Five years’ retrospective analysis of childhood ocular morbidities: A priority setting guidelines for pediatric eye clinic

Abstract

Objectives: To observe patterns of Pediatric eye diseases over five years 2015-19, to improve management of ophthalmic pediatric units in the developing countries. Methods: It was an observational, cross-sectional study carried out in a tertiary eye care Hospital, Karachi. Records of the children under 16 years of age from 2015 to 2019 were retrieved. Inclusion criteria included complete records with age, gender of the children, symptoms, examination, investigation if necessary, and diagnosis. All incomplete records were excluded. Results: A total of 35348 records with 55.17% boys and 44.82% girls were analyzed. Similar gender difference was reflected in disease frequency. Seven percent of the children did not have detectable ocular pathology. Conjunctivitis, refractive errors and squint were the three most common ocular morbidities observed in decreasing order of frequency as 32.67%, 20.08% and 14.7% respectively. Cataract was present in 4.51%, Corneal disease in 4.11%, Retinal pathology in 1.04%, Glaucoma in 0.49% cases; but Retinoblastoma was present in 55 cases and ROP in 4 cases only. Almost 60% of the children had simple ocular problems like conjunctivitis, refractive error and absence of any pathology. Conclusion: Majority of the children attending pediatric ophthalmology had simple problems manageable at primary health facility level. Strengthening of the primary health care facility will reduce considerable burden of pediatric unit at the tertiary level. Optometrists and orthoptists are important members of the team for refraction and squint management. doi: https://doi.org/10.12669/pjms.38.6.5441 How to cite this:Bukhari S, Azam S, Ahsan S, Mahmood T, Memon MS, Haseeb U, et al. Five years’ retrospective analysis of childhood ocular morbidities; A priority setting guidelines for pediatric eye clinic. Pak J Med Sci. 2022;38(6):---------. doi: https://doi.org/10.12669/pjms.38.6.5441 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Pak J Med Sci July - August 2022 Vol. 38 No. 6 www.pjms.org.pk 1501
INTRODUCTION
Ocular morbidity describes spectrum of eye
diseases experienced by a population that are
either signicant to the individual or to eye
professionals.1 Eye problems in children are one
of the important cause of medical consultation
and If not attended may lead to severe visual
impairment and blindness.2 Visual impairment
in young children delays motor, language,
emotional, social and cognitive development,
with lifelong consequences. School going children
Correspondence:
Dr. Muhammad Saleh Memon, FRCS (Eden).
Director Research,
Al Ibrahim Eye Hospital,
Isra Postgraduate Institute of Ophthalmology,
Karachi, Pakistan.
Email: salehmemon@yahoo.com
* Received for Publication: September 30, 2021
* Revision Received: April 11, 2022
* Revision Accepted: April 26, 2022
Original Article
Five years’ retrospective analysis of childhood ocular
morbidities: A priority setting guidelines
for pediatric eye clinic
Sadia Bukhari1, Shua Azam2, Shahid Ahsan3,
Tauseef Mahmood4, Muhammad Saleh Memon5,
Uzma Haseeb6, Muhammad Arslan7
ABSTRACT
Objectives: To observe patterns of Pediatric eye diseases over ve years 2015-19, to improve management
of ophthalmic pediatric units in the developing countries.
Methods: It was an observational, cross-sectional study carried out in a tertiary eye care Hospital,
Karachi. Records of the children under 16 years of age from 2015 to 2019 were retrieved. Inclusion criteria
included complete records with age, gender of the children, symptoms, examination, investigation if
necessary, and diagnosis. All incomplete records were excluded.
Results: A total of 35348 records with 55.17% boys and 44.82% girls were analyzed. Similar gender
difference was reected in disease frequency. Seven percent of the children did not have detectable
ocular pathology. Conjunctivitis, refractive errors and squint were the three most common ocular
morbidities observed in decreasing order of frequency as 32.67%, 20.08% and 14.7% respectively. Cataract
was present in 4.51%, Corneal disease in 4.11%, Retinal pathology in 1.04%, Glaucoma in 0.49% cases; but
Retinoblastoma was present in 55 cases and ROP in 4 cases only. Almost 60% of the children had simple
ocular problems like conjunctivitis, refractive error and absence of any pathology.
Conclusion: Majority of the children attending pediatric ophthalmology had simple problems manageable
at primary health facility level. Strengthening of the primary health care facility will reduce considerable
burden of pediatric unit at the tertiary level. Optometrists and orthoptists are important members of the
team for refraction and squint management.
KEYWORDS: Conjunctivitis, Eye disease, Pediatric ophthalmology, Primary eye care, Refractive error.
doi: https://doi.org/10.12669/pjms.38.6.5441
How to cite this:
Bukhari S, Azam S, Ahsan S, Mahmood T, Memon MS, Haseeb U, et al. Five years’ retrospective analysis of childhood ocular
morbidities; A priority setting guidelines for pediatric eye clinic. Pak J Med Sci. 2022;38(6):1501-1507.
doi: https://doi.org/10.12669/pjms.38.6.5441
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Sadia Bukhari et al.
Pak J Med Sci July - August 2022 Vol. 38 No. 6 www.pjms.org.pk 1502
with visual impairment can also experience lower
levels of educational achievement. Consequently,
it impacts quality of life in adulthood.3 Especially
in low income countries with less resources and
decient education they get less employment
opportunities. They might also face difculties
in social interactions which can lead to social
loneliness, anxiety and depression.3
Globally 19 million children have visual
impairment with 1.26 million blind bilaterally
and, an estimated 70 million blind years are
caused by childhood blindness.4 Data for visually
impaired and blind children for Pakistan is not
available. The available evidence suggests that
the prevalence varies from 0.3/1000 children
in economically developed countries to over
1.0/1000 children in underdeveloped societies.5
Population of children under 15 years is 90
million6 (43.4% of country’s population). One
can project number of visually impaired children
at 1.0/1000 children as 0.09 million or 90000
children. Almost half of all blindness in children
particularly those in the poor countries is due
to avoidable causes that are amenable to cost
effective interventions.7 The goal of VISION 2020
recommends one ophthalmologist trained in
pediatric eye diseases for every 10 million people
by 2020.8 There are enough practicing pediatric
ophthalmologist but very few properly trained
and experienced pediatric ophthalmologist. All
the tertiary centers are trying to develop pediatric
ophthalmology units and need equipment and
human resource. Nationally there is no guide
line for such development. This study intends to
develop these guide lines.
In the past few years’ childhood ocular
morbidity is dominated by allergic conjunctivitis
and refractive errors.9 Studies from Pakistan also
reported similar pattern of ocular problems.10,11
Eye trauma in children is common cause of
unilateral severe visual impairment and cosmetic
disgurement resulting in psychological impact
on personality and behavior.12
This study will give us baseline data of pediatric
ocular morbidities in children attending tertiary
eye care centre, Karachi. This baseline data will
provide clinical based evidence for the relevant
authorities to formulate a policy to reduce the
burden on tertiary eye care hospitals and provide
chances to the pediatric ophthalmologist to
concentrate on training, teaching and research in
addition to the clinical work. This study will also
draw attention of institutional heads to identify
the areas of efcient allocation, investment and
prioritization of nancial as well as human
resources.
METHODS
It was an observational, cross-sectional study
with retrospective data collection retrieved from
Hospital Information Management System (HIMS)
of Al Ibrahim Eye Hospital, Karachi from Jan 2015
to Dec 2019. A prior Ethical Approval was taken
from Institute Research Ethical Committee. Study
protocol number was A-00094. Non-probability
purposive sampling technique was used for
sample collection from software. Inclusion criteria
was clinical records of all children aged up to 15
years attending outpatient department of Pediatric
Ophthalmology unit were retrieved irrespective
of age, gender and ethnicity. Missing records
or unclear diagnosis with incomplete data were
excluded from the study.
Data Collection Procedure: All these patients
underwent detailed examination including
History taking, checking visual acuity with the
help of recommended tools including Central,
steady and maintained (CSM), Lea Gratings,
Cardiff visual acuity cards and Snellen’s chart.
Cycloplegic refraction was done when needed.
Complete Ophthalmic examination was carried
out with the help of direct ophthalmoscope, slit
lamp (Hand held slit lamp was used in younger
children), +90 D lens and indirect ophthalmoscope
were used for examination of fundus. B-scan
ultrasound performed in cases where fundus view
was not clear. Examination under sedation or
general anesthesia was carried out where needed.
After detailed clinical examination diagnosis was
made and recorded.
Statistical Analysis: Data was retrieved from
HIMS software and exported to SPSS version 23.0
for data analysis. Mean and Standard deviation was
calculated for continuous variables. Frequency and
percentages were reported for categorical variables
like gender, age groups and diagnosis. Bar chart
was made to present age groups. Cross tabulation
was done between diagnosis with gender and
age groups using Chi-square test. P-value ≤ 0.05
considered to be statistically signicant.
RESULTS
Complete records of 35348 children visiting
pediatric clinic of Al-Ibrahim Eye Hospital with
different ocular problems were retrieved. Mean

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age of the patient was 7.58 ± 4.42 years. Gender
distribution was observed as boys 19503 (55.17%)
and girls 15845 (44.82%). Boy to girl ratio was 1.2:1.
Among four age groups, 2077 (5.9%) patients
were of age less than one year, 10118 (28.6%) were
in between one to ve years. Frequency of the
children in the third age group (6-10 years) was
12261 (34.6%) and 10892 (30.8%) patients were in
between 11 to 15 years (Fig.1).
Conjunctivitis with 11550 (32.67%) children
was commonest disease. Amongst conjunctivitis,
allergic was commonest (37.6%), bacterial was
found in 37.5%, vernal conjunctivitis 14.42%, viral
5.67% and 4.77% were labeled nonspecic. Second
commonest cause was Refractive error which was
found in 7100 (20.08%) children. Hypermetropia
found was 45.75%, myopia 33%, astigmatism
18%. Children found to be amblyopic were 3.38%
(Table-I). The third common cause was squint 5198
(14.70%). Children who did not have any visible
disease were 2476 (7%). Cataract was present in
1597 (4.51%), Cornea affected in 1461 (4.11%),
Retinal disease in 370 (1.04%). Glaucoma was
present in 176 (0.49%) cases. Boys’ dominance
was easily seen in conjunctivitis as 6778 (19.17%)
against 4772 (13.50%) girls. Similarly, more boys
3625 (10.25%) compared to girls 3475 (9.83%) were
diagnosed with different types of refractive error.
Likewise, Squint cases had a slightly upper share
2677 (7.57%) in boys as compare to girls 2521
(7.13%) (Table-II).
Diagnosis on the basis of age groups are presented
in Table-III. Most of the cases of conjunctivitis 4150
(11.74%) belong to age group 6 to 10 years. While
refractive error 3640 (10.29%) mostly found in
between 11 to 15 years of age. Similarly, most of
the squint cases 1999 (5.65%) found in early age of
one to ve years. Cataract 566 (1.60%), Cornea 562
(1.58%) and Retina 142 (0.40%) related cases were
mostly found in between 6 to 10 years of age.
DISCUSSION
This study validates ndings of earlier studies
regarding childhood ocular morbidity dominated
by allergic conjunctivitis and refractive errors.10,11
The data shows that over a period of 5 years,
conjunctivitis was present in 32.67% children.
Of this 37.6% were allergic and 14.4% were
VKC. Study from Sind Province reported 34.1%
conjunctivitis cases in children attending 10
BHUs.13 In a study from Punjab Province reported
22.1% VKC and 34% refractive errors.11 Study
from Karachi reported 24.8% VKC and 15.2%
refractive errors.12 Another tertiary center in
Bahawalpur13 reported 32.2% conjunctivitis and
21.9% refractive errors. A study from Ethiopia
showed 30.5% infections of conjunctiva and
lid, 21.9% refractive errors and VKCs 28% and
allergic conditions. There seems consensus on
the ndings that conjunctivitis is commonest eye
disease in children in the developing countries.
Second common cause of ocular morbidity in
children is refractive errors. Present study shows
Refractive error in 20.08% children. Other national
studies also present refractive errors as common
morbidity in children with variable frequency
from 33%11, 14.8%12 and 32.1%.13 Present study
differs from majority of studies where myopia is
more common. The population-based prevalence
of myopia, hyperopia (≥ +2.00 D) and astigmatism
Childhood ocular morbidities
Fig.1: Age Distribution.
Table-I: Proportion of Conjunctivitis and Refractive Error.
Conjunctivitis Count %
Allergic Conjunctivitis 4344 37.61
Bacterial Conjunctivitis 4335 37.53
Vernal Keratoconjunctivitis (VKC) 1665 14.42
Viral Conjunctivitis 655 5.67
Nonspecic conjunctivitis 551 4.77
Total 11550 100
Refractive Error Count %
Hypermetropia 3245 45.7
Myopia 2338 32.92
Astigmatism 1469 17.99
Amblyopia 240 3.38
Total 7100 100

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in India was 5.3%, 4% and 5.4%, respectively.14
Study from Pakistan showed myopia as 52%,
astigmatism as 38% and Hypermetropia as 10%.15
Our study is supported by Slaveylokov K et al.16
where hypermetropia was seen in 78.85%. High
number of hypermetropic patients in our study is
probably because of signicant number of squint
patients attending the clinic.
All these studies show that 60% (conjunctivitis
33%, normal eyes 7% and refractive errors 20%)
children could have been treated at Basic Health
Unit (BHUs) and Rural Health Centres (RHCs).
Strengthening BHUs and RHCs can not only
lessen the burden of pediatric eye care centers
by 60% but will make the treatment of children
more accessible and cost effective. Strengthening
will include education of the professionals of
primary eye care facility specially regarding
management of allergic conjunctivitis and Vernal
Keratoconjunctivitis (VKC). Patients with VKC
and allergic conjunctivitis should always be told
the hidden effect of steroid which are frequently
used in the treatment of these two diseases.
Steroid induced glaucoma17 and cataract18 are
known complications of long term use of steroids
leading to blindness. Apparently simple diseases
become important due to the complications of
treatment. Constant vigilance and education of
the professionals as well patients are required.
Another important emerging complication of
VKC is Keratoconus.19,20 It is to be reminded to
the primary health facilitators that if allergic
conjunctivitis and VKC does not respond to
treatment in few weeks, they are to be referred to
tertiary level facility.
Remaining 40% cases need to be referred
to a Pediatric unit. They can be conveniently
grouped on the basis of expertise of the surgeon
Sadia Bukhari et al.
Table-II: Gender wise diagnosis.
Diagnosis
Gender
P-value
Boys Girls Total
Conjunctivitis 6778 (19.17%) 4772 (13.50%) 11550 (32.67%)
0.001
Refractive Error 3625 (10.25%) 3475 (9.83%) 7100 (20.08%)
Squint 2677 (7.57%) 2521 (7.13%) 5198 (14.70%)
Normal Quite Eye 1251 (3.53%) 1225 (3.46%) 2476 (7%)
Eye Lid Pathology 1052 (2.97%) 1112 (3.14%) 2164 (6.12%)
Lacrimal Systematic Disease 948 (2.68%) 889 (2.51%) 1837 (5.20%)
Cataract 1039 (2.93%) 558 (1.57%) 1597 (4.51%)
Corneal diseases 913 (2.58%) 548 (1.55%) 1461 (4.13%)
Trauma 323 (0.91%) 170 (0.48%) 493 (1.39%)
Retinal diseases 245 (0.69%) 125 (0.35%) 370 (1.04%)
Glaucoma 100 (0.28%) 76 (0.21%) 176 (0.49%)
Orbital diseases 89 (0.25%) 80 (0.22%) 169 (0.47%)
Dry Eye 90 (0.25%) 64 (0.18%) 154 (0.43%)
Optic Nerve diseases 73 (0.20%) 51 (0.15%) 124 (0.35%)
Developmental Anamolies 50 (0.14%) 27 (0.07%) 77 (0.21%)
Pthysis Bulbi 40 (0.11%) 14 (0.04%) 54 (0.15%)
Endophthalmitis 29 (0.08%) 19 (0.05%) 48 (0.13%)
Uveitis 20 (0.06%) 16 (0.04%) 36 (0.10%)
Down Syndrome 11 (0.03%) 8 (0.02%) 19 (0.05%)
Other Diagnosis 150 (0.43%) 95 (0.27%) 245 (0.69%)
Total 19503 (55.17%) 15845 (44.82%) 35348 (100%)

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needed. First Group will consist of Squint
(14.8%), pediatric cataract (4.57%) and ocular
trauma (1.39%) which can be managed by general
pediatric ophthalmologist. Second Group will
include corneal diseases (4.18%), retinal problems
(1.0%), congenital/developmental glaucoma
(0.5%), Lacrimal (6.12%), lids (5.2%), orbit (0.47%)
and advanced cases of ocular trauma which can be
managed by pediatric ophthalmologist trained in
particular sub-specialty.
In the first group Squint was reported as
commonest pediatric problem in this study
(14.8%), mostly (10.87%) in the age group 1-10
years. No gender difference was found (7.5%
boys and 7.13% girls). Other studies reported
almost same or near frequency, 12.4% by Farrukh
S et.al from Karachi11, 13.5% by Sethi et al. from
North West Frontier Province of Pakistan.21
Assessment of the squint is most important
aspect of the management of squint and is best
carried by orthoptist or trained optometrist.
Tertiary center should have an orthoptist to
manage squints.
Cataract is the most important cause of treatable
blindness in childhood.22 National studies have
reported 24.3%9 (BHUs, sample 1000 children) 6%13
(tertiary hospital with 1000 sample) and 23.1%14
(tertiary hospital and 1000 sample). In present
study Cataract was found in 4.57% (N;1598) of
the children attending a pediatric unit of Karachi
during ve years. The low number of pediatric
cataract as compared to National statistics is
probably due to missing records. Management of
cataract in children has undergone tremendous
Table-III: Age wise diagnosis.
Diagnosis
Age Groups
Total P-value
less than 1 yr. 1 to 5 yr. 6 to 10 yr. 11 to 15 yr.
Conjunctivitis 635 (1.79%) 3721 (10.52%) 4150 (11.74%) 3044 (8.61%) 11550 (32.67%)
0.001
Refractive Error 40 (0.11%) 757 (2.14%) 2663 (7.53%) 3640 (10.29%) 7100 (20.08%)
Squint 144 (0.40%) 1999 (5.65%) 1848 (5.22%) 1207 (3.41%) 5198 (14.70%)
Normal Quite Eye 126 (0.36%) 603 (1.70%) 867 (2.45%) 880 (2.49%) 2476 (7%)
Eye Lid Pathology 54 (0.15%) 585 (1.65%) 787 (2.22%) 738 (2.08%) 2164 (6.12%)
Lacrimal Systematic
Disease 807 (2.28%) 847 (2.39%) 116 (0.32%) 67 (0.19%) 1837 (5.20%)
Cataract 111 (0.31%) 532 (1.50%) 566 (1.60%) 388 (1.10%) 1597 (4.51%)
Corneal diseases 93 (0.26%) 440 (1.25%) 562 (1.58%) 366 (1.03%) 1461 (4.13%)
Trauma 1 (0.003%) 160 (0.45%) 205 (0.58%) 127 (0.36%) 493 (1.39%)
Retinal diseases 10 (0.03%) 103 (0.29%) 142 (0.40%) 115 (0.32%) 370 (1.04%)
Glaucoma 25 (0.07%) 64 (0.18%) 43 (0.12%) 44 (0.12%) 176 (0.49%)
Orbital diseases 11 (0.03%) 84 (0.24%) 42 (0.12%) 32 (0.09%) 169 (0.47%)
Dry Eye 1 (0.003%) 34 (0.10%) 57 (0.16%) 62 (0.17%) 154 (0.43%)
Optic Nerve diseases 7 (0.02%) 36 (0.10% 44 (0.12%) 37 (0.10%) 124 (0.35%)
Developmental
Anamolies 2 (0.005%) 29 (0.08%) 23 (0.06%) 23 (0.06%) 77 (0.21%)
Pthysis Bulbi 0 (0%) 10 (0.02%) 26 (0.07%) 18 (0.05%) 54 (0.15%)
Endophthalmitis 1 (0.003%) 18 (0.05%) 16 (0.04%) 13 (0.03%) 48 (0.13%)
Uveitis 1 (0.003%) 6 (0.01%) 16 (0.05%) 13 (0.04%) 36 (0.10%)
Down Syndrome 1 (0.003%) 10 (0.03%) 2 (0.005%) 6 (0.01%) 19 (0.05%)
Other Diagnosis 7 (0.02%) 80 (0.23%) 86 (0.24%) 72 (0.20%) 245 (0.69%)
Total 2077 (5.87%) 10118 (28.62%) 12261 (34.68%) 10892 (30.81%) 35348 (100%)
Childhood ocular morbidities

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Sadia Bukhari et al.
change after advances in the technology like
anterior vitrectomy23 and IOL as primary
procedure24 or scleral xations25 as secondary
procedure.
Among the second group, most important
problem to be addressed is the ocular trauma. There
are many local studies on this subject.16,26 Ocular
trauma is a leading cause of visual morbidity in
children. This is preventable to certain extent
by better care and supervision. Besides, direct
damage to the ocular structures resulting in loss of
vision, poor visual outcome may also due to dense
amblyopia caused by prolonged period of visual
deprivation.
Important retinal problems are retinoblastoma
and retinopathy of prematurity (ROP). There were
only 55 recorded retinoblastomas and four ROPs.
One can only presume that these diseases may
have been dropped as incomplete records. None
of the national studies cited above have reported
Retinoblastoma and ROPs.
Recommendations: Strengthening BHUs and RHCs
can not only decrease the burden of pediatric eye
care centers by 60%; but will make the treatment
of children more accessible and cost-effective.
Constant vigilance and education of professionals
including pharmacy personals as well patients are
required in prescription and usage of steroids. It is
to be reminded to the primary health facilitators
that if allergic conjunctivitis and VKC does
not respond to treatment in couple of months,
they are to be referred to tertiary level facility.
Optometrist and orthoptist should be included
in the pediatric ophthalmic team. Tertiary care
units of Pediatric ophthalmology should include
specially trained ophthalmologists (including
pediatric oncologist) who can deal with cases of
pediatric cornea, glaucoma, retina, and pediatric
ocular malignancies. Pediatric ophthalmology
units should also include facilities of low vision
clinics to deal with children who are permanently
blind including their rehabilitation academic
and career counselling. Pediatric ophthalmology
units should primarily be equipped by Phaco and
vitrectomy machines. Secondly digital fundus
camera and indirect ophthalmoscope with laser
should be acquired.
Limitations: Although we have representation
from different ethnic backgrounds but most of
the patients were from Sindh and Baluchistan. It’s
retrospective data from one of the large tertiary care
hospitals in Pakistan but it is a single-center data
and future publications are needed incorporating
data from multiple tertiary care centers. Also,
our center is a pure eye center thus the systemic
diseases might have less frequency documented
than the actual numbers.
CONCLUSION
Majority of the children attending pediatric
department are simple diseases to be treated
at primary eye care level if strengthened by
optometrist and primary level ophthalmologist.
For prevention and early diagnosis of blindness
due to ROP, retinal digital imaging should be
made available at pediatric ophthalmology units
of tertiary care eye hospitals.
Acknowledgement: We are thankful to the
Sightsavers (UK) for their nancial support in
making Pediatric department in Al- Ibrahim Eye
Hospital, Karachi.
Conict of Interest: None.
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Authors:
1. Dr. Sadia Bukhari, (MS Ophth).
2. Ms. Shua Azam, M.Phil. (Optometry).
Isra School of Optometry,
Al Ibrahim Eye Hospital,
Isra Postgraduate Institute of Ophthalmology,
Karachi, Pakistan.
3. Dr. Shahid Ahsan, M.Phil. (Bio), M.Phil (NCD), PhD Fellow.
Department of Biochemistry,
Jinnah Medical & Dental College, Karachi, Pakistan.
4. Mr. Tauseef Mahmood, M.Sc. (Statistics).
5. Dr. Muhammad Saleh Memon, FRCS (Eden).
6. Dr. Uzma Haseeb, (FCPS).
7. Mr. Muhammad Arslan, (MCSW).
Department of Research & Excellence,
Al-Tibri Medical College,
Karachi, Pakistan.
1,6: Department of Ophthalmology,
Al Ibrahim Eye Hospital,
Isra Postgraduate Institute of Ophthalmology,
Karachi, Pakistan.
4,5: Department of Research,
Al Ibrahim Eye Hospital,
Isra Postgraduate Institute of Ophthalmology,
Karachi, Pakistan.
Pak J Med Sci July - August 2022 Vol. 38 No. 6 www.pjms.org.pk 1507
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Authors’ Contribution:
Sadia Bukhari: Concept of study, methodology
writing and critical review.
Shua Azam: Introduction and literature search.
Shahid Ahsan: Final review.
Tauseef Mahmood: Statistical analysis and result
write-up.
Muhammad Saleh Memon: Discussion writing. He
is also responsible for the integrity and accuracy of
the study.
Uzma Haseeb: Review from a clinical point of view
as an ophthalmologist.
Muhammad Arslan: Editing of the manuscript.
Childhood ocular morbidities