International Ophthalmology17: 229-234, 1993.

9 1993KluwerAcademicPublishers.Printedin the Netherlands.

Section: Geographical ophthalmology

Causes of blindness in children attending four schools for the blind in

Thailand and the Philippines
A comparison between urban and rural blind school populations

Clare Gilbert & Allen Foster

International Centre for Eye Health, Department of Preventive Ophthalmology, Instituw of Ophthalmology,
Bath Street, London EC1V 9EL, UK

Received 6 October1992;accepted23 March1993

Key words: childhood blindness, retinopathy of prematurity, Vitamin A deficiency

Abstract

Using WHO definitions of visual loss and a standardised methodology, 256 children were examined in schools
for the blind in Thailand (1 school) and the Philippines (3 schools). 244 (95%) were blind (BL) or severely
visually impaired (SVI). Causes of SVI and blindness were classified anatomically and aetiologically, and
avoidable causes identified.
Causes of visual loss in Khon Kaen, Thailand (n = 65) and Manila, Philippines, (n ; 113) were similar, with
conditions of the whole globe accounting for 27.7 and 27.4% of SVI/BL; retinal divease 29.2 and 23.0%;
cataract 16.9 and 16.8%; corneal disease 12.3 and 13.4%; and optic nerve disease and glaucoma 6.2 and 8.8%.
Perinatal factors accounted for 20.0 and 23.0% of SVI/BL; hereditary disease 13.8 and 17.7%; and 12.3 and
15.0% was due to events occurring during childhood. The underlying aetiology could not be determined in
50.8 and 41.6% of cases, respectively. In the two schools together twenty six children (15%) were blind from
retinopathy of prematurity (ROP) and 16 (9 %) from corneal scarring attributed to Vitamin A deficiency. 103
of 178 (58%) children had avoidable causes of visual loss.
In the Filipino towns of Baguio and Davao (n = 66), the causes of visual loss were different from those in
Khon Kaen and Manila, with 54.8 and 42.9 % of SVI/BL being due to corneal disease, and only 3.2 and 8.5 % to
retinal disease. Childhood factors were more important (61.3 and 57.1%) than hereditary (9.7 and 17.1%) or
p erinatal factors (0 and 2.9 % ). Thirty one children (47 %) had SVI/B L attributed to Vitamin A deficiency. No
child was blind from ROR 42 of 66 (64%) of children had avoidable causes of blindness.
Overall 60 % of children with SVI/BL had avoidable causes of visual loss in these 4 schools. Approximately
half could have been prevented by primary health and eye care services and half could have been managed by
surgical ophthalmological procedures. The causes of blindness identified in this blind school study suggest
that the major causes are different for schools serving rural populations compared to those serving urban
communities. Different control strategies are required for the different situations.
230 C Gilbert & A. Foster
Introduction
Vitamin A deficiency (VAD) leading to nutritional
blindness is known to be a significant public health
problem in Indonesia [1], parts of Thailand [2] and
the Philippines [3] and other countries of South
East Asia [4]. This pilot study was undertaken in
order to determine the causes of visual loss in chil-
dren attending 4 schools for the blind in Thailand
and the Philippines with a view to identifying avoid-
able causes, including Vitamin A deficiency.
There is paucity of data concerning the causes of
visual loss in children in Thailand and the Philip-
pines. A hospital based study, undertaken in a rural
province of North East Thailand in 1967-68, report-
ed that 42% of children aged 0-10 years (8/19) were
blind from congenital abnormalities, and 21% from
Vitamin A deficiency [5].
Subjects and methods
Children attending 4 schools for the blind (n = 230)
and children in integrated education (n = 26) in
Khon Kaen, Thailand and three schools in the Phi-
lippines were examined by one observer (CEG).
Khon Kaen is a city in the North East of the country,
population 1.3 million (1989). The schools in the
Philippines were situated in the capital city, Manila
(1.6 million population), Baguio, a small town of
183,000, north of Manila on the island of Luzon, and
Davao a larger town of 850,000 situated on the
southern island of Mindanao. The age range was 5-
19 years; young adults who became blind before the
age of 16 were included in the study.
Visual acuity levels of 6/18, 6/60 and 3/60 were
measured with an Illiterate E chart by one observer
in each blind school. Each eye was tested separate-
ly, with correction if normally worn. If examination
of the eyes indicated that visual acuity could be im-
proved, testing was repeated with a pinhole. Levels
of visual acuity were categorised according to
W H O definitions of visual loss, which uses the cor-
rected acuity of the better eye. Severe visual impair-
ment is defined as an acuity in the better eye of less
than 6/60 but equal to or better than 3/60; blindness
is defined as a corrected acuity in the better eye of
less than 3/60.
Refraction was not performed routinely and vi-
sual fields were not tested. Anterior segment exam-
ination was performed with a torch and magnifying
loupe and posterior segment examination was un-
dertaken after dilating the pupil where indicated,
using a direct and/or indirect ophthalmoscope. In-
traocular pressures were not routinely measured.
Records giving details of past medical and ocular
history were available at each of the schools, but
these were often inadequate and inaccurate. Further
information was obtained from the children, teach-
ers at the school and occasionally from parents.
All data were recorded on a standard Eye Exam-
ination Record for Children with Blindness and
Low Vision which has been developed with the
World Health Organisation's Programme for the
Prevention of Blindness [6]. The form is accompa-
nied by Coding Instructions, which give instructions
for use, definitions and methods of classification.
The form includes sections for recording demo-
graphic data, including home town, and causes of
visual loss using a descriptive anatomical classifica-
tion, and an aetiological classification.
Anatomical classification
An anatomical classification has been included so
that the site of abnormality leading to visual loss can
be recorded. This is useful for situations where
medical records or details of past medical history
are absent or unreliable.
- Whole globe e.g. phthisis bulbi,
microphthalrnos, buphthalmos
- Cornea e.g. corneal scarring, corneal
dystrophy
- Lens e.g. cataract, aphakia
- Uvea e.g. coloboma, albinism
- Retina e.g. retinal dystrophy, retinopathy
of prematurity
- Optic nerve e.g. optic atrophy, optic nerve
hypoplasia
- Normal globe e . g . cortical blindness
 Urban and rural blindness in schools 231

A etiological classification Results

This classification takes into account the time of on- Visual acuity
set of the disease or insult that led to blindness.
Results of visual acuity measurement are given in
- Hereditary e.g. genetic disease, chromosomal Table 1. The majority of children were blind or had
factors abnormalities
- Intrauterine e.g. congenitally acquired rubella, severe visual impairment (91.2-100%).
factors effects of teratogens
- Perinatal e.g. retinopathy of prematurity,
factors ophthalmia neonatorum Anatomical causes of visual loss
- Childhood e.g. Vitamin A deficiency, measles,
factors trauma
The anatomical and aetiological causes of visual
- Cannot This includes conditions such
determine as microphthalmos and loss were similar for the schools in Khon Kaen and
cataract often present since Manila. These differed from the schools in Baguio
birth where the underlying and D a v a o (Tables 2 and 3).
cause is not known and where The anatomical causes of SVI/BL are shown in
the condition cannot be
Table 2. Corneal scarring/phthisis bulbi was the
attributed to genetic disease or
intrauterine events. commonest cause of SVI/BL in the blind schools in
Baguio and Davao (54.8 and 42.9%) whereas le-
After examining each child, the major anatomical sions of the whole globe and retinal disease were
site of abnormality leading to visual loss was deter- the commonest cause of visual loss in the schools in
mined for each eye, and for the child as an individu- Khon Kaen and Manila (27.7% and 27.4%; 29.2%
al. If one eye had more than one structural abnor- and 23.0%, respectively). Corneal scarring was at-
mality, or if the abnormalities were different for the tributed to V A D in 31/66 (47%) children in Baguio
right and left eyes, the major abnormality for each and D a v a o compared to 16/178 (9%) of children in
eye and the child were selected using criteria given schools in the large cities. Retinopathy of prematur-
in the coding instructions, which places emphasis on ity (ROP) was the single commonest cause of reti-
the identification of preventable or treatable condi- nal disease in Khon Kaen and Manila (26/178,
tions. The aetiology of visual loss was also deter- 14.6%); in contrast to the schools in Davao and Ba-
mined for each eye and for the child as an individual. guio where no child was blind from R O R
The results presented are for the anatomical and
aetiological causes of severe visual impairment and
blindness (SVI/BL) in each child.

Table 1. Results of visual acuity measurement in 256 children in four blind schools in Thailand and the Philippines (by %).
W.H.O. Category of visual loss Thailand Philippines
(acuity of better eye)
K.Kaen (n = 66) Manila (n = 121) Baguio (n = 34) Davao (n = 35)

No Impairment 0 0 2.9 0
(6/18 or better)
Visual Impairment 1.5 6.6 5.9 0
(VI: < 6/18, but _>6/60)
Severe Visual Impairment 12.1 6.6 29.4 0
(SVI: < 6/60, but _>3/60)
Blind (BL) 86.4 86.8 61.8 100.0
(BL: < 3/60)
232 C Gilbert & A . Foster

Table 2. Anatomicalcauses of blindness and severe visual impairment in children attending schoolsfor the blind in Khon Kaen (Thailand)
and Manila (Philippines), and in two Filipino towns (Baguio and Davao).

Khon Kaen (Thailand) Manila (Philipp.) Baguio (Philipp.) Davao (Philipp.)

n % n % n % n %

Whole globe 18 27.7 31 27.4 7 22.6 10 28.6

Corneal scar/phthisis 8 1.2.3 15 13.4 17 54.8 15 42.9
Lens 11 16.9 19 16.8 3 9.7 4 11.4
Uvea 1 1.5 1 0.9 1 3.2 2 5.7
Retina 19 29.2 26 23.0 1 3.2 3 8.5
Optic nerve 4 6.2 10 8.8 2 6.5 0 0
Glaucoma 4 6.2 10 8.8 0 0 1 2.9
Normal globe 0 0 1 0.9 0 0 0 0
Total 65 100 113 100 31 100 35 100

A e t i o l o g y o f visual loss mos, buphthalmos and cataract, which could not be

The aetiological categories of visual loss are given
in Table 3. In each location hereditary disease ac-
counted for similar proportions of visual loss (9.7-
17.7%). Intrauterine factors, such as congenitally
acquired rubella, were responsible for 0 %-3.1% of
SVI/BL. Perinatal factors, including R O P (26 chil-
dren) and ophthalmia n e o n a t o r u m (13 children),
were more important causes of visual loss in Khon
Kaen and Manila than Baguio and D a v a o (20.0 and
23.0% compared to 0 and 2.9%, respectively).
Childhood factors, such as V A D and measles ac-
counted for 61.3 and 57.1% of SVI/BL in Baguio
and D a v a o compared to 12.3 and 15.0% in Khon
Kaen and Manila. In each location the aetiology
could not be determined in a high proportion of
children (22.9-50.8%). The majority of these chil-
dren had abnormalities which has been present
since birth, such as microphthalmos, anophthal-
attributed to hereditary disease or events occurring
during the intrauterine period. Few children in this
category had corneal scarring or leucocoria.
A v o i d a b l e causes o f ch i l d h o o d blindness
Some causes of childhood blindness are amenable
to primary preventive measures,-i.e, nutrition edu-
cation and Vitamin A supplementation to prevent
blinding xerophthalmia, immunisation to prevent
measles and congenitally acquired rubella; ocular
prophylaxis in the newborn to prevent ophthalmia
neonatorum; and genetic counselling to prevent
certain autosomal dominant and X-linked diseases.
Other conditions, if identified early, can be treated
to prevent blindness (i.e. are amenable to second-
ary prevention), e.g. cataract, glaucoma and Stage
III 'plus' R O P [7].

Table 3. Aetiologicalcategory of visual loss for children attending schools for the blind in Thailand and the Philippines.

Khon Kaen (Thailand) Manila (Philipp.) Baguio (Philipp.) Davao (Philipp.)

n % n % n % n %

Hereditary 9 13.8 20 17.7 3 9.7 6 17.1

Intrauterine 2 3.1 3 2.7 0 0 0 0
Perinatal 13 20.0 26 23.0 0 0 ! 2.9
Childhood 8 12.3 I7 15.0 19 61.3 20 57.1
Unclassified 33 50.8 47 41.6 9 29.0 8 22.9
Total 65 100 113 100 31 100 35 100

Table 4, Causes of avoidable childhood blindness.
K. Kaen/Manila (n = 178)
n %
Preventable conditions
Corneal scar/phthisis from
VAD/measles 16 9 31
Ophthalmia neonatorum 13 7 1
Autosomal D disease 11 6 4
Congenital rubella 5 3
Treatable conditions
RO P 26 15
Cataract 17 10
Glaucoma 13 7 2
Others 2 1
Total 103 58
Table 4 shows the preventable and treatable
causes of visual loss. Appropriate primary preven-
tive measures could have prevented 54% of child-
hood blindness in Baguio and Davao and 25% in
Khon Kaen and Manila. Treatable causes of visual
loss accounted for 9% of blindness in Baguio and
Davao and 33% in Khon Kaen and Manila.
Discussion
Data obtained from blind school studies need to be
interpreted with caution because children attend-
ing schools for the blind may not be representative
of the total childhood blind population for a variety
of reasons. For example, children of preschool age
are often not represented; children with additional
handicap may not be admitted; and children from
poor, rural, isolated communities may not seek ad-
mission. The advantage of blind school studies are
that a large number of children can be examined in
a relatively short period of time, by one observer
using a standard methodology and system of classi-
fication. In countries that do not have blind regis-
ters accurate data on prevalence and causes can
only be obtained from population based surveys.
However, due to the low prevalence of blindness in
children, (approximately 0.2/1.000 children in in-
dustrialised countries [8-10] increasing to approxi-
mately 1.0/1.000 in poorer developing countries [11,
Urban and rural blindness in schools 233
Baguio/Davao (n = 66) Subtotal (n = 244)
n % %
47 19
1 6
6 6
0 0 2
0 0 11
2 3 8
3 6
2 3 2
42 64 60
12]) very large samples would be needed. Blind
school studies are useful as they can give an indica-
tion of the major causes of visual loss in children
from a particular area.
This pilot study, undertaken in Thailand and the
Philippines, suggests that the pattern of visual loss is
different for children attending blind schools in the
large cities, which mainly serve urban populations
compared to those in the more provincial towns
which mainly serve rural populations. Events oc-
curring during childhood, particularly VAD, were
responsible for the majority of childhood blindness
in Baguio and Davao. Continued vigilance is re-
quired in order to identify communities of children
at risk of nutritional blindness, particularly in rural
areas of the Philippines, so that they can be targeted
with nutrition education and Vitamin A supple-
mentation programmes.
In Khon Kaen and Manila perinatal factors, par-
ticularly ROR are important, possibly due to im-
proved neonatal care services and increased surviv-
al of low birth weight and premature babies. Recent
treatment trials have shown that cryotherapy is eff-
fective at halting the progression of Stage lII 'plus'
ROP in approximately 50% of cases [7], making
ROP a potentially avoidable cause of childhood
blindness. Screening and treatment of at risk babies
(i.e. those weighing 1,500 gins or less at birth and
those born before 32 weeks gestation) requires
close cooperation between Neonatologists and
234 C Gilbert & A. Foster
Ophthalmologists, special training and equipment,
and a high level of motivation. This study suggests
that ROP may be an important cause of childhood
blindness in some large South East Asian cities.
Other avoidable causes of childhood blindness
identified were cataract (7.4%) and glaucoma
(5.9 %). These two conditions require early identifi-
cation and referral to ophthalmic centres for spe-
cialist treatment. Visual loss was attributed to oph-
thalmia neonatorum in 5.1% of all children and
7.3% in the city blind schools. Health education
concerning sexually transmitted diseases (STDs),
and identification and treatment of STDs during
pregnancy, together with ocular prophylaxis in the
newborn are necessary steps to prevent visual loss
from this cause.
Conclusion
The pattern of blindness in children in this pilot
blind school study undertaken in four schools for
the blind in Thailand and the Philippines shows that
there are different causes in children attending
large city blind schools compared to those seen in
the more provincial blind schools. The data sug-
gests that ROP is an important cause of blindness in
urban areas and Vitamin A deficiency in rural Fil-
ipino areas.
Overall more than half the children were blind
from preventable or treatable conditions. Surveil-
lance of the changing patterns of blindness in chil-
dren from one situation to another, and in one place
over time, is important in planning and implement-
ing programmes for the control of childhood blind-
ness.
Acknowledgement
This study was supported by the Oxford Ophthalm-
ological Congress Award and Christoffel Blinden-
mission, Germany.
References
1. Sommer A. Nutritional blindness. Xerophthalmia and Ker-
atomalacia. Oxford University Press 1982.
2. Van Agtmaal EJ. Vitamin A proteins in tear fluid: a nutri-
tional field survey on preschool children in Northeast Thai-
land. Thesis 1989.
3. Vitamin A news Notes. Winter 1990. Helen Keller Interna-
tional.
4. Vital News. 1990; 1.
5. Konyama K, Srisupan V. The causes of blindness in a rural
province of Thailand. Trans APAO 1968; 3: 146-54.
6. Gilbert CE, Foster A, Negrel AD, Thylefors B. Childhood
blindness: a new form for recording causes of blindness and
low vision in children. WHO Bulletin 1993 (in press).
7. Multicentre trial of cryotherapy for retinopathy of prema-
turity. One year outcome - structure and function. Cryoth-
ermy for Retinopathy of Prematurity Cooperative Group.
Arch Ophthalmo11990; 108: 1408-16.
8. Foster A, Gilbert CE. Epidemiology of childhood blindness.
Eye 1992; 6: 173-6.
9. Goggin M, O'Keefe M. Childhood blindness in the Republic
of Ireland: a national survey. Brit J Ophthalmol 1991; 75:
425-9.
10. Riise R, Flage T, Hansen E, Rosenberg T, Rudanko S-L,
Voggosson G, Warburg M. Visual impairment in Nordic
children. I Nordic registers and prevalence data. Acta Oph-
thalmologica 1992; 70: 145-54.
11. Chirambo MC, Tielsch JM, West KR Katz J, Tizazu T,
Schwab L, Johnson G, Swartwood J, Taylor HR, Sommer A.
Blindness and visual impairment in southern Malawi. Bull
WHO 1986; 64: 567-72.
12. Faal H, Minassian D, Sowa S, Foster A. National survey of
blindness and low vision in The Gambia. Brit J Ophthalmol
1989; 73: 82-7.