School Eye health presentation by Prof Adio A.

1. School Eye Health in
Nigeria: the
situation now and
what the future
holds
Adedayo Adio
Professor of Ophthalmology and Chair of
NIPOSS
26th June 2022

2. No financial
disclosures

3. Children have rights
• Convention for the Rights of the Child was adopted by the United
Nations (UN) in 1989, which recognised for the first time that
children have rights of their own and are not passive objects of care
and charity.
• Right to healthcare and nutrition including vitamin A deficiency
• Right to clean water eradicating preventing trachoma blindness,
electrical power and a safe environment to prevent ocular trauma
the major cause of monocular blindness in children
• Right to quality Education which ensures children with visual
impairment and blindness receive appropriate and adequate
education and social inclusion
• Right to guidance from a caring adult ensuring early identification
and early presentation for uptake of eye care services and ensuring
follow up including the lifelong approach to care.
United Nations Convention on the Rights of the Child. www.ohchr.org/EN/ProfessionalInterest/Pages/CRC.aspx
National School eye health guidelines; Federal Ministry of Health Nigeria 2020

4. Schools are the major
institutions in the society
established for the purpose of
transferring knowledge and
culture to the young.
Childhood blindness and visual
impairment produces many
years of living with blindness
and vision impairment in
children if not addressed
promptly and properly.

5. There is a strong link between
children’s health, including their
visual health, and the quality of their
learning and achievement at school.
This, in turn affects, children’s future,
quality of life and economic
productivity.
School eye health programmes
provide a unique opportunity to
deliver comprehensive eye health
services to school-going children

6. What is School Eye
health?(SEH)
• School eye health is a comprehensive health service that
has been set up exclusively for school children to enable
them work and learn in a healthy, conducive
environment as well as to receive eye care.
• Requires team work
• Seeks to maintain and improve not only the eye health
of the school children but also the school staff through
instructions, health services, healthful school living as
well as through school community cooperation.

7. Benefits of school eye health
• Correction of refractive error and provision of affordable,
durable spectacles that are comfortable and look good.
• Identification and referral of children with other causes of
visual impairment-[those with strabismus, corneal opacities,
or high degrees of refractive error, and those for whom visual
acuity does not improve to normal with refraction]
• Identification, referral and treatment of common eye
complaints in children, e.g. conjunctivitis
• Identification and referral of teachers with visual impairment
• Provision of reading spectacles for presbyopia in teachers, if
required
Wedner SH, Ross DA, Balira R, Kaji L, Foster A. Prevalence of eye diseases in primary school children in a rural area of
Tanzania. Br J Ophthalmol. 2000 Nov;84(11):1291-7. doi: 10.1136/bjo.84.11.1291. PMID: 11049957; PMCID:
PMC1723290.

8. Aim of SEH
•To Prevent Blindness

9. Services that
should be
rendered
• Promotive
• Preventive
• Curative
• Rehabilitative

10. Objectives of SEH
• To ensure good eye health of school children while the children
take advantage of the education provided.
• To prevent eye diseases or injuries.
• To provide information on the importance of seeking care early in
order to prevent blindness
• Early detection and treatment and ocular problems by health
personnel.

11. To attract participation of schoolteachers and acquaint them with relevant
knowledge and skills required for early detection of eye diseases.
To provide knowledge on first aid care in accidents or injuries.
To promote positive eye health by making the pupil conscious of the
importance of their sight throughout life.
To discourage unnecessary absenteeism and truancy at school by attending eye
hospital.

12. • To have child to child method of screening by their full participation, the
children understanding visual acuity helping other children, families and
communities at large.
• To promote healthy school living through encouraging safety and sanitation,
proper food services and proper mental and emotional health.
• To identify and define problems for research in the school eye health.

13. • The World Health Organization (WHO)
reports that 43% of all visual impairment is
due to uncorrected refractive errors. This
amounts to 122.5 million people, 12 million
of whom are children.
• A recent study demonstrates that
programmes for the detection and
treatment of uncorrected refractive error
(URE) among school children are highly cost
effective.
1 Resnikoff S, Pararajasegaram R. Blindness prevention programmes: past, present, and future. Bulletin of the World Health
Organisation 2001;79(3):222–6.
2 Powell C, Wedner S, Hatt SR. Vision screening for correctable visual acuity deficits in school-age children and adolescents.
Cochrane Database of Systematic Reviews OCT 2004 DOI: 10.1002/14651858.CD005023.pub2
3 WHO Fact Sheet No. 282: Visual impairment and blindness. www.who.int/mediacentre/factsheets/fs282/en/

14. The current situation
in Nigeria
• Approximately 4.25 million adults are blind or visually impaired with over 80%
of the blindness from avoidable causes
• Causes
• Cataract-commonest cause of blindness
• Uncorrected refractive error-commonest case of visual impairment
• Reasons why?
• Rising poverty rates
• Poor education and
• Underfunded healthcare systems
• Majority of ophthalmologists are concentrated in urban areas
• http://www.nigerianstat.gov.ng/Connections/Pop2006.pdf
Abah ER, Oladigbolu KK, Samaila E, Gani-Ikilama A. Ocular disorders in children in Zaria children's school. Niger J Clin Pract.
2011 Oct-Dec;14(4):473-6. doi: 10.4103/1119-3077.91759. PMID: 22248953.

15. Other reasons why..
In the absence of accessible orthodox eye care, patients access other sources, for
example, patent medicine vendors, traditional healers and couchers, which may
exacerbate the visual loss through harmful practices or delay appropriate treatment.
Inequity in access and higher costs for patients and providers.
Eye conditions like presbyopia and conjunctivitis which can be treated at the primary
level are principally delivered at secondary and tertiary levels
Ayanniyi AA, Olatunji FO, Mahmoud AO, Ayanniyi RO. Knowledge and attitude of guardians towards eye health of primary
school pupils in Ilorin, Nigeria. Niger Postgrad Med J. 2010 Mar;17(1):1-5. PMID: 20348974.

16. • Under-five mortality rate (U5MR), a proxy indicator for the
prevalence of childhood blindness, has declined in the country over
the last 40 years from 292.7 deaths per thousand live births in 1969
to 119.9 deaths per thousand live births in 2018.
• Decline in major preventable causes of visual impairment such as
corneal blindness and vitamin A deficiency disease.
• Steady increase in the sight related burden of non-communicable
diseases (NCDs) such as inherited congenital cataracts, retinopathy of
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Huh GJ, Simon J, Grace Prakalapakorn S. Causes of childhood blindness in Ghana: results from a blind school survey in Upper
West Region, Ghana, and review of the literature. Int Ophthalmol. 2018 Aug;38(4):1415-1423. doi: 10.1007/s10792-017-0600-
9. Epub 2017 Jun 13. PMID: 28612329; PMCID: PMC5729053.

17. • An efficient school health program can be one of the most cost-
effective investments a nation can make to improve education and
health.
• This has led to several global initiatives to enhance school health in
the context of health, education, national development, rights of
children and persons with disabilities.

18. Global school health initiatives
• WHO’s “Health Promoting Schools”;
• UNICEF’s Child Friendly School initiative and
• UNESCO’s Focusing Resources on Effective School Health.

19. • Eye health is an essential part of a school health program and should
be comprehensive and respond to the relevant range of eye
conditions and diseases prevalent in the program area.
• Strategies for school eye health programs need to be comprehensive
and go beyond the detection and treatment of refractive errors.

20. What are the
goals of school
eye health?
Using the sustainable
development goals
Gilbert C, Murthy GV. The Sustainable Development
Goals and Implications for Eye Health Research.
Ophthalmic Epidemiol. 2015;22(6):359-60. doi:
10.3109/09286586.2015.1104365. PMID: 26653258.

21. Goal#1:No
Poverty
• “Restoring someone’s sight is the single most
cost-effective health intervention to reduce
poverty” (World Health Organisation 2010)
• Approximately 90% of the world’s vision
impaired live in developing countries (World
Health Organisation 2014).

22. Goal #3:
Good Health
and Well
Being
• By 2050 half of the world’s population will
be myopic (Holden et al. 2016)-potentially
the biggest public health issue of our
generation.
• Up to 80% of vision impairment is
preventable or treatable (World Health
Organisation 2012).

23. Goal #4:
Quality
Education
• If you struggle to see, you struggle to learn:
• 80% of what young children learn is
processed through their sight
• Approximately 90% of children with
disabilities who live in developing countries
are deprived of schooling, and this includes
children with visual loss (UNICEF 2015).

24. Goal #5:
Gender
Equality
• Women and girls are less likely to access
vision services in many countries.
• If a girl has her vision corrected, she has a
better chance of achieving more at school.
• And for each year she stays in school her
income will rise by 10-20% (Plan
International 2015).
• An educated girl will grow up to gain her
rightful place in society and be a force for
change, raising the status of girls and
women.

25. Goal #8:
Good Jobs
and
Economic
Growth
• The global economy loses USD$202 billion in
productivity each year because of
uncorrected vision impairment (Smith et al.
2009).
• That’s more than the total GDP of sixty
countries –combined.

26. Goal #10:
Reduce
Inequalities:
• The burden of blindness lies with developing
countries.
• The prevalence of blindness in children is
approximately 10 times greater in
developing countries than in developed
countries (Gilbert & Rahi 2011).

27. Components of a comprehensive school eye
health program
• An ideal SEH programme should be integrated into the broader school
health programme and encompass the following:
 Screening, referral and treatment
 Health promotion and education
 Service delivery
 Follow up
Standard Guidelines for Comprehensive School Eye Health Programmes (PDF, 4 MB). Available on this
page: http://iceh.lshtm.ac.uk/files/2014/07/Standard-Guidelines-for-Comprehensive-School-Eye-Health-
Programs.compressed.pdf

28. • School eye health programmes must be planned properly
• Before any work begins, everyone needs to be clear on what the
objectives are and how the team will monitor their progress.
• Only then will programmes achieve their maximum impact.
• What is the VA cut off 6/12? 6/9?
• What age do you want to do the first examination- India 5-6years?
• What equipment do you want to use?
• What will you do when you find a need?
• What referral systems are in available?

29. Screening, referral and treatment
• Activities to benefit school children
• Detect and treat refractive errors in school children
• Detect and refer children identified with other eye conditions
• Train school nurses to detect and treat simple eye conditions in children in schools
• Health education on how children can keep their eyes healthy
• Activities to benefit teachers
• Detecting and treating refractive errors, including presbyopia, in teachers
• Detecting and referring teachers who have poor vision or a history of cataract, glaucoma or diabetic
retinopathy.
• Activities to benefit communities
• Teaching children how to be agents of change for healthy eyes in their families and communities
• (see www.childtochild.org.uk).

30. Equipment required
• Tape measure
• Torchlight
• Full tumbling E chart (or multi-
letter Snellen). Ideally, this should
be the logMAR version
• Eye occluder or a piece of card to
place over one eye
• Student record sheet.
• Referral sheets

31. Procedure
• Explain the test to the child
• Measure the acuity one eye at a time
• Ensure that the chart is at the student’s eye
level.
• Cover the left eye with the eye occluder or a
piece of card. It is advisable that they do not
use their hand as they may be able to see
between their fingers.
• To see any particular line of the chart, the
child must be able to see at least three of
the five Es or letters.

32. Actual screening
• Visual acuity is measured at 6 metres
• To limit memorisation, and to improve reliability, a
tumbling E chart can also be used.
• Tip: Rotate the chart between eyes and between
children.
• Only one student should be examined at a time;
keep others outside the examination room.
• During screening, students should read the cut-off/
threshhold line only (6/12 or 6/9).
• High-contrast black on white should be used, with a
dark surround, as this improves reliability when
only using one row of optotypes . 3 or 4 of 5 read is
ok

33. Refraction
• Refraction should be undertaken by a competent practitioner experienced in
refracting children.
• NOTE: Children whose visual acuity does not improve to normal with
refraction must be referred for examination to determine the cause so that
appropriate action can be taken.
• Retinoscopy, or preliminary assessment using an autorefractor appropriate for
children, should be followed by comprehensive subjective refraction.
• Children should be referred for cycloplegic refraction if they are uncooperative,
if there is a variable or inconsistent end-point to refraction, in the presence of
strabismus or suspected amblyopia and if they are difficult to refract because
of media opacities or irregular corneas.

34. Health promotion and education
• Health education to prevent locally endemic diseases in children,
• Promoting a clean, safe and healthy school environment
• Encourage children to take eye health messages home-information
sheet or pamphlet or send an SMS to parents.
• They can act as ‘case detectors,’ identifying people in their
community who need eye services.
Paudel P, Yen PT, Kovai V, Naduvilath T, Ho SM, Giap NV, Holden BA. Effect of school eye health promotion on children's eye health
literacy in Vietnam. Health Promot Int. 2019 Feb 1;34(1):113-122. doi: 10.1093/heapro/dax065. PMID: 29040581.
Marshall EC, Meetz RE, Harmon LL. Through our children's eyes--the public health impact of the vision screening requirements for
Indiana school children. Optometry. 2010 Feb;81(2):71-82. doi: 10.1016/j.optm.2009.04.099. PMID: 20152780.

35. • The health education component
of school eye health should be
delivered by qualified eye care
professionals, such as nurses or
clinical officers or optometrists, at
a level that children can
understand.

36. Purpose of health education
To increase children's knowledge about the eye, how it
works and what can go wrong (in simple language), and
to tell them how they can keep their own eyes healthy.
Ideally, this should be an integral component of the
school curriculum.
Ayanniyi AA, Olatunji FO, Mahmoud AO, Ayanniyi RO. Knowledge and attitude of guardians towards eye health of primary
school pupils in Ilorin, Nigeria. Niger Postgrad Med J. 2010 Mar;17(1):1-5. PMID: 20348974.

37. Service delivery
• Ideally, the Ministry of health ought to provide financial support for
programs, including the provision of spectacles
• If this fails, the average cost of refraction and spectacles should be
kept affordable for parents
• The key to a successful programme is well trained and dedicated eye
care personnel with clearly defined roles and responsibilities.
• Low power spectacles should not be provided( will not be worn)
• Waste of resources and the programme is open to exploitation
through unscrupulous prescribing

38. Personnel required
Educational sector
• Educational coordinator
Local education authority
• Head teacher
• contact teacher (one for each class)
• Class teacher
• Screener
• Child welfare officer
• Student/pupils
• Managers &/ development partners
• National and State Eye Health Coordinator
• Technical Program Manager/ MoE Program Focal
Person
Eye Health Sector
3. Eye health sector
1. School nurse
2. Ophthalmic nurse
3. Childhood blindness cordinator
4. Senior optometrist in partner
hospital/ department
5. Optometrist/ refractionist
6. Dispensing opticians
7. Parent(s)
8. Ophthalmologist
9. Federal Ministry of Health

39. Teaching teachers
• Training teachers is typically carried out in two sessions.
• In the first session, ophthalmologists train teachers to recognise eye conditions in
children such as squint, nystagmus, corneal opacities, ptosis, conjunctivitis and
eyelid swellings.
• The teachers are also given posters and pictures.
• In the second session, optometrists instruct teachers in vision screening using
eye charts.
• The teachers are equipped with Snellen screener charts (both number and
tumbling E), 6 metre tape and data forms to record whether the child can or
cannot see the optotypes with each eye.
• They practise on one another to standardise methods and to test reliability.

40. Follow-up
• The success of any programme depends on follow-up.
• Resources should be allocated to this and systems put in place to
follow up all children who fail vision screening or who are found to
have an eye condition
• Follow-up may be needed after referral for refraction, to obtain
spectacles, or for an eye examination at the local hospital or vision
centre.
• Accurate and efficient record-keeping is essential, both by those who
are screening and referring and those who are receiving referrals.

41. Monitoring of progress
must be SMART
• The objectives guide the data that need to be collected (the
indicators) to continuously monitor progress and assess the quality of
the programme
• Number vary from place to place depending on information from
publications or previous SEH in the location
• Examples are:
• The number of teachers trained
• The number of children screened
• The number of children prescribed spectacles
• The number of children referred.
• After 4months , number of kids still wearing the spectacles
• How many teachers were given glasses or referred for treatment
• How many are satisfied at 4months

42. How to
improve
delivery
• There is a need for LMICs to provide
universal access to eye care for blinding
conditions and for conditions that cause
ocular morbidity.
• 1984, the World Health Organisation (WHO)
advocated a PHC approach to increase
access to eye care.

43. The
Situation
now/
Challenges
of SEH
• Few school eye health
programs going on
• Many school eye health
initiatives are
• narrow in focus,
• do not involve Ministries of
Health or Education,
• are not integrated into other
school health initiatives and
• do not provide annual or
biannual vision screening to
identify new cases and to
follow-up children already
identified with myopia which
can progress with age.
• National School Eye Health
Guidelines; Federal Ministry of
Health Nigeria 2020
• Vongsachang H, Friedman
DS, Inns A, Kretz AM,
Mukherjee MR, Callan J, Wahl
M, Repka MX, Collins ME.
Parent and Teacher
Perspectives on Factors
Decreasing Participation in
School-Based Vision Programs.
Ophthalmic Epidemiol. 2020
Jun;27(3):226-236. doi:
10.1080/09286586.2020.1730
910. Epub 2020 Feb 20. PMID:
32079450.

44. • These lead to poor co-ordination, ownership
and sustainability.
• Lack of standard approaches to screening,
prescribing, referral and follow up
• Poor parental cooperation
• No political will
• Poor funding

45. Other
challenges
• Inadequate monitoring and evaluation
-lead to inefficiencies and poor
assessment of outcomes and impact.
• Lack of equitably distributed trained
personnel for screening, accurate
diagnosis and acceptable treatment.
• The lack of availability of appropriate
and affordable spectacle frames and
lenses for children with refractive
error,
• Poor access to specialist treatment for
diagnosis and management of other
eye conditions

46. What does
the future
hold?

47. Critical analysis of the present situation of eye care in Nigeria by
stakeholders
Identify area(s) of strengths, weaknesses and opportunities that
can be leveraged upon and the threats that need to be addressed
A coordinated approach is very important-lacking
Global Estimates of Visual Impairment 2010. Pascolini, D and Mariotti, S. 2012,BJO 96(5):614-618
Chandna, A and Gilbert, C. 72, 2010, CEHJ, Vol. 23, pp. 1-3.

48. How to
establish a
need and the
degree
• Do a mini survey
• Obtain information from other local school
eye health programs or the Federal Ministry
of Health
• What is the prevalence of vitamin A
deficiency in preschool age children?
• What is the prevalence of severe vernal
conjunctivitis in children?

49. One significant weakness is the
inadequate funding of child
eye health

50. Funding strategies

51. The National health Bill
• In December 2014, the National Health Bill was signed into law in
Nigeria and became the National Health Act
• Components of the budget that directly affect the health sector in
Nigeria include the N44.5 billion earmarked for the Basic Health Care
Provision Fund (BHCPF)
• The goal of the fund is to substantially increase revenue and improve
Primary Health Care (PHC) as contained in the country’s National Health
Act

52. Where is child eye health in the budget?
• Should be included in the budget of the state eye health and general health
plan.
• Refractive errors have been targeted for intervention through a school eye
health programme.
• Insurance schemes or formal private-public partnerships should include
treatments for eye conditions of children.
• Teachers can be engaged if there are constraints

53. Advocacy
• Tireless advocacy by stakeholders (OSN, NIPOSS,
Nigerian Optometry Association(NOA) to relevant
bodies
• Academic papers in the area to support need-
publish in visible journals
• Awareness programs-Radio, TV, IEC materials,,
visits to the ministers for education and health,
social welfare, special ministries, commissioners,
permanent secretaries, NUJ, FIDA
• Social media blitz
• Fundraisers
• Workshops to train teachers
• Talk with PTAs

54. Training teachers to
conduct screening in SEH
• Train teachers to educate children
about eye health, conduct eye
screening checks and refer them for
treatment.
• Teachers are perfectly placed to
identify children at risk of vision
impairment before it impacts on
educational attendance and
performance.
Priya A, Veena K, Thulasiraj R, et al. Vision screening by teachers in Southern Indian schools: Testing a new “all
class teacher” model. Ophthalmic Epidemiology 2015; 22:60-5.
Sudhan A, Pandey A, Pandey S, et al. Effectiveness of using teachers to screen eyes of school-going children in
Satna district of Madhya Pradesh, India. Indian Journal of Ophth. 2009; 57:455-8

55. Early detection and treatment
This can be corrected with simple interventions such as a pair of
glasses or low-cost surgery.
The challenge is reaching these children with early interventions
before vision impairment severely impacts their development
Results in delayed learning and low rates of school participation
and educational attainment – or worse, becomes permanent.
Vongsachang H, Friedman DS, Inns A, Kretz AM, Mukherjee MR, Callan J, Wahl M, Repka MX, Collins ME. Parent and
Teacher Perspectives on Factors Decreasing Participation in School-Based Vision Programs. Ophthalmic Epidemiol. 2020
Jun;27(3):226-236. doi: 10.1080/09286586.2020.1730910. Epub 2020 Feb 20. PMID: 32079450.

56. Don’t forget color
vision…

57. Have a coordinated
plan for special kids
• Ministries working in disability can also be a key
partner in school eye health programmes
• Responsible for schools for children with disabilities,
or schools for the blind, or can have details of
children who do not attend school due to a disability
• In addition, schools that practice inclusiveness in
preparation for integration of children with visual
impairment into main stream schools require
attention.
• Children with multiple disability require special
schools to enable them fulfil their educational
potential.

58. Dispense only what will be used
• There is evidence that a high proportion of children
given spectacles do not wear them for a range of
reasons
• Minimize or overcome by health education of
parents, teachers, affected children and their peers
• Only dispensing spectacles to children who really
need them, and ensuring comfortable, cosmetically
acceptable frames should be provided free of cost or
at a minimal cost.
Morjaria P, Evans J, Murali K, Gilbert C. Spectacle Wear Among Children in a School-Based Program for Ready-Made vs
Custom-Made Spectacles in India: A Randomised Clinical Trial. JAMA Ophthalmol. 2017 Jun 1;135(6):527- 533. doi:
10.1001/jamaophthalmol.2017.0641
Congdon et al. 2008; Pavithra et al. 2014

59. Frames for kids
• Young children do not have a well-developed
bridge to their nose
• Spectacle frames for children must be selected
and fitted carefully
• They must be cosmetically appealing,
comfortable and robust enough to withstand
normal wear and tear.
• The lenses must be able to withstand impact.
• Glass lenses should not be used.
• Plastic lenses are light but can become
scratched and should be replaced if badly
scratched.
• If most children see better with spectacles than
without, a higher proportion will wear them.

60. Have a plan for
sustainability

62. • School eye health programmes provide a unique opportunity to
positively influence the health of 700 million children globally
• The impact of school eye health (SEH) goes far beyond good
vision— it encompasses education, social development and
economic productivity
• School eye health programmes have the potential to change the
lives of school children and their teachers by detecting eye
conditions and ensuring access to quality eye care
• Health education delivered at schools also has the potential to
reduce eye disease and visual impairment in the future

63. • Comprehensive programmes should be undertaken in
collaboration with Ministries of Health and Ministries of
Education, and need to be monitored and evaluated to ensure
they are a good use of resources and bring about positive change
• School eye health programs need to be funded in a sustainable
way with full involvement of teachers and parents
• We as ophthalmologists should be ready to actively lead the team
to resuscitate school eye health as the future of our country
depends on this

65. Thank you