Original Article

Five years’ retrospective analysis of childhood ocular

morbidities: A priority setting guidelines
for pediatric eye clinic
Sadia Bukhari1, Shua Azam2, Shahid Ahsan3,
Tauseef Mahmood4, Muhammad Saleh Memon5,
Uzma Haseeb6, Muhammad Arslan7
ABSTRACT
Objectives: To observe patterns of Pediatric eye diseases over five years 2015-19, to improve management
of ophthalmic pediatric units in the developing countries.
Methods: It was an observational, cross-sectional study carried out in a tertiary eye care Hospital,
Karachi. Records of the children under 16 years of age from 2015 to 2019 were retrieved. Inclusion criteria
included complete records with age, gender of the children, symptoms, examination, investigation if
necessary, and diagnosis. All incomplete records were excluded.
Results: A total of 35348 records with 55.17% boys and 44.82% girls were analyzed. Similar gender
difference was reflected in disease frequency. Seven percent of the children did not have detectable
ocular pathology. Conjunctivitis, refractive errors and squint were the three most common ocular
morbidities observed in decreasing order of frequency as 32.67%, 20.08% and 14.7% respectively. Cataract
was present in 4.51%, Corneal disease in 4.11%, Retinal pathology in 1.04%, Glaucoma in 0.49% cases; but
Retinoblastoma was present in 55 cases and ROP in 4 cases only. Almost 60% of the children had simple
ocular problems like conjunctivitis, refractive error and absence of any pathology.
Conclusion: Majority of the children attending pediatric ophthalmology had simple problems manageable
at primary health facility level. Strengthening of the primary health care facility will reduce considerable
burden of pediatric unit at the tertiary level. Optometrists and orthoptists are important members of the
team for refraction and squint management.
KEYWORDS: Conjunctivitis, Eye disease, Pediatric ophthalmology, Primary eye care, Refractive error.
doi: https://doi.org/10.12669/pjms.38.6.5441
How to cite this:
Bukhari S, Azam S, Ahsan S, Mahmood T, Memon MS, Haseeb U, et al. Five years’ retrospective analysis of childhood ocular
morbidities; A priority setting guidelines for pediatric eye clinic. Pak J Med Sci. 2022;38(6):1501-1507.
doi: https://doi.org/10.12669/pjms.38.6.5441
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

INTRODUCTION
Ocular morbidity describes spectrum of eye
Correspondence: diseases experienced by a population that are
Dr. Muhammad Saleh Memon, FRCS (Eden). either significant to the individual or to eye
Director Research, professionals.1 Eye problems in children are one
Al Ibrahim Eye Hospital,
of the important cause of medical consultation
Isra Postgraduate Institute of Ophthalmology,
Karachi, Pakistan. and If not attended may lead to severe visual
Email: [email protected] impairment and blindness.2 Visual impairment
* Received for Publication: September 30, 2021
in young children delays motor, language,
* Revision Received: April 11, 2022 emotional, social and cognitive development,
* Revision Accepted: April 26, 2022 with lifelong consequences. School going children

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 Sadia Bukhari et al.

with visual impairment can also experience lower the areas of efficient allocation, investment and
levels of educational achievement. Consequently, prioritization of financial as well as human
it impacts quality of life in adulthood.3 Especially resources.
in low income countries with less resources and
METHODS
deficient education they get less employment
opportunities. They might also face difficulties It was an observational, cross-sectional study
in social interactions which can lead to social with retrospective data collection retrieved from
loneliness, anxiety and depression.3 Hospital Information Management System (HIMS)
Globally 19 million children have visual of Al Ibrahim Eye Hospital, Karachi from Jan 2015
impairment with 1.26 million blind bilaterally to Dec 2019. A prior Ethical Approval was taken
and, an estimated 70 million blind years are from Institute Research Ethical Committee. Study
caused by childhood blindness.4 Data for visually protocol number was A-00094. Non-probability
impaired and blind children for Pakistan is not purposive sampling technique was used for
available. The available evidence suggests that sample collection from software. Inclusion criteria
the prevalence varies from 0.3/1000 children was clinical records of all children aged up to 15
in economically developed countries to over years attending outpatient department of Pediatric
1.0/1000 children in underdeveloped societies.5 Ophthalmology unit were retrieved irrespective
Population of children under 15 years is 90 of age, gender and ethnicity. Missing records
million6 (43.4% of country’s population). One or unclear diagnosis with incomplete data were
can project number of visually impaired children excluded from the study.
at 1.0/1000 children as 0.09 million or 90000 Data Collection Procedure: All these patients
children. Almost half of all blindness in children underwent detailed examination including
particularly those in the poor countries is due
History taking, checking visual acuity with the
to avoidable causes that are amenable to cost
help of recommended tools including Central,
effective interventions.7 The goal of VISION 2020
steady and maintained (CSM), Lea Gratings,
recommends one ophthalmologist trained in
Cardiff visual acuity cards and Snellen’s chart.
pediatric eye diseases for every 10 million people
Cycloplegic refraction was done when needed.
by 2020.8 There are enough practicing pediatric
Complete Ophthalmic examination was carried
ophthalmologist but very few properly trained
out with the help of direct ophthalmoscope, slit
and experienced pediatric ophthalmologist. All
lamp (Hand held slit lamp was used in younger
the tertiary centers are trying to develop pediatric
children), +90 D lens and indirect ophthalmoscope
ophthalmology units and need equipment and
were used for examination of fundus. B-scan
human resource. Nationally there is no guide
ultrasound performed in cases where fundus view
line for such development. This study intends to
was not clear. Examination under sedation or
develop these guide lines.
general anesthesia was carried out where needed.
In the past few years’ childhood ocular
morbidity is dominated by allergic conjunctivitis After detailed clinical examination diagnosis was
and refractive errors.9 Studies from Pakistan also made and recorded.
reported similar pattern of ocular problems.10,11 Statistical Analysis: Data was retrieved from
Eye trauma in children is common cause of HIMS software and exported to SPSS version 23.0
unilateral severe visual impairment and cosmetic for data analysis. Mean and Standard deviation was
disfigurement resulting in psychological impact calculated for continuous variables. Frequency and
on personality and behavior.12 percentages were reported for categorical variables
This study will give us baseline data of pediatric like gender, age groups and diagnosis. Bar chart
ocular morbidities in children attending tertiary was made to present age groups. Cross tabulation
eye care centre, Karachi. This baseline data will was done between diagnosis with gender and
provide clinical based evidence for the relevant age groups using Chi-square test. P-value ≤ 0.05
authorities to formulate a policy to reduce the considered to be statistically significant.
burden on tertiary eye care hospitals and provide RESULTS
chances to the pediatric ophthalmologist to
concentrate on training, teaching and research in Complete records of 35348 children visiting
addition to the clinical work. This study will also pediatric clinic of Al-Ibrahim Eye Hospital with
draw attention of institutional heads to identify different ocular problems were retrieved. Mean

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 Childhood ocular morbidities

Table-I: Proportion of Conjunctivitis and Refractive Error.

Conjunctivitis Count %

Allergic Conjunctivitis 4344 37.61

Bacterial Conjunctivitis 4335 37.53
Vernal Keratoconjunctivitis (VKC) 1665 14.42
Viral Conjunctivitis 655 5.67
Nonspecific conjunctivitis 551 4.77
Total 11550 100

Refractive Error Count %

Hypermetropia 3245 45.7

Fig.1: Age Distribution. Myopia 2338 32.92
Astigmatism 1469 17.99
age of the patient was 7.58 ± 4.42 years. Gender Amblyopia 240 3.38
distribution was observed as boys 19503 (55.17%) Total 7100 100
and girls 15845 (44.82%). Boy to girl ratio was 1.2:1.
Among four age groups, 2077 (5.9%) patients
were of age less than one year, 10118 (28.6%) were one to five years. Cataract 566 (1.60%), Cornea 562
(1.58%) and Retina 142 (0.40%) related cases were
in between one to five years. Frequency of the
mostly found in between 6 to 10 years of age.
children in the third age group (6-10 years) was
12261 (34.6%) and 10892 (30.8%) patients were in DISCUSSION
between 11 to 15 years (Fig.1).
Conjunctivitis with 11550 (32.67%) children This study validates findings of earlier studies
was commonest disease. Amongst conjunctivitis, regarding childhood ocular morbidity dominated
allergic was commonest (37.6%), bacterial was by allergic conjunctivitis and refractive errors.10,11
found in 37.5%, vernal conjunctivitis 14.42%, viral The data shows that over a period of 5 years,
5.67% and 4.77% were labeled nonspecific. Second conjunctivitis was present in 32.67% children.
commonest cause was Refractive error which was Of this 37.6% were allergic and 14.4% were
found in 7100 (20.08%) children. Hypermetropia VKC. Study from Sind Province reported 34.1%
found was 45.75%, myopia 33%, astigmatism conjunctivitis cases in children attending 10
18%. Children found to be amblyopic were 3.38% BHUs.13 In a study from Punjab Province reported
(Table-I). The third common cause was squint 5198 22.1% VKC and 34% refractive errors.11 Study
(14.70%). Children who did not have any visible from Karachi reported 24.8% VKC and 15.2%
disease were 2476 (7%). Cataract was present in refractive errors.12 Another tertiary center in
1597 (4.51%), Cornea affected in 1461 (4.11%), Bahawalpur13 reported 32.2% conjunctivitis and
Retinal disease in 370 (1.04%). Glaucoma was 21.9% refractive errors. A study from Ethiopia
present in 176 (0.49%) cases. Boys’ dominance showed 30.5% infections of conjunctiva and
was easily seen in conjunctivitis as 6778 (19.17%) lid, 21.9% refractive errors and VKCs 28% and
against 4772 (13.50%) girls. Similarly, more boys allergic conditions. There seems consensus on
3625 (10.25%) compared to girls 3475 (9.83%) were the findings that conjunctivitis is commonest eye
diagnosed with different types of refractive error. disease in children in the developing countries.
Likewise, Squint cases had a slightly upper share Second common cause of ocular morbidity in
2677 (7.57%) in boys as compare to girls 2521 children is refractive errors. Present study shows
(7.13%) (Table-II). Refractive error in 20.08% children. Other national
Diagnosis on the basis of age groups are presented studies also present refractive errors as common
in Table-III. Most of the cases of conjunctivitis 4150 morbidity in children with variable frequency
(11.74%) belong to age group 6 to 10 years. While from 33%11, 14.8%12 and 32.1%.13 Present study
refractive error 3640 (10.29%) mostly found in differs from majority of studies where myopia is
between 11 to 15 years of age. Similarly, most of more common. The population-based prevalence
the squint cases 1999 (5.65%) found in early age of of myopia, hyperopia (≥ +2.00 D) and astigmatism

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 Sadia Bukhari et al.

Table-II: Gender wise diagnosis.

Gender
Diagnosis P-value
Boys Girls Total

Conjunctivitis 6778 (19.17%) 4772 (13.50%) 11550 (32.67%)

Refractive Error 3625 (10.25%) 3475 (9.83%) 7100 (20.08%)
Squint 2677 (7.57%) 2521 (7.13%) 5198 (14.70%)
Normal Quite Eye 1251 (3.53%) 1225 (3.46%) 2476 (7%)
Eye Lid Pathology 1052 (2.97%) 1112 (3.14%) 2164 (6.12%)
Lacrimal Systematic Disease 948 (2.68%) 889 (2.51%) 1837 (5.20%)
Cataract 1039 (2.93%) 558 (1.57%) 1597 (4.51%)
Corneal diseases 913 (2.58%) 548 (1.55%) 1461 (4.13%)
Trauma 323 (0.91%) 170 (0.48%) 493 (1.39%)
Retinal diseases 245 (0.69%) 125 (0.35%) 370 (1.04%)
Glaucoma 100 (0.28%) 76 (0.21%) 176 (0.49%) 0.001
Orbital diseases 89 (0.25%) 80 (0.22%) 169 (0.47%)
Dry Eye 90 (0.25%) 64 (0.18%) 154 (0.43%)
Optic Nerve diseases 73 (0.20%) 51 (0.15%) 124 (0.35%)
Developmental Anamolies 50 (0.14%) 27 (0.07%) 77 (0.21%)
Pthysis Bulbi 40 (0.11%) 14 (0.04%) 54 (0.15%)
Endophthalmitis 29 (0.08%) 19 (0.05%) 48 (0.13%)
Uveitis 20 (0.06%) 16 (0.04%) 36 (0.10%)
Down Syndrome 11 (0.03%) 8 (0.02%) 19 (0.05%)
Other Diagnosis 150 (0.43%) 95 (0.27%) 245 (0.69%)
Total 19503 (55.17%) 15845 (44.82%) 35348 (100%)

in India was 5.3%, 4% and 5.4%, respectively.14 Keratoconjunctivitis (VKC). Patients with VKC
Study from Pakistan showed myopia as 52%, and allergic conjunctivitis should always be told
astigmatism as 38% and Hypermetropia as 10%.15 the hidden effect of steroid which are frequently
Our study is supported by Slaveylokov K et al.16 used in the treatment of these two diseases.
where hypermetropia was seen in 78.85%. High Steroid induced glaucoma17 and cataract18 are
number of hypermetropic patients in our study is known complications of long term use of steroids
probably because of significant number of squint leading to blindness. Apparently simple diseases
patients attending the clinic. become important due to the complications of
All these studies show that 60% (conjunctivitis treatment. Constant vigilance and education of
33%, normal eyes 7% and refractive errors 20%) the professionals as well patients are required.
children could have been treated at Basic Health Another important emerging complication of
Unit (BHUs) and Rural Health Centres (RHCs). VKC is Keratoconus.19,20 It is to be reminded to
Strengthening BHUs and RHCs can not only the primary health facilitators that if allergic
lessen the burden of pediatric eye care centers conjunctivitis and VKC does not respond to
by 60% but will make the treatment of children treatment in few weeks, they are to be referred to
more accessible and cost effective. Strengthening tertiary level facility.
will include education of the professionals of Remaining 40% cases need to be referred
primary eye care facility specially regarding to a Pediatric unit. They can be conveniently
management of allergic conjunctivitis and Vernal grouped on the basis of expertise of the surgeon

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 Childhood ocular morbidities

Table-III: Age wise diagnosis.

Age Groups
Diagnosis Total P-value
less than 1 yr. 1 to 5 yr. 6 to 10 yr. 11 to 15 yr.

Conjunctivitis 635 (1.79%) 3721 (10.52%) 4150 (11.74%) 3044 (8.61%) 11550 (32.67%)
Refractive Error 40 (0.11%) 757 (2.14%) 2663 (7.53%) 3640 (10.29%) 7100 (20.08%)
Squint 144 (0.40%) 1999 (5.65%) 1848 (5.22%) 1207 (3.41%) 5198 (14.70%)
Normal Quite Eye 126 (0.36%) 603 (1.70%) 867 (2.45%) 880 (2.49%) 2476 (7%)
Eye Lid Pathology 54 (0.15%) 585 (1.65%) 787 (2.22%) 738 (2.08%) 2164 (6.12%)
Lacrimal Systematic
807 (2.28%) 847 (2.39%) 116 (0.32%) 67 (0.19%) 1837 (5.20%)
Disease
Cataract 111 (0.31%) 532 (1.50%) 566 (1.60%) 388 (1.10%) 1597 (4.51%)
Corneal diseases 93 (0.26%) 440 (1.25%) 562 (1.58%) 366 (1.03%) 1461 (4.13%)
Trauma 1 (0.003%) 160 (0.45%) 205 (0.58%) 127 (0.36%) 493 (1.39%)
Retinal diseases 10 (0.03%) 103 (0.29%) 142 (0.40%) 115 (0.32%) 370 (1.04%)
Glaucoma 25 (0.07%) 64 (0.18%) 43 (0.12%) 44 (0.12%) 176 (0.49%) 0.001
Orbital diseases 11 (0.03%) 84 (0.24%) 42 (0.12%) 32 (0.09%) 169 (0.47%)
Dry Eye 1 (0.003%) 34 (0.10%) 57 (0.16%) 62 (0.17%) 154 (0.43%)
Optic Nerve diseases 7 (0.02%) 36 (0.10% 44 (0.12%) 37 (0.10%) 124 (0.35%)
Developmental
2 (0.005%) 29 (0.08%) 23 (0.06%) 23 (0.06%) 77 (0.21%)
Anamolies
Pthysis Bulbi 0 (0%) 10 (0.02%) 26 (0.07%) 18 (0.05%) 54 (0.15%)
Endophthalmitis 1 (0.003%) 18 (0.05%) 16 (0.04%) 13 (0.03%) 48 (0.13%)
Uveitis 1 (0.003%) 6 (0.01%) 16 (0.05%) 13 (0.04%) 36 (0.10%)
Down Syndrome 1 (0.003%) 10 (0.03%) 2 (0.005%) 6 (0.01%) 19 (0.05%)
Other Diagnosis 7 (0.02%) 80 (0.23%) 86 (0.24%) 72 (0.20%) 245 (0.69%)
Total 2077 (5.87%) 10118 (28.62%) 12261 (34.68%) 10892 (30.81%) 35348 (100%)

needed. First Group will consist of Squint North West Frontier Province of Pakistan. 21
(14.8%), pediatric cataract (4.57%) and ocular Assessment of the squint is most important
trauma (1.39%) which can be managed by general aspect of the management of squint and is best
pediatric ophthalmologist. Second Group will carried by orthoptist or trained optometrist.
include corneal diseases (4.18%), retinal problems Tertiary center should have an orthoptist to
(1.0%), congenital/developmental glaucoma manage squints.
(0.5%), Lacrimal (6.12%), lids (5.2%), orbit (0.47%) Cataract is the most important cause of treatable
and advanced cases of ocular trauma which can be blindness in childhood.22 National studies have
managed by pediatric ophthalmologist trained in reported 24.3%9 (BHUs, sample 1000 children) 6%13
particular sub-specialty. (tertiary hospital with 1000 sample) and 23.1%14
In the first group Squint was reported as (tertiary hospital and 1000 sample). In present
commonest pediatric problem in this study study Cataract was found in 4.57% (N;1598) of
(14.8%), mostly (10.87%) in the age group 1-10 the children attending a pediatric unit of Karachi
years. No gender difference was found (7.5% during five years. The low number of pediatric
boys and 7.13% girls). Other studies reported cataract as compared to National statistics is
almost same or near frequency, 12.4% by Farrukh probably due to missing records. Management of
S et.al from Karachi 11, 13.5% by Sethi et al. from cataract in children has undergone tremendous

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 Sadia Bukhari et al.

change after advances in the technology like and future publications are needed incorporating
anterior vitrectomy23 and IOL as primary data from multiple tertiary care centers. Also,
procedure24 or scleral fixations25 as secondary our center is a pure eye center thus the systemic
procedure. diseases might have less frequency documented
Among the second group, most important than the actual numbers.
problem to be addressed is the ocular trauma. There
are many local studies on this subject.16,26 Ocular CONCLUSION
trauma is a leading cause of visual morbidity in Majority of the children attending pediatric
children. This is preventable to certain extent department are simple diseases to be treated
by better care and supervision. Besides, direct at primary eye care level if strengthened by
damage to the ocular structures resulting in loss of optometrist and primary level ophthalmologist.
vision, poor visual outcome may also due to dense For prevention and early diagnosis of blindness
amblyopia caused by prolonged period of visual due to ROP, retinal digital imaging should be
deprivation. made available at pediatric ophthalmology units
Important retinal problems are retinoblastoma of tertiary care eye hospitals.
and retinopathy of prematurity (ROP). There were
only 55 recorded retinoblastomas and four ROPs. Acknowledgement: We are thankful to the
One can only presume that these diseases may Sightsavers (UK) for their financial support in
have been dropped as incomplete records. None making Pediatric department in Al- Ibrahim Eye
of the national studies cited above have reported Hospital, Karachi.
Retinoblastoma and ROPs. Conflict of Interest: None.
Recommendations: Strengthening BHUs and RHCs
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Authors:

1. Dr. Sadia Bukhari, (MS Ophth).

2. Ms. Shua Azam, M.Phil. (Optometry).
Isra School of Optometry,
Al Ibrahim Eye Hospital,
Isra Postgraduate Institute of Ophthalmology,
Karachi, Pakistan.
3. Dr. Shahid Ahsan, M.Phil. (Bio), M.Phil (NCD), PhD Fellow.
Department of Biochemistry,
Jinnah Medical & Dental College, Karachi, Pakistan.
4. Mr. Tauseef Mahmood, M.Sc. (Statistics).
5. Dr. Muhammad Saleh Memon, FRCS (Eden).
6. Dr. Uzma Haseeb, (FCPS).
7. Mr. Muhammad Arslan, (MCSW).
Department of Research & Excellence,
Al-Tibri Medical College,
Karachi, Pakistan.
1,6: Department of Ophthalmology,
Al Ibrahim Eye Hospital,
Isra Postgraduate Institute of Ophthalmology,
Karachi, Pakistan.
4,5: Department of Research,
Al Ibrahim Eye Hospital,
Isra Postgraduate Institute of Ophthalmology,
Karachi, Pakistan.

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