Primary eye care in pediatric population-I study (PREPP-I study): Demographic and clinical profile of pediatric patients treated in six major vision centers of a tertiary eye care facility in South India

Abstract

Purpose:

The study intends to evaluate the demographic and clinical profile of pediatric patients (0–18 years) attending six vision centers (VCs) of a tertiary eye care facility in south India.

Methods:

This is a cross-sectional observation study conducted at six major peripheral VCs of a tertiary eye care facility in South India from June 20 to Dec 20. All children presenting at the VCs under a base hospital (BH) in Pondicherry, whose parents gave consent were included. Data were entered by the ophthalmic assistants in the VC and cross checked by the principal investigator at the BH.

Results:

A total of 250 pediatric patients were brought to the VCs during the study period, predominantly males (60.8%), with a mean age of 8.2 ± 4.5 years (0–18 years). Half of them were staying within 5 km from the VCs. Most children were escorted by their parents (88%), and the expenditure of travel to the VC was affordable for most of the parents (75%). Also, 53.6% of patients were in their primary school, while schooling had not started for 28% of children. Visual acuity (VA) could be assessed only for school-going children and older children due to lack of age-matched VA assessment tools. Most children (91.3%) had uncorrected VA better than or equal to 6/18 in the better eye, and approximately 3% had VA worse than 6/60. All patients had best corrected VA of 6/6–6/18 after cycloplegic refraction. Most children reported to the VC for allergic conjunctivitis (25%), followed by refractive error (13%) and squint (10.4%). Urgent referral to the BH was made for 47 children.

Conclusion:

Primary eye care in pediatric population-I (PREPP-I) showed that most children can be treated at the VCs and only one-fifth of the children require active intervention at higher referral centers. Further study on satisfaction of services provided for pediatric patients in these VCs and barriers of not reporting to the BH when referred are considered for the PREPP-II study.

Ever since the Alma-Ata Declaration has been made, primary eye health-care service has always remained the prime goal to achieve universal access to health care and also to achieve Millennium Development Goals.[1] It was proposed that primary eye health-care implementation would lead to health equity in all countries rich and poor and, as a result, promote human and national development.[2] Primary health care (PHC) intends to provide wide range of preventive and curative services and makes it a cost-effective approach to address the large population health challenges in developing countries.[1] Vision center (VC) is one form of primary eye care service which is designed to identify the major causes of visual impairment and address other potentially blinding conditions, health education, and appropriate referrals to the base hospital in Pondicherry. Globally, an estimated 1.4 million children suffer from avoidable blindness and three-quarters of these children live in the poorest regions of Asia and Africa.[3] An analysis of causes of avoidable blindness highlights the fact that a properly planned and developed system of primary eye care can have greater impact by increasing accessibility, availability, and affordability of eye care to the rural populations of the world.[4] Not only for adults, these VCs are also efficient to provide primary eye care to pediatric patients, dispensing spectacles, detecting morbidities, and arranging for early referral to the base hospital (BH). As of 2021, there are 11 functioning VCs in the rural areas of Pondicherry at an average distance of 30–100 km from the BH. These centers have been functioning for almost 10 years. Each VC has a trained vision technician called as mid level ophthalmic personnel (MLOP), who can perform eye examination including refraction, slit-lamp evaluation, and applanation tonometry. It also has a fundus camera and teleconsultation facility. The unique feature in our VCs is that patients can interact through telecommunication with the ophthalmologists at the BH for consultation, unlike other models of primary eye care centers where only the optometrist or vision technician interacts and institutes the treatment.

Previous studies in literature have been conducted for the adult population only and they cover the various aspects of primary eye care for its utilization, prevalence of common ocular morbidities in the patients accessing it, and their perception and awareness about ocular diseases.[5-7] There is scarcity of literature about the disease profile of the pediatric patients accessing the VCs across India. The authors feel this study would help to know better about the common ocular presentations of pediatric patients in our VCs and the rate of referrals to the BH.

Methods

This is a prospective cross-sectional study conducted for a duration of 6 months from June 2020 to Dec 2020. All children in the age group of 0–18 years (as per the World Health Organization’s [WHO] definition of pediatric age group) whose parents were willing to participate were included in the study [study design is shown in Fig. 1]. The study was conducted in 6 Vision Centres (Tirukkanur, Marakkanam, Kurinjipadi, Nellikuppam, Pennadam, Ulundurpet) in the Pondicherry region which come under the primary care services of Aravind Eye Care System in Pondicherry. All the VCs belong to the rural communities providing comprehensive eye care services to a population of 50,000–70,000. The patients presenting at the VCs who were more than 18 years of age or children <18 years whose parents did not agree to participate in the study were excluded. Informed consent was obtained from the parents who agreed to participate, after explaining the nature of the study to them. The VC technician took the patients for further steps of examination – visual acuity (VA) and refraction (both uncorrected and best corrected), slit-lamp examination, dilation if performed, and fundus exam with its photograph – and entered the details in Electronic medical record (EMR). Doubtful cases were consulted via teleophthalmology services at the BH. All the details were entered in the proforma by the principal investigator. Parents of referred patients were provided a token for easy identification at the BH. The principal investigator traced the referred patients to see whether they reached the BH after referral, and the final diagnosis was made at the BH by the pediatric ophthalmologist.

Figure 1.

Flowchart showing the study design.

Statistical analysis

Mean (standard deviation [SD]) and frequency (percentage) were used to describe the summary statistics. Fisher’s exact test/Chi-squared test was used to find out the association between categorical variables (gender, education, socioeconomic status). Continuous variables (age, VA, distance, expenses) were analyzed using independent t-test/Mann–Whitney U-test. P value less than 0.05 was considered as statistically significant. All statistical analyses were performed using statistical software STATA 14.0 (StataCorp LLC, College Station, TX, USA).

Results

A total of 250 children reported in the major VCs during the study period. The mean age was 8.22 ± 4.52 years (range 0–18 years). Of these, 152 (60.8%) patients were males and 98 (39.2%) patients were females. The pediatric patients were escorted mostly by parents (mother > father) followed by grandparents (mostly grandmother) [Table 1]. Maximum children reporting to the VCs were in their primary schooling (53.6%), whereas 28% of patients were still in their preschool age group. Almost half of the patients were staying within 5 km distance from the VCs and only 16% patients had to travel more than 10 km to reach the VC. The demographic profile of pediatric patients attending the VCs is presented in Table 1. Only 47 out of 250 patients were referred to the BH which was located approximately 60 km from these VCs. Those patients were primarily referred for amblyopia management or for conditions which were amblyogenic (cataract, squint, corneal scar) or requiring urgent medical or surgical attention. The common ocular morbidities of these patients were allergic conjunctivitis (26%), refractive error (23%), followed by strabismus (10.4%) and congenital nasolacrimal duct obstruction (CNLDO; 9.6%). The common ocular morbidities of pediatric patients presenting to VCs are depicted in Table 2. The age-wise distribution of ocular morbidity is shown in Table 3. Most children (91.3%) had uncorrected VA better than or equal to 6/18 in the better eye and approx. 3% had VA worse than 6/60. All patients had best corrected VA of 6/6–6/18 after cycloplegic refraction.

Table 1.

Baseline characteristics and demographic profile of pediatric patients attending the VCs

Parameters	(n=250), n (%)
Age (years)
Mean±SD	8.22±4.52
Min.-Max.	7 months-18 years
Gender
Male	152 (60.8)
Female	98 (39.2)
Relation of informant
Mother	116 (46.4)
Father	105 (42.0)
Grandmother	19 (7.6)
Grandfather	5 (2.0)
Others	10 (4.0)
Education
Preschool	70 (28.0)
Primary school	134 (53.6)
High school	46 (18.4)
Distance of home from the VC
Within 5 km	122 (48.8)
5-10 km	87 (34.8)
>10 km	41 (16.4)
Transport type
Walking	73 (29.2)
Private vehicle	147 (58.8)
Public transport	17 (6.8)
Own vehicle	13 (5.2)
Transportation cost
<100 Rs	152 (75.2)
100-500 Rs	46 (22.8)
>500 Rs	4 (2.0)
Socioeconomic score
Upper	08 (3.2)
Upper middle	39 (15.6)
Lower middle	59 (23.6)
Upper lower	99 (39.6)
Lower	7 (2.8)

SD=standard deviation, VC=vision center

Table 2.

Ocular morbidities of pediatric patients presenting to the VCs

Diagnosis	Number	Percentage
Allergic conjunctivitis	65	26
Refractive error	58	23.2
DES	10	4
Blunt injury	18	7.2
Chalazion	11	4.4
Conjunctivitis	12	4.8
Strabismus	27	10.8
CNLDO	24	9.6
FB	04	1.6
Cataract	05	2
Viral keratitis	03	1.2
Corneal abrasion	12	4.8
Chemical injury	1	0.4
Total	250	100

CNLDO=congenital nasolacrimal duct obstruction, CPH=caterpillar hair, DES=digital eye strain, FB=foreign body, VC=vision center

Table 3.

Age-wise distribution of ocular morbidities

Allergic conjunctivitis	22	15	16	12	65
Myopia	8	6	8	6	28
Hypermetropia	4	4	2	4	14
Myopic astigmatism	5	4	4	5	18
Hypermetropic astigmatism	3	1	2	2	8
Amblyopia	4	2	3	3	12
Strabismus	9	5	6	7	27
Cataract	3	1	0	1	5

Two out of every 10 patients (47/250) were referred from VCs to the BH. Among referrals were the patients requiring active amblyopia management or surgical intervention. The parents were explained the cause of referral and were given a referral token which would help in early triaging in the BH and offering a prompt management. The referred patients were identified at the registration corner of the BH by a green referral card provided to the parents at the respective VCs. Once they arrived, the principal investigator or the study coordinator was intimated immediately and the patients were escorted to the subspeciality outpatient department (OPD).

Discussion

This study describes the demographic and clinical characteristics of pediatric patients presenting to six major VCs of a tertiary care eye care hospital in southern India. To the best of our knowledge, there are no previous reports of such a VC study among patients of the pediatric age group. Out of 250 pediatric patients reporting to the VCs during the study period, male showed preponderance. The male: female ratio was 1.5:1. Although the authors could not directly compare the present study with any other similar study in literature, studies on adult population showed female preponderance or equal proportion of male and female patients.[8-10] One of the studies mentioned that there were equal number of male and female patients in the age group 0–14 years in the VCs.[8] Females have been the major beneficiaries of the VC services, the reason being women can easily leave their househ old chores to access eye care when it is nearby, and moreover, the MLOPs being females make them more comfortable, thus breaking the cultural barriers.[11] The scenario is different for tertiary eye care hospitals where male predominance has been observed, which probably can be justified by the fact that boys receive more social and cultural values.[10] In relation to this, the authors want to highlight one important observation that most of the pediatric patients in our study were escorted by mother, grandmother, sister, or aunt. This clearly implies that policymakers and program implementers must create awareness to ensure equitable access to health care. Most of these patients were residing within 10 km radius of the VC, beyond which only 16% patients reported. This might indicate that the services of VC are utilized to the maximum when it is situated within 10 km radius of the community or village. Moreover, the transport cost plays an important role as children need to be escorted by one or two family members, which doubles the expenditure for these lower middleclass group of people. So, we found that three-fourths of the pediatric patients utilized the eye care services of VC when the traveling cost was less than 100 Rs. Among the ocular complaints, children mostly presented with itching, redness, diminution of vision, watering, and discharge. Refractive error was the most common ocular morbidity among children in various population-based studies performed in rural settings.[10-12] The most prevalent ocular morbidities for which pediatric patients reported in our VCs were allergic conjunctivitis, refractive error, and squint. Allergic conjunctivitis was prevalent in younger age group.[13] Among refractive errors, the most prevalent were myopia and myopic astigmatism.[14] The prevalence of strabismus in the pediatric age group ranged from 0.8% to 6% (age group 5–16 years).[15,16] Also, 10.8% patients presented with strabismus in our study (age 0–18 years).

Nearly two out of every 10 patients were referred either for amblyopia management or surgical intervention (cataract, probing, squint, corneal injury).

Conclusion

This study demonstrated that in a setting where access to eye health-care services screening remains low, ocular morbidity among children could be easily identified through VC model under primary health-care services. Since most ocular morbidities can be well treated in VCs, creating awareness among parents to access these services further reduces burden at tertiary hospitals and thus promotes standard care delivery to all.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.