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Middle East African Journal of Ophthalmology Middle East African Journal of Ophthalmology
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  Table of Contents 
Year : 2012  |  Volume : 19  |  Issue : 2  |  Page : 190-193  

Xerophthalmia in a Traditional Quran Boarding School in Sudan

1 Department of Paediatrics, University of Khartoum, Khartoum, Sudan
2 Department of Research and Biostatistics, Sudan Medical and Scientific Research Institute, Khartoum, Sudan
3 Department of Ophthalmology, University of Medical Sciences and Technology, Khartoum, Sudan

Date of Web Publication21-Apr-2012

Correspondence Address:
Abdelmoneim E. M. Kheir
Department of Paediatrics, Faculty of Medicine, University of Khartoum, P.O. Box 102, Khartoum
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0974-9233.95247

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Purpose: To determine the prevalence of xerophthalmia at a traditional boarding school where children do not receive a diet adequate in vitamin A.
Materials and Methods: A cross-sectional survey of 406 males residing in a Quranic traditional school was conducted using the World Health Organization xerophthalmia checklist. The association between the prevalence of night blindness and proportion of students staying at the school for 6 consecutive months and those eating solely at the school was investigated. The difference in age between children with night blindness and those without was investigated. Statistical significance was indicated by P<0.05.
Results: The prevalence of night blindness, conjunctival xerosis and Bitot's spots was 24%, 12.5% and 1%, respectively. None of the boys had corneal ulceration, corneal scars and corneal xerosis. No significant association was observed between the differences in mean age and development of night blindness (P=0.657). There was a significant association between the duration of stay (cut-off of 6 months continuously) at the institute and the development of night blindness (P=0.023). There was no statistical significance between regularly eating at the "maseed" and outside the "maseed" and the development of night blindness (P=0.75).
Conclusion: Children residing at a traditional school are vulnerable to developing xerophthalmia where the diet is inadequate in vitamin A. Institutional caregivers should be made aware of the importance of providing a balanced diet rich in vitamin A. Institutional caregivers should also be educated on the signs and symptoms of vitamin A deficiency for early detection of xerophthalmia.

Keywords: Children, Night blindness, Xerophthalmia

How to cite this article:
Kheir AE, Dirar TO, Elhassan HO, Elshikh MA, Ahmed MB, Abbass MA, Idris SS. Xerophthalmia in a Traditional Quran Boarding School in Sudan. Middle East Afr J Ophthalmol 2012;19:190-3

How to cite this URL:
Kheir AE, Dirar TO, Elhassan HO, Elshikh MA, Ahmed MB, Abbass MA, Idris SS. Xerophthalmia in a Traditional Quran Boarding School in Sudan. Middle East Afr J Ophthalmol [serial online] 2012 [cited 2022 Oct 3];19:190-3. Available from: http://www.meajo.org/text.asp?2012/19/2/190/95247

   Introduction Top

Xerophthalmia is a clinical complication of vitamin A deficiency (VAD). Worldwide, VAD is regarded as a public health nutrition problem among preschool children in 118 developing countries. [1] It is believed that there are approximately 127 million preschool children with VAD. [2] VAD is a major cause of impaired immunity and increased morbidity and mortality from childhood infectious diseases in many developing countries, [3] and is known to extend through school age and adolescent years into adulthood. [4]

An important risk factor for VAD is an inadequate intake of vitamin A. Prolonged periods of VAD result in vitamin A deficiency disorders (VADD). Sixty countries are listed by the World Health Organization (WHO) where VADD is a public health problem and approximately 5-7% of children below 6 years of age are affected in these countries. [2] An estimated 2.8 million children aged less than 5 years are clinically affected by VAD in the world and 258 million are believed to be subclinically affected. [5]

VADD can manifest clinically as xerophthalmia. [2] Xerophthalmia affects approximately 4.4 million children. [1] Xerophthalmia includes night blindness, Bitot's spots, corneal xerophthalmia, and keratomalacia. [6] Nightblindness is an early reversible clinical manifestation of VAD among preschool children. [3] However, xerophthalmia may eventually lead to blindness from irreversible ulceration and destruction of the cornea. [5] Xerophthalmia continues to be the leading cause of blindness among children in developing countries. [6] A prevalence of xerophthalmia higher than 1% among preschool children is considered a public health problem. [7]

The aim of this study was to measure the prevalence of xerophthalmia among children residing in a traditional boarding school "maseed0" in a rural region on the outskirts of Khartoum. The "maseed" is a traditional boarding school for teaching the Quran and the basics of reading and writing. "Maseeds" are quite common throughout Sudan. Most "maseed" attendees are males from 6 to 14 years of age. Boys spend a considerable time at the "maseed,0" away from home.

The diet provided to the children at the "maseed" is mostly nutritionally deficient in vitamin A. We had obtained information on local dietary practices at the "maseed0" in a prior exploratory visit. Boys are exposed almost exclusively daily (for prolonged periods of time) to a diet that consists of a staple cereal (sorghum or millet) and "mullah" (water, scanty, grinded dried meat and okra). We therefore, regard children at the " maseed" as a vulnerable group for VADD and with high likelihood for xeropthalmia.

   Materials and Methods Top

This was a cross-sectional survey conducted at Umm-dawanban Maseed, a traditional boarding school, where the Quran is taught. It hosts approximately a total of 500 part-time and temporary students from different regions of Sudan. The institute is located in a rural area 45 kilometers east of the capital Khartoum. The survey was conducted during May 2009.

We surveyed 406 students. Sommer et al., have shown that a history of night blindness is a reliable indicator of VAD. [8] We used the local term for night blindness in Arabic "asha laily" to confirm the presence or absence of a history of night blindness. If the child was unfamiliar with the meaning, a history of night blindness was ascertained if the child responded positively to the following three questions recommended by the WHO (slightly modified for our study): 1. Do you have any problem seeing during the day time? 2. Do you have any problem seeing at night time? 3. If yes, is this different from other children in the " maseed"? [2] Older peers who resided with children in the same dormitory were asked to communicate the term to any child who did not understand the local term or the questions.

All children with night blindness were referred to the ophthalmologists for examination for xerophthalmia. Two ophthalmologists examined the eyes using a torch and magnifying loupe.

Xerophthalmia was diagnosed using definitions provided by WHO. [9] Other questions were asked to collect background information such as age, duration of stay in months and pattern of eating.

Data were analyzed with SPSS version 15 software (IBM Corp., Armonk, NY). Frequency analysis for background variables was performed. The Chi-square test was used to determine the association between the prevalence of night blindness and proportion of students staying at the " maseed" for six consecutive months and to determine the relationship between night blindness and eating solely at the "massed". The independent t-test was used to assess the difference in age between children with night blindness and those without. Level of significance was set on an α-level at 0.05.

Approval was obtained from the ethics committee of the University Medical Sciences and Technology and it is registered with this institute as part of the fulfillment criteria for a diploma in research methodology and biostatistics.

Ethical clearance was obtained from the administrators of the " maseed" to conduct the study. All children interviewed and examined at the " maseed" were given vitamin A capsules as a prophylactic measure. All students with signs of VAD or other ophthalmological problems were referred to the local hospital for further assessment and treatment.

   Results Top

The cohort comprised 406 male children. The mean age was 13.8 ± 3.8 years. The mean duration of stay at the "maseed" was 14.3 ± 17.2 months. Seventy-four (18%) children stayed at the " maseed" for a continuous period of 6 months compared to 332 (82%) who resided for less than 6 months. Similarly the proportion of children who only ate at the " maseed" was 189 (47%), compared to 217 (53%) who regularly ate outside the " maseed".

[Table 1] presents the prevalence of xerophthalmia. The prevalence of night blindness was 23.6%; 12 (12.5%) of the children with night blindness had conjunctival xerosis.
Table 1: Prevalence of xeropthalmia

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The mean age of children with night blindness was 13.6 ± 3.4 years and 13.8 ± 3.9 years for those who did not have night blindness. No significant association was observed between the differences in mean age and development of night blindness (P=0.657). The mean duration of stay at the institute for those with night blindness was 15.3 ± 15.9 months. Forty-six (48%) children with night blindness only ate at the " maseed", while 50 (52%) of the children with night blindness frequently ate outside the " maseed" (P= 0.75). There was a significant association between the duration of stay (cut-off of 6 months continuously) at the institute and the development of night blindness (P=0.023). There was no statistical significance between regularly eating at the "maseed" and outside the " maseed" and the development of night blindness (P=0.75).

   Discussion Top

To our knowledge, this is the first study that examines xerophthalmia in male children residing in a " maseed". The results of our study indicate a high prevalence of night blindness. However, assessment of night blindness was not determined objectively using the dark adaptation test. However, the dark adaptation test in the current setting is time consuming, expensive and requires skilled personnel and a specially equipped setting all of which are were unavailable during the study.

Irrespective of age, all students residing at the " maseed" were at equal risk of developing night blindness. We found that the length of stay at the " maseed" is a significant risk factor for development of night blindness. The data also indicates that eating outside the " maseed" is not a significant factor in the development of night blindness. Likely, the students who regularly eat outside the " maseed" most probably consume foods lacking vitamin A as well.

We consider children residing in traditional boarding schools as a vulnerable group with regards to VAD and VADD, as a result of a consumption of diet which is deficient in vitamin A. Further surveys are needed to measure the magnitude of xerophthalmia among children at other traditional boarding schools and the implications as a public health problem.

Efforts should be made to increase the awareness of the institutional caregivers on the importance of implementing a balanced and nutritionally adequate diet that includes vitamin A and provitamin A carotenoids. The " maseed" administrators should receive education on signs and symptoms of VAD and VADD. The children need to be targeted with VAD and VADD interventions. The need to provide periodic vitamin A supplementation, fortified food and dietary diversification would also be beneficial and should form the basis of a long-term policy

aimed at preventing VAD and VADD. This policy will also improve the nutritional status of malnourished children who study at the " maseed". The policy should include follow-up visits for screening for VAD and VADD among children attending "maseed". We believe these actions will reduce health-related expenses for the students.

To conclude, xerophthalmia is prevalent among children residing at traditional boarding school or " maseed". This segment of the population constitutes another vulnerable group that remains undetected. Awareness about xerophthalmia and methods of prevention should be promoted among the institutional caregivers.

   Acknowledgments Top

The authors would like to gratefully thank Dr. Mohamed Kardaman and Dr. Mohamed Abdelrahman for critically reviewing the proposal. The authors also express their appreciation the candidates of the Research and Biostatistics Diploma Program for assisting in the pretesting and data collection process. Finally, the authors thank the President of the University of Medical Sciences for providing the funds necessary to conduct the survey.

   References Top

1.Singh V, West KP. Vitamin A deficiency and xerophthalmia among school-aged children in Southeastern Asia. Eur J Clin Nutr 2004;58:1342-9.  Back to cited text no. 1
2.Dole K, Gilbert C, Deshpande M, Khandekar R. Prevalence and determinants of xerophthalmia in preschool children in Urban Slums, Pune, India: A preliminary assessment. Ophthalmic Epidemiol 2009;16:8-14.  Back to cited text no. 2
3.Semba RD, De Pee S, Panagides D, Poly O, Bloem MW. Risk factors for night blindness among women of childbearing age in Cambodia. Eur J Clin Nutr 2003;57:1627-32.  Back to cited text no. 3
4.West KP Jr. Extent of vitamin A deficiency among preschool children and women of reproductive age. J Nutr 2002;132:2857-66.  Back to cited text no. 4
5.Getaneh T, Assefa A, Tadesse Z. Dietary practices and xerophthalmia in under-fives in Jimma Town, Southwest Ethiopia. East Afr Med J 2000;77:313-5.  Back to cited text no. 5
6.Semba RD, de Pee S, Panagides D, Poly O, Bloem MW. Risk factors for xerophthalmia among mothers and their children and for mother-child pairs with xerophthalmia in Cambodia. Arch Ophthalmol 2004;122:517-23.  Back to cited text no. 6
7.World Health Organization. Control of Vitamin A Deficiency and Xerophthalmia. Geneva, Switzerland: World Health Organization; 1982. World Health Organization Technical Report Series 672.  Back to cited text no. 7
8.Sommer A, Hussaini G, Muhilal, Tarwotjo I, Susanto D, Saroso J. History of night blindness: A simple tool for xerophthalmia screening. Am J Clin Nutr 1980;33:887-91.  Back to cited text no. 8
9.Sommer A. Vitamin A deficiency and its consequences: A field guide to their detection and control. 3 rd ed. Geneva: World Health Organization; 1995.  Back to cited text no. 9


  [Table 1]

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