Journal of Clinical Ophthalmology and Research

: 2022  |  Volume : 10  |  Issue : 2  |  Page : 63--66

Prevalence of ocular morbidity in preschool children in Pune, Maharashtra

Sagar Kalamkar1, Parikshit Madhav Gogate2, Hardeep Kaur3, Supriya Pramod Phadke4, Amit Shinde3,  
1 School of Optometry, Bharati Vidyapeeth Medical College, Pune; Madhav Netralaya, Nagpur, Maharashtra; Community Eye Care Foundation, Dr. Gogate's Eye Clinic, India
2 Community Eye Care Foundation, Dr. Gogate's Eye Clinic; Department of Ophthalmology, D.Y. Patil Medical College, Pune, India; School of Medicine, Dentistry and Biomedical Engineering, Queens University, Belfast, United Kingdom
3 School of Optometry, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
4 Community Eye Care Foundation, Dr. Gogate's Eye Clinic, Pune, Maharashtra, India

Correspondence Address:
Parikshit Madhav Gogate
Dr. Gogate's Eye Clinic, 102-202, Kumar Garima, Tadiwala Road, Pune - 411 001, Maharashtra


Purpose: The purpose of this study was to determine the prevalence of ocular morbidity in preschool children in Anganwadis of Pune. Methods: All preschool children from Anganwadi in the area of Vishrantwadi and Yerawada in Pune city, western India, in the age group 36 to <72 months, underwent comprehensive eye examination in October 2019–February 2020: visual acuity estimation of each eye separately, slit-lamp examination, cycloplegic refraction, orthoptic evaluation, and fundoscopy. Prior to screening, an informed written consent form was taken from their parents and class teacher. All children needing optical or medical care were provided the same. Results: We examined 1341 children (aged 3 to <6 years, mean: 3.85 ± 1.0) in 36 Anganwadis, and 693 (51.7%) were girls; 81 (6%) children were detected to have ocular morbidities. There were refractive error in 42 (3.1%), strabismus 8 (0.6%), disorder of lid and adnexa 11 (0.8%), allergic conjunctivitis 2 (0.15%), bacterial conjunctivitis 3 (0.2%), viral conjunctivitis 2 (0.15%), corneal opacity 3 (0.2%), nystagmus 4 (0.3%), convergence insufficiency 3 (0.2%), and cataract 2 (0.15%). There was no gender difference for any morbidity, but older children were more likely to have one (P < 0.001). Out of 42 having refractive error, 5/42 (12%) had myopia, 1/42 (2%) hypermetropia, 11/42 (26%) myopic astigmatism, 3/42 (7%) compound myopic astigmatism, and 22/42 (52%) had mixed astigmatism. Conclusion: Refractive error in preschool children was not an insignificant problem. Most of the morbidities were treatable, and visual impairment was preventable.

How to cite this article:
Kalamkar S, Gogate PM, Kaur H, Phadke SP, Shinde A. Prevalence of ocular morbidity in preschool children in Pune, Maharashtra.J Clin Ophthalmol Res 2022;10:63-66

How to cite this URL:
Kalamkar S, Gogate PM, Kaur H, Phadke SP, Shinde A. Prevalence of ocular morbidity in preschool children in Pune, Maharashtra. J Clin Ophthalmol Res [serial online] 2022 [cited 2022 Aug 17 ];10:63-66
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Full Text

Visual development is a very important part of early childhood development and overall health. Early childhood is a very sensitive period for developing visual system.[1] If ocular disorders are not treated in time, when the visual system is plastic, they can lead to permanent visual impairment.[2]

In preverbal children, visual acuity may be quantified by a motor response (optokinetic nystagmus testing and forced-choice preferential looking) as well as by a sensory response (visually evoked responses).[3] The critical period for binocular vision development of preschool children is till 3 years of age, with visual system remaining plastic till the 6th year of life.[4] Nonverbal communication is important for interaction in infants and preschoolers. This communication is not in the form of spoken word but instead through vocalization, gestures, and/or eye movement and depends on vision.[5] Amblyogenic factors like ocular morbidity interfere in normal development of the visual pathways during a critical period of maturation.[6]

Usually, preschool children may not complain of blur vision as they have less knowledge of what normal vision is, and if they do not see far objects, they may squeeze their eyes for clear vision.[7]

Their parents also may not be aware of their eye problems. There have been few studies looking at visual disorder of preverbal children from India, but they were clinic based.[8],[9] A study of Anganwadis (kindergarten school or day-care centers for preschoolers) from Pune two decades ago had looked at Vitamin A deficiency and not causes of visual impairment.[10]

The aim of our study was to determine the prevalence of ocular morbidity and visual impairment in Anganwadi/preschool children in city in western India and treat those in need.


Anganwadi is a kindergarten school and is a part of the Integrated Child Development Scheme (ICDS) program. Permission of ICDS officer was obtained. It was a cross-sectional study of preschool children in the age group (36–71 months) in Pune.

The sample size was calculated the using [INSIDE:1] formula. The sample size was calculated by using the expected proportion of abnormalities/morbidities as 8% with the experimental error of 1.5%. Thus, n = sample size, Za = standard normal variate for a = 0.05 (95% confidence interval) was 1.96, P = proportion (%) under interest = 8%; q = 100 − p = 92%, and d = allowable error, 1.5%. By substituting the above values in the formula, the minimum required sample size needed was 1328.

Each Anganwadi has about 25–30 preschool children. Anganwadi's name and number were written on separate slips and they were folded and mixed up and 36 were chosen randomly out of 50 using a lottery method. They were in the area of Vishrantwadi and Yerawada in the eastern part of Pune city, in the state of Maharashtra, India. The examination was performed from October to December 2019, and spectacle dispensing and follow-up were done in January–February 2020.

Ethics approval was obtained from the Ethics Committee of Bharati Vidyapeeth Medical College, Pune.

Prior to screening, an informed written consent form was taken from their parents and class teacher. The teachers' and parents' input regarding the gross history and general gross appearance of eyes was taken.

All the subjects underwent thorough comprehensive eye examinations. A mobile eye clinic carrying all the necessary instruments was used for the examination. They were Cardiff acuity chart model number 474000, HOTV wide-spaced distance chart model number 52394, handheld slit lamp (model S2 portable slit lamp), portable autorefractometer (plusoptiX A12R), ophthalmoscope (Heine Beta 100), retinoscope (1302-P-1011), and color vision chart (Ishihara chart 38 plate ISH-001).

Visual acuity was measured with the help of Cardiff acuity chart at the age (3 to <4 years) and HOTV chart of the age group (>4 to <6 years) under normal daylight illumination. One eye was occluded by a handheld occluder while assessing visual acuity for the other eye. Visual acuity of each eye was estimated separately.

For detection of strabismus, Hirschberg test and cover–uncover test were performed. Cover test was done for 10 feet and 40 cm in primary gaze. Prism bar cover test was done to measure the deviation. Dry retinoscopy was performed on all the students. Children whose vision did not improve to 6/9 by retinoscopy and simple refraction, or had symptoms of ocular fatigue, underwent cycloplegic refraction.

Torchlight was used for examination of lids while conjunctiva, cornea, iris, anterior chamber, pupil and its reaction, and crystalline lens were examined using a portable slit lamp. These were performed by a qualified optometrist.

If any of those children needed further eye investigation, such as cycloplegic refraction, detailed orthoptic evaluation, and fundus examination, they were referred to Dr. Gogate's Eye Clinic where a pediatric ophthalmologist performed a comprehensive eye examination. In retinoscopy, if fluctuating glow was observed, cycloplegic refraction was performed followed by postmydriatic test and final spectacle prescription, and spectacle was given.

Cyclopentolate eye drops were used for the abovementioned cycloplegic refraction, and fundus camera was used for posterior segment assessment (Forus Trinetra Classic).

A written consent form from the subject's parent was taken before putting the cycloplegic drops. All children with significant refractive error dispensed spectacles free of cost.

The data collected were coded and entered in Microsoft Excel Sheet. The result was presented in a tabular and graphical format. The data were analyzed using SPSS (Statistical Package for the Social Sciences) version 25.0 software (SPSS software by IBM India, Bangalore, India). Qualitative data were analyzed using the Chi-square test. P < 0.05 was considered to be clinically significant


A total of 1341 preschool children from 36 Anganwadis (3 up to 6 years) underwent comprehensive eye examinations, and 693 (51.7%) children were female.

Of 1341 children, 618 (46.1%), children were aged 3 to <4 years, 230 (17.2%) aged 4 to <5 years, while 493 (36.8%) aged 5 to <6 years.

Ocular morbidity was seen in 81/1341 (6.0%) children. The details are enumerated in [Table 1].{Table 1}

In the 3 to <4 years age group, ocular morbidity was present in 21 (3.4%), the 4 to <5 years age group had ocular morbidity present in 12 (5.2%) while the 5 to <6 years age group had them in 48 (9.7%) children. There was no gender difference for any morbidity, but older children were more likely to have one (P < 0.001).

Out of 42 children with refractive errors, parents of three preschool children did not give consent for cycloplegic refraction. In these three children, dry retinoscopy was used for assessing refractive errors and dispensing spectacles. Myopia was detected in 5 out of 42 (12%) preschool children, one (2%) had hypermetropia, 11/42 (26%) had myopic astigmatism, 3/42 (7%) had compound myopic astigmatism, and 22/42 (52%) had mixed astigmatism. Hyperopic astigmatism and compound hyperopic astigmatism were not found in any preschool children. Girls had a slightly higher prevalence of refractive errors, but it was not statistically significant.


The present study was conducted to assess the prevalence of ocular morbidities in preschool children aged between (3 to <6 years) attending Anganwadis in Vishrantwadi and Yerawada in Pune. The study revealed that the total prevalence of ocular morbidities was 6%. There was no gender difference, though older children were more likely to have an ocular problem. The visual acuity charts, Cardiff cards, and HOTV charts used to measure the vision of each eye separately were similar to the ones used in the series from Manipal, Karnataka.[8]

A study done by the Department of Community Medicine, Karnataka Institute of Medical Sciences, Hubballi, among preschool children showed a prevalence of ocular morbidity of 20%, with refractive error as the most common cause of children.[11] However, they had examined 120 children from 6 Anganwadis to get this result. The hospital-based study from Manipal, Karnataka, had 33% of children having significant refractive errors.[9]

In the present study, the prevalence of refractive error was 3%. The prevalence of refractive error among preschool children was 8% in a study conducted in Riyadh, Saudi Arabia, by Al-Rowaily, while it was 4.5% in Madinah City, Saudi Arabia, which is relatively higher compared to the present study.[12],[13]

In this present study, the prevalence of Vitamin A deficiency was not seen any child. This could be because the government provides a dose of Vitamin A every 6 months to all Anganwadi children. The prevalence of night blindness and Bitot's spot was 0.8% and 1.4% respectively in a study conducted in Madhya Pradesh, India, by Arlappa et al.[14] The prevalence of Vitamin A deficiency was more in lower socioeconomic status, children with illiterate mothers, and older preschoolers. Vitamin A deficiency was seen in 6.4% of preschool children in a study conducted in southern Assam in 2015.[15] The prevalence was lower at 1.3% in a study conducted among Anganwadis in Pune in 2003.[10] This difference between Assam and Maharashtra was evident even from the schools for the blind series where corneal causes of blindness were more common in the northeastern states as compared to Maharashtra.[16],[17] The relatively lower prevalence of Vitamin A deficiency in our series may be due to reduction in infection and improvement in health-care delivery and Vitamin A supplementation.

There were two cases of cataract, both in boys, which would need surgical and optical care. This is in line with results from population-based studies.[18] Disorders of lid and adnexa and various forms of conjunctivitis were also present and would need medical care.

The strength of our study was that we examined all the children in a particular Anganwadi, rather than a random sample. The vision of each eye was tested separately allowing for uniocular causes of vision loss to be detected. The limitation was that we did not do a 6-month or 1-year follow-up as the Anganwadis were closed due to the COVID pandemic.


We conclude that refractive error in preschool children in India was not an insignificant problem and would require concerted efforts of health-care workers, education professionals, and parents to manage. Most of the ocular morbidities in preschool children are either preventable or treatable.


We acknowledge Miss. Vaibhavi Naik M. Optom for help in data collection and Mr. Rupesh Deshmukh and Mr. Shrivallabh Sane for their help in biostatistics. Last but not least, we thank all study subjects who participated in this study without whom this study would not have been possible.

Financial support and sponsorship

This study was financially supported by the Community Eye Care Foundation, Pune.

Conflicts of interest

There are no conflicts of interest.


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