Strabismus

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Amblyopia and Strabismus in Iranian

Schoolchildren, Mashhad

Mohammad Faghihi, Hadi Ostadimoghaddam & Abbas Ali Yekta

To cite this article: Mohammad Faghihi, Hadi Ostadimoghaddam & Abbas Ali Yekta (2011)
Amblyopia and Strabismus in Iranian Schoolchildren, Mashhad, Strabismus, 19:4, 147-152, DOI:
10.3109/09273972.2011.622341

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Strabismus, 19(4), 147–152, 2011
© 2011 Informa Healthcare USA, Inc.
ISSN: 0927-3972 print/1744-5132 online
DOI: 10.3109/09273972.2011.622341

original Article

Amblyopia and Strabismus in Iranian Schoolchildren,

Mashhad
Mohammad Faghihi, MD1, Hadi Ostadimoghaddam, PhD2, and Abbas Ali Yekta, PhD2
Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran, and 2Department of
1

Optometry, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran

ABSTRACT
Purpose: To determine the prevalence of amblyopia and strabismus among the population of schoolchildren
Mashhad, Iran.
Materials and Methods: In a cross-sectional study with cluster sampling, 2510 schoolchildren were selected from
schools of district 1 in Mashhad. Uncorrected visual acuity (UCVA) and best corrected visual acuity (BCVA)
were recorded for each participant. Amblyopia was distinguished as a reduction of BCVA to 20/30 or less in
one eye or 2-line interocular optotype acuity differences in the absence of pathological causes.
Results: Of the 2510 selected schoolchildren, 2150 participated (response rate, 85.6%). The mean (± standard
deviation) age of the participants was 13.2 ± 3.2 (range, 6-21) years. The prevalence of amblyopia was 1.9% (95%
CI: 0.94-2.90); 2.1% (95% CI: 0.10-3.16) in girls and 1.7% (95% CI: 0.30-3.12) in boys (P = 0.6). Among myopic,
hyperopic, and astigmatic students, 3.7%, 27.8%, and 6.5% had amblyopia, respectively (P<0.001). The causes
of amblyopia were anisometropia in 65.9%, strabismus in 24.4%, and isoametropia in 9.8%. The prevalence of
strabismus was 3.1% (95% CI, 1.3% to 4.3%); 4.2% (95% CI, 3.05 to 5.7%) in girls, and 2.0% (1.3% to 2.9%) in
boys (P = 0.0011). Strabismus was significantly more prevalent among hyperopic students (7.9%) compared
with myopic ones (3.7%).
Conclusion: Results of the present study indicate that the prevalence rate of amblyopia was in the mid-range of
other studies, and the prevalence of strabismus was relatively high. Since refractive errors, especially hypero-
pia, are responsible for some cases of strabismus.
Keywords:  Amblyopia, mashhad, schoolchildren, cross sectional study

INTRODUCTION
Refractive errors, amblyopia, and strabismus are
the major causes of visual impairment in children.1-4
Refractive errors are more prevalent than amblyo-
pia and strabismus, yet they are easier to correct.5
Amblyopia and strabismus, on the other hand, are
considered the most important ocular disorders in
children; if not treated in a timely fashion, the visual
impact can be permanent.6 Amblyopia and strabismus
are major causes of visual impairment in children,
and amblyopia is one of the most important causes
of unilateral blindness in adults.7-9 Failure to diagnose
and treat these disorders can lead to loss of career
opportunities in the children’s future. Amblyopia
treatment may be associated with negative impacts,
insufficient compliance, and sometimes social stigma
for the children and their parents.10
Reported rates of amblyopia, based on various
definitions, range between 0.02%11 and 3.9%12, and the
prevalence rates seen for strabismus were between
0.5%13 and 4.3%14. Reports indicate prevalence rates
of 0.5%-5% for these two conditions.3,4,15–18 Many
countries now have protocols to ensure the timely
diagnosis of these conditions.19-22 In some countries,
preschool screening is done, and in some others,
objective tests such as forced choice preferential look-
ing and visually evoked potential are used to screen
for amblyopia in preverbal children.23 Recent studies
have demonstrated a declining trend for amblyopia
and strabismus in some countries.24

Received 03 March 2011; revised 08 August 2011; accepted 07 September 2011

Correspondence: Hadi Ostadimoghaddam, PhD, Department of Optometry, School of Paramedical Sciences, Mashhad University
of Medical Sciences, Mashhad, Iran

147
148    H. Ostaadimoghaddam et al.
In Iran, visual screening programs have been con-
ducted for more than a decade. These examinations are
performed annually by teachers in primary schools at
the beginning of the academic year to evaluate students’
visual acuity and detect cases of amblyopia. If a student
is found to have impaired vision, his/her parents are
informed and the student is referred to an ophthalmolo-
gist or optometrist for further evaluation.
Nonetheless, reports suggest that amblyopia and
strabismus are the second most prevalent visual prob-
lems among school children after refractive errors.5,15 In
light of the large population of schoolchildren in Iran,
more studies are needed to demonstrate the prevalence
of amblyopia and strabismus in this group. Results can
also add to our knowledge about these two conditions
in the Middle East region. Extensive epidemiologic
studies throughout the country can give us a better esti-
mate of the situation with amblyopia and strabismus,
and when conducted periodically, they can evaluate the
effectiveness of screening programs. Mashhad is the sec-
ond most populated city in Iran, and the prevalence of
refractive errors in Mashhad schoolchildren has already
been reported.25 Here we present results of our study in
terms of the prevalence of amblyopia and strabismus
among schoolchildren in Mashhad.
METHODS AND MATERIALS
The present report concerns part of a larger cross-
sectional eye study investigating the prevalence rates
of refractive errors among Mashhad’s district 1 school-
children in 2006.25
Sampling area—Khorasan, the second most populated
province in Iran, is located in the northeast of the coun-
try, and has the city of Mashhad as its center. This study
was done in Mashhad, which is also the second most
populated city in Iran.
Study population—The target population was the
85,000 school children studying in Mashhad schools in
district 1.
There are 266 schools in this district of Mashhad—119
elementary schools, 96 middle schools, and 51 high
schools. Of the target population, 30.7% were in elemen-
tary school, and 23.6%, and 45.7% were in middle and
high school, respectively. To accomplish proportionate
sampling from the target population, we randomly
chose 6 elementary schools, 5 middle schools, and 10
high schools. From each cluster, we randomly chose
120 students for participation in the study, choosing an
equal number of students in each grade; 24 from each
of the 5 grades in elementary school, 40 from each of
the 3 grades in middle school, and 30 for each of the 4
grades in high school. Exclusion criteria included par-
ents’ unwillingness, cardiovascular or nervous system
disorders in first to eighth graders, any type of opacity
in ocular media interfering with refraction tests, and
also any anomaly in the posterior eye such as optic
nerve atrophy, optic neuritis, or macular degeneration.
The examining team comprised 4 optometrists and
one ophthalmologist, who performed complete vision
tests.
Examinations
After the initial interview and filling out the form on
demographics, the slit lamp examination, direct and
indirect ophthalmoscopy, and retinoscopy were done
by the ophthalmologist to rule out the presence of any
opacity or organic abnormality. Then, the uncorrected
visual acuity (UCVA) was tested using the standard
Snellen E chart at a 6-meter distance. For children who
had spectacles, the spectacle corrected visual acuity
was tested and their spectacles were checked with a
lensometer by the optometrists. High school students
underwent manifest refraction tests and first to eighth
graders had cycloplegic refraction tests using the Topcon
8000 autorefractometer 45 minutes after instilling cyclo-
pentolate eye drops, twice, 5 minutes apart. Other tests
included best corrected visual acuity (BCVA) and uni-
lateral cover test (cover- uncover) at 6 m and 50 cm to
assess strabismus with and without correction.
Ethical Issues
Written informed consents were obtained from the stu-
dents and their parents or guardians for all steps of the
study, including use of eye drops before examinations.
Definitions
In this study, amblyopia was defined as a BCVA of 20/30
or worse, or a 2-line interocular optotype acuity differ-
ence in the absence of any pathology.15,26 Myopia was
defined as a spherical equivalent (SE) of −0.50 diopter
(D) or worse and hyperopia as SE +2D and +0.50D or
more for cycloplegic and noncycloplegic refractions,
respectively, and astigmatism was defined as a cylin-
der power equal to or greater than 0.5 D. Sphere and
cylinder errors were studied separately with other cut-
points to assess the relationship between amblyopia
and type of refractive errors. Strabismus was defined
as heterotropia at distance or near fixation.
Statistical Analyses
We determined the prevalence of amblyopia and stra-
bismus and the 95% confidence intervals (CI), adjusting
for the design effect of cluster sampling. We used mul-
tiple logistic regression and odds ratios (OR) to assess
Strabismus

the association between amblyopia and age, gender,
refractive errors, and strabismus. All analyses were
done using the STATA statistical software, version 8.0.
RESULTS
Of the 2510 eligible students who were selected in
sampling, 2150 students participated in this study. The
response rate was 85.6%; 942 (43.8%) were girls and
1208 (56.2%) were boys. The mean (± standard devia-
tion) age of the participants was 13.2 ± 3.2 (range, 6-21)
years. Among the participating students, 16.5% were
under 9 years of age, 15.9% were 10-12, 34.8% were
13-15, and 32.8% were aged over 15 years.
Of the participants, 31% were in primary school,
23.4% in junior high school, and 45.6% were in high
school. The mean SE was 0.0014 ± 0.85 D. Figure 1
demonstrates the distribution of SE in the studied
schoolchildren. Among the participants, 41 schoolchil-
dren had amblyopia, accounting for a sampling design
adjusted prevalence rate of 1.9% (95% CI: 0.94-2.90);
2.1% (95% CI: 0.10-3.16) in girls and 1.7% (95% CI: 0.30-
3.12) in boys (P = 0.6, logistic regression) (Table 1). Table
1 shows the prevalence of amblyopia in different age
groups; there were no statistical differences among dif-
ferent age groups (P = 0.802). Amblyopia was detected
in the right eye in 31.7% of amblyopic cases (n = 13), in
the left eye in 41.5% (n = 17), and both eyes in 26.8% of
cases (n = 11).
The mean absolute SE in amblyopic schoolchildren
was 1.26 ± 1.58 D; this was statistically significantly dif-
ferent from that in schoolchildren free of the disorder
(0.4 ± 0.66 D) (P<0.001, independent sample t-test).
Among myopic, hyperopic and astigmatic students,
3.7%, 27.8%, and 6.5% had amblyopia respectively
(P<0.001). As shown in Table 2, anisometropia was the
most frequent cause of amblyopia, involving 65.9% of
amblyopia cases.
Table 1  The distribution of amblopia by age group
Boys (1208) Girls (942) Total (2150)
Age group (y) n % (95% CI) % (95% CI) % (95% CI)
≤9 354 1.2 (1.1–1.3) 2.8 (2.8–2.8) 1.7 (0.4–3)
10 to 12 342 0 1.7 (1.2–2.3) 1.5 (0.5–2.5)
13 to 15 748 1.9 (1.2–2.5) 2.5 (1.5–3.5) 2.3 (1.6–3.0)
>15 706 2.1 (1.9–2.3) 1.5 (1.4–1.6) 1.8 (1.2–2.5)
Total 2150 1.71 (0.3–3.12) 2.08 (1–3.16) 1.92 (0.94–2.9)
Table 2  The prevalence of amblyopia by type
Number Proportion % (95 % CI)*
Anisometropic 27 65.9 1.3 (0.8–1.8)
Strabismic 10 24.4 0.5 (0.2–0.9)
Isoametropic 4 9.8 0.2 (0.1–0.5)
Total 41 100 1.9 (0.94−2.90)
*Design effect of cluster sampling has been considered in calcu-
lation of 95% CI.
© 2011 Informa Healthcare USA, Inc.
Strabismus and Amblyopia in Schoolchildren    149
The prevalence of strabismus was 3.1% (95% CI, 1.3%
to 4.3%)—4.2% (95% CI, 3.05 to 5.7%) in girls, and 2.0%
(1.3% to 2.9%) in boys, accounting for a 2/1 ratio for
girls to boys (P = 0.0011). Also, the prevalence of strabis-
mus significantly decreased with age (P = 0.015, logistic
regression), in the total group and in both genders even
after the gender effect was eliminated. The prevalence
rates of esotropic, exotropic, and vertical strabismus
in the studied population were 0.9%, 2.1%, and 0.1%,
respectively; intergender differences in these rates were
not statistically significant (P = 0.1, P = 0.3, and P = 0.2
respectively, logistic regression). Unlike esotropia
which was not significantly associated with age, the
prevalence of exotropia significantly decreased with
age (P<0.001; OR = 0.90; 95% CI, 0.86 to 0.95, logistic
regression). Strabismus was significantly more preva-
lent among hyperopic students (7.9%) compared with
myopic ones (3.7%).
DISCUSSION
This is the second exclusive report that concerns ambly-
opia and strabismus in Iranian schoolchildren.15 Other
studies have been conducted in Dezful and Shahroud as
well; nonetheless, their main focus was the prevalence of
refractive errors and details about amblyopia and stra-
bismus were limited.5,27 The study in Shahroud assessed
preschool children, and thus it was different from the
present study and the one carried out in Shiraz.5,15,27
According to our results, 1.9% of the studied students
were amblyopic. Results of other similar studies are
summarized in Table 3, according to which the preva-
lence rate found in this study falls in the mid-range, and
that rates reported from Singapore and Japan were con-
siderably lower.28,29 Part of the observed differences may
be due to different definitions used in these studies.
In addition to ethnic and racial factors, screening pro-
grams in some countries cover children at early ages, and
thus, cases of amblyopia are diagnosed and treated. On
the contrary, lack of screening programs in some other
countries has lead to a cumulative increase in the preva-
lence of amblyopia among schoolchildren. Therefore, the
wide range of results shown in Table 3 can be an effect of
combining screened and unscreened populations. Most
studies included in this table do not mention whether
the studied population had been screened before, and
thus, we were not able to separate them.
In this student population, under-16-year-olds were
probably screened, and we expected to see lower preva-
lence rates in younger students. However, the difference
between age groups was not significant and it seems
that screening programs lack sufficient efficiency in
identifying cases of amblyopia. Therefore, the validity
of screening programs needs to be assessed periodically.
We found no significant correlation between amblyopia
and age or gender, a finding previously reported in the
150    H. Ostaadimoghaddam et al.

Table 3  Prevalence of amblyopia in preschool and schoolchildren from other studies

Author Place Age Diagnostic Criteria Prevalence %
Preslan12 Baltimore Elementary school Physician’s diagnosis 3.9
Brown46 Victoria (Australia) 40-92 VA <20/30, >1-line difference 3.1
Eibschitz-Tsimhoni47 Haifa (Israel) 1-2 VA <20/40 or >1-line difference 2.6
MePEDSG3 Hispanic/Latino 6 to 72 m VA <20/30 or >2-line difference 2.6
Ohlsson48 Mexico 12-13 VA <20/40 2.5
Newman49 Cambridge 5.5 VA <6/9 or >1-line difference 2.5
Yekta15 Shiraz (Iran) 7-17 VA <20/30 or >2-line difference 2.29
Chang31 Taiwan 3-6 Physician’s diagnosis 2.2
This study Mashhad (Iran) 6-21 VA <20/30 or >2-line difference 1.9
Abolfotouh50 Abha (Saudi Arabia) Elementary school 6/9 or worse 1.85
Sapkota7 Kathmandu (Nepal) 10-15 VA <20/40 1.8
Robaei9 Australian 6 VA <20/40 or >2-line difference 1.8
Jamali27 Shahrood,(Iran) 6 VA <20/40 or >2-line difference 1.7
MePEDSG3 African American 6 to 72 m VA <20/30 or >2-line difference 1.5
Yassur51 African 10-18 VA <20/40 1.2
Jensen52 Denmark 2nd-5th grades VA <20/40 1.1
Ohlsson53 Odense (Denmark) 12-13 VA <20/40 1.1
Eibschitz-Tsimhoni47 Haifa (Israel) 1-2 VA <20/40 or >1-line difference 1.0
Lithander54 Sultanate (Oman) 6-12 VA <20/40 0.92
Ross55 Saskatoon (canada) grade 1 VA <20/40 0.8
Rosman29 Singapore VA <20/40 0.35
Matsuo24 Japan 6-12 0.20
Matsuo28 Japan 6-12 0.14
Bremner11 Australia 4-12 Physician’s diagnosis 0.02

study in Shiraz.15 In terms of age, our findings were
similar to that found in 7- to 72-month-old children.3
In our study, the most common cause of amblyopia
was anisometropia; this was similar to the observation
in Shiraz.15 Although most studies3,29–31 state that ani-
sometropia is the most common cause of amblyopia,
some suggest strabismus as the main cause.9
Since the leading cause of amblyopia is refractive
errors, it seems that timely correction of severe cases
of refractive error, especially anisometropia, improves
the prognosis in children and helps prevent refractive
amblyopia. Some studies have demonstrated that a sim-
ple spectacle correction of refractive errors at a young
age can be a useful treatment for amblyopia.32,33 We
also found that amblyopia was more prevalent among
hyperopic students; this is in agreement with findings
of previous studies.34,35 It seems that the unclear retinal
image at all distances (near and far) for hyperopic chil-
dren, especially high hyperopic ones, makes them more
susceptible to amblyopia.
Strabismus was more prevalent than amblyopia
in our schoolchildren. Although the prevalence of
amblyopia fell in the mid-range compared with other
studies, the prevalence of strabismus in Mashhad
schoolchildren was relatively higher. As demonstrated in
Table 4, strabismus is more prevalent in East Asian coun-
tries, while schoolchildren in European and American
countries show lower prevalence rates for strabismus.
Since heredity plays an important role, it seems that
the different observations could mostly be attributed to
environmental and ethnic differences.
One of the findings of our study was the reduced
prevalence of strabismus with age, and the higher
prevalence among girls. It is known that hyperopia,
especially high hyperopia, can cause strabismus in
childhood.36,37 We observed a higher rate of strabismus
among hyperopic subjects too. On the other hand, some
other studies have demonstrated a higher prevalence
of hyperopia in schoolgirls,38,39 and thus, it seems that
part of the higher strabismus rate among girls could
be attributed to the higher prevalence of hyperopia
in girls.40 In terms of the association between age and
strabismus, some reports confirm our finding that the
prevalence of strabismus decreases with age.28,40,41 One
of the important reasons for this observation is the
decreased prevalence of hyperopia with age, which has
been demonstrated in most previous studies in children
and schoolchildren.15,42,43
In our study, exotropia was the most common type
of strabismus. This was in agreement to the finding
in Shiraz,15 while the study in Dezful5,15 indicated a
higher prevalence for esotropic strabismus. Table 4
demonstrates the prevalence rates of different types
of strabismus as reported in previous studies. The
varying results can be attributed to ethnic differences.
Nonetheless, refractive errors play an important role
too. Exotropia is known to be associated with myopia,
while esotropia is associated with hyperopia.44,45 The
higher rate of exotropia in East Asian countries could
thus be partly due to the higher prevalence of myopia
in these populations.

Strabismus

Table 4  Prevalence rates of strabismus and its different types in previous studies
Place Age (years)
Iran (Shiraz)15 6–21
Iran (Dezful)5 7–18
Finland56 7 2
Canada57 6 1.7
USA58 7 1.2
Japan28 6 to 11
USA (Hispanic)3 6 to 72 months
USA (African)3 6 to 72 months
UK 59 5-6
*Proportion.
One of the most important limitations of our study
was the lack of information about students’ previous
visual status; a history of amblyopia treatment or
strabismus surgery can lead to an underestimation.
Nonetheless, we determined the current prevalence
rates in a large sample size, which has important impli-
cations for public health in the student population.
CONCLUSION
According to our study on the schoolchildren of
Mashhad, the prevalence rate of amblyopia was in the
mid-range and the prevalence of strabismus was rela-
tively high. Exotropia was the most common type of
strabismus. Since refractive errors, especially hyperopia,
are responsible for some cases of strabismus.
ACKNOWLEDGMENTS
The authors wish to thank the Vice Chancellor for
Research of Mashhad University of Medical Sciences
for the financial support (grant code: 85258).
Declaration of interest: The authors declare no conflict
of interest.
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Strabismus