The Level of Awareness of Keratoconus Among the General Population in Hail Region, Saudi Arabia

Background Keratoconus (KC) is a non-inflammatory corneal disease with an early onset in adulthood, leading to a reduction in visual acuity. This study aims to evaluate the level of awareness of keratoconus among the general population in the Hail region of Saudi Arabia. Methodology Data were collected through a pre-designed and pre-validated online questionnaire (Appendix) distributed via social media platforms. The questionnaire was divided into two sections. The first section included demographic profiles, while the second section inquired about knowledge and awareness regarding Keratoconus. The collected data was reviewed, coded, and inputted into IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Statistical analyses were performed using the Pearson Chi-Square test, with statistical significance set at p<0.05. Results The total number of respondents was 550, among whom 40% were males and 60% were females. 79.6% of the participants were in the age range of 18-30 years. The level of education and a positive family history of KC showed significant associations with the level of knowledge about KC (p<0.05). The age group had a non-significant association (p=0.059), while gender had a significant association with the level of knowledge about keratoconus (p<0.05). Conclusion In conclusion, the overall awareness regarding KC progression, interventions, and the consequences of eye rubbing was limited among the participants. Specific efforts are crucial to enhance public awareness and understanding of KC, ensuring a more informed and proactive approach to eye health within the community.


Introduction
Keratoconus (KC) is a non-inflammatory corneal disease that affects both genders and has an early onset in adulthood [1].It manifests as bilateral progressive steepening and thinning of the central or paracentral cornea; the thinnest corneal location is typically intertemporal.It is linked to a reduction in visual acuity, most notably myopia and irregular astigmatism [2].The etiology is still unclear, but is associated with risk factors such as eye rubbing [3], sun exposure, atopy, genetic and environmental factors [4].There is a notable correlation between increasing age and the severity of keratoconus symptoms [5].In the Middle East, the prevalence of KC is up to 5%, and geographically, the mountainous regions have the highest rate of KC patients [1,6].KC is classified into four stages: subclinical, early, moderate, and severe, according to clinical presentation and topography.In the subclinical stage, there is only suspicious keratoconus on topography with a normal slit lamp examination and visual acuity.In the early stage, mild differences in refractive error and reduction in visual acuity can be present, along with mild, localized corneal steepening and thinning, increasing keratometric differences between the inferior and superior cornea, and increases in corneal aberrations, the scissor reflex, and Charles Louis' oil droplet reflex [2].Slit-lamp examination can detect advanced keratoconus, which includes the classic clinical signs Munson's sign, Vogt's striae, and Fleischer ring, as well as severe corneal thinning and steepening (>55 D) and corneal scarring [2,7].Tomographic imaging is used in the diagnosis and screening of KC [8].The diagnosis of keratoconus needs to be made early because good outcomes are associated with early intervention [9].KC treatment in early diagnosis includes glasses and contact lenses, as well as surgical intervention such as intracorneal ring segment (ICRS) implantation and corneal crosslinking (CXL), whereas in late diagnosis, it is not possible to practice, and patients are left with only penetrating keratoplasty (PK) or deep anterior lamellar keratoplasty (DALK) [9,10].This study is being conducted to assess the level of awareness regarding KC among the general population in the Hail region of Saudi Arabia.

Materials And Methods
This is a cross-sectional analytical study that was conducted from July 2023 to November 2023.The study population consisted of adult males and females residing in Hail City, Saudi Arabia.The inclusion criteria comprised individuals of both genders aged 18 years and older who reside in Hail.Exclusion criteria included males and females under 18 years old and individuals living in regions other than Hail.The calculated sample size was based on the latest census in the Hail region (746,406).Using the Roasoft calculator with a 5% margin of error and a 95% confidence interval, the estimated calculated sample size was 385 participants.However, the final sample size was 550 after data collection.
Data were collected through a pre-designed and pre-validated online questionnaire from a prior study conducted in Jeddah, Saudi Arabia [11].The questionnaire was distributed using a self-administered Google form through a WhatsApp broadcast messaging app (Meta Platforms, Inc., Menlo Park, California, United States) that contained the questionnaire, research objectives, and study rationale.The questionnaire was translated into Arabic and then back into English.The validity of the questionnaire was tested through a pilot study, and the data from the pilot study were excluded from the main study.
The questionnaire was preceded by informed consent, which ensured the confidentiality of the data.The questionnaire consisted of 24 questions and was divided into two sections.The first section inquired about the socio-demographic profile.This section was utilized to confirm the inclusion criteria of the study participants, including the presence of an underlying allergy or ophthalmic condition, a history of ophthalmic surgery, or a family history of KC, while the second section used 10 items to assess the knowledge and awareness regarding KC and two items to assess the frequency of participants eye rubbing habits and their reasoning for the mentioned habit.This study has been reviewed and approved by the Research Ethics Committee (REC) at the University of Hail.

Data analysis
The data collected were reviewed, coded, and inputted into IBM Corp. Released 2013.IBM SPSS Statistics for Windows, Version 22.0.Armonk, NY: IBM Corp. after extraction.Statistical analyses were performed using the Pearson Chi-Square test, with statistical significance set at p<0.05.For knowledge and awareness questions, each correct response was assigned a score of one point, and the total score was calculated.Poor awareness was defined as a score below 5 points, moderate awareness fell within the range of 5 to 7 points, and a score of at least 8 points denoted good awareness.Descriptive analysis was performed on all variables, including participants' biographical data, family history of KC, medical history of ophthalmic conditions, and the frequency of eye rubbing, based on frequency and percent distribution.Frequency tables and graphs were used to assess participants' awareness levels regarding KC.Cross-tabulation was used to determine the distribution of participants' awareness levels based on their personal data and practices.

Results
The study questionnaire was completed by 550 individuals.Table 1 shows that 79.6% of the participants were in the age range of 18-30 years, while the 31-40 age group constituted 12% of the study population.Furthermore, among the study population, 60.2% were females, and 67.6% held a university degree, while high school graduates accounted for 29.5% of the participants.About 30.5% reported having some form of allergy, with eye atopy being the most frequently reported (16.9%), followed by skin allergies (11.3%) and asthma (8.2%).47.5% of the participants had an underlying eye condition, with refractive errors being the most common eye disorder (34.4%), followed by chronic dry eyes (17.8%).Of the participants, 34 reported having a diagnosis of KC, while 65 participants reported a family history of KC.Fifty-nine participants reported undergoing refractive surgery, while 14 had undergone cataract removal surgery.Moreover, 36.5% of the participants had previously heard about KC, with the most commonly reported sources of information being the internet and social media (14%), followed by lectures and reading (13.5%), and friends and family (10.1%).

Count Percentage
Age group

2: Awareness and perception of keratoconus among study participants
Figure 1 illustrates that 11.8% of the participants had a family history of KC, while Figure 2 illustrates the distribution of poor, moderate, and good knowledge levels regarding Keratoconus among the participants, with percentages of 59.14%, 32.02%, and 8.8%, respectively.Table 3 shows that the level of education and having a family history of keratoconus had significant associations with the level of knowledge about keratoconus (p<0.05).The age group had a non-significant association (p=0.059),while sex had a significant association with the level of knowledge about keratoconus (p<0.05).A significant relationship was found between participants' knowledge level about KC and having a form of allergy (p=0.00).Moreover, being diagnosed with an ophthalmic condition also had a significant relationship with the level of knowledge (p<0.00).However, other characteristics, such as undergoing ophthalmic surgery and the frequency of eye rubbing, had a non-significant association.

Discussion
The importance of awareness and knowledge about KC plays a significant role in the emergence and prognosis of the disease.A study conducted in Saudi Arabia shows that only 27.2% (n = 113) provided a correct definition of KC [12].According to another study in the Aseer region, it was found that 23.6% of participants aged 30-39 years had a good awareness level compared to 9.1% of older participants, with recorded statistical significance (P = 0.049) [13].Given the fluctuation in awareness percentages, it is essential to educate society about the nature of the disease, its risk factors, and available treatment measures.
In a nationwide study conducted in 2021, a poor knowledge score of 67.5% was reported regarding KC despite its high prevalence in Saudi Arabia compared to other Middle Eastern countries [12].In this study, 550 participants from the Hail region in Saudi Arabia, including 60.2% females and 39.8% males, provided data.The calculated levels of poor, moderate, and good knowledge regarding keratoconus among the participants were 59.14%, 32.02%, and 8.8%, respectively.
Of the participants, 32.9% (n=181) acknowledged the hereditary nature of keratoconus, and 11.8% (n=65) had a family history of the disease.Research linking genetics to KC suggests that family history plays a significant role, in line with previous reports that genetics may influence keratoconus presentations [14][15][16].
In 2020, a study reported that 73% of keratoconus patients admitted to aggressively squeezing their eyes [13].This analysis supports the theory that there is a relationship between KC and the habit of eye rubbing, which was appreciated by nearly half of our respondents (44.2%).In terms of the complications of keratoconus, respondents' insufficient knowledge may have been caused by important misunderstandings.Only 19.8% correctly identified the unlikelihood of KC progressing to blindness.Almost a fifth of the participants (19.3%) cited no specific source as their primary source of knowledge.Other sources of information came from the internet and social media (14.0%), lectures and reading (13.5%),followed by close friends and relatives (10.1%).Healthcare professionals were ranked fifth as a source of information.
Young age, high education, having a disease-causing visual impairments, and using a doctor as the primary information source were the most significant predictors of public awareness.
Regarding the treatment of KC, 44.7% correctly answered about the possibility of surgical intervention for advanced keratoconus.When it comes to wearing prescription glasses, only 17.6% correctly answered that it may not halt the progression of the disease.
Education emerged as a determinant influencing participants' knowledge about KC, consistent with another study in the Aseer region of Saudi Arabia [17].However, it is common for higher education to correlate with increased health awareness [18,19].This underscores the need for targeted educational campaigns, particularly for individuals with limited educational backgrounds, to enhance their comprehension of KC.Interestingly, age displayed no significant association with KC knowledge, contrasting studies conducted in various regions of Saudi Arabia [12,17,20].A study by Al-Amri et al. revealed that younger individuals exhibited a poorer understanding of KC [21].
Moreover, family history emerged as a substantial risk factor for KC [15,22], significantly influencing participants' knowledge.While some studies in Saudi Arabia found family history nonsignificant [12,17], others identified it as significant [20,23], potentially due to variations in knowledge levels and methodologies.This suggests that individuals with a family history of KC engage in information-seeking behaviors, gaining knowledge through research and ophthalmology visits.This correlation emphasizes the role of familial background in shaping KC awareness, enabling healthcare professionals to target specific demographics for educational interventions and awareness campaigns.Such efforts may lead to early detection and improved management within affected families.
Additionally, gender exhibited a significant association with KC knowledge, contrasting previous studies that found it nonsignificant [12,17,23].This underscores the need for gender-specific educational campaigns to bridge the knowledge gap effectively.Concerning allergies, particularly systemic and ocular allergies, these conditions were key risk factors associated with KC pathogenesis [24].
Participants with allergies or previous ocular conditions displayed higher KC knowledge, likely due to their regular interactions with healthcare providers.It is well known that individuals with pre-existing health conditions tend to possess increased awareness.Therefore, integrating KC-related information into broader healthcare discussions, especially for patients with allergies or other ocular conditions, is crucial.
Although eye rubbing constitutes a risk factor for KC [3], this study found no significant association between ophthalmic surgery, eye rubbing frequency, and KC knowledge.This implies that these factors might not significantly influence participants' awareness of KC.This result is consistent with previous studies in the Aseer region and Medina in Saudi Arabia [17,23], which also found no significant association despite a high prevalence of eye rubbing.Nevertheless, further studies are needed to investigate this non-association.However, the study had certain limitations, notably its non-probability nature and the restriction to the Hail region of Saudi Arabia, which might limit the generalizability of the findings to a broader population.

Conclusions
In conclusion, the study underscores a notable gap in knowledge about keratoconus, particularly among participants in the 18-30 age group.Despite a significant prevalence of family history related to KC, only a small fraction exhibited a correct understanding of crucial aspects of the condition.The overall awareness regarding keratoconus progression, interventions, and the consequences of eye rubbing was limited among the participants.The identified associations between knowledge level and factors such as education, family history, age, and gender emphasize the necessity for focused educational initiatives.Specific efforts are crucial to enhance public awareness and understanding of keratoconus, ensuring a more informed and proactive approach to eye health within the community.

FIGURE 1 :FIGURE 2 :
FIGURE 1: Percentage distribution of the participants according to having a family history of Keratoconus

Questionnaire Tool 1 : 2 :
Demographic and ophthalmic items used in the study Awareness and knowledge items used in the study Keratoconus may be described as Autoimmune disease Inflammation in the cornea Increase in the thickness of the cornea I do not know Decrease in the thickness and coning of the cornea is Keratoconus hereditary?Yes No I do not Know Is there a relationship between Keratoconus and eye rubbing or allergy?Does advanced Keratoconus require a surgical intervention?Yes No I do not Know Yes 2023 Alshammari et al.Cureus 15(12): e50026.DOI 10.7759/cureus.50026

Table 2
reports participants' answers to the knowledge and awareness items used in the current study's questionnaire.It reveals that only 21.4% of the participants correctly reported that KC is characterized by the thinning of the cornea.Regarding the hereditary aspect of KC, 32.9% answered correctly that it has a hereditary element.Furthermore, 44.2% correctly reported that KC is related to allergies and eye rubbing.When asked about the adverse effect of KC on visual acuity, the majority of participants answered correctly (53.3%).In terms of the progression of KC to blindness, 19.8% answered correctly.Regarding the possibility of surgical intervention for advanced KC, 44.7% answered correctly.When it comes to wearing prescription glasses, 17.6% answered correctly that it may not halt the progression of the disease.When asked if KC necessitates frequent doctor evaluations and follow-ups, most of the participants answered correctly (54.4%).Moreover, half of the participants (50.4%) correctly reported that eye rubbing may lead to KC, while only 5.5% stated that it was a safe habit.Among the study subjects, only 4.4% believed that no treatment was available for KC, while 15.5% mentioned having the habit of frequently rubbing their eyes.The most common reasons for eye rubbing were itchiness, followed by stress and headaches (37.8%).