Sauer TC et al. Vision impairment in children.
Prevalence of Vision Impairment
in School Children of Puente
Piedra, Peru
Theodor Sauer, MD MPH1,2, Marlene Martin, MD1,3, Jorge A. Alarcon, MS1,5,
Jorge O. Alarcon, MD MPH4, Joseph Zunt, MD MPH5
1
Fogarty International Clinical Research Training Program, Bethesda, MD USA
2
Stein Eye Institute, UCLA, Los Angeles, CA
3
Stanford University, Stanford, CA USA
4
Universidad Nacional Mayor de San Marcos, Lima, Peru
5
Departments of Neurology, Global Health, Epidemiology and Medicine (Infectious
Diseases), University of Washington, Seattle, WA USA
Funding: Fogarty International Center-National Institutes of Health Award Number
R24TW007988
Proprietary/financial interest: None
ABSTRACT
Purpose: To document the prevalence of vision
impairment among children in a resource-poor
community in Peru.
Methods: Cross-sectional study of children 5 to 18
years old in Puente Piedra, Peru from March to April,
2011. Participants underwent standard vision screening
exam, consisting of distance visual acuity (VA),
stereopsis, external eye exam, and color vision testing
and completed a socio-demographic and health risk
factor questionnaire.
Results: 380 children were examined. The mean
uncorrected VA was 0.07 0.13 Log Mar. Children
wearing eyeglasses were 3.7%. Visual impairment was
found in both eyes in 8.9% and in one eye in 26.3%.
Severe visual impairment (<20/200) was found in both
eyes in one child (0.3%) and in the worse eye of 3 (0.7%)
children. Thirteen (3.5%) children failed the stereopsis
exam and 20 (5.5%) boys and 7 (1.9%) girls failed the
color vision exam. Overall, 37.3% of children met the
criteria for referral to an ophthalmologist. Major factors
for referral included the history of eyeglasses use,
previous eye exam, or parental concern about the
childs vision. Factors for untreated vision impairment
included not having seen a physician regularly, no
previous eye exam, and having a blind family member.
Conclusion: There is a high prevalence of vision
impairment in children living in Puente Piedra,
Peru. Few children wore glasses or have ever been
examined before. Basic eye care is needed for this
underprivileged population.
Keywords: Prevention of blindness; vision
impairment; visual acuity.
INTRODUCTION
The prevalence and causes of visual impairment
(VI) in children across the globe varies widely and
V I S I O N P A N - A M E R I C A N
Corresponding author: Dr. Theodor C. Sauer
100 Stein Eye Plaza
Stein Eye Institute, University of California Los Angeles
Los Angeles, CA 90095 USA
Telephone: 1-339-832-0335
Email: sauer@jsei.ucla.edu
Date of submission: 11/09/2016 Date of Approval: 09/11/2016
is influenced by environmental and socio-
economical factors as well as genetics.1-4 In
Australia, uncorrected VI was present in 4.1% of
6 year-olds and 5.0% of 12 year-olds.5,6 In China,
uncorrected visual impairment was as high as 41%.7
In the Refractive Error Study in Children (RESC)
assessed in China8, India9, South Africa10, Nepal11,
Chile12, and Malaysia13, Chiles prevalence of 15.8%
of uncorrected VI was one of the highest. Even
though Chile is more economically developed
than Peru, 65.1% of children who would benefit
from glasses, did not have them available.12
The life-long impact of VI on children is not
confined to the eye. Poor vision affects physical,
mental, and emotional development.1 Pediatric
vision disorders also have long-term negative
effects on health, self-perception, educational
status, and vocational choices.14 Identifying and
treating VI earlier, can diminish the medical
and economic burden of low-vision in children
and is part of the World Health Organization
Vision 2020 goals.15 Furthermore, correction of
refractive error in children, the leading causes
of pediatric VI, is one of the priorities of the Pan
American Health Organization.
Color blindness screening is often neglected,
probably because there is no currently available
treatment. However, up to 90% of dichromatic color
blind people reported difficulty with everyday tasks
and early detection can prevent later frustration
and allow social and vocational adaptation to color
blindness.16,17 There are few studies about color
blindness in South America and the only color
vision study in Peru involved 39 children, of whom,
2 (5.13%) were found to be color blindtwice the
rate reported in comparable populations in Niger
and Colombia.18-21
T H E P A N - A M E R I C A N J O U R N A L O F O P H T H A L M O L O G Y
 Vis. Pan-Am. 2016; 15(4): 115-121.
Reports of VI in Peru vary significantly across
populations and the burden of the disease in the
growing population outside the capital city, Lima, is
unknown. The primary objective of this study was to
measure the prevalence of VI in a population of school-
aged Peruvian children in an impoverished urban
settlement of Lima, Peru and determine the risk factors
associated with vision impairment and eye disease in
Peruvian children.
MATERIALS and METHODS
Design
Cross-sectional study about vision impairment in
Peruvian children living in a resource-poor community
outside Lima.
Population
The study was carried out in the school system
Colegio 8183 Pitagoras in Las Lomas de Zapallal, a
growing settlement on the district of Puente Piedra
near Lima, Peru. The proposed study was approved by
the Pitagoras school board as well as the Institutional
Review Board of the Instituto de Medicina Tropical de la
Universidad Nacional Mayor de San Marcos (Peru), the
University of Washington (USA), and Duke University
(USA) and was conducted in accordance with the
tenets of the Declaration of Helsinki.
Participants with age from 5 to 18 years were
cluster-sampled by classroom. Of the 51 classrooms
from 1st to 11th grade, 17 classrooms were selected to
participate, representing 532 of the approximately 1500
enrolled students. Eligibility was open to all selected
boys and girls between 5 and 18 years of age at the
Pitagoras School. Subjects were excluded if informed
consent by a parent or guardian or assent by the child
was not provided.
Procedures
Recruitment
Students were recruited to participate between
March and April, 2011 by contacting parents via a
letter describing the purpose of the study and an
invitation to the registration day at the school. Child
who wished to be examined but who were not part
of the study were invited to a free community-wide
screening campaign at the end of the study. During
the registration days, written informed consent was
obtained from the parent or legal guardian or if the
parent or guardian was illiterate, a verbal consent was
obtained in the presence of a witness. Parents or legal
guardians were also guided through a confidential
25-question questionnaire. Parents or guardians who
were unable to attend the informational meeting were
contacted individually and offered the opportunity
for their child to participate. All children underwent a
similar assent process immediately before beginning
the study.
Exams
Visual acuity was measured at a distance of 3 meters
using an HOTV visual acuity. Each child performed
116
the test while seated and under the instruction of a Spanish-
speaking Peruvian ophthalmic technician. The right eye
was measured first, while the left was covered with a plastic
occluder by the technician; then the left eye, and then both
eyes together. If glasses were used, the child was examined
first without glasses and then with glasses.
Random Dot E Stereo, cover test, and corneal light reflex
test were performed according to criteria approved by the
American Academy of Pediatrics (AAP) and the American
Academy of Ophthalmology (AAO).22 Color vision was tested
using an 8-plate Ishihara numbers book. Children who did
not know numbers were tested on the 7-plate Ishihara shapes
book. Near point of convergence was tested by drawing the
attention of the child to a small object directly in line with the
childs eyes approximately 30cm away and slowly advancing
the object toward the bridge of the nose. Passing criteria were
symmetrical convergence of the two eyes with constriction of
the pupils to a distance of 7cm from the bridge of the nose.
Follow-up
At the end of the study, all participants and their parents
or guardians received a letter explaining the results of the
study and were offered a free ophthalmic examination, if any
abnormality was detected. Children who failed the screening
test were referred to a local eye hospital under the agreement
of receiving treatment and subsidized glasses. As many in the
community lack the means to travel, a team of ophthalmic
technicians, optometrists, and an ophthalmologist traveled
to the school twice at the end of the study to perform
comprehensive eye exams and screen concerned members of
the community who did not partake in the study.
Definitions
Vision impairment in children 6 years of age and older
was defined as visual acuity >0.2 LogMar (20/30). Vision
impairment was further classified as mild, (0.3-0.5 LogMar
or 20/4020/60 Snellen), moderate (0.6-0.9 LogMar or 20/80-
20/160 Snellen), and severe (1.0 LogMar or <20/200 Snellen);
except in 5 years-old children were visual acuity 0.3 LogMar
(20/40) was considered normal.
The risk of amblyopia was defined as >0.1 LogMar
difference between eyes, approximately a two-line difference.
Criteria for passing the vision screening was defined as a visual
acuity >0.2 LogMar (20/30) in both eyes, normal stereopsis
test , and no obvious pathology on an external penlight exam.
Data Handling and Statistics
All statistical analysis was performed using JMP 9 (SAS
Institute, Cary, North Carolina, USA) and STATA 12 (StataCorp,
College Station, Texas, USA). Data analysis involved Pearsons
chi-square comparative analysis of proportions, t-test for
difference in means, Cohens kappa coefficient, and multiple
logistic regression.
RESULTS
Subjects
We had 380 (71.4%) out of 532 students invited to
participate in the study, enrolled. From them, 378 completed
both the questionnaire and examination aspects of the study.
The mean age of participants was 10.7 years (range 5.3
18.9 years). The average household had 5 family members,
 Sauer TC et al. Vision impairment in children.

VI (n=100) No VI (n=278) P-value

Gender (female) 54.0% 58.3% .46

Age, mean years 10.9 10.8 .77
Age Categories .95
5-6 years 14.0% 14.0%
7-8 years 16.0% 16.2%
9-10 years 18.0% 21.6%
11-12 years 26.0% 26.3%
13-14 years 15.0% 11.9%
15-18 years 11.0% 10.1%
Household members, mean 5.0 5.0 .93

Household income, monthly mean $207 $203 .78

Mother Employed 23.7% 28.0% .41

Household Items
TV 93.0% 91.8% .73
Refrigerator 44.4% 44.0% .42
Computer 6.1% 7.8% .57
Maternal Education
Elementary School
27.6% 24.8%
Middle School
42.8% 44.9%
High School .91
25.5% 23.7%
College/Technical
4.1% 6.6%

Paternal education
Elementary School 21.7% 17.5%
Middle School 40.2% 36.6%
High School 33.7% 36.9% .60
College/Technical 4.3% 9.0%

Table 1. Select socio-demographic variables

*VI defined as not passing visual acuity in either eye without correction

including 3 minors. The education level of the parents
was incomplete high school education. As proxies of
socioeconomic status, only 33% of families owned a
refrigerator and 8% a computer.
Further socio-demographic and health risk factors
collected from questionnaires are presented in Table 1.
Eyeglasses were reported to be used by 9.5% of children
(95% CI: 6.5% - 12.5%), 14% of their siblings, and the
parents of 12.0% of girls and 6.2% of boys (p =0.05). Over half of the
parents (58%) were concerned about their childs vision. (Table 2)
There were no statistical differences in socio-demographic or health
risk factors between boys and girls enrolled in the study, besides the
use of glasses by their parents.
VI was not associated with socio-economic status, age, gender,
or parental education (Table 1). VI was associated with a history
of use of eyeglasses (p < 0.001), previous eye examination (p =

V I S I O N P A N - A M E R I C A N T H E P A N - A M E R I C A N J O U R N A L O F O P H T H A L M O L O G Y
 Vis. Pan-Am. 2016; 15(4): 115-121.

VI was 0.070.13 LogMar (20/25 1 line). There was

No VI (n=278) P-value no significant mean difference between males
(n=100) and females (Students t-test, p = 0.30). Visual
impairment of any level was present in both eyes in
Born Premature 6.1% 8.1% .53 9.8% (95% CI 7.2% - 13.1%) of children and in one eye
Birth Outside Healthcare Fa- in 26.8% (95% CI 22.2% - 31.0%). Mild VI was found
23.0% 19.4% .46 in one eye of 17.6% of children and moderate VI in
cility
7.9%. Severe VI in both eyes was only found in one
History of Regular Doctor child (0.3%), which improved to severe impairment
39.0% 44.7% .32
Check-Ups in only one eye with the use of eyeglasses (Table 3).
Have Eyeglasses 21.6% 5.9% <.001 Other Vision Exams
Ever Had An Eye Exam 26.5% 13.0% <002 6.6% of children failed the random dot E
History of Eye Injury 5.2% 5.6% .90 stereopsis exam, a marker for potential amblyopia.
A two-line difference or greater in visual acuity
History of Eye Surgery 3.1% 1.8% .47 between eyes was detected in 39 (10.3%) of
Hearing Impairment 7.2% 5.9 .65 children. These children had an odds ratio (OR)
of 9.15 (95% confidence interval (CI) 3.80-22.03)
Mother Used Eyeglasses As
4.1% 4.4% .90 of failing the stereopsis exam. Color blindness, as
Child detected by Ishihara color plates, was found in 9
Father Used Eyeglasses As (5.5%) of boys and 4 (1.9%) girls. Additional exam
4.2% 5.2% .68
Child failure rates were 9.8% for the cover test, 2.4% for the
corneal light reflex, and 7.7% for near convergence.
Sibling Who Uses Eyeglasses 14.6% 14.3% .69
The Kappa coefficient for agreement between
Blind Person In Family 10.2% 6.6% .25 failure of these tests and visual impairment (visual
acuity testing) was low (Table 4). Overall, 37.3%
Parent Concern About Childs
70.0% 54.1% .005 of children failed the screening exam. The only
Vision
significant risk factor for not passing the screening
Table 2. Select health characteristics test was parental concern about the vision of the
*VI defined as not passing visual acuity in either eye without correction child, which persisted even after correcting for
multiple confounders (Table 5).
Visual Impairment and Use of Eyeglasses
In the study enrollment questionnaire, 36 (10%)
parents reported that their child used eyeglasses;
however, at exam only 14 (3.7%) children were
wearing eyeglasses. Of children with VI, 21% of
parents reported their child wore eyeglasses.
During the exam, 13% of children with VI wore
eyeglasses: 2 (66%) children with severe VI, 5
(15%) with moderate VI, and 6 (10%) with mild VI.
Additionally, one child who tested normal, was
wearing eyeglasses. Among those with VI, socio-
economic status was not associated with the use
of eyeglasses. Health characteristics associated
with using eyeglasses included seeing a doctor
regularly (ChiSq = 11.4, p < 0.001), a previous
eye exam (ChiSq = 19.9, p < 0.0001), and a blind
family member (ChiSq = 5.8, p < 0.016). A logistic
Figure 1: Uncorrected visual impairment of both eyes by age group.
regression of untreated VI on multiple socio-
demographic and medical history factors found no
statistically significant associations.
0.002), and parental concern about the childs vision (p
= 0.005) (Table 2). DISCUSSION

In a multivariate logistic regression model We conducted a school-based cross-sectional

of passing visual acuity, there was no significant
relationship with any of the socio-demographic factors
reported in the questionnaires.
Visual Acuity
All children identified the H, O, T, and V letters
without difficulty. Mean visual acuity with both eyes
study to determine the prevalence and risk factors
associated with VI in Peruvian children aged from
5 to 18 years, living in a resource-poor community
near Lima, Peru. This is the first report of VI in
Peruvian children from a resource-poor community.
A high prevalence of binocular VI (8.9%) and
monocular VI (26.8%) was present in this population

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 Sauer TC et al. Vision impairment in children.

Logarithm of
Category of Vi- Minimal Angle of Snellen Visual Uncorrected Eyeglasses Presenting Visual
sion Impairment Resolution Units Acuity Cutoff Visual Acuity Use Acuity
(Log MAR)

Passing * 0.2 20/30* 280 (73.7%) 1 (0.3%) 279 (73.4%)

Mild VI 0.3-0.5 20/40*- 20/70 66 (17.4%) 6 (9.1%) 67 (17.6%)

Moderate VI 0.6-0.9 20/80-20/160 31 (8.1%) 5 (16.1%) 30 (7.9%)

Severe VI 1.0 20/200 3 (0.7%) 2 (66.6%) 4 (1.1%)

Total 380 (100%) 14 (3.7%) 380 (100%)

Table 3a: Distribution of visual acuity Worse seeing eye (n = 380)

*In children of 5 years of age, a visual acuity of 0.3 (20/40) or better is considered passing.
Uncorrected visual acuity is without the use of glasses
Presenting visual acuity is with glasses if the child brought them to the exam

of Peruvian school children, which is similar to the 31.3%

reported in urban Chinese children23 and the 22.7%
reported in metropolitan Malaysian children.13 Puente
Piedra is a semi-urban environment; however, many of
the children and their families recently emigrated from
rural Andean communities. In our study, the prevalence
of uncorrected VI (8.1%) and severe VI (0.7%) was similar
to Perus neighbor, Chile.12 However, the prevalence of
VI was higher than the 2.9% prevalence reported in
Nepal11 or the 4.1% reported in 6-year-old Australian
children5 and the 11.4% in 12-year-old Australian
children.6 Of note, some differences in prevalence may
be attributable to the method of screening as we used
an HOTV chart, while other studies used a simpler
Tumbling Es chart.10-12
The use of eyeglasses by Peruvian children was low
(3.7%), even in students with VI (13%). Moreover, more
Figure 2: The reported and actual observed usage of eyeglasses and history of a prior eye exam in chil-
than half of the children whose parents reported them dren, by age group.
as having glasses, did not use them. As refractive error
is the most common cause of VI in children22, there is
clearly a need for better screening and compliance
with eyeglasses in this community. the parents and community, high cost of corrective lenses, limited
availability of convenient eye care appointments, and adolescents
This problem is not specific to Peru. In Chile, more reluctance to wear eyeglasses.25 In Peruvian children with VI, factors
than 7% of children were in need of eyeglasses.12 In associated with the use of eyeglasses included seeing a doctor regularly,
China, 9% of children would have benefitted from having had a previous eye exam, and having a blind family member. Of
prescription eyeglasses.8 Even in Baltimore, MD,USA, note, household income and other markers of socio-economic status
5.1% of preschoolers would benefit from eyeglasses, were not associated with the need of eyeglasses.
but only 1.3% had them.24
Similarly, there were no statistically significant associations between
In previous studies, barriers to obtaining eyeglasses VI and socioeconomic status, including parental education, parental
and seeking eye care included lack of community vocation, household income, or household possessions. However, our
awareness about the frequency and potential effect study population in Puente Piedra was uniformly poor and medically
of refractive error in children, a parental perception underserved. We observed that eyeglasses were frequently wrapped in
of inadequate communication between school and tissue paper and with broken nose braces or scratched lenses. Getting

V I S I O N P A N - A M E R I C A N T H E P A N - A M E R I C A N J O U R N A L O F O P H T H A L M O L O G Y
 Vis. Pan-Am. 2016; 15(4): 115-121.

Logarithm of
Category of Vi- Minimal Angle of Snellen Visual Uncorrected Eyeglasses Presenting Visual
sion Impairment Resolution Units Acuity Cutoff Visual Acuity Use Acuity
(Log MAR)

Passing * 0.2 20/30* 346 (91.1%) 1 (0.3%) 350 (92.1%)

Mild VI 0.3-0.5 20/40*- 20/70 27 (7.1%) 6 (9.1%) 26 (6.8%)

Moderate VI 0.6-0.9 20/80-20/160 7 (1.8%) 5 (16.1%) 4 (1.1%)

Severe VI 1.0 20/200 0 (0.0%) 2 (66.6%) 0 (0.0%)

Total 380 (100%) 14 (3.7%) 380 (100%)

Table 3b: Distribution of visual acuity Better seeing eye (n = 380)

*In children of 5 years of age, a visual acuity of 0.3 (20/40) or better is considered passing.
Uncorrected visual acuity is without the use of glasses
Presenting visual acuity is with glasses if the child brought them to the exam

Stereoacuity Cover Testing Hirschberg Convergence

(n=380) (n=379) (n=379) (n=379)
With VI 19 16 5 20

Without VI 6 13 4 17

Total (%) 25 (6.6%) 37 (9.8%) 9 (2.4%) 29 (7.7%)

Observed Agreement 0.77 0.74 0.74 0.74

Cohens Kappa
0.27 0.24 0.07 0.2
Coefficient ()

Table 4: Failure rate in additional tests and agreement with visual acuity Testing

children to wear eyeglasses also seemed to be a barrier in the
Peruvian study population. While 36 (10%) parents reported
their children had eyeglasses, only 14 (3.7%) reported using
them at the time of the exam. Several children were sent back
to their classroom to return with their eyeglasses.
Color blindness was present in 5.5% of males and 1.9% of
females. Limited data are available on color vision blindness in
Latin America, but the higher prevalence in males is consistent
with international reports and the known pattern of X-linked
inheritance.19 Color vision tests are not included in most school
screenings or even comprehensive eye examinations, as there is
no treatment option and the impact of the disease is assumed to
be minimal. However, color blindness can lead to social limitations
and knowledge of the deficiency may lessen the impact.26
There are several potential limitations that could affect
the interpretation of the results of this study. Only 73% of the
invited population was enrolled in the study. There is a potential
for immigration selection bias of children with VI. Since we do
not have access to health or socio-demographic data for non-
participants, we were unable to determine if bias occurred at
enrollment. Children may not have been enrolled in the study because
they assumed their vision was good, they already had an eye exam, or
for other cultural concerns. The male-female ratio of the study sample
and the school population was not significantly different.
A second limitation is that testing children in a school setting can
result in underperformance, because of distraction. We attempted to
decrease this limitation by calling back for retesting students who had
failed the examination. Finally, our study included screening rather than
a comprehensive eye exam and determination of the exact cause of
decreased vision or failed stereopsis exam could not be determined.
The passing rate of visual acuity testing would undoubtedly be higher if
best-corrected visual acuity (BCVA) had been tested.
In conclusion, vision impairment was highly prevalent among
children in a resource-poor community near Lima, Peru. Nearly 1 out of
3 children was referred for a comprehensive eye exam. Use of eyeglasses
and a history of eye exams were exceptionally low in this population and
underscore the need for increased eye-related public health measures to
increase both screenings to identify VI and treatment to correct it. Further
research is needed into the etiology of eye disease in this population and
the most effective screening and treatment protocols.

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 Sauer TC et al. Vision impairment in children.

Crude Adjusted
OR 95% CI P-Value OR 95% CI P-Value

Age Categories .56 .26

5-6 years 1.0 - - 1.0 - -

7-8 years .97 .44-2.13 .94 1.26 .49-3.17 0.63
9-10 years .87 .42-1.84 .72 1.25 .51-3.07 0.62
11-12 years .63 .31-1.28 .20 0.61 .26-1.44 0.26
13-14 years .56 .24-1.27 .17 0.60 .22-1.62 0.32
15-18 years .86 .37-1.98 .72 1.01 .36-2.79 0.98
Female 1.00 .66-1.53 .98 0.80 .49-1.29 0.36
Hearing
.63 .27-1.46 .28 0.65 .26-1.64 0.37
Problems
Mother uses
.97 .35-2.74 .96 0.99 .29-3.32 0.99
glasses
Father uses
1.19 .44-3.24 .74 2.15 .63-7.26 0.22
glasses
Sibling uses
.93 .53-1.64 .81 0.92 .50-1.68 0.78
glasses

Parents
concerned about .65 .42-1.00 .05 0.57 .35-0.93 0.02
childs vision

Table 5: Crude and adjusted odds ratios of passing the vision screening
*Adjusted model includes age, sex, history of hearing problems, use of glasses by mother,
father, and siblings, and parental concern about childs vision.

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