Eye diseases in children are a significant cause of visual disability, impacting development, education, future work, and quality of life. Pediatric ocular morbidities present unique challenges due to children’s limited ability to express symptoms and the risk of developing amblyopia. Although many ocular conditions are preventable or treatable, lack of awareness and delayed detection can result in irreversible visual impairment or blindness.1 Globally, childhood blindness is considered a priority due to the potential years of blindness that follow, highlighting the need for early diagnosis and intervention.2

The epidemiological pattern of pediatric eye diseases varies across regions. In developing countries, infections and malnutrition are predominant causes, while optic nerve lesions and retinal disorders are more common in developed nations. However, refractive errors remain the leading cause of visual impairment globally. Additional disorders include Vitamin A deficiency, cataract, conjunctivitis, squint, trauma, and amblyopia.3 Refractive errors and childhood cataracts are priority areas under various initiatives by the World Health Organization (WHO), aimed at eliminating avoidable blindness.4

While several international studies address the prevalence of ocular diseases among children, Indian research is often limited to isolated conditions such as squint, ocular trauma, or refractive errors. Comprehensive studies encompassing all pediatric ocular morbidities remain scarce, creating a gap in understanding the overall profile of pediatric eye diseases in India.

A thorough investigation into all pediatric ocular diseases is essential to establish baseline data for effective planning of child eye care services. Understanding the disease profile will aid in resource allocation, prioritization of interventions, and formulation of prevention and control measures. The current study aims to address this gap by providing a comprehensive overview of ocular diseases causing morbidity in the pediatric population.

The prospective observational study was conducted at Sri Chamundeshwari Medical College Hospital & Research Institute, Channapatna, involving pediatric patients aged 0 to 18 years with ocular complaints attending the Ophthalmology Outpatient Department. The study period was for 12 months, with a minimum sample size of 200 patients, accounting for a 20% dropout rate from an estimated monthly turnout of 20 patients.

Detailed clinical histories were recorded, including chief complaints, presenting illness, antenatal, natal, postnatal history, family history, and personal history. Visual acuity was assessed using age-appropriate methods like Snellen’s chart, Kay pictures, and CSM method. Refraction was performed under cycloplegia with cyclopentolate 1% eye drops, and anterior segment examination was done with a torch and slit lamp biomicroscope. Fundus examination utilized indirect ophthalmoscopy and slit lamp biomicroscopy, while intraocular pressure was measured using Goldman applanation tonometry, non-contact tonometer, or tonopen. Squint assessment was performed using prisms and stereopsis tests.

Patients received treatment including glasses, medical management, or surgical interventions, with a six-month follow-up period. Visual acuity was classified into five categories from 6/6-6/18 to No perception of light. Surgical outcomes were categorized by deviation angles as Good (Orthophoric or <10 PD), Satisfactory (10-20 PD), and Poor (>20 PD), with success defined as ≤10 PD deviation. Amblyopia treatment outcomes were labeled as Good (improvement by two lines or more), Satisfactory (one line improvement), or Poor (no improvement).

The details compiled from the selected cases were documented in Microsoft Excel. Descriptive statistics, such as means and standard deviations, were used to represent continuous data, while categorical data was expressed in frequencies and proportions. Statistical analysis was carried out using SPSS-Software version 26, employing appropriate tests of significance based on the nature of the data. A p-value below 0.05 was considered statistically significant, with adherence to all relevant rules of statistical tests.

Our study encompassing 200 pediatric patients, the age group of 7 to 12 years constituted the largest proportion, accounting for 42.0% of the total cohort, highlighting that middle childhood is a predominant period for presenting ocular morbidities. Regarding gender distribution, males outnumbered females, representing 58.5% compared to 41.5%, indicating a modest male predominance among pediatric patients presenting with ocular complaints. (Table 1)

Table 1: Characteristics of the study subjects

An assessment of visual acuity revealed that the majority had relatively good vision, with 74.0% of better eyes achieving visual acuity between 6/6 and 6/18. A similar trend was observed individually for the right and left eyes, with 69.0% and 70.5% respectively falling within this range. Only, about one-fifth of eyes (approximately 22.0%) had visual acuity that could not be converted to Snellen equivalent, likely due to age-related or developmental limitations in cooperation. (Table 2)

Table 2: Visual acuity of the study subjects

In our study, the most frequently diagnosed ocular condition was refractive error, accounting for 26.0% of all ocular morbidities. Conjunctival disorders followed next at 17.0%, reflecting common external eye diseases in the pediatric group. Disorders involving the adnexa and normal findings each contributed to 13.0%, whereas squint was noted in 9.0% of cases. Corneal disorders, retina and optic nerve disorders, and cataracts were less common, each constituting between 6.0% and 6.5% of the distribution. Glaucoma and miscellaneous others were very rare, together comprising less than 3%. (Figure 1)

When ocular disorders were stratified according to age, refractive errors were predominantly seen in the 7 to 12 years group (53.8%), followed by adolescents aged 13 to 18 years (34.7%), and least in 0 to 6 years (11.5%). Squint and cataracts showed an opposite trend, being most frequent in younger children aged 0 to 6 years (55.6% for squint and 58.3% for cataract). As age increased, the incidence of these disorders declined considerably. This pattern emphasizes the different developmental and physiological vulnerabilities across pediatric age groups. (Table 3)

Table 3: Age-wise distribution of ocular disorder

Upon gender-wise analysis, a consistent male predominance was observed across most categories of ocular morbidity. Males represented a greater proportion in conjunctival disorders (70.6%), retina and optic nerve disorders (69.2%), squint (66.7%), cataract (66.7%), and refractive errors (55.8%). Even for adnexal pathologies and normal findings, males had slightly higher numbers compared to females. Notably, the only case of glaucoma was reported in a male child. Although females were affected across categories, they were comparatively fewer in number. (Table 4)

Table 4: Gender-wise distribution of ocular disorder

Among 14 subjects diagnosed with amblyopia, the isometropic type was the most common, accounting for 50.0%, followed by anisometropic amblyopia at 35.7%, and strabismic amblyopia at 14.3%. Notably, there were no cases of stimulation deprivation amblyopia in this study group. Regarding the underlying causes, refractive errors emerged as the primary contributor, responsible for 71.4% of amblyopia cases, while squint and cataract accounted for 21.4% and 7.2%, respectively. The absence of amblyopia due to ptosis or other deprivation causes is noteworthy. (Table 5)

Table 5: Details regarding amblyopia among the study subjects

Regarding the management strategies adopted, medical treatment constituted the highest proportion at 29.5%, followed closely by prescription of glasses in 26% of children. Observation without immediate intervention was chosen in 24% of cases, and surgical management was required in 11.5%. A smaller group, 9%, needed referral for specialized care or further evaluation. This pattern reflects a conservative approach predominantly favoring non-invasive treatments, with surgical intervention reserved for select indications. (Figure 2)

Among the 23 children who underwent surgical procedures, outcomes were predominantly favorable. A majority, 78.3%, achieved good surgical outcomes as per the deviation angle criteria, while 13% had satisfactory outcomes, and a minor fraction, 8.7%, had poor results. The high success rate with surgical interventions reflects the effectiveness of the chosen surgical techniques and postoperative management protocols. Only a small percentage failed to achieve desired outcomes, possibly due to factors like late presentation or complex underlying pathology. (Figure 3)

Our study with prospective observational design was conducted over 12 months, enrolling pediatric patients aged 0–18 years with ocular complaints. A minimum sample size of 200 was targeted, accounting for a 20% dropout. Comprehensive clinical histories were recorded, and visual acuity assessed using age-appropriate methods. Cycloplegic refraction, anterior segment examination with slit lamp biomicroscopy, fundus evaluation via indirect ophthalmoscopy, intraocular pressure measurement, and squint assessments were performed. Treatment included glasses, medical management, surgical intervention, or observation, with a six-month follow-up. Surgical outcomes were categorized as good, satisfactory, or poor.

Characteristics of study subjects

Our study included 200 children aged 0–18 years, with the largest group between 7–12 years (42%) and a male predominance of 58.5% compared to 41.5% females. Agrawal D et al.5 in a previous study assessed 1557 children aged 5–15 years with a mean age of 10.3 years, reporting a female predominance of 55.6%. Similarly, Rao GN et al.6 evaluated 633 children aged 6–17 years and found a slight female majority at 53.97%. In contrast, Dube M et al.7 observed 1276 children aged 7–14 years and noted 60.4% belonged to the 11–14 years group with males comprising 55.9%, consistent with our findings. Kelkar J et al.8 studied a younger cohort, with 50.19% being ≤5 years old and 57.07% males. Kemmanu V et al.9 analyzed a rural cohort where 61% of blind children were males, although overall gender breakdown was not elaborated. Although previous studies varied in age profiles, a general trend of male predominance was consistent with our findings except in Agrawal D et al.5 and Rao GN et al.6, who reported higher female participation, suggesting that male dominance in ocular morbidity is common in hospital-based studies, while community-based assessments may reveal greater female representation.

Visual acuity distribution

In our study, 74% of children demonstrated visual acuity between 6/6 and 6/18 in the better eye, with 1.5% having moderate visual impairment (6/21–6/60) and 2.5% with severe impairment (5/60–1/60), while 0.5% had no light perception. Agrawal D et al.5 evaluated VA using Snellen charts but did not present category-wise data. Dube M et al.7 mentioned further evaluating children with VA less than 6/9 without detailed categorization. Kelkar J et al.8 found 58.57% of eyes had BCVA ≥20/60, with 5.22% between <20/60 to 20/200, and a large proportion (35.16%) with indeterminable vision due to young age. Kemmanu V et al.9 primarily focused on identifying blindness, reporting 0.08% blindness (VA <3/60) without detailed acuity breakdowns. Rao GN et al.6 identified refractive errors among those with VA worse than 6/9 but lacked detailed classification. Compared to previous studies, our study was unique in comprehensively detailing Snellen visual acuity ranges, offering a richer understanding of baseline vision status among children, which most previous studies broadly assessed without in-depth stratification.

Ocular morbidity

In our study, refractive errors were the most common ocular disorder (26%), followed by conjunctival disorders (17%) and squint (9%). Agrawal D et al.5 reported vitamin A deficiency (10%) as the leading disorder, followed by refractive errors (5.2%), differing from our pattern. Dube M et al.7 reported a very high prevalence of refractive errors (51.1%), with infections at 18.8%, while Kelkar J et al.8 found refractive errors to be 28.97%, followed by allergic conjunctivitis (7.64%). In contrast, Kemmanu V et al.9 noted Bitot spots (1%) as the most common morbidity, with refractive errors accounting for only 0.6%. Rao GN et al.6 documented refractive errors in 54.62%, followed by congenital abnormalities (9%) and allergic conjunctivitis (8.52%). While minor variations existed, previous studies largely corroborated the prominence of refractive errors as a significant morbidity, except Kemmanu V et al.9, reflecting the influence of rural malnutrition and public health disparities on ocular health patterns.

Age-wise distribution of ocular disorder

Our study found that refractive errors were most prevalent in the 7–12 years group (53.8%), while squint (55.6%) and cataracts (58.3%) were commoner in the 0–6 years group. Agrawal D et al.5 also observed higher refractive errors in older children (11–15 years), resembling our findings. Similarly, Dube M et al.7 reported a higher incidence of refractive errors and neuro-ophthalmological disorders in the 11–14 years group. Kelkar J et al.8 found that refractive errors were higher in the 5–10 years group than in younger children, although disorders like squint showed a more even age distribution. Kemmanu V et al.9 demonstrated a rise in myopia with increasing age from 0.08% in ≤5 years to 1.02% in 11–15 years. Rao GN et al.6 noted an increase in refractive errors, trauma, and congenital anomalies with age. Across all previous studies, age-dependent trends were evident, and our study aligned with this broad pattern showing that refractive errors increasingly burden school-aged and adolescent children, whereas congenital and developmental ocular disorders manifest earlier in life.

Gender-wise distribution of ocular disorder

In our study, males had a higher prevalence across almost all ocular disorders, including squint (66.7%) and cataract (58.3%). Agrawal D et al.5 similarly found that boys had a higher overall morbidity (25.3%) compared to girls (18%), with notable male predominance in color blindness (6.6% vs. 0.7%). Dube M et al.7 identified that males had higher infection rates, while refractive errors were comparable between sexes. Kelkar J et al.8 reported a male preponderance overall but did not specify disorder-specific gender differences. Kemmanu V et al.9 mentioned that among blind children, 61% were male. Interestingly, Rao GN et al.6 observed a higher prevalence of refractive errors, congenital abnormalities, and squint among females. This pattern indicates that while our study corroborates findings from most previous studies showing male predominance, regional differences like those highlighted by Rao GN et al.6 underscore that female preponderance in specific morbidities may arise depending on community health access and biological susceptibility.

Our study comprehensively highlights that refractive errors are the leading cause of pediatric ocular morbidity, predominantly affecting children aged 7–12 years, with a notable male preponderance. Most children maintained good visual acuity, and early medical or optical interventions were sufficient in the majority. Amblyopia was primarily attributed to uncorrected refractive errors. Surgical interventions, when required, yielded excellent outcomes. These findings align with the study objective of providing an overview of pediatric ocular diseases, underscoring the importance of early detection, timely treatment, and targeted screening programs to reduce preventable visual impairment in children.

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