISION 2020 and a plan team members, eye‑care delivery will be enhanced. In countries, for better implementation of low vision care in the member where the primary health care system is not organized in all parts countries. Using the key informant method in the community of the country, eye‑screening centers could be developed in such is another approach adopted in underprivileged countries to areas, and children with ocular pathologies could be referred to locate children with visual disabilities.47 Already existing studies the centers of excellence. Few training centers are supported from the hospital based‑data, although biased in a number of by the International Nongovernmental Organisations related to ways, are rich sources of information in providing additional the prevention of blindness in the region. methods of care on childhood blindness.23 Changing trends of childhood blindness has made it mandatory for Group 1 Child eye health practices should be instituted at the community and 2 countries to adopt new programs to integrate low vision as well as at the primary, secondary, and tertiary health care rehabilitation of children into VISION 2020. The International levels and with a direct engagement of other social public sectors Agency for the Prevention of Blindness - EMR has taken the ranging from social welfare to education and others. Teamwork initiative to plan low vision care in the region.48 A selective in addressing the childhood visual impairment and blindness and focal approach was adopted in the past by Oman, Qatar, must be the ultimate goal. We present a schematic diagram to UAE, Saudi Arabia, Pakistan, etc.49 An institutional‑based address CBVI, depicting intervention at different health care approach for low vision care needs to be complimented by levels [Figure 2]. community‑based rehabilitation. Children with other sensory impairments have a higher risk of abnormal visual function.50 Reviews of the screening programs and models of vision and eye Thus, countries with limited resources can begin focusing examination for children have confirmed their benefits. Carlton on low vision care services targeting children in schools for et al. suggested that amblyopia screening at 3 or 4 years of age is the blind, schools for the deaf, and schools for the mentally cost‑effective.57 A subsequent review by Schmucker et al. revealed challenged. Ironically, half of the children studying in schools uncertainty about age at which treatment of amblyopia remains for the blind have low vision disability rather than absolute effective.58 Although vision improved following amblyopia blindness, and a more individualistic approach is needed for treatment, its impact on vision related quality‑of‑life was low.59 these children.51 Integrated and collaborative medical teams, Mema et al. justified preschool screening program for amblyopia consisting of orthoptists, pediatric optometrists, etc., would detection and care that is ongoing in different provinces in certainly enhance and build the necessary bridges in providing Canada.43 The EMR countries with school health programs and a better care and improving access as well as implementing vision screening programs could adapt a suitable model for early preventive medicine. Hence, adopting a multi‑disciplinary detection of amblyopia and its causes. approach and involving all the stakeholders in the childcare is crucial for success.52 Health staff at the primary level can contribute significantly to prevent eye morbidity in children. The proposed role of the Human resources need primary health care worker is given below. Limited resources for addressing childhood blindness are a major challenge in many member states in EMR. The emphasis Primary health care staff should perform the following functions: on developing human resources and pediatric eye care service • Judiciously implement visual screening for developmental centers, as “centres of excellence” was recommended in 2002.53 milestones during the vaccination visit of children Murthy et al. evaluated these resources in India and found them • Consult an ophthalmologist for ROP screening if a baby is inadequate and not appropriately distributed. 54 Similar evaluation born <2000 g or <32 weeks and rule out ROP in case a and monitoring are required in countries in EMR region. If we newborn has respiratory distress syndrome use the estimate of one pediatric ophthalmologist at one child • Perform vision screening of preschool children eye‑care center with a well‑trained team for a target population • Diagnose and treat Vitamin A deficiency, infective

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Figure 2: Schematic diagram for addressing childhood blindness at different health care levels

and • Refer cases to a pediatric ophthalmologist at tertiary eye • Use grading card to diagnose active trachoma centers as warranted and treat the case as per accepted medical protocols • Follow treatment and follow‑up plan after child has been • Advocate preventive eye measures to avoid infectious eye assessed/treated by a pediatric ophthalmologist. diseases and take the appropriate educational activities in the prevention of ocular injuries There were some limitations to our study. Countries • Detect and treat cases of chronic allergic conjunctivitis (Syria, Libya and Yemen) that faced civil disturbances in 2011 leading to secondary keratopathy and 2012 may have different < 5 mortality rates and GDP • Promptly refer ocular emergencies to an ophthalmologist than that documented based on mid ‑ 2011 data, thus skewing • Refer children who fail a screening test to experienced our reported results. Some demographics may vary such as ophthalmologists high fertility rate, higher consanguinity, late pregnancies, use • Counsel children and parents to comply with the medical of traditional medicine etc., resulting in higher prevalence of advice from eye‑care professionals (surgery, spectacles, FLV and blindness in this region compared to the developed etc.). countries. We urge caution in interpreting our final data as the rates and causes of blindness and FLV are based on hospital and The role of general ophthalmologists in child eye health cannot blind school data of studies in the past and extrapolation to EMR be overemphasized. In settings where there is no pediatric countries may result in inaccurate conclusions. Hence, our study ophthalmologist, the general ophthalmologists will take many likely underestimates the rates of blindness and FLV in these of the roles of the pediatric ophthalmologists. The following are countries. In large countries with dense population centers, the minimal roles suggested for the general ophthalmologists: the situation within certain governorates or provinces may vary • Comprehensive eye assessment of children referred with a and fluctuate. Therefore, the scenario of childhood blindness diagnosis of cataract, glaucoma, low vision, ROP, amblyopia, in such countries should be reviewed with caution, and further and ocular birth defects planning to address childhood blindness should be carried out • Treat common eye conditions (allergic conjunctivitis, on a smaller scale level. Although uncorrected refractive error infectious conjunctivitis, etc.) in children could be a major contributor in visual disabilities, • Liaise with pediatrician to evaluate systemic pathologies as the definition used for calculating possible blindness did not part of ocular syndrome include this subset of children. Hence, the FLV data should be • Liaise with anesthetist to determine the status of the child for interpreted with caution while planning refractive error services. surgical intervention under general anesthesia (in children with significant cataract, glaucoma, ocular malignancies, In summary, current studies on childhood blindness give enough etc.) evidence‑based information, albeit with certain shortcomings,

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to plan and strengthen a public health approach in appropriately Khan MS, Alsulaiman RA. Magnitude and Causes of Low Vision dealing with childhood blindness in the region. Rehabilitation Disability (Moderate and Severe Visual Impairment) among Students of Al‑Noor Institute for the Blind in Al‑Hassa, Saudi of children with visual disabilities should be part of the public Arabia: A case series. Sultan Qaboos Univ Med J 2012;12:62‑8. health program of an individual country. Further research to 16. Kazmi HS, Shah AA, Awan AA, Khan J, Siddiqui N. Status of generate evidence on the cost‑effectiveness of screening for children in blind schools in the northern areas of Pakistan. amblyopia and its long‑term utility on visual loss and the best J Ayub Med Coll Abbottabad 2007;19:37‑9. approaches are recommended. Better methodologically designed 17. Mirdehghan SA, Dehghan MH, Mohammadpour M, Heidari K, Khosravi M. Causes of severe visual impairment and blindness studies in a cohort of selective population of the region would in schools for visually handicapped children in Iran. Br J allow a re‑evaluation and revision of the program strategies for Ophthalmol 2005;89:612‑4. dealing with this complex health issue. 18. Khandekar R, Shah R, Shah M, Al Harby S, Vora U, Al Balushi F. Ocular status and functional adaptation of visually challenged REFERENCES children of a special school in Oman. Oman J Ophthalmol 2011;4:17‑20. 19. Kotb AA, Hammouda EF, Tabbara KF. Childhood blindness 1. United Nations Convention on the Rights of a Childhttp. at a school for the blind in Riyadh, Saudi Arabia. Ophthalmic Available from: http://www. 2.ohchr.org/english/law/crc. Epidemiol 2006;13:1‑5. htm. [Last accessed on 2013 Jan 22]. 20. Sight Savers International. Current Status of the Aetiology, 2. Seymour D. 1989‑2009. Convention brings progress on child Prevalence And Distribution Of Childhood Blindness in Pakistan. rights, but challenges remain. Available from: http://www. Report 2003: 17‑18. Available from: http://www.sightsavers.org/ unicef.org/rightsite/237.htm. [Last accessed on 2013 Jan 22]. in_depth/policy_and_research/education/13177_Current%20 3. Babalola OE. Addressing residual challenges of VISION 2020: status%20Childhood%20Blindness%20in%20Pakistan. The right to sight. Middle East Afr J Ophthalmol 2011;18:91‑2. pdf. [Last accessed on 2013 Jan 25]. 4. Mittelmark MB. Millenium Development Goals. Glob Health 21. Elder MJ, De Cock R. Childhood blindness in the West Bank Promot 2009;16:3‑4, 73‑4, 88‑9. and Gaza Strip: Prevalence, aetiology and hereditary factors. 5. Khandekar R. Visual disabilities in children including childhood Eye (Lond) 1993;7:580‑3. blindness. Middle East Afr J Ophthalmol 2008;15:129‑34. 22. Tabbara KF, El‑Sheikh HF, Shawaf SS. Pattern of childhood 6. Mowafi H. Conflict, displacement and health in the Middle East. blindness at a referral center in Saudi Arabia. Ann Saudi Med Glob Public Health 2011;6:472‑87. 2005;25:18‑21. 7. Qureshi MB, Al‑Rajhi A, Al‑Qureshi S. The need for 23. Al‑Merjan JI, Pandova MG, Al‑Ghanim M, Al‑Wayel A, evidence‑based planning for VISION 2020. Clin Experiment Al‑Mutairi S. Registered blindness and low vision in Kuwait. Ophthalmol 2012;40:423‑4. Ophthalmic Epidemiol 2005;12:251‑7. 8. World Health Organization Eastern Mediterranean Region. 24. Razavi H, Kuper H, Rezvan F, Amelie K, Mahboobi‑Pur H, Statistics and Figures in Control of Prevention of Blindness Oladi MR, et al. Prevalence and causes of severe visual and Deafness. Available from: http://www.emro.who. int/control‑and‑preventions‑of‑blindness‑and‑deafness/ impairment and blindness among children in the lorestan about‑the‑programme/about‑the‑programme.html. [Last province of iran, using the key informant method. Ophthalmic accessed on 2013 Jan 05]. Epidemiol 2010;17:95‑102. 9. World Health Organization– Prevention of blindness and 25. Bamashmus MA, Al‑Akily SA. Profile of childhood blindness deafness. Childhood blindness in priority eye diseases. and low vision in Yemen: A hospital‑based study. East Mediterr Available from: http://www.who.int/blindness/causes/priority/ Health J 2010;16:425‑8. en/index4.html. [Last accessed on 2013 Jan 05]. 26. Kong L, Fry M, Al‑Samarraie M, Gilbert C, Steinkuller PG. An 10. Courtright P, Hutchinson AK, Lewallen S. Visual impairment in update on progress and the changing epidemiology of causes children in middle‑and lower‑income countries. Arch Dis Child of childhood blindness worldwide. J AAPOS 2012;16:501‑7. 2011;96:1129‑34. 27. Durnian JM, Cheeseman R, Kumar A, Raja V, Newman W, 11. Gilbert C, Foster A. Childhood blindness in the context of Chandna A. Childhood sight impairment: A 10‑year picture. VISION 2020 – The right to sight. Bull World Health Organ Eye (Lond) 2010;24:112‑7. 2001;79:227‑32. 28. Maida JM, Mathers K, Alley CL. Pediatric ophthalmology in the 12. World Health Organization. Country statistical profile in ‘The developing world. Curr Opin Ophthalmol 2008;19:403‑8. work of WHO in the Eastern Mediterranean Region: Annual 29. Hussain R. The effect of religious, cultural and social identity report of the Regional Director 1 January–31 December on population genetic structure among Muslims in Pakistan. 2011’. Available from: http://www.emro.who.int/about‑who/ Ann Hum Biol 2005;32:145‑53. annual‑reports/annual‑report‑2011.html. [Last accessed on 30. Yamamah G, Abdel‑Raouf E, Talaat A, Saad‑Hussein A, 2013 Jan 07]. Hamamy H, Meguid NA. Prevalence of consanguineous 13. Gilbert CE, Ellwein LB, Refractive Error Study in Children marriages in South Sinai, Egypt. J Biosoc Sci 2013;45:31‑9. Study Group. Prevalence and causes of functional low vision 31. Saha N, Hamad RE, Mohamed S. Inbreeding effects on in school‑age children: Results from standardized population reproductive outcome in a Sudanese population. Hum Hered surveys in Asia, Africa, and Latin America. Invest Ophthalmol 1990;40:208‑12. Vis Sci 2008;49:877‑81. 32. Babay ZA. Attitudes of a high‑risk group of pregnant Saudi 14. Global Finance GDP data of South Africa, India and Arabian women to prenatal screening for chromosomal Nepal in 2010. Available from: http://www.gfmag.com/ anomalies. East Mediterr Health J 2004;10:522‑7. gdp‑data‑country‑reports/255‑india‑gdp‑country‑report. 33. Al‑qudsi S. The demand for children in Arab countries: html#axzz2subDsSFU. [Last accessed on 2014 Feb 10]. Evidence from panel and count data models. J Popul Econ 15. Al‑Wadani F, Khandekar R, Al‑Hussain MA, Alkhawaja AA, 1998;11:435‑52.

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Khandekar, et al.: Childhood Blindness in EMR Region

34. Tasman W. Retinopathy of prematurity: Do we still have a 48. Prevention of Blindness Union. Conference Recommendations. problem? The Charles L. Schepens lecture. Arch Ophthalmol Doha Early Intervention Conference April 2011 held in Qatar. 2011;129:1083‑6. Available from: http://www.pbunion.org/files/LVR%20 35. Wani VB, Kumar N, Sabti K, Raizada S, Rashwan N, Shukkur MM, Workshop%20Documents/1.%20Agenda%20and%20 et al. Results of screening for retinopathy of prematurity in a other%20documents/Recommendations%20Doha%20 large nursery in Kuwait: Incidence and risk factors. Indian J Conference11May.pdf. [Last accessed on 2013 Jan 7]. Ophthalmol 2010;58:204‑8. 49. Khandekar R, Mohammed AJ. Assessment and care of children 36. Kheir AE, Dirar TO, Elhassan HO, Elshikh MA, Ahmed MB, with low vision disability in Oman. Situation analysis. Saudi Abbass MA, et al. Xerophthalmia in a traditional Quran boarding Med J 2005;26:1028‑30. school in Sudan. Middle East Afr J Ophthalmol 2012;19:190‑3. 50. Vora U, Khandekar R, Natrajan S, Al‑Hadrami K. Refractive error 37. Limburg H, Gilbert C, Hon do N, Dung NC, Hoang TH. and visual functions in children with special needs compared Prevalence and causes of blindness in children in Vietnam. with the first grade school students in oman. Middle East Afr Ophthalmology 2012;119:355‑61. J Ophthalmol 2010;17:297‑302. 38. World Health Organization. Summary report on Regional 51. Woodhouse JM, Davies N, McAvinchey A, Ryan B. Ocular and workshop for integrating and strengthening primary eye visual status among children in special schools in Wales: The care within primary health care in the Eastern Mediterranean burden of unrecognised visual impairment. Arch Dis Child Region. WHO‑EM/CPB/008/E. 2011. Available from: http://www. 2014;99:500‑4. applications.emro.who.int/docs/IC_Meet_Rep_2011_EN_14438. 52. Hyvärinen L, Walthes R, Freitag C, Petz V. Profile of visual pdf. [Last accessed on 2013 Jan 7]. functioning as a bridge between education and medicine in 39. IAPB EMR/WHO EMRO. Guidelines for School Eye Health for the assessment of impaired vision. Strabismus 2012;20:63‑8. the Eastern Mediterranean Region (EMR) 2009. Available from: 53. World Health Organization. Five Year project for the Prevention http://www.pbunion.org/IMPACT‑EMR‑Guidelines‑1.pdf. [Last of Childhood Blindness. Geneva: World Health Organization; accessed on 2013 Jan 7]. 2002. p. 4‑5.[WHO/PBL/02.88]. 40. Al Wadaani FA, Amin TT, Ali A, Khan AR. Prevalence and pattern 54. Murthy G, John N, Gupta SK, Vashist P, Rao GV. Status of of refractive errors among primary school children in Al Hassa, pediatric eye care in India. Indian J Ophthalmol 2008;56:481‑8. Saudi Arabia. Glob J Health Sci 2012;5:125‑34. 55. World Health Organization. A five‑year project for the prevention 41. El‑Bayoumy BM, Saad A, Choudhury AH. Prevalence of of childhood blindness: Report of a WHO Consultation. Geneva: refractive error and low vision among schoolchildren in Cairo. WHO; 2002. [WHO/PBL/02.88]. East Mediterr Health J 2007;13:575‑9. 56. World Health Organization. Elimination of avoidable visual 42. Qureshi MB. Training to meet the need for refractive error disabilities due to refractive error. Report of informal planning services. Community Eye Health 2007;20:48‑51. meeting in July 2000. P40. Available from: http://www.who. 43. Mema SC, McIntyre L, Musto R. Childhood vision screening int/ncd/vision2020_actionplan/documents/WHO_PBL_00.79. in Canada: Public health evidence and practice. Can J Public pdf. [Last accessed on 2013 Jan 23]. Health 2012;103:40‑5. 57. Carlton J, Karnon J, Czoski‑Murray C, Smith KJ, Marr J. The 44. Fierson WM, American Academy of Pediatrics Section on clinical effectiveness and cost‑effectiveness of screening Ophthalmology, American Academy of Ophthalmology, programmes for amblyopia and strabismus in children up to the American Association for Pediatric Ophthalmology and age of 4‑5 years: A systematic review and economic evaluation. Strabismus, American Association of Certified Orthoptists. Health Technol Assess 2008;12:iii, xi‑194. Screening examination of premature infants for retinopathy 58. Schmucker C, Kleijnen J, Grosselfinger R, Riemsma R, Antes G, of prematurity. Pediatrics 2013;131:189‑95. Lange S, et al. Effectiveness of early in comparison to late (r) 45. World Health Organization, Prevention of Blindness and treatment in children with amblyopia or its risk factors: A Deafness. Elimination of Avoidable Visual Disability Due to systematic review. Ophthalmic Epidemiol 2010;17:7‑17. Refractive Errors: Report of an Informal Planning Meeting, 59. Mathers M, Keyes M, Wright M. A review of the evidence on the Geneva, July 2000. Published Geneva, Switzerland; 2001. effectiveness of children’s vision screening. Child Care Health 46. Gogate P, Khandekar R, Shrishrimal M, Dole K, Taras S, Dev 2010;36:756‑80. Kulkarni S, et al. Delayed presentation of in children: Are they worth operating upon? Ophthalmic Epidemiol 2010;17:25‑33. Cite this article as: Khandekar R, Kishore H, Mansu RM, Awan H. The Status 47. Muhit MA, Shah SP, Gilbert CE, Hartley SD, Foster A. The key of Childhood Blindness and Functional Low Vision in the Eastern Mediterranean Region in 2012. Middle East Afr J Ophthalmol 2014;21:336-43. informant method: A novel means of ascertaining blind children in Bangladesh. Br J Ophthalmol 2007;91:995‑9. Source of Support: Nil, Conflict of Interest: None declared.

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