ADDIS ABABA UNIVERSITY

COLLEGE OF HEALTH SCIENCES SCHOOL OF MEDICINE

DEPARTMENT OF OPHTHALMOLOGY

Prevalence and pattern of strabismus

among primary school students in Butajira
town, Ethiopia.

BY- TIGIST TESFAYE, MD

Ophthalmology resident

ADVISOR- ZELALEM GIZACHEW, MD

Assistant Professor of Ophthalmology

Addis Ababa, Ethiopia

 Contents

Introduction

Significance of the study

Literature Review

Objective of the study

General Objective
Specific Objective

Subjects and Methods

Data collection and Analysis

Ethical Consideration
INTRODUCTION

The term strabismus is derived from the Greek word strabismos—“to squint, to look
obliquely or askance”—and means ocular misalignment.(1) The prevalence of strabismus
varies in different parts of the world.

Worldwide prevalence of strabismus in the general population is about 3-5%(2) but studies in
Africa show that the prevalence of strabismus among Africans is lower.(3-7)

Amblyopia is a unilateral or, less commonly, bilateral reduction of best-corrected visual

acuity that cannot be attributed directly to the effect of any structural abnormality of the eye
or visual pathways.(1) Amblyopia is responsible for more cases of childhood-onset unilateral
decreased vision than all other causes combined.(1) Amblyopic vision loss is preventable or
reversible with timely detection and intervention. Thus, it is important that children with or at
risk for amblyopia be identified at a young age, when the prognosis for successful treatment
is best.

Strabismus is the most common amblyogenic factor. Approximately 40% of children with
manifest strabismus have amblyopia.(1,8) Children with strabismus and/or amblyopia will
lack the ability to fully develop binocular single vision if left untreated and may have an
impaired reading performance at school.

They may have difficulties later in life as they may not be able to join professions for which
binocular single vision is required. In addition, children and adults with strabismus often
suffer from several psychosocial and emotional consequences with poor self-image, negative
social bias and ridicule at school..

Despite the fact that strabismus is an important cause of visual impairment among children,
so far there are only few studies done towards it in our country.

Significance of study
Early detection and initiation of treatment are critical in preventing permanent visual
impairment in children. Strabismus and/or amblyopia may have an impact on learning
capability and educational potential.Knowing the prevalence of strabismus in schools will
help in developing guidelines and policies for school screening and management.
Literature review
Prevalence and Pattern of Strabismus in Primary School Pupils in Benin City, Nigeria a
cross-sectional study carried out on primary school pupils in government schools by
Benedicta Aghogho Akpe, Oseluese Anastatsia Dawodu et al, showed an overall prevalence
of tropias of 0.89%. Esotropia was seen in 0.56% and exotropia in 0.33% of the students.
Infantile esotropia was the most common form of esotropia while alternating exotropia was
the most common pattern of exotropia. Heterophoria was seen in 57.04% of the students.(9)

Another cross-sectional study, Prevalence of manifest horizontal strabismus

among basic school children in Khartoum City,Sudan by Aalaa Omer Taha, Samira
Mohamed Ibrahim showed prevalence of horizontal squint of 2.8%, Esotropia was the
predominant type with a 2.2% and significant association between the father’s educational
level, socioeconomic status and their attitude towards eyes’ health(10).

Prevalence of strabismus among preschool children community in butajira town, a cross

sectional study done by Abeba Tekle Giorgis, Abebe Bejiga showed out of 1894 children
1.53% had strabismus. Esotropia was the commonest followed by exotropia. Strabismic
ambylopia was found in 51.7%.(7)

Prevalence of amblyopia and strabismus in young Singaporean Chinese children, a cross-

sectional study by Audrey Chia, Mohamed Dirani et el,.The amblyopia prevalence in children
aged 30 to 72 months was 1.19% with no age or sex differences. Unilateral amblyopia was
twice as frequent as bilateral amblyopia. The most frequent causes of amblyopia were
refractive error and strabismus. Of children with amblyopia, 15.0% had strabismus, whereas
12.5% of children with strabismus had amblyopia.(11)

Objectives

General objective
 To assess the prevalence and pattern of strabismus in elementary school students in
butajra town.

Specific objective
 To assess the prevalence strabismus in elementary school students in butajra
 To assess pattern of strabismus in elementary school students in butajra
 To assess the prevalence of strabismic ambylopia in elementary school students in
butajra town
Subjects and Methods

Study area and population

Butajira town is found in Gurage zone, SNNPR located 108 km south of Addis Ababa.
According to 2007 census the town has a total population of 33,406 , of which 16,923are
males and 16,483 are females

There are 5 government and 9 private primary school with 7742 and 1836 students
respectively which makes a total of 9578 students.

Study design and period

A Cross sectional study will be conducted from May to June 2019 in public primary
schools in Butajira town, Gurage zone, SNNPR, Ethiopia.

Source population

All students attending first and second cycle primary school education in a Butajira town

Study population

All students attending first and second cycle primary school education in a Butajira town.

A Cross sectional study will be conducted from April to May 2019 in private and public
primary schools in butajira town, Gurage zone, SNNPR, Ethiopia.
Sample size

The minimum sample size

with 95% confidence limit was determined using the
following formula.

Z2 p(1−p)
n=
d2

where, n, the desired sample size,

z, the standard normal deviate (1.96),
p, a prevalence of 1.53 % was chosen based on a previous study on preschool school students
with strabismus in butajira town.

d, degree of accuracy desired. The degree of precision was set at P/3 because the prevalence
was less than 10% making it a rare disease.(12)

n = 2225

Non response rate of 10% will be taken making the sample size

n=2472

A multistage sampling technique will be used to identify the school and sections.

Cluster sampling technique will be used to select classes from each school.

Inclusion criteria

 Students attending first and second cycle primary school education in a Butajira
town.

Exclusion criteria

 Students not willing to participate and/or have no parent or guardian consent.

 Students absent on the day of screening.
Study materials

Snellen acuity chart

Pen torch

Translucent eye occluder

Stereo fly test

Cyclopentolate 1% eyedrop

Direct ophthalmoscope

Retinoscope

Refraction set

Operational definition

Manifest Strabismus (Hetrotropia) - any misalignment of the visual axes of the eyes (constant or
intermittent) at near or distance fixation measured by cover uncover test

Esotropia – inward horizontal deviation of the eye at primary gaze or after cover uncover test

Exotropia – outward horizontal deviation of the eye at primary gaze or after cover uncover test

Sensory strabismus - horizontal strabismus following loss or impairment of vision.

Infantile esotropia - initial manifest esodeviation with onset between birth and 6 months of age.

Strabismic amblyopia –best corrected visual acuity ≤ 6/12 in the affected eye or a two line difference
between the two eyes, with no structural abnormality and presence of manifest strabismus.
Data collection and Analysis

AAU department of ophthalmology will send request letters to educational office of

butajira town. Then requisition letters will be given to the primary schools heads and the
purpose and method of examination will be explained. Consent will be obtained from the
parent of each student and class supervisor after they were fully informed about the
screening.
Data will be collected using the data collection form.( Appendix)

Based on sampling strategy samples will be selected.

A large room or an outdoor space will be selected for the screening program.
Stereo acuity will be measured using stereo fly test
Visual acuity examinations will be conducted using Snellen charts.
The right eye is tested first, then the left eye, each time occluding the fellow eye.
Acuity is measured first with spectacles, if the child wears them, followed by measurement of
uncorrected (unaided) vision.
Pin hole testing will be done for students with V/A of 6/12 and below.
Hirschberg’s test (corneal light reflex) will be done using a pen torch for uncooperative
subjects or those with poor or eccentric fixation
Cover uncover test will be done by occluding each eye for a minimum of 3 seconds at both
distance and near. If any movement of the not-covered eye is observed, presence and type of
heterotropia will be recorded. Alternate cover tests will also be done to determine the
presence of tropias and phorias.
Ocular motility will be checked.
Students with hetrotropias will continue to have further examinations.
For those students with low vision but no strabismus referral to Girarbet hospital for further
treatment will be given.

For students with hetrotropias anterior segment examination will be done using pen torch and
magnifying loupe. And posterior segment evaluation will be done using Direct
ophthalmoscope.
Cycloplegic refraction will be done after two doses of cyclopentolate eyedrops (1% ) 5
minutes apart. Retinoscopy will be done after 30 minutes following instillation of the second
drop of cyclopentolate.
Brief history will be taken from Parents/guardians about the onset of strabismus and history
of treatment.
Data will be entered and analyzed using SPSS software (SPSS for windows, version 23.0).

Ethical Consideration

Ethical clearance was obtained from Department of Ophthalmology research and

publication committee.
Reference

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