Studies conducted with Orbis International conclude that positive improvements in children’s mental and academic health provided appropriate eye care and eyewear, filling important research gaps and providing essential guidance for future interventions and research.
Visual impairment and blindness affect 2.2 billion people worldwide, including 19 million children. For these children, vision impairment can significantly affect their lives, including their educational achievement and mental health.
Two studies conducted in collaboration with the non-profit eye care organization Orbis International conclude that providing children with free glasses improves their ability to learn in school, and that addressing children’s vision impairment can ease depression and anxiety. Both studies fill important research gaps and provide essential guidance for future interventions and research.
Glasses and education for children
of the first study published in BMJwas conducted in rural areas of western China, where only 15% of children who need glasses have them.
The study was a double-masked, cluster-randomized controlled trial (RCT), and cross-arm contamination was minimized by selecting 1 school per residence. Primary schools in 2 neighboring provinces, Gansu and Shaanxi, were considered for eligibility. Areas sampled included low- and middle-income settlements in each province.
In total, 252 schools were selected – 1 per settlement and 1 fourth and fifth grade from each school. Children in these selected classes were eligible to participate in the study if their uncorrected visual acuity (UCVA) was 6/12 ³ in each eye and could be improved to 6/12 ³ in both eyes by wearing glasses.
The researchers began by providing questionnaires to children, parents and math teachers. Questionnaires for children asked about their vision and personal information. Questionnaires for parents and teachers asked about the possession and use of the blackboard, respectively.
Visual acuity for each child was assessed at the beginning of the study. Automated refraction with subjective refinement was then performed on children with UCVA £6/12. Mathematics scores were assessed at baseline and at the end of the study using separate timed and predicted tests appropriate for each grade. Eyewear use was assessed at the end of the study by direct examination and self-report measures.
Schools were randomized to receive 1 of 3 interventions: free glasses, vouchers for free glasses, or a prescription (control group). Children in the voucher and control groups received free glasses at the end of the study if needed, but were not informed about this initially.
The schools were further randomly divided into 2 groups: those that received education to encourage the use of glasses (such as watching a video, receiving a brochure or a class discussion) or that did not receive education.
All information was created to express that myopia is common in China, glasses are the safest and most effective treatment, and wearing glasses does not harm children’s eyes.
Ultimately, 3,177 children in 251 schools were eligible to participate in the study. Only 15% of eligible children already wore glasses. At the end of the study, 41% of children in the free glasses group were observed to wear glasses, while 68% self-reported wearing glasses. In comparison, 26% were observed and 37% self-reported hearing in the control group.
Providing children with free glasses improved math test scores equivalent to half a semester of additional instruction. The improvement was particularly marked when half or more of the instruction used blackboards (a plausible result, since these children were mostly myopic and thus at a particular disadvantage when reading from a distant blackboard, compared to a text school at their desk).
Giving free glasses affected test scores more than parental education and family wealth. This effect was seen even with less than perfect compliance (about 40% in this case), but further encouraging the use of glasses can be expected to further increase the effect.
This study provides a rationale for cost-effective government programs to provide free eyeglasses to school children. The low cost of wholesale eyeglasses increases affordability for government programs, and pilot programs providing free eyeglasses to children have begun in Gansu and Shaanxi provinces as a result of this study. The study also helped catalyze a 2018 Chinese national myopia control program announced by none other than Xi Jinping.
Visual impairment and mental health
of the second study published in Ophthalmologyshowed that children with visual impairment have higher rates of depression and anxiety than their peers without visual impairment.
Myopic children, in particular, have higher depression and anxiety scores, and those with other causes of vision impairment have higher anxiety scores. Additionally, children receiving strabismus corrective surgery were shown to have improved symptoms of depression and anxiety.
This study provides clear evidence that can guide governments to act on children’s vision, particularly regarding the provision of spectacles and insurance coverage for strabismus-corrective surgery when the cost is otherwise prohibitive.
Depression and anxiety pose a greater risk to children when they are not identified and remedied promptly. The lifetime burden in terms of years affected by these conditions is also much higher in children.
The Orbis study posits that the mental health of visually impaired children can be negatively affected because they tend to participate in less physical activity, have lower academic achievement and are more socially isolated.
Additionally, negative attitudes toward strabismus appear to emerge as early as age 6, and early detection and treatment can profoundly affect children’s mental health.
This study reported on a systematic review and meta-analysis to investigate whether visual impairment, ocular morbidity and their treatments are associated with mental health problems – particularly depression and anxiety – in children.
The study analyzed 36 articles from 9 different databases. These articles analyzed studies involving children and young adults undergoing ophthalmic interventions and provided a narrative review of mental health findings in adults with visual impairment (visual acuity <6/12) or childhood ocular morbidity.
Additionally, the study evaluated 23 observational studies related to depression and anxiety, eight observational studies related to strabismus, and 7 intervention studies. In total, about 700,000 participants were enrolled in these studies. Of the 36 studies, 22 were from low- and middle-income countries, and 9 of them focused on myopia in China.
While there is a large body of work focused on the impact of visual impairment on depression and anxiety in adults, studies investigating mental health in children with visual impairment are few and have not previously been reviewed in this comprehensive manner.
This research has profound implications for health care planners when allocating resources and designing interventions to curb vision impairment. For example, in some countries, strabismus surgery is viewed as a cosmetic procedure and is excluded from insurance coverage, forcing families to pay out of pocket. These barriers may prevent patients of low socioeconomic status from seeking treatment and keep the mental health benefits of corrective surgery out of reach.
More accessible eye care treatments will improve children’s mental health and overall well-being.
These studies provide important information on the effect of visual impairment and avoidable blindness on children’s educational outcomes and mental health.
Uncorrected refractive error continues to be the leading cause of vision loss in the world. The inability to see clearly and the proven impact of poor vision on educational performance can be a source of anxiety and depression, especially in high-pressure educational environments such as China, where more than half of children aged 6 to 18 they have myopia.
Ultimately, the results of both studies provide policy makers and health care planners with important information for intervention design and resource allocation as they highlight the negative impacts of visual impairment and the positive impacts of treatment.