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Year : 2014  |  Volume : 17  |  Issue : 4  |  Page : 467-470

Refractive errors in children with autism in a developing country

1 Department of Ophthalmology, University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria
2 Private Practice, 1410 East Iron, Suite 6 Salina, Kansas, USA
3 Department of Psychological Medicine, University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria

Date of Acceptance27-Nov-2013
Date of Web Publication6-Jun-2014

Correspondence Address:
I R Ezegwui
Department of Ophthalmology, University of Nigeria Teaching Hospital, Enugu, Enugu State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1119-3077.134042

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Background: In a resource-limited country visual problems of mentally challenged individuals are often neglected.
Aim: The present study aims to study refractive errors in children diagnosed with autism in a developing country.
Materials and Methods: Ophthalmic examination was carried out on children diagnosed with autism attending a school for the mentally challenged in Enugu, Nigeria between December 2009 and May 2010. Visual acuity was assessed using Lea symbols. Anterior and posterior segments were examined. Cycloplegic refraction was performed. Data was entered on the protocol prepared for the study and analyzed using Statistical Package for the Social Sciences version 17 (Chicago IL, USA).
Results: A total of 21 children with autism were enrolled in the school; 18 of whom were examined giving coverage of 85.7%. The age range was 5-15 years, with a mean of 10.28 years (standard deviation ± 3.20). There were 13 boys and 5 girls. One child had bilateral temporal pallor of the disc and one had bilateral maculopathy with diffuse chorioretinal atrophy. Refraction revealed 4 children (22.2%) had astigmatism and 2 children (11.1%) had hypermetropia.
Conclusion: Significant refractive error mainly astigmatism was noted in the children with autism. Identifying refractive errors in these children early and providing appropriate corrective lenses may help optimize their visual functioning and impact their activities of daily life in a positive way.

Keywords: Autism, developing country, refractive error

How to cite this article:
Ezegwui I R, Lawrence L, Aghaji A E, Okoye O I, Okoye O, Onwasigwe E N, Ebigbo P O. Refractive errors in children with autism in a developing country. Niger J Clin Pract 2014;17:467-70

How to cite this URL:
Ezegwui I R, Lawrence L, Aghaji A E, Okoye O I, Okoye O, Onwasigwe E N, Ebigbo P O. Refractive errors in children with autism in a developing country. Niger J Clin Pract [serial online] 2014 [cited 2022 Jun 29];17:467-70. Available from:

   Introduction Top

Autism spectrum disorder (ASD) is a developmental neurological disorder characterized in varying degrees by difficulties in social interaction, verbal and non-verbal communication and repetitive behaviors. [1] The exact etiology is unknown, but multiple causes such as insult to the brain stem early in embryogenesis, genetic and environmental factors, tuberous sclerosis, congenital rubella and phenylketonuria have been implicated. [2],[3] The prevalence in Nigeria is not known. The prevalence in U.S. is said to be rising rapidly over a short period and is currently estimated to be 1 in 110 children. [4] A study from South Thames, UK [5] documented a prevalence of 116.1/10,000. The authors concluded that the prevalence of autism and related ASD is substantially higher than previously reported.

Ophthalmic findings reported in children with autism include abnormal electroretinograms, deficient evoked visual potentials, atypical optokinetic nystagmus, abnormal saccades and a higher incidence of strabismus than normal. [6],[7],[8],[9],[10],[11],[12] In one study, refractive error is said to range between −4.25 DS and +3.25 DS. [11] There is a paucity of data on ophthalmic findings in children with autism in Africa.

There is variation in severity of autism symptoms. Whereas some children with autism have strong intellectual and language abilities, others require lifelong care. [2] It is reported that about 70% of children with ASD have intellectual disabilities. [13] It has been suggested that many children will require special education and residential care. [2]

In resource-limited countries eye care services are not optimal. [14],[15] There is inadequate manpower across all cadres of eye health workers both in terms of number and distribution. [16],[17] In this kind of setting, it is easy to neglect the visual problems of individuals with intellectual disabilities and poor communication skills. The purpose of this study was to identify refractive errors in children with autism in a developing country with a view to provide appropriate corrective lenses.

   Materials and Methods Top


Therapeutic Day Care Center and Boarding School Abakpa-Nike, Enugu, Nigeria is a special education center for the mentally challenged, though there is a section for normal children. Among the mentally challenged, some are under residential care, while others are day students.


Ethical clearance was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital, Enugu.

Having obtained informed consent from the administrator of the school on behalf of the parents, all children with autism in the school underwent ocular examination between December 2009 and May 2010. The diagnosis of autism was made by the referral pediatricians using the Diagnostic and Statistical Manual of Mental Disorders 4 th edition. [18] The school also observed the children over a period to affirm the diagnosis.

Unaided visual acuity (VA) for distance and near was assessed using Lea symbols (good - lite #250200 and #250900 respectively). The former was performed at a distance of 3 m and the latter at 40 cm. For the children who could not match the symbols on the Lea chart, the hundreds and thousands test was performed. The teachers were trained to carry out the VA test. None of the children had ever worn spectacles previously. Anterior segment was examined with torch light and head loupe by IRE and AEA. Strabismus was assessed by Hirschberg test. Ocular motility was assessed and pupillary reaction to light was also checked. Posterior segment was examined with direct and indirect ophthalmoscope after dilation of the pupils with tropicamide 1% and cyclopentolate 1% eye drops by LL and IRE. All children who could co-operate underwent cycloplegic refraction 30 min after instillation of the aforementioned eye drops. Spectacles were dispensed free of charge to those that needed them.

Data entry and analysis were performed using Statistical Package for the Social Sciences version 17 (Chicago IL, USA).


For the purpose of this study the following definitions [19] were adopted:

  1. Hypermetropia ≥ +1.50 DS
  2. Myopia > −1.00 DS
  3. Astigmatism ≥ ±1.00 DC.

   Results Top

Out of the 21 children enrolled, 18 were examined (coverage 85.7%). The rest were not available in the school on the days the research team visited. The mean age of the children was 10.28 ± 3.20 years (range 5-15 years). There were 13 boys (72.2%) and 5 girls (27.8%) giving a male to female ratio of 2.6:1.

Distance VA could not be assessed in 16 children. The two children who co-operated had VA in each eye of 6/4.8 and 6/7.5 respectively. Near VA assessment was possible in only 10 children and the result is shown in [Table 1].
Table 1: Near vision distribution of the children

Click here to view

The anterior and posterior segments were essentially normal for all the children. One child had bilateral temporal pallor of the disc and one had bilateral maculopathy with diffuse chorioretinal atrophy. These two were referred to the pediatric ophthalmology clinic of the University of Nigeria Teaching Hospital Enugu for further evaluation.

A total of 15 children co-operated for cycloplegic refraction. The results are shown in [Table 2]. 6 children (33.3%) had significant refractive error by definitions of the study; 4 children (22.2%) had astigmatism and 2 (11.1%) had hypermetropia. Among the 4 children with astigmatism, 1 had mixed astigmatism in both eyes; 1 had simple myopic astigmatism in both eyes; 1 had compound hypermetropic astigmatism in the right eye and simple hypermetropic astigmatism in the left eye; and 1 had mixed astigmatism in the right eye and compound hypermetropic astigmatism in the left eye [Table 2].The spherical correction in the children ranged from −1.00 DS to +4.00 DS while the cylindrical correction ranged from −1.50 DC to +2.00 DC. One child had anisometropic hypermetropia of +3.00 DS (right eye +1.00 DS and left eye +4.00 DS). Spectacles were given to the six children. The prescription for the spectacles was based on the retinoscopy findings.
Table 2: Refractive errors in the children with autism

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   Discussion Top

Hypermetropia and astigmatism were the major refractive errors in our series. This is similar to the findings of Denis et al. [10] Ikeda et al. [3] in their study remarked that significant refractive error, strabismus and amblyopia in that order of occurrence are some of the ophthalmologic disorders found in children with autism. Maximizing VA for activities of daily living is felt to be important for children. [20] Children with autism are faced with many challenges including poor communication skills and intellectual disabilities; identifying refractive errors and appropriate interventions may impact positively on their quality of life.

As has been reported [3] co-operation for vision screening in children with autism is poor. Many of the common VA testing charts (Lea's symbols, HOTV chart and Snellen's chart) require interaction between the child and the examiner. The flawed verbal and non-verbal communication skills of a child with autism may become a challenge during VA assessment. Spectacle prescription was based on retinoscopy findings; due to lack of co-operation for subjective refraction.

The limitations of this study include the small sample size, inability to assess visual pathway involvement and oculomotor disturbances (which may be subclinical) due to limited facilities and inability to do subjective refraction on the children. Although Gogate et al. [20] in a study on ocular disorders in children with learning disabilities similarly dispensed spectacle prescriptions based on retinoscopy findings if subjective refraction was not possible.

As is the experience in other parts of the world, autism may be much more common in Nigeria. A future study screening children in regular schools for autism is advocated.

   Conclusion Top

Significant refractive errors were noted in the children with autism in this study. Vision screening and refraction services should be part of the general screening for children with autism, to help maximize vision for activities of daily living and improve developmental outcomes.

   Acknowledgment Top

The authors would like to thank the Management of Therapeutic Day Care Centre Abakpa-Nike Enugu for permission to examine their students. We thank Drs Uche, Okpala, Ezeanosike, Echedom and Ekweremadu, senior registrars (as at the time of the study) who assisted us. We are grateful to Dr Enechi an optometrist who worked with us.

   References Top

1.Autism Speaks. What is autism? Available from: [Last accessed on 2013 Aug 05].  Back to cited text no. 1
2.Miller MT, Strömland K, Gillberg C, Johansson M, Nilsson EW. The puzzle of autism: An ophthalmologic contribution. Trans Am Ophthalmol Soc 1998;96:369-85.  Back to cited text no. 2
3.Ikeda J, Davitt BV, Ultmann M, Maxim R, Cruz OA. Brief report: Incidence of ophthalmologic disorders in children with autism. J Autism Dev Disord 2013;43:1447-51.  Back to cited text no. 3
4.Proceedings of workshop on U.S. data to evaluate changes in the prevalence of Autism Spectrum Disorder, 2011. Available from: [Last accessed on 2013 Aug 05].  Back to cited text no. 4
5.Baird G, Simonoff E, Pickles A, Chandler S, Loucas T, Meldrum D, et al. Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: The Special Needs and Autism Project (SNAP). Lancet 2006;368:210-5.  Back to cited text no. 5
6.Trachtman JN. Background and history of autism in relation to vision care. Optometry 2008;79:391-6.  Back to cited text no. 6
7.Stanley-Cary C, Rinehart N, Tonge B, White O, Fielding J. Greater disruption to control of voluntary saccades in autistic disorder than Asperger's disorder: Evidence for greater cerebellar involvement in autism? Cerebellum 2011;10:70-80.  Back to cited text no. 7
8.Pensiero S, Fabbro F, Michieletto P, Accardo A, Brambilla P. Saccadic characteristics in autistic children. Funct Neurol 2009;24:153-8.  Back to cited text no. 8
9.Kemner C, Verbaten MN, Cuperus JM, Camfferman G, van Engeland H. Abnormal saccadic eye movements in autistic children. J Autism Dev Disord 1998;28:61-7.  Back to cited text no. 9
10.Denis D, Burillon C, Livet MO, Burguière O. Ophthalmologic signs in children with autism. J Fr Ophtalmol 1997;20:103-10.  Back to cited text no. 10
11.Scharre JE, Creedon MP. Assessment of visual function in autistic children. Optom Vis Sci 1992;69:433-9.  Back to cited text no. 11
12.Nowinski CV, Minshew NJ, Luna B, Takarae Y, Sweeney JA. Oculomotor studies of cerebellar function in autism. Psychiatry Res 2005;137:11-9.  Back to cited text no. 12
13.Miller MT, Strömland K, Ventura L, Johansson M, Bandim JM, Gillberg C. Autism with ophthalmologic malformations: The plot thickens. Trans Am Ophthalmol Soc 2004;102:107-20.  Back to cited text no. 13
14.Ezegwui IR, Aghaji AE, Uche NJ, Onwasigwe EN. Challenges in the management of paediatric cataract in a developing country. Int J Ophthalmol 2011;4:66-8.  Back to cited text no. 14
15.Omoti AE, Uhumwangho OM. Problems of management of primary congenital glaucoma in Benin City, Nigeria. Niger Postgrad Med J 2007;14:310-3.  Back to cited text no. 15
16.Eze BI, Maduka-Okafor FC. An assessment of the eye care workforce in Enugu State, south-eastern Nigeria. Hum Resour Health 2009;7:38.  Back to cited text no. 16
17.Odusote KA. Human resources development for the prevention of blindness in Anglophone West Africa. West Afr J Med 1998;17:1-8.  Back to cited text no. 17
18.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th ed. Washington, DC: American Psychiatric Association; 1994.  Back to cited text no. 18
19.Aghaji AE, Lawrence L, Ezegwui I, Onwasigwe E, Okoye O, Ebigbo P. Unmet visual needs of children with Down syndrome in an African population: Implications for visual and cognitive development. Eur J Ophthalmol 2013;23:394-8.  Back to cited text no. 19
20.Gogate P, Soneji FR, Kharat J, Dulera H, Deshpande M, Gilbert C. Ocular disorders in children with learning disabilities in special education schools of Pune, India. Indian J Ophthalmol 2011;59:223-8.  Back to cited text no. 20
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  [Table 1], [Table 2]

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