Ocular morbidity among school children in Uttarakhand: Himalayan state of India



Background: This study may be a foundation pillar for future planning of school eye screening programs in Uttarakhand: Himalayan State of India as there is very little, if any, data is available till now. Aims: This study was done to know the prevalence and pattern of various causes of ocular morbidity among school children in Uttarakhand, India. Settings and design: A cross sectional multistage randomized study was done on school children between 5 -16 years of age in Doiwala block of Dehradun-capital of Uttarakhand, India. Material and Methods: School children were taken up for ophthalmological examination. Any child with subnormal vision or abnormal ocular finding was further evaluated in a tertiary care hospital. Statistical Analysis: Results were expressed in percentage and ratio. Chi-square test (with Yates correction whenever needed) was used for analysis of data. Ninety five percent CI was also calculated. The data with p value less than 0.05 was considered statistically significant. Results: Out of 5918 children, the prevalence of ocular morbidity was 4.92% (291 children). The most common causes of ocular morbidity were refractive error in 164 (2.77%) children, convergence weakness in 32 (0.54%), strabismus in 24 (0.40%) and conjunctivitis in 23 (0.38%) children. Ocular morbidity was more in children of age group 5 – 10 years in comparison to age group 11-16 years(P = 0.002). Conclusions: Refractive error was the commonest cause of ocular morbidity affecting school going children in Uttarakhand, India. The prevalence of ocular morbidity decreased with increasing age of child.

Keywords: Ocular morbidity, ocular disorders, school screening, prevalence

How to cite this article:
Sharma A, Maitreya A, Semwal J, Bahadur H. Ocular morbidity among school children in Uttarakhand: Himalayan state of India. Ann Trop Med Public Health 2017;10:149-53
How to cite this URL:
Sharma A, Maitreya A, Semwal J, Bahadur H. Ocular morbidity among school children in Uttarakhand: Himalayan state of India. Ann Trop Med Public Health [serial online] 2017 [cited 2017 Jul 15];10:149-53. Available from: https://www.atmph.org/text.asp?2017/10/1/149/196823

Prevalence and pattern of ocular morbidity in school children varies among countries and even in various geographical areas within a country. There is no published study on ocular morbidity among school children in Uttarakhand state in Himalayan region of North India till now. Such a study is important to prepare a long-term strategy to prevent and treat childhood ocular disorders.

Keeping the above points in consideration, this study was done to evaluate the prevalence and pattern of ocular morbidity in school children in Doiwala block of Dehradun capital of Uttarakhand state.

Material and Methods

The proposed study was conducted in Dehradun, Uttarakhand. A cross-sectional, completely randomized stratified multistage design was adopted for this study to get reliable information.

There were 13 zones in Doiwala block, out of which six (46.15%) were selected for the study. Total number of schools in the six zones were 42. Out of these, 21 (50%) schools were randomly selected. This was the first stage of study.

In the second stage, school children between age group of 5 and 16 years were screened. The age limit was 5–16 years as at 5 years, children are cooperative enough for Snellen’s visual acuity and beyond 16 years, they usually leave school.

All the children present in the school on the day of examination were included in the study. Absentees were excluded from the study. Prior to examination, the Principals of various schools were informed about the screening programme. Informed consent and permission was taken from them.

Ophthalmological examination was done in the respective schools. Clean, quiet, well-lighted rooms were selected for examination. The students were asked about presence of any ocular problems. The respective class teachers were also asked about any specific ocular complaints and about any abnormality noticed by them in the children.

The visual acuity was measured using Snellen’s chart. A torch light examination was done at the school. It included Hirschberg test, extraocular movements, cover test for distance and near for manifest strabismus, pupillary reaction, convergence assessment, and anterior segment examination.

Referral card to the tertiary care hospital was given to the school teachers for the children with: visual acuity less than 6/9 in either eye, strabismus, cataract, ptosis, trauma, corneal disorders, developmental anomalies, or any other ocular disorder. Complete ophthalmological examination of the children who were referred to tertiary care hospital was done in the Pediatric Ophthalmology Unit of the hospital. This examination included visual acuity recording with Snellen’s chart, Hirschberg test, extraocular movements, cover test for distance and near for manifest strabismus, pupillary reaction, and convergence assessment. Anterior segment examination was done with slit lamp. For cycloplegia and mydriasis, one drop of homatropine hydrobromide 2% eye drop was put followed by one drop of tropicamide 1% eye drop after 5 min. Retinoscopy (Heine retinoscope, Germany) was done after 45 min followed by fundus examination by indirect ophthalmoscope (Keeler, United Kingdom).

Prior approval of ethics committee of institute was obtained. Procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional).

Interpretation and analysis of the data were done using Epi Info Software and chi-square test (with Yates correction whenever needed) was used. Ninety five percent Confidence Interval was also calculated to make the study more efficient. Data with P value less than 0.05 were considered statistically significant.


A total of 5,918 children consisting of 3,462 (59%) boys and 2,456 (41%) girls with male to female ratio of 1.41 : 1 were included in the study.

Out of 5918 children, ocular morbidity was found in 291 children (prevalence rate 4.92%) [Table 1].

Table 1: Sex and ocular disease wise distribution of children

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The most common cause of ocular morbidity was refractive error. One hundred sixty four out of total 5918 children (2.77%) were having refractive errors. Second common cause was convergence weakness which was found in 32 children (0.54%). Manifest strabismus was next in order. Total 24 children out of 5918 children were having manifest strabismus (0.40%). Conjunctivitis was present in 23 children (0.38%). Other ocular disorders were uncommon. Coloboma was found in four children (0.06%). Iris and choroidal coloboma were found in one male and two females, and optic nerve head coloboma was present in one female. Corneal opacity was also seen in four children (0.06%).This was present as nebulo macular corneal opacity in two males and one female, and adherent leucoma in one male. Vitamin A deficiency was detected in two children (0.03%) in the form of conjunctival xerosis in one male and one female. Two children were having retinal disorders (0.03%), one with exudative retinal detachment, and the other one with solar retinopathy [Table 1].

Ocular morbidity was more in children of less than 10 years of age as compared with children greater than 10 years of age. This relationship was found to be statistically significant (P = 0.002, X² = 9.4749, Odd’s ratio = 1.49, 95% CI = 1.15–1.92) [Table 2].

Table 2: Age wise distribution of children with ocular morbidity

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There was no relationship between sex of the child and ocular morbidity [Table 3].

Table 3: Sex wise distribution of children with Ocular Morbidity

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Childhood is the time when accurate vision is a vital key factor in ensuring acquisition of knowledge in the form of school studies. Identification and correction of ocular abnormalities like refractive errors is a must to ensure proper studies.

If the child is visually challenged, it may affect his/her education, development, and job prospects. In a developing country like India, it becomes even more significant as there is a huge population and lesser jobs as compared with developed nations.

Thus, it becomes imperative to carry out large scale planned school screening initiatives in this area but unfortunately the data from Uttarakhand state on prevalence and pattern of ocular diseases among school children is highly inadequate and scant till date. This study is the first initiative in this direction in Uttarakhand state in order to achieve detailed future planning of school eye screening programmes.

In the present study, the prevalence of ocular morbidity was 4.92%. In other studies done in North India [1],[2],[3] and adjacent Nepal,[4],[5] the prevalence of ocular morbidity was more than 10%. This could probably be ascribed to the smaller sample size and variable geographical location in all these studies as compared with the present study.

In our study, refractive error was the commonest cause of ocular morbidity, with a prevalence of 2.77%. In most of the Indian, as well as international studies also, commonest ocular disorder in school children was refractive error[1],[2],[4],[5],[6],[7],[8],[9] but the prevalence in different studies varies widely from very low to very high. In India, in Kariapatti pediatric eye evaluation project, undertaken by Aravind eye hospital, refractive error was seen in 0.55% children.[6] On the contrary, study by Das A et al.[10] found refractive error in 25.11% children. Various other Indian studies reported prevalence of refractive error between these two studies.[12],[11],[12],[13] Data from international studies also depicted a variable prevalence of refractive error. A study conducted in a rural area of Tanzania by Wedner et al.[14] found that the rate of refractive error was 1.01%. On the contrary, refractive error was found in 21.9% children in Nepal.[5] Reports from other countries also vary in the prevalence of refractive error.[4],[7],[8],[9],[15],[16] This wide variation in prevalence of refractive error may be due to difference in genetic, geographical, and environmental factors, as well as different diagnostic criteria in different studies. This study reiterates the fact that refractive error is the commonest eye disorder in children of this area, as also in school children of other areas of the world. Further long-term plans could include visits for school screening that provides facilities for refraction along with spectacle prescription at the same visit.

Convergence is an important part of school screening as all the students have to use it while studying. Convergence insufficiency can lead to asthenopia, which may ultimately cause reluctance to study but strangely, not many school screening studies have reported its prevalence. The prevalence of convergence weakness was 0.54% in the present study, which was comparable to a study by Pratap and Lal [17] who reported a prevalence of 1.72%. Convergence insufficiency was found to be the second most common ocular disorder among school children in our study. It may be possible for a child to have normal vision but a convergence insufficiency may cause asthenopic symptoms while reading books. Such a child may have to face ridicule from parents and teachers. It is vital to include convergence testing in all the future school screenings.

In our study, the prevalence of manifest strabismus was 0.40%.The results from various Indian, as well as International studies[6],[7],[13],[14] also reported a prevalence of strabismus less than 1%. In few studies from India[2],[17] and outside India[4],[5] strabismus was more common (1.63–3.5%) than our study. All these studies either mentioned prevalence of strabismus (which includes both latent and manifest strabismus)[2],[17] or also included other orthoptic problems with strabismus.[5]

The prevalence of conjunctivitis was 0.38% in present study. The results were comparable with a study from Shimla (another hilly area of India) by Gupta M et al.[2] who reported a prevalence of 0.8%. In India, other studies from non-hilly areas like Delhi or desert area like Rajasthan, conjunctivitis was found to be more common.[1],[18] All these studies including ours reinforce the fact that prevalence of conjunctivitis depends upon hygiene and climate of a specific area. As conjunctivitis is among the top contenders for ocular abnormality among school children, antibiotic eye drops must be included while visiting schools for screening.

As reported in other studies in India[1],[2],[13],[18], adjacent Nepal[4] and other countries[14], our study further reinforces the fact that like anywhere else, in this area also, other causes contribute little to ocular morbidity in school children. The notable exception is vitamin A deficiency, which was less in our study (.03%) as compared to other studies.[1],[2],[14],[18] The possible explanation for this may be different dietary habits.

There was a decline in ocular morbidity with increase in age in our study. This pattern is reported in other studies as well.[2],[18] This decrease in ocular morbidity with increase in age could be due to the fact that with increase in age there occur decrease in hypermetropia and children may have better ocular hygiene. However, for unknown reasons the reverse is also reported.[1] Our study suggests that younger children warrant more attention in future school screening.

Limitations of current study are that children with multiple disabilities, from schools for visually impaired, preschool age children, and those from lower socioeconomic groups who do not attend the school were likely to be underrepresented and absentees were not tracked.

It is recommended that the refractive errors, convergence insufficiency, squint, and conjunctivitis should be the primary concerns while planning for a screening event among school children of Uttarakhand.

Keeping all the above considerations in mind, it may be possible to plan an effective and efficient school screening programme for the masses in future. This pilot study may be expanded to screening of a much larger study population and based on the results, a wide school screening programme may be planned at State level for the entire state of Uttarakhand.


We are extremely thankful to the respective school staff for their co-operation. We are grateful to Prof (Dr.) R. C. Nagpal and Prof (Dr.) Renu Dhasmana for their support. We are also thankful to Mr. Hem Chandra Sati for his contribution to statistics used in this study.

Financial support and sponsorship

Financial support for the study was provided by “ORBIS” and “Swam Rama Himalayan University”

Conflicts of interest

There are no conflicts of interest.

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.196821


[Table 1], [Table 2], [Table 3]

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