AVEH African Vision and Eye Health 2413-3183 2410-1516 AOSIS AVEH-83-940 10.4102/aveh.v83i1.940 Review article Refractive errors among schoolchildren in the Middle East: A systematic review and meta-analysis https://orcid.org/0000-0001-9197-4748 Mohamed Zoelfigar D. 1 https://orcid.org/0000-0003-3554-0915 Ismail Galal M. 1 https://orcid.org/0000-0003-0247-8780 Alrasheed Saif H. 2 https://orcid.org/0000-0002-8072-5487 Vankudre Gopi S. 1 https://orcid.org/0000-0003-1482-9939 Noushad Babu 1 https://orcid.org/0000-0001-7450-4621 Ayyappan Janitha P. 1 Department of Optometry, College of Health Science, University of Buraimi, Al Buraimi, Oman Department of Optometry, College of Applied Medical Sciences, Qassim University, Buraidah, Saudi Arabia Corresponding author: Zoelfigar Mohamed, abumihad2010@gmail.com 04102024 2024 83 1 940 20042024 02092024 © 2024. The Author(s) 2024 Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License. Background

Refractive errors are the most prevalent ocular conditions among adolescents and children.

 Aim

The purpose of this systematic review and meta-analysis is to evaluate the prevalence of refractive error (RE) among children aged 5–17 years in the Middle East Region.

 Method

The research adhered to the Preferred Reporting Criteria for Systematic Reviews and Meta-Analyses (2020) in conducting the study. A comprehensive search for relevant studies was conducted on multiple databases. The analysed dataset was classified based on gender and the methods employed to estimate REs.

 Results

The meta-analysis included data from 38 population-based studies in 11 countries, covering 103 053 children. The overall pooled prevalence rates of myopia, hyperopia and astigmatism were 5.74%, 5.35% and 13.16%, respectively. Females had slightly higher prevalence rates at 7.25%, 5.54% and 15.50%, compared to males at 6.09%, 5.07% and 12.20%, respectively. The prevalence of myopia, hyperopia and astigmatism was higher with cycloplegic refraction at 6.33%, 6.36% and 14.39%, respectively, compared with non-cycloplegic refraction at 4.07%, 2.73% and 9.64%, respectively. Significant heterogeneity was observed between the reviewed studies (p < 0.0001).

 Conclusion

This meta-analysis revealed that astigmatism was the most common RE in Middle Eastern children aged 5–17 years, followed by myopia and hyperopia. There was no significant difference in the pooled prevalence of RE between genders. The findings indicated that myopia, hyperopia and astigmatism measurements varied between cycloplegic and non-cycloplegic refractions.

 Contribution

These findings concur with the global trend and emphasise the need for deliberate action to address childhood REs in the Middle East.

 children refractive errors Middle East Region public health prevalence Funding information This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Introduction

Refractive error (RE) occurs when the refractive system is unable to properly refract the parallel light rays at the centre of the fovea.1,2 They are classified as myopia, hyperopia and astigmatism.3 Uncorrected RE is the leading cause of moderate to severe visual impairment and the second leading cause of blindness worldwide. and is classified as a serious public health concern.4,5,6 Furthermore, the relative prevalence of uncorrected RE increases in the younger population with a higher incidence of myopia.5 Uncorrected RE is the most common cause of vision impairment in children, and it can be avoided with timely investigation and interventions.7,8,9

Global estimates show that approximately 19 million children between the age of 5 and 15 years suffer from visual impairment because of uncorrected RE, and nearly 90% of them live in developing countries.10,11 The most prevalent RE in children in China was myopia, followed by astigmatism and hyperopia.12 A study conducted in 2020 to estimate the prevalence of RE in the Middle East population reported that astigmatism is more prevalent among children concurring with a study conducted on Indian children.9,13 Another worldwide report in 2018 observed that among children and adolescents, astigmatism was the most prevalent RE (14.9%), followed by myopia and hyperopia. Likewise, astigmatism was the most prevalent RE in American children (27.2%).14

Uncorrected RE has the potential to impact the quality of life and socioeconomic status of an individual.10,15 The consequences of uncorrected RE in children are multifaceted because the resulting visual impairment can have a negative impact on a child’s social, psychological and academic development.15,16 Therefore, a timely intervention is crucial. A sound mechanism at the community level is important to screen children for their vision such as school eye health initiatives to identify children with visual impairment and its debilitating consequences such as amblyopia.17,18,19,20 This early detection of RE can support mitigation of uncorrected visual impairment and improving their academic performance and quality of life.21

The prevalence and distribution of RE vary between countries and regions.22 In a meta-analysis study conducted in 2020 among different age groups, the prevalence of childhood REs in the Middle Eastern region was reported without mentioning the methods of refraction assessment, such as wet or dry refraction.13 Therefore, the present study was conducted to complement those findings, because the RE prevalence reported in our study is based on gender, cycloplegic refraction and non-cycloplegic refraction.

 Methods Search plan and quality assessment of epidemiological studies

The recommended reporting items for systematic reviews and meta-analyses framework was applied in this study as shown in the Preferred Reporting Criteria for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram in Figure 1.23 This study covered the epidemiological studies on the prevalence of RE in the Middle East covering 19 countries including Saudi Arabia, Afghanistan, Pakistan, Bahrain, Iran, Iraq, Jordan, Kuwait, Lebanon, Oman, Palestine, Qatar, Syria, Turkey, United Arab Emirates, Yemen, Egypt, Libya and Sudan. It focussed on an organised search and review for the studies reported between January 2008 and October 2023. The quality of the studies was evaluated on an individual basis utilising the checklist that was designed by Downs and Black.24 Each article was graded and given a score based on a 10-items as shown in Table 1.

PRISMA 2020 flow diagram model for systematic reviews used in the prevalence of RE in the Middle East.

Characteristics of studies reporting the prevalence of refractive error across the Middle East Region (2008–2023).

Authors and year of study Country Sample size Range of age (years) Age in years (mean ± s.d.) Cycloplegic refraction Myopic Hyperopic Astigmatism Quality assessment score
Ghalib et al. 202028 Sudan 400 6–15 - Yes 24 22 49 9
Mohamed et al. 201729 Sudan 822 5–15 12.41 ± 1.99 No 14 5 19 8
Alrasheed et al. 201630 Sudan 1678 6–15 10.8 ± 2.8 Yes 114 32 42 10
Alsaqr et al. 201731 Saudi Arabia 335 3–6 4.5 ± 0.87 Yes 14 27 67 10
Alrahili et al. 201732 Saudi Arabia 1893 3–10 6.2 ± 1.9 No 13 28 473 9
Alomair et al. 202033 Saudi Arabia 850 6–15 - Yes 120 51 72 8
AlThomali et al. 202234 Saudi Arabia 7356 7–18 11.8 ± 2.2 Yes 2442 1295 3688 10
Abbas et al. 201935 Pakistan 2491 - - No 101 21 124 8
Hameed 201636 Pakistan 1644 5–15 - No 56 20 59 8
Latif et al. 201437 Pakistan 533 9–18 13.9 ± 1.6 Yes 66 15 26 9
Ullah et al. 202038 Pakistan 2288 5–12 8.10 ± 2.3 No 53 46 25 9
Atta 201539 Pakistan 300 5–20 - Yes 65 35 24 7
Mahjoob et al. 201625 Iran 320 7–12 9.11 ± 1.62 Yes 20 186 11 10
Norouzirad et al. 201540 Iran 1130 6–15 11.05 ± 2.93 Yes 168 146 509 10
Hashemi et al. 201741 Iran 602 5–15 10.02 ± 3.19 Yes 16 24 NA 9
Hashemi et al. 201642 Iran 4106 7 7 No 125 255 716 9
Abdelrheem et al. 202143 Egypt 14 787 6–12 9.22 ± 1.64 Yes 340 754 1523 10
Farida et al. 201844 Egypt 1272 11–15 13.14 ± 0.91 Yes 703 145 649 10
Elsabagh et al. 202045 Egypt 1075 9–13 10.79 ± 0.92 Yes 42 34 162 9
Kandi et al. 202146 UAE 733 6–10 - Yes 38 16 50 8
Hussam et al. 201847 Iraq 735 6–8 6.1 ± 0.34 Yes 144 148 54 9
Hussein et al. 200848 Jordan 1647 11–17 13.2 ± 2.1 N0 256 47 85 8
Alghamdi 202049 Saudi Arabia 417 6–13 9.2 ± 1.9 No 32 37 14 9
Al-Rowaily et al. 201050 Saudi Arabia 1319 4–6 - No 33 28 33 9
Yamamah et al. 201551 Egypt 2070 6–17 10.7 ± 3.1 Yes 64 75 318 9
Aldebasi 201452 Saudi Arabia 5176 5–15 9.5 ± 1.8 Yes 300 36 228 10
Rajavi et al. 201453 Iran 2417 7–12 9.4 ± 1.7 No 118 85 546 9
Elmajri 201754 Libya 920 6–11 9.53 ± 1.5 Yes 16 56 34 7
Al Wadaani et al. 201255 Saudi Arabia 2002 6–15 9.4 ± 203 Yes 180 27 67 9
Gilal et al. 202256 Pakistan 400 6–15 10.5 Yes 15 7 5 9
Jamali et al. 200957 Iran 827 6 6 Yes 14 170 162 8
Fotouhi et al. 201158 Iran 3481 8–14 10.7 ± 2.3 Yes 14 352 230 10
Caca et al. 201359 Turkey 21 062 6–14 10.56 ± 3.59 Yes 674 1243 3012 8
Aydoğan et al. 201760 Turkey 1729 7–14 9.43 ± 2.06 No 187 66 455 9
Abdianwall 202061 Afghanistan 951 11–15 - No 27 13 5 9
Khandekar et al. 201662 Oman 286 Grade 7 - yes 27 3 13 8
Anuradha 201563 Oman 12 448 5–15 - No 354 7 - 8
Mohamed et al.64 Sudan 551 5–15 12.46 ± 1.97 No 28 6 18 9
All - 103 053 - 9.69 ± 1.75 - 8.28% 7.12% 12.6% -

NA, not applicable; s.d., standard deviation.

This work limited itself to cross-sectional studies reported in English, available online in peer-eviewed publications, that addressed the prevalence of RE among children in Middle Eastern countries. The databases such as Scopus, Google Scholar, Web of Sciences, Index Medicus for the EMR, ProQuest, Medline and PubMed were searched till October 2023. A thorough search of the titles and abstract was done using the keywords with Boolean operators (OR/AND). The search terms were – prevalence OR incidence OR rate OR proportion OR frequency OR proportion OR epidemiology OR distribution AND REs in children in the Middle East region (MER).

 Inclusion and exclusion criteria

For full text review, all population-based studies on the prevalence of RE in male and female school aged children 5–17 years old were considered including population and school-based studies. The studies employed an observational study design with a detailed description of the data collection approaches such as the sampling method, the RE measuring technique (whether cycloplegic or non-cycloplegic refraction) as well as subjective or objective refraction. The benchmarked criteria for categorising REs were myopia as spherical equivalent (-0.5 D SPH),25 hyperopia (1.5 D SPH)26 and astigmatism (0.5 D CYL).27 Studies that lacked the inclusion criteria were omitted, studies that did not show a valid frequency or prevalence were excluded and those datasets reported outside of Middle Eastern countries were also excluded.

 Data extraction

The first and second authors carefully screened and reviewed the titles of studies conducted in Middle Eastern countries among children with REs that met the inclusion criteria. Thereafter, the authors examined the abstract of each selected study, focussing on the prevalence of REs such as hyperopia, myopia and astigmatism, as well as the methods used for measuring REs, whether with or without cycloplegia. Finally, the full texts of the included studies were carefully reviewed to extract information such as sample size, gender and the number of affected children with REs, in order to calculate pooled prevalence based on overall totals, gender and refractive methods. Next, the data such as the first author’s name, publication year, country, participant’s characteristics (age, gender and sample size), technique employed for RE measurement (cycloplegic or non-cycloplegic refraction) and the benchmarks for defining the RE according to predefined study protocol were extracted. For addressing disagreements between authors in this review, clear standards and protocols were developed to guide the review process and build open communication to reach consensus by arguing different viewpoints and referring to established protocol.

 Data analysis

The data from the inclusive studies were documented in a conditioned Microsoft Excel sheet including databases, participants age (mean ± standard deviation [s.d.]), samples size and the prevalence and frequency of myopia, hyperopia, astigmatism as well as the total RE. MedCalc-Version 19.6.1 software (MedCalc, Mariakerke, Belgium) was used for meta-analysing the prevalence of RE.

In the present study, heterogeneity among articles was checked by a Q-statistic that is allotted as Chi-square under the assumption of homogeneity of effect sizes, and I2 index I2 values ranged between 0% and 75%, representing none to high heterogeneity. MedCalc-Version 19.6.1 was used to build tables that showed the prevalence of RE among children, by age (mean ± s.d.), sex, refraction procedure in different studies and the weight for each article. The overall pooled prevalence of RE (myopia, hyperopia and astigmatism) was estimated using a random-effect model and its associated 95% confidence intervals (CI), p values were less than 0.05.

 Ethical considerations

This article followed all ethical standards for research without direct contact with human or animal subjects.

 Results Study characteristics

Figure 1 shows 18 250 studies selected by the authors. After removing duplicates, they analysed 9240 study titles. A total of 9122 studies were removed because they did not meet the inclusion criteria. Another 83 studies were excluded because their data were inaccessible. Therefore, this meta-analysis comprised of 38 studies from 12 countries from 2008 to 2023 (Table 1). The articles sampled 103 053 children aged 5–17 years with their mean (± s.d.) age of 9.65 ± 1.8 years from 38 studies.

 Prevalence of refractive error among Middle East schoolchildren (2008–2023)

The meta-analysis to estimate the prevalence of RE among Middle Eastern schoolchildren between 5 and 17 years of age was conducted as shown in Table 2. The pooled prevalence of myopia was 5.74% (95% CI: 5.59–5.89, p < 0.001), and about 42.85% of reviewed articles (n = 15) showed a considerably greater prevalence of myopia, while 57.15% (n = 20) reported a lower prevalence. The study conducted by Farida et al.44 found that Egyptian children had the highest prevalence of myopia (55.35%, 95% CI: 52.57–58.10), whereas Fotouhi et al.58 reported that Iranian children had the lowest prevalence of myopia (0.4% 95% CI: 0.22–0.67). The pooled prevalence of myopia in this review was comparable to Ghalib et al.28 among Sudanese children (6.00%, 95% CI: 3.882–8.796).

The meta-analysis prevalence of childhood refractive errors in Middle East Region (2008–2023).

Authors and year of study Country Sample size Myopia
 Hyperopia
 Astigmatism
 Weight (%)
Prevalence (%) 95% CI Prevalence (%) 95% CI Prevalence (%) 95% CI
Ghalib et al. 202028 Sudan 400 6.00 3.882–8.796 5.50 3.479–8.209 12.25 9.202–15.870 0.45
Mohamed et al. 201729 Sudan 822 1.70 0.934–2.841 0.61 0.198–1.414 2.31 1.397–3.586 0.92
Alrasheed et al. 201630 Sudan 1678 6.79 5.636–8.105 1.85 1.259–2.612 2.50 1.810–3.368 1.87
Alsaqr et al. 201731 Saudi Arabia 338 4.18 2.303–6.912 8.06 5.378–11.510 20.00 15.849–24.69 0.37
Alrahili et al. 201732 Saudi Arabia 1893 0.69 0.366–1.171 1.53 1.028–2.193 25.30 23.358–27.326 2.11
Alomair et al. 202033 Saudi Arabia 850 14.12 11.846–16.642 6.00 4.500–7.814 8.47 6.687–10.549 0.95
AlThomali et al. 202234 Saudi Arabia 7356 33.21 32.135–34.301 17.63 16.767–18.522 50.14 48.987–51.285 6.19
Abbas et al. 201935 Pakistan 2491 3.97 3.242–4.818 0.84 0.523–1.286 4.62 3.826–5.516 2.77
Hameed 201636 Pakistan 1644 3.29 2.477–4.264 1.28 0.792–1.946 3.65 2.796–4.673 1.83
Latif et al. 201437 Pakistan 533 12.38 9.708–15.483 2.81 1.583–4.599 4.88 3.211–7.066 0.59
Ullah et al. 202038 Pakistan 2288 2.23 1.664–2.920 2.05 1.513–2.722 1.09 0.708–1.609 2.55
Atta 201539 Pakistan 300 21.67 17.138–26.764 11.67 8.262–15.851 8.00 5.193–11.670 0.34
Mahjoob et al. 201625 Iran 320 6.25 3.859–9.488 58.13 52.509–63.589 3.44 1.728–6.067 0.36
Norouzirad et al. 201540 Iran 1130 14.87 12.842–17.077 12.92 11.019–15.017 44.96 42.027–47.910 1.26
Hashemi et al. 201741 Iran 602 2.66 1.527–4.280 3.99 2.571–5.874 - - 0.67
Hashemi et al. 201642 Iran 4106 3.04 2.540–3.617 6.21 5.491–6.992 17.44 16.289–18.634 2.57
Abdelrheem et al. 202143 Egypt 14 787 2.88 2.617–3.163 5.19 4.835–5.557 10.30 9.814–10.801 13.15
Farida et al. 201844 Egypt 1272 55.35 52.565–58.102 11.32 9.631–13.191 50.94 48.157–53.725 1.42
Elsabagh et al. 202045 Egypt 1075 3.91 2.830–5.245 3.16 2.200–4.392 15.07 12.983–17.350 1.20
Kandi et al. 202146 UAE 733 5.18 3.694–7.047 2.18 1.253–3.521 6.82 5.105–8.894 0.82
Hussam et al. 201847 Iraq 735 19.59 16.781–22.649 20.14 17.293–23.221 7.21 5.448–9.326 0.82
Hussein et al. 200848 Jordan 1647 15.54 13.826–17.385 2.85 2.104–3.777 5.16 4.143–6.342 1.84
Alghamdi 202049 Saudi Arabia 417 7.67 5.308–10.661 9.11 6.529–12.293 3.12 1.670–5.272 0.47
Al-Rowaily et al. 201050 Saudi Arabia 1319 2.50 1.728–3.496 2.05 1.353–2.964 2.50 1.728–3.496 1.47
Yamamah et al. 201551 Egypt 2070 3.09 2.389–3.931 3.62 2.860–4.521 15.36 13.835–16.989 2.31
Aldebasi 201452 Saudi Arabia 5176 5.80 5.175–6.468 0.68 0.471–0.939 4.41 3.862–5.000 5.0
Rajavi et al. 201453 Iran 2417 4.88 4.057–5.818 3.52 2.819–4.330 22.59 20.936–24.310 2.69
Elmajri 201754 Libya 920 1.74 0.997–2.809 6.20 4.726–7.953 3.70 2.573–5.126 1.03
Al Wadaani et al. 201255 Saudi Arabia 2002 8.99 7.774–10.330 1.35 0.891–1.956 1.65 1.137–2.307 2.23
Gilal et al. 202256 Pakistan 400 3.75 2.114–6.110 1.75 0.706–3.572 1.25 0.407–2.893 0.45
Jamali et al. 200957 Iran 827 1.69 0.929–2.824 20.56 17.850–23.474 19.59 16.936–22.461 0.92
Fotouhi et al. 201158 Iran 3481 0.40 0.220–0.674 10.11 9.130–11.162 6.61 5.804–7.484 3.88
Caca et al. 201359 Turkey 21 062 3.20 2.966–3.447 5.90 5.587–6.228 14.30 13.830–14.781 21.45
Aydoğan et al. 201760 Turkey 1729 10.76 9.336–12.314 3.82 2.964–4.831 26.32 24.253–28.459 1.93
Abdianwall 202061 Afghanistan 951 2.84 1.879–4.104 1.37 0.730–2.326 0.53 0.171–1.223 1.06
Khandekar et al. 201662 Oman 286 9.40 7.90–11.20 1.09 0.90–2.72 4.54 3.53–6.01 0.32
Anuradha 201563 Oman 12 448 2.84 1.879–4.104 0.07 0.05–0.09 NA NA 7.76
Mohamed et. al64 Sudan 551 5.08 4.01–6.8 1.09 1.01–2.50 3.27 2.301–4.71 0.50
Total - 103 053 5.74 5.589–5.894 5.35 5.204–5.500 13.16 12.937–13.382 100.00

Note: p (Heterogeneity between groups) < 0.0001; I2, Myopia 99.59%; Hyperopia 99.09%; Astigmatism 99.71%.

NA, not applicable.

Approximately 42.85% of the reviewed articles (n = 15) reported a significantly higher estimation of hyperopia while 57.15% (n = 20) reported a lower prevalence compared with the pooled prevalence across the Middle East as shown in Table 2. The estimated overall pooled prevalence of hyperopia was (5.35%, 95% CI: 5.20–5.50, p 0.001). In a cross-sectional study, Mahjoob et al.25 observed that the prevalence of hyperopia was highest among Iranian schoolchildren (58.13%; 95% CI: 52.51–63.59) and lowest among Omani children (0.07%; 95% confidence interval: 0.05–0.09).62 The pooled prevalence of hyperopia in this review was comparable to that reported by Ghalib et al.28 for Sudanese children (6.00%, 95% CI: 3.88–8.80) and Abdelrheem et al.43 for Egyptian children (5.19% 95% CI: 4.84–5.56).

The total pooled prevalence of astigmatism was 13.16% (95% CI: 12.94–13.38, p < 0.001). Approximately 35.29% of the reviewed articles (n = 12) appeared to have a significantly higher prevalence of astigmatism while 64.71% (n = 22) reported a lower estimation in comparison to the total pooled prevalence across the Middle East as shown in Table 2. In contrast to Farida et al.,44 who found that Egyptian schoolchildren had the highest astigmatism prevalence (50.94%; 95% CI: 48.16–53.73), Abdianwall,61 found that Afghan schoolchildren had the lowest estimated astigmatism prevalence (0.53%; 95% CI: 0.17–1.22).

 The prevalence of refractive error according to gender among Middle East schoolchildren (2008–2023)

Table 3 illustrates the prevalence of RE according to gender. Between male and female students, there were significant differences in the pooled prevalence of myopia, hyperopia and astigmatism (p < 0.001). In comparison to male students (6.09%, 95% CI: 5.83–6.37), females had a greater total pooled prevalence of myopia (7.25, 95% CI: 6.94–7.56). The presence of hyperopia was somewhat greater in females (5.54%, 95% CI: 5.27–5.82) than in males (5.07%, 95% CI: 4.82–5.32), and the prevalence of astigmatism was higher in females (15.50%, 95% CI: 15.07–15.94) than in males (11.83–12.57). T test showed no significant difference between genders considering the types of REs (myopia p = 0.941, hyperopia p = 0.896 and astigmatism p = 0.484).

Childhood refractive errors prevalence by gender in Middle East Region (2008–2023).

Authors and year of study Country Sample size Myopia
 Hyperopia
 Astigmatism
 Weight (%)
Prevalence (%) 95% CI Prevalence (%) 95% CI Prevalence (%) 95% CI
Male
Ghalib et al. 202028 Sudan 284 3.52 1.701–6.380 3.52 1.701–6.380 5.99 3.525–9.411 0.93
Mohamed et al. 201729 Sudan 822 1.70 0.934–2.841 0.61 0.198–1.414 2.31 1.397–3.586 2.70
Alrasheed et al. 201630 Sudan 827 6.89 5.262–8.838 1.81 1.019–2.974 1.94 1.110–3.123 2.72
Alsaqr et al. 201731 Saudi Arabia 162 2.78 0.908–6.363 6.67 3.492–11.356 NA NA 0.59
Alrahili et al. 201732 Saudi Arabia 947 0.53 0.172–1.228 2.32 1.461–3.496 25.13 22.397–28.022 3.11
AlThomali et al. 202234 Saudi Arabia 3674 31.30 29.803–32.829 17.23 16.021–18.490 47.69 46.060–49.316 12.05
Abbas et al. 201935 Pakistan 1250 3.76 2.776–4.969 0.96 0.497–1.671 4.00 2.983–5.240 4.10
Hameed 201636 Pakistan 951 2.73 1.794–3.980 1.68 0.965–2.718 3.47 2.400–4.839 3.12
Ullah et al. 202038 Pakistan 1746 1.83 1.257–2.578 2.18 1.545–2.975 0.92 0.525–1.484 5.73
Mahjoob et al. 201625 Iran 160 8.75 4.866–14.245 63.75 55.788–71.192 5.00 2.183–9.614 0.53
Hashemi et al. 201741 Iran 294 35.37 29.911–41.136 22.45 17.809–27.654 NA NA 0.97
Hashemi et al. 201642 Iran 2127 3.06 2.366–3.879 5.08 4.184–6.098 15.47 13.956–17.075 6.98
Abdelrheem et al. 202143 Egypt 7450 3.03 2.656–3.449 4.85 4.369–5.358 9.96 9.289–10.662 24.44
Farida et al. 201844 Egypt 460 56.52 51.853–61.106 7.83 5.541–10.670 45.22 40.604–49.893 1.51
Kandi et al. 202146 UAE 411 6.08 3.975–8.849 2.92 1.518–5.045 9.25 6.626–12.469 1.35
Hussam et al. 201847 Iraq 486 14.20 11.217–17.621 16.26 13.086–19.842 5.97 4.032–8.458 1.60
Alghamdi 202049 Saudi Arabia 417 7.67 5.308–10.661 9.11 6.529–12.293 3.12 1.670–5.272 1.37
Aldebasi 201452 Saudi Arabia 2573 4.70 3.917–5.593 0.78 0.475–1.198 10.07 8.930–11.294 8.44
Rajavi et al. 201453 Iran 1238 4.52 3.435–5.834 3.88 2.872–5.108 25.20 22.804–27.718 4.06
Al Wadaani et al. 201255 Saudi Arabia 966 7.25 5.692–9.067 1.45 0.795–2.420 1.35 0.718–2.290 3.17
Gilal et al. 202256 Pakistan 203 0.49 0.0125–2.714 1.97 0.539–4.968 0.49 0.0125–2.714 0.67
Fotouhi et al. 201158 Iran 1598 0.38 0.138–0.815 12.58 10.991–14.304 7.07 5.863–8.440 5.24
Aydoğan et al. 201760 Turkey 827 9.92 7.964–12.158 4.60 3.272–6.253 27.57 24.548–30.752 2.72
Abdianwall 202061 Afghanistan 574 2.27 1.211–3.842 0.70 0.190–1.775 0.17 0.00441–0.967 1.89
Total 30 465 6.09 5.827–6.367 5.07 4.822–5.318 12.20 11.828–12.572 100
Female
Ghalib et al. 202028 Sudan 116 12.07 6.758–19.420 10.35 5.461–17.373 27.59 19.695–36.657 0.43
Alrasheed et al. 201630 Sudan 839 6.79 5.186–8.713 1.91 1.094–3.078 3.10 2.034–4.508 3.05
Alsaqr et al. 201731 Saudi Arabia 176 5.81 2.689–10.736 9.68 5.518–15.459 NA NA 0.57
Alrahili et al. 201732 Saudi Arabia 946 0.85 0.366–1.659 0.74 0.298–1.519 25.48 22.726–28.379 3.44
AlThomali et al. 202234 Saudi Arabia 3682 35.12 33.574–36.684 18.03 16.804–19.314 52.58 50.952–54.204 13.39
Abbas et al. 201935 Pakistan 1241 4.19 3.145–5.459 0.73 0.332–1.372 5.24 4.065–6.628 4.52
Hameed 201636 Pakistan 639 4.38 2.931–6.271 0.78 0.255–1.817 5.79 4.109–7.893 2.33
Ullah et al. 202038 Pakistan 542 3.51 2.124–5.420 1.66 0.762–3.129 1.66 0.762–3.129 1.97
Mahjoob et al. 201625 Iran 160 3.75 1.388–7.983 52.5 44.466–60.439 1.88 0.388–5.382 0.59
Hashemi et al. 201741 Iran 308 20.78 16.386–25.744 25.97 21.167–31.250 - 1.12
Hashemi et al. 201642 Iran 1979 3.03 2.321–3.886 7.43 6.311–8.673 19.56 17.829–21.373 7.20
Abdelrheem et al. 202143 Egypt 7337 2.73 2.365–3.125 5.53 5.021–6.081 10.65 9.948–11.373 26.68
Farida et al. 201844 Egypt 812 54.68 51.183–58.143 13.30 11.040–15.831 54.19 50.689–57.655 2.96
Kandi et al. 202146 UAE 322 4.04 2.167–6.805 1.24 0.339–3.150 3.73 1.940–6.419 1.17
Hussam et al. 201847 Iraq 249 30.12 24.489–36.233 27.71 22.246–33.715 9.64 6.274–14.002 0.91
Aldebasi 201452 Saudi Arabia 2603 6.88 5.934–7.917 0.58 0.323–0.949 9.68 8.572–10.882 9.47
Rajavi et al. 201453 Iran 1179 5.26 4.055–6.691 3.14 2.219–4.300 19.76 17.525–22.152 4.29
Al Wadaani et al. 201255 Saudi Arabia 1036 0.97 0.464–1.768 1.26 0.670–2.136 1.93 1.183–2.966 3.77
Gilal et al. 202256 Pakistan 177 7.91 4.392–12.915 1.70 0.351–4.873 2.26 0.619–5.685 0.65
Fotouhi et al. 201158 Iran 1883 0.43 0.184–0.835 8.02 6.832–9.339 6.21 5.165–7.400 6.85
Aydoğan et al. 201760 Turkey 902 11.53 9.519–13.796 3.10 2.072–4.455 25.17 22.364–28.132 3.28
Abdianwall 202061 Afghanistan 377 3.71 2.045–6.152 2.39 1.097–4.483 1.06 0.290–2.694 1.37
Total 27 484 7.25 6.942–7.559 5.54 5.271–5.815 15.50 15.069–15.935 100

Note; p < 0.0001; I2 (male), Myopia 99.33%; Hyperopia 98.70%; Astigmatism 99.56%; I2 (female), Myopia 99.49%; Hyperopia 98.84%; Astigmatism 99.60%.

NA, not applicable.

 Prevalence of refractive error depending on refraction technique among Middle East schoolchildren

Table 4 presents the pooled prevalence of RE among Middle East children. The results showed that studies that used cycloplegic refraction reported a higher prevalence of myopia (6.33%, 95% CI: 6.15–6.51), hyperopia (6.36%, 95% CI: 6.18–6.55) and astigmatism (14.39%, 95% CI: 14.16–14.66) among school-aged children, compared with studies that used non-cycloplegic refraction – myopia (4.07%, 95% CI: 3.81–4.34), hyperopia (2.73%, 95% CI: 2.51–2.95) and astigmatism (9.64%, 95% CI: 9.26–10.04). Meta-analysis reports a significant heterogeneity between both groups of articles that used cycloplegic and non-cycloplegic refraction (p < 0.001).

The prevalence of refractive errors by refraction technique among Middle East schoolchildren.

Authors and year of study Country Myopia
 Hyperopia
 Astigmatism
 Weight (%)
Prevalence (%) 95% CI Prevalence (%) 95% CI Prevalence (%) 95% CI
Cycloplegic refraction technique
Ghalib et al. 202028 Sudan 6.00 3.882–8.796 5.50 3.479–8.209 12.25 9.202–15.870 0.59
Alrasheed et al. 201630 Sudan 6.79 5.636–8.105 1.85 1.259–2.612 2.50 1.810–3.368 2.47
Alsaqr et al. 201731 Saudia Arabia 4.18 2.303–6.912 8.06 5.378–11.510 20.00 15.849–24.690 0.49
Alomair et al. 202033 Saudia Arabia 14.12 11.846–16.642 6.00 4.500–7.814 8.47 6.687–10.549 1.25
Althomali et al. 202234 Saudia Arabia 33.21 32.135–34.301 17.63 16.767–18.522 50.14 48.987–51.285 10.81
Latif et al. 201437 Pakistan 12.38 9.708–15.483 2.81 1.583–4.599 4.88 3.211–7.066 0.78
Atta 201539 Pakistan 21.67 17.138–26.764 11.67 8.262–15.851 8.00 5.193–11.670 0.44
Mahjoob et al. 201525 Iran 6.25 3.859–9.488 58.13 52.509–63.589 3.44 1.728–6.067 0.47
Norouzirad et al. 201540 Iran 14.87 12.842–17.077 12.92 11.019–15.017 44.96 42.027–47.910 1.66
Hashemi et al. 201741 Iran 2.66 1.527–4.280 3.99 2.571–5.874 - - 0.89
Abdelrheem et al. 202143 Egypt 2.88 2.617–3.163 5.19 4.835–5.557 10.30 9.814–10.801 21.73
Farida et al. 201844 Egypt 55.35 52.565–58.102 11.32 9.631–13.191 50.94 48.157–53.725 1.87
Elsabagh et al. 202045 Egypt 3.91 2.830–5.245 3.16 2.200–4.392 15.07 12.983–17.350 1.58
Kandi et al. 202146 UAE 5.18 3.694–7.047 2.18 1.253–3.521 6.82 5.105–8.894 1.08
Hussam et al. 201847 Iraq 19.59 16.781–22.649 20.14 17.293–23.221 7.21 5.448–9.326 1.08
Yamamah et al. 201551 Egypt 3.09 2.389–3.931 3.62 2.860–4.521 15.36 13.835–16.989 3.04
Aldebasi 201452 Saudia Arabia 5.8 5.175–6.468 0.68 0.471–0.939 4.41 3.862–5.000 7.61
Elmajri 201754 Libya 1.74 0.997–2.809 6.20 4.726–7.953 3.70 2.573–5.126 1.35
Al Wadaani et al. 201255 Saudia Arabia 8.99 7.774–10.330 1.35 0.891–1.956 1.65 1.137–2.307 2.94
Gilal et al. 202256 Pakistan 3.75 2.114–6.110 1.75 0.706–3.572 1.25 0.407–2.893 0.59
Jamali et al. 200957 Iran 1.69 0.929–2.824 20.56 17.850–23.474 19.59 16.936–22.461 1.22
Fotouhi et al. 201158 Iran 0.40 0.220–0.674 10.11 9.130–11.162 6.61 5.804–7.484 5.12
Caca et al. 201359 Turkey 3.20 2.966–3.447 5.90 5.587–6.228 14.30 13.830–14.781 30.94
Total 6.33 6.147–6.514 6.36 6.181–6.550 14.39 14.125–14.656 100.00
Non-Cycloplegic Refraction Technique
Mohamed et al. 201729 Sudan 1.70 0.934–2.841 0.61 0.198–1.414 2.31 1.397–3.586 3.79
Alrahili et al. 201132 Saudi Arabia 0.69 0.366–1.171 1.53 1.028–2.193 25.30 23.358–27.326 8.71
Abbas et al. 201935 Pakistan 3.97 3.242–4.818 0.84 0.523–1.286 4.62 3.826–5.516 11.46
Hameed 201636 Pakistan 3.29 2.477–4.264 1.28 0.792–1.946 3.65 2.796–4.673 7.57
Ullah et al. 202038 Pakistan 2.23 1.664–2.920 2.05 1.513–2.722 1.09 0.708–1.609 10.53
Hashemi et al. 201642 Iran 3.04 2.540–3.617 6.21 5.491–6.992 17.44 16.289–18.634 18.89
Hussein et al. 200848 Jordan 15.54 13.826–17.385 2.85 2.104–3.777 5.16 4.143–6.342 7.58
Alghamdi 202049 Saudi Arabia 7.67 5.308–10.661 9.11 6.529–12.293 3.12 1.670–5.272 1.92
Al-Rowaily et al. 201050 Saudi Arabia 2.50 1.728–3.496 2.05 1.353–2.964 2.50 1.728–3.496 6.07
Rajavi et al. 201453 Iran 4.88 4.057–5.818 3.52 2.819–4.330 22.59 20.936–24.310 11.12
Aydoğan et al. 201760 Turkey 10.76 9.336–12.314 3.82 2.964–4.831 26.32 24.253–28.459 7.96
Abdianwall 202061 Afghanistan 2.84 1.879–4.104 1.37 0.730–2.326 0.53 0.171–1.223 4.38
Total 4.07 3.814–4.344 2.73 2.512–2.950 9.64 9.255–10.044 100.00

Note: Cycloplegic Refraction Technique - p < 0.0001; I2, Myopia 99.71%; Hyperopia 99.25%; Astigmatism 99.75%; Non-Cycloplegic Refraction Technique - p < 0.0001; I2, Myopia 98.11%; Hyperopia 96.20%; Astigmatism 99.53%.

 Discussion

This meta-analysis estimated the prevalence of childhood RE in the MER, considering uncorrected RE measurement approaches and gender. The standards used in this study to describe myopia, hyperopia and astigmatism are spherical equivalent (-0.5 D SPH), +1.50 D SPH, and 0.5 Cylinder, respectively. The meta-analysis revealed that myopia (5.74%), hyperopia (5.35%) and astigmatism (13.16%) were the three most common types of RE among school age children. This examination revealed substantial heterogeneity among the published studies as well as significant variances within and between Middle Eastern nations (p < 0.0001). Astigmatism is more common maybe because of a combination of genetic and environmental elements and the effect of sample size.

Children in Egypt were found to have the highest myopia estimates,44 whereas Iranians had a much lower prevalence of myopia.58 This study’s pooled prevalence of myopia was comparable to that of Sudanese children.28 The prevalence of hyperopia is lowest among Omani children62 and highest among Iranians.25 A comparable prevalence finding was observed in school-age Sudanese28 and Egyptian students.44 The Egyptian children had the highest prevalence of astigmatism,44 while Afghani children showed the lowest prevalence.61

While Iran showed variation in the prevalence of myopia within the country (6.25%,25 14.87%,40 2.66%,41 and 3.04%42), Saudi Arabia showed variation in its hypermetropia prevalence (8.06%,31 1.53%,32 6.0%,33 17.63%34). The highest prevalence of myopia (55.35%)44 and astigmatism (50.94%)44 was reported from Egypt, and the same for hypermetropia was from Iran (58.3%).25 This study found significant regional variations in the prevalence of REs, which is consistent with other studies.44,65 Such differences are reported even within the same geographic area. The possible reasons for those differences might be because of the different benchmarks used for describing REs or genetic factors, or differences in the technique utilised to estimate the RE (cycloplegic or non-cycloplegic). This study investigated the pooled prevalence of all REs for studies that used cycloplegic and non-cycloplegic refraction independently.

The overall pooled prevalence of myopia among children in the Middle East is higher than that reported from Africa,66 but lower than the figures globally, including estimations in Indian and Chinese children.14,67,68 This might be because of the reduction of outdoor activities, and screen-related visual stress. The pooled prevalence data of hypermetropia was higher than the global finding14,69 and slightly lower than the children from Eastern Mediterranean region.65

This prevalence of hyperopia in Middle Eastern children compared with the other regions may be because of the difference in the genetic tendency to hyperopia development and that most of studies used non-cycloplegic refraction that could lead to reduce the prevalence of hyperopia.

The pooled prevalence of astigmatism was higher than the estimates from Indian schoolchildren,12 and lower than global and Chinese prevalence.12,14 This variation could be because of differences in geographic, socioeconomic and ethnic factors. The Middle East is a geographic region that includes countries in Asia and Africa. Most of the observations in this study were from Middle Eastern Asian nations, which may indicate the results’ heterogeneity and slight variations in the prevalence of myopia, hyperopia and astigmatism in children.

The prevalence of all RE in schoolchildren was not significantly different between females and males (p ˃ 0.05). Most of the studies reviewed in this analysis showed no statistically significant difference between gender and REs, which agrees with previous studies conducted in Middle East and Africa.65,66 However, a significant gender difference was reported from India in myopic and astigmatic REs.9

This analysis showed that the studies that used cycloplegic refraction technique reported a significantly higher prevalence of childhood myopia, hyperopia and astigmatism compared with non-cycloplegic refraction studies, which is inconsistent with Manny et al.,69 Alrasheed et al.65 and Castagno et al.,70 which showed that cycloplegic refraction is the acceptable technique to diagnose REs accurately. The increase in myopia prevalence among cycloplegic studies might be because of the variations in sample sizes and RE estimation accuracy in some studies.

This systematic review and meta-analysis had some limitations, including the inherent variations within the studies considered for this review, such as sample sizes, which could cause the prevalence of REs to be overestimated or underestimated, and some studies used cycloplegic refraction and others didn’t. Additionally, some studies limited themselves to the term schoolchildren instead of mentioning the average age. Because of categorisation issues or differences in age groups, some research was eliminated from this review, causing a reduction in the number of studies that were included. Additionally, the multitude of variables influencing the prevalence of RE were not examined in this study.

 Conclusion

This meta-analysis reveals that the most common RE in the Middle Eastern schoolchildren between 5 and 17 years of age was astigmatism followed by myopia and hyperopia. However, there was no significant difference between male and female in the pooled prevalence of REs. The results found that myopia, hyperopia and astigmatism estimations varied between cycloplegic and non-cycloplegic refractions. These findings, which generally concur with the global trend, call for deliberate action to tackle childhood REs.

 Acknowledgements Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

 Authors’ contributions

The idea was created and written by Z.D.M. and S.H.A. Furthermore, Z.D.M. and S.H.A. were also involved in data gathering and data analysis. The theory and concept were developed by Z.D.M. and G.M.I. J.P.A. and B.N. conducted the data examination, and G.S.V. and B.N. verified the analytical techniques created by Z.D.M. and S.H.A. Z.D.M. was the work supervisor. Every author participated in the final article review and talked about the findings.

 Data availability

The data that support the findings of this study are available upon request from the corresponding author, Z.D.M.

 Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

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How to cite this article: Mohamed ZD, Ismail GM, Alrasheed SH, Vankudre GS, Noushad B, Ayyappan JP. Refractive errors among schoolchildren in the Middle East: A systematic review and meta-analysis. Afr Vision Eye Health. 2024;83(1), a940. https://doi.org/10.4102/aveh.v83i1.940