Research article EMHJ – Vol. 26 No.

11 – 2020

Prevalence of refractive error and visual impairment among

school-age children of Hargesia, Somaliland, Somalia
Zahra Abdi Ahmed,1 Saif Hassan Alrasheed2,3 and Waleed Alghamdi3

1
Department of Primary Eye Care, Faculty of Optometry and Visual Sciences, Al-Neelain University, Khartoum, Sudan. 2Department of Binocular
Vision, Faculty of Optometry and Visual Sciences, Al-Neelain University, Khartoum, Sudan (Correspondence to: Saif Alrasheed: [email protected]).
3
Department of Optometry, College of Applied Medical Sciences, Qassim University, Qassim, Saudi Arabia.

Abstract
Background: Childhood visual impairment is a global public health problem, especially in low and middle-income coun-
tries. Its most common causes are avoidable by early diagnosis and treatment.
Aims: To assess prevalence of refractive error and visual impairment among school-aged children in Hargeisa, Somali-
land, Somalia.
Methods: This was a cross-sectional study of 1204 students (aged 6–15 years) in 8 randomly selected primary schools in
Hargeisa from November 2017 to January 2018. We used the modified Refractive Error Study in Children to determine
prevalence of refractive error and visual impairment, including the following investigations: distance visual acuity, as-
sessed by Snellen Tumbling E-chart; refraction, assessed by retinoscope binocular vision assessment; and examination
of anterior and posterior segments.
Results: Prevalence of uncorrected, presenting and best-corrected visual impairment of 6/12 or worse was 13.6%, 7.6% and
0.75%, respectively. Only 16 of 91 (17.6%) children were using spectacles and the rest were unaware of the problem. Refrac-
tive error was the cause of visual impairment in 76.8% of participants, amblyopia in 22.0%, trachoma in 2.4%, and corneal
opacity and cataract in 0.6%. Anterior segment abnormalities were found in 8.3%, mainly vernal keratoconjunctivitis,
while posterior abnormalities were observed in 0.7%. Prevalence of myopia was 9.1%, hypermetropia 2.7% and astigmatism
3.9%. Prevalence of visual impairment because of Refractive Error was associated with increasing age, but there was no
significant association with school grade or sex.
Conclusion: Prevalence of visual impairment among school-aged children in Hargeisa was high, and the leading cause
was uncorrected Refractive Error. There are barriers to care and it is critical that they are overcome.
Keywords: refractive error, childhood visual impairment, myopia, hypermetropia, vernal keratoconjunctivitis
Citation: Abdi Ahmed Z; Alrasheed SH; Alghamdi W. Prevalence of refractive error and visual impairment among school-age children of Hargesia,
Somaliland, Somalia. East Mediterr Health J. 2020;26(11):1362-1370. https://doi.org/10.26719/emhj.20.077
Received: 18/03/19; accepted: 19/11/19
Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO
license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction defines VI in children as presenting with visual acuity

(VA) less than 6/12 in the better eye. However, uncor-
Globally, it is estimated that there are 36 million people
rected VA (UVA) is defined as VA less than 6/12 in one or
who are blind, 216.6 million have moderate to severe
both eyes (7). VI among children in developing countries
visual impairment (VI) and 188.5 million have mild VI.
is a priority of eye health programmes, including Vision
The leading cause of VI is uncorrected refractive error
2020: the Right to Sight Initiative (9). Globally, the prin-
(RE) (1,2). Furthermore, 90% of people with VI live in de-
cipal cause of VI is uncorrected REs (43%) and cataracts
veloping countries. Almost 19 million children aged < 15
(33%) (1). Special attention should be given to children,
years have VI globally. In developing countries, 7–31% of
because VI restricts their education and general perfor-
childhood blindness is avoidable, 10–58% is treatable, and
3–28% is preventable (3). RE is an eye condition in which mance, personality development, future quality of life
light from a distant object is not focused on the retina; it and career opportunities (10). The Refractive Error Study
might be focused in front of or behind the retina. There in Children (RESC) protocol was developed by WHO in
are 3 types of RE: myopia, hypermetropia and astigma- collaboration with, and under financial support from the
tism. The exact cause of ametropia remains unknown National Eye Institute, National Institutes of Health and
with common risk factors being hereditary, nutritional the United States of America to assess the prevalence of
and environmental (4). Population-based studies on VI VI and RE worldwide, as well as to assess the effect of
and RE in children have been conducted on populations childhood VI due to uncorrected RE (11,12).
with different racial backgrounds and environments in Somaliland, Somalia has a population of 4.5 million,
Africa. These studies have shown that the prevalence of with estimated urban poverty of 29%, which is similar
VI among children was 2.15% in South Africa (5), 5.5% in to 26% in Ethiopia. Only about half of children aged
Khartoum, Sudan (6), 4.4% in South Darfur, Sudan (7), and 6–13 years go to primary school in Somaliland, in stark
9.5% in Ethiopia (8). World Health Organization (WHO) contrast to 87% in neighbouring Ethiopia (13,14). No

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studies have assessed VI and RE among school-aged Clinical investigation

children in Hargeisa, Somaliland. The aims of this study
The clinical examinations were performed using the
were to assess the common causes of VI, types of RE, and modified RESC protocol. Demographic information
differences in prevalence according to sex, age and school was collected from participants, and VA at distance was
grade. measured using the Snellen Tumbling E-chart with E’s of
standard size at a 6-m distance. Participants with VA ≤
Methods 6/12 were assessed by pinhole test, and if their vision im-
proved, they underwent retinoscopy without cycloplegia
Study design and subjective refraction. All children were examined by
This was a cross-sectional, school-based study of VI and a penlight and low-power hand magnifier to assess any
RE among children from Hargeisa, Somaliland. Accord- anterior-segment abnormalities in the eyelids, conjunc-
ing to the Ministry of Education, the overall number of tiva, cornea, pupils and pupillary reflex reaction. A cover
test was conducted for heterophoria or heterotropia and
students enrolled in public and private primary schools
the angle of deviation was measured using the corneal
in Hargeisa during 2017–2018 was 243 485, comprising
light reflex (Hirschberg test) and the Prism Cover Test at
127 829 boys and 115 656 girls. The modified RESC pro-
distance and near fixation, respectively. The ocular mo-
tocol was used to assess the prevalence of VI and RE in
tility test was performed to assess eye muscle function.
these children. Noncycloplegic refraction was used to as-
Subjective refraction was determined using a standard
sess the prevalence of RE, which is defined as follows: (1) refraction trial set to achieve best correct vision for chil-
myopia ≥ −0.5 D in one or both eyes; (2) hypermetropia ≥ dren whose vision improved with the pinhole test. Chil-
2.0 D ; and (3) astigmatism ≥ 0.75 D cylindrical refraction dren with VA ≤ 6/12 whose vision did not improve by
(11). pinhole test had outer eye and fundus examination by
direct ophthalmoscopy, and any abnormal findings were
Inclusion and exclusion criteria
recorded as causes of VI.
Children aged 6–15 years who attended school on the
days of examination and their parents agreed to partic- Data analysis
ipate in the study. Children unable to provide parental Data for each participant were analysed descriptively
consent were excluded. using standard deviations and percentages with SPSS
version 22. The relationship between measures was de-
Study sample termined using correlation, cross-tabulations and χ2 anal-
The study sample was selected through stratified multi- ysis. For all statistical determinations, significance levels
stage sampling. We assumed a prevalence of RE of 5% were established at P = 0.05.
according to the estimated prevalence of childhood RE
in Africa (5%), Sudan (6.8%) (5) and Kenya (5.1%) (15, 16). Results
Considering a prevalance of RE of 5%, 95% confidence in-
terval and maximum acceptable random sampling error Study population
of 1.5%, a sample size of 811, based on the formula below, A total of 1351 children were selected to participate in the
was estimated. Considering the design effect = 1.5, a final study and 1204 (89%) were actually entered into the study.
sample of 1216 was estimated.
Demographic characteristics of participants
n = (z2 pq)/d2 = (1.962 × 0.05 × 0.95)/0.0152 = 811 => 811 × 1.5 = 1216 The 1204 participants were aged 6–15 years, with a mean
Considering a nonresponse rate = 10%, the final sample of 11.18 [standard deviation (SD); 2.45] years (Table 1).
There were 658 (54.7%) boys and 546 girls (45.3%). The
size was 1351 schoolchildren. The study sample com-
mean (SD) age of the boys and girls was 11.15 (2.47) and
prised 8 schools (4 for boys and 4 for girls) that were ran-
11.21 (2.44) years, respectively. Most participants were
domly selected from 22 districts of Hargesia. One class
aged 11 (14.2%) and 12 (13.7%) years, respectively. The ages
from each grade (1–8) with a minimum of 21 children was
with the fewest participants were 6 (3.2%) and 7 (5.1%)
randomly chosen. years, respectively. There was no significant difference
Ethical considerations in mean age between the boys and girls (ANOVA: F =
0.167, P = 0.683), although there was a significant differ-
Ethical permission for the study was obtained from Al- ence in mean ages of the children according to school
Neelain University, Khartoum, Sudan because of un- grades (ANOVA: F = 341.733, P = 0.01).
availability of an ethics committee in Somaliland. The
study was conducted according to the Declaration of Hel- Distribution of ocular signs and symptoms
sinki guidelines. Informed consent was obtained from all A total of 943 (78.8%) participants did not complain of
participants. All forms and data sheets were shredded as any ocular symptoms; 153 (12.7%) complained of blurred
soon as the details were entered into the database system vision; 87 (7.2%) had itching and redness; and 15 (1.2%) had
for analysis. pain and photophobia.

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Table 1 Demographic characteristic of participants

Age (years) Sex Total
Male Female
n % n % n %
6 20 3.0 18 3.3 38 3.2
7 35 5.3 27 4.9 62 5.1
8 58 8.8 40 7.3 98 8.1
9 58 8.8 57 10.4 115 9.6
10 95 14.4 62 11.4 157 13.0
11 92 14.0 79 14.5 171 14.2
12 80 12.2 85 15.6 165 13.7
13 83 12.6 66 12.1 149 12.4
14 71 10.8 58 10.6 129 10.7
15 66 10.1 54 9.9 120 10.0
Total 658 546 1204

VA alence of VI (2%, 95% CI, 1.2–2.8%) than those aged 10–11

years (3.4%, 95% CI, 2.4–4.4%), and the highest prevalence
A total of 1044 children presented with normal vision
(6/6) in the right eye; 1034 had normal vision in the was in children aged 14–15 years (4.4%, 95% CI, 3.2–5.7%).
left eye; and 1071 had normal vision in the better eye Binocular anomalies
(Table 2). Thirty-six, 38 and 42 children had uncorrected
vision (6/9) in the right, left and better eye, respective- Tropia was found in 9 (0.7%) children: 4 with esotropia
ly. An uncorrected VI was found in 164 children (13.6%, and 5 with exotropia.
95% CI, 11.7–15.5%), while 91 (7.6%, 95% CI, 6.1–9.1%) chil- Anterior-segment examination
dren had VI. With best-corrected VA, this decreased to 9
(0.75%, 95% CI, 0.3–1.2%) children. A total of 1104 children (91.7%, 95% CI, 90.1–93.3%) had no
abnormalities detected in the right eye and 1103 (91.6%,
Prevalence of VI 95% CI, 90.0–93.2) had no abnormalities in the left eye.
The prevalence of presenting VI was 91 (7.6%, 95% CI, Ninety-seven children (8.1%, 95% CI, 6.6–9.6%) had vernal
6.1–9.1%) and only 16 (17.6%) of these children were wear- keratoconjunctivitis in both eyes. Three children (0.25%,
ing spectacles. There were no significant association be- 95% CI, 0.03–0.5%) had trachoma in the left eye and 2
tween prevalence of VI and age (P = 0.209), sex (P = 0.060) (0.2%, 95% CI, 0.1–0.5%) had trachoma in the right eye.
and school grade (P = 0.393). Girls had a higher prevalence One child had cataract in the right eye (0.1%, 95% CI, −0.1
of VI (4.6%, 95% CI, 3.4–5.8) than boys had (2.6%, 95% CI, to 0.3%) and one (0.1%, 95% CI, 0–0.3%) had corneal opaci-
1.7–3.5%). Younger children age 6–7 years had lower prev- ty in the left eye.

Table 2 Distribution of uncorrected visual acuity for right, left and better eye by percentage and confidence interval
UVA Right eye Left eye Better eye Best-corrected VA

n % (95% CI) n % (95% CI) n % (95% CI) n % (95% CI)

6/6 1044 86.7 (84.8–88.6) 1034 85.9 (83.9–87.9) 1071 89.0 (87.2–90.8) 1182 98.1 (97.5–99.0)
6/9 36 3.0 (2.0–4.0) 38 3.2 (2.2–4.2) 42 3.5 (2.5–4.5) 13 1.08 (0.5–1.7)
6/12 21 1.7 (1.0–2.4) 28 2.3 (1.5–3.2%) 24 2.0 (1.2–2.8) 3 0.25 (0.03–0.53)
6/18 32 2.7 (1.8–3.6) 32 2.7 (1.8–3.6) 31 2.6 (1.7–3.5) 2 0.17 (0.0–0.4)
6/24 29 2.4 (1.5–3.3) 32 2.7 (1.8–3.6%) 19 1.6 (0.9–2.3) 2 0.17 (0.0–0.4)
6/36 23 1.9 (1.13–2.67) 19 1.6 (0.9–2.3) 9 0.7 (0.2–1.2) 2 0.17(0.0–0.4)
6/60 12 1.0 (0.4–1.6) 13 1.1 (0.5–1.7) 4 0.3 (0.01–0.61) — —
CF 6 0.5 (0.1–0.9) 7 0.6 (0.16–1.04) 4 0.3 (0.01–0.61) — —
HM 1 0.1 (0.0–0.3) 1 0.1 (0.0–0.3) — — — —

Total 1204 100.0% 1204 100% 1204 100.0% 1204 %100.0

VA ≥ 6/12 91 7.6 (6.1–9.1) 9 0.75(0.3–1.2)
CF = count fingers; CI = confidence interval; HM = hand movement; UVA = uncorrected visual acuity; VA = visual acuity.

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Prevalence of RE Posterior-segment examination

A total of 189 children (15.7%, 95% CI, 13.7–17.8%) had Posterior-segment examination revealed that 1196 chil-
REs, and 1015 (84.3%, 95% CI, 82.3–86.4%) were emme- dren (99.3%, 95% CI, 98.8–99.8%) had no abnormalities.
tropic (Table 3). Myopia had the highest prevalence Ocular media and fundus abnormalities were seen in 8
(0.7%) children. Retinal disorders were found in 6 (0.5%)
(n = 110, 9.1%), followed by astigmatism (n = 47, 3.9%) and
children and media opacity in 2 (0.2%).
hypermetropia (n = 32, 2.7%). The prevalence of RE was
significantly associated with age (P = 0.011) but not sex Principal causes of VI
(P = 0.073) or school grade (P = 0.168). Prevalence of REs was The causes of UVA of 6/12 or worse at least in 1 eye are
higher among girls (n = 100, 18.3%) than boys (n = 89, 13.5). presented in Table 4. RE was the main cause of VI in 126
Prevalence of REs significantly increased with age. Chil- (76.8%) affected children, followed by amblyopia (n = 36,
dren aged 15 years had the highest prevalence (n = 21; 22.0%) and corneal opacity and cataract (n = 1, 0.6%).
17.5%), compared to those aged 8 years (n = 14, 14.3%), Schoolchildren who received eye drops or were
7 years (n = 10, 16.1%) and 6 years (n = 5, 13.2%). Children referred
in school grade 4 had the highest prevalence of REs (n =
One hundred and forty-two children (11.8%, 95% CI, 10.0–
33, 21.9%), and those in grade 2 had the lowest prevalence 13.6%) had uncorrected REs and were referred to Manhal
(n = 16, 10.7%). The prevalence of myopia was increase Specialist Hospital, Hargeisa. Two children were referred
with age; it was more common in children aged 15 years for further examination and treatment of media opacity.
(10.8%) than in those aged 6 (5.3%), 7 (8.1%) and 8 (7.1%) Eighty-seven children (7.2%, 95% CI, 5.7–8.7%) were pre-
years. In contrast, prevalence of hypermetropia was scribed eye drops, and 15 (1.2%, 95% CI, 0.6–1.8%) received
highest in children aged 6 years (5.3%), and lowest in only advice for their complaints.
those aged 15 years (0.8%). According to the gender the
prevalence of myopia, hypermetropia and astigmatism Discussion
was higher in girls at 10.3, 2.7 and 5.3%, respectively, than Childhood blindness and VI are priority conditions tar-
in boys at 8.2, 2.6 and 2.7%, respectively. geted in Vision 2020: the Right to Sight Initiative of WHO

Table 3 Prevalence of refractive error in one or both eyes by age, sex and school grade
Category Emmetropia Myopia Hypermetropia Astigmatism no funds reflex Total
(95% CI, 82.3–86.4) (95% CI, 7.5–10.7) (95% CI, 1.8–3.6) (95% CI, 2.8–5.0) (95% CI, 1.4–1.6)
n % n % n % n % n % n %
Age 6 33 86.8 2 5.3 2 5.3 1 2.6 0 0 38 3.2
( P = 0.011)
7 52 83.9 5 8.1 3 4.8 2 3.2 0 0 62 5.1
8 84 85.7 7 7.1 5 5.1 2 2.0 0 0 98 8.1
9 100 87.0 9 7.8 5 4.3 1 0.9 0 0 115 9.6
10 132 84.1 14 8.9 4 2.5 7 4.5 0 0 157 13.0
11 145 84.8 17 9.9 2 1.2 7 4.1 0 0 171 14.2
12 136 82.4 17 10.3 6 3.6 6 3,6 1 0.6 165 13.7
13 129 86.6 13 8.7 2 1.3 5 3.4 0 0 149 12.4
14 105 81.4 13 10.1 2 1.6 9 7.0 0 0 129 10.7
15 99 82.5 13 10.8 1 0.8 7 5.8 0 0 120 10.0
Sex M 569 90.6 54 8.2 17 2.6 18 2.7 0 0 658 54.7
( P = 0.073)
F 445 81.5 56 10.3 15 2.7 29 5.3 1 0.2 546 45.3
Class level 1 129 87.2 6 4.1 7 4.7 6 4.1 0 0 148 12.3
( P = 0.168)
2 134 89.3 10 6.7 3 2.0 3 2.0 0 0 150 12.5
3 122 81.3 17 11.3 7 4.7 4 2.7 0 0 150 12.5
4 118 78.1 22 14.6 3 2.0 7 4.6 1 0.7 151 12.5
5 130 86.1 12 8.0 4 2.6 5 3.3 0 0 151 12.5
6 130 85.5 11 7.2 3 2.0 8 5.3 0 0 152 12.6
7 122 80.8 18 11.9 3 2.0 8 5.3 0 0 151 12.5
8 129 85.4 14 9.3 2 1.3 6 4.0 0 0 151 12.5
Total 1015 84.3 110 9.1 32 2.7 47 3.9 1 0.1 1204 100%
CI = confidence interval.

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Table 4 Causes of uncorrected visual acuity 6/12 or worse

Causes Children with VA 6/12 or worse in one Prevalence in the population in one or both eyes,
or both eyes % (95% CI)
n %
Refractive error 126 76.8 10.5 (8.8–12.2)
Amblyopia 36 22.0 3.0 (2.04–4.0)
Corneal opacity 1 0.6 0.08 (−0.08 to 0.24)
Cataract 1 0.6 0.08 (0.08–0.24)
Any cause 164 100.0 13.6 (11.7–15.5)
CI = confidence interval; VA = visual acuity.

(17). Knowledge of the prevalence of RE and VI among The prevalence of myopia was 9.1%, which is higher
school age children can help the relevant authorities to than 6.0% in Ethiopia (24) but lower than 14.1% in Ghana
plan and provide eye care services in the particular geo- (30). In our study, older school children had a higher
graphical area. The present study attempted to provide prevalence of myopia, which was similar to a study in
this information, as well as being the first study in So- Viet Nam (32). Alrasheed et al. (7) attributed this age-
maliland to assess the prevalence of the VI and RE among associated increase in myopia with decreased outdoor
school-aged children. activity of many children and this has been reported as
Noncycloplegic refraction was used to assess REs an issue in other studies (5,25,32).
in this study, similar to studies of school-aged children The prevalence of hypermetropia in this study was
in Nigeria (18) and South Africa (19). Noncycloplegic 2.7%, which is significantly lower than that reported
refraction was chosen so as not to interfere with the in studies in Ethiopia 26.4% (24) and Saudi Arabia 6.9%
academic activity of the children. (35). However, it is higher than in South Africa (1.8%) (10)
The prevalence of VI in the present study was 7.6%, and China (1.6%) (36) but similar to Tunisia (2.61%) (37).
which is lower than 10.1% in Malaysia (20) and 10.3% in The lower prevalence of hypermetropia in our study
China (21), but higher compared with 1.2% in South Africa might have been due to use of noncycloplegic refraction,
(5) 1.2%, 2.67% in South America (22) and 3.5% in the Islamic which could have missed a significant number of cases
Republic of Iran (23). These results indicate that VI among of hypermetropia. The prevalence of hypermetropia
school-aged children requires urgent intervention by the decreased with age and was higher in children aged 6 and
community and nongovernmental organizations. The 7 years compared with 14 and 15 years. This result agreed
results also reflect lack of childhood eye care services in with Chebil et al. (37), who reported that this variation
this region as well as lack of community awareness about could be related to a decrease in the dioptric power of the
the consequences of childhood VI. lens (it goes form 23 D at age 3 years to 20 D at 14 years), or
with an increase in the optical density of the crystalline
In the present study, the prevalence of VI was higher
cortex.
among girls than boys (4.6% vs 2.6%), which agrees with
a study in Ethiopia (3.2% for girls and 2.6% for boys) (24). The prevalence of astigmatism in the current study
This might have been due to socioeconomic factors that was 3.9%. This is lower than that found in the Islamic
contributed to better access to health services for boys. Republic of Iran (6.6%) (38) and South Africa (14.6%) (5) but
However, the difference was not significant. similar to that in Poland (4%) (39).
The prevalence of RE in either eye was 15.7%, which The prevalence of manifest strabismus was 0.7%,
is lower than that in Ghana (25.6%) (25), India (25.1%) which is similar to that among children in the United
(26), Egypt (22.1%) (27) and Qatar (19.7%) (28), but higher Republic of Tanzania (0.5%) (40) but lower than in Iranian
than in Uganda (11.6%) (29), Ghana (13.3%) (30) and Saudi school children (1.2%) (41).
Arabia (13.7%) (31). The prevalence of RE in our study was In this study, uncorrected RE was the most common
similar to that in Viet Nam (16.3%) (32) and Saudi Arabia cause of VI among children, and was responsible for
(16.3%) (33). This variation may be related to the type of 76.8% of cases. This is similar to other studies that used
sampling method used, size of population screened, and RESC protocol, such as in Ethiopia (77.3%) (24) and India
variation in geographic location. We found no significant (77%) (26) but lower than in Malaysia (87.0%) (20) and in
association between prevalence of RE and school grade the Islamic Republic of Iran (87.3%) (23). Alrasheed et al. (7)
or sex. However, we did show that the prevalence of VI suggested that this could have been because of genetic
caused by uncorrected RE increased significantly with differences as well as different lifestyles in terms of
age. Nevertheless, we found that prevalence of RE was outdoor activities. The second most frequent cause of VI
higher among girls than boys (81.3% vs 13.5%), which, as among children was amblyopia at 22.0%, which is higher
mentioned above, might have been due to better access than in Sudan (5.6%) (6) and South Africa (9.6%) (4). This
to health care for boys in this culture. This is consistent may be due to the high rate of poverty and illiteracy in
with a similar study in Saudi Arabia (34). Somaliland and the poor health system in the country.

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In the present study, out of 91 children with VI, only and seventh grades, and children aged 6 and 7 years were
16 (17.6%) were already using spectacles, while the rest less prevalent in this study, because many children in
were not aware of the problem. This may have been due Somaliland start school later than the recommended
to lack of child and parental awareness of the vision 6 years. Fifth, Log Mar charts were not available, so
problem, attitudes regarding the need for spectacles, cost we used Snellen Tumbling E-charts, and slit lamps
of spectacles, cosmetic appearance, peer pressure and
and fundus biomicroscopy were not easy to transport
concerns that wearing glasses may cause progression of
RE (42,43). between locations, so they were replaced by torch and
magnifier, and ophthalmoscopy. Finally, RE was assessed
This study had several limitations. First, a large
by noncycloplegic refraction, which could have missed a
number of schools were not registered with the Ministry
of Education in Hargeisa, so the study sample did not significant number of cases of hypermetropia.
include all schools. Second, almost half of school-age
children were not attending school due to poverty, thus Conclusions
the study only included children who attended school.
Third, places of study and examination differed among The prevalence of VI among school-aged children in Har-
schools in terms of lighting, ventilation and comfort. geisa, Somaliland was high and the commonest causes
Fourth, distribution of children’s ages at school levels was were uncorrected REs. There are barriers to care and it is
not uniform, so older children were not only in the eighth critical that they are overcome.

Acknowledgement
We are grateful to all schools included in this study and their staff for help with data collection. We also thank all the
students who participated in this study and their parents, as well as the students of the Faculty of Optometry and Visual
Science, University Of Hargeisa. We are grateful to Manhal Specialist Hospital ,which provided us with the required in-
strumentation, and free treatment for any student who was referred to the hospital.
Funding: None.
Competing interests: None declared.

Prévalence du vice de réfraction et de la déficience visuelle chez les enfants d’âge sco-
laire de Hargesia, au Somaliland (Somalie)
Résumé
Contexte : Les troubles visuels chez l’enfant constituent un problème de santé publique mondial, en particulier dans les
pays en développement. Ses causes les plus courantes sont évitables par un diagnostic précoce et la mise en place rapide
d’un traitement.
Objectifs : La présente étude avait pour objectif d’évaluer la prévalence du vice de réfraction et de la déficience visuelle
chez les enfants d’âge scolaire à Hargeisa, au Somaliland (Somalie).
Méthodes : Il s’agissait d’une étude transversale menée auprès de 1204 élèves (âgés de 6 à 15 ans) de huit écoles primaires
sélectionnées de manière aléatoire à Hargeisa, entre novembre 2017 et janvier 2018. Nous avons utilisé l’étude modifiée
sur le vice de réfraction chez les enfants afin de déterminer la prévalence de cette affection et de la déficience visuelle,
comprenant les examens suivants : acuité visuelle à distance, évaluée par l’échelle de Snellen avec des E ou C directionnels ;
la réfraction, évaluée par examen de la vision binoculaire par rétinoscopie ; et examen des segments antérieurs et
postérieurs.
Résultats : La prévalence de la déficience visuelle non corrigée, détectée et la mieux corrigée de 6/12 ou un score inférieur
était respectivement de 13,6 %, de 7,6 % et de 0,75 %. Seuls 16 enfants sur 91 (17,6 %) portaient des lunettes tandis que les
autres n’avaient pas conscience du problème. Le vice de réfraction était la cause de la déficience visuelle chez 76,8 % des
participants, l’amblyopie dans 22,0 % des cas, le trachome chez 2,4 % des enfants, et l’opacité cornéenne et la cataracte
chez 0,6 % d’entre eux. Des anomalies du segment antérieur ont été observées chez 8,3 % des participants à l’étude,
principalement des kératoconjonctivites vernales, tandis que des anomalies du segment postérieur ont été observées dans
0,7 % des cas. La prévalence de la myopie était de 9,1 %, celle de l’hypermétropie de 2,7 % et celle de l’astigmatisme de 3,9 %.
La prévalence de la déficience visuelle due à un vice de réfraction était associée à un âge supérieur, sans toutefois que l’on
puisse noter de corrélation significative avec le niveau scolaire ou le sexe.
Conclusion : La prévalence de la déficience visuelle chez les enfants d’âge scolaire de Hargesia était élevée, principalement
en raison d’un vice de réfraction non corrigé. Il existe des obstacles aux soins et il est essentiel de les surmonter.

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)‫ صوماليالند (الصومال‬،‫معدل انتشار اخلطأ االنكساري وضعف البرص بني األطفال يف سن الدراسة يف هرجيسا‬
‫ وليد الغامدي‬،‫ سيف الرشيد‬،‫زهرة عبدي أمحد‬
‫اخلالصة‬
َّ ‫ وال‬،‫ ُي َعدُّ ضعف البرص يف مرحلة الطفولة مشكل ًة من مشكالت الصحة العامة عىل الصعيد العاملي‬:‫اخللفية‬
.‫سيام يف البلدان املنخفضة الدخل‬
َ ‫ويمكن جتنب أسبابه األكثر شيوع ًا عن طريق التشخيص والعالج ا ُمل‬
.‫بكر ْين‬
‫ صوماليالند‬،‫ هدفت هذه الدراسة إىل تقييم معدل انتشار اخلطأ االنكساري وضعف البرص بني األطفال يف سن الدراسة يف هرجيسا‬:‫األهداف‬
)‫(الصومال‬
‫ مدارس ابتدائية خمتارة عشوائي ًا يف‬8 ‫ سنة) يف‬15‫ سنوات و‬6 ‫ طالب (ترتاوح أعامرهم بني‬1204 ‫ شملت هذه الدراسة املقطعية‬:‫طرق البحث‬
‫ واستخدمنا دراسة اخلطأ االنكساري املعدَّ لة لدى األطفال‬.2018 ‫كانون الثاين‬/‫ إىل يناير‬2017 ‫ ترشين الثاين‬/‫هرجيسا خالل الفرتة من نوفمرب‬
‫ التي تم تقييمها بواسطة خمطط‬،‫ حدة البرص عن ُبعد‬:‫ بام يف ذلك االستقصاءات التالية‬،‫لتحديد معدل انتشار اخلطأ االنكساري وضعف البرص‬
.‫ وفحص األجزاء األمامية واخللفية‬،‫ الذي تم تقييمه من خالل تقييم رؤية العينني بمنظار الشبكية‬،‫ واالنكسار‬،Snellen Tumbling E-chart
‫ عىل‬%0.75‫ و‬%7.6‫ و‬%13.6 ‫صحح عىل أفضل وجه‬ ِ ‫صحح وا ُمل‬
َّ ‫ستعلن وا ُمل‬ َّ ‫ أو أقل غري ا ُمل‬12/6 ‫ بلغ معدل انتشار ضعف البرص بقيمة‬:‫النتائج‬
‫ وكان سبب ضعف البرص هو‬.‫) يستخدمون النظارات وكان الباقون غري مدركني للمشكلة‬%17.6( ‫ال‬ ً ‫ طف‬91 ‫ فقط من بني‬16 ‫ وكان‬.‫التوايل‬
.‫ من املشاركني‬%0.6 ‫وعتَامة ال َق ْرنِ َّية والسا ّد يف‬
َ ،‫ منهم‬%2.4 ‫ والرتاكوما يف‬،‫ منهم‬%22.0 ‫والغ َمش يف‬َ ،‫ من املشاركني‬%76.8 ‫اخلطأ االنكساري يف‬
ِ
‫ يف حني لوحظت تشوهات‬،‫ وعىل وجه اخلصوص التهاب ال َق ْرن َّية وامللتحمة الربيعي‬،‫ من املشاركني‬٪8.3 ‫ووجدت تشوهات يف اجلزء األمامي يف‬ ُ
َ
‫ وارتبط معدل انتشار ضعف البرص الناجم‬.%3.9 ‫ والالبؤرية‬،%2.7 ‫ ومد البرص‬،%9.1 ‫ وبلغ معدل انتشار احل َس‬.‫ منهم‬٪0.7 ‫يف اجلزء اخللفي يف‬
.‫ ولكن مل يكن هناك ارتباط مهم بالصف املدريس أو نوع اجلنس‬،‫عن اخلطأ االنكساري بزيادة العمر‬
‫ وكان السبب الرئييس وراءه اخلطأ االنكساري غري‬،‫ كان معدل انتشار ضعف البرص بني األطفال يف سن الدراسة يف هرجيسا مرتفع ًا‬:‫االستنتاجات‬
َّ ‫ا ُمل‬
.‫ ومن األمهية بمكان أن يتم التغلب عليها‬،‫ و َث َّمة عوائق حتول دون تقديم الرعاية‬.‫صحح‬

References
1. Bourne RRA, Flaxman SR, Braithwaite T, Cicinelli MV, Das A, Jonas JB et al. Magnitude, temporal trends, and projections of the
global prevalence of blindness and distance and near vision impairment: a systematic review and meta-analysis. Lancet Glob
Health. 2017;5(9):e888–97. http://dx.doi.org/10.1016/S2214-109X(17)30293-0 PMID:28779882
2. Flaxman SR, Bourne RRA, Resnikoff S, Ackland P, Braithwaite T, Cicinelli MV et al. Global causes of blindness and distance
vision impairment 1990–2020: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(12):e1221–34. http://dx.doi.
org/10.1016/S2214-109X(17)30393-5 PMID:29032195
3. Kong L, Fry M, Al-Samarraie M, Gilbert C, Steinkuller PG. An update on progress and the changing epidemiology of causes of
childhood blindness worldwide. J AAPOS. 2012 Dec;16(6):501–7. http://dx.doi.org/10.1016/j.jaapos.2012.09.004 PMID:23237744
4. Benjamin WJ. Borish’s clinical refraction E-book. Elsevier Health Sciences; 2006
5. Naidoo KS, Raghunandan A, Mashige KP, Govender P, Holden BA, Pokharel GP, Ellwein LB. Refractive error and visual impair-
ment in African children in South Africa. Invest Ophthalmol Vis Sci. 2003 Sep;44(9):3764–70. http://dx.doi.org/10.1167/iovs.03-
0283. PMID:12939289
6. Zeidan Z, Hashim K, Muhit MA, Gilbert C. Prevalence and causes of childhood blindness in camps for displaced persons in Khar-
toum: results of a household survey. East Mediterr Health J. May–Jun 2007;13(3):580–5. PMID:17687831
7. Alrasheed SH, Naidoo KS, Clarke-Farr PC. Prevalence of visual impairment and refractive error in school-aged children in South
Darfur State of Sudan. Afr Vis Eye Health. 2016 Oct 27;75(1):1–9. https://doi.org/10.4102/aveh.v75i1.355
8. Mehari ZA, Yimer AW. Prevalence of refractive errors among schoolchildren in rural central Ethiopia. Clin Exp Optom. 2013
Jan;96(1):65–9. http://dx.doi.org/10.1111/j.1444-0938.2012.00762.x PMID:22784031
9. Courtright P, Hutchinson AK, Lewallen S. Visual impairment in children in middle-and lower‑income countries. Arch Dis Child.
2011 Dec 1;96(12):1129–34. http://dx.doi.org/10.1136/archdischild-2011-300093 PMID:21868404
10. Holden BA. The role of optometry in Vision 2020. Community Eye Health. 2002;15(43):33–6. PMID:17491876
11. Logan N. The development of refractive error. In: Optometry: science, techniques and clinical management. 2nd ed. Oxford:
Elsevier Health Sciences; 2009 Jun 22:159–71.
12. Assessment of the prevalence of visual impairment attributable to refractive error or other causes in school children. Protocol
and manual of procedures. Geneva: World Health Organization; 2007 (https://www.who.int/blindness/causes/RESCProtocol.
pdf?ua=1, accessed 20 May 2020).

1368
Research article EMHJ – Vol. 26 No. 11 – 2020

13. Somalia: Somaliland, including government structure, security, and presence of internally displaced persons (IDPs) from
Somalia (2016–March 2018) [website]. Geneva: United Nations High Commissioner for Refugees (https://www.refworld.org/
docid/5ad453514.html, accessed 20 May 2020).
14. New world Bank GDP and poverty estimates for Somaliland [website]. Washington DC: World bank; 2014 (https://www.world�-
bank.org/en/news/press-release/2014/01/29/new-world-bank-gdp-and-poverty-estimates-for-somaliland, accessed 20 May 2020).
15. Muma MK, Kimani K, Kariuk, Wanyike MM. Prevalence and significant refractive errors in primary school children of a rural
district of Kenya. East Afr J Ophthalmol. 2007;13(2):48–51.
16. Minassian D. Sample size calculation for eye surveys: a simple method. Community Eye Health. 1997;10(23):42–44. https://www.
cehjournal.org/article/sample-size-calculation-for-eye-surveys-a-simple-method/
17. The World Health Report 1998: life in the 21st century a vision for all. Geneva: World Health Organization; 1998 (https://www.
who.int/whr/1998/en/, accessed 20 May 2020).
18. Adegbehingbe BO, Oladehinde MK, Majemgbasan TO, Onakpoya HO, Osagiede EO. Screening of adolescents for eye diseases in
Nigerian high schools. Ghana Med J. 2005 Dec;39(4):138–42. PMCID:PMC1790830
19. Mabaso RG, Oduntan AO, Mpolokeng MB. Refractive status of primary school children in Mopani district, Limpopo Province,
South Africa. Afr Vis Eye Health. 2006 Dec 19;65(4):125–33. https://doi.org/10.4102/aveh.v65i4.267
20. Goh PP, Abqariyah Y, Pokharel GP, Ellwein LB. Refractive error and visual impairment in school-age children in Gombak Dis-
trict, Malaysia. Ophthalmology. 2005 Apr 1;112(4):678–85. http://dx.doi.org/10.1016/j.ophtha.2004.10.048 PMID:15808262
21. He M, Huang W, Zheng Y, Huang L, Ellwein LB. Refractive error and visual impairment in school children in rural southern
China. Ophthalmology. 2007 Feb ;114(2):374–82. http://dx.doi.org/10.1016/j.ophtha.2006.08.020 PMID:17123622
22. Furtado JM, Lansingh VC, Carter MJ, Milanese MF, Peña BN, Ghersi HA, et al. Causes of blindness and visual impairment in
Latin America. Surv Ophthalmol. 2012 Mar–Apr;57(2):149–77. http://dx.doi.org/10.1016/j.survophthal.2011.07.002 PMID:22137039
23. Fotouhi A, Hashemi H, Khabazkhoob M, Mohammad K. The prevalence of refractive errors among schoolchildren in Dezful,
Iran. Br J Ophthalmol. 2007 Mar;91(3):287–92. http://dx.doi.org/10.1136/bjo.2006.099937 PMID:17035280
24. Yared AW, Belaynew WT, Destaye S, Ayanaw T, Zelalem E. Prevalence of refractive errors among school children in Gondar
Town, Northwest Ethiopia. Middle East Afr J Ophthalmol. 2012 Oct;19(4):372–6. http://dx.doi.org/10.4103/0974-9233.102742
PMID:23248538
25. Ovenseri-Ogbomo GO, Omuemu VO. Prevalence of refractive error among school children in the Cape Coast Municipality,
Ghana. Clin Optom. 2010 Jul 3;2:59–66.
26. Padhye AS, Khandekar R, Dharmadhikari S, Dole K, Gogate P, Deshpande M. Prevalence of uncorrected refractive error and
other eye problems among urban and rural school children. Middle East African journal of ophthalmology. 2009 Apr;16(2):69–74.
http://dx.doi.org/10.4103/0974-9233.53864 PMID:20142964
27. El-Bayoumy BM, Saad A, Choudhury AH. Prevalence of refractive error and low vision among schoolchildren in Cairo. East
Mediterr Health J. 2007 May–Jun;13(3):575–80. PMID:17687830
28. Al-Nuaimi AA, Salama RE, Eljack IE. Study of refractive errors among school children Doha. World Fam Med J. 2010;8(7):41–8.
29. Kawuma M, Mayeku R. A survey of the prevalence of refractive errors among children in lower primary schools in Kampala
district. Afr Health Sci. 2002 Aug;2(2):69–72. PMID:12789105
30. Ovenseri-Ogbomo GO, Assien R. Refractive error in school children in Agona Swedru, Ghana. Afr Vis Eye Health. 2010 Dec
11;69(2):86–92. https://doi.org/10.4102/aveh.v69i2.129
31. Al Wadaani FA, Amin TT, Ali A, Khan AR. Prevalence and pattern of refractive errors among primary school children in Al Hassa,
Saudi Arabia. Glob J Health Sci. 2012 Nov 11;5(1):125–34. http://dx.doi.org/10.5539/gjhs.v5n1p125 PMID:23283044
32. Paudel P, Ramson P, Naduvilath T, Wilson D, Phuong HT, Ho SM, et al. Prevalence of vision impairment and refractive error in
school children in Ba Ria –Vung T au province, Vietnam. Clin Exp Ophthalmol. 2014 Apr;42(3):217–26. http://dx.doi.org/10.1111/
ceo.12273 PMID:24299145
33. Aldebasi YH. Prevalence of correctable visual impairment in primary school children in Qassim Province, Saudi Arabia. J Optom.
2014 Jul–Sep;7(3):168–76. http://dx.doi.org/10.1016/j.optom.2014.02.001 PMID:25000873
34. Dandona R, Dandona L, Srinivas M, Sahare P, Narsaiah S, Munoz SR, et al. Refractive error in children in a rural population in
India. Invest Ophthalmol Vis Sci. 2002 Mar;43(3):615–22. PMID:11867575
35. Al-Rowaily MA. Prevalence of refractive errors among pre-school children at King Abdulaziz Medical City, Riyadh, Saudi Arabia.
Saudi Journal of Ophthalmology. 2010 Apr;24(2):45–8. http://dx.doi.org/10.1016/j.sjopt.2010.01.001 PMID:23960874
36. Li Z, Xu K, Wu S, Lv J, Jin D, Song Z, Wang Z, Liu P. Population‐based survey of refractive error among school‐aged children in
rural northern China: the Heilongjiang Eye Study. Clin Exp Ophthalmol. 2014 May–Jun;42(4):379–84. http://dx.doi.org/10.1111/
ceo.12198 PMID:23952961
37. Chebil A, Jedidi L, Chaker N, Kort F, Limaiem R, Mghaieth F, et al. Characteristics of astigmatism in a population of Tuni-
sian school-children. Middle East Afr J Ophthalmol. 2015 Jul–Sep;22(3):331–4. http://dx.doi.org/10.4103/0974-9233.150635
PMID:26180472

1369
Research article EMHJ – Vol. 26 No. 11 – 2020

38. Khalaj M, Gasemi M, Zeidi IM. Prevalence of refractive errors in primary school children [7–15 years] of Qazvin City. Eur J Sci
Res. 2009;28(2):174–85.
39. Czepita D, Mojsa A, Ustianowska M, Czepita M, Lachowicz E. Prevalence of refractive errors in schoolchildren ranging from 6 to
18 years of age. Ann Acad Med Stetin. 2007;53(1):53–6. PMID:18561610
40. 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 Nov;84(11):1291–7. http://dx.doi.org/10.1136/bjo.84.11.1291 PMID:11049957
41. Jamali P, Fotouhi A, Hashemi H, Younesian M, Jafari A. Refractive errors and amblyopia in children entering school: Shahrood,
Iran. Optom Vis Sci. 2009 Apr;86(4):364–9. http://dx.doi.org/10.1097/OPX.0b013e3181993f42 PMID:19289975
42. Alrasheed SH, Naidoo KS, Clarke-Farr PC. Attitudes and perceptions of Sudanese high-school students and their parents towards
spectacle wear. Afr Vis Eye Health. 2017 Apr 11;77(1):1–7. https://doi.org/10.4102/aveh.v77i1.392
43. Alrasheed SH, Naidoo KS, Clarke-Farr PC, Binnawi KH. Building consensus for the development of child eye care services in
South Darfur State in Sudan using the Delphi technique. Afr J Prim Health Care Fam Med. 2018 Oct 24;10(1):1–9. http://dx.doi.
org/10.4102/phcfm.v10i1.1767 PMID:30456975

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