https://doi.org/10.35845/kmuj.2023.23247 ORIGINAL ARTICLE
Association of asthenopia with refractive errors in
madrassa students
Sharmeen Shahid 1
, Sania Abdul Rauf
1, Shanza Dastgir1, Farhana Ali 1, Rabia
Saifullah1, Uswa Fatima1
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1: University Institute of Optometry and Vision Sciences, The University of Lahore, Lahore, Pakistan
Email Contact #: +92-344-4441100
Date Submitted:November 10, 2022 Date Revised:April 19, 2023 Date Accepted:May 16, 2023 |
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THIS ARTICLE MAY BE CITED AS:Shahid S, Rauf SA, Dastgir S, Ali F, Saifullah R, Fatima U.Association of asthenopia with refractive errors in madrassa students. Khyber Med Univ J 2023;15(2):101-5. https://doi.org/10.35845/kmuj.2023.23247
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ABSTRACT
OBJECTIVE: To determine the association of presenting clinical features of asthenopia in madrassa students with different refractive errors.
METHODS: This cross-sectional study was conductedfrom September-November 2022 at different Madrassas in Lahore, Pakistan. Study was performed on a sample of 108 patients, who had different refractive difficulties. Informed consent was taken from the patients aging≥18 years and fromparents/ guardians of patients aging <18 years. A self-designed questionnaire was used to gather the data of all patients. Patients with different refractive errors within the range of 8-25 years were taken into consideration. Data were analyzed by using SPSS version 25. A statistically significant p-value of 0.05 was considered.
RESULTS: Out of 108 patients, 38 (35.2%) were males and 70 (64.8%) were females. Majority (n=59; 54.6%) were >16 years of age. Common asthenopic symptoms included hazy vision (n=106; 98.1%), headache (n=93; 86.1%), discomfort (n=79; 73.1%), pain (n=76; 70.4%) and eye strain (n=72; 66.7%). Common refractive errors were myopia (n=59; 54.6%), hypermetropia (n=25; 23.2%) and astigmatism (n=24; 22.2%). Severity of refractive errors was mild in majority of cases of myopia (n=24/59; 40.7%) and hypermetropia (n=12/25: 48%) and moderate in astigmatism (n=16; 64%). Headache, eye strain and blurring of vision had significant association with myopia, hypermetropia, and astigmatism.
CONCLUSION: Myopia and hypermetropia are the most common refractive errors;hazy vision and headache are the common asthenopic symptoms. There is a strong association between asthenopic symptoms and refractive errors.
KEYWORDS: Refractive Errors (MeSH); Asthenopia (MeSH); Myopia(MeSH); Hypermetropia(MeSH); Astigmatism(MeSH); Headache(MeSH).
INTRODUCTION
Asthenopia, or ocular strain, is a condition resulting from eye fatigue or overwork, often during intense focus activities like digital screens, reading or other close-up tasks. Common symptoms include blurred vision, photophobia, headaches, stinging sensations, diplopia, eye ache, epiphora, and foreign body sensations.1 It's often linked to refractive errors and can cause dry eye.2 Patients might bring items closer to their eyes while reading, increasing convergence and exacerbating asthenopia.3
Headache associated with refractive errorsis abbreviated as HARE.4The usage of portable digital gadgets is usually associated with asthenopia.5All patients with uncorrected refractive defects should have adequate and accurate corrections to reduce the symptoms of ocular tiredness.6
Worldwide, thirty-six million people are estimated to be blind,188.5 million have mild visual impairment, and 216.6 million have moderate to severe visual impairment.7 Uncorrected refractive errors are the leading cause of visual impairment. Globally,nineteen million children of <15 years’ ageare visually impaired.7-31% of childhood blindness is avoidable in developing countries,3-28% is preventable and 10-58% is treatable.8
Refractive errors have become oneof the most common problems among school going children, especially in madrassa students who are neglected by the lack of school health services.A study on 168 madrassah students found 81.1% myopic, 7.6% hyperopic, and 11.3% astigmatic refractive errors, highlighting the need for awareness screening for potential blindness among madrassa students.9Another cross-sectional study at Al-Shifa Trust, found that 29% of 410 male madrassa students in Rawalpindi had uncorrected refractive errors, with mobile use being 9 times more common than non-mobile users. Family history of refractive errors and outdoor activities were associated with refractive errors in madrassa students. Myopia was the most common refractive error, followed by astigmatism and hyperopia.10 Uncorrected refractive errors can lead to other eye diseases such as amblyopia and even blindness therefore it must be detected as early as possible.11
Although, there have been a few studies on the prevalence of refractive errors among madrassa students and the associated risk factors, there seems to be a lack of comprehensive awareness and screening programs for potential blindness among this specific student population in Pakistan. This gap suggests the need for further research and interventions aimed at addressing refractive errors and promoting eye health among madrassa students, particularly in terms of preventive measures and timely detection.
Given that madrassa students perform a lot of close work and that there are numerous obstacles to screening madrassa students due to a lack of health services, we decided to investigate the relationship between asthenopic symptoms and refractive errors among this group of students
METHODS
The study was carried out in different madaris from September-November,2022.The sample size was calculated through a non-probability convenient sampling technique. One hundred and eight patients were included in this study according to this sample formula
=z21-d/2 p(1-P)=(0.96)2(0.62)(1-0.62)/(0.05)2
Both gender males and females having different types of refractive errors were included in this study with an age range of 8-25 years. Patients of all other ages, and having any other ocular or systemic disorders were excluded from the study. Data was collected by taking informed consent from Madrassa heads and parents of children. Study approval was taken from the institutional review board. All the patients were screened by taking their visual acuity on Snellen’s chart. After screening 206 patients 108 were included in the study who had refractive errors.Retinoscopy was performed to assess their visual status and then their refraction was carried out. Ophthalmoscope was used to examine fundus to rule out any ocular pathology. So patients who had only refractive errors were included. Patients who had amblyopia, strabismus or another pathology were excluded. Data were analyzed by using SPSS version 25. Categorical variables' results were expressed as percentages and proportions. Continuous data were described using the mean and standard deviation. Pearson chi-square test was applied to analyze the association between refractive errors and asthenopic symptoms. A statistically significantp-value of 0.05 was considered.
RESULTS
Among 108 patients, 38 (35.2%) were males and 70 (64.8%) were females. Most of the asthenopic subjects belong to age group 16 to 25 years while the most common refractive error was myopia.We have checked all types of refractive errors which included 59 myopic, 25 hypermetropic and 24 astigmatic patients (Table I).
Table I: Demographic data distribution of the study
participants
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Variable |
Number (n=108) |
Percentage |
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Age (years) |
8 to 12 |
25 |
23.1 |
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>12 to 16 |
24 |
22.2 |
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>16 to 21 |
27 |
25.0 |
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>21 to 25 |
32 |
29.6 |
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Gender |
Males |
38 |
35.2 |
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Females |
70 |
64.1 |
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Refractive errors |
Myopia |
59 |
54.6 |
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Hypermetropia |
25 |
23.2 |
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Astigmatism |
24 |
22.2 |
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Table II: Frequency of asthenopic symptoms in study subjects
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Variables |
Frequency |
Percentage |
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Hazy Vision |
106 |
98.1 |
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Headache |
93 |
86.1 |
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Discomfort |
79 |
73.1 |
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Pain |
76 |
70.4 |
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Eye Strain |
72 |
66.7 |
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Photophobia |
55 |
50.9 |
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Watering |
55 |
50.9 |
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Tearing |
43 |
39.8 |
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Itching |
39 |
36.1 |
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Burning Sensation |
30 |
27.8 |
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Diplopia |
26 |
24.1 |
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Vertigo |
24 |
22.2 |
Table III shows that refractive errors are associated with asthenopic symptoms. Headache is the most common associated complaint. It has a significant association with myopia, hypermetropia, and astigmatism. The blurring of vision and eye strain is also significantly associated with all refractive errors. Discomfort is significantly associated with astigmatism and myopia. Itching is significantly reported in hypermetropia. Astigmatism and hypermetropia are significantly associated with watering. Vertigo is significantly associated with astigmatism. Astigmatic and hypermetropic patients report significant photophobia. Hypermetropic individuals report a significant complaint of pain in the eyes. The burning sensation was not clinically significantly observed in all refractive errors.
Table III: Association of different refractive errors with asthenopia in study subjects
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Symptoms |
Refractive Errors |
P value |
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Headache |
Astigmatism |
0.05 |
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Hypermetropia |
0.03 |
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Myopia |
0.05 |
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Eye strain |
Astigmatism |
0.03 |
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Hypermetropia |
0.04 |
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|
Myopia |
0.03 |
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Blur vision |
Astigmatism |
0.05 |
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Hypermetropia |
0.02 |
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Myopia |
0.004 |
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Discomfort |
Astigmatism |
0.01 |
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Hypermetropia |
0.11 |
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Myopia |
0.01 |
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Itching |
Astigmatism |
0.28 |
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Hypermetropia |
0.02 |
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Myopia |
0.34 |
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Watering |
Astigmatism |
0.002 |
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Hypermetropia |
0.005 |
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Myopia |
0.11 |
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Vertigo |
Astigmatism |
0.03 |
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Hypermetropia |
0.24 |
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Myopia |
0.53 |
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Photophobia |
Astigmatism |
0.01 |
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Hypermetropia |
0.01 |
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Myopia |
0.1 |
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Diplopia |
Astigmatism |
0.29 |
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Hypermetropia |
0.33 |
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Myopia |
0.44 |
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Pain |
Astigmatism |
0.08 |
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Hypermetropia |
0.05 |
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Myopia |
0.14 |
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Burning Sensation |
Astigmatism, |
0.07 |
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Hypermetropia, |
0.12 |
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Myopia |
0.21 |
Severity of the refractive errors is presented in Table IV. Majority of the study subjects presented with mild myopia and mild to moderate hypermetropia while, moderate astigmatism is found in most of the cases.
Table IV. Types of refractive errors in study subjects
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Severity of Refractive Errors |
Myopia (n=59) |
Hypermetropia (n=25) |
Astigmatism (n=24) |
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Mild |
24 (40.7%) |
12 (48%) |
5 (20%) |
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Moderate |
23 (39%) |
10 (40%) |
16 (64%) |
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High |
12 (20.3%) |
3 (112%) |
4 (16%) |
DISCUSSION
According to our study myopia is the most common refractive defect among students and so are the asthenopic symptoms, followed by hyperopia and then astigmatism regardless of severity. Myopia is a significant concern among madrassah students as their near work is much more than other school-going students. Females are more affected than males as their ratio is higher in the general population. The most common asthenopic symptom is blurry vision followed by headache, discomfort, pain, eye strain, photophobia, watering, tearing, itching, burning sensation, diplopia, and last but not least vertigo. Depending upon socioeconomic status and age group the best possible treatment to minimize the asthenopic symptoms are spectacles.
Farva et al.,2 conducted a study in which detailed examination of patients including visual acuity, and refractive errors, and questioning their complaints about symptoms helped in concluding that there was a close correlation between refractive errors and asthenopic symptoms were tested. 48.26% reported asthenopic symptoms. The most common complaint of the patient was headache (96.5%). The complaint of asthenopia was more in female patients (57.56%) than in males (42.40%). Myopia and astigmatism had a significant relation with asthenopic symptoms that is 56.4% and 59.3% respectively. Each symptom had a significant relation with different refractive errors with statistically significant values p<0.05.2
Our study also shows similarities that there was a close correlation between Refractive errors and asthenopia. Butdifferences show that there is high prevalence of myopia followed byhyperopia and astigmatism and the most common asthenopic symptom related to Refractive error was blurry visionwhile their study shows high prevalence of astigmatism followed by myopia andheadache was the most common asthenopic symptom related to them.
Jing wang etal., conducted a study on myopia; patients were inquired about their eye habits and were requested to complete an asthenopia questionnaire and ocular examinations. Age, gender, occupation, anisometropia, eye care education, weekly outdoor activity time, duration of continuous near work, daily screen time, dry eye, near phoria, and binocular accommodative facility were calculated. Out of the 65 myopic patients, 57% showed asthenopia, 52% experienced blurry vision, 37% felt their eyes hurt or sore, and 28% felt tired when performing close work. Asthenopia patients were older than patients without asthenopia. Daily screen time, continuous near-work time, eye care education, and dry eye were positively correlated with asthenopia (χ 2 = 8.64, p=0.003; χ2 = 13.873, p < 0.001, χ2 = 9.643, p=0.002; χ2 = 7.035, p=0.008).12
Kuswanto V etal.,11 conducted a research in a public elementary school in Indonesia, SDN Penjaringan 10, in 2019 in which 111 students aged 10-13 years old were included. A questionnaire was used to assess asthenopia and the Snellen Chart, trial frames, and trial lenses were used for refractive errors examination. It was demonstrated that 87.4% of respondents experienced asthenopia, and 53.2% of respondents suffered from uncorrected refractive errors, mostly due to myopia. Fisher’s exact test results showed an association between refractive errors and asthenopia (p=0.019) with all myopic students experienced asthenopia. However, there was no significant association between astigmatism and asthenopia (p=0.754).11
Our study also shows that asthenopia related to blurry vision has the highest prevalence in myopia.
A crossectional study was on 300 students in madrrasas of Haripur.Myopia was the leading refrective error in maddarssas population.13 A similar study was carried out among madrassas of Lahore on 200 students between age of 9-19 years.Myopia was the most frequent refractive error.14
A comparative retrospective study was conducted on 90 patients to evaluate headache associated with refrective errors (HARE). A significant association was found between ametropia and headache.Moderate hyperopia had (p=0.01) and astigmatism p(0.03) were found risk factors of HARE.15
Our study concludes regardless of the duration and onset of refractive error which asthenopic symptoms are affecting different types of refractive errors. But this study doesn’t provide the correlation of refractive errors and asthenopia in patients less than 8 years and above 25 years of age. Data sample size is very less and it has been taken from limited locality on single visit. We did not include strabismus and amblyopic patients they should also be considered in future. So in the future studies should be conducted that in a broader view.
CONCLUSION
Myopia and hypermetropia are the most common refractive errors; hazy vision and headache are the common asthenopic symptoms. There is a strong association between asthenopic symptoms and refractive errors
The most prevalent complaints among students who took part in this study were headaches and hazy eyesight.Myopia and hypermetropia are the most common refractive errors. The uncorrected refractive errors cause significant asthenopic symptoms. To avoid them, all patients with untreated refractive problems should be advised to rectify their refractive defects. Eye camps and social media should be used to do this.
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6. Heus P, Verbeek JH, Tikka C. Optical correction of refractive error for preventing and treating eye symptoms in computer users. Cochrane Database Syst Rev 2018;4(4):CD009877. https://doi.org/10.1002/14651858.CD009877.pub2
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Following authors have made substantial contributions to the manuscript as under:
SS: Concept and study design, analysis and interpretation of data, drafting the manuscript, critical review, approval of the final version to be published SAF, SD, FA, RS & UF: Acquisition of data, drafting the manuscript, approval of the final version to be published RS & UF: Concept and study design, acquisition, analysis and interpretation of data, drafting the manuscript, approval of the final version to be published
Authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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CONFLICT OF INTEREST Authors declared no conflict of interest
GRANT SUPPORT AND FINANCIAL DISCLOSURE Authors declared no specific grant for this research from any funding agency in the public, commercial or non-profit sectors |
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DATA SHARING STATEMENT The data that support the findings of this study are available from the corresponding author upon reasonable request |
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KMUJ web address: www.kmuj.kmu.edu.pk Email address: kmuj@kmu.edu.pk |