The Ayounkon project: Visual impairment, eye diseases and unmet eye care needs in the Syrian refugee population and the hosting community in Lebanon

Aim: To report on the distribution of eye diseases, aetiologies of severe visual impairment/blindness (SVI/BL) and unmet eye care needs of the Syrian refugee population and the Lebanese host community. Methods: This retrospective study analysed the data of patients that were examined during the Ayounkon project – an eye health care project offering medical and surgical treatment for Syrian refugees and Lebanese host community in the Bekaa Valley in Lebanon. The project took place in three different primary health care centres and involved cooperation between several NGOs and ophthalmologists working on a voluntary basis. Data was analysed for distribution of eye diseases and aetiologies responsible for monocular and binocular SVI/BL. Results: A total of 2067 patients were included, 677 were children <18 years. The most frequent pathologies were ocular allergy (10%), and cataract (7.4%). 158 patients (7.6%) were referred for surgery. Glasses were prescribed for 1103 patients (53.4%), of whom 242 (21.9%) were children of school age. SVI/BL was found in 276 patients (13%). The condition was bilateral in 116 patients (42%). SVI/BL was signi�cantly more frequent in the Syrian population than in the Lebanese (186 patients, 14.8% vs. 86 patients, 11.3%; p=0.04). The main causes for SVI/BL were cataract, keratoconus/corneal decompensation and amblyopia. Conclusion: The Syrian refugee population and the Lebanese


Introduction
According to the United Nations High Commissioner for Refugees (UNHCR) there has been a steady increase in forced displacement worldwide reaching 89.3 million people by the end of 2021.Between 2009 and 2011, this gure signi cantly increased, primarily as a result of the Syrian con ict.It is estimated that about 7 million Syrian migrants live abroad.[1] With about 1.5 million registered Syrian refugees, Lebanon has the greatest proportion of refugees per capita and per square kilometre, worldwide. 2They are particularly concentrated in the Bekaa Valley with 90% of refugees living in extreme poverty in informal tented settlements with very limited access to healthcare.More than half of the migrants are minors under the age of 18 years.[2,3] The current economic crisis of Lebanon adds to the burden that health care services are suffering from.
Several studies have shed light on the di culties that the refugee community faces in accessing adequate health care services, as well as their poorer health outcomes.A higher prevalence of infections, communicable diseases, and non-communicable diseases has also been documented, resulting in signi cant morbidity and mortality as well as a signi cant nancial impact on patients and health-care systems.[4,5] Furthermore, people in vulnerable situations, such as refugees and people with poor socioeconomic status, are more likely to have ocular problems, low vision and blindness.[6][7][8][9] Bin Yameen et al. reported on visual impairment and unmet eye care need in a Syrian refugee population in Canada and found that adults were 13 times more likely than the general Canadian population to have poor visual acuity and that 95% of children under the age of 18 had not seen an eye specialist in the year preceding the study.[6] To our knowledge, no research exists on the ophthalmological situation of Syrian refugee populations and vulnerable host communities in developing countries.The present study aims to report on the distribution of eye diseases, severe visual impairment/blindness (SVI/BL) and unmet eye care needs in the Syrian refugee population and the host community in Lebanon.

Methods
In this cross-sectional descriptive study, we included patients that participated in the Ayounkon project, an eye health campaign organized by YA and SeK (GENEAH NGO) in association with Arci Culture Solidali (ARCS), AMEL Association, World Rehabilitation Fund (WRF) and funded by the United Nations O ce for the Coordination of Humanitarian Affairs (UN-OCHA).The project spanned ve years beginning in 2017 and concluding in 2021.However the data presented in this paper was collected between May 2018 and April 2019 and between May 2021 and April 2022.The ophthalmological screenings took place at three primary healthcare centres (PHC) located in Arsal, Kamed el-Loz and Machghara.All PHC are situated in the Bekaa Valley.Word of mouth, social media and the existing network of NGOs and PHCs were used to inform participants about the project.All patients that presented to the PHC were included, disregarding age and nationality, as the aim of the project was to reach all refugees as well as the host community in need.
This was a retrospective study where no patient's identi er information was used.The institutional review board approval was therefore waived.The study adhered to the tenets of the Declaration of Helsinki.
All patients that participated were interviewed before examination using a standardized questionnaire (supplemental material) to collect socio-demographic data and past medical, surgical and ophthalmological history.Patients underwent a complete ophthalmological examination including presenting distance visual acuity (PDVA; i.e. with optical correction if normally worn), corrected distance visual acuity (CDVA), anterior segment evaluation, and dilated fundus examination.Data was noted in a paper form.Eyeglasses were distributed for patients with a spherical equivalence (SE) <-0.5diopters or > + 0.5D as well as reading glasses when needed.
Ophthalmologists at the PHC had the possibility to refer patients to a tertiary referral centre, the Beirut Eye and ENT Specialist Hospital, for a second opinion, supplementary examination, or for surgery if needed.Transportation, surgery cost, and postoperative treatment were covered.
Seven ophthalmologists participated in the screening phase and 8 ophthalmologists performed surgeries.
Children were divided into two subgroups, preschool (< 6 years) and school age (between 6 and 18 years).Binocular and monocular SVI/BL were de ned according to the WHO International Classi cation of Diseases (ICD-10, Version: 2016) [13].Binocular severe visual impairment was considered if PDVA was between 6/60 and 3/60 Snellen in the better eye and binocular blindness was considered if PDVA was < 3/60 Snellen in the better eye.Monocular severe visual impairment was considered if PDVA was between 6/60 and 3/60 Snellen in one eye and equal to or better then 6/60 in the other eye.Monocular blindness was considered if PDVA was < 3/60 Snellen in one eye and equal to or better then 6/60 in the other eye.
[10] Children too young for reliable VA were included if there was an absence of a preferential looking behaviour for a high contrast visual stimuli.High myopia was de ned as a SE <-6.0 dioptres.

Discussion
In this cross-sectional study, we evaluated the ophthalmological situation of both a Syrian refugee population, mainly living in informal tented settlements and its Lebanese host community.About 24% of patients were of school age with a mean age of 11.5 years.Of those, only 75% attended school.Among school-aged children, 242 needed glasses (48%).A study about unmet eyes care needs in a Syrian paediatric refugee population of a mean age of 8 years in Canada found around 25% of children in need of spectacle correction.
[6] In a screening in refugee and migrant school children on the Thai -Burma border, 26% of the examined children were given glasses.[9] This difference may be explained by a different recruitment method or a population more vulnerable than that sampled in this study.
Amblyopia was found to be the second most frequent cause of unilateral SVI/BL after cataract.It was present in 3% of the population.The prevalence of amblyopia in our population was higher than the worldwide pooled prevalence of 1.36% (95%CI: 1.27-1.46%)[11].This sheds the light on the importance of visual screening in vulnerable populations in order to initiate treatment early and thus prevent amblyopia.
Cataract was found to be the most common pathology in our population as well as the most frequent cause of unilateral SVI/BL and the second most common cause of bilateral SVI/BL.Similar studies reported cataract to be among the leading causes of visual impairment among refugees: 32.7% in Afghan refugees in Pakistan and 37.6% among Ethiopian refugees.[8,12] Diabetes and hypertension were highly prevalent in our population, 10% and 17% respectively.Among diabetic patients, diabetic retinopathy was reported in 17% (36 patients) and more than half of these patients suffered from unilateral or bilateral SVI/BL (53%).Similar results were reported in Saudi Arabia, where the prevalence of diabetic retinopathy was found to be 19.7% and more than half (53%) had a proliferative disease.[13] The high prevalence of diabetic retinopathy and consequent SVI/BL in our population could be due to poorly controlled diabetes and associated hypertension as well as limited access to health care and ophthalmological screening.[14,15] Trauma was also found to be frequent in our population (25 patients, 2%) and was the third most common cause of unilateral SVI/BL.In fact, ocular trauma is one the most important aetiologies of unilateral visual loss particularly in developing countries.[16,17] In a study about blindness in Cambodia, a country with high landmine densities, trauma was reported to be the cause of 4% of bilateral blindness.
[18] The prevalence of trauma-induced SVI/BL in our sampled population could also have been increased by the war that pushed the Syrian population to ee.Warfare was estimated to signi cantly increase the incidence of ocular injuries.[19] The most frequent anatomical site of eye diseases was the cornea including endothelial decompensation, keratoconus and graft failure.The high rate of ocular allergy, around 10% of the population, favours the development of keratoconus and its complications resulting in deterioration of visual acuity and the need to perform corneal grafts.The incidence of keratoconus in Lebanon was found by el Khoury et al. to be 0.53% in the paediatric population and 3.78% among adult patients in a tertiary referral centre.[20] Corneal diseases have been previously reported to be a frequent cause of visual impairment in refugee populations.[8,12] Awareness should be raised in vulnerable population to limit eye rubbing and treat ocular allergy in order to avoid keratoconus and the need for corneal graft.This campaign helped raise this awareness and provided corneal graft surgery for 6 patients.
One of the limitations of our study is that patients were either self-referred or referred by other acting NGOs, which could overestimate the pathologies and the SVI/BL.Since patients had limited access to the health care system, the prevalence of systemic diseases, their complications and duration could be underestimated.The advantage of this study is that it also sheds light on the need of the hosting community, as the mass migration of the population puts a strain on the available resources and the healthcare system In conclusion, the present study helped shed the light on the ophthalmological needs of Syrian refugees living in informal tented settlements as well as the host community.Screening campaigns and spectacle distribution should be organized in order to correct refractive errors, prevent the development of amblyopia and limit the incidence of SVI/BL.Treatment of cataract is also a priority as it is the main reason of reversible visual impairment.Diabetes mellitus and other cardiovascular risk factors should be well controlled and screening for diabetic retinopathy should be initiated in the concerned population.

Table 1
Baseline characteristics of all patients included in the study.NA: not available; SD: standard deviation.

Table 4
Aetiologies of bilateral severe visual impairment/blindness in all of the patients, n = 116.Forteen patients have multiple aetiologies.