The epidemiology of visual loss

in adults

Report of the Pakistan National Blindness and

Visual Impairment Survey (2002-2003)
 Acknowledgements
This survey, turned from a daunting task into successful reality by the tremendous
hard work and dedication of the ‘Pakistan National Eye Survey Study Group,’ is
one of the largest studies of its kind and it is a pleasure to acknowledge all those that
assisted in making it happen. The following individuals deserve a special mention:
Professor Mohammad D Khan, Professor Allen Foster, Mohammad Aman Khan,
Clare E Gilbert, Professor Gordon J Johnson, Mohammad Zahid Jadoon, Brendan
Dineen, Rupert R Bourne, Shaheen P Shah, Professor Shad Mohammed (Provincial
Coordinator, NWFP), Professor Zia Uddin Sheikh (Provincial Coordinator, Sindh),
Professor Asad Aslam (Provincial Coordinator, Punjab), Professor Nasim Panazai
(Provincial Coordinator, Balochistan), Dr Shabbir Mir (Provincial Coordinator,
Kashmir), Dr Niaz Ali (Provincial Coordinator, Northern Areas), Mr Pak Sang Lee
(Technical Coordinator), Dr Haroon Awan (Sight Savers International), Dr Rubina
Gillani (Fred Hollows Foundation), Dr Babar Qureshi (Christoffel Blinden Mission),
Dr Mohammed Shabbir and Dr Falak Naz (Clinical and Community
Ophthalmologists, respectively, NWFP team), Dr Abdul Ghafoor and Dr
Kiramatullah (Clinical and Community Ophthalmologists, respectively, Punjab
Team), Dr Waheed Shaikh and Dr Amjad Shaikh (Clinical and Community
Ophthalmologists, respectively, Sindh Team).
The Sri Lanka Eye Foundation offered assistance of training.

Acknowledgement is also made to our funding supporters the ‘International

Blindness Prevention Collaborative Group.’ Without their support the survey
would have never materialised. They consisted of:
The Government of Pakistan, the World Health Organization East Mediterranean
Regional Office & Pakistan Office, Sight Savers International, Christoffel Blinden
Mission, Fred Hollows Foundation, the International Centre for Eye Health in
London, and the Pakistan Institute of Community Ophthalmology.
Heidelberg Engineering (Heidelberg, Germany) kindly lent the survey two HRT-II
instruments. In addition, two companies based in Lahore, Pakistan (‘Lateef Brothers
Lahore’ and ‘S.Haji Ameerdin and Sons’) were also generous in their instrument
support during survey preparations. Ophthalmic medications were generously donated
by the NWFP divisions of the companies Remington and Kobec.

This report, compiled by Dr Shaheen P Shah and Dr Zahid Jadoon on 9th October 2006, was prepared
and disseminated to members of the national committee for purposes of planning and formulating
research strategies for the national 5 year eye care plan for Pakistan.

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 The survey teams

NWFP team

Sindh Team

Punjab Team

Balochistan Team

3
 CONTENTS
ACKNOWLEDGEMENTS 3
CONTENTS 4

1. INTRODUCTION 5
i. Aims and Objectives 5
ii. Background 5

2. MATERIALS AND METHODS 7

A. Study Protocol 7
i. Inclusion criteria 7
ii. Sample size and Sampling strategy 7
iii. Ethical approval 8
iv. Training and pilot studies 9
v. Survey Data Collection 9
vi. Data management and statistical methods 11
B Categorisation of variables 12
i. Definitions of the outcome variables 12
ii. Explanatory Variables 14

3. RESULTS 16
A. Response rates and demography of the adult sample 16
B. Blindness and visual impairment 18
i. Prevalence 18
ii. Magnitude 21
C. Causes of visual loss 22
i. Principle cause 22
ii. Provincial differences in cause of blindness 25
iii. Unilateral cause 25
iv. Magnitude by cause 26
D. Functional low vision 27
i. Prevalence 27
ii. Magnitude 27
iii. Causes 29
E. Refractive Error in adults 32
i. Prevalence 32
ii. Magnitude 35
iii. Coverage 36
F. Lens opacity and cataract 39
i. Prevalence of lens opacity 39
ii. Risk factors for lens opacity 39
iii. Cataract prevalence 41
iv. Bilateral cataract blind 41
v. Magnitude of cataract 41
G. Outcomes of eye care provision 42
i. Prevalence of cataract surgery and surgical output 42
ii. Cataract surgical coverage 42
iii. Cataract surgical rate 43
iv. Cataract surgical outcomes 44
H. Barriers to cataract surgical service uptake 45

4. SUMMARY OF FINDINGS ARISING FROM THIS SURVEY 46

i. Key points 46
iv. Strengths and weaknesses 50

5. REFERENCES 51

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 1. Introduction
i. Aims and Objectives of the Survey

• To establish the age- and sex-specific point prevalence’s for blindness and low
vision in a) adults aged 30 years and older and, b) children aged 10 to 15 years
living in enumerated households in Pakistan.
• To identify the causes of blindness and visual impairment within the two study
sample groups.
• To estimate the national needs for low vision services
• To determine the refractive status within the two study sample groups.
• To examine the risk factors for lens opacities in Pakistan
• To evaluate cataract service delivery by measuring a) cataract surgery prevalence
b) cataract surgical coverage (CSC) and c) cataract surgical rate (CSR) and d)
outcomes of cataract surgery
• To identify the socio-economic and cultural barriers to up-take of cataract surgical
services.

ii. Background

Pakistan, a developing country in the Eastern Mediterranean Region of the World

Health Organization (EMRO, WHO) has a population of approximately 140 million
(Y2003) people (52% male) making it the sixth most populous country in the world.
Approximately 67% of the national population lives in rural areas. The country is
divided into six regions for administrative purposes. The four provinces are Punjab,
Sindh, North West Frontier Province (NWFP) and Balochistan. These regions differ
widely in their geography as well as density of population. The country ranks 135 in
the UNDP Human Development Index, only 0.7% of the Gross National Product is
spent on health, and of this 2% is allocated to eye care.
Until 1980 there were no data available on blindness and its causes in Pakistan.
Following a report by the WHO, the Government of Pakistan instituted a national eye
camp planning committee for the prevention of blindness. In 1987, an initiative was
taken by the Government of Pakistan with the help of the WHO to perform a national
survey of blindness. The study (1988-1990) revealed that the national prevalence of
blindness for individuals of all ages was 1.78% (blindness defined as best corrected
<3/60 visual acuity in the better eye). It was found that 70% of blindness was caused
by age-related cataract. The ‘all age’ blindness prevalence in the provinces of Sindh,
Balochistan, NWFP, and Punjab were 1.14%, 2.69%, 1.00%, and 2.17%, respectively.
This study had some methodological limitations but the results served the purpose at
that time. As a result of that study a National Committee for Prevention of Blindness
in Pakistan was formed in 1990. This committee produced the five years National
Plan for the Prevention of Blindness 1994-1999, a policy document that outlined the
strategies that were needed to improve the eye care situation in the country. Following
several years of implementing expanded eye care services in Pakistan, it was felt for a
number of reasons that a more detailed survey was required. A survey with more
diagnostically rigorous methodology was needed, with one which would detect
diseases of the posterior segment, the importance of which has been highlighted in
two recent low vision and blindness surveys in Bangladesh and India.

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Based on the results of the original survey, the eye services were adapted to meet the
identified need for expanded cataract surgical service delivery. A more up-to-date
survey would assess the impact of current eye care provision and identify diseases and
populations which require targeting. Characteristics of the population, such as total
number, average age, certain lifestyle factors, have altered since the original study. In
addition, the structure of eye care provision in Pakistan has changed, with the
establishment of a National Committee for Prevention of Blindness administered at
provincial level, and an increased number of eye care centres throughout the country.
From a global perspective there have recently been renewed efforts to obtain accurate
prevalence data and identify causes of blindness. (Vision 2020: The Right to Sight,
the WHO’s Initiative for the Elimination of Avoidable Blindness and the Global
Elimination of Trachoma (GET 2020) worldwide). The launch of Vision 2020 in
Pakistan took place in February 2001.

This report focuses on results for the adult population assessing the prevalence of
visual impairment and its causes, estimating magnitudes as well as evaluating cataract
service indicators, thus identifying needs that require further program planning and/or
research evaluation.

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 2. Materials and Methods
A full description of the study’s methods has been published in Ophthalmic
Epidemiology.
A. Study protocol
i. Inclusion criteria
The principal inclusion criterion for the survey was age. For this survey two separate
age groups were targeted, namely adults aged 30 years and older and all young
persons aged 10 to 15 years normally resident in the enumerated households.
According to the official 1998 national census data, there are an estimated 44.7
million persons in the adult age group (31.6%), and 21 million persons (14.8%) aged
10 to 15 years nationally. Demographic data indicate that the majority of the
population resides in rural areas (67.5%) while 32.5% live in urban zones.
Examination of children under the age of ten would have required specialist
equipment and training, and it was felt that these were beyond the scope of the
intended survey.
The lower age limit for adults (30 years) corresponds to other similar blindness
prevalence surveys in South Asia (e.g. Bangladesh and India), which allows direct
comparisons to be made from the three studies.

ii. Sample size and sampling strategy

The sample size for the study was calculated for the adult group of subjects. The
parameters taken into account were: an assumed prevalence of 1.8% of blindness in
persons 30 years and older; random sampling error precision of 0.3%; a design effect
of 2.0 with a 95% level of confidence. Based on these values the adult sample size
was 16,600 which included an additional 10% increase for potential non-response. An
a priori sample size for children was not carried out. Rather, as described below, the
cohort of children examined in this survey were those who resided in the households
of eligible enumerated adults.
Multi-stage stratified cluster random sampling, with probability proportional-to-size
(PPS) procedures, was adopted as the strategy for the selection of a cross-sectional,
nationally representative sample of the population. For the purposes of this survey, a
rural cluster consisted of a village while an urban cluster comprised a street block.
Stratification of the sample according to rural and urban residence was incorporated in
the sample selection process. Within each of the four provinces of Pakistan, a
proportional number of clusters in relation to the overall national population was
identified based upon official census data. A total of 221 cluster sample sites were
selected by PPS of which 112 were rural villages while the remaining 109 were urban
block areas. The rural cluster areas consisted of 100 subjects, while the urban study
areas consisted of 50 subjects each. The logistical advantages of this sampling
strategy included efficiency in terms of time, transport and subject enumeration and
subsequent examination per cluster.
Prior to the examination of subjects, enumeration of all persons who were living in
households was undertaken until the target number of adults was attained, i.e. 100
adults for each rural site and 50 for each urban cluster. The sample of children
included those who resided in the households of the adults who had been enumerated
for the study. Recruitment of children in this manner was logistically possible.

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Moreover, given that persons of all ages living in the household were enumerated, it
was possible to determine the response rate of participation for both adults and
children. Subject identification involved the two-person enumeration teams serially
assigning a number to each household and registering the names and ages of all
habitual occupants until the required number of eligible subjects was attained for a
given cluster. All eligible subjects were informed that they would be asked to attend
for an examination in their community in the next few days.
It was projected that an average of 50 subjects would be surveyed per day by each of
the three survey teams taking part in data collection. Taking into account other
logistical issues (travel, religious holidays) the nation-wide survey was projected to
have a duration of approximately twelve months.

Map of Pakistan demonstrating the cluster sites around the country

iii. Ethical and Official Government Approval

The research project was an officially agreed collaboration among the following
bodies: the National Leprosy, Blindness and Tuberculosis Control Board of the
Pakistan Ministry of Health; the Pakistan Institute of Community Ophthalmology; the
National Co-ordinator and the Provincial Co-ordinators for the Prevention of
Blindness; the International Centre for Eye Health, London School of Hygiene and
Tropical Medicine, London, and the international non-governmental development
organisations Sight Savers International (SSI), Christoffel Blinden Mission (CBM)
and Fred Hollows Foundation (FHF).

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iv. Training and pilot studies
Three separate survey teams were appointed, one each from the North West Frontier
province, the Punjab province and the Sindh province. The Punjab team was also
designated to survey the sparsely-populated province of Balochistan.
Each survey team consisted of one clinical and one community ophthalmologist, one
senior ophthalmic nurse and two medical technicians (all Pakistani nationals). Other
non-medical staff within each team included six enumerators, one female enumeration
‘facilitator’ and one interviewer. Four data processors were also specially trained to
carry out double entry and database maintenance.
All survey team members underwent specialised training for two two-week periods. A
detailed survey protocol manual outlining the survey activities, a guide for completing
the questionnaire interview and information about the duties and responsibilities of all
survey personnel was given to each team member.
Two pilot studies were conducted following completion of the comprehensive training
sessions for all survey team personnel. Inter-observer agreement studies were
performed for the various components of the eye examination protocol.

v. Survey data collection

Examination flow chart

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10
Oral informed consent was obtained from each subject by the senior ophthalmic
nurse. Personal and demographic data were recorded prior to eye examination by a
trained interviewer. All subjects had their height and weight measured. All subjects
underwent distance visual acuity measurement with a reduced logarithm of minimum
angle of acuity (logMAR) tumbling “E” chart, which was used as literacy levels are
low in Pakistan. Visual acuities were measured in each eye separately at 4 metres, and
at 1 meter if necessary.
Based on presenting visual acuity, subjects were either marked as a “red card” (visual
acuity worse than 6/12 in either eye) or marked as a “green card” (better than 6/12 in
each eye). All patients then underwent an ophthalmic examination by the
ophthalmologist. All subjects also underwent automated refraction and biometry. Red
card holders were then examined in more detail, which included retesting visual
acuity with the autorefraction results placed in a trial lens frame. Red carders also had
a slit lamp examination with dilated fundus check. Jects also had visual field, HRT II
and fundus photos as per protocol. Visual functioning and Quality of life
questionnaires were administered.
One of every five subjects aged 40 years or older, consecutively attending the survey
station, was recruited for a ‘normative database’ in advance of visual acuity testing.
All people with <6/18 vision were referred to the nearest district hospital (these
hospitals were sensitized in advance by letters from the local Health Department).
The survey team also provided treatments (free of cost) to the survey subjects if they
had minor ailments (e.g. conjunctivitis).

Ophthalmic diagnostic equipment used in this survey

Reduced LogMAR visual acuity ‘E’ chart
Autorefractor
A scan ultrasound
Slit lamp + Goldman tonometer
Direct and indirect Ophthalmoscopes
Humphrey Visual Field Analyser
Heidelberg Retinal Tomograph-II (HRT-II).
Non Dilation Fundus Camera
Visual functioning and quality of life Questionnaire

vi. Data management and statistical analysis

A record sheet was completed for each eligible enumerated subject, even if the subject
was a non-responder (see above). Two members of staff independently entered the
data onto two independent databases. These two databases were later compared and
mismatches investigated and corrected in order to form one final database. Data were
entered into EPI INFO and transferred to STATA (Statcorp. Release 9.0.College
Station TX:,Stata Corporation) for analysis.
Descriptive analyses and cross tabulations with calculation of Pearson chi squared
tests were performed. Further analyses were undertaken to explore risk factors for
subjects using logistic regression with generalised estimating equations to adjust for
dependency in the data due to clustered sampling. All tests are two sided, and the
odds ratios (OR) and 95% confidence intervals (CI) quoted are derived from logistic
regression models. To account for differential non-response, the blindness prevalence
estimate was standardized by age and gender, using the most recent population
estimates. US census bureau data was used when calculating projections for the year
2020.

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 B. Definitions and categorisation of variables.

i. Defining the outcome variables

Presenting visual acuity definitions.

The categories are visual acuity in the better eye (i.e. spectacles if normally worn)

Blindness Less than 3/60 (0.05*)

Severe visual loss Less than 6/60 but better than 3/60
(ICD10 Category2)

Moderate visual loss Less than 6/18 (0.48*) but better than 6/60
(ICD10 Category1)

Near Normal Less than 6/12 (0.3*) but better than 6/18

Normal Better than 6/12

* LogMAR equivalent

As visual fields were only assessed on a subset of the sample, constricted visual fields
were not included in the definition of blindness. The Snellen notation for visual acuity
has been used in this paper for ease of comparison with the above definitions.

Unilateral severe visual impairment and blindness

This was defined as a subject with 6/12 or better presenting visual acuity in one eye
and<6/60 in the fellow eye.

Functional low vision (FLV)

Best-corrected distance visual acuity of <6/18 to perception of light (PL) in the better
eye and an untreatable cause in both eyes.
Conditions considered treatable were any refractive error, cataract and posterior
capsular opacification following cataract extraction. All the other causes were
considered untreatable.

Low vision assessment requirements in different levels of impairment

Visual Acuity (n) Optical devices Non optical/ Rehabilitation

(score) environmental
(adults in Pakistan) modification
<6/18-6/60 Yes (+++) Yes (+++++) No

<6/60 - <3/60 Yes (+++++) Yes (+++++) Yes (++)

SVI1

<3/60 can see at least one letter or can count Yes (++) Yes (+++++) Yes (++++)
fingers

Cannot see any letters on chart or count No Yes (+) Yes (+++++)
fingers but >PL

NPL in both eyes * No No Yes (+++++)

* No light perception of light (NPL) in both eyes – considered as total blindness

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Adults with FLV and total blindness were subsequently categorized into three non
mutually exclusive groups according to the assessment requirements that they would
require; a) optical requirements b) non optical/environmental modification and c)
rehabilitation (non visual sensory stimulation e.g. audio tapes). Subjects with a best
corrected vision of <6/18 to ≥6/60 were considered to only require optical and non
optical/environmental rehabilitation. Subjects <6/60 to ≥3/60 in the better eye but who
were able to read at least one letter on the logMAR chart at 1m or who could count
fingers in at least one eye were categorized as still having ‘form vision’ and were
potentially able to benefit from all the interventions. Subjects that could not read any
letters on the chart at 1m or could not count fingers in either eye but were at least PL
in the better eye were categorized as potentially benefiting from environmental
modification and rehabilitation. Subjects that were totally blind were categorized as
requiring only rehabilitation.

Refractive Error
Low Myopia was defined as a spherical equivalent (SE) refractive error (RE) of less
than -0.5D (<-0.5D) but ≥ -5D. High myopia was defined as an SE of <-5D. Similarly
low hypermetropia was defined as an SE >+0.5D but ≤+5D and high hypermetropia
was defined as >+5D.
Astigmatism (defined in the minus cylinder format) was defined as a cylindrical error
<-0.75D. “With the rule” astigmatism was present if the axis lay between 15° on
either side of the horizontal meridian, against the rule if the axis lay between 15° on
either side of the vertical meridian, and oblique if the axis lay between 15° and 75° or
between 105° and 165°.
All persons with pseudo/aphakia or with missing autorefraction result in the right eye
were excluded in the analysis. Refractive error for each eye were analyzed separately
but in keeping with previous studies and because the results in the left eye were
similar to that of the right eye, we report on data from the right eye.

Spectacle coverage
A cut off visual acuity of 6/12 was used. Coverage (%) was calculated as the (met
need / met +unmet need)*100.
Met need – describes the number of adults wearing spectacles who had a visual acuity
of <6/12 without correction but achieved >6/12 vision with their distance spectacles.
Unmet need – describes adults not wearing spectacles who had a visual acuity of
<6/12 but improved to >6/12 with correction.

Lens opacity
In defining this variable (used in the risk factor analysis) information from the Mehra
Minassian lens opacity grading system was used. Grades 2a, 2b or 3 identified
cataract and Grade 4 identified pseudo/ aphakia in that eye.

Catarct Surgical Coverage

(CSC persons)
This measure indicates to what extent the services have covered the needs.
Calculation of CSC was performed for three visual impairment cut-offs: <3/60, <6/60
and <6/18 using the formula: (x + y)/(x + y + z) * 100 where:
x = persons with unilateral pseudo/aphakia and visual impairment in contralateral eye
y = persons with bilateral pseudo/aphakia, regardless of acuity.
z = persons with <3/60, <6/60 and <6/18 in whom the principle cause was cataract
(unilateral or bilateral)

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CSC (eyes)
This measure gives an indication of the proportion of eyes with operable cataract that
have had surgery in the community at a given point in time.
Calculation of CSC (eyes) was performed for three visual impairment cut-offs: <3/60,
<6/60 and <6/18 using the formula: (a/a+b) x100 where
a = all eyes which are aphakic or pseudo/aphakic, regardless of acuity.
b = all eyes with cataract causing an acuity of <3/60, <6/60 or <6/18.

CSR
Defined as number of cataract operation performed / year / million population. Date
of surgery was obtained from the pseudo/aphakic subjects. CSR was calculated using
population estimates for the specific time period.

Explanatory variables

Adult
Defined as subject aged 30 years and over

Age
Age was categorised into 10 yearly age groups (30-39 etc up to age 69), with any
person aged 70 years and above entered into one category.

Smoking
Smoking was defined by a binary variable identifying whether someone
previously/currently smoked (either cigarettes or the hookak) or never smoked.

Medical history of diabetes

This (Yes/No) variable was produced from response to the nurse’s direct questioning.

Hypertension
Hypertension (Yes/No) was defined on past medical history or if the average
measured systolic blood pressure was found to be >160mmHg and/or diastolic blood
pressure >90mmHg.

Anthropometric Measures
BMI was generated by using the formula (Weight (Kg) / Height(m)*Height(m))
Subjects were classified as lean if BMI was <20 for males and <19 for females; as
normal if the BMI was between 20-25 for males and 19-24 for females; as heavy if
the BMI was 25-30 for males and 24-29 for females; and obese if the BMI was >30 in
males and >29 in females.

Literacy and Education

Literate subjects were ones who could read/write with ease or with a little difficulty.
Educational achievement was assessed as to whether the subject had attended
school/college/university and if so to what level. This then generated 3 categories 0;
No schooling, Primary level only, 3; Higher.

Occupation and household income

Individuals’ occupations were categorised into 3 categories: non manual, manual or
unemployed/student/retired, and their household’s income was determined by the
highest status occupation within the household. For example, if there was only one
worker and he was a non manual worker this was regarded as the status for that house.

14
If there were 2 or more working individuals in the household the house was classified
by the highest status occupation (i.e. using non manual > manual >
retired>unemployed/student).

Deprivation Index
Deprivation scores at the district level stratified on urban/rural location within that
district were extracted from a report which analysed the Population and Housing
Census 1998 data.
The deprivation for each rural/urban location in each district was categorised into low
level (<25th centile), medium level (25-75th centile) and high levels (>75th centile.)

15
 Results

A. Response rates and a demographic description of the

study population

Flow chart for Adults in the Pakistan National survey.

Punjab Sindh Balochistan NWFP

Districts: 35 21 11 27
visited

Cluster: 120 55 11 35
sites

17,311 Adults Enumerated

804 ‘non responders’

16,507 (95.3%) Adults examined in study including ‘Specials’

(n = 1,962)

‘Green’ Carders ‘Red’ Carders

(n = 10,468, 63.4%) (n = 6,039, 36.6%)

There was some geographical variation in non-response: non response was highest in
Balochistan (8.9%) and lowest in Sindh (2.2%). Overall, response rates were higher
for women (97.0%) than for men (92.7%) (p<0.001). Reasons quoted for non
response included: at work/out of town/unavailable (n=586, 72.9%); refused
examination (n=138, 17.2%); disability (n=8, 1%), and other (n=28, 3.5%). No reason
was recorded in the remaining 44 individuals (5.5%).

The mean age of the sample was 47.3 years (range 30 to 105 years, Table A1a,b).
Women accounted for 53.1% of the study sample, their mean age being significantly
lower than that of males (45.9 years vs. 48.9 years respectively, p<0.001). Mean age
was lowest in Balochistan (46.1 yrs) and highest in Punjab (47.8yrs) province.

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Table A1 a. Age and gender of subjects included in the study.

Male Female Total

Age group n % n % n (%)
30-39 years 2,498 28.5 3,457 44.7 5,955 36.1
40-49 years 1,615 18.4 1,974 25.5 3,589 21.7
50-59 years 1,419 16.2 1,451 18.7 2,870 17.4
60- 69 years 1,225 14.0 1,120 14.5 2,345 14.2
70+ years 984 11.2 764 9.9 1,748 10.6
Total 8,776 100.0 7,741 100.0 16,507 100.0

Table A1 b. Age and gender of subjects in each province.

Province Age group Male Female Total

n % n % n (%)
NWFP <50 years 769 43.6 993 56.4 1762 100
≥50 years 714 53.6 618 46.4 1332 100
Balochistan <50 years 259 46.6 297 53.4 556 100
≥50 years 210 54.0 179 46.0 389 100
Punjab <50 years 2,118 42.2 2,904 57.8 5022 100
≥50 years 1,966 52.0 1,816 48.0 3782 100
Sindh <50 years 967 43.9 1,237 56.1 2204 100
≥50 years 738 50.5 722 49.5 1460 100

Rural and Urban

Total of 11084 (67.2%) adults lived in rural areas. NWFP had highest proportion of
people living in rural areas (n=2650, 85.6%) compared to Sindh having the lowest
(n=1907, 52.1%). Urban areas were associated with younger age compared rural areas
(p<0.001.)

Education
The overall literacy rate was 29.5%. When questioned about school attendance a
striking 70.2% admitted to not having attended school. Women were much more
likely to have not attended school (14.9% vs. 46.7%, p<0.001.) Punjab had the highest
literacy rates (31.4%) followed by Sindh (30.9%) then NWFP (24.7%) and lastly
Balochistan (21.4%). The rates were also significantly different in rural vs. urban
populations (23.3% vs. 42.0%, p<0.001). A significant association was found between
age and literacy: amongst those aged 30-39 years, 60% were illiterate compared with
91% in subjects aged 70 years and above. Subjects living in rural areas were more
likely to be illiterate than urban dwellers (76.7% vs. 58.0%).
Amongst the subjects that attended school the median number of years schooling was
8yrs (IQR 5-12) with just over half attending primary level education and 8.9%
reaching university level.

Smoking
14.1% of the adults admitted to ever being smokers. Furthermore there were only 72
female smokers in the entire sample.

Anthropometric measures
Mean height was 1.6m (SD 0.1m) and mean weight was 58.3kg (SD 13.5kg). There
was a statistically significant difference between weights of people in urban vs. rural
districts in both males and females whereas height was similar in both populations.

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BMI variable was positively skewed, showing a median BMI of 21.4 (IQR 19.0 –
24.2) in males and 22.5 (IQR 19.5 – 26.4) in females.
Hypertension
Overall 3699 (22.40%) of the population were classified as hypertensive. There were
significantly more hypertensive subjects in urban areas (24.9%) compared to rural
areas (21.2%, p<0.001.)

Diabetes
The survey identified 488 (3.0%) subjects with a medical history of diabetes. A
significant difference comparing urban to rural populations was found (p<0.001.)
Increasing age was also found to be associated with increasing diabetes rates
(p<0.001) as was increasing BMI (p<0.001.)

House Income
Information on occupation was available on 16,411 subjects. A manual job accounted
for the majority (55.10%) of households. A further 28.8% were classified as ‘non
manual’ households status, 12.3% classified as either unemployed or students and a
further 3.8% are ‘retired’. As expected there were significantly more ‘non manual
households’ in the urban areas compared to rural areas (38.0% vs. 24.3%, p<0.001).

Deprivation Index
This index was produced at the district level stratified on rural/urban dwelling. There
were significant deprivation differences between the two areas; rural areas having
much higher deprivation (median 68.2 (IQR 63.5 72.6)) compared to urban areas
(median 37.08 (IQR 29.2 45.1)). The highest deprivation province was Balochistan
with 55.2 % of the area classified as high deprivation. Karachi was the lowest
deprived district in the country. As expected, deprivation index was found to be
highly correlated with education (r = -0.18, p<0.0001) and BMI status (r = -0.20,
p<0.0001)

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B. Blindness and visual impairment

i. Prevalence

4,416 subjects (26.7%) were identified with a visual acuity of <6/12 in the better eye
on presentation. Of these, 561 persons were blind (<3/60). The crude prevalence of
blindness was, therefore, 3.4% (95%CI: 3.1 to 3.7 %). The crude prevalence of
SVI/BL (<6/60) was 4.9 % (95%CI 4.5 to 5.2%). There were 2,364 subjects (14.3%),
who presented with <6/18 but ≥3/60 in their better eye (MVI and SVI).

‘All age’ Blindness prevalence

The prevalence of blindness among all ages was also estimated, using published
assumptions concerning the prevalence in individuals aged 0-29 years (i.e. 0.1-0.2%
for persons aged 15-29, and 0.08% for those aged <15 years) and the age and gender
standardised data from this survey (i.e. 2.7%, see below). The prevalence of ‘all age’
The all age prevalence estimate from this survey (0.9%, 95%CI: 0.8 to 1.0%) agrees
with the database, which has estimated the prevalence of blindness in populations in
the Eastern Mediterranean sub-region, to be 1.0%.

Visual acuity and age

Blindness prevalence increased with age from 0.4% in those aged 30-39 years to
15.7% in persons 70 years and older, the increase being approximately exponential.
Figure A1. The vast majority of the 561 bilaterally blind subjects (489, 87.2%) were
aged 50 or above, and the prevalence of blindness in this age group was 7.0%.

Figure A1. Prevalence of blindness increasing exponentially with age

17.5

15.7
15.0

12.5

10.0 Blindness prevalence

( %)
7.5 Exponential trend
6.1
5.0
2.5
2.5 1.3
0.4
0.0
30-39 40-49 50-59 60-69 70+

Age group

Visual acuity and gender

Overall crude prevalence of blindness estimates were similar between men and
women (3.4% vs. 3.5%, respectively, Table B1) however a large gender difference in
blindness prevalence was observed in Balochistan. (men 3.6%, women 4.0%). After

19
 stratifying by age, the prevalence of blindness was higher in women in every age
category except those aged 30-39 years. Thus, after adjusting for age differences in
the sample, the odds of a woman being blind were 30% higher than for a man (OR
1.3; 95%CI 1.1 to 1.6, p=0.001).

Visual acuity and location

Significantly higher rates of blindness were found in rural communities than urban
communities (3.8% vs. 2.5%, p <0.001). Rural Balochistan had the highest prevalence
of blindness (5.0%).

Visual acuity and socioeconomic indicators:

The prevalence of blindness was significantly higher in illiterate subjects compared
with those who were literate (4.5%, vs. 0.7%), and these differences were significant
for both genders (men p<0.001; women p=0.006). Even after adjusting for age,
illiterate subjects had greatly increased odds of blindness (OR 3.4, 95%CI 2.4 to 4.8,
p<0.001) compared to literate subjects. Overall, 0.7% of subjects from ‘non manual’
households were classified as blind compared with 2.9% in ‘manual’ households and
4.2% in households classified as ‘unemployed/student/retired’. Statistically significant
differences in deprivation scores were found between subjects who presented blind
compared with those presenting with better visual acuities (mean deprivation scores
60.8 vs. 57.4 respectively, p<0.001).

B1. Overall visual acuity in the better eye, by gender, location and literacy.

Normal % Near % Moderate % Severe % Blind % Total %

Normal
Gender Men 5815 75.1 605 7.8 935 12.1 127 1.6 259 3.4 7741 100
Women 6276 71.6 886 10.1 1186 13.5 116 1.3 302 3.5 8766 100
Location Rural 8109 73.2 981 8.8 1392 12.6 177 1.6 425 3.8 11084 100
Urban 3982 73.4 510 9.4 729 13.4 66 1.2 136 2.5 5423 100
Literate Yes 4238 87.1 282 5.8 290 6.0 19 0.4 35 0.7 4864 100
No 7852 67.5 1,209 10.4 1831 15.7 224 1.9 526 4.5 11642 100
Normal (≥6/12); Near Normal (<6/12to≥6/18); MVI (<6/18to≥6/60); SVI (<6/60to≥3/60)

B2. Table of visual acuity in each province by gender, location and literacy

NWFP
Normal % Near % Moderate % Severe % Blind % Total %
Normal
Gender Men 1163 78.4 107 7.2 157 10.6 20 1.3 36 2.4 1483 100
Women 1217 75.5 149 9.2 185 11.5 17 1.1 43 2.7 1611 100
Location Rural 2058 77.7 212 8.0 280 10.6 29 1.1 71 2.7 2650 100
Urban 322 72.5 44 9.9 62 14.0 8 1.8 8 1.8 444 100
Literate Yes 691 90.7 35 4.6 27 3.5 4 0.5 5 0.7 762 100
No 1689 72.4 221 9.5 315 13.5 33 1.4 74 3.2 2332 100

Balochistan
Normal % Near % Moderate % Severe % Blind % Total %
Normal
Gender Men 358 76.7 34 7.3 49 10.5 9 1.9 17 3.6 467 100
Women 367 76.8 34 7.1 52 10.9 6 1.3 19 4.0 478 100
Location Rural 467 76.1 43 7.0 65 10.6 8 1.3 31 5.0 614 100
Urban 258 77.9 25 7.6 36 10.9 7 2.1 5 1.5 331 100
Literate Yes 187 92.6 9 4.5 5 2.5 0 0.0 1 0.5 202 100
No 538 72.4 59 7.9 96 12.9 15 2.0 35 4.7 743 100

20
 B2. Table of visual acuity in each province by gender, location and literacy
(cont’d)

Punjab
Normal % Near % Moderate % Severe % Blind % Total %
Normal
Gender Men 3045 74.6 337 8.3 497 12.2 55 1.3 150 3.7 4084 100
Women 3303 70.0 515 10.9 662 14.0 54 1.1 186 3.9 4720 100
Location Rural 4213 71.2 565 9.6 791 13.4 82 1.4 262 4.4 5913 100
Urban 2135 73.8 287 9.9 368 12.7 27 0.9 74 2.6 2891 100
Literate Yes 2407 87.0 174 6.3 157 5.7 8 0.3 20 0.7 2766 100
No 3940 65.3 678 11.2 1002 16.6 101 1.7 316 5.2 6037 100

Sindh
Normal % Near % Moderate % Severe % Blind % Total %
Normal
Gender Men 1249 73.3 127 7.4 229 13.4 46 2.7 54 3.2 1705 100
Women 1389 70.9 188 9.6 290 14.8 36 1.8 56 2.9 1959 100
Location Rural 1371 71.9 161 8.4 256 13.4 58 3.0 61 3.2 1907 100
Urban 1267 72.1 154 8.8 263 15.0 24 1.4 49 2.8 1757 100
Literate Yes 953 84.0 64 5.6 101 8.9 7 0.6 9 0.8 1134 100
No 1685 66.6 251 9.9 418 16.5 75 3.0 101 4.0 2530 100

Significant differences in visual acuity categories were present throughout the country
(Table B2). Punjab and Balochistan had the highest crude prevalence of blindness
(both 3.8%), followed by Sindh (3.0%). NWFP had the lowest blindness prevalence
(2.6%).

ii. Estimation of the magnitude of blindness in Pakistan

The age and gender standardised prevalence of blindness among Pakistani adults aged
30 years and older was 2.7% (95%CI 2.4 to 2.9%). The estimated number of blind
adults aged 30 years and above in each of the provinces is shown in Table B3.

The estimated number of blind individuals of all ages in Pakistan in 2003 is estimated
to be 1.25 million (1,100,000 to 1,350,000). Using population projections for the
whole population of Pakistan, the number of blind people in Pakistan will increase to
approximately 2.4 million by the year 2020 assuming the prevalence of blindness
remains unchanged.

B3. Estimated number of blind adults in each Province of Pakistan, based on

the age/gender standardised prevalence of blindness

Standardised
Province Prevalence (%) Estimate with 95% confidence limits

Punjab 3.1 769,000 (682,000 to 864,000)

Sindh 2.1 200,000 (159,000 to 250,000)
NWFP 2.1 114,000 (88,000 to 144,000)
Balochistan 2.8 52,000 (35,000 to 77,000)
National 2.7 1.14 million (962,000 to 1,330,000)
Age and sex-standardized prevalence calculated from Pakistan Demographic Survey data.

21
C. Causes of visual loss in Pakistan

‘All Causes’
Initially, all possible pathologies of a reduced visual acuity in eyes that presented with
<6/12 vision were recorded by the examining ophthalmologist (total of 14,881 eyes).
Refractive error and cataract were recorded as causes in 5,463 (36.7%) and 5,345
(35.9%) eyes, respectively. The next most common cause was central corneal opacity
(912 eyes, 6.1%), uncorrected aphakia (430 eyes, 2.9%) and macular degeneration
(418 eyes, 2.8%).

i. Principal cause (Table C1, C2)

Avoidable
Overall an extremely high proportion of all categories of visual loss were due to
conditions which could have been treated or prevented. A striking 85.5% of blindness
was due to avoidable causes. Unoperated cataract together with uncorrected aphakia
and posterior capsule opacification (PCO) accounted for 21.7%, 46.8% 78.1% and
63.7% of near normal, mild visual impairment, severe visual impairment and
blindness respectively. Under/uncorrected refractive errors accounted for 70.2% of
visual loss in individuals with near normal vision, but only 2.7% of blindness.
Glaucoma was an important cause of blindness (7.1%) particularly in the more severe
degrees of visual loss. Diabetic retinopathy accounted for approximately equal
proportions across the different visual acuity categories. Regarding preventable
causes, corneal pathology accounted for a relatively low proportion of visual loss in
milder forms, but affected 11.8% of individuals who were blind.

Unavoidable
The principle single group of unavoidable cause of blindness was phthisis
bulbi/absent eyes. Macular degeneration accounted for 2.1% of blindness. Amongst
the 47 blind from “other” causes, posterior segment disorders dominated, including
chorioretinitis, vasculopathies, retinitis pigmentosa, and retinal detachments.

22
Table C1. Principal cause of visual loss for persons, by category of visual loss in the better eye (presenting visual
acuity).

<6/12-6/18 <6/18-6/60 <6/60-3/60 <3/60

N % N % N % N %
Treatable Cataract 287 19.2 883 41.6 166 67.8 289 51.5
Uncorrected Aphakia 23 1.5 66 3.1 13 5.3 48 8.6
Glaucoma 10 0.7 36 1.7 6 2.4 40 7.1
PCO 15 1.0 45 2.1 11 4.5 20 3.6
Refractive error 1,047 70.2 905 42.7 17 6.9 15 2.7
Diabetic retinopathy 4 0.3 10 0.5 1 0.4 1 0.2
1,386 93.0 1,945 91.7 214 87.3 413 73.6
Total treatable

Preventable Central corneal scar 29 1.9 55 2.6 8 3.3 66 11.8

Total avoidable 1,415 94.9% 2,000 94.3% 222 90.6% 479 85.4%

Unavoidable Phthisi/absent globe 1 0.1 3 0.1 1 0.4 15 2.7

Macular degeneration 8 0.5 21 1.0 5 2.0 12 2.1
Optic atrophy 2 0.1 5 0.2 1 0.4 5 0.9
Amblyopia 10 0.7 13 0.6 2 0.8 3 0.5
Other 55 3.7 79 3.7 14 5.7 47 8.4

Total unavoidable 76 5.1 121 5.7 23 9.4 82 14.6

Total 1,491 100.0 2,121 100.0 245 100.0 561 100.0

23
Table C2. Principal cause of visual loss for persons with moderate visual impairment (visual acuity in the better eye of
less than 6/18 but better than 6/60).

Treatable Preventable Unavoidable

(%) (%) (%)
N= RE Cataract PCO UA DR Glaucoma Corneal Optic MD Other
opacity atrophy
Gender
Female 1186 45.4 39.8 2.1 3.3 0.6 1.3 2.4 0.3 0.8 4.0
Male 935 39.1 45.4 2.1 2.9 0.3 2.1 2.9 0.2 1.2 3.8
Province
Balochistan 101 38.6 29.7 1.0 3.0 0.0 3.0 9.9 1.0 1.0 12.8
NWFP 342 48.5 36.5 2.3 1.5 0.3 0.9 4.1 0.9 1.2 3.8
Punjab 1159 40.7 43.0 1.2 5.0 0.8 2.1 2.3 0.0 1.0 3.9
Sindh 519 43.9 44.3 4.2 0.0 0.0 1.0 0.8 0.2 0.8 4.8
Location
Urban 729 47.5 34.6 2.5 2.5 1.2 1.5 2.9 0.1 1.8 5.4
Rural 1392 40.2 45.3 1.9 3.4 0.1 1.8 2.4 0.3 0.6 4.0
Literacy
Literate 290 59.3 28.6 1.0 1.7 1.4 1.7 1.4 0.3 0.3 4.3
Illiterate 1831 40.0 43.7 2.3 3.3 0.3 1.7 2.8 0.2 1.1 4.6

NWFP= North West Frontier Province

RE: Refractive Error: PCO: Posterior Capsule Opacification; UA: Uncorrected Aphakia; DR: Diabetic Retinopathy; MD: Macular Degeneration.

24
Cause by demography
Among blind subjects cataract was the main cause in all age groups. There were no
persons blind as a result of glaucoma or uncorrected aphakia in the 30-39 year age
group, however among those aged 70 years and older, glaucoma and uncorrected
aphakia accounted for 9% and 10%, respectively. PCO was not a cause of blindness in
the youngest age groups (i.e. 30-59 years) but in older subjects it was a prominent
treatable cause (6.3% in 60-69 year olds). The highest proportion of phthsis/absent
globe as a cause was found in the 30-39 year olds (7.8%).

In individuals with MVI, cataract accounted for 14% among subjects aged 30-39
years, increasing to 53% in those aged 70 years and above. Refractive error had a
converse relationship with age, accounting for 73% of MVI in the youngest age group
compared with 29% in the oldest age group. The other causes showed little variation
with age, all accounting for less than 5% in each 10-year age group.

In men the principle cause was cataract (45.4%), whereas in women it was refractive
error (45.4%). Refractive error was more common in urban settings (47.5%) (whereas
in rural settings cataract dominated (45.3%)) and in literate subjects (59.3%).

ii. Provincial Differences in cause of blindness

Cataract was the main cause in all provinces. In Punjab and Sindh corneal opacities
were the second leading cause. Corneal opacities were more particularly prevalent in
Sindh province, Table C3. Glaucoma and macular degeneration were the second
leading causes of blindness in Balochistan and NWFP respectively.

Table C3. Provincial differences in cause of blindness

NWFP Punjab Balochistan Sindh

Cataract 46(58.2) 177 (52.7) 16 (44.4) 50 (45.5)
CO 2 (2.5) 42 (12.5) 3 (8.3) 19 (17.3)
UA 1 (1.3) 38 (8.2) 0(0) 9(8.2)
Glaucoma 2 (2.5) 26 (2.7) 5 (13.9) 7 (6.4)
PCO 3(3.8) 9(2.7) 2(5.6) 6(5.5)
Macular degeneration 7 (8.9) 3 (0.9) 1 (0.9) 1 (2.1)
RE 5 (6.3) 8 (2.4) 1 (2.8) 1 (0.9)
Total (incl all other) 79 (100) 336 (100) 36 (100) 110 (100)
CO corneal opacity, UA uncorrected aphakia, PCO Posterion capsular opacification, RE Refractive Error

iii. Causes of unilateral severe visual impairment and blindness (SVI/BL)

The main causes of unilateral reduced vision are presented in Figure C1. Of the 427
subjects who met these criteria, cataract was the most common cause (150 subjects,
35.1%), followed by central corneal opacity (61 subjects, 14.3%), phthisical or absent
globe (49 subjects, 11.5%), and amblyopia (31 subjects, 7.3%). All other causes each
accounted for less than 5%.

25
Figure C1. Main causes of unilateral reduced vision in 427 subjects with <6/60
presenting vision in one eye and 6/12 or better in the fellow eye. The ten most
common causes are presented.

Optic Atrophy

Macular Degeneration

Refractive Error

Posterior Capsule Opacification

Glaucoma

Uncorrected Aphakia

Amblyopia

Phthisis/ Absent globe

Central Corneal Opacity

Cataract

0 5 10 15 20 25 30 35 40
%

iv. Estimate of the number of adults presenting with visual impairment in

Pakistan by cause
There are almost 904,000 (95%CI: 736,000 to 1,107,000) adults aged 30 years and
above with SVI/BL who require cataract surgery in Pakistan. A further 173,000
individuals have uncorrected aphakia or PCO. A total of 1,390,000 adults have a
presenting visual acuity of <6/60 in the better eye due to avoidable causes (Table
C3). Regarding adults with MVI (<6/18 to ≥6/60, better eye) 2,140,000 would benefit
from having their refractive error corrected. Assuming the prevalence and patterns of
causes remain unchanged, the figures for the year 2020 show that a total of 2,560,000
adults will have avoidable causes of <6/60 vision. Projections for the year 2020 are
shown on Table C4. Regarding subjects with MVI, refractive error as a cause will
affect 4,320,000 adults in 2020.

Table C4. Estimated number of adults (≥30 years) in Pakistan with severe
visual impairment and blindness (presenting vision <6/60 in the better eye) by
cause. (Age/gender standardized figures)

2003 2020
(41.5 million)* (84.7 million)*
Cause
Treatable
Refractive Error 72000 147,000
Cataract 904000 1860000
Posterior Capsule Opacification 57000 119000
Uncorrected aphakia 116000 238,000
Glaucoma 89000 185000
Diabetic retinopathy 3200 6900
Preventable
Central Corneal Opacity 150000 308000
Other
Optic atrophy 15000 32000
Macular Degeneration 35000 72000

Total † 1620000 3320000

Age and sex-standardized prevalence calculated from Pakistan Demographic Survey data.
* Pakistans adult (≥30years) population, † Including other causes

26
 D. Functional Low Vision

Overall 343 subjects had FLV, 167 (48.7%) of whom were women. Overall 71.1% of
subjects with FLV were rural dwellers and 91.5% were illiterate. 36% of women were
above 70 years of age compared with 47.2% of men.

i. Prevalence of functional low vision (FLV)

The overall crude prevalence of FLV in Pakistani adults was 2.1% (CI 1.9 to 2.3%).
Approximately half (n=175, 51%) had a best corrected visual acuity of <6/18 to 6/60
in the better eye, and a further 21 subjects (6.1%) had a best corrected visual acuity of
<6/60 to 3/60 in the better eye. The remaining 147 subjects (42.9%) were <3/60 in the
better eye, 34 of whom had NPL in one eye. The prevalence of FLV increased almost
exponentially with age. The province of Balochistan had the highest crude prevalence
of FLV (2.8%, CI 1.9 to 4.1%) followed by Punjab (2.2%, CI 2.0 to 2.6%), Sindh
(1.9%, CI 1.5 to 2.4%) and NWFP (1.5%, CI 1.1 to 2.0%).

The prevalence of FLV was significantly higher in illiterate subjects (2.7%; CI 2.4 to
3%) than literate subjects (0.6%; CI 0.4 to 0.9%, p<0.001, Table D1) and marginally
higher in rural dwellers (2.2%, CI 1.9 to 2.5%) than in urban (1.8%; CI 1.5 to 2.2%,
p=0.09). Stratified on province, rural Balochistan had the highest prevalence of FLV
(3.6%; CI 2.3 to 5.4%) whereas urban areas in NWFP the lowest (1.1%; CI 0.4 to
2.6%).

Table D1. Crude prevalence of visual acuity groups according to geographical

dwelling and literacy stratified on age.

(n) Crude Prevalence %

6/18 to ≥6/60 <6/60 to ≥3/60 <3/60 can see at Cannot see any NPL3
SVI 1 least one letter or letters on chart or
count fingers count fingers but
>PL2

Rural Working age 4 (44) 0.54 (4) 0.05 (16) 0.20 (20) 0.24 (5) 0.06
Retired 5 (73) 2.49 (14) 0.48 (34) 1.16 (40) 1.36 (22) 0.75
Urban Working age (24) 0.56 (1) 0.02 (3) 0.07 (9) 0.21 (2) 0.05
Retired (34) 2.93 (2) 0.17 (15) 1.29 (10) 0.86 (3) 0.26
Total (175) 1.06 (21) 0.13 (68) 0.41 (79) 0.48 (32) 0.19

Literate Working age (10) 0.23 (0) 0 (2) 0.047 (7) 0.16 (2) 0.05
Retired (7) 1.22 (1) 0.18 (1) 0.17 (1) 0.17 (1) 0.17
Illiterate Working age (58) 0.71 (5) 0.06 (17) 0.21 (22) 0.33 (5) 0.06
Retired (100) 2.84 (15) 0.42 (48) 1.36 (49) 1.39 (24) 0.68
Total (175) 1.06 (21) 0.13 (68) 0.41 (79) 0.48 (32) 0.19
Correction of refractive error with trial lenses based on results of autorefraction.
1 SVI Severe Visual Impairment
2 PL Perception of light
3 NPL No Perception of light
4 Working age 30 to 59yrs
5 Retired ≥ 60 yrs

ii. Magnitude of Functional low vision

The age and sex-standardized prevalence of FLV was (1.7% (CI 1.5 to 1.9%). The
total number of adults with FLV in Pakistan is, therefore, estimated to be 727,000
(586,000 to 891,000). Estimates at provincial level are shown in Table D2. The

27
number of adults with FLV will more than double by the year 2020, to 1,480,000,
assuming the age specific prevalence remains unchanged.

An ‘all age’ estimate was calculated using the figure from a similar paper by
Dandona* et al conducted in India quoting a crude prevalence of 0.3% in 0-15 years
and 0.4% in 15-30 year olds. The ‘all age’ prevalence in Pakistan is estimated to be
0.8%. 1,000,000 people are affected with FLV in Pakistan equating to 7,200 per
1,000,000 population.

Subjects in whom rehabilitation assessment is required (Table D3)

32 subjects (15 women) were identified as totally blind. 84.4% were living in rural
areas, 20 (62.5%) were over 70 years of age, and 90.6% were uneducated. The age
and sex adjusted prevalence of total blindness in adults in Pakistan is 0.2% (CI 0.1 to
0.2%). There are estimated to be 424,000 adults requiring rehabilitation assessments
in Pakistan.

Table D2. Estimated Magnitude of Functional Low Vision in adults in Pakistan

using standardised prevalence

Province Estimate of number with functional low vision (95% confidence Limit)

Punjab 483,000 (413,000 to 559,000)

Sindh 132,000 (96,000 to 171,000)
NWFP 73,000 (52,000 to 98,000)
Balochistan 39,000 (25,000 to 63,000)
Total 727,000 (586,000 to 891,000)
Age and sex-standardized prevalence calculated from Pakistan Demographic Survey data.

Subjects in whom environmental modification assessment is required (Table

D3)
FLV subjects unable to read any letter on the LogMar acuity chart at 1m and unable to
count fingers are unlikely to benefit from optical devices but may benefit from non
optical and the other aspects of low vision care. It was estimated that 735,000 adults
in Pakistan would need an assessment for these interventions.

Subjects in whom optical aids assessment is required (Table D3)

FLV subjects that have the ability to resolve letters or count fingers have the potential
to benefit from optical devices as well as other aspects of low vision care. It is
estimated that 565,000 adults would need an optical assessment as part of their low
vision service.

* Dandona R, Dandona L, Srinivas M, Giridhar P, Nutheti R, Rao GN. Ophthalmology. Planning low
vision services in India: a population-based perspective.2002 Oct;109(10):1871-8

28
 Table D3. Low vision assessment requirements.

Visual Acuity (n) Age and sex Optical devices Non optical/ Rehabilitation
standardized (score) environmental
prevalence (%) (adults in Pakistan) modification

<6/18-6/60 0.9 Yes Yes No

(381,000) (381,000)
<6/60 - <3/60 0.1 Yes Yes Yes
SVI1 (43,000) (43,000) (43,000)

<3/60 can see at least one letter 0.3 Yes Yes Yes
or can count fingers (141,000) (141,000) (141,000)

Cannot see any letters on chart 0.4 No Yes Yes

or count fingers but >PL2 (170,000) (170,000)

NPL3 in both eyes 0.2 No No Yes

(70,000)
Total 565,000 735,000 424,000
1
SVI Severe Visual Impairment
2
PL Perception of light
3
NPL No Perception of light

iii. Causes of functional low vision

Distribution of causes of FLV is shown in Table D4. Just over a third (34.4%) of FLV
was due to corneal opacities. Retinal causes and ambylopia were more likely to
produce less severe visual loss whereas glaucoma, optic atrophy and corneal causes
were more likely to produce more severe impairment (Figure D1).

The main cause of FLV in NWFP and Balochistan was retinal (47.8% and 33.3%
respectively), whereas in Punjab and Sindh the main cause was corneal (38.8% and
33.3% respectively). Optic atrophy was more common in NWFP (13%) than in other
provinces, and Sindh had the highest percentage of amblyopia (8.7%). Striking
differences were found in subjects living in rural areas compared to those from urban
areas: retinal disease was the most common cause in urban populations (39.8% vs
26.5%) whereas corneal opacity was the most common in rural areas (38.0% vs
25.5%). In these rural areas, Balochistan had the lowest proportion of FLV (13.6%)
due to corneal pathology and Punjab had the highest (43.6%).

Optic atrophy was the leading cause of FLV in 30-39 year olds (28%) steadily
decreasing thereafter. Corneal, retinal and glaucomatous diseases increased with
increasing age. Glaucoma was slightly more common in rural dwellers (13.1% vs.
9.1%). No cases due to glaucoma were seen in 30-39 year old subjects. In the totally
blind group, corneal opacities and phthisis bulbi (31.3%), and glaucoma (28.1%) were
the commonest causes.

29
Table D4. Causes of functional low vision in Pakistan

Cause N % Crude Prevalence % (95% CI 1)

Corneal 118 34.4 0.7 (0.6 to 0.9)
Retinal 104 30.3 0.6 (0.5 to 0.8)
Glaucoma 42 12.2 0.3 (0.2 to 0.3)
Amblyopia 15 4.4 0.1 (0.1 to 0.2)
Optic atrophy 3 15 4.4 0.1 (0.1 to 0.2)
Phthsical 6 1.8 0.04 (0.01 to 0.08)
Other causes2 9 2.6 0.05 (0.02 to 0.1)
Unable to determine cause 4 33 9.6 0.2 (0.1 to 0.3)
Total 343 100% 2.1% (1.9, 2.3%).
1 Confidence Interval
2 e.g. uveitis, congenital eye anomalies
3 Other than glaucoma
4 Specific cause was not determined but subjects were assumed to have untreatable disease.

Figure D1. Cause of functional low vision and total blindness by visual
category
Form vision = individuals that were able to discriminate (at a minimum) either one letter at 1m
or were able to count fingers.
No form vision = individuals that could only identify hand movement or light perception or
were totally blind.

45

40
Retinal
35
Corneal
30
Glaucoma
25 Amblyopia
%

20 Optic atrophy
Other
15
Phthisical
10
Unable
5

0
Form vision (n=264, 100%) No form vision (n=111, 100%)

Unable category includes subjects in whom a specific cause was not determined but
untreatable disease was inferred.

30
 Risk Factors for FLV
Age was the most important risk factor for FLV. There was no significant gender
difference. Poor education and high deprivation were also significantly associated
with FLV, Table D5. Geographical differences were also significant, with
Balochistan and Punjab having higher risk of FLV than NWFP.

Table D5. Association analysis of subjects with functional low vision

N= Univariate analysis Age adjusted OR Adjusted OR 2

OR (95% CI) (95% CI) (95% CI); p value
30-49 25/ 5,955 1 1 1
40-49 41/ 3,589 2.7 (1.7, 4.5) † 2.7 (1.7,4.5 ) † 2.6 (1.6, 4.3) <0.001
Age 50-59 79/ 2,870 4.63 (2.9, 7.5) † 4.6 (2.9, .5 ) † 4.3 (2.6, 6.9) <0.001
60-69 79/2,345 8.4 (5.3, 13.2) † 8.4 (5.3, 13.2) † 7.1 (4.5, 11.2) <0.001
70+ 143/1,748 20.9 (13.7 32.2) † 21.0(13.7, 32.3) † 17.0 (11.0, 26.3) <0.001
Female 167/ 8,766 1 1
Gender
Male 176/ 7,741 1.2 (0.9, 1.5) 1.0(0.8, 1.2)
NWFP 46/ 3,094 1 1 1
Balochistan 27/ 945 1.9(1.2, 3.2) † 2.2 (1.3, 3.5) † 2.1 (1.3, 3.4) 0.003
Province
Punjab 201/ 8,804 1.5(1.1, 2.1) † 1.5 (1.1, 2.1) † 1.6 (1.1, 2.1) 0.007
Sindh 69/ 3,664 1.3(0.9, 1.9) 1.3 (0.9, 1.9) 1.4 (0.9, 2.0) 0.1
Urban 99/ 5,423 1 1
Location
Rural 244/ 11,084 1.2(1.0, 1.6 ) † 1.1 (0.8, 1.4)
Never 314/ 11,586 1 1 1
Education Primary 5/ 1,429 0.1(0.1, 0.3) † 0.2(0.1, 0.4) † 0.2 (0.1, 0.4) <0.001
Higher 1 24/3,488 0.2 (0.2, 0.4) † 0.5 (0.3, 0.7) † 0.5 (0.3, 0.7) <0.001
Low 65/ 3,953 1 1
DI 3 Moderate 174/ 8,104 1.3 (1.0, 1.74) † 1.1 (0.8, 1.4)
High 104/4,107 1.5 (1.1, 2.1) † 1.4 (1.1, 1.9) †
1 Higher includes all subjects that attended school beyond primary school level.
2 Multivariable logistics regression model including age, province and school
attendance.
3 Deprivation Index; low <25%, Moderate 25-75%, High >75% [11]
† Statistically significant at p<0.05

31
E. Refractive Error
2017 subjects were removed from the analysis as there was no refractive data. No
gender differences (p=0.180) were detected amongst the subjects that were excluded
however they were more likely to be older (mean age 60.5 years vs. 45.5 years,
p<0.001), more likely to be illiterate (86.1% vs. 68.4%, p<0.001) and more likely to
be rural dwellers (74.3% vs. 66.2%, p<0.001).

The mean and median SE was -0.4D (2.6), and -0.25D (IQR -1 to +0.625),
respectively. The distribution of the SE of right eyes is shown on Figure E1,
displaying a fairly normal distribution pattern. SE in men was -0.50 (2.7) and mean
SE in women was -0.3 (2.6), (p<0.001).

Figure E1. Refractive error of the right eye, (n=14,490).

1600

1400

1200

1000
Subjects

Female
800
Male

600

400

200

0
<-5 <-1 to ≥ -5 <-0.5 to ≥ -1 <0 to -≥0.5 >0 to ≤0.5 >0.5 to ≤1 >1 to ≤5 >5
Mean Spherical Equivalence

i. Prevalence of Refractive Error

There were 5282 (36.5%) subjects identified as emmetropic. No gender differences

were observed in emmetropia (p=0.431). The crude prevalence of myopia (<-0.5D)
was found to be 36.5% (n=5284, 95%CI: 35.7, 37.3), the prevalence of hypermetropia
(>+0.5D) was 27.1% (n= 3924, 95%CI: 26.4, 27.8). Thus the overall prevalence of
any refractive error (i.e SE<-0.5D or >0.5D) is 63.5%. (62.8, 64.3%)
The prevalence of myopia by age followed a J pattern, Figure E2. The prevalence of
hypermetropia increased with age peaking in the 50’s decade and then decreasing.
Prevalence of high myopia increased almost exponentially with age whereas the
increase in high hypermetropia was more linear. Overall crude prevalence of high
myopia was 4.6% (95%CI: 4.3, 4.9) and of high hypermetropia was 1.7% (95%CI:
1.5, 1.9). There was a negative correlation of SE with age (r = -0.08).
A total of 996 subjects were identified with visually disabling (>6/12) cataract in their
right eye. The effect of index myopia was evident in that the prevalence of myopia is
this ‘cataract group’ was 74.6% and prevalence of high myopia was 36.1%. By
excluding these subjects the prevalence of high myopia decreased by half to 2.3%
(95%CI: 2.0, 2.5), the mean SE was -0.2D and correlation of SE with age now
demonstrated a positive relationship (r= +0.04, p<0.001).

32
Figure E2. Prevalence of refractive error in Pakistani adults.

70

60

50

40 Myopic
Emmetropic
%

30 Hyperopic

20

10

0
30-49 40-49 50-59 60-69 70+
Age groups (yrs)

Crude prevalence by demography is shown on Table E1. Myopia was present in

38.5% of the men compared to 34.7% of the women, (p<0.001) and was also more
prevalent in urban areas (36.0% vs. 32.6%, p<0.001) and in the literate (39.1% vs.
35.3%, p<0.001)
Geographical differences were apparent with Balochistan (28.1%) having the lowest
myopia (<-0.5D) rate, followed by NWFP (32.3%), Sindh (37.3%) and Punjab
(38.4%). The mother tongue spoken by the subjects also reflected these provincial
differences; Balochi speakers having the lowest prevalence (28.6%) followed by
Pashto (31.0%), Sindhi (37.5%), Punjabi (38.1%) and Urdu speakers (41.5%).
The prevalence of hypermetropia was higher in women (28.6%) compared to men
(25.4%, p<0.001). Illiterate subjects also had a higher prevalence (28.9% vs. 23.2%,
p<0.001) however no difference was found between rural and urban dwellers.
Province of Sindh had the lowest hypermetropia prevalence (20.5%) followed by
NWFP (26.1%), Punjab (29.5%) and Balochistan (33.7%).

33
 Table E1. Crude prevalence of Refractive Error in Adults in Pakistan (right eye n=14490).

High myopia Low Myopia Emmetropia Low Hypermetropia High Hypermetropia

N (†) Male (%) Female(%) Male(%) Female (%) Male (%) Female(%) Male (%) Female Male (%) Female (%)
(%)
Age group 30-39 5724 (58.2) 0.8 1.2 46.2 39.0 39.3 44.5 13.0 14.6 0.7 0.7
40-49 3370 (55.0) 2.2 2.8 24.2 20.6 49.3 41.9 22.8 33.4 1.5 1.4
50-59 2540 (49.6) 4.8 5.5 20.6 21.4 34.3 27.6 37.8 43.3 2.4 2.1
60-69 1814 (46.6) 10.4 10.9 29.9 27.2 23.2 20.5 23.0 38.2 3.1 3.2
70+ 1042 (41.8) 21.5 15.1 38.4 41.3 14.7 14.0 21.5 25.5 4.0 4.1
Dwelling Rural 9586 (52.1) 5.8 4.0 32.5 28.4 36.4 38.8 23.5 27.3 1.7 1.4
Urban 4904 (55.6) 3.6 4.4 35.2 34.4 35.6 32.9 23.6 26.9 2.0 1.8
Province NWFP 2590 (52.2) 5.1 3.3 30.5 26.1 41.6 41.6 21.9 28.1 0.9 1.0
Balochistan 829 (51.1) 4.9 3.1 23.5 24.8 38.8 37.7 30.9 33.7 2.0 0.7
Punjab 7769 (53.6) 5.3 4.7 35.9 31.3 31.0 33.1 25.4 28.7 2.4 2.2
Sindh 3302 (54.0) 4.6 3.8 32.5 33.6 43.1 41.4 18.6 20.5 1.1 0.7
Literate No 9906 (65.3) 7.4 4.6 31.7 28.6 33.7 37.0 27.5 28.1 2.5 1.7
Yes 4584 (27.3) 2.7 2.0 35.1 40.4 38.6 32.2 22.3 21.3 1.2 1.1
Mother Balochi 388 (60.8) 2.6 2.1 25.0 27.1 35.5 35.6 34.9 34.3 2.0 0.8
Tongue* Pashto 1712 (49.4) 4.8 3.4 29.8 23.9 40.7 43.9 23.0 28.2 1.7 0.6
Punjabi 7460 (53.8) 5.2 4.6 35.3 31.5 32.0 33.0 25.1 28.7 2.3 2.2
Sindhi 2141 (52.4) 5.9 3.7 32.8 32.8 43.5 43.4 16.8 19.5 1.1 0.6
Urdu 690 (55.2) 3.9 5.0 36.2 37.5 38.5 33.6 20.1 22.6 1.3 1.3
Total 14490 (53.3) 665 (4.6) 4619 (31.9) 5282 (36.5) 3679 (25.4) 245 (1.7)

* Other mother tongues not included in analysis = 2099 subjects

† Percent women in each stratum

34
Astigmatism
The overall crude prevalence of astigmatism was found to be 37% (95%CI: 36.2,
37.8%). 44% of this astigmatism was found to be oblique, against the rule accounting
for 42% and with the rule only 14%. Significant differences in astigmatism were
identified between the genders. Men had a significantly higher prevalence than
women (n= 2616, 38.7% vs. n=2742, 35.5%, p<0.001). Prevalence of types of
astigmatism stratified by demography is shown on Table E2.

Table E2. The prevalence of astigmatism in Pakistani adults.

Overall
With the rule Against the rule Oblique prevalence N=
Dwelling Rural 5.51 8.59 7.53 37.51 9586
Urban 4.42 14.88 17.13 35.93 4904
Province NWFP 5.17 16.78 14.72 35.52 2590
Balochistan 4.34 10.74 15.08 30.16 829
Punjab 5.34 15.74 17.87 38.95 7769
Sindh 4.85 15.81 14.54 35.19 3302
Literate No 5.70 16.43 18.55 40.69 9906
Yes 3.93 13.55 11.48 28.95 4583
Ethnic Origin* Balochi 4.12 11.60 12.63 28.35 388
Pashto 5.32 13.90 14.49 33.70 1712
*756 missing Punjabi 5.23 15.68 17.39 38.30 7460
Sindhi 5.42 15.32 16.58 37.32 2141
Urdu 4.49 19.86 13.19 37.54 690
TOTAL 5.14 15.52 16.31 36.98 14490
* Astigmatism defined as >0.75D cylinder.

No significant differences were found between rural and urban dwellers (37.5 vs.
35.9%, p=0.06). Illiterate subjects had a significantly higher prevalence than literate
subjects (40.7 vs. 29.0%, p<0.001).
The prevalence of astigmatism increased with age predominantly due to increases in
oblique and against the rule astigmatism.

ii. Magnitude
Using the age/sex standardized prevalence’s of myopia (34.9%, 95%CI: 34.1 to 35.6)
it was estimated that there were 14,925,000 adults with SE of <-0.5D. Of these at least
1,840,000 were high myopes (<-5D). Provincial estimates are provided on Table E3.
The standardised prevalence of hypermetropia was 27.2% (95%CI: 26.5 to 28.0) the
number of adults estimated to be 11,425,000 and of these at least 700,000 were high
hypermetropes (>5D).
Using population predictions we estimate that there will be 30,440,000 adults with
myopic RE and a further 23,050,000 adults with hyperopic RE in Pakistan.

35
Table E3. Provincial estimates for refractive errors in Pakistani adults.

(not accounting for RE changes due to cataract extraction)

Myopia (<-0.5D) Hypermetropia (>0.5D) Burden of

refractive error
Punjab 9,310,000 7,370,000 16,680,000
Sindh 3,415,000 2,045,000 5,460,000
NWFP 1,670,000 1,380,000 3,050,000
Balochistan 530,000 630,000 1,160,000
National 14,925,000 11,425,000 26,350,000
Age and sex-standardized prevalence calculated from Pakistan Demographic Survey data.

iii. Spectacle coverage

A total of 2691 (16.3%) subjects improved their vision by ≥ 1 WHO vision category
from their presenting visual acuity to when best corrected with a trial lens of their
autorefraction result.

1646 subjects improved from less than 6/12 to better than 6/12 with optimal
correction. 17.8% of the women were able to improve compared to 14.6% of the men,
(p<0.001).

Using the age/sex standardised prevalence (14.6%) we estimate 5,980,000 adults

could improve their visual acuity status by 1 WHO category with appropriate
spectacle correction. No significant rural urban split was identified in subjects that
could improve (p=0.165) however illiterate subjects were significantly more likely to
be able to improve (19.1% vs. 9.5%, p<0.001).

Spectacle use
1148 (7.0%) of the sample wearing glasses at examination station. 14,932 (90.6%)
had no glasses. 404 (2.5%) forgot / given but does not wear glasses.

In subjects that improved by ≥ 1 WHO vision category 290 (10.8%) had been tested
with their own glasses. 150 subjects were already wearing their own glasses but
improved from <6/12 to ≥6/12 with best correction.
Nearly half of the subjects that were wearing spectacles (n=547 (47.6%)) had had
pervious cataract surgery in one/both eyes. Visual acuity was more likely to be worse
in spectacle wearers. They were also older, literate and living in urban areas. (Table
E4)

Met and unmet need

A need for spectacles was identified in 1789 subjects. Age/sex standardised
prevalence of need is 10.3% (95%CI: 9.9% to 10.9%). 293 subjects had met need and
1496 subjects had unmet need. The overall spectacle coverage was found to be
16.4%. The demographic distribution of spectacle coverage is shown on Table E5.

36
 Table E4. Demographic variation of spectacle and non spectacle wearers

Spectacle Wearers Non Spectacle Wearers

Female Male Total Female Male Total
Age † 30-39 98 (17.0) 76 (13.3) 174 (15.2) 3,357 (41.1) 2,420 (33.78) 5777 (37.7)
40-49 91 (15.7) 54 (9.5) 145 (12.6) 1,875 (23.0) 1,561 (21.79) 3426 (22.4)
50-59 116 (20.1) 105 (18.4) 221 (19.3) 1,332 (16.3) 1,314 (18.34) 2646 (17.3)
60-69 109 (18.9) 140 (24.6) 249 (21.7) 1,007 (12.3) 1,081 (15.09) 2088 (13.6)
70+ 164 (28.4) 195 (34.2) 359 (31.3) 600 (7.3) 789 (11.01) 1389 (9.1)
Province NWFP 97 (16.8) 119 (20.9) 216 (18.8) 1,498 (18.3) 1,358 (18.95) 2,856 (18.6)
Balochistan 15 (2.6) 34 (6.0) 49 (4.3) 461 (5.6) 435 (6.07) 896 (5.8)
Punjab 371 (64.2) 318 (55.8) 689 (60.0) 4,348 (53.2) 3,766 (52.56) 8,114 (52.9)
Sindh 95 (16.4) 99 (17.4) 194 (16.9) 1,864 (22.8) 1,606 (22.41) 3,470 (22.6)
Dwelling Urban 305 (52.8) 244 (42.8) 549 (47.8) 2,712 (33.2) 2,160 (30.15) 4,872 (31.8)
Rural 273 (47.2) 326 (57.2) 599 (52.2) 5,459 (66.8) 5,005 (69.85) 10,464 (68.2)
Literacy Illiterate 439 (75.9) 316 (55.4) 755 (65.8) 7019 (85.9) 3,848 (53.71) 10,867 (70.9)
Literate 139 (24.1) 254 (44.6) 393 (34.2) 1,151 (14.1) 3,317 (46.29) 4,468 (29.1)
VA Normal 262 (45.3) 278 (48.8) 548 (47.7) 6,000 (73.4) 5,533 (77.22) 11,534 (75.2)
Near normal 85 (14.7) 93 (16.3) 173 (15.1) 799 (9.8) 511 (7.13) 1,310 (8.5)
MVI 183 (31.7) 150 (26.3) 330 (28.7) 1,001 (12.2) 784 10.94) 1,785 (11.6)
SVI 19 (3.3) 18 (3.2) 37 (3.2) 97 (1.2) 109 (1.52) 206 (1.3)
Blind 29 (5.0) 31 (5.4) 60 (5.2) 273 (3.3) 228 (3.18) 501 (3.3)
Total 578 (100) 570 (100) 1148 (100) 8171 (100) 7165 (100) 15,336 (100)
* In 23 subjects spectacle use not recorded and excluded from analysis.

37
Table E5. Spectacle coverage and the association analysis for ‘met’ need
stratified by socio – demographic variables in Pakistan.

N= unmet % met % Coverage Odds Ratio 95%CI

Age † 30-39 5955 195 3.3 79 1.3 0.29 1
40-49 3589 303 8.4 57 1.6 0.16 0.5 0.3, 0.7
(p<0.001)
50-59 2870 398 13.9 60 2.1 0.13 0.3 0.2, 0.5
(p<0.001)
60-69 2345 395 16.8 50 2.1 0.11 0.3 0.2, 0.4
(p<0.001)
70+ 1748 205 11.7 47 2.7 0.19 0.5 0.3, 0.7
(p<0.001)
Sex Women 8766 926 10.6 150 1.7 0.14 1
Men 7741 570 7.4 143 1.8 0.20 1.50 1.2, 1.9
p=0.002
Province NWFP 3094 276 8.9 62 2.0 0.18 1
Balochistan 945 75 7.9 14 1.5 0.16 0.9 0.5, 1.8
Punjab 8804 757 8.6 168 1.9 0.18 1.0 0.7, 1.4
Sindh 3664 388 10.6 49 1.3 0.11 0.6 0.4, 0.9
(p=0.014)
Dwelling Urban 5423 543 10.0 168 3.1 0.24 1
Rural 11084 953 8.6 125 1.1 0.12 0.39 0.3, 0.5
(p<0.001)
Literacy Illiterate 11642 1173 10.1 135 1.2 0.10 1
Literate 4864 323 6.6 158 3.2 0.33 4.5 3.4, 5.9
p<0.001
Total 16507 1496 293 16.4

The magnitude of unmet need in the different provinces is shown on Table E6. The
unmet need was significantly higher in women (10.5%) than in men (6.6%, p<0.001).

Table E6. Estimated magnitude of the unmet need for spectacle correction in
Pakistan.

Province Estimate with 95% confidence limits

Punjab 2,040,000 (1,900,000 to 2,190,000)

Sindh 965,000 (874,000 to 1,060,000)
NWFP 456,000 (405,000 to 511,000)
Balochistan 145,000 (114,000 to 180,000)
Total 3,606,000 (3,293,000 to 3,941,000)

38
F. Lens Opacity and Cataract

i. Prevalence of lens opacity (Figure F1)

A total of 4,096 (25.0%, 95%CI 24.3, 25.6%) participants were identified who
fulfilled the definition of lens opacity (LO). The prevalence of LO was highest in
Punjab (26.2%) and lowest prevalence in Balochistan (22.0%).

At a district level, the prevalence of LO ranged from 9.2% in Swat District, NWFP to
46.3% in Khushab District, Punjab. Figure F1 shows a map of the prevalence of LO
in each district. The figure shows a clustering of districts with a high proportion of LO
in the Indus valley with the northern mountainous areas and Balochistan plateau areas
showing lower proportions. The prevalence of LO was found to be higher in rural
areas compared with urban areas (26.4% vs. 22.2%, p<0.001). A statistically
significant higher mean deprivation index was found in subjects with LO compared to
those without (58.6 vs. 57.1, p<0.001).

Figure F1. The prevalence of lens opacity in the 94 districts sampled in

Pakistan

ii. Risk factors for lens opacities:

Variables found to be significantly associated with LO were increasing age,
hypertension, history of diabetes, smoking, reduced BMI, rural area of dwelling,
provinces of Sindh and Punjab, lack of education, manual households, increased
deprivation index, higher district temperatures and lower district annual rainfall
(Table F1). In the univariable analysis males were more likely to have LO, but after
adjusting for the confounding effect of age, females had a higher odds of LO (OR 1.3
(95%CI: 1.2, 1.4). This significant association was not evident when variation
(particularly in literacy and BMI) was accounted for in the multivariate model.

39
 Table F1. Univariate, age and sex adjusted, and multivariate analysis of risk
factors for lens opacity

Univariate Adjusted for age Multivariate

Variable analysis and sex analysis Odds p value 1
Odds ratio and Odds ratio and ratio and 95%
95% confidence 95% confidence confidence
interval interval interval5

Individual exposures:
Age 30-39 years 1 1 1 1 1 1
10 year increase in age 3.5 3.3, 3.6 3.5 3.3, 3.6 3.2 3.1, 3,4 <0.001
Gender Male 1 1 1 1 1 1
Female 0.9 0.8, 0.9 1.3 1.2, 1.4 1.0 0.9, 1.1 0.330
Hypertension No 1 1 1 1 1 1
Yes 1.3 1.2, 1.4 1.1 1, 1.3 1.2 1.1, 1.3 <0.001
History of diabetes No 1 1 1 1 1 1
Yes 2.8 2.3, 3.3 2.0 1.6, 2.5 2.6 2, 3.2 <0.001
Smoking No 1 1 1
Yes 1.2 1.1, 1.3 1.3 1.1, 5 1.3 1.1, 1.5 <0.001
Body mass index Lean 1.6 1.4, 1.7 1.4 1.3, 1.6 1.4 1.3, 1.6 <0.001
Normal 1 1 1 1 1 1
Heavy 0.7 0.6, 0.8 0.8 0.7, 0.9 0.8 0.7, 0.9 0.007
Obese 0.6 0.5, 0.7 0.7 0.6, 0.9 0.7 0.6, 0.8 <0.001
Education None 1 1 1 1 1 1
Primary level 0.4 0.4, 0.5 0.6 0.5, 0.7 0.6 0.5, 0.8 <0.001
Higher 0.2 0.2, 0.3 0.5 0.4, 0.5 0.5 0.4, 0.5 <0.001
Location exposures:
Household income NonManual 1 1 1 1 1 1
Manual 1.5 1.3, 1.6 1.3 1.1, 1.4 1 0.9, 1.2 0.332
Other 2.0 1.8, 2.2 1.3 1.1, 1.5 1.2 1.0, 1.4 0.010
Dwelling Location Rural 1 1 1 1 1 1
Urban 0.8 0.7, 0.8 0.9 0.8, 1.0 1.0 0.9, 1.1 0.538
Province NWFP 1 1 1 1 1 1
Balochistan 1.0 0.8, 1.1 1.1 0.9, 1.4 1.0 0.8, 1.3 0.380
Punjab 1.2 1.1, 1.3 1.3 1.2, 1.5 1.3 1.2, 1.5 <0.001
Sindh 1.1 1.0, 1.2 1.3 1.1, 1.5 1.3 1.1, 1.5 0.003
Ecological exposures:
Deprivation Index Low (<40) 1 1 1 1 1 1
Medium(40-64) 1.5 1.3, 1.7 1.2 1.1, 1.4 1.1 0.9, 1.3 0.247
High(≥65) 1.3 1.1, 1.4 1 0.9, 1.2 0.8 0.7, 1.1 0.110
Maximal temperature <30 0 C 1 1 1 1 1 1
300 C 1.1 1, 1.3 1.1 0.9, 1.2 1.0 0.8, 1.1 0.603
>300 C 1.4 1.2, 1.5 1.4 1.2, 1.5 1.3 1.1, 1.5 <0.001
Average annual rainfall <200mm 1 1 1 1 1 1
200 – 600mm 0.8 0.7, 0.8 0.8 0.7, 0.9 0.8 0.7, 0.9 <0.001
>600mm 0.7 0.6, 0.8 0.7 0.6, 0.8 0.7 0.6, 0.8 <0.001
BMI - Body Mass Index; Lean <20 for males,<19 for females; normal 20-25 for males, 19-24 for females;
overweight 25-30 for males, 24-29 for females; obese> 30 in males, >29 in females. Likelihood ratio test
p=0.02
Multivariate model adjusted for age, gender, hypertensive and diabetes status, BMI, dwelling location,
education, household status and deprivation index. Separate multivariable models built when analysing
province, maximal temperatures and rainfall, with each of these models adjusted for age, gender,
hypertensive and diabetes status, BMI, dwelling location, education, household status and deprivation index.
1 From multivariate model.

40
iii. Cataract prevalence
289 (51.5%) subjects were blind with cataract as the principle cause (crude prevalence
1.8%, 95% CI: 1.6 to 2.0%, Table F2). The prevalence of cataract blindness was
higher in Punjab province, in rural areas and among illiterate subjects. Prevalence of
cataract blind was higher in women than men (1.8% vs. 1.7%, p<0.001). The
prevalence of cataract causing <6/60 in eyes was 5.0% (95%CI: 4.7 to 5.2%).

Table F2. Crude prevalence (%) of cataract as the principal cause of visual
impairment.

Presenting visual acuity

<6/18 <6/60 <3/60

Province Punjab (8804) 748 (8.5) 250 (2.8) 177 (2.0)

p<0.001* Sindh (3664) 343 (9.4) 113 (3.1) 50 (1.4)
NWFP (3094) 195 (6.3) 70 (2.2) 46 (1.5)
Balochistan 52 (5.5) 22 (2.3) 16 (1.7)
(945)
Dwelling Rural (11084) 589 (5.3) 337 (3.0) 214 (1.9)
p=0.004* Urban (5423) 968 (8.7) 118 (2.2) 75 (1.4)
Literacy Illiterate 1,225 (10.5) 425 (3.7) 273 (2.3)
(11642)
p<0.001* Literate (4864) 113 (2.3) 30 (0.6) 16 (0.3)
Total (16507) 1,338 (8.1) 455 (2.8) 289 (1.8)
* Chi squared test (<3/60)
iv. Bilateral cataract blindness
Of the 289 blind subjects where cataract was the principle cause, 179 (61.9%) were
bilaterally cataract blind (crude prevalence 1.1%, 95%CI: 1.0 to 1.3%), ranging from
0.8% in Balochistan and Sindh to 1.0% in NWFP and 1.3% in Punjab. The proportion
of ‘cataract blind’ adults due to bilateral cataract was highest in NWFP (38%) and
lowest in Balochistan (22%).

v. Magnitude of cataract
There are estimated to be 570,000 adults (225,000 male, 345,000 female) who are
blind from cataract in Pakistan, projected to increase to 1,210,000 by the year 2020.
There are an estimated 3,560,000 eyes with a visual acuity of <6/60 due to cataract in
Pakistan. This number is projected to increase to 7,380,000 by the year 2020.

41
G. Outcomes of eye care provision

i. Prevalence of cataract surgery and surgical output:

1,317 adults (633 males; 684 females) had undergone cataract surgery in one eye (845
subjects, 64.2%) or both eyes (472 subjects, 35.8%). Among individuals who had had
cataract surgery, 48% of men and 39% of women were above the age of 70 years and
90% were aged ≥50 years. The crude prevalence of aphakia/pseudophakia (in one or
both eyes) was 8.0% (95%CI: 7.6, 8.4%, Table G1). The prevalence varied from
6.1% in NWFP to 8.6% in Sindh. Overall men had a slightly higher prevalence than
women (8.2% vs. 7.8%, p=0.425).
From these data, approximately 2.7 million people have undergone cataract surgery
(1,700,000 in Punjab; 600,000 in Sindh; 270,000 in NWFP and 130,000 in
Balochistan).

Table G1. Crude prevalence of aphakia/pseudophakia (unilateral or bilateral)

Prevalence (%) Prevalence (%)

Male Female <50yrs ≥50yrs Total

Province Punjab 8.1 8.5 1.7 17.2 8.3

Sindh 9.6 7.8 1.0 20.2 8.6
NWFP 6.4 5.8 0.9 12.9 6.1
Balochistan 8.7 7.8 1.8 17.5 8.3
Dwelling Rural 8.5 7.7 1.4 17.6 7.7
Urban 7.3 8.0 1.3 17.9 8.1
Literacy Illiterate 4.5 1.7 0.9 11.3 3.7
Literate 11.3 8.9 1.7 18.3 9.4
Total 8.2 7.8 1.4 17.0 8.0

ii. Cataract Surgical Coverage

The CSC (person) at visual acuity cut-offs of <3/60, <6/60 and <6/18 were 77.1%,
69.3% and 43.7%, respectively (Table G2). Coverage at the <3/60 level varied
between the provinces. Coverage was higher in urban than rural areas (p=0.087); in
males than in females (p=0.009) and in literate subjects compared with illiterate
subjects (p<0.001). CSC for eyes at <3/60, <6/60 and <6/18 cut-offs were 61.4%,
52.2% and 40.7% respectively (Table G3). As with coverage for people, coverage for
eyes was significantly higher in men, in literate subjects and urban dwellers.

42
 Table G2. Cataract surgical coverage in persons (%)

Presenting VA<6/18 Presenting VA<6/60 Presenting VA<3/60

Male Female Total Male Female Total Male female Total

Province Punjab 43.1 42.4 42.7 69.3 69.7 69.4 76.9 74.8 75.7
Sindh 45.5 45.6 45.3 68.2 69.8 69.0 84.8 78.7 81.7
NWFP 43.4 40.7 42.0 71.8 64.5 68.1 79.8 70.6 75.0
Balochistan 53.6 44.2 49.2 77.2 59.5 68.6 78.9 71.8 75.7
Age <50 47.2 35.4 39.5 72.0 65.3 67.7 73.1 71.8 72.4
≥50 44.4 43.9 44. 2 70.0 68.9 69.3 80.0 75.3 77.6
Dwelling Rural 43.6 41.8 42.7 68.9 67.4 68.1 77.9 74.0 75.9
Urban 47.3 45.3 46.2 73.2 71.0 72.0 83.9 76.9 80.0
Literacy Literate 51.2 40.0 50.0 81.8 70.5 80.5 89.7 71.4 87.9
Illiterate 43.0 43.0 43.0 67.3 68.5 68.0 77.2 75.1 76.0
Total 44.6 42.8 43.7 70.1 68.4 69.3 79.6 74.9 77.1

Table G3. Cataract surgical coverage in eyes (%)

Presenting VA<6/18 Presenting VA<6/60 Presenting VA<3/60

Male Female Total Male Female Total Male Female Total

Province Punjab 39.2 39.9 39.6 52.3 52.1 52.2 60.9 59.7 60.2
Sindh 42.1 41.1 41.6 52.9 54.5 53.7 67.8 64.0 65.9
NWFP 44.1 38.4 41.1 53.6 46.2 49.7 62.4 54.8 58.5
Balochistan 50.4 44.8 47.7 56.9 51.1 54.1 65.9 61.0 63.6
Age <50 43.9 32.9 36.8 56.7 43.8 48.5 58.6 52.0 54.6
≥50 41.0 41.2 41.1 52.6 52.7 52.7 63.5 61.0 62.2
Dwelling Rural 39.6 38.6 39.1 51.4 49.6 50.5 61.3 58.2 59.8
Urban 45.7 43.4 44.4 56.9 55.8 56.3 67.6 63.3 65.2
Literacy Literate 48.2 47.5 48.1 62.2 59.2 61.8 71.4 65.9 70.7
Illiterate 36.9 40.0 39.7 50.4 51.4 51.0 60.7 59.7 60.2
Total 42.8 38.6 40.7 54.5 50.0 52.2 64.5 58.4 61.4

iii. Cataract surgical rate

386 eyes were operated on in Y1998/1999 and 469 eyes in Y2000/2001. This
represents an annual CSR of 3575 / year /million population in Y1998/1999 and a
CSR of 4390 in years Y2000/2001. The provincial differences in CSR in the 4 years
before the survey are demonstrated in Table G4.

Table G4. Cataract Surgical Rate (per million/year) in Pakistan.

1998/1999 2000/2001
NWFP 2225 3945
Balochistan 3228 4578
Punjab 4243 4615
Sindh 3163 4175

National 3575 4390

Note: It must be remembered that due to recall bias of the date of surgery by the
subjects, the accuracy of the CSR calculation must be interpreted with caution.

43
iv. Cataract surgical outcomes
1317 subjects, 633 men and 684 women, had undergone cataract surgery in one or
both eyes (1788 cataract operated eyes). Intracapsular cataract surgery had been
performed on 1099 (61.5%) eyes, and 607 (33.9%) eyes underwent extracapsular
cataract surgery with an intraocular lens. In 54 eyes (3.0%), the ophthalmologist was
unable to determine whether the technique had been extracapsular without an IOL or
intracapsular. In 14 (0.8%) eyes the cataract had been couched, and in a further 14
(0.8%) eyes, an anterior chamber IOL had been inserted.

The ratio of ECCE+IOL:ICCE in the last 3 years was 1.2:1, quite different to a ratio
of 1:3.3 ≥4 years before the survey.

Of the 1728 cataract surgeries where the operative location was identified, 248
(14.3%) had taken place in eye camps and 1480 (85.6%) in hospitals. The ratios of
eye camp to hospital surgery more than 3 years before the survey, and within 3 years
of the survey were 1:6.2 (number of eyes; 124:772) and 1:5.72 (number of eyes;
121:692), respectively.

In hospitals, the ratio of ICCE: ECCE + IOL was 1.62:1 (number of eyes, 877:541),
while in eye camps, the ratio of ICCE: ECCE + IOL was 3.25:1

Of the 1788 cataract-operated eyes, 275 (15.4%) had a presenting visual acuity of
6/12 or better, and 29.5% were blind. With “best” refractive correction these values
were 563 (31.5%), and 334 (18.7%), respectively. Among eyes operated on using an
ECCE+IOL technique, 50% had a good outcome (6/18 or better), 37% had a
borderline outcome (6/18 to 6/60) and 14% had a poor outcome (worse than 6/60).
Refractive error was the principal cause of less than 6/12 presenting vision in 808
eyes (54.4%) and amongst those eyes, 567 (70.2%) were ICCE operations. Almost
30% of ICCE-operated had never been corrected with a spectacle lens since surgery.
Operative complications were the principal cause for 47% of eyes with less than 6/18
best corrected visual acuity.

The most common cause of visual acuity <6/12 following ‘best correction’ was
posterior capsule/posterior hyaloid face opacification, accounting for 38.5% of eyes.

In conclusion, this nationally-representative study of cataract surgical outcomes has

reported presenting and best-corrected visual outcomes which are considerably poorer
than the WHO recommendation of 85% with a good outcome (6/6 to 6/18), 10% with
a borderline outcome (<6/18 to 6/60) and less than 5% with a poor outcome (<6/60).

44
H. Barriers to cataract surgical service uptake
455 subjects presented with <6/60 vision in the better eye in whom cataract was the
principle cause, and information on barriers was obtained from 356 (78.2 %), 54% of
whom were women. 94.4% were illiterate and 73% lived in rural areas. There were no
statistically significant demographic differences between subjects who were
interviewed about barriers and those who were not. Cost was overwhelmingly the
commonest barrier (76.1%) followed by lack of knowledge of the condition (11.5%),
‘waiting for the cataract to mature’ (9 %), no escort (1.7%) and fear of surgery
(1.4%). In all adults that gave more than one response cost was always the first
barrier. Compared to adults in NWFP, subjects in Balochistan (OR 7.0, 95%CI: 1.50,
33.4, p=0.014) and subjects in Punjab (OR 8.10, 95%CI: 4.10, 16.10, p<0.001) were
significantly more likely to report cost as a barrier. Women were 27% (95%CI: 0.8,
2.1, p=0.34) more likely to report cost as a barrier as were rural dwelling subjects (OR
1.3, 95%CI: 0.74, 2.2, p=0.4) and illiterate subjects (1.1 95%CI: 0.4 to 3.0, p=0.90).

45
 Summary of findings arising from this
survey
i. Key Points

Prevalence of visual impairment

1. Standardised prevalence of blindness (<3/60) for adults aged ≥30 years old is
2.7% (95%CI 2.4 to 2.9%). 7% of ≥50 year olds are blind.
2. All age prevalence appears to have decreased from 1.78% in 1990 to 0.9%
(95%CI 0.8 to 1.0%).
3. Just over a quarter of adults <6/12 vision.
4. The current estimate suggests that there are 1.25 million blind individuals of
all ages (of who 1.14 million are adults) in Pakistan (Y2003 population data)
compared to Memon’s estimate of 2 million in 1990.
5. Prevalence of blindness increased exponentially with age
6. Women had 30% higher odds of being blind than similarly aged men (OR
95%CI 1.1 to 1.5)
7. Rural dwellers and illiterate subjects at significantly higher odds of SVI/BL
8. Provincial differences show that Punjab (3.1%), followed by Balochistan
(2.8%) have the highest adult standardised blindness prevalence’s.
9. 92% projected increase in the number of blind individuals between 2003 and
2020

Causes of visual impairment

1. 85.5% of blindness (<3/60) is avoidable, 93% of adults <6/12 is avoidable
2. 1,400,000 adults in Pakistan that are <6/60 due to avoidable causes
3. Despite an expanded surgical service provision cataract was still found to
cause over half (51.5%) of the blindness in Pakistan.
4. 900,000 adults are still SVI/BL due to ‘operable’ cataract
5. One in ten blind adults were due to sequelae of cataract surgery (uncorrected
aphakia and PCO). PCO accounted for 3.6% of blindness
6. Corneal opacity was the second largest cause of blindness in Sindh and
Punjab, however in NWFP and Balochistan the second most common cause
was macular degeneration and glaucoma respectively
7. Refractive error is the major cause at milder levels visual loss (42.7% of low
vision (6/18-6/60)), particularly in working age-groups. RE as a cause of
severe visual impairment or blindness was three times more likely in rural
areas compared to urban ones (OR 3.5, 95%CI: 1.1, 11.7).
8. The principle single group of unavoidable cause of blindness was phthisis
bulbi/absent eyes.
9. Macular degeneration causing blindness (2.7%). The predicted increase of
Pakistani’s over 50 year old is from current 17,100,000 to 30,600,000 in
Y2020.
10. Glaucoma important cause of blindness (7%), may be under-reported as field
of vision was not included as a criteria in the blindness definition.
11. Diabetes not found to be a major cause of visual impairment in this survey.
However Pakistan is predicted to be in top five countries with highest
prevalence of Diabetes by year 2025. Diabetic retinopathy in this survey may
be under-reported as more treatable conditions take preference (e.g. cataract)

46
 and bilateral vitreous haemorrhage classified under ‘other’ but may have been
due to diabetic retinopathy.
12. One in four adults with unilateral blindness due to corneal opacity/phthisis,
highlighting the possibility of ocular trauma as an underlying aetiology

Functional low vision

1. As VISION 2020 enters its second 5 year phase the provision of low vision
services and their integration into national eyecare programs is a top priority
as this has been a neglected area in the past
2. The standardized prevalence of FLV in adults in Pakistan is 1.7% (CI 1.5 to
1.9%) translating to 727,000 (586,000 to 891,000) adults.
3. The ‘all age’ prevalence in Pakistan is estimated to be 0.8%. 1,000,000 people
are affected with FLV in Pakistan equating to 7,200 per 1,000,000 population.
4. The ratio of Blindness : FLV in Pakistan is, therefore 1.6 : 1. This is in
contrast to the WHO estimates where the Blindness : FLV ratio is currently
estimated to be 0.54 (37 million people who are blind compared with 68
million with FLV.
5. The province of Balochistan had the highest crude prevalence of FLV (2.8%,
CI 1.9 to 4.1%) followed by Punjab (2.2%, CI 2.0 to 2.6%), Sindh (1.9%, CI
1.5 to 2.4%) and NWFP (1.5%, CI 1.1 to 2.0%).
6. The age and sex adjusted prevalence of total blindness (Bilateral No
Perception of Light) in adults in Pakistan is 0.2% (CI 0.1 to 0.2%)
7. Pakistan requires the capacity to provide an assessment for optical assessments
for 565,000 subjects, non optical/environmental modification assessments for
735,000 and rehabilitation assessments for 424,000 adults.
8. Planning also needs to take account of the fact that the overwhelming majority
of people with FLV identified in this survey were illiterate (91.5%) and 41.7%
of the subjects were 70 years or older.
9. The main cause of FLV in NWFP and Balochistan was retinal (47.8% and
33.3% respectively), whereas in Punjab and Sindh the main cause was corneal
(38.8% and 33.3% respectively).
10. Corneal, glaucoma and optic atrophy cases were more likely to have more
severe visual loss compared to retinal causes and ambylopia.
11. Optic atrophy was the leading cause of FLV in 30-39 year olds (28%)
12. Retinal disease was the most common cause in urban populations (39.8% vs
26.5%) whereas corneal opacity was the most common in rural areas (38.0%
vs 25.5%)
13. Lack of training/knowledge (82.3%) and of awareness (74.7%) were the
perceived barriers to the provision of low vision services by ophthalmologists
in India.*

*Khan SA, Shamanna B, Nuthethi R.Perceived barriers to the provision of low vision services among
ophthalmologists in India. Indian J Ophthalmol. 2005 Mar;53(1):69-75.

47
Refractive Error
1. The prevalence of myopia (<-0.5D) was found to be 36.5% (95%CI: 35.7,
37.3%) and hyperopia was (>+0.5D) was 27.1% (95%CI: 26.4, 27.8).
2. Overall crude prevalence of high myopia was 4.6% (95%CI: 4.3, 4.9) and of
high hypermetropia was 1.7% (95%CI: 1.5, 1.9).
3. The effect of cataract induced myopia was clearly evident in this analysis
(with the mean MSE and the correlation coefficient with age changing once
visually disabled cataract eyes were removed from the analysis).
4. The prevalence of myopia by age followed a J pattern,. The prevalence of
hypermetropia increased with age peaking in the 50’s decade and then
decreasing thereafter.
5. Prevalence of high myopia increased almost exponentially with age whereas
the increase in high hypermetropia was more linear.
6. Myopia was present in 38.5% of the men compared to 34.7% of the women,
(p<0.001) and was also more prevalent in urban areas (36.0% vs. 32.6%,
p<0.001) and in the literate (39.1% vs. 35.3%, p<0.001)
7. The prevalence of hypermetropia was higher in women (28.6%) compared to
men (25.4%, p<0.001). Illiterate subjects also had a higher prevalence (28.9%
vs. 23.2%, p<0.001)
8. Geographical differences were apparent with Balochistan (28.1%) having the
lowest myopia (<-0.5D) rate, followed by NWFP (32.3%), Sindh (37.3%) and
Punjab (38.4%).
9. Province of Sindh had the lowest hypermetropia prevalence (20.5%) followed
by NWFP (26.1%), Punjab (29.5%) and Balochistan (33.7%).
10. Men had a significantly higher prevalence of astigmatism than women (n=
2616, 38.7% vs. n=2742, 35.5%, p<0.001). Astigmatism was predominantly
oblique and against the rule
11. An estimated 26,350,000 adults in Pakistan have either myopia (<-0.5D) or
hypermetropia (>0.5D). Of these at least 1,840,000 were high myopes (<-5D).
12. Only 1148 (7.0%) of the sample wearing glasses at examination station.
13. 10% of subjects examined improved from presenting less than 6/12 in better
eye to better than 6/12 in better eye with optimal correction.
14. An estimated 6,000,000 adults could improve their visual acuity status by 1
WHO category with appropriate spectacle correction.
15. Nearly half of the subjects that were wearing spectacles to the examination
station had had pervious cataract surgery in one/both eyes.
16. The overall spectacle coverage (6/12 visual acuity cutoff) was found to be
16.4%
17. A need for spectacles was identified in 1789 subjects. Age/sex standardised
prevalence of need is 10.3% (95%CI: 9.9% to 10.9%).
18. The unmet need was significantly higher in women (10.5%) than in men
(6.6%, p<0.001).
19. The magnitude of unmet need for spectacles was 3,600,000 adults.

Lens opacity (LO) and Cataract

1. A quarter of adults examined showed evidence of LO. (25.0%, 95%CI 24.3,
25.6%)
2. The prevalence of LO was highest in Punjab (26.2%) and lowest prevalence in
Balochistan (22.0%).

48
3. Risk factors for LO included increasing age, hypertension, history of diabetes,
smoking, reduced BMI, rural area of dwelling, provinces of Sindh and Punjab,
lack of education, manual households, increased deprivation index, higher
district temperatures and lower district annual rainfall
4. The crude prevalence of cataract blind was 1.8% (95% CI: 1.6 to 2.0%).
5. There are estimated to be 570,000 adults (225,000 male, 345,000 female) who
are blind from cataract in Pakistan, projected to increase to 1,210,000 by the
year 2020
6. The prevalence of cataract blindness was higher in Punjab province, in rural
areas and among illiterate subjects. Prevalence of cataract blind was higher in
women than men (1.8% vs. 1.7%, p<0.001)
7. Just over 60% of the cataract blind were blind due to bilateral cataract.
8. The prevalence of cataract causing <6/60 in eyes was 5.0% (95%CI: 4.7,
5.2%) which projects to an estimated 3,560,000 eyes with a visual acuity of
<6/60 due to cataract in Pakistan. This number is projected to increase to
7,380,000 by the year 2020.

Outcomes of eye care provision

1. The crude prevalence of aphakia/pseudophakia (in one or both eyes) was 8.0%
(95%CI: 7.6, 8.4%). The prevalence varied from 6.1% in NWFP to 8.6% in
Sindh.
2. Pakistan has a good surgical coverage for cataract. The CSC (person) at visual
acuity cut-offs of <3/60, was 77.1% and for CSC (eyes) was 61.4%.
3. Coverage was higher in urban than rural areas (p=0.087); in males than in
females (p=0.009) and in literate subjects compared with illiterate subjects
(p<0.001).
4. Annual CSR of 3575 / year /million population in Y1998/1999 and a CSR of
4390 in years Y2000/2001.(Note: potential recall bias)
5. Of the 1788 cataract-operated eyes, only 275 (15.4%) had a presenting visual
acuity of 6/12 or better
6. Intracapsular cataract surgery had been performed on 61.5% eyes.
7. A shift towards ECCE surgery in the last 3 years was identified.
8. The majority of cataract surgeries had been performed in hospitals rather than
eye camps (86% vs 14%)
9. In hospitals, the ratio of ICCE: ECCE + IOL was 1.62:1 while in eye camps,
the ratio of ICCE: ECCE + IOL was 3.25:1
10. Cataract surgeries performed on subjects in rural areas were more likely to be
associated with a poor outcome than urban subjects.
11. Eye camp surgeries were significantly more likely to result in a visual acuity
of <6/18 than hospital based surgeries
12. Among eyes operated on using an ECCE+IOL technique, 50% had a good
outcome (6/18 or better), 37% had a borderline outcome (6/18 to 6/60) and
14% had a poor outcome (worse than 6/60). With refractive correction these
proportions improved to 61%, 28% and 11%, respectively.
13. Operative complications were the principal cause for 47% of eyes with less
than 6/18 best corrected visual acuity

49
 Barriers to cataract surgical services
1. Cost was the principle barrier (76.1%)
2. Women and rural dwellers were more likely to list cost as the barrier.
3. 94.4% of the subjects were illiterate
4. An in-depth qualitative assessment with interview was not conducted. Thus
caution is advised as it is possible that the cost barrier may have simply been
the easiest of the options available for the subject to pick, the real barrier
remaining masked.

iI. Strengths and weaknesses of the survey

This is one of the largest cross-sectional population-based survey’s of its kind
undertaken to date. Particular strengths of this survey include the sampling
methodology used to obtain a representative group, use of logMAR visual acuity
testing and autorefraction of all subjects, a dilated, slit lamp based, posterior segment
examination, and the use of a 'less than 6/12' threshold for further examination. This
lower threshold addresses the burden of refractive error, which, with cataract, are two
of the diseases specifically targeted by Vision 2020. The rigorous protocol utilized to
minimise non response of enumerated subjects provided a higher than expected
response rate (95.3%). The results of this survey are quoted using the day to day
vision of the subject (“presenting” visual acuity) which best assesses the social and
physical functioning of that person in their environment.

For logistical reasons perimetry was only conducted on a selected subgroup of

subjects which means that individuals who would have been classified as blind on the
basis of visual field defects alone (e.g. from glaucoma or retinitis pigmentosa) would
have been under reported. Another limitation of this survey, as with all cross sectional
studies, is the lack of temporality of risk factor data, which means that significant
associations need to be interpreted with caution. Furthermore some of the data
collected (e.g. date of surgery) depended on patient recall and is thus open to bias.

50
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U.S. Census Bureau, Population Division, International Programs Center
http://www.census.gov/cgi-bin/ipc/idbsum.pl?cty=PK

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