Undiagnosed Myopia Among Back-Row Secondary School Students: A Cross-Sectional Study from Pakistan Running Title: Back-Row Myopia in Secondary Schools

 

 

Participant Demographics A total of 350 secondary school students participated. The mean age was 14.8 years (range 4-19 years, though the target range was 14-16 years; younger ages represented pilot testing). The largest age groups were 15 years (n=72, 20.6%) and 16 years (n=51, 14.6%). Female students comprised 78.8% (n=275) of the sample, while males accounted for 21.2% (n=74) (Figure 1).

  

Figure 1: Gender Distribution of Participants

 Back-Row Seating and Visual Perception When asked whether sitting in the back row affected their ability to see clearly, 342 students (98.0%) responded affirmatively. Only seven students (2.0%) reported no difficulty (Figure 2).

 

Figure 2: Perception of Back-Row Seating on Vision

Screen Time Daily screen time distribution showed that 191 students (54.7%) spent less than 2 hours on screens, 116 (33.2%) spent 2-4 hours, and 42 (12.0%) spent more than 4 hours daily (Figure 3).

Figure 3: Daily Screen Time Distribution

 

Figure 3: Perception of Back-Row Seating on Vision

 Eye Strain Eye strain while viewing the classroom board was reported by 308 students (88.3%). Only 41 students (11.7%) denied experiencing such difficulty

 Clinical Findings Suspected refractive errors were identified in 347 students (99.1%). Only two students (0.6%) had no significant clinical findings. Among the 57 students who reported wearing glasses or contact lenses, all 57 (100%) showed suspected refractive errors. Among the 292 students not using corrective eyewear, 290 (99.3%) had suspected refractive errors.

 Wearing Glasses/Contact Lenses No Significant Findings Refractive Error Suspected Total Yes 0 (0%) 57 (100%) 57 No 2 (0.7%) 290 (99.3%) 292 Total 2 (0.6%) 347 (99.4%) 350 3.6 Visual Acuity Range Among affected students, uncorrected distance visual acuity ranged from 6/12 to 6/36. Subsequent clinical evaluation prescribed myopic corrective lenses between -0.50 and -3.00 dioptres.

 Association Between Screen Time and Clinical Findings Suspected refractive errors were present across all screen time categories: 189 of 191 students (99.0%) in the <2 hours group, all 116 (100%) in the 2-4 hours group, and all 42 (100%) in the >4 hours group. Chi-square analysis showed no statistically significant association between screen time and clinical findings (χ²=1.664, df=2, p=0.435) (Table 2).

 Table 2: Chi-Square Test for Screen Time and Clinical Findings

Wear Glasses or Contact Lenses	No Significant Findings	Refractive Error Suspected	Total
Yes	0	57	57
No	2	290	292
Total	2	347	350

 Test Value df p-value Pearson Chi-Square 1.664 2 0.435 Likelihood Ratio 2.421 2 0.298 Linear-by-Linear Association 1.357 1 0.244 3.8 Association Between Eye Strain and Clinical Findings Among the 308 students reporting eye strain, all 308 (100%) had suspected refractive errors. Among the 41 students without eye strain, 39 (95.1%) had suspected refractive errors and 2 (4.9%) had no significant findings. Chi-square analysis revealed a statistically significant association between eye strain and clinical findings (χ²=15.111, df=1, p<0.001) (Table 3, Figure 5).

Table 3 Chi-square analysis revealed a statistically significant association between eye strain and clinical findings

ye Strain Status	Suspected Refractive Errors	No Significant Findings	Total
Eye Strain	308 (100.0%)	0 (0.0%)	308 (100.0%)
No Eye Strain	39 (95.1%)	2 (4.9%)	41 (100.0%)

Chi-Square Tests

Statistic	Test Value	df	p-value
Pearson Chi-Square	1.664	2	0.435
Likelihood Ratio	2.421	2	0.298
Linear-by-Linear	1.357	1	0.244

 

Figure 5: association between eye strain and clinical findings

 Test Value df p-value Pearson Chi-Square 15.111 1 <0.001 Continuity Correction 7.762 1 0.005 Likelihood Ratio 8.654 1 0.003 Fisher's Exact Test 0.014 Figure 5: Eye Strain vs. Clinical Findings

[Insert grouped bar chart: For eye strain group, Refractive Error Suspected 100%; for no eye strain group, Refractive Error Suspected 95.1%, No Significant Findings 4.9%]

 Recommendations Based on clinical findings, glasses prescription was recommended for 343 students (98.3%). Three students (0.9%) were advised six-month follow-up, one student (0.3%) was referred to an eye specialist, and three (0.6%) required no action (Figure 6).

Figure 6: Recommendations Given to Participants

 

This study revealed an extraordinarily high prevalence of suspected refractive errors (99.1%) among back-row secondary school students in Rahim Yar Khan, Pakistan. This finding substantially exceeds previously reported prevalence rates in similar populations, including the 25.6% visual impairment rate reported in Rawalpindi government schools [5] and the 24.7% refractive error prevalence in Mozambican youth [10].

 Several factors may explain this disparity. First, our study specifically targeted back-row students who likely have greater difficulty seeing classroom boards, potentially selecting a higher-risk subgroup. Second, the majority (88.3%) reported active eye strain, suggesting that many students were consciously struggling to maintain visual function. Third, the low rate of prior eye examinations and corrective eyewear use (only 16.3% wore glasses) indicates that these students represent an underserved population with accumulated undiagnosed pathology.

 The association between eye strain and refractive errors (p<0.001) is clinically significant. Eye strain—manifesting as squinting, brow ache, or difficulty maintaining focus—represents a compensatory response to blurred distance vision. Teachers should be trained to recognise these behaviours not as signs of inattention or laziness but as potential indicators of visual impairment requiring referral.

Interestingly, screen time showed no significant association with refractive findings (p=0.435). While this contradicts some previous research linking prolonged screen use to myopia progression [11], our cross-sectional design may not capture cumulative lifetime exposure. Additionally, the uniformly high prevalence of refractive errors across all screen time categories suggests that other factors—genetic predisposition, near-work intensity, outdoor time, or classroom environmental factors—may play more prominent roles in this population [12].

The finding that 98.0% of students perceived back-row seating as impairing their vision aligns with classroom ergonomics research. Visual demand increases exponentially with distance from instructional boards [13]. Students with uncorrected myopia experience progressive blur as distance increases, creating a measurable educational disadvantage. This is particularly concerning given that 99.3% of non-glasses-wearing students had suspected refractive errors requiring correction.

Our results have important implications for school health policy. First, routine vision screening should be mandatory for all students, not limited to those who complain of symptoms. Children often lack awareness of normal vision and may not recognise their impairment as abnormal [14]. Second, seating arrangements should be considered a temporary accommodation rather than a solution. While moving students to front rows may provide short-term relief, it does not address the underlying refractive error. Third, glasses compliance programmes must address barriers including breakage, loss, discomfort, and social stigma [15].

The limitations of this study warrant consideration. The cross-sectional design prevents causal inference. The sample was limited to one geographic region, limiting generalisability. Convenience sampling may introduce selection bias. Visual acuity was assessed using Snellen chart only, without cycloplegic refraction to confirm myopia objectively. Academic performance was assessed through self-reported visual experiences rather than formal grade records. Future research should employ longitudinal designs with objective cycloplegic refraction and standardised academic outcome measures.

Undiagnosed myopia is highly prevalent among back-row secondary school students in Pakistan, affecting 99% of those screened. Eye strain is a significant clinical marker for refractive errors. The vast majority of affected students are not using corrective eyewear despite experiencing substantial visual difficulty during lessons.

Routine school-based vision screening programmes are urgently needed, particularly targeting students in back rows who may be at highest risk. Policymakers should prioritise integrating vision screening into existing school health services, ensuring affordable access to corrective spectacles, and training teachers to recognise behavioural signs of visual impairment.

 Recommendations for Clinical Practice For pharmacists and healthcare providers: Consider school-aged children reporting headaches or eye strain as potential candidates for vision referral. Dispense spectacles with education about proper use and care.

 For school health services: Implement annual distance visual acuity screening for all students, with particular attention to those seated in back rows.

For educators: Receive training to identify students who squint, lean forward, or lose focus during board-based instruction—these behaviours warrant vision screening.

 For policymakers: Allocate resources for school-based vision screening programmes, subsidised spectacles, and follow-up care in underserved communities.

 Acknowledgements

The authors thank the school administrations, teachers, parents, and students who participated in this study. Gratitude is expressed to Dr. Zubair Nazar for supervision and guidance.

 Conflict of Interest

Statement The authors declare no conflicts of interest.

 Funding Statement

This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.