Refractive Error and Visual Impairment in African Children in South Africa

PURPOSE: To assess the prevalence of refractive error and visual impairment in school-aged African children in South Africa. METHODS: Random selection of geographically defined clusters was used to identify a sample of children 5 to 15 years of age in the Durban area. From January to August 2002, children in 35 clusters were enumerated through a door-to-door survey and examined in temporary facilities. The examination included visual acuity measurements, ocular motility evaluation, retinoscopy and autorefraction under cycloplegia, and examination of the anterior segment, media, and fundus. In nine clusters, children with reduced vision and a sample of those with normal vision underwent independent replicate examinations for quality assurance. RESULTS: A total of 5599 children living in 2712 households were enumerated, and 4890 (87.3%) were examined. The prevalence of uncorrected, presenting, and best-corrected visual acuity of 20/40 or worse in the better eye was 1.4%, 1.2%, and 0.32%, respectively. Refractive error was the cause in 63.6% of the 191 eyes with reduced vision, amblyopia in 7.3%, retinal disorders in 9.9%, corneal opacity in 3.7%, other causes in 3.1%, and unexplained causes in the remaining 12.0%. Exterior and anterior segment abnormalities were observed in 528 (10.8%) children, mainly corneal and conjunctival. Myopia (at least -0.50 D) in one or both eyes was present in 2.9% of children when measured with retinoscopy and in 4.0% measured with autorefraction. Beginning with an upward trend at age 14, myopia prevalence with autorefraction reached 9.6% at age 15. Myopia was also associated with increased parental education. Hyperopia (+2.00 D or more) in at least one eye was present in 1.8% of children when measured with retinoscopy and in 2.6% measured with autorefraction, with no significant predictors of hyperopia risk. CONCLUSIONS: The prevalence of reduced vision is low in school-age African children, most of it because of uncorrected refractive error. The high prevalence of corneal and other anterior segment abnormalities is a reflection of the inadequacy of primary eye care services in this area.