Awareness of Keratoconus and Its Relationship With Eye Rubbing Among the Population of the Eastern Province of Saudi Arabia

Background: Keratoconus is an eye condition where the cornea, the clear, dome-shaped front part of the eye, becomes thinner and gradually bulges outward into a cone shape. Keratoconus usually affects both eyes. The exact cause of keratoconus is unknown, but it is believed to involve a combination of genetic and environmental factors. Aim: This study aims to assess the awareness level of keratoconus and its relation to eye rubbing among the population in the Eastern Province of Saudi Arabia. Methods: A cross-sectional study was conducted in the Eastern Province of Saudi Arabia, involving all eligible participants via an online pre-designed questionnaire from March to June 2023. The data were collected through social media. Results: A total of 388 eligible participants completed the study questionnaire. Participants’ ages ranged from 19 to 60 years, with a mean age of 26.2 ± 13.9 years. There were 265 (68.3%) female participants. Regarding public awareness about keratoconus among participants in the Eastern Province of Saudi Arabia, our research revealed a total of 101 (26%) participants had an overall good awareness of keratoconus, while 287 (74%) had a poor awareness level. The most reported source of information included scientific lectures (21.6%). Precisely, 316 (81.4%) of the research subjects rub their eyes primarily because of allergies (7%), strain headaches (25%), and itching (66.5%). Conclusion: Most of the study participants have poor awareness about keratoconus and its relation to eye rubbing. Health education programs for the population should be conducted to enhance public awareness about keratoconus.


Introduction
Keratoconus is an eye disease that affects the cornea and is a major cause of corneal transplants.It is a gradual and progressive condition that alters the shape of the cornea, leading to thinning, irregular astigmatism, and low vision [1,2].As the condition progresses, the central or paracentral portion of the cornea protrudes, giving it a cone-shaped appearance [3,4].Typically, individuals experience the onset of the disease during adolescence, and it continues until their third or fourth decade of life [4].
The development of keratoconus can be influenced by various factors, including hereditary and environmental influences [1].First-degree family members and twins of keratoconus patients have a higher risk of developing the condition compared to the general population [5].While several genetic variations have been linked to keratoconus, few of these associations have been consistently replicated [6].The pathophysiology of keratoconus has been associated with environmental variables such as eye rubbing, atopy, allergic eye illness, dermatitis, and exposure to UV radiation [7][8][9][10][11][12][13]. Ethnicity is also considered a factor, with Asians experiencing a more severe and early onset of keratoconus than Caucasians [4].
Keratoconus is estimated to affect 1.38 people out of every 1,000 [9].Saudi Arabia has the highest prevalence of keratoconus globally, with 4,790 cases per 100,000 individuals in the Middle East [10].In Saudi Arabia, a study in the Najran region found 87.3 incidences of keratoconus for every 100,000 individuals, with 8.59% of the population in Taif having the condition [3,4].A six-year study conducted in Saudi Arabia identified keratoconus as the most common reason for corneal transplants in the Eastern Province [11].

Study design and participants
This community-based cross-sectional study targeted participants in the Eastern Province of Saudi Arabia aged 18 years and older.The recruitment involved the administration of an online questionnaire in Arabic, distributed through social media platforms from March 2023 to June 2023.

Questionnaire development and distribution
The questionnaire used in this study was previously validated in the Arabic language by Kordi et al. [14].The survey questionnaire comprised three sections.The first section collected demographic data, including age, sex, and education level.The second section consisted of yes-or-no questions to assess eye allergies, other allergies, eye diseases, and vision problems.The third section included nine items evaluating participants' awareness of keratoconus, its causes, treatment, and reasons for eye rubbing.
The sample size of 385 participants was calculated using the formula n = z2pq/d2 for a 95% confidence level and 5% margin of error.To ensure broad participation, we employed a targeted approach through various social media platforms, strategically disseminating the survey link on channels such as Meta (previously known as Facebook), X (previously known as Twitter), and WhatsApp groups.This method allowed us to engage participants across different demographics and geographic locations within the Eastern Province of Saudi Arabia.

Data analysis
Upon data extraction, IBM SPSS version 22 (IBM Corp., Armonk, NY) was employed for data editing, coding, and importation.Two-tailed tests were used for statistical analysis, considering p-values below 0.05 as statistically significant.The total score for keratoconus awareness and knowledge was calculated by summing scores from each item.Individuals were classified as having poor awareness if their total score was less than 60% and good awareness if it was 60% or higher.Descriptive analyses were conducted for variables, and a graph was created to display information sources and knowledge levels.Pearson's chi-square test and exact probability test were used for small frequency distributions to measure participants' awareness, with results presented in cross-tabulation graphs.
Regarding the participants' medical and family history, allergies were reported by 115 participants (29.6%), with skin allergies (43.5%) being the most common.A total of 213 (54.9%) participants reported having one or more eye diseases, including keratoconus (4.2%).Twenty-four participants (6.2%) had a family history of keratoconus (Table 1).The percentages are calculated based on the total number of responses for each awareness item."N" represents the total number of participants who provided responses for each specific item.

FIGURE 1: Participants' general public awareness of keratoconus in the Eastern Province of Saudi Arabia
Figure 2 displays the primary sources of information, with scientific lectures (21.6%) and social media (12.1%) being the most commonly reported sources; a significant proportion (56.7%) reported having no source of information.

FIGURE 2: Sources of information about keratoconus among study participants in the Eastern Province of Saudi Arabia
Eye rubbing and sun exposure habits  The percentages are calculated based on the total number of responses for each awareness item."N" represents the total number of participants who provided responses for each specific item.
Of the participants, 316 (81.4%) reported eye rubbing for various reasons, including itching (66.5%) and strain headache (25%).Moreover, 181 (46.6%) were exposed to sunlight, and (50.3%) used sunglasses.The table presents factors associated with participants' awareness of keratoconus in the Eastern Province of Saudi Arabia.The columns display the number (N) and percentage (%) of participants with poor and good overall awareness levels for each factor.The statistical significance is indicated by the p-value, with a threshold of 0.05 considered significant.

Factors associated with keratoconus awareness
Statistically significant associations were observed, with young age (31.5% vs. 6.9% in the older age group) and single status (32.4% vs. 14.1% in married participants) correlating with higher overall awareness.Participants with visual impairments (30.5% vs. 20.6%)and those with a family history of keratoconus (45.8% vs. 24.7%)demonstrated significantly higher awareness levels.Additionally, participants informed by medical universities and healthcare workers showed good understanding, contrasting with those receiving information from friends or having no information (p =.007).Keratoconus awareness is essential to increasing understanding and knowledge about keratoconus, a condition causing the cornea to gradually thin and bulge outward.Various organizations and initiatives dedicate efforts to raising awareness about keratoconus [1,2].The National Keratoconus Foundation (NKCF) is the world's oldest and largest organization focused on increasing awareness of keratoconus [3].They appointed the National Association for Stock Car Auto Racing (NASCAR) driver Joey Gase as their ambassador, providing information through their "Clearly KC" campaign.Promoting awareness about keratoconus is crucial for encouraging early detection, timely treatment, and supporting affected individuals.

Discussion
The purpose of this study was to evaluate awareness about keratoconus and its relationship with eye rubbing among the population in the Eastern Province of Saudi Arabia.The study revealed that over half of the participants had eye problems, mainly refractive errors, and keratoconus was reported in less than one-fifth of the participants.A lower prevalence of keratoconus was reported by Althomali et al. [4], finding that 8.5% of study participants in Taif had keratoconus, with bilateral cases among 6.6%.Similarly, numerous studies conducted globally revealed significant disparities in prevalence rates [4,9].Various factors contribute to these variations, including geographical location, ethnicity, participant characteristics, and diagnostic methods [10][11][12].
Regarding participants' awareness of keratoconus, the current study indicated that approximately 25% exhibited satisfactory overall awareness.Over half of them knew that keratoconus leads to poor eyesight.Concerning treatment, participants were most aware of surgery, followed by eyeglasses and contact lenses, with about half unaware of treatment methods.Scientific lectures, social media, and doctors were the most reported sources of information.The study found higher awareness levels among younger participants, those experiencing visual impairments or eye-related ailments, participants with a family history of keratoconus, and those informed about keratoconus through a medical university and health workers.A similar awareness level was reported in the Aseer region by Al-Amri et al. [15], documenting that 18.7% of respondents had an overall good awareness of keratoconus.Another study in Abha revealed that the majority of participants (57.5%) reported no prior knowledge or awareness of keratoconus; only 32 (8.1%) became aware through information from healthcare providers [13].Similarly, Al Rashed concluded that there was poor public awareness about keratoconus in Saudi Arabia [16].
Concerning eye rubbing and its relation to keratoconus, the study revealed that 164 (42.3%) participants believed eye rubbing may lead to keratoconus.Alamri et al. [17] found that 33.1% of participants considered eye rubbing a harmful habit.A much lower awareness level about eye rubbing was reported by Kordi et al. [14], with only 28.9% believing it could potentially lead to keratoconus.Furthermore, a significant majority (80.4%) reported engaging in eye-rubbing behavior, primarily due to itching.
While utilizing an online questionnaire helped reach a wide population from diverse regions, a limitation of this study was the absence of assigned data collectors for each specific region in the Eastern Province.This may result in an unequal distribution of participants throughout the province, impacting the generalizability of the findings.

TABLE 2 : Awareness of keratoconus among participants in the Eastern Province of Saudi Arabia (n=388)
The percentages are calculated based on the total number of responses for each awareness item."N" represents the total number of participants who provided responses for each specific item.

Table 3
details the reasons why the participants rub their eyes and showcases their sun exposure habits.

Table 4
explores factors associated with participants' keratoconus awareness.