Prevalence Of Eye Diseases Among Primary School Pupils

1.0 INTRODUCTION
The eye is an organ that detects light and sends signals along the optic nerve to the brain. In humans, the eye is a valuable sense organ that gives us the ability to see. It allows for light perception and vision, including the ability to differentiate between colors and depth (Troy Bedinghaus, OD 2009).
Disease is a disordered or abnormal condition of an organ or other part of an organism resulting from the effect of genetic or developmental errors, infection, nutritional deficiency, toxicity or unfavorable environmental factors, illness, sickness. Disease may also be classified into those which develop during fetal life (congenital) and those which develop or arise at anytime during postnatal life (Gilbert, 1998).
Eye diseases in children are important cause of medical consultation (Nwosu, 1999). Children are important cause of medical consultation (Nwosu, 1999). Children should receive prompt and proper eye care in order to avoid vision problems and eye morbidities, which could affect their learning ability, personality and adjustment in school (Pratab and Lai, 1989). Vision is the act or power of sensing with the eyes, sight. Vision is an important requirement for learning and communication (Adegbehinghe et al, 2005).
A study of the prevalence of ocular diseases in school children is very important because the spectrum of ocular problems varies from school to school and even from region to region in the same state. Some eye conditions are just causes of ocular morbidity, others invariably lead to blindness. Many ocular diseases have their origin in childhood and the morbidity may go unnoticed and adversely affect the child’s performance in school and may also cause severe ocular disability in the later part of life. Effective methods of vision screening in school children are useful in detecting correctable causes of decreased vision and in minimizing long-term visual disability. Children in the school going age (5-16 years) represent 25% of the population in the developing countries. They fall best in the preventable blindness age group, are a controlled population that is, they belong to certain age group and are easily accessible and schools are the best forum for imparting health education to the children (Murthy, 2000).

1.1 BACKGROUND INFORMATION
Biologically, a child (Plural: children) is a human between the stage of birth and puberty. UNICEF also defines a child as an individual less than 16 years old, within this age group there is active growth and development which depends largely on hereditary nutritional and environment factors.
Just as the body develops with its organs developing alongside any eye diseases occurs very early in life apart from the symptom of pain, the child may not complain of any ocular problem due to poor communication and poor understanding of the ocular problem, a lot now lies on the parents and class teachers to observe carefully for any abnormality in the visual functions. Some of the eye diseases could occur from ocular injuries and environmental conditions.
Common causes of pediatric eye diseases findings will be useful for pediatric ophthalmic care planning and could also serve as a baseline for the development of a pediatric ophthalmology sub-specialty in the tertiary hospital. (Onakponya and Adeoye, 2009).
More recent reports have credited the expanded programme on immunization for a downward trend in the incidence of measles infection and associated ocular morbidities in Nigeria (Bodunde and Onabolu (2004).
This study is aimed at determining the common causes of eye disease amongst primary school pupils in Owerri Municipal, Imo State. The eye diseases include but not limited to:
1. Allergic conjunctivitis
2. Bacterial conjunctivitis
3. Style
4. Ptosis
5. Chalazion
6. Blepharitis
7. Dacrycystities
8. Trachoma
9. Congenital Cataract
10. Keratitis
11. Uvieties.
1.1.1 ALLERGIC CONJUNCTIVITIS
Allergic conjunctivitis refers to a group of disorders affecting the ocular surface associated with type 1 hypersensitivity reactions. (Ono and Abelson, 2005). It is the inflammation of the conjunctiva due to allergic or hypersensitivity reactions which may be immediate or delayed. The conjunctiva is ten times sensitive than the skin to allergen (Kphurana, 2007).
The classification of allergic eye disease is based entirely on clinical features; the mild forms of allergic eye disease have fluctuating symptoms of itching, tearing, and swelling which may be distress but not sight threatening. Chronic forms of the disease give rise, in addition, to more severe symptoms including pain, visual loss from corneal scarring, cataract or glaucoma, and disfiguring skin and lid changes.
a. Seasonal Allergic Conjunctivitis (SAC)
This is the commonest and one of the mildest forms of allergic conjunctivitis. It accounts for 25% – 50% of all cases of ocular allergy; (Sheldrick et al 1992) affects between 10% and 15% of the UK population, is self limiting, and is characterized by small tarsal papillae.
b. Atopic Keratoconjunctivitis
(AKC) it is a more serious form of ocular allergy, with prolonged symptoms, sight threatening changes, and atopic dermatitis. (Tuff et al, 1986) Around 3% of the populations have atopic dermatitis, of which 25% – 40% have some form of ocular involvement. Conjunctivitis scarring, papillae formation (with shrinking of the fornices) (Oster CS and calonge MD 1990) and a puntate corneal keratopathy) may develop (Tuft SJ et al 1991). This may progress to serve corneal epithelia disease, opacification, pannus, and superficial vascularisation.
There is also an association with cataracts and keratoconus in AKC strict attention should be paid to lid toilet in order to reduce lid crusting and possible staphylococcal colonization of the lid. Powerful anti-CD+T cell agents such cyclosporine should be kept for several affected cases. (Oscar and Calonge, 1990.
c. Vernal Catarrh or Vernal Keratoconjunctivitis (VKC)
The condition usually resolves spontaneously by puberty but if it does persist, the sex distribution equalizes. This comprises 0.5% of allergic eye diseases, patients are usually under 14years of age with males predominating over females in ration of 2.1 there is a seasonal peak in incidence in spring when exposure to tree grass pollens increases, suggesting an extrinsic element in the disease. VKC is a florid condition characterized by giant papillae found in either the upper tarsal conjunctiva or at the limbus, (Tuft SJ, 1989).
d. Giant Papillary Conjunctivitis (GPC)
It’s an iatrogenic disease associated with foreign bodies in the eye such as contact lenses, prostheses, or protruding corneal sutures of which may precipitate and perpetuate an inflammatory reaction. It has a possible allergic mechanism because of the similar to that of VKC, which clinical it resembles.
Topical treatment offers several obvious advantages. Eye drops are easily applied and seldom lead to systemic side effects. In cases where corneal involvement occurs, particularly in VKC with corneal ulcers in the visual axis, the ulcers need to be derided quickly to prevent scarring and the onset of amblyopia. Topical antibiotic may be added to the intensive topical steroid regimen while ulceration lasts.
In AKC strict attention should be paid to lid toilet in order to reduce lid crusting and possible staphylococci colonization of the lid, but the exact role of staphylococci in this condition is uncertain if blepharomeibomianitis is severe, then systemic oxytetracycline, 250mg twice a day for a month, may be needed, particularly if it is associated with a punctuate keratopathy. For GPC, removal of the allergen such as a contact lens, if necessary coupled with a mast cell stabilizer, will be sufficient. (Tuft et al, 1989).

1.1.2. BACTERIAL CONJUNCTIVITIS
Baterical such as Chlamydia trachomatis or moraxella can cause a non-oxidative but persistent conjunctivitis without much redness. This is due to common pyogenic bacteria, course marked grittiness/irritation and a stingy, opaque, grayish or yellowish mucopurulent discharge that may cause the lid to stick together, especially after sleep. Another symptom that could be caused by bacterial conjunctivitis is severe crusting of the infected eye and the surrounding skin. However contrary to popular belief, discharged is not essential to diagnosis. The gritty or scratchy feeling is sometimes localized enough for patients to insist they must have a foreign body in the eye, the eye more the acute: pyogenic infection can be painful. It usually affects only one eye but may spread easily to the other eye. Corynebacterium diphtheria causes membrane formation in conjunctiva of non-immunized children (Fisher et al, 2007).

1.1.3. STYLE
Style is usually a localized area of inflammation, but it may be associated with staphylococcal blepharitis. It is also called hordeolum is an acute staphylococcal infection of the glands of zies and moll. The lesions are often associated with fatigue, poor diet and stress can be recurrent. (Alexander 1980).
The lesion usually present as a localized area of redness tenderness, and swelling near the lid margin. The primary symptom is localized pain of recent onset. Within a few days of onset of redness and tenderness, the localized area develops a tallow point. In most cases the abscess will drain spontaneously within 3 to 4 days following pointing.
The application of not compresses several times daily will serve to hasten pointing and drainage.
Generally, this is all that is necessary for resolution; topically applied antibiotic solutions or ointments several times daily may prevent infection of surrounding lash follicles but will not affect the course of tile external hordeolum itself. (Trevor, 1974).

1.1.4. PTOSIS
Congenital as well as acquiring forms of ptosis exist (Beard et al, 1978). This is when the margin of upper eyelid covers more than 2.0mm of the superior cornea (Stasior et al, 1993). In some instance however topically applied or systemically administered medication may be of value.

1.1.5. CHALAZION
A chalazion (meibomian cyst) is a granuloma of the lipid secreting meibomain gland that lie in the lid. It is probably as a result of a blocked duct with local reaction to the accumulation of lipid (Khaw and Elkington, 2000) the patient may initially complain of a lump in the lid that is hard and inflamed. This settles and the patients is the left with a discrete blurring vision. Clinically there is a hard lump in the lid which is clearly visible when the lid is inverted.
Many Chalazion settles on conservative treatment. They comprises of warm compression (within a towel socked in warm water) and the application of chloramphenicol eye ointment. If the chalazion is uncompleted, excessively large persistent or disturbing vision, it can incised and curetted under local anesthesia, from the inner conjunctiva a side of the eyelid.

1.1.6. BLEPHARITIS
Blepharitis, an inflammatory condition associated with itches, redness, flaking, and crusting of the eyelid, it a common eye condition that affects both children and adults. It is common in all ethnic groups and across all ages. Although infrequent, blepharitis can lead to permanent alterations to the eyelid margin or vision loss from superficial keratopthy (abnormality of the cornea) corneal neovascularisation, and ulceration. Most importantly, blepharitis frequently causes significant ocular symptoms such as burning sensation, irritation, tearing, and red eyes as well as visual problems such as photophobia and blurred vision. The exact etiopathogenesis is unknown, but suspected to be multifactorial, including chronic low-grade infections of the ocular surface with bacteria infestation with certain parasites such as demodex, and inflammatory skin condition such as atopy and seborrhea.
Blepharitis can be categorized in several different ways. First, categorization is based on the length of disease process: acute or chronic blephariitis. Second, categorization is based on the anatomical location of disease; anterior, or front of the eye (e.g. staphylococcal and seborrheic blepharitis), and posterior, or back of the eye (e.g. Meibomian Gland Dysfunction MGD). (Lindsley et al, 2012).

1.1.7 TRACHOMA
Trachoma, the world’s leading cause of preventable blindness, is the subject of worldwide control efforts via the SAFE (Surgery, Antibiotic Treatment, Facial Cleanliness and Environmental improvement strategy (Bailey 2007).
Trachoma is the most common infectious regions cause of blindness worldwide. It afflicts some of the poorest regions of the globe, predominantly in Africa and Asia. The disease is initiated in early childhood by repeated infection of the ocular surface by Chlamydia Trachomatis. This triggers recurrent chronic inflammatory episodes, leading to the development of conjunctival scarring, this scar tissue contracts, distorting the eyelids (entropion) causing contract between the eyelashes and the surface of the eye (trichiasis). These compromises the cornea and blinding specification often ensure. The World Health Organization is leading global efforts to eliminate blinding Trachoma through the implementation of the SAFE strategy. This involves surgery for trichiasis, antibiotics for infection, facial cleanliness (hygiene promotion) and environmental improvement to reduce transmission of the organism. Where this programme has been fully implemented, it has met with some success. However, there are significant gaps in the evidence base and optimal management remains uncertain (Burton, 2007).

1.1.8 CONGENITAL CATARACT
Cataracts are cloudy patches in the lens of the eye that can make vision blurred or misty. They are called childhood cataracts (also known as congenital or infantile cataracts) when a child is born with cataracts in children are rare. An estimated 200 children are born with cataracts every year.
They can often be more affected than the other. The lens is normally clear, it allows light pass through the back of the eye. If parts 07 lens become cloudy (opaque) light cannot pass through the cloudy patches. Over time these cloudy patches usually become the more sight will develop. The cloudier the lens becomes the more sight will be affected. Childhood cataracts are often referred to as congenital cataracts that are present when a baby is born or shortly afterwards.
Development, infantile or juvenile cataracts are diagnosed in older babies of children, the causes of cataracts in children most cases of childhood cataracts, there is no family history and exact cause is not known, however some possible cause include genetic conditions of infections during pregnancy. Treating cataracts in a child is through surgery can be performed to remove the cloudy lens and replace it with an artificial lens. (Sethi et al, 2008).

1.1.9 BACTERIAL KERATITIS
The patients with bacterial keratitis will generally present with a unilateral, acutely painful, photophobic, intensely injected eye. Visual acuity is usually reduced, and profuse tearing is common. There will be a focal stromal infiltrate with an overlying area of epithelial excavation. Often, there will be a history of contact lens wear, which is the most common precipitating condition. Corneal trauma or preexisting keratopathy are also common participating conditions. (Bourcier et al, 2003).
Once the corneal defenses are breached, the cornea is prone to colonization and infection by pathogenic bacteria. Factors known to compromise corneal defenses include direct corneal trauma, chronic eyelid disease, systemic immune disease, tear film abnormalities affecting the ocular surface and hypoxic trauma from contact lens wear. (Schaefer et al 2001).
The most common infective organism in bacterial keratitis is staphylococcus aureus, and it appears that there is an increased incidence of Gram-positive recovery in infectious keratitis. (Alexandrakis et al, 2010). The first step in management should be to obtain corneal scrapings for microbiologic studies. If the patient has been cultured, initiate broad-spectrum and empirical antibiotic therapy prior to receiving the results, monotherapy with fluoroquinolone eye drops has been shown to result in shorter duration of intensive therapy and shorter hospital stay when compared with combined fortified therapy (tobramycin-cefazolin). (Sotozone et al, 2002).

1.1.10. UVEITIS
The term uveitis strictly means inflammation of the uvea tissue only. However, practically, there’s always some associated inflammation of the adjacent structures such as retain, vitreous, sclera and cornea. Due to close relationship of the anatomically distinct parts of the uvea tract, the inflammatory process usually tends to involve the uvea as a whole (Khurana, 2007). The type of intraocular inflammation (uveitisi) was classified according to the anatomical site of the major inflammatory manifestation and the most probable aetiological factors associated with this reaction as described earlier. Diagnosis of “posterior uveitis” (posterior segment intraocular inflammation) is made in the presence of inflammatory cells within the posterior vitreous with retinal vasculitis and/or retinal or choroids infiltrates. In eyes harbourinh anterior and posterior segment intraocular inflammatory signs, a diagnosis of “panuveitis” (Panintraocular inflammation) is made. (Block-Michel and Nussenblatt, 1987).
Bacteria is the direct and indirect cause for the intraocular inflammation in 18 children, 19.6% of the infectious causes and 6.5% of all causes. Toxoplasma was diagnosed in 20 and toxocara in 13 children. In 10 additional children, visceral larva migrans other than Toxocara were found. In all, an antihelminthic regimen combined with a short course of oral corticosteroids (prednisone 1.25 to 1.5 mg/day as starting dose tapered to discontinuation over 6 weeks) had marked beneficial therapeutic effects. (BenEzra et al, 2005). Tearing and photophobia are the presenting symptoms in 24.3% of the cases while a “red eye” was the cause for referral in 15.9% of the cases.
A drop of vision reported by the child is the symptomatic cause of referral in only 12% of the cases. Leukocorea and Strabismus were the presenting signs in 4.0% and 5.4% of the children, respectively. (BenEzra et al, 2005).

1.1.11. CORNEAL ULCER
Corneal ulcer may be caused by bacteria, viral and fungal infections. This may occur due to abrasions, contact lens wears or use of topical steroids. Pain is usually a prominent feature as the cornea is an exquisitely sensitive organ. There may be clues such as similar past attacks, facial cold sores, recent abrasion or the wearing of contact lenses.
Visual acuity depends on the location and size of the ulcer, and normal visual acuity does not exclude on ulcer. There may be a watery discharge due to reflex lacrimation or a conjunctival injection might be generalized or localized. If the ulcer is peripheral, giving a due to its presence. Flourescein must to be used or an ulcer may easily be missed (Khaw and Elkington, 2000).
Patients with corneal ulceration should be referred urgently to an eye department or the eye may be lost. The appropriate swabs and cultures should be arranged to try to identify the causative organism.

1.1.12. DACRYOCYSTITIS
The primary etiology of dacryo-cystitis is nasolacrimal apparatus obstruction secondary to muscocele of the lacrimal sac which is precipitated by chronic blockage of the interosseous or intermenbraneous nasolacrimal duct. (Grove, 1991). Infantile dacryosystitis is uncommon but presents with the same signs and symptoms. A study examining the most frequently recovered anaeorbes from dacryo-cystitis reported pepto-streptococcus spp. Prospionibacterium spp., prevotella spp., and Fusobacterium spp., as the most frequently associated pathogens. (Brook, 2001).
The signs symptoms are pain, redness and swelling over the inner aspect of the lower eyelid and epiphora may signify aggravated blepharitis, meibomianitis or canaliculitis. If the problem becomes recurrent, associated with fever and severe erythematous swelling around the nasal aspect of the lower lid involving the lactrimal sac such that a mucopurulent discharge can be expressed from the inferior punctum when pressure is applied, the suspicion of dacryocystiti should be high (Morgan, 2004).
Management of the nonferbrile child includes oral amoxicillin/clavulanate (Augmentin, GlaxoSmithKline) 20-40amg/kg/day, po, tid or oral cefaclor 204mgs/kg/day pot id, alone with topical antibiotic drops tid, ointments, bid, warm compresses and acetaminophen.
1.1.13 BRIEF DESCRIPTION OF THE RESEARCH AREA
Owerri municipal is a local government area of Owerri in Imo State, Nigeria. Oweri is the capital of Imo State in Nigeria, set in the heart of Igboland. Imo State which is the eastern heart land of Nigeria. Owerri is borded by the Otamiri River to the eats and the Nworie River to the South. The headquarters of Owerri municipal are in the city of Owerri.
Owerri municipal has an area of 58km2 and a population of 127,213 as at the 2006 census. The postal code of the area if 460. The area code of Owerri is 083. Owerri municipal has urban setting with one autonomous community made of five (5) indigenous kindred (Owerre nchi ise) vis: Umuoronjo, Amawom, Umuodu, Umuonyeche and Umuoyima, under the leadership of one of paramount traditional ruler, presently Eze Dr. Emmanuel Emenyeonu Njamanze Ozuruigbo V. There are about a total of thirty five (35) primary school in Owerri Municipal, private and public.

1.2 STATEMENT OF THE PROBLEM
Eye disease is one of the major causes of reduced vision and blindness in Nigeria school children. Series of works have been undertaken by some researcher in the last century on the incidence prevalence distribution of eye diseases, yet the prevalence of eye diseases amongst primary school children has not been analyzed in details due to variations in geographical, environmental, rural age, school and development level among other factors of distribution from country to country.
This study will therefore check if the prevalence of eye diseases amongst primary school children can rule out the eye health status of the school children and also determine the effect of the appropriate treatment measures of these diseases. “

1.3 AIMS AND OBJECTIVES OF THE STUDY
AIM
To determine the most prevalent eye diseases amongst primary school pupils in Owerri municipal.
OBJECTIVES
1. To determine if age have effect on the prevalence of eye diseases in school children.
2. To determine if gender have effect on the prevalence of eye diseases in school children.
3. To determine the effect of eye disease on the visual function of primary school children.
4. To determine the appropriate treatment measures of these disease.

1.4 RESEARCH QUESTIONS
1. What is the rate of occurrence of the eye diseases amongst boys and girls in primary school in Owerri municipal?
2. What is the prevalence of eye diseases amongst primary school pupils in Owerri municipal.

1.5 SIGNIFICANCE OF THE STUDY
Knowledge of the prevalence of eye disease amongst primary school pupils will be important to the society at large in the following ways:
1. To parents, pupils and teachers, it will inform them of the effect of these eye diseases on the pupils thereby encouraging them to seek for professional advice whenever the need arises and for the pupil to be conscious of their eye.
2. The result of this study will form appraisal for the assessment of eye care services in our society and further stress the need for regular visual screening exercise in our schools.
3. It will help eye care practitioners with knowledge of the eye disease in the area thereby preparing them for any in future.
4. The result of this study could be used especially by the ministry of Health and Ministry of Education to compute data for necessary control and management.

1.6 SCOPE OF THE STUDY
1. Study will be based on screening primary school children in some selected primary schools in Owerri Municiapl to classify them in various groups of eye diseases.
2. This study will further involve the number of school children in selected five (5) schools in Owerri Municipal.

1.7 APPROACH OF THE PROBLEM
This research will be based on determining the prevalence of eye diseases amongst primary school children in Owerri Municipal, Owerri, Imo State.
Case history of school children will be taken, visual acuity, external examination will be done to examine the ocular adnexa of every children also ophthalmosocopy to check the fundus background will be used to determine the prevalence and percentage of eye disease amongst these school children in Owerri Municipal.