Refractive Error and Visual Impairment in School-Age Children in Gombak District, Malaysia

Published:February 11, 2005DOI:


      To assess the prevalence of refractive error and visual impairment in school-age children in Gombak District, a suburban area near Kuala Lumpur city.


      Population-based, cross-sectional survey.


      Four thousand six hundred thirty-four children 7 to 15 years of age living in 3004 households.


      Random selection of geographically defined clusters was used to identify the study sample. Children in 34 clusters were enumerated through a door-to-door survey and examined in 140 schools between March and July 2003. The examination included visual acuity measurements; ocular motility evaluation; retinoscopy and autorefraction under cycloplegia; and examination of the external eye, anterior segment, media, and fundus.

      Main Outcome Measures

      Distance visual acuity and cycloplegic refraction.


      The examined population was 70.3% Malay, 16.5% Chinese, 8.9% Indian, and 4.3% of other ethnicity. The prevalence of uncorrected (unaided), presenting, and best-corrected visual impairment (visual acuity ≤20/40 in the better eye) was 17.1%, 10.1%, and 1.4%, respectively. More than half of those in need of corrective spectacles were without them. In eyes with reduced vision, refractive error was the cause in 87.0%, amblyopia in 2.0%, other causes in 0.6%, and unexplained causes in 10.4%, mainly suspected amblyopia. Myopia (spherical equivalent of at least −0.50 diopter [D] in either eye) measured with retinoscopy was present in 9.8% of children 7 years of age, increasing to 34.4% in 15-year-olds; and in 10.0% and 32.5%, respectively, with autorefraction. Myopia was associated with older age, female gender, higher parental education, and Chinese ethnicity. Hyperopia (≥2.00 D) with retinoscopy varied from 3.8% in 7-year-olds, 5.0% with autorefraction, to less than 1% by age 15, with either measurement method. Hyperopia was associated with younger age and “other” ethnicity. Astigmatism (≥0.75 D) was present in 15.7% of children with retinoscopy and in 21.3% with autorefraction.


      Visual impairment in school-age children in urban Gombak District is overwhelmingly caused by myopia, with a particularly high prevalence among children of Chinese ethnicity. Eye health education and screening may help address the unmet need for refractive correction.
      To read this article in full you will need to make a payment


      Subscribe to Ophthalmology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Holden B.A.
        • Resnikoff S.
        The role of optometry in Vision 2020.
        J Community Eye Health. 2002; 15: 33-36
        • Zainal M.
        • Ismail S.M.
        • Ropilah A.R.
        • et al.
        Prevalence of blindness and low vision in Malaysian population: results from the National Eye Survey 1996.
        Br J Ophthalmol. 2002; 86: 951-956
        • Garner L.F.
        • Mohidin N.
        • Chung K.M.
        • et al.
        Prevalence of visual disorders in Malaysia.
        Sains Malaysiana. 1987; 16: 339-346
        • Chung K.M.
        • Mohidin N.
        • Yeow P.T.
        • et al.
        Prevalence of visual disorders in Chinese schoolchildren.
        Optom Vis Sci. 1996; 3: 695-700
      1. World Health Organization. Elimination of avoidable visual disability due to refractive errors. WHO/PBL/00.79. Available at:

        • Negrel A.D.
        • Maul E.
        • Pokharel G.P.
        • et al.
        Refractive Error Study in Children: sampling and measurement methods for a multi-country survey.
        Am J Ophthalmol. 2000; 129: 421-426
        • Pokharel G.P.
        • Negrel A.D.
        • Munoz S.R.
        • Ellwein L.B.
        Refractive Error Study in Children: results from Mechi Zone, Nepal.
        Am J Ophthalmol. 2000; 129: 436-444
        • Zhao J.
        • Pan X.
        • Sui R.
        • et al.
        Refractive Error Study in Children: results from Shunyi District, China.
        Am J Ophthalmol. 2000; 129: 427-435
        • Maul E.
        • Barroso S.
        • Munoz S.R.
        • et al.
        Refractive Error Study in Children: results from La Florida, Chile.
        Am J Ophthalmol. 2000; 129: 445-454
        • Dandona R.
        • Dandona L.
        • Srinivas M.
        • et al.
        Refractive error study in children in a rural population in India.
        Invest Ophthalmol Vis Sci. 2002; 43: 615-622
        • Murthy G.V.
        • Gupta S.K.
        • Ellwein L.
        • et al.
        Refractive error in children in an urban population in New Delhi.
        Invest Ophthalmol Vis Sci. 2002; 43: 623-631
        • Naidoo K.S.
        • Raghunandan A.
        • Mashige K.P.
        • et al.
        Refractive error and visual impairment in African children in South Africa.
        Invest Ophthalmol Vis Sci. 2003; 44: 3764-3770
        • He M.
        • Zeng J.
        • Liu Y.
        • et al.
        Refractive error and visual impairment in urban children in southern China.
        Invest Ophthalmol Vis Sci. 2004; 45: 793-799
        • Department of Statistics Malaysia
        Preliminary Count Report. Population and Housing Census of Malaysia 2000.
        Department of Statistics Publications, Kuala Lumpur2001
      2. Stata Statistical Software [computer program]. Release 8.0. College Station, TX: Stata Corp.; 2003.

        • Zhan M.Z.
        • Saw S.M.
        • Hong R.Z.
        • et al.
        Refractive errors in Singapore and Xiamen, China—a comparative study in school children aged 6 to 7 years.
        Optom Vis Sci. 2000; 77: 302-308
        • Mutti D.O.
        • Zadnik K.
        • Adams A.J.
        Myopia: the nature versus nurture debate goes on.
        Invest Ophthalmol Vis Sci. 1996; 37: 952-957
        • Saw S.M.
        • Chua W.H.
        • Hong C.Y.
        • et al.
        Nearwork in early-onset myopia.
        Invest Ophthalmol Vis Sci. 2002; 43: 332-339
      3. He M, Xu J, Yin Q, Ellwein LB. Need and challenges of refractive correction in urban Chinese school children. Optom Vis Sci. In press.