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Ophthalmic Epidemiology
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Lens Opacities in Adults in Pakistan: Prevalence and
Risk Factors
Shaheen P. Shah a; Brendan Dineen a; Zahid Jadoon b; Rupert Bourne a;
Mohammad Aman Khan b; Gordon J. Johnson a; Bianca De Stavola c; Clare
Gilbert a; Mohammad Daud Khan b
a
International Centre for Eye Health, Clinical Research Unit, Department of
Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine,
b
Pakistan Institute of Community Ophthalmology, Kyber Institute of Ophthalmic
Medical Sciences, Peshawar, Pakistan
c
Department of Medical Statistics, London School of Hygiene and Tropical
Medicine,

Online Publication Date: 01 November 2007

To cite this Article: Shah, Shaheen P., Dineen, Brendan, Jadoon, Zahid, Bourne, Rupert, Khan, Mohammad Aman,
Johnson, Gordon J., De Stavola, Bianca, Gilbert, Clare and Khan, Mohammad Daud (2007) 'Lens Opacities in Adults in
Pakistan: Prevalence and Risk Factors', Ophthalmic Epidemiology, 14:6, 381 - 389
To link to this article: DOI: 10.1080/09286580701375179
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Ophthalmic Epidemiology, 14:381–389

ISSN: 0928-6586 print / 1744-5086 online
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c 2007 Informa Healthcare USA, Inc.
DOI: 10.1080/09286580701375179

Lens Opacities in Adults in Pakistan:

Prevalence and Risk Factors
Shaheen P. Shah,1 Brendan Dineen,1 Zahid Jadoon,2 Rupert Bourne,1 Mohammad Aman Khan,2 Gordon J. Johnson,1
Bianca De Stavola,3 Clare Gilbert,1 and Mohammad Daud Khan2
1 International Centre for Eye Health, Clinical Research Unit, Department of Infectious and Tropical Diseases,
London School of Hygiene and Tropical Medicine
2 Pakistan Institute of Community Ophthalmology, Kyber Institute of Ophthalmic Medical Sciences, Peshawar, Pakistan
3 Department of Medical Statistics, London School of Hygiene and Tropical Medicine

ABSTRACT
Purpose: To investigate the prevalence and risk factors for lens opacity (LO) amongst a na-
tionally representative sample of the adult population of Pakistan. Methods: This national study
of blindness and visual impairment (adults ≥30 years) used multistage, stratified, cluster ran-
dom sampling. Grading of LO was conducted using the Mehra/Minassian classification system.
LO, partly or wholly obscuring the red reflex, or previous cataract surgery were indicators of
opacity. Results: 16,402 (94.7%) adults were included in this analysis (study conducted 2002–
2003). A total of 4,096 (standardized prevalence 20.9%, 95%CI: 20.3, 21.5%) adults were found
to have LO. The highest prevalence of LO was found in Punjab province (22.2%), the lowest
in Balochistan Province (18.0%). Significant positive associations were increasing age (multi-
variable odds ratio (OR) 3.2: 95%CI: 3.1, 3.4), hypertension (OR 1.2, 95%CI: 1.1, 1.3), history of
diabetes (OR 2.6: 95%CI 2.0, 3.2) and smoking (OR 1.3: 95%CI: 1.1, 1.5). Higher body mass index
(BMI) (OR 0.8: 95%CI 0.7, 0.9, heavy vs. normal BMI) and attendance to school (OR 0.6: 95%CI:
0.5, 0.8) were associated with lower risk of LO. Individuals in districts classified as hot were
at significantly increased risk (OR 1.3: 95%CI: 1.1, 1.5), and those in wet districts (>600 mm
annual rainfall) had lower odds than individuals living in dry districts (OR 0.7: 95%CI: 0.6, 0.8).
Conclusions: Almost a fifth of the adult population had LO. Significant positive associations
were age, smoking status, hypertension, diabetes, and increased deprivation level. Protective
factors included high BMI and educational achievement. The climatic associations offer novel
hypothesis for further research into cataractogenesis.

INTRODUCTION It has been estimated that 32 million cataract operations will

Despite highly effective surgical interventions which can re-
store sight at low cost, age related cataract remains the principle
cause of blindness globally.1
Received 4 August 2006; accepted 23 March 2007.
Keywords: Lens opacities, cataract, risk factors, Pakistan,
epidemiology, prevalence
The contributors to the Pakistan National Eye Survey Study Group
are listed at the end of this article.
Correspondence to:
Shaheen Shah
Clinical Research Unit
Department of Infectious and Tropical Diseases
London School of Hygiene and Tropical Medicine
Keppel St, London WC1B 3RA.
email: shaheen.shah@lshtm.ac.uk
be required by the year 2020 to control cataract blindness but if
the incidence of cataract could be reduced by 10%, this would
reduce the current number of cataract operations required by
2 million/year.2,3 The economic cost of vision loss due to cataract
is enormous, and as it has been estimated that a ten-year delay
in the onset of cataract could result in a 50% reduction in preva-
lence further research into potentially modifiable risk factors is
justified.4,5
In the recent national survey of the prevalence and causes of
blindness in Pakistani adults, cataract accounted for just over
50% of blindness.6 Although the proportion was lower than in a
study conducted 10 years earlier7 cataract remains the country’s
leading cause of avoidable blindness.
In 1994 it was estimated that approximately 500 ophthalmol-
ogists performed 140,000 cataract surgeries in Pakistan, giving
a cataract surgical rate (CSR) of 1,115/million population/year.8
Although the current CSR is uncertain it is estimated to be similar

Ophthalmic Epidemiology November–December 2007 381

Downloaded By: [University of London London Sch Hygiene & Trop Med] At: 18:03 7 January
to the Indian estimate which is now >4,000/million/year.9 In
the recent national survey the prevalence of cataract surgery
(aphakia/pseudophakia) was 8.0% in participants aged ≥30
years and 17% in ≥50 year olds.10 Pakistan is situated in the
World Health Organization’s (WHO) Eastern Mediterranean Re-
gion and is bordered by India, China, Iran and Afghanistan. The
1998 national census estimated the population to be 132 mil-
lion, making it the sixth most populous country in the world.11
Pakistan also has extremes of geography and climate, which also
allow investigation of climatic associations with lens opacities
(LO).
This article reports on the prevalence of, and risk factors
for LO in a nationally representative sample of Pakistani adults
(≥30 years) who were recruited to a survey of the prevalence
and causes of blindness and low vision.6,12
MATERIAL AND METHODS
Full details of the methods for the Pakistan national survey
have been described.13 In summary, the sample size calculated
was 16,600 adults aged ≥30 years, using an assumed preva-
lence of blindness of 1.8%, a random sampling error precision
of 0.3% and a design effect of 2.0, and allowing for a 10% non-
response rate. Multi-stage, stratified cluster random sampling,
with probability in proportional to size procedures, was used
to obtain a nationally representative sample of the population.
Ethical approval was obtained from the Pakistan Medical Re-
search Council. The study was explained in detail to all potential
participants and their voluntary consent was obtained.
All participants were interviewed by a trained interviewer,
who collected demographic and socio-economic data. Partici-
pants were asked if they smoked regularly, and if so, how many
cigarettes they smoked per day, or if they smoked a hookah. All
participants had their height, weight and blood pressure mea-
sured by a trained nurse. Blood pressure was measured 3 times
on each individual at 5-minute intervals in the sitting position
with the wrist facing upwards and the arm supported. All subjects
underwent distance visual acuity measurement using a reduced
logarithm of minimum angle of acuity (logMAR) tumbling “E”
chart14 (required in a population that has high levels of illiter-
acy). The WHO categories of visual impairment were used for
this study.15
Experienced ophthalmologists took detailed past ophthalmic
and medical histories and all participants underwent a basic eye
examination. This included assessment of lens opacities using
the method described by Mehra and Minassian (MM)16 which
entails determining the status of the lens against the red reflex,
through an undilated pupil, using direct ophthalmoscopy. The
objective of the ophthalmoscope is set at +2 D, and the red
reflex is viewed at 1/3 meter, 25◦ temporal to the visual axis. Lens
status is then classified using six categories based on obscuration
of the red reflex, where 0 = clear red reflex with no opacity;
1 = few small dot opacities which occupy <1 mm2 maximum
area; 2a = lens opacity obscuring less than 50% of red reflex;
2b = lens opacity obscuring more than 50% of the red reflex; 3 =
lens opacity totally obscuring the red reflex; 4 = pseudoaphakia,
382 November–December 2007 Ophthalmic Epidemiology
aphakia or displaced lens; and 5 = unable to assess the red reflex
owing to corneal opacity, for instance. Interobserver assessments
were carried out regularly, and the results have been published.10
A subset of individuals (i.e., those with a presenting visual acuity
of <6/12 in one or both eyes, and 1 in 7 individuals over the age
of 40 years) also underwent lens grading using the Lens Opacity
Classification System (LOCS III)17 after pupil dilation.
Outcome variable
MM grades were used to define LO. Individuals were defined
as having LO if he/she had MM grades 2a, 2b, 3, or 4 in one or
both eyes (i.e., the definition included individuals who had had
cataract surgery in one or both eyes), and the highest LO grade in
the right eye or in the left eye was used as the grade for the person.
Explanatory risk factors
Potential risk factors explored in this study included age,
sex, smoking status, diabetes, anthropometric measures, levels
of education, and household income. Novel explanatory factors
modeled included a district level measure of deprivation and dis-
trict level climatic conditions i.e., maximal annual temperature
(Celsius) and maximal annual rainfall (in millimeters).
Age was categorized into 10 yearly age groups (30–39 years
etc up to the age of 69, with any person over the age of
70 entered into one category). Individuals were classified as
smokers (if they were regular current or regular past smokers
(cigarettes or hookah)) or as non-smokers. Individuals were
defined as hypertensive from their medical history, or if their
systolic blood pressure was >140 mmHg and/or if their dias-
tolic blood pressure was >90 mmHg. Diabetics were identified
from their medical history. Body mass index was calculated
(weight (kg)/height (m) squared) and classified using the fol-
lowing WHO criteria: <18.50 underweight, ≥18.5 to <25.0
normal, ≥25.0 to <30.0 overweight, ≥30.0 obese.18
Educational achievement was assessed in two ways i.e.,
whether the individual was literate or not, and whether they had
attended school and if so, to what level. The latter generated the
following categories: no schooling; primary or less; secondary;
higher education. Occupation status for each household used
the highest category among individals living in the household.
The following order for the occupational categories was used:
non manual > manual > retired > unemployed/student. If there
was only one worker and he was a non manual worker this was
then regarded as the status for that house. If there were 2 work-
ing individuals in the household then the house was classified
according to the higher status occupation.
Deprivation index scores at the district level, stratified by
urban/rural location, were extracted from a report which ana-
lyzed the Population and Housing Census data (1998).19 This
index uses the same indicators as the United Nations Develop-
ment Program (UNDP) for deriving their Human Poverty In-
dex i.e., education, housing quality, and congestion, residential
services, and employment. The degree of deprivation for each
rural and urban area within the districts was categorized into
low deprivation (<25th centile), medium deprivation (25–75th
centile) and high deprivation (>75th centile).
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Table 1. Demographic distribution of 16,402 subjects according to lens opacity status

Total number included Lens opacity1 Prevalence in Prevalence in Overall Overall 95%
in the survey (MM grade 2a, 2b, 3 or 4) men (%) women (%) Prevalence (%) Confidence Interval
Age group: 30–39 5942 (36.2) 172 (4.2) 2.6 3.2 2.9 2.5, 3.4
40–49 3567 (21.7) 384 (9.4) 9.8 11.5 10.6 9.6, 11.7
50–59 2858 (17.4) 811 (19.8) 24.6 32.2 28.2 26.5, 29.9
60–69 2322 (14.2) 1314 (32.1) 54.9 58.6 56.6 54.5, 58.6
70+ 1713 (10.4) 1415 (34.6) 72.2 83.4 81.2 79.3, 83.0
Province:
NWFP Urban 441 (2.7) 97 (2.4) 14.9 20.7 17.8 14.2, .21.6
Rural 2627 (16.0) 596 (14.6) 20.7 18.6 19.7 18.2, 21.3
Balochistan Urban 330 (2.0) 75 (1.8) 20.2 17.0 18.7 14.7, 23.4
Rural 613 (3.7) 132 (3.2) 20.1 15.0 17.7 14.8, 21.0
Punjab Urban 2874 (17.5) 618 (15.1) 18.0 20.1 19.0 17.5, 20.5
Rural 5869 (35.8) 1674 (40.8) 22.7 24.6 23.6 22.5, 24.7
Sindh Urban 1753 (10.7) 405 (9.9) 18.9 21.0 19.9 18.0, 21.9
Rural 1895 (11.6) 499 (12.2) 19.8 16.7 18.4 16.7, 20.2

Total 16,402 (100) 4096 (100) 20.5 21.2 20.9 20.3, 21.5

∗ Mehra and Minassian cataract grading system13

Maximum annual temperature and annual rainfall were es-
timated for each district from United Nations Environmental
program maps and were categorized into tertiles.20 Accurate in-
formation on district level UV exposure was not available.
Statistical analysis
Two trained data processors carried out double data entry
and were responsible for database maintenance throughout the
survey. Data were transferred into STATA for analysis (Statcorp.
Release 9.0.College Station, TX: Stata Corporation). District
prevalence data were mapped by geographical location.21
The distribution of categorical variables was compared using
the Pearson chi squared test and the chi squared test for lin-
ear trend statistics, when appropriate. The distributions of con-
tinuous variables were compared using non-parametric Mann
Whitney tests. Quoted prevalence figures for LO (using MM
grades) are age and sex standardized (direct method) using the
Pakistan Demographic Survey data (2003).11 Agreement be-
tween the MM grading and LOCS scoring on each eye was
performed using kappa statistics.22 For this comparison the fol-
lowing LOCS scores determined presence of opacity in each eye:
nuclear opalescence scores 3–6 and/or cortical opacity scores 3–
5 and/or posterior subcapsular opacity scores 2–5.
Assessment of risk factors was performed using univariable,
age and sex adjusted and multivariable logistic regression mod-
els leading to estimated odds ratios (OR). Robust methods to
estimate standard errors and therefore 95% confidence intervals
(CI) were used to allow for correlation within clusters. Score
Tests were used to assess the significance of effects.23
RESULTS
Study participants and the prevalence
of lens opacity
A total of 17,311 subjects aged 30 years and above were enu-
merated, 16,402 (94.7%) of whom were included in this analysis.
The non responders and the potential for bias in the sample has
been previously described.12 Women (who constituted 53.1%
of the sample) were significantly younger than men (mean 45.9
years vs. 48.9 years respectively, p < 0.001). A total of 4,096
participants were identified who fulfilled the MM definition of
LO given above: 1,317 had undergone cataract surgery in one
or both eyes; 1,241 (30.3%) had MM grade 2a opacities, 826
(20.2%) had MM grade 2b, and 712 (17.4%) participants had
grade 3 opacities. The age/sex standardized prevalence of LO
was found to be 20.9% (CI 20.3, 21.5%).
The prevalence of LO was highest in Punjab province (22.2%)
and lowest in Balochistan province (18.0%) (Table 1). At dis-
trict level the prevalence of LO ranged from 8% in Gilgit district,
North West Frontier Province (NWFP) to 34.5% in Sukkur Dis-
trict, Sindh (Figure). The figure shows clustering of districts with
a high prevalence in the Indus valley, with lower prevalence’s in
districts in northern mountainous areas and in Balochistan. The
prevalence of LO overall was higher in rural areas compared
with urban areas (21.7% vs. 19.2%, p < 0.001). Significant dif-
ferences in prevalence were observed between the provinces in
rural areas (p < 0.001) but not in urban areas (p = 0.64). Partic-
ipants living in districts with a higher mean deprivation index
were more likely to have LO than individuals living in less de-
prived districts (p < 0.001).
Comparison of Lens Opacity Classification
System (LOCS III) grading to
Mehra/Minassian grading
LOCS scores were available for 6621 individuals, and as
findings were equivalent in both eyes we report on the right
eye only. 2544 participants had opacity using the definition for
LOCS given above. In these individuals, using the LOCS scores,
the majority had mixed opacities (44%), followed by nuclear
only (28.4%), posterior subcapsular only (22.2%), and cortical
only (5.4%). Overall kappa agreement between MM and LOCS

Ophthalmic Epidemiology November–December 2007 383

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Figure 1. Prevalence of lens opacity in the 94 districts sampled in Pakistan.
scores was 86.3%. Lowest agreement between the two grading
systems was identified for isolated cortical opacities (kappa =
54%). Subsequent analyses are based on the MM grades.
Exposure to risk factors
The survey identified 488 (3%) participants known to suf-
fer from diabetes, and these individuals were significantly older
(p < 0.001), had higher BMI’s (p < 0.001), and were more likely
to live in urban areas than rural areas (p < 0.001) than non-
diabetics. Overall 4,683 individuals (28.4%) were classified as
hypertensive, again rates were higher in individuals living in
urban areas (p < 0.001). Of all subjects 11.6% had regularly
smoked or were currently cigarette smokers and a further 2.5%
smoked hookahs: a significant gender difference was found
with only 72 women admitting to being smokers. School at-
tendance was generally very low (29.8%), and women were
much more likely not to have attended school than men (14.9%
vs. 46.7%, p < 0.001). Punjab and Sindh had the highest liter-
acy rates (31.4% and 30.9%, respectively), followed by NWFP
(24.7%) and Balochistan (21.3%). Literacy rates were also sig-
nificantly different between rural and urban populations (23.3%
vs. 42.0%, p < 0.001). Over half the households were classified
as having a manual occupation (55.1%), with 28.8% of house-
holds being classified as non manual, 12.3% as unemployed or
students and a further 3.8% were classified as retired. Mean
height was 1.6 m (SD 0.1, range 0.7–2.0 m) and mean weight
384 November–December 2007 Ophthalmic Epidemiology
was 58.3kg (SD 13.5, range 20–165 kg). BMI values were posi-
tively skewed, showing a median BMI of 21.4 (IQR 19.0–24.2)
in males and 22.5 (19.5–26.4) in females. BMI was strongly
related to deprivation index in that 30.5% of the lean subjects
had high deprivation compared to 13% of the obese participants
(p < 0.001).
Rural/urban dwelling and deprivation were closely associ-
ated, rural areas being significantly more deprived than urban
areas (p < 0.001). Over half of Balochistan was classified as
highly deprived. Karachi district was the least deprived in the
country. Maximal average temperatures throughout the country
ranged from 20 to 34 degrees Celsius. There was an inverse cor-
relation between maximal temperatures and rainfall (r = −0.6,
p < 0.001).
Risk factor analysis
Variables found to be significantly associated with LO in the
univariable analysis were increasing age, being male, hyperten-
sion, having a history of diabetes, smoking, having a low BMI,
living in a rural area, living in the provinces of Sindh and Punjab,
lack of education, not being in a non manual occupation house-
hold, living in districts with a high deprivation index, high district
temperatures and low annual rainfall (Table 2). The univariable
positive association with male gender reversed after adjusting
for the confounding effect of age, with females now having a
30% increased odds of LO in the age-adjusted model (OR 1.3,
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Table 2. Univariable, age-, and sex-adjusted, and multivariable analysis of risk factors for lens opacity

Univariable analysis Adjusted for age and sex. Multivariable analysis.

Odds ratio and 95% Odds ratio and 95% Odds ratio and 95%
Variable confidence interval confidence interval confidence interval5 p value6

Individual exposures:
Age 30–39 years 1 1 1 1 1 1
10 year increase 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 0.360

Hypertension1 No 1 1 1 1 1 1
Yes 1.6 1.5, 1.8 1.2 1.1, 1.4 1.3 1.1, 1.4 <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 index2 Lean 1.8 1.6, 1.9 1.5 1.3, 1.7 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 0.008
Obese 0.6 0.5, 0.7 0.7 0.6, 0.9 0.7 0.6, 0.8 <0.001

Education3 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, 0.7 <0.001
Secondary 0.3 0.3, 0.4 0.5 0.4, 0.6 0.5 0.4, 0.6 <0.001
Higher 0.1 0.1, 0.2 0.4 0.3, 0.5 0.4 0.3, 0.5 <0.001
Location:
Household Non manual 1 1 1 1 1 1
occupation Manual 1.5 1.3, 1.6 1.3 1.1, 1.4 1 0.9, 1.2 0.344
Other4 2.0 1.8, 2.2 1.3 1.1, 1.5 1.2 1.0, 1.4 0.010

Urban/rural 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 0.541

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 0.420
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 (<45) 1 1 1 1 1 1
Medium 1.5 1.3, 1.7 1.2 1.1, 1.4 1.1 0.9, 1.3 0.262
High (≥70) 1.3 1.1, 1.4 1 0.9, 1.2 0.8 0.7, 1.1 0.110

Maximal <30◦ C 1 1 1 1 1 1
temperature 30◦ C 1.1 1, 1.3 1.1 0.9, 1.2 1.0 0.8, 1.1 0.686
>30◦ C 1.4 1.2, 1.5 1.4 1.2, 1.5 1.3 1.1, 1.5 <0.001

Average annual <200 mm 1 1 1 1 1 1

rainfall 200–600 mm 0.8 0.7, 0.8 0.8 0.7, 0.9 0.8 0.7, 0.9 <0.001
>600 mm 0.7 0.6, 0.8 0.7 0.6, 0.8 0.7 0.6, 0.8 <0.001

1 Defined as >90 mmHg diastolic and/or >140 mmHg systolic

2 BMI - Body Mass Index; Lean <18.50 underweight, ≥18.5 to <25.0 normal, ≥25.0 to <30.0 overweight, ≥30.0 obese
3 Educational achievement units in order: None, primary, secondary, or higher
4 Retired/Unemployed/Student
5 The multivariable model included: age, gender, hypertensive and diabetes status, BMI, dwelling location, province, education,

household status and deprivation index. Separate multivariable models built when analyzing 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.
6 Score test from multivariable models.

Ophthalmic Epidemiology November–December 2007 385

Downloaded By: [University of London London Sch Hygiene & Trop Med] At: 18:03 7 January
95%CI: 1.2,1.4). There was however no significant gender dif-
ference after the confounding effect of other variables (particu-
larly literacy and BMI) was accounted for (Table 2, last column).
All other variables mentioned above, with the exception of liv-
ing in a rural area and the deprivation index, maintained their
significant effects after controlling for the other variables. No
significant interactions between the individual exposures were
identified.
DISCUSSION
This cross sectional study, one of the largest of its kind, pro-
vides the first nationally representative population based data on
LO and their risk factors in Pakistan. Risk factors studies have
been undertaken in other ethnic groups16,24−27 and this article
provides the first reliable data on risk factors applicable to the
general adult Pakistani population.
The overall prevalence of LO in adults was 20.9% (95%CI:
20.3, 21.5%), translating to approximately 8.6 million people
with some degree of LO in Pakistan. Not all subjects with LO will
require surgical intervention as some will have adequate visual
function. In fact, Mehra et al. found that 40% of his subjects with
grade 2a score had better than 6/18 vision.16 As our definition of
LO did not include visual acuity the prevalence figures cannot be
directly compared to other studies. However, there is currently
no accepted definition of cataract, which makes comparison with
other studies difficult.
As expected, age was the most significant risk factor, with
the odds of LO increasing more than 3 fold with every decade
increase in age (95%CI: 3.1, 3.4 after controlling for other risk
factors). The population of Pakistan is predicted to increase in
both size and age over the next decades: if the age specific in-
cidence of LO remains constant, the number of subjects with
LO is predicted to increase by another 10.3 million by the year
2020.28
Other studies have also shown females to be at higher risk
of LO than males29−32 and this was found in our age adjusted
analysis (OR 1.3, 95%CI: 1.2, 1.4) but not in the multivari-
able analysis. As the sample included individuals who had had
cataract surgery, this difference cannot be explained by gender
differences in accessing eye care services, but suggests a higher
incidence of LO’s in females. Although hormonal differences
have been implicated, as have the biological stresses of child
rearing,33−35 these were not explored in our study.
The prevalence of diabetes in our study population was com-
parable to WHO estimates (3.0% compared with 3.5%)36 and, as
in other studies,24,27,37,38 diabetes was identified as a significant
risk factor. In our study diabetes increased the adjusted odds of
cataract by 2.6 (95% CI: 2, 3.2), being the second most impor-
tant risk factor after age. The WHO estimates a 170% increase
in the number of people with diabetes in developing countries,
from 84 million in 1995 to 228 million in 2025, and predicts
that the major burden of morbidity due to this disease will also
occur in these countries. Pakistan has been identified as being
particularly affected and will be among the five countries with
the largest number of diabetics by the year 2030.39
386 November–December 2007 Ophthalmic Epidemiology
The association between smoking and LO is well established,
and causation seems likely given the temporal relationships and
dose response.26,27,29,40 In Pakistan a 30% increased odds of
cataract was detected in current/ex regular smokers and as smok-
ing is a growing public health issue occurring almost exclusively
in men, any heath education needs to target this sector of the
community.
The association between hypertension and LO is less well
established, being identified as a risk factor in some cross
sectional27,41 and case control studies.42 In the Physicians Health
Study (a cohort study) the association between hypertension and
LO was not strong, and the authors interpreted the finding as be-
ing due to residual confounding.43 In our study hypertension re-
mained a significant modifiable risk factor in the univariable and
adjusted analyses, conferring a 30% (95%CI: 1.1, 1.4) increased
odds. We suggest that further longitudinal study is required to
confirm this observation.
Lean subjects had 40% greater adjusted odds of LO (95%CI:
1.3, 1.6) compared to normal subjects whereas heavy and obese
individuals were found to be at lower risk. Similar relation-
ships between BMI and cataract have been reported in other
studies in Asia.44,45 A different pattern of risk seems to oc-
cur in industrialized countries: for example, the Health Profes-
sionals Follow-Up Study in the United States found a signifi-
cantly increased risk of incident cataract in individuals with a
BMI greater than 22 compared to individuals with a BMI lower
than 22.46 Differences between industrialized and developing
nations may indicate differences in the health status of individ-
uals in different categories of BMI. In developing countries low
BMI is likely to be associated with poverty, with an increased
risk of chronic malnutrition, micronutrient deficiencies and se-
vere dehydrational crises. Conversely, in industrialized countries
lower BMI may reflect healthier lifestyles and greater health
consciousness.
In our study the univariable odds of LO were higher in
districts with medium/high deprivation scores and in rural
dwellings. As deprivation was greater in rural areas and was
significantly associated with BMI, history of diabetes, hyper-
tension, literacy and household occupation, both deprivation and
rural/urban location were no longer significant in the adjusted
model. Whilst lower income has been identified as a risk factor
for cataract25,47 we are, to our knowledge, unaware of previ-
ous reports of associations between LO and UNDP deprivation
indices.
Higher odds of LO in individuals who were uneducated as
well as those not in non-manual income households supports the
evidence that socio-economic status is important in the develop-
ment of LO. The biological mechanisms for this are unclear, but
it is possible that uneducated individuals and those with lower
socioeconomic status have poorer diets, more episodes of ill-
ness, and greater exposure to environmental factors (e.g., UV
light through working outdoors) which could account for their
increased risk. A hope is that as subsequent cohorts become
more educated, particularly girls, the risk will be reduced.
The meteorological associations fit the geographical distribu-
tion of LO prevalence. The odds of LO were higher in districts
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with maximal temperatures above 30◦ C compared to districts
with cooler temperatures, and lower odds were found in dis-
tricts with high annual rainfall compared to drier areas. Increas-
ing ambient temperatures have been shown to increase posterior
chamber temperature by up to 4.5◦ C, and it has been suggested
that in dry and hot tropical areas of the world temperature in-
creases in the lens after exposure to sunlight may initiate or
accelerate cataractogensis.48 Alternatively, if one assumes high
temperatures and poor rainfall to be proxy measures for UV-B
exposure, the findings mirror those in other ecological and case
control studies in Australia,49 Nepal,50 China,51 and Italy.26 Al-
ternatively, low rainfall and high temperatures may increase the
risk of dehydration, heat stroke, and diarrheal disease. Several
case control studies, mainly in India, have implicated dehydra-
tional crises in cataractogenesis52−54 with laboratory evidence
suggesting cyanate-induced carbamylation of lens proteins55 ;
osmotic stress and acidosis are other possible mechanisms.56
It must be remembered however that, as with all studies with
data not at an individual level, these findings are subject to the
ecological fallacy.
Added caution is needed in interpreting the findings of this
study due to lack of information on temporality. For example, the
association with deprivation index needs to be interpreted with
caution as the data from which the index was derived were col-
lected before the survey. However, it is unlikely that significant
changes would have occurred in the indicators used to derive
the index (e.g., levels of education) between 1998 and 2003.
The potential for misclassification bias, particularly for identi-
fying subjects with self reported conditions such as diabetes,
also needs to be recognized. For logistical reasons, only 1 in 5
individuals over the age of 40 years had their pupils dilated as
well as those with a presenting visual acuity of <6/12 in one or
both eyes, and so LOCS grading data were only available on a
selected subset. As there was excellent agreement between MM
grading and LOCS scoring (kappa >85%) we can be confident of
the validity of using the MM approach. Cortical cataract had the
lowest agreement which one would expect as the lens changes,
being mostly peripheral, are not visible through an undilated
pupil.
This study identifies high risk adult groups, who can be tar-
geted in public health initiatives. The study’s strengths include
the high response rate, and the very large sample size which
provides greater statistical power. Analysis of risk factors for
different types of lens opacity (nuclear, cortical and posterior
subcapsular) was not possible, but from the LOCS data, almost
half of the LO were of mixed type.
Information on other known risk factors, such as diet, specific
dehydrational episodes, UV exposure, and drug history would
have improved the study, as would estimation of pack years of
smoking but collecting these data was not possible within the
constraints of a very large survey.
In summary, 20% of the adult Pakistani population have LO’s.
Modifiable factors included smoking, hypertension, diabetes,
anthropometric measures and education, literacy and poverty
indices. The climatic associations generate novel hypothesis for
further research into cataractogenesis.
Ophthalmic Epidemiology
ACKNOWLEDGMENTS
The authors are grateful for the contribution of the Pakistan
National Eye Survey Study Group which consisted of the fol-
lowing individuals: Shad Mohammed, Zia Uddin Sheik, Asad
Aslam, Nasim Panazai, Shabbir Mir Niaz Ali, Pak Sang Lee
(Technical Coordinator, International Centre for Eye Health,
London), Ikram Ullah Khan (Biomedical Engineer, Pakistan In-
stitute of Community Ophthalmology), Haroon (Sight Savers In-
ternational); Rubina Gillani (Fred Hollows Foundation), Babar
Qureshi (Christoffel Blindenmission), Mohammed Shabbir and
Falak Naz (Clinical and Community Ophthalmologists, respec-
tively, North West Frontier Province team), Abdul Ghafoor and
Kiramatullah (Survey Ophthalmologists, Punjab & Baluchistan
Teams), and Waheed Shaikh and Amjad Shaikh (Survey Oph-
thalmologists, Sindh Team).
The survey was financially supported by the International
Blindness Prevention Collaborative Group which consisted of
the Government of Pakistan, the World Health Organization East
Mediterranean Regional Office and Pakistan Office, Sight Savers
International, Christoffel Blinden Mission, and the Fred Hollows
Foundation.
The authors also wish to thank Tauqeer Abbas and Fakhre-e
Alam for data entry, Mahwash Akhtar-Khan, Yelena Alexande,
and Rahul Shah for assisting in data cleaning, and Fazl-Subhan
and Jyoti Shah for assisting with financial management. Heidel-
berg Engineering (Heidelberg, Germany) kindly lent two HRT-II
instruments. Lateef Brothers, Lahore and S. Haji Ameerdin and
Sons, both based in Lahore, Pakistan, were generous in their
instrument support. Ophthalmic medications were generously
donated by the NWFP divisions of the companies Remington
and Kobec.
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