International Ophthalmology 17: 161-165, 1993.

9 1993 Kluwer Academic Publishers. Printed in the Netherlands.

Section: Geographical ophthalmology

Prevalence and causes of visual impairment and blindness in the South

Western region of Saudi Arabia

Mubarak E A1 Faran, 1'3Ali A. A1-Rajhi,20thman M. A1-Omar, 3 Saleh A. A1-Ghamdi4 & Monzer Jabak 2
1Directorate of Health Affairs, and Prince Abdullah Hospital, Bisha, P.O. Box 86863, Riyadh H632, Saudi
Arabia; 2 King Khaled Eye Specialist Hospital, Riyadh; 3 College of Medicine, King Saud University, Riyadh;
4 King Fahd Hospital, Al-Baha

Received5 January1993;accepted9 March1993

Key words: blindness, visual impairment, cataracts, refractive errors, Saudi Arabia

Abstract

A population-based survey of the prevalence of maj or causes of blindness and visual impairment was conduct-
ed in Bisha region, Saudi Arabia. Overall, 2882 people were examined. The prevalence of blindness (visual
acuity of < 3/60 in the better eye with best available correction) was 0.7 % and the prevalence of visual impair-
ment (visual acuity < 6/12 but _ 3/60 in the better eye with best available correction) was 10.9%. Cataracts
were responsible for 52.6% of blindness and 20.6% of visual impairment. Refractive errors accounted for
67.9% of visual impairment. Proper management of cataracts and correction of refractive errors will cure
73.6% of blind subjects and 88.5% of visually handicap people in this part of the world.

Introduction dergoing development and so the natural course of

Saudi Arabia is a vast country with various topo-
graphical and environmental conditions, and fre-
quency of ocular disorders leading to visual loss in
each area is of great interest.
Bisha region is inhibited by 90,749 Saudi people
scattered over a rocky desert land placed at the
south west of the border of central province within
the south western part of Saudi Arabia. It is
1000 Km south of Riyadh and 250 Km north east of
Abha city and 300 meter above the sea level. The
people are mainly farmers with a prosperous date
industry. This region is a typical area to study causes
and prevalence of visual impairment and blindness
for two reasons. First is that, Bisha is a multi tribal
area where most of Saudi tribes with different cul-
tural habits and ways of living are represented. The
second, is that the ophthalmic resources are still un-
ocular diseases has not been altered. The main ob-
jectives of this study were to identify the common
ocular disorders leading to visual loss in this typical
area of Saudi Arabia, and to direct the available eye
health care resources in order to provide the best
care for such conditions.
Materials and methods
The sample for this study was designed to represent
the settled population of the Bisha region. Non-
Saudi people were excluded. It was s systematic
sample which was selected from the log books of the
Primary Health Care Centres (PHCCs). The region
was first divided into metropolitan (Bisha city) and
rural (all villages around Bisha city) community
types. A list of all people living in these communi-
162 M.E AI Faran
ties were obtained from the PHCCs. The list con-
tained the number of people in the households, age
and sex of all these people. A random start was se-
lected and the total number of households was di-
vided by the number of households in the sample to
yield an increment which was used as an interval be-
tween the selected households. Every 20th house-
hold and every 11th household in Bisha city and the
villages respectively, were selected. A pre-listing
process to identify every household in the sample
was done 6-8 weeks before the field work. There
were two examination teams. Each examination
team consisted of a qualified ophthalmologist, 2
ophthalmic assistants, and 2 female nurses. Two
drivers and 2 guides from the PHCCs were avail-
able.
Ophthalmic examination was performed by the
qualified ophthalmologists following history taking
and visual acuity measurement carried out by the
ophthalmic assistants. The subjects were examined
at their homes during the afternoon and evening
hours (1600H-2100H) when the likelihood of find-
ing all family members at home was greatest. Visual
acuity was measured using a Landholt-C optotype
calibrated at one meter. If visual acuity was found to
be less than 6/12, a pinhole visual acuity was ob-
tained.
Anterior segments were examined with pen
torches and binocular magnifying loops and where
necessary with a portable slit-lamp. Direct and in-
direct ophthalmoscopes, retinoscopes, refraction
lenses, and other diagnostic equipments were uti-
lized. Intraocular pressure (lOP) was measured
with Schiotz tonometer on all individuals 40 years
of age or more.
Data were entered into a microcomputer daily.
Table 1. Age & sex distribution of 2882 subjects surveyed in Bisha region, Saudi Arabia, 1991.
Age in years Male (%)
0- 9 543 (49.6)
10-19 394 (48.6)
20-39 176 (33.0)
40-59 144 (49.5)
60 and above 96 (62.7)
Total 1353 (46.9)
Verification of data completion and correct entry
were made on daily basis to enable the ophthalmol-
ogist to re-examine subjects in case of any discre-
pancy or missing information.
Medications were dispensed as needed and any
patient who needed further examination or treat-
ment was referred to the Eye department in Prince
Abdullah Bin Abdulaziz Hospital at Bisha.
Blindness was defined according to WHO crite-
ria as an acuity of < 3/60 in the better eye with best
available correction [1]. Visual impairment was also
defined as visual acuity of between 6/18 and 3/60 in
the better eye with best available correction.
Results
A total of 2963 persons were selected to represent
the population. Of this sample, 2882 persons were
examined by two examination teams with an excel-
lent participation rate of 97.3 % in the period of be-
tween 25 October and 30 November 1991.
Of the 2882 individuals in this study, there were
1353 (46.9%) males and 1529 (53.1%) females with
almost equal male to female ratio (1: 1: 2). The
younger age group predominated with 85 % of peo-
ple under 40 years, and only 5% (153 persons) were
60 years of age or older (Table 1).
The visual acuities of 2882 persons are shown in
Table 2. A total of 2547 (67.9 %) individuals had vi-
sual acuity of 6/12 or better, 316 (10.9%) individuals
had impaired vision and 19 (0.7 %) individuals were
blind. Two patients (0.4%) were blind at the age of
between 20 and 39 years, and 14 (9.3%) patients
were blind at the age of 60 years or older (Table 3).
Visual impairment was seen in 5 patients (0.8%) at
Female (%) Total (%)
552 (50.4) 1095 (38.0)
416 (51.4) 810 (28.1)
357 (67.0) 533 (18.5)
147 (50.5) 291 (10.1)
57 (37.3) 153 (5.3)
1529 (53.1) 2882 (100)
 Impairment and blindness 163

Table 2. Visual acuity among 2882 subjects surveyed in Bisha region, Saudi Arabia, 1991.

Visual acuity Male Female Total

No. (%) No. (%) No. (%)

>__6/12 (Normal) 1194 (41.2) 1354 (46.7) 2547 (67.9)

6/18-3/60 (Impaired) 152 (5.3) 163 (5.6) 316 (10.9)
< 3/60-NLP (Blind) 7 (0.2) 12 (0.4) 19 (0.7)

Total 1353 (47.0) 1529 (53.0) 2882 (100)

the age of between 5 and 9 years, and in 53 (10%) Discussion

patients at the age of between 20 and 39 years. One
hundred and thirty (44.7%) patients between 40
and 59 years of age and 100 (66.2%) patients of 60
years of age or more were visually impaired (Table
4).
Causes of blindness among 19 individuals are
shown in Table 5. Of these, 10 (52.6%) people were
blind from cataract, 2 patients had phthisis bulbi,
one patient had glaucoma, and one patient had reti-
nal degeneration. Four (21.0%) patients lost vision
due to iatrogenic causes. Of these, 3 (75 %) patients
were blind because of complicated cataract surgery.
Visual impairment was seen in 315 individuals. Of
these, 214 (67:9%) persons were due to refractive
errors, 65 (20.6%) persons had cataract, 12 (3.8%)
people had corneal opacities. Four (1.3 %) individu-
als had amblyopia, 4 (1.3 %) people had diabetic ret-
inopathy, 3 (1.0%) patients had glaucoma, 2 (0.6%)
patients had retinal degeneration and one patient
had optic atrophy (Table 6).
This study shows that most of the surveyed people
were under 20 years of age (66.1%) and 85% were
under 40 years of age. This is the typical pattern for
a developing country with a preponderance of indi-
viduals in the younger age cohort. Blindness has
long been recognised as a major cause of human
handicap and suffering in developing countries, in-
cluding Saudi Arabia. The National Eye Survey
conducted in 1984 revealed that 1.5% of the pop-
ulation in Saudi Arabia is blind and 7.8% were vi-
sually impaired by World Health Organisation
(WHO) standards [2]. Saudi Arabia being a vast
country with various topographic, and environmen-
tal conditions, the prevalence of blindness varies
from region to region. The highest prevalence of
blindness was 3.3 % in the Eastern province [2]. Tre-
mendous efforts were directed to the Eastern prov-
ince to lower that high rate of blindness. These ef-
forts included treatment of endemic eye diseases
such as trachoma, public education campaign on
prevention and treatment of eye diseases, and exist-
ing ophthalmic facilities were properly evaluated

Table 3. Prevalence of blindness among 2882 persons seen in Bisha Eye Survey by age group and sex.

Age (years) Male Female Total

No./sample (%) No./sample (%) No./sample (%)

0-19 0/938 (0.0) 0/971 (0.0) 0/1909 (0.0)

20-39 0/176 (0.0) 2/355 (0.6) 2/531 (0.4)
40-59 2/144 (1.4) 1/147 (0.7) 3/291 (1.0)
_>60 5/96 (5.2) 9/55 (16.4) 14/151 (9.3)
Total 7/1354 (0.5) 12/1528 (0.8) 19/2882 (0.7)
164 M.E AI Faran

Table 4. Prevalence of visual impairment among 2882 persons seen in Bisha Eye Survey by age group and sex.

Age group (years) , Male Female Total

No./sample (%) No./sample (%) No./sample (%)

O- 4 0/240 (0.0) 0/242 (0.0) 0/482 (0.0)

5- 9 4/2989 (1.3) 1/306 (0.3) 5/605 (0.8)
10-19 10/399 (2.5) 17/423 (4.0) 27/822 (3.3)
20-39 12/176 (6.8) 41/355 (11.5) 53/531 (10.0)
40-59 59/144 (41.0) 71/147 (48.3) 130/291 (44.7)
> 60 67/96 (69.8) 33/55 (60.0) 100/151 (66.2)
Total 15111354 (11.2) 163/1528 (10.7) 315/2882 (10.9)

and equipped to provide the ophthalmologists with Eastern province. Saudi Arabia has witnessed sig-
suitable, modem microsurgical instrumentation in nificant, positive socioeconomic changes in the last
accordance with established standards. This was in 40 years and in an accelerated fashion during the
addition to the significant improvements in socioec- past 10 years. These have reflected on health facil-
onomics which have been witnessed by most of the ities in general and on ocular disorders leading to
regions of Saudi Arabia including Bisha region. blindness in particular.
In 1990, the research department of the King Cataract has been found to be the leading cause
Khalid Eye Specialist Hospital (KKESH), conduct- of blindness in Saudi Arabia, accounting for 55 % of
ed a population-based survey in the Eastern prov- all cases [2, 4]. In this survey it was found to be the
ince of Saudi Arabia where blindness rate was single most important cause of blindness (52.6%)
found to be 1.5% [3]. This significant reduction in and the second leading cause of visual impairment
the rate of blindness was explained by attrition of (20.6 %). It is important to note that iatrogenic caus-
the frequently blind older age group and increased es lead to blindness in 4 (21.0%) patients. In 3
number of younger persons, who are overall, (75%) patients, the iatrogenic causes were related
healthier due to rapid improvements of socioec- to cataract surgery. These facts point out the impor-
onomics of the region [3].
The prevalence of blindness in this study was
found to be 0.7% which is lower than that of East- Table 6. Causes of visual impairment in Bisha Eye Survey, 1991.
ern province even after being reduced to 1.5 %. This
can be explained by the fact that trachoma does not Causes No. (%)
seem to be a problem in this region as it was in the
Refractive error 214 (67.9)
Cataract 65 (20.6)
Table 5. Causes of blindness in Bisha Eye Survey, 1991. Corneal opacity 12 (3.8)
Trachoma 6 (1.9)
Cause No. of blind (%) Other infections 5 (1.6)
Trauma 1 (0.3)
Cataract 10 (52.6) Amblyopia 4 (1.3)
Iatrogenic 4 (21.0) Diabetic retinopathy 4 (1.3)
Phthisis bulbi 2 (10.5) Glaucoma 3 (1.0)
Glaucoma 1 (5.3) Retinal degeneration 2 (0.6)
Retinal dystrophy 1 (5.3) Optic atrophy 1 (0.3)
Refractive error 1 (5.3) Others 10 (3.2)
Total 19 (100.0) Total 315 (100.0)

tance of giving the blinding cataract the priority for
a modern successful elimination.
Saudi Arabia has made sizable efforts to develop
a comprehensive system of primary, secondary, and
tertiary health care. Through this set up, health edu-
cation should be developed to create awareness
that cataract blindness is curable and that patients
with visual loss should seek help. The referral sys-
tem for patient seeking cataract surgery should be
expedited and priority given to patients with inca-
pacitating visual loss. Centers for cataract surgery
should be established in regions where facilities are
inadequate, and the available ophthalmologists
should be upgraded in their surgical skills and tech-
niques to perform effective cataract surgery.
In this survey, it is interesting to note that refrac-
tive error was the leading cause of visual impair-
ment and accounted for 67.9% of the cases. This
fact is supported by the finding of the National Eye
Survey, that the error of refraction was the most
common cause of visual loss in Saudi Arabia [2].
This significant clinical problem might be attribut-
ed to the customs and cultural habits of the people
in Saudi Arabia.
Although refractive error is the major cause of
visual loss, two thirds of the population who need
correction are not wearing eyeglasses. Public edu-
cation should be developed to acquaint the public
with the beneficial effects of wearing glasses or con-
tact lenses in order to make them more acceptable.
Optical services should be expanded to eliminate
refractive error as a cause of visual loss and to avoid
amblyopia in childhood.
Noteworthy is that the rate of blindness increases
dramatically with age; 89.5% of blind persons are
aged 40 years or over, and no blindness was noted in
subjects under the age of 40 years. This observation
is not commonly encountered in populationbased
studies in developing countries [5-9]. The absence
Impairment and blindness 165
of blind people under the age of 40 years can be at-
tributed to the fact that majority (78.2%) of them
were under the age of 20 years which are healthier
and grown in favourable socioeconomic circum-
stances. This indicates that in coming generations
we expect lower rate of blindness in all age groups.
Finally this study point the major clinical prob-
lems which need early solution to decrease the rate
of blindness and visual impairment in this popula-
tion. The backlog of blinding cataract cases should
be given priority for surgery, and correction of re-
fractive errors has to be encouraged. It is expected
that, once the cataract backlog is controlled, other
conditions such as glaucoma, retinal diseases may
become main causes of blindness.
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