Visual Impairments and Eye Morbidities among School-age Children (5 to 18 Years old) Qualitative Assessment in Dubai, UAE, 2016
, Al Abadi K2
, Hussein HY3
, Al Faisal W3
, Wasiful Alam M2
, AlBehandy NS3
Primary Health Care Services Sector, Dubai Health Authority, Dubai, UAE.
2 Public Health and Safety Department, Dubai Health Authority, Dubai, UAE.
3.Health Affairs Department, Primary Health Care Services Sector, Dubai Health Authority, Dubai, UAE.
Background: Refractive errors are common in children and are the commonest cause of visual impairment around the world and the
second leading cause of treatable blindness. As children progress in school, they face increasing demands on their visual abilities. Vision
problems are common among school-age kids. According to Prevent Blindness America, one in four school-age children have vision
problems that, if left untreated, can affect learning ability, personality and adjustment in school. Therefore, it is crucial to protect school
aged children 5-18 sight.
Objective: To assess the extent of visual impairment and ocular morbidity and to identify influencing factors and key challenges for eye
vision among school-aged children 5–18 years in Dubai. It is of particular importance to understand their needs and assess any gaps in
eye care or services.
Methodology: Data sources are qualitative and quantitative. Qualitative source was from an in–depth interview with school health
doctors, focusing on different eye health topics, and on how eye health problems vary within different age groups, nationalities, gender
and other confounders. Quantitative data were derived from the official school health annual reports in concerns with student’s eye
Results: Vision problems are common among school-age kids. School health officials said that in one of population-based crosssectional
survey which was undertaken among 266343 students in Dubai, it was shown that there were 1008 cases of visual disorders
in 2015-2016 academic years (3.8 per one thousand), whom they were diagnosed by ophthalmologists and enrolled in management
program. Refractive errors are the most common cause of vision problems among school-age children in Dubai private schools. The
main types of refractive errors are myopia (near sightedness), hyperopia (far sightedness), presbyopia (loss of near vision with age),
and astigmatism. There are many environmental and genetics factors play a role in the development of vision disorders in children
such as: family history, and premature birth. A number of neurodevelopment disorders (e.g., cerebral palsy, Down syndrome, autism
spectrum disorders, hearing impairment and speech delay) also are associated with higher rates of vision problems. The most significant
preventable risk factor for visual disorders in children is maternal smoking. Children of women who smoked cigarettes during pregnancy
have higher rates of strabismus, hyperopic, and astigmatism.
Conclusion: The study concluded that visual impairments among school age children is not uncommon, most of the time under estimated
and has not been screened systematically. Visual assessments at school level is not efficient enough to tackle visual impairment cases at
earlier stages. Services wise, visual impairments at school level are underserved as based on absent of comprehensive and structured visual
health program. School Eye health program and services with full component (early detection, management, awareness, monitoring) are
of priority to be addressed for students in Dubai schools.
Visual Impairment, School Age, Dubai, Qualitative assessment
Conflict of interest:
The authors declare that they do not have any conflict of interest.
The estimated number of people visually impaired in the world
is 285 million, 39 million blind and 246 million having low
vision;  It is estimated that about 153 million people around
the world are visually impaired because of uncorrected refractive
errors.  It seems that these errors are the commonest cause
of visual impairment and the second leading cause of treatable
blindness. [3,4] Globally the principal causes of visual impairment
are uncorrected refractive errors and cataracts, 43% and 33 %
respectively. Other causes are glaucoma, 2%, age related macular
degeneration (AMD), diabetic retinopathy, trachoma and corneal
opacities, all about 1%. A large proportion of causes, 18%, are
Eye health problems are common among school age children.
Demands are increasing as children progress in the school. Poor
vision may influence the child’s performance in school and has a
negative impact on his or her future life in terms of affecting the
child’s personality and adjustment in school. 
It has been estimated that as much as 80% of the learning a child
does occurs through his or her eyes. Reading, writing, chalkboard
work, and using computers are among the visual tasks students
perform daily. A child’s eyes are constantly in use in the classroom
and at play. When his or her vision is not functioning properly,
education and participation in sports can suffer. 
Hence it is recommended by the World Health Organization
(WHO) to integrate vision screening and refractive services for
school students within screening for other health issues, and to
have control of blindness in children as one of the priority areas in
“Vision 2020— the right to sight” program. [6-9]
Situation analysis of eye health in Dubai is very important. It
is essential to have up to date information on prevalence and on
causes of visual impairment.  Decision makers will be able to
set priorities and plan for the appropriate policies and strategies
for the prevention of visual impairment and the improvement of
eye health. The aim of this work is to provide an overview of eye
health among school aged children for policy makers in Dubai to
make informed decisions.
To assess the extent of visual impairment and ocular morbidity;
and to identify influencing factors and key challenges for eye
vision among school-aged children 5–18 years in Dubai. It is of
particular importance to understand their needs and assess any
gaps in eye care or services.
Data sources are qualitative and quantitative. Qualitative source
was from semi structured in–depth interview with school health
doctors, focusing on different eye health topics, and on how eye
health problems vary within different age groups, nationalities,
gender and other confounders. Quantitative data were derived
from the official school health annual reports in concerns with
student’s eye morbidities.
A qualitative data collection method, in-depth interviews offer
the opportunity to capture rich, descriptive data about people’s
behaviours, attitudes and perceptions, and unfolding complex
processes. An in-depth interview is a loosely structured interview.
It allows freedom for both the interviewer and the interviewee to
explore additional points and change direction, if necessary. 
The interview is conducted using a discussion guide, which
facilitates the flushing out of the respondent’s views through openended
questioning. We have used this method because the depth
discussion might explore topics that were previously unknown
thereby identifying new issues or perspectives on the eye health
topics among school-aged children in Dubai. For the evaluation
of school-aged vision in Dubai, we invited experts in the field of
Guide of the discussion consisted of different topics and openended
questions with accompanying queries that probe for more
detailed and contextual data. The questions were relevant to vision
for school-aged children in Dubai, such as:
• What are the main eye conditions among school-aged children?
How these vary by age, gender, nationalities?
• What are the main risk factors for eye health problems?
• What are the main health care services? How these services can
• What is your opinion regarding screening: Childhood visual
screening (Pre-school screening, Screening in school-aged
• What is your opinion regarding awareness and training: Target,
families, schools medical staff, teachers, students etc.
• How can eye health intelligence data improved?
Data of the interviews were audio recorded, transcribed and
analysed. With these data, the 5-step method of data analysis
developed by McCracken for long interviews was used. 
The results of the in-depth discussions held with school health
experts who work routinely with school health services in Dubai
highlighted key issues that are relevant for vision care to schoolaged
children. The results can help decision makers to take further
actions and to make appropriate decisions about improving the
services in future.
School health care services in Dubai are divided between public
and private sectors. The Ministry of Health (MoH) covers the public schools while Dubai Health Authority (DHA) covers the
private schools. There are around 81 public schools and 186 private
schools in Dubai. The estimated number of children in public
school is around 30,000, and the number of children at private
school is approximately 266343 (School Health Annual Report,
2015-2016). The estimated total population in 2016 for Dubai is
2,568,300 (Dubai Statistics Center). Therefore, the school-aged
children represent almost 11.5% of the total population. Overall,
there are 6 out of 186 (3.2%) DHA-supervised special needs
schools to accommodate children with special educational needs
(SEN) including children suffering from eye disorder as primary
or secondary causes. Children with moderate to severe disability
are enrolled in such schools settings.
The Primary Health Care Services Sector (PHCSS) of Dubai Health
Authority has a Schools and Educational Institutions Health Unit
(SEIHU) that provide school health services to private schools
in Dubai. The school health services aim to assist school-aged
children to grow and develop into healthy adults by encouraging
healthy lifestyles, conducting health assessments, administering
immunisations and by providing support and advice at school,
and annual updates and supervision. The team has the knowledge
and skills of child health development to ensure that assessment,
promotion and monitoring of children’s health development is in
line with local and federal guidelines.
The school health team play also important role in developing
guidelines, policies, training, and auditing to protect and improve
child health. It has a duty to safeguard and promote the health
of children at private schools. Each school has a medical team
managed directly by the school while DHA supervise their work.
The medical team at each school consists of a nurse and a doctor.
There are regulations that schools have to abide by a minimum
number of healthcare professionals on site. In Dubai, that means
one full-time nurse for schools with up to 500 children, two fulltime
nurses for schools with 500-2000 children, and one additional
full-time nurse for every additional 1,000 children for schools with
more than 2,000 pupils. Regarding physicians, the schools should
have one part time physician for schools with up to 750 children,
one full-time physician for schools with 750-2000 children, and
two full time physicians for schools with more than 2,000 pupils.
(WEYAK initiative, Health Regulation Department, DHA). In
addition to that, in each school there is a “coordinator school health
program”. One of the competences of such program is to have a
counsellor position. People who fulfil such positions should have
the knowledge and skills necessary to integrate schools health,
mental health, and safety programs and carry a psychology degree
to provide psychological and social support and enable them to
tackle any issues such as bulling of students complaining from
School health official said that in one of population-based crosssectional
which study was undertaken among 266343 students in
Dubai, it was shown that there were about 1008 case of visual
disorders in 2015-2016 academic years (3.8 per one thousand) as
shown in figure (1) and Table (1), whom they were diagnosed by
Vision problems are common among school-age kids. Refractive errors are the most common cause of vision problems among schoolage
children in Dubai private schools. Refractive error means that the shape of your eye does not bend light correctly, resulting in a
Another screening program showed that about 38.9% of the total screened students visually assessed were having error of refraction, and
about 42% of students with error of refractions are wearing glasses, while about 16.4% of total students examined were being wearing
glasses as reflected by table (2).
Distribution of visually assessed students according to presence of error of refractions and wearing glasses
The main types of refractive errors are myopia (near sightedness), hyperopia (far sightedness), presbyopia (loss of near vision with age),
and astigmatism. Another condition is amblyopia (Sometimes called “lazy eyes”). Vision loss occurs because nerve pathways between
the brain and the eye are not properly stimulated.
The screening conducted in Dubai private schools revealed that the common error of refractions identified among the sample were (myopia
(9.8%), hypermetropia (4.8%), astigmatism (43.9%) as shown in table (3).
Distribution of the types of error of refraction among visually screened students
Vision problems in children tend to emerge between 18 months
and 4 years old and frequently seen at grades 1, 2, 3, or 4. It is often
detected through school doctor, paediatrician, the school nurse, or
an eye specialist. In addition to that, the teacher might identify
vision problems among school-age children as they are having a
hard time seeing the blackboard (near sighted) or they are having a
hard time reading up close (far sighted).
There are many environmental and genetics factors play a role in
the development of vision disorders in children such as:
• Family history of refractive error is a risk factor for children to
develop vision disorder.
• Premature birth might cause retinopathy of prematurity (ROP).
It usually affects both eyes and is the main reason children have
• A number of neurodevelopment disorders (e.g., cerebral palsy,
Down syndrome, autism spectrum disorders, hearing impairment
and speech delay) also are associated with higher rates of vision
• The most significant preventable risk factor for visual disorders
in children is maternal smoking. Children of women who smoked
cigarettes during pregnancy have higher rates of strabismus,
hyperopic, and astigmatism.
Therefore, family history of eye problems together with eye exams
for children is extremely important to identify vision problems as
early as possible.
School-aged children 5-18 years of age, at private schools in Dubai
receive four comprehensive medical check-up during different
stages while they are attending schools. The medical assessment
covers general health, medical examinations including eye and
hearing examination. It is done at grades 1, 5, 9, and 12, and it
includes a number of tests and procedures to evaluate the eyes.
Students with visual issues may be referred to a secondary care
professional or through communication with his family members
to resolve the issue.
However, these periodic medical examination results may not be
of high quality because it is not monitored closely or evaluated by
a third party or an ophthalmologists; therefore leaving a question
mark on its data provided. It is necessary to offer vision-screening
programs as early as possible i.e. pre-school vision screening or
even earlier than this. It is an efficient and cost-effective method
to identify children with vision problems as early as possible.
Children have different eye health needs than adults; some eye
problems can become irreversible once a child is older.  The
results of the eye screening proposed program could be better if it
is being delivered by independent party such as Al Jaber optical,
Noor Dubai or others.
The eye health awareness is important to promote eye health for
school-aged children. The eye care awareness/programs target
school children, teachers, and families. Awareness programs focus
on the need of each of the three-targeted groups. For example, the
awareness campaigns for families should highlight the benefits
of early detection and treatment. In addition, families’ awareness
about the risk factors for avoidable blindness and vision loss is
also important. It should target families who have history of vision
impairment. Eye health education is among the most important
components of the coordinated school health program in Dubai.
However, there are substantial differences between schools in
delivering eye health education. Hence, school nurses and teachers
require further and continuous training how to detect vision
problems in students.
Children with glasses or vision impairment are at increased risk
of bullying in school. There are sporadic cases in Dubai but are
managed well. The school teachers/nurses are trained enough to
The schools collect visual information on each child. However,
these records are stored as paper records. One of the major tasks that
schools should accomplish is the converting of all the information
in paper medical records to electronic medical records. This will
help in conducting research and better understanding of overall
eye health problems or any other medical issues. In addition to
that it is also required to conduct periodically surveys to assess
visual impairment in children attending schools in align with other
health topics which will help to understand other vision issues
not possibly measured through health registries i.e. measure care
satisfactions, etiological factors, etc.
The study revealed significant eye impairment among students
in Dubai schools. When derived from school student files, it was
found that they are much less than percentages found in other
studies like the one conducted in India in 2011 and showed high
eye morbidities. 
Other studies conducted in many other countries reported high
prevalence of eye morbidities among primary schools students
compared to our current study. Examples are the study of primary
school children between 6 and 14 years of age in the rural Tibetan
area of Maqin County, China, reports that 18.36% had ocular
morbidity. Refractive errors were found in 11.07%, strabismus
in 2.49%, corneal leukoma in 1.20%, amblyopia in 1.02%, and
vernal conjunctivitis in 0.65%. Monocular blindness was seen in
Among the school children aged 5 to 10 years in Kolkata a study
showed that 25.11% had refractive errors, myopia being the
commonest (14.02%); astigmatism affected 3.93%. The prevalence
of refractive errors increased with age with no difference of
refractive errors between boys and girls. 
A study of school children 7 to 15 years of age showed that the
prevalence of uncorrected (unaided), presenting, and best-corrected
visual impairment (visual acuity < or =20/40 in the better eye) was
17.1%, 10.1%, and 1.4%, respectively. In eyes with reduced vision,
refractive error was the cause in 87.0%, amblyopia in 2.0%, other
causes in 0.6%, and unexplained causes in 10.4%. Myopia was
present in 9.8% of children seven years of age, increasing to 34.4%
in 15-year-olds; and hyperopia in 10.0% and 32.5%, respectively”.
Myopia was associated with older age, female gender. 
A study from the Darjeeling district of West Bengal noted a
prevalence of abnormal Visual Acuity (VA) (< 20/30 in any eye)
of 3.65% and it was highest in the seven to eight years age group
in both the sexes contributing to 75% of the total students having
abnormal VA. Prevalence of Vitamin A deficiency was 8.16%.
Prevalence of Bitot’s spot was 3.63%; females outnumbered the
males.  School children 5-15 years of age, screened for eye morbidity,
revealed that trachoma (18%) was the most common ocular morbidity followed by vitamin A deficiency (10.6%), refractive error (7.4%) and apparent / latent squint (7.4%). 
In an Iranian study it was shown that the prevalence of myopia,
hyperopia and astigmatism was 29.3% [95% confidence interval
(CI), 25-33.6%], 21.7% (95%CI, 17.8-25.5%), and 20.7%
(95%CI, 16.9-24.6%), respectively. The prevalence of myopia
increased significantly with age [odds ratio (OR)=1.30, P=0.003]
and was higher among boys (OR=3.10, P<0.001). The prevalence
of hyperopia was significantly higher in girls (OR=0.49, P=0.003).
The prevalence of astigmatism was 25.9% in boys and 15.8%
in girls (OR=2.13, P=0.002). The overall prevalence of high
myopia and high hyperopia were 0.5% and 1.2%, respectively.
The prevalence of with-the-rule, against-the-rule, and oblique
astigmatism was 14.5%, 4.8% and 1.4%, respectively. Overall,
4.6% (95%CI, 2.6-6.6%) of subjects were anisometropic. 
This in-depth interview with experts working with school-aged
children revealed four top priorities for improving eye care for
school-aged children. The first of these priorities is the importance
of gathering routine information for eye care, which includes
establishing health registries at schools. The current paper based
healthcare records are not reliable source of data to detect the main
vision problems or identify the group of children at higher risk
than others and does not support research easily.
Dubai Health Authority has successfully invested in a new
system named Panorama, which has two components, computer
system as a public health management solution, and smart phone
application. Panorama system supports service providers and
public health decision makers with good solutions for public
health management. The tool will support health professionals
with information regarding eye health or other health issues.
On the other hand, the schools should implement a new healthcare
records management strategy shifting from paper records to
electronic records in align with the new DHA medical electronic
records system (EMR). Recently, Noor Dubai agreed to lead on
the eye awareness programs for the schools, this is an excellent
achievement for the schools as Noor Dubai has lot of experience
in eye care and awareness programs. We need to ensure that these
programs target families, students, teachers and nurses.
It is important to have a national or local eye screening service
for all children between the ages of 4-5 years. Detection of eye
problems in the very young and pre-school child requires expert
clinical examination. Therefore, this should be an Ophthalmologist led service. Finally, it is relevant to assess whether it is feasible to
develop a local high quality services in Dubai for children with
eye impairment or other special needs in the community. This will
strengthen the capacity of the childcare in addition to the care they
received at schools of special needs.
The study concluded that visual impairments among school age
children is not uncommon, most of the time under estimated and
has not been screened systematically. Visual assessments at school
level is not efficient enough to tackle visual impairment cases at
earlier stages. Services wise, visual impairments at school level are
underserved as based on absent of comprehensive and structured
visual health program. School Eye health program and services
with full component (early detection, management, awareness,
monitoring) are of priority to be addressed for students in Dubai
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