Evaluation of Impact of Cataract Surgery on Socioeconomic Indicators in Bilateral Cataract Blindness

Introduction

Cataract is the most common cause of blindness worldwide.¹ It is characterized by clouding or opacity of the eye’s natural lens, which is normally transparent. This opacity impairs the transmission of light to the retina, resulting in gradual loss of vision. Cataracts often develop slowly and may cause symptoms such as blurred vision, glare, and difficulty seeing at night. While cataracts are primarily age-related, they can also occur due to trauma, systemic diseases, prolonged use of certain medications, or excessive exposure to ultraviolet radiation. Cataracts are a leading cause of low vision in both developed and developing countries. According to the World Health Organization (WHO), an estimated 42 million people globally are blind, with 17 million of those cases attributable to cataracts.¹ The WHONPCB (National Programme for Control of Blindness) survey (1986–1989) reported that in India, cataracts are responsible for nearly 81% of severe visual impairment and blindness.² Despite the expansion of high-quality surgical services and increased awareness of the benefits of cataract surgery, the uptake remains low in rural areas due to socioeconomic barriers, lack of awareness, and accessibility issues.

Cataracts can be classified by their location, such as nuclear (central), cortical (outer layer), or posterior subcapsular (back of the lens), and by their stage of maturity, including immature, mature, and hypermature cataracts. In the early stages, cataracts may be managed with corrective lenses, as the refractive power of the lens changes. However, when visual acuity cannot be improved with spectacles, surgical intervention becomes necessary. Cataract surgery involves removing the cloudy lens and, in most cases, implanting an artificial intraocular lens. It is a safe, cost-effective procedure, with increasing cataract surgical rates (CSR) observed in many countries, including India.³

Cataracts may also need to be removed even in the absence of significant visual impairment if they hinder the treatment of other ocular conditions such as diabetic retinopathy or macular degeneration.⁴ Surgery not only restores vision but also enhances quality of life, psychological well-being, and economic productivity.⁵ Socioeconomic factors significantly influence access to care and outcomes.⁶ Vision-related quality of life (VRQoL) is a major concern, as cataracts profoundly affect daily functioning and independence.⁷

Materials & Methods

Study Design and Population

This hospital-based, prospective cross-sectional study was carried out at the M.M. Joshi Eye Institute in Hubli, Karnataka, and involved the recruitment of 160 patients diagnosed with bilateral cataracts who attended community clinics and outreach camps. A stratified random sampling method was employed to ensure adequate representation across different age groups, genders, and socioeconomic backgrounds. Prior to enrolment, each participant was informed in detail about the objectives and procedures of the study, and written informed consent was obtained.

Inclusion and Exclusion Criteria

Individuals aged 40 years and above, presenting with bilateral cataracts and a best corrected visual acuity (BCVA) of less than or equal to 3/60 in the better eye, were included. Patients with unilateral cataract, uncontrolled diabetes mellitus or hypertension, advanced glaucoma, retinal or corneal pathologies, or other systemic and ocular conditions that could influence visual outcomes were excluded from the study.

Research Tool

Demographic and clinical information was collected using a structured case sheet specifically designed for this study. Trained ophthalmic personnel, including nurses, optometrists, and social workers, conducted face-to-face interviews with each participant using a structured, validated questionnaire intended to assess vision-related quality of life and functional status. All interviewers underwent a standardized training program to ensure uniform data collection and minimize interviewer-related bias. Visual acuity assessment was carried out using a standard Snellen chart for distance vision and a reduced Snellen chart for near vision. Objective refraction was performed through retinoscopy, followed by subjective refinement. A comprehensive slit-lamp examination was also conducted to assess anterior segment findings and grade lens opacities. To evaluate the impact of cataract and its surgical intervention on quality of life, a self-developed questionnaire was administered.

Construction of Questionnaires

The questionnaire development process began with a series of Focus Group Discussions (FGDs) involving a multidisciplinary expert panel, including community ophthalmologists, optometrists, psychologists, biostatisticians, public health professionals, and Kannada language experts. Thematic analysis of the FGDs identified four core domains: self-care, mobility, social interaction, and functional ability. Based on literature review and expert opinion, the questions were formulated and translated into Kannada. The preliminary version underwent both qualitative and quantitative validation, including content validation by subject matter experts and exploratory factor analysis (EFA) to determine construct validity.

Testing a Questionnaire (Pilot Study)
A pilot study was subsequently conducted on a subset of the target population to evaluate clarity, feasibility, and internal consistency, yielding a Cronbach’s alpha value of 0.82, indicating satisfactory reliability.

Final Data Collection with the Validated Questionnaires

The finalized, validated questionnaire was used for all study participants before and after cataract surgery, with interviews administered in person by trained staff. Questions were explained and repeated as necessary to ensure participant understanding.

Ethical Clearance 

Ethical approval for the study was obtained from the Institutional Ethics Committee of M.M. Joshi Eye Institute, Hubli, Karnataka (Approval No. IEC/ MMJEI/OP/2024/DOI). All procedures adhered to the Declaration of Helsinki principles, and personal identifiers were excluded to ensure confidentiality.

Data Analysis

Collected data were systematically tabulated and subjected to statistical analysis using the Statistical Package for Social Sciences (SPSS) version 22.0. Graphs and charts were prepared using GraphPad Prism version 5.03. Paired t-tests were applied to compare pre and post-operative outcomes, with a P-value of less than 0.05 considered statistically significant. Efforts were made to minimize bias through the use of standardized protocols, trained interviewers, and rigorous sampling and validation techniques.

Results

A total of 160 participants diagnosed with bilateral cataract were included in the study. Of these, 89 were males (55.62%) and 71 were females (44.37%). The age distribution revealed that 50 participants (31.25%) were aged between 40 and 59 years, while 110 participants (68.75%) were aged 60 years or above. The overall mean age was 63.39 years.

Occupational Distribution

The background of participants was diverse, with the majority being farmers (n=65, 40.63%) and housewives (n=55, 34.38%). Other occupations included mechanics and teachers (n=9 each, 5.63%), drivers (n=5, 3.13%), and smaller groups such as carpenters, nurses, and social workers (n=4 each, 2.50%). Less common occupations included barbers and child caretakers (n=2 each, 1.25%) and electricians (n=1, 0.63%) (Table 1).

Occupational groups demonstrated varying degrees of improvement across the four quality-of-life domains: self-care, mobility, social functioning, and functional capacity. Farmers showed consistent improvement across most domains, especially in self-care (–1.77) and functional capacity (+0.25). Child caretakers showed the greatest improvement in social functioning (+2.50), and also improved in mobility (+1.00) and functional capacity (+0.50). Housewives demonstrated marked gains in social functioning (+1.65) and moderate improvements in other areas. Mechanics and carpenters showed small but positive changes across domains, particularly in selfcare and mobility.

Age-wise Comparison across Quality-of-Life Domains Following Surgery

Age-wise comparison revealed that participants aged 40–59 years showed greater improvement in mobility (+0.10), social functioning (+0.76), and functional capacity (+0.18), while those aged 60 years and above had slightly better outcomes in self-care (–1.70). Overall, both age groups benefitted from surgery, with variations in domain-wise gains (Figure 1).

Pre- and post-operative comparisons showed statistically significant improvements in all domains of quality of life (Figure 3). Self-care improved with a mean change of +0.58 (t(159) = 5.67, P <0.001). Mobility improved by +0.24 (t(159) = –2.43, P=.016), social functioning by +0.61 (t(159) = –5.35, P <0.001), and functional capacity by +0.22 (t(159) = –2.28, P=.024). These results indicate that cataract surgery led to meaningful improvements in daily functioning, interpersonal engagement, and visual independence among the participants.

Discussion

This study highlights the significant positive impact of cataract surgery on vision-related quality of life (VR-QoL) among individuals with bilateral cataract-induced blindness, particularly within rural and underserved populations. By focusing on patients accessing cataract care through outreach camps and community clinics, it underscores the role of accessible surgical services in improving both functional and psychosocial outcomes for marginalized groups. A striking demographic feature of this study was the high proportion of farmers (40.63%) and housewives (34.38%), suggesting that cataract induced vision loss may disproportionately affect individuals engaged in visually dependent and labour intensive roles. Farmers, in particular, demonstrated meaningful improvements in self-care and functional capacity, reflecting the restoration of their ability to perform essential daily tasks and occupational duties. This aligns with previous observations by Finger et al., who emphasized the substantial occupational benefits of improved vision among agricultural workers in low resource settings.⁸ The age-related analysis revealed that younger participants (aged 40–59) experienced greater improvements in mobility and social functioning compared to those aged ≥60 years. This finding may be attributed to the greater physical and social engagement typically associated with younger age groups, thus amplifying the perceived benefit of vision restoration. The observation aligns with results from studies that reported stronger QoL improvements in younger cohorts following cataract surgery.^9,10\

Another notable strength of this study lies in the use of a locally developed and validated QoL questionnaire tailored to the sociocultural context of the population. With a Cronbach’s alpha of 0.82, the tool demonstrated high internal consistency, enabling a more nuanced assessment of functionally relevant domains often underrepresented in global instruments like the National Eye Institute Visual Function Questionnaire (NEI-VFQ-25).¹⁰ This approach allowed for capturing improvements in specific roles, such as those of child caretakers and housewives, where the post-operative improvements extended beyond visual functioning to enhanced interpersonal and emotional well-being. This mirrors findings from studies that reported substantial psychosocial recovery among individuals who are bilaterally blind following cataract extraction.^11,12

Statistically significant improvements were observed across all four QoL domains: self-care (+0.58, P <0.001), mobility (+0.24, P=0.016), social functioning (+0.61, P <0.001), and functional capacity (+0.22, P=0.024). These results suggest that cataract surgery not only restores vision but also re-establishes the capacity for self-sufficiency and social engagement, factors critical for quality of life and reintegration into the community.

Despite these encouraging outcomes, certain limitations must be acknowledged. The cross-sectional design with a short follow-up period of six weeks limits our ability to assess long-term sustainability of the observed improvements. Longer-term, prospective studies would be valuable to evaluate how enhanced vision influences economic productivity, mental health, and social reintegration over time. Additionally, although the QoL tool was culturally appropriate and psychometrically sound, its applicability to other regions or populations remains uncertain and would require further validation.

Conclusion

The present study shows that cataract surgery not only restores vision but also significantly improves quality of life, productivity, and economic independence for individuals and their families. It emphasizes that carefully designed, self-administered questionnaires are valuable for evaluating the quality of life and psychosocial factors in cataract patients both before and after surgery. By restoring vision, the procedure enables individuals to rejoin the workforce, reduces reliance on caregivers, and eases financial strain. These improvements lead to higher household income, reduced poverty, greater access to education and social opportunities, and increased community engagement. Consequently, cataract surgery emerges as a cost-effective medical solution with profound implications for personal well-being, societal progress, and economic development, significantly alleviating the burden of blindness on individuals, families, and communities.

Conflict of interest

None