It is widely recognised that in developing countries, children with vision impairment have fewer education opportunities. Perhaps less well known is the startling fact that a large proportion of children in developing countries die within a few years of becoming blind.
Children in all regions of the world are affected by a range of eye diseases and conditions, some of which may lead to permanent vision impairment in childhood, or later in life.
Poor vision can have a large effect on a child’s life, including difficulties with activities such as daily living, mobility, reading and fine work.1 This can have a severe impact on education, personal development and economic productivity. For example, it is estimated that at least one third of the world’s 72 million children who are not in school have a disability (including those with a vision impairment).2
Many of the causes of poor vision in children, such as lack of access to clean water, premature birth, measles, congenital rubella syndrome and vitamin A deficiency, are also causes of child mortality. In developing countries, a large proportion of children die within a few years of becoming blind, from systemic complications of the condition causing blindness, or because of poor support services for families with blind children.3,4 Even at a less drastic level, a child who has red and itchy eyes or does not see the board at school clearly, may struggle to learn.
Many of the causes of poor vision in children, such as lack of access to clean water, premature birth, measles, congenital rubella syndrome and vitamin A deficiency
Many of these conditions are preventable or treatable. Interventions are available for most of the causes of childhood blindness and much can be done through primary health care and school health programs
by strengthening the eye health component to include early detection and referral of children with eye problems.
The Mandate
In 1989, the Convention for the Rights of the Child was adopted by the United Nations (UN). This Convention, for the first time, recognised children to have a set of rights of their own, not a passive object of care and charity. It became the most ratified Convention in history.
Poor eye health affects the realisation of these rights. For example, a child’s right to health including treatment of illness and rehabilitation of health, their right to education and the right to an adequate standard of living.
As a result, many global action plans call for improvement in the living conditions of children. The UN Convention on the Rights of Persons with Disabilities makes specific reference to the rights of children with disabilities and the responsibilities of states to ensure the full enjoyment by children with disabilities of all human rights. In addition to this, goal two and four of the UN Millennium Development Goals include achieving universal primary education and reducing child mortality. The World Health Organization (WHO) has made childhood blindness a priority eye disease and calls for action in prevention, treatment and rehabilitation.
As such, the mandate for ensuring eye health access for all children, regardless of gender, disability, race, religion or geographic location, is clear.
Magnitude
Globally, there are 19 million children with vision impairment.5 The burden of blindness lies with developing countries, with the prevalence in children approximately 10 times greater in developing than developed countries.6
Causes of Poor Eye Health in Children
Uncorrected Refractive Error
Of the 19 million children with vision impairment, approximately 12 million have significant uncorrected refractive error. Refractive errors occur in children in all regions of the world, but the pattern of prevalence and the type of refractive errors vary. Of particular concern is that in areas such as East Asia, the prevalence of myopia appears to be increasing rapidly, with the rate among children found to be as high as 78 per cent in China.7
Trachoma
In the most under-served communities in the world, up to 50 per cent of children aged 0 to10 years have active trachoma, caused by chlamydia infection. Repeated infection, left untreated, can lead to corneal scarring and blindness in adult life.8 Women, who usually perform the role of caregiver to children, are most at risk.9
Vitamin A Deficiency
Vitamin A deficiency causes night blindness, perforation of the cornea, growth retardation, increased risk of infections and even mortality. The WHO estimates that night blindness due to vitamin A deficiency affects 5.2 million preschool aged children, with those most at risk living in developing countries.
The highest burden lies with Africa and South-East Asia where 44–50 per cent of preschool aged children have a Vitamin A deficiency.10
Cataract
Paediatric cataract affects between 1–15/10,000 children. Although affecting children in all regions, blindness due to paediatric cataract is 10 times greater in developing countries than developed countries, probably due to earlier diagnosis and management.11 Early detection and surgical management of cataract by paediatric teams leads to improved visual functioning, even if surgery is performed too late to give good visual acuity.
Other
Allergies, red sticky eyes and injuries are other eye problems that will be frequently seen among children.
Key Strategies for Child Eye Health
Clinical interventions are available for most of the causes of childhood blindness outlined above. Yet, to have a meaningful impact on child eye health issues, we need to advocate for, design and implement strong public health programs.
These need to be planned with diverse stakeholders, including parents, teachers, government and children, ensuring that children’s voices are heard and given due weight. Programs need to be accessible to all children, including vulnerable groups such as children with disabilities, girls and children who are out of school. Furthermore, programs need to be well integrated into the fabric of society, including the community and broader health and education systems, and include human resource development and health education components. Finally, child eye health programs need to have appropriate child protection mechanisms in place, ensuring children who come in contact with programs are safe.
The Path Ahead
Child eye health is a significant public health issue, particularly in developing countries, and requires well-integrated, innovative strategies to address the growing need. The consequences of inaction range far beyond vision, affecting education, social participation and future economic productivity.
With the UN Convention on the Rights of the Child being the most ratified human rights convention in history, the mandate for communities, civil society and governments to come together to address childhood blindness, is clear.
The authors all work with the Brien Holden Vision Institute: Hasan Minto, Sumrana Yasmin, Vingfai Chan and Stephanie Looi
Hasan Minto Dip Opt FAAO is Director of Sustainable Service Development; Sumrana Yasmin MSc MBA, is Programs Manager, South East Asia & Eastern Mediterranean region; Vingfai Chan BOptom, is Research Manager for Africa region; and Stephanie Looi B App Sci (Optom) MPH, is the Manager of Sustainable Service Development at Brien Holden Vision Institute and Project Manager for Vision CRC.
References
1. Chadha, R.K. & Subramanian, A. (2010). The effect of visual impairment on quality of life of children aged 3–16 years. British Journal of Ophthalmology, bjo-2010.
2. Nations Secretary General’s Report on the Status of the Convention on the Rights of the Child (2011) UN Doc A/66/230. Accessed at: http://daccess-dds-ny.un.org/doc/UNDOC/GEN/N11/442/45/PDF/N1144245.pdf?OpenElement
3. Gilbert, C. & Foster, A. (2001). Childhood blindness in the context of VISION 2020: the right to sight. Bulletin of the World Health Organization, 79(3), 227-232.
4. Steinkuller, P. G., Du, L., Gilbert, C., Foster, A., Collins, M. L. & Coats, D. K. (1999). Childhood blindness. Journal of American Association for Pediatric Ophthalmology and Strabismus, 3(1), 26-32.
5. World Health Organization. Visual impairment and blindness – Fact Sheet No. 282. 2012; Available from: www.who.int/mediacentre/factsheets/fs282/en/.
6. Gilbert, C. E., Anderton, L., Dandona, L. & Foster, A. (1999). Prevalence of visual impairment in children: a review of available data. Neuro-Ophthalmology, 6(1), 73-82.
7. Wu L., Sun X., Zhou X. & Weng C., Causes and 3-year-incidence of blindness in Jing-An District, Shanghai, China 2001-42009, BMC Ophthalmology 2011, 11:10.
8. www.iapb.org/sites/iapb.org/files/School%20Health%20Programme%20Advocacy%20Paper%20BP.pdf
9. Congdon, N., West, S., Vitale, S., Katala, S. & Mmbaga, B. B. O. (1993). Exposure to children and risk of active trachoma in Tanzanian women. American journal of epidemiology, 137(3), 366-372.
10. World Health Organization. (2009). Global prevalence of vitamin A deficiency in populations at risk 1995-2005: WHO global database on vitamin A deficiency.
11. Foster, A., Gilbert, C. & Rahi, J. (1997). Epidemiology of cataract in childhood: a global perspective. Journal of Cataract & Refractive Surgery,23, 601-604.
