|Year : 2013 | Volume
| Issue : 1 | Page : 61-65
Blindness and severe visual impairment in pupils at schools for the blind in Burundi
Patrick Ruhagaze1, Kahaki Kimani Margaret Njuguna1, Lévi Kandeke1, Paul Courtright2
1 Department of Eye, University of Nairobi, Nairobi, Kenya, Université du Burundi, Bujumbura, Burundi
2 Kilimanjaro Centre for Community Ophthalmology, Moshi, Tanzania
|Date of Web Publication||23-Jan-2013|
B.P. 955 Bujumbura, Burundi
Source of Support: This project was supported by the Netherlands Lions and
Wilde Ganzen. Additional support was provided by the University of Nairobi,, Conflict of Interest: None
| Abstract|| |
Purpose: To determine the causes of childhood blindness and severe visual impairment in pupils attending schools for the blind in Burundi in order to assist planning for services in the country.
Materials and Methods: All pupils attending three schools for the blind in Burundi were examined. A modified WHO/PBL eye examination record form for children with blindness and low vision was used to record the findings. Data was analyzed for those who became blind or severely visually impaired before the age of 16 years.
Results: Overall, 117 pupils who became visually impaired before 16 years of age were examined. Of these, 109 (93.2%) were blind or severely visually impaired. The major anatomical cause of blindness or severe visual impairment was cornea pathology/phthisis (23.9%), followed by lens pathology (18.3%), uveal lesions (14.7%) and optic nerve lesions (11.9%). In the majority of pupils with blindness or severe visual impairment, the underlying etiology of visual loss was unknown (74.3%). More than half of the pupils with lens related blindness had not had surgery; among those who had surgery, outcomes were generally poor.
Conclusion: The causes identified indicate the importance of continuing preventive public health strategies, as well as the development of specialist pediatric ophthalmic services in the management of childhood blindness in Burundi. The geographic distribution of pupils at the schools for the blind indicates a need for community-based programs to identify and refer children in need of services.
Keywords: Burundi, Childhood Blindness, Schools for the Blind
|How to cite this article:|
Ruhagaze P, Njuguna KM, Kandeke L, Courtright P. Blindness and severe visual impairment in pupils at schools for the blind in Burundi. Middle East Afr J Ophthalmol 2013;20:61-5
|How to cite this URL:|
Ruhagaze P, Njuguna KM, Kandeke L, Courtright P. Blindness and severe visual impairment in pupils at schools for the blind in Burundi. Middle East Afr J Ophthalmol [serial online] 2013 [cited 2020 Aug 4];20:61-5. Available from: http://www.meajo.org/text.asp?2013/20/1/61/106390
| Introduction|| |
There are an estimated 1.4 million blind children in the world ,, over 90% of whom live in middle income and low-income countries.  Although not a major problem in terms of absolute number compared to adults, childhood blindness remains a priority for a number of reasons; children who are born blind or who become blind and survive have a lifetime of blindness ahead of them. There is a large emotional, social and economic cost to the child, the family, and society. Many of the causes of blindness in children are either preventable or treatable. Children are born with an immature visual system and, for normal visual development to occur, they need clear, focused images to be transmitted to the visual pathways, thus, there is a level of urgency for treating childhood eye disease.
Generating information on the prevalence of childhood blindness is costly and difficult; recent key surveys in Eastern Africa have suggested that the prevalence of blindness in children ranges from 0.2-0.8 per 1,000 children.  The magnitude of childhood blindness in Burundi has not been assessed and, as a first step, a survey of children at all schools for the blind in Burundi was undertaken.
The Republic of Burundi is a small densely populated (320 people/km  ) landlocked country in the Great Lakes region of Eastern Africa. Burundi has a GDP per capita of $174 and over 90% of population lives on less than $2 a day.  Children make up 47% of its population. 
| Materials and Methods|| |
A descriptive cross-sectional study was conducted in November 2010 in all schools for the blind in Burundi. The country has three schools for the blind, all residential, located in Bubanza (northwest), Gitega (center) and Kayanza (north) provinces. All pupils were interviewed and examined but only those who became visually impaired before 16 years of age were included in the analysis. Informed consent was obtained from each school's director at the time of interview/examination. Ethical approval was provided by the Ministry of Health, Burundi.
Information was gathered using interviews with students and school staff. The WHO/PBL eye examination record for children with blindness and low vision form was used to collect the data with a slight modification to collect information on pupils who may have had cataract surgery. Data were collected on the age at onset of visual loss, family history, history of consanguinity and information about hereditary diseases, intrauterine, perinatal or childhood factors and previous eye surgery. Monocular and binocular distance visual acuities (VA) were measured for each student with Snellen's illiterate E chart with the available refractive correction (if any) at the time of the study. All the pupils were examined by two of the authors. Physical examination was carried out to identify additional disabilities. Anterior segment examination was performed with torchlight and a simple magnifying loupe or slit lamp. Dilated fundus examination was carried out with indirect ophthalmoscope and slit lamp where appropriate. Objective and subjective refractions were performed for pupils with VA less than 6/18 in whom there was no obvious anatomical cause of visual loss. Any required therapeutic interventions were recorded and all pupils who needed treatment were referred to the appropriate clinician for management.
To determine the major anatomical site of abnormality leading to visual loss for each eye when two or more sites of abnormality were present in the same eye, we used the criteria given in the "WHO/PBL examination record for children with blindness and low vision, coding instructions". The same manual was used to determine the anatomical site of abnormality leading to visual loss for the child and the etiology of visual loss. The definitions of blindness and visual impairment (BL/VI) used in this study followed the International Statistical Classification of Diseases and Related Health Problems, 10 th Revision, version for 2007 (ICD-10): H54; blindness was defined as presenting visual acuity of <3/60 in the better eye, severe visual impairment <6/60-3/60, visual impairment <6/18-6/60, and normal vision 6/18 or better. Data were collected on the residence of the child from the school records. Data were analyzed using SPSS software version 17.0 (IBM Corp., Armonk, NY, USA).
| Results|| |
A total of 118 pupils were enrolled and examined. One child became blind at the age of 16 years and was excluded from this study. There were 65 (55.5%) males and 52 (44.5%) females; 60 (51.3%) pupils were aged 5 - 15 years, and 57 (48.7%) were aged 16 years and above; the age range was 5 to 28 years with a mean age of 15 years. A family history of poor vision was recorded in 23 (19.7%) and parental consanguinity in 3 (2.6%). Six (5.1%) pupils had no visual impairment; 2 (1.7%) had visual impairment; 8 (6.8%) were severely visually impaired and 101 (86.4%) were blind [Table 1].
|Table 1: Visual status of pupils attending schools for the blind in Burundi, n = 117 |
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Data on causes of blindness and severe visual impairment (BL/SVI) showed that corneal pathology/phthisis bulbi were the leading anatomical cause (23.9%) followed by lens disorders (18.3%) and uveal conditions (14.7%) [Table 2]. Among the 20 pupils with lens disorders, 13 (65%) had un-operated cataract, 4 (20%) had posterior capsular opacity and 3 (15%) had cortex matter in the visual axis. Among the 11 pupils with amblyopia 6 (54.5%) were secondary to lens removal. If these pupils were included as lens-related causes of blindness then lens-related causes would equal corneal/phthisis related causes of blindness (n = 26). Among the 19 pupils who had undergone cataract surgery, 16 (84.2%) remained blind or severely visually impaired; amblyopia was present in 6 (37.5%), posterior capsule opacification in 4 (25.0%), cortex matter in the visual axis in 3 (18.8%) and pre-existing ocular diseases (keratoconus, optic nerve atrophy and chorioretinal scar) in 3 (18.8%). The age at the time of cataract surgery was between 1 and 20 years with a mean age of 11.5 years and median age of 12 years. Only one child who had cataract surgery was wearing spectacles.
|Table 2: Anatomical site of abnormality leading to BL/SVI among the 109 pupils |
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In 81 pupils (74.3%), an etiologic cause of visual loss could not be determined. These were mainly pupils with cataract, uveitis, optic nerve atrophy, glaucoma and anterior segment dysgenesis. Among the known etiologies, childhood factors predominated with 16.5% of all cases followed by intrauterine factors (5.5%), perinatal/neonatal factors (2.8%) and hereditary factors (0.9%). Vitamin A deficiency as a presumed etiologic cause was detected in two pupils. Overall, 67.9% of pupils were blind from potentially preventable or treatable conditions.
As the map [Figure 1] and [Table 3] illustrate, 35 (30%) of the 117 pupils in the three schools came from the provinces of the school placement, while these three provinces only account for 1,648,658 (20.5%) of Burundi's 8 million population. Two provinces, the most peripheral, contributed no children to the schools and the Eastern half of the country, comprising just over half of the country's population only contributed 24 (20.5%) pupils to the schools for the blind.
|Table 3: Residence of the pupils attending the three schools for the blind |
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|Figure 1: Residence of the pupils attending the three schools for the blind|
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| Discussion|| |
This is the first study of blindness and severe visual impairment in schools for the blind in Burundi. It should be recognized that these pupils represent only a small group of the blind children in the country because the latter has only 3 schools for the blind and their capacity is very limited. It is believed that in most developing countries only about 10% of blind children are in schools for the blind.  Assessment of where these pupils came from indicates that the existing schools are only covering a limited geographic area; the Eastern half of the country contributes few pupils to the schools. There is no reason to expect in this small country that there is a lower prevalence of childhood blindness in the Eastern regions.
Similar to other recent studies from schools for the blind in Africa, ,, there is no single major cause of childhood blindness in children in these schools; instead, it is a mix with corneal causes and lens related causes being the most common. Lens related conditions predominate in the younger (<16 years old) age group while corneal conditions predominate in the older (≥16 years old) age groups. Earlier studies in schools for the blind in Africa, India and Indonesia have listed preventable corneal causes (notably corneal scars due to vitamin A deficiency, measles or harmful traditional eye medicines). ,,,,, Vitamin A deficiency blindness has not been recognized as a problem in Burundi. This may be attributed to vitamin A supplementation in 6 - 59 months old children during Mother and Child Health Weeks (MCHW) organized around the country twice per year since 2003, as well as increased awareness in terms of heath care leading to usage of heath facilities. There was no child with a history of measles related blindness. This is probably due to the high immunization coverage in Burundi [Table 4] and [Figure 2]. However, unreliable histories and absence of medical reports could have underestimated the role of measles and VAD in this study. In Burundi, among pupils at schools for the blind, 67.9% of pupils were blind from avoidable causes.
|Table 4: Measles immunization and vitamin A supplementation coverage in Burundi |
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|Figure 2: Measles immunization and vitamin A supplementation coverage in Burundi. Source: PPAC 2011 (Plan Pluri Annuel Complet), Health Ministry of Burundi and WHO Burundi|
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In contrast to recent studies of children at schools for the blind in Eastern Africa,  children in the schools for the blind in Burundi appear to be appropriately placed; however, 6 children (5.1%) had no visual impairment. However, there is an absence of optical services (spectacles, low vision devices, other non-optical devices) which could improve the quality of vision of some children. Currently, there are no services for children with low vision in Burundi and it is likely that children with low vision remain in the community without access to care. More than half of pupils with lens related blindness have not had surgical intervention. The large proportion of children requiring surgery have also been reported in studies from India. , The low rate of surgical intervention contrasts with findings from elsewhere in Eastern Africa where most children with lens related blindness in the schools have undergone surgery. , Unlike Tanzania, Kenya, Uganda, and Malawi, Burundi does not have pediatric ophthalmology programs and services. Among those who had surgery the outcomes were generally poor. The cohort children in the current study were not identified and offered good quality surgical treatment in a timely fashion. There are no programs in Burundi focused on identification and referral of children with childhood cataract or other causes of severe vision loss or blindness.
At the time of the study, parents were not present and no medical records were available. Information was gathered using interviews with students and school staff. In most cases, school staff did not have enough information on the past medical, surgical and ocular history, as well as family history of the pupils. Thus, we had to rely on the history given by pupils. Due to unreliable history, lack of medical records and limited scope for investigation of the affected pupils and family, the underlying etiology of visual loss could not be determined in the majority the cases.
In conclusion, these findings suggest the importance of continuing primary prevention of preventable causes of blindness through promotion of health education, vitamin A supplementation, and immunization in children. The findings also suggest that Burundi requires a specialized pediatric ophthalmology unit, as well as systems for early identification and referral. Finally, many pupils at the schools for the blind could benefit from optical services; this would require developing strong links between the education and health sectors.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]