The Burden of Pediatric Visual Impairment and Ocular Diagnoses in Barbados

**Background:** Pediatric visual impairment (VI) affects a child's quality of life, education, and future employment. Worldwide, 239 million children live with poor vision, and approximately 40% of childhood blindness is avoidable. The causes of VI vary by socioeconomic development; in high-income countries, leading causes include cortical visual impairment, retinopathy of prematurity (ROP), and optic nerve hypoplasia, while in low-income countries, vitamin A deficiency and ophthalmia neonatorum predominate. The Caribbean has an estimated prevalence of blindness nearly three times higher than the United States, yet data on pediatric VI in the region are scarce. Barbados is a high-income Caribbean island nation with a population of over 287,000, where public pediatric eye care is provided at two centers (Queen Elizabeth Hospital [QEH] and Winston Scott Polyclinic [WSPC]) by a single pediatric ophthalmologist. This study aimed to determine the patterns of pediatric eye diseases and VI in Barbados.

**Methods:** A cross-sectional review of medical records was conducted for all patients under 19 years of age who attended pediatric ophthalmology clinics at QEH and WSPC between 1 January and 31 December 2019. Data extracted included age at first presentation, sex, best-corrected visual acuity (BCVA) at the final visit in 2019, past medical history, and clinical diagnoses. Visual impairment was defined according to WHO criteria as BCVA of 6/12 or worse in the better eye, categorized as mild (6/12–6/18), moderate (<6/18–6/60), severe (<6/60–3/60), or blindness (worse than 3/60). Patients were grouped by age: preschool (0 to <5 years), school age (5 to <12 years), and older children (12 to 18 years). Analysis was performed using SAS version 9.4.

**Key Results:** Of 3504 pediatric patients on visit logs, 3278 (93.6%) were included; 226 were excluded due to age ≥19, unavailable records, or non-attendance. The mean age at first visit was 7.8 ± 3.9 years. There were 1438 males (43.9%) and 1840 females (56.1%) (male:female ratio 1:1.3). School-age children comprised the largest group (67.9%). A total of 589 children (18%) were seen at QEH and 2689 (82%) at WSPC; 71 visited both clinics. QEH patients presented at a significantly younger age than WSPC patients (3.9 ± 4.6 years vs. 8.7 ± 2.7 years; p < 0.0001). The main referral source was the Schools Eye Service (SES), accounting for 44.8% of referrals; referral source was unknown for 34.1% of children. Refractive error was the most common diagnosis (45.6%), followed by allergic eye disease (34.4%), strabismus and amblyopia combined (10.1%), and adnexal diseases (2.2%). Five hundred ninety-five children (18%) had more than one diagnosis. Visual impairment was observed in 80 children (2.4%): 62 had mild VI, 16 had moderate VI, and 2 were blind. No children had severe VI. Among the 80 visually impaired children, 70 (87.5%) had refractive error and 50 (62.5%) had amblyopia. Other diagnoses in this group included strabismus (22), allergic eye disease (16), glaucoma (4), corneal disease (4), cataract (2), uveitis (1), retinal disease (1), nystagmus (3), bilateral aphakia (1), ectopia lentis (1), and unknown (1). Most visually impaired children were school-age (52.5%) or preschool (38.75%).

**Clinical Implications:** The study demonstrates that pediatric VI in Barbados is largely avoidable, with refractive error and amblyopia as the predominant causes. The majority of affected children presented at school age (mean age 7.8 years), suggesting that earlier detection through preschool vision screening could significantly reduce the burden of VI. The existing SES, which provided nearly half of all referrals, primarily captures school-age children; expanding screening to preschool-age children—potentially through integration with the well-established Child Health clinic infrastructure at polyclinics or through school entry screening—could enable earlier intervention. The absence of ROP as a cause of VI in this cohort contrasts with other Caribbean countries like Suriname and warrants further investigation. The study's limitations include reliance on public sector records only (though private pediatric ophthalmology care is limited), missing referral source for one-third of patients, and missing visual acuity data for some children. Nonetheless, the findings support the implementation of a comprehensive preschool vision screening program co-managed by the Ministries of Health and Education to lower the prevalence of pediatric VI in Barbados.