Prevalence of Cataract in Rural Indonesia

Rahat Husain, MRCOphth,1,2,3 Louis Tong, FRCS (Ed), DM (Nott),1,3 Alan Fong, MBBS,1,3
Jin F. Cheng, MRCS (Ed),1,3 Alicia How, MRCS (Ed),1,3 Wei-Han Chua, MRCS (Ed),1,3
Llewelyn Lee, MBBS,1,3 Gus Gazzard, FRCOphth,2,3 Donald T. Tan, FRCS (Ed), PhD,1,3
David Koh, MBBS, PhD,4 Seang M. Saw, MBBS, PhD3,4
Purpose: To describe the prevalence of cataract in adults in rural Sumatra, Indonesia.
Design: Population-based cross-sectional study.
Participants: A random sample of all adults aged 21 years or older living in 3 rural villages in central Sumatra
was assessed. Nine hundred nineteen of 1089 (84.4%) eligible adults participated.
Methods: A team of 7 ophthalmologists examined the anterior segment of both eyes using a portable slit
lamp after pupil dilatation. Lens opacity was graded according to the Lens Opacities Classification System III
(LOCS III). A structured questionnaire was used to collect data on education level and income.
Main Outcome Measures: Cataract was defined as either a LOCS III nuclear region score of 4.0, cortical
4.0, or posterior subcapsular (PSC) cataract 2.0, in either eye.
Results: Two hundred one (21.9%) of 919 subjects were found to have cataract. The age-adjusted prevalence rate of cataract (including cataract surgery) was 23.0% (95% confidence interval, 20.8 25.2). The most
common type of cataract for both genders (adjusted for age) was mixed (13%) followed by nuclear only (5.7%),
and cortical only (4%). The prevalence rate of any cataract for adults aged 21 to 29 was 1.1%, increasing to
82.8% for those aged older than 60 years. Similar trends with age were noted for nuclear, cortical, and PSC
cataract. Women had higher prevalence rates than men for all types of cataract except cortical. There was a trend
of increasing prevalence of all types of cataract with decreasing education (P0.001).
Conclusions: Cataract prevalence in adults aged 21 years and older in rural Indonesia is among the
highest reported in Southeast Asia. Despite this, there are inadequate resources available to manage this
treatable disease. Allocation of resources to tackle the present burden of cataract would likely have large
personal, social, and economic benefits. Ophthalmology 2005;112:12551262 2005 by the American
Academy of Ophthalmology.

It has been estimated that cataract is responsible for more

than half the worlds 38 million blind.1 Even in those not
classified as blind, cataract is associated with visual disability and decreased quality of life.2 Southeast Asia has a
disproportionate burden of blindness, with one quarter of
the global population residing in this region yet contributing
one-third to the worlds blind.3
The World Health Organization (WHO) estimates Indonesias population to be more than 210 million people, the
most populous country in Southeast Asia. The ethnic origins
of Indonesias population are also similar to Malays in
Malaysia and Singapore. A recent survey in rural Indonesia
Originally received: July 9, 2004.
Accepted: February 2, 2005.
Manuscript no. 240548.
1
Singapore National Eye Centre, Singapore.
2
Institute of Ophthalmology, London, United Kingdom.
3
Singapore Eye Research Institute, Singapore.
4
National University Singapore, Singapore.
Presented at: Association for Research in Vision and Ophthalmology
meeting, April, 2004; Fort Lauderdale, Florida.
Supported by the Singapore Eye Research Institute, Singapore (grant no.:
R320/13/2003).
Reprint requests to Assoc Prof Saw Seang Mei, Department of Community, Occupational and Family Medicine, National University Singapore,
16 Medical Drive, Singapore 117597.
2005 by the American Academy of Ophthalmology
Published by Elsevier Inc.

found an age-adjusted bilateral blindness rate of 2.2% in

adults aged 21 years or older, with cataract being the main
cause of both bilateral blindness and low vision.4 A survey
of 1510 individuals older than 40 years of age in 1989 in an
area of rural West Sumatra found a cataract prevalence of
25.1%.5 Cataract was defined qualitatively using a classification established by the Japanese Co-operative Cataract
Epidemiology Study Group. The same group studied the
prevalence of cataract in 3 towns in Japan using identical
methods and found that the prevalence of nuclear cataract
was significantly higher in Indonesia than in the areas
surveyed in Japan.6
The purpose of this study is to describe the prevalence of
cataract in a rural population of adults aged 21 years and
older in Sumatra, Indonesia, using the internationally recognized objective lens grading system, the Lens Opacities
Classification III (LOCS III).7

Materials and Methods

This population-based survey was conducted in 3 rural villages,
Rantau Baru, Sering, and Pelalawan in central Sumatra, Indonesia,
during July and August 2003. The 3 villages are situated alongside
the Kampar River and have a tropical climate, being located only
1 north of the equator. The nearest large city is Pekan Baru,
capital of Riau province. These villages were chosen because they
ISSN 0161-6420/05/$see front matter
doi:10.1016/j.ophtha.2005.02.015

1255

Ophthalmology Volume 112, Number 7, July 2005

Table 1. Comparison of Survey Data with Those of Rural
Indonesia by Age and Gender
Rural Indonesia Data*
Age Range
2129
3039
4049
5059
60

Survey Data

Female/Male
Ratio

Female/Male
Ratio

31.4
25.7
17.1
12.9
12.9

1.1
1.0
1.0
1.0
1.1

29.7
24.9
20.7
11.9
12.7

1.7
0.8
1.0
1.2
1.3

the pupil diameter was at least 6 mm. The study ophthalmologists

then examined the lens using the portable slit lamp. Nuclear
opalescence and brunescence were assessed with a narrow slit
beam, and cortical and posterior subcapsular (PSC) opacities were
assessed with retroillumination. Lens opacity was graded according to modified LOCS III charts, using the standard color photographs for comparison.
A team of 7 ophthalmologists was trained 2 weeks before the
studys commencement on assessment of lens opacity using the
LOCS III. The ophthalmologists were standardized between themselves such that the weighted score was not 0.7 for any 2
investigators.

*United Nations Statistics division common database, 1990. Available at: http://unstats.un.org/unsd/cdbdemo/cdb_advanced_data_extract_
fm.asp?HSrID14890&HCrID360&HYrID1990&ofIDr&txtSS
NewSelectionName. Accessed January 1, 2005.

Diagnostic Definitions

were located near a paper and pulp manufacturing plant that was
providing assistance for a larger community study on the effect of
pollution. The villages were fairly representative of rural Indonesia
in terms of age distributions and gender ratios, with the exception
of a higher proportion of women to men in the 20- to 29-year age
group (Table 1).
A random sample of all adults aged 21 years or older living in
the 3 villages was assessed. All houses in the villages were
individually mapped and assigned a number by an enumeration
team. A 1-stage cluster sampling strategy of 190 randomly selected
houses per village was adopted, whereby the sampling unit was the
housing unit, and all houses in the 3 villages were part of the
sampling frame. Because Rantau Baru had only 152 houses, all
were selected. Membership of a household was defined as habitual
occupation with a presence in that house for at least 2 weeks of the
preceding 4 weeks.
One thousand eighty-nine adults 21 years of age and older were
selected to take part in this study. Examinations were performed on
919, a participation rate of 84.4%. Nonparticipants included noncontactibles (despite visits to the house on 3 separate occasions)
and refusals. These numbered 64 and 106 persons, respectively.
Nine hundred fourteen subjects provided data for analysis. Of
the 5 subjects who did not provide data, 3 did not undergo
pupillary dilatation because of the presence of occludable angles
on gonioscopy, and 2 subjects had missing data. Three hundred
fifty-two of 919 (38%) were from Pelalawan, 324 of 919 (35%)
from Sering, and 243 of 919 (26%) from Rantau Baru.
Informed written consent was obtained from all subjects, and
all were treated in accordance with the tenets of the Declaration of
Helsinki. Approval for the study was obtained from the ethics
committee of the Singapore Eye Research Institute.

Questionnaire

A decimal grade ranging from 0.1 to 5.9 (for cortical and PSC) or
6.9 (for nuclear), using 0.1-unit intervals was assigned to each
region of the lens. Nuclear cataract was defined as a LOCS III
score of 4.0 or more for nuclear opalescence or 4.0 or more for
nuclear color, a LOCS III score of 2.0 or more for cortical cataract,
and a LOCS III score of 2.0 or more for PSC cataract. Any cataract
or cataract surgery was defined as the presence in either eye of any
cataract in any region (as preceding) or a history of previous
cataract surgery. These definitions have been used previously.8 We
analyzed any cataract in a person as follows: any nuclear, any
cortical, any PSC. We also analyzed distinct types of cataract in
the right eye: nuclear only, cortical only, PSC only, or mixed.
Right eye data were used, because results from left eye data were
similar. If a person had cataract surgery in 1 eye or an ungradable
lens, the LOCS III score of the fellow eye was used to determine
person-based rates.

The questionnaire was translated into Bahasan Indonesian and

back-translated into English. Any discrepancies between the original and translated versions were resolved. Household interviews
were conducted in Bahasan Indonesian by trained interviewers
conversant in Indonesian and English. Information obtained from
the individual questionnaire included total family income and
highest level of education for that individual. Total family income
per month was divided into 6 categories: 200,000, 200,000 to
500,000, 500,000 to 1 million, 1 to 2 million, 2 to 3 million, and
3 million Indonesian rupiah. Highest education level was classified as no formal education, primary education (defined as having
attended school for the compulsory 9 years), secondary education
(schooling for more than 9 years), and higher (university or polytechnic). Main occupation was defined as the job the subject
performed that provided the greater part of their income on the
basis of 15 different categories in the questionnaire.

Ocular Examinations
The anterior segment of both eyes was examined by an ophthalmologist using a portable slit lamp (SL-14, Kowa, Tokyo, Japan),
and the depth of the anterior chamber at the limbus was estimated.
If this was less than 25% of the corneal thickness, gonioscopy was
performed (Goldmann 2-mirror lens, Haag-Streit, Berne, Switzerland) without indentation and in darkened conditions and low
ambient illumination. If the angle was found to be occludable
(defined as inability to see the posterior trabecular meshwork for
90 of the angle circumference), pupillary dilatation was not
performed because of the risk of provoking acute angle closure.
The pupils of all other subjects were dilated with topical 1%
tropicamide (Alcon-Couvruer, Puurs, Belgium) and 2.5% phenylephrine hydrochloride (Alcon Laboratories, Fort Worth, TX) until

1256

Data Analysis
The prevalence rates and 95% confidence intervals of any cataract
were estimated, allowing for clustering by villages and households. The prevalence rates were estimated for adults of different
gender, age groups, and socioeconomic status. Logistic regression
models, allowing for household clustering, were used to estimate
the effects of different risk factors for cataract, adjusting for
potential confounders. The P values quoted are 2-sided; they are
considered statistically significant when values are 0.05. Data
analysis was conducted using STATA version 7.0. A sample size
of 833 was needed to detect a prevalence rate of cataract of 25.0%
and allowable difference of 2.5%, if the type I error, , was 0.05.

Husain et al Prevalence of Cataract in Rural Indonesia

Table 2. Lens Opacity Grade by Age Group and Gender in Indonesia
Nuclear Opalescence Grade

Men
2129
3039
4049
5059
60
Women
2129
3039
4049
5059
60

Total

Mean

101
124
94
50
50

27
20
4
1
0

45
57
25
9
1

25
25
26
17
7

3
22
20
12
8

1
0
19
11
34

1.1
1.4
2.3
2.5
3.5

171
104
95
59
64

56
17
6
0
1

56
35
20
7
1

53
23
31
17
3

6
23
20
17
17

0
6
18
18
42

Total

101
124
94
50
50

95
112
62
33
17

4
5
12
7
7

0
4
11
2
9

171
104
95
59
64

171
88
71
29
23

0
6
7
11
9

0
1
8
10
9

Nuclear Color Grade

0

Mean

1
1
2
2
4

26
20
5
1
0

50
57
21
8
1

21
28
29
18
7

3
19
20
13
9

1
0
19
10
33

1.0
1.4
2.3
2.5
3.5

1
1
2
2
4

1.1
1.7
2.3
2.8
3.5

1
1.5
2
3
4

57
17
7
1
3

59
35
18
6
1

48
29
31
17
3

7
17
23
17
12

0
6
16
18
45

1.0
1.6
2.2
2.8
3.5

1
1.5
2
3
4

Mean

Median

Mean

Median

1
3
6
5
10

1
0
3
3
7

0.1
0.2
0.7
0.8
1.7

0
0
0
0
2

100
124
87
42
29

0
0
2
3
4

1
0
4
2
11

0
0
0
2
4

0
0
1
2
4

0.0
0.0
0.2
0.3
0.9

0
0
0
0
0

0
6
9
8
10

0
3
0
1
13

0.0
0.4
0.5
1.0
1.7

0
0
0
1
1.5

171
99
90
48
35

0
1
1
6
2

0
3
4
3
11

0
1
0
1
12

0
0
0
1
3

0.0
0.1
0.1
0.3
1.1

0
0
0
0
0

Median

Cortical Cataract Grade

Men
2129
3039
4049
5059
60
Women
2129
3039
4049
5059
60*

Median

Posterior Subcapsular Cataract Grade

*For women 60 years or older, only 63 provided data for posterior subcapsular cataract grade (in 1 subject no view was obtained).

Results
Of the 914 subjects who provided data for this study, 897 provided a
LOCS III score for all regions of the lens for both eyes. Nine hundred
four provided data of for all lens regions of the right eye only.
Mean age of subjects examined was 39.9 years (range, 21 86
years). Four hundred twenty-one of 914 (46.1%) were male. Most
of the subjects (708 of 914 [77.5%]) had primary education or less,
with 221 of 914 (24.2%) having had no formal education. Median
household income was 500,000 to 1,000,000 Indonesian rupiah per
month (approximately US$60 120, based on exchange rate at the
time of the survey). Seven hundred forty-four of 914 (81.4%) had
a total household income of less than 1,000,000 rupiah per month
(US$120). More than 50% of the men were fishermen or farmers,
with more than 60% of women describing themselves as homemakers. Fish from the Kampar River and locally grown vegetables
constituted the main dietary intake. All subjects in this survey were
of the Malay race.
Table 2 shows the number of subjects with each grade of lens
opacities for different age groups. There were 132 adults with a
nuclear opalescence grade of 0 (14.4%), 137 adults with a nuclear
color grade of 0 (15.0%), 701 adults with a cortical cataract grade
of 0 (76.7%), and 825 adults with a PSC grade of 0 (90.2%). As
expected, both for men and women, the mean LOCS III score for
each region of the lens increased with age. Overall, women tended
to have higher mean scores for each region.
Table 3 shows the prevalence of any cataract, any cataract or
cataract surgery, and any cataract subtype for men and women of
different ages. Overall, 201 of 914 (22.0%) subjects were found to
have cataract. The age-adjusted prevalence rate of cataract (direct
standardization to the 1990 Indonesian population census) was

23.0% (95% confidence interval (CI), 20.8 25.2). For cataract or

cataract surgery, the age-adjusted prevalence rate was 23.1% (95%
CI, 20.9 25.3). For adults older than 40 years of age, the crude
prevalence rate for any cataract or cataract surgery was 43.5%
(95% CI, 0 100). The prevalence of different types of cataract in
those older than 40 years of age is displayed in Table 4. In those
older than 50 years of age, the crude prevalence rate for any
cataract or cataract surgery was 59.6% (95% CI, 6.3100).
Cataract prevalence as a whole (Fig 1) and by subtype increased significantly with age for both genders (P for trend
0.001). There was no significant difference between the rates for
men or women (P0.05) for any of the age groups analyzed,
except for the age group 30 to 39 years. For this group, 6 of 104
(5.8%) women had nuclear cataract compared with 0 of 124 for
men (P 0.02).
For subjects aged older than 60 years, 55 of 65 (84.6%) women
and 41 of 51 (80.4%) men had cataract or had had cataract surgery.
This is approximately 18 times as prevalent as in those younger
than 40 years of age. Cortical cataract was as prevalent as nuclear
at all age groups except those older than 60 years, in whom nuclear
was more prevalent (69.3% compared with 50.9%, respectively,
both genders). Posterior subcapsular cataract was less prevalent,
having approximately half the rate of nuclear for all age groups
(age-adjusted prevalence of 7.9% and 16.3%, respectively).
There was an inverse relationship between cataract of all types
and increasing level of highest education attained. One hundred
five of 220 (47.7%) of those with no formal education had some
form of cataract compared with only 15 of 203 (7.4%) of those
with higher than primary level. This trend was significant for all
cataract types (P0.001). No such trend was evident for analysis
by level of household income except in the case of PSC cataract,

1257

Ophthalmology Volume 112, Number 7, July 2005

Table 3. Prevalence of Any Cataract, Any Nuclear Cataract, Any Cortical
Any Cataract

Men
2129
3039
4049
5059
60
All men
P for trend
Women
2129
3039
4049
5059
60
All women
P for trend
Total
2129
3039
4049
5059
60
All adults (age-adjusted % in bold)
P for trend

101
124
94
50
51
420

3
7
24
13
41
88

3.0
5.6
25.5
26.0
80.4
21.0

171
104
95
59
65
494

0
11
22
25
55
113

272
228
189
109
116
914

3
18
46
38
96
201

Any Cataract or Cataract

95% Confidence
Interval

95% Confidence
Interval

0.08.7
0.029.7
0.0100.0
0.099.0
45.4100.0
0.058.1
0.001

101
124
94
50
51
420

3
7
24
13
43
90

3.0
5.6
25.5
26.0
80.4
21.0

0.08.7
0.029.7
0.0100.0
0.099.0
45.4100.0
0.058.1
0.001

0.0
10.6
23.2
42.4
84.6
22.9

0.00.0
0.055.2
0.0100.0
0.0100.0
50.8100.0
0.062.2
0.001

171
104
95
59
65
494

0
11
23
25
58
117

0.0
10.6
24.2
42.4
84.6
23.1

0.00.0
0.055.2
0.0100.0
0.0100.0
50.8100.0
0.062.0
0.001

1.1
7.9
24.3
34.9
82.8
23.0

0.03.4
0.041.4
0.0100.0
0.0100.0
49.1100.0
20.825.2
0.001

272
228
189
109
116
914

3
18
47
38
101
207

1.1
7.9
24.9
34.9
82.8
23.1

0.03.4
0.041.4
0.0100.0
0.0100.0
49.1100.0
20.925.3
0.001

where those with less income (200,000 rupiah) tended to have

higher prevalence than individuals who reported incomes of
1,000,000 or more per month.
The prevalence of distinct regional cataracts for the right eye is
shown in Table 5. The most common type of cataract for both
genders was mixed (11.8%; 95% CI, 0 42.7) followed by nuclear
only (5.0%; 95% CI, 0.8 9.2), and cortical only (3.8%; 95% CI,
0 8.4). Women tended to have higher prevalence rates than men
for all regions of the lens except cortical, although this was not
statistically significant, except in the age group 30 to 39 years,
where 5 of 104 (4.8%) women had mixed cataract compared with
none in the men. For men, nuclear only, cortical only, and mixed
cataract showed an increased prevalence with age (P0.01). There
were no male patients with PSC cataract only for any age group.
For women, this trend of increasing prevalence with increasing age

was evident for all types of cataract except PSC (P 0.137). The
most common types of cataract, mixed and nuclear only, also
showed an increase in prevalence with decreasing level of education (P0.001). Fifty-three of 215 (24.7 %) subjects with no
formal education had mixed cataract compared with only 4 of 203
(2.0%) for those with higher than primary level education. An
inverse relationship between higher income and prevalence of
nuclear only cataract was also evident (P0.001).
Only 6 subjects had undergone cataract surgery, none of whom
had had bilateral surgery. Of these, only 2 subjects had had an
intraocular lens implant, and in both of these eyes, there was
clinically significant posterior capsular thickening. Of the 4 subjects left aphakic, 3 were in possession of aphakic spectacles.
There was no association between level of income or education on
the rates of cataract surgery.

Table 4. Prevalence of Cataract and Cataract Type in Those Aged over 40 Years by Gender in Indonesia
Any Cataract or Cataract
Surgery

Men
Women
Total

(95%
Confidence
Interval)

195
219
414

78
102
180

40.0
46.6
43.5

0.0100.0
0.0100.0
0.0100.0

Any Nuclear Cataract

194
218
412

65
82
147

Nuclear Cataract Only

Men
Women
Total

1258

(95%
Confidence
Interval)

194
218
412

19
28
47

9.8
12.8
11.4

0.815.8
3.022.7
4.118.7

Any Cortical Cataract

(95%
Confidence
Interval)

33.5
37.6
35.7

0.095.6
0.0100.0
0.0100.0

194
218
412

56
68
124

194
218
412

8
14
22

(95%
Confidence
Interval)

(95%
Confidence
Interval)

28.9
31.2
30.1

0.091.4
0.094.2
0.092.6

194
217
411

27
35
62

13.9
16.1
15.1

0.038.1
0.038.3
0.037.9

Posterior Subcapsular
Cataract Only

Cortical Cataract Only

Any Posterior Subcapsular

Cataract

(95%
Confidence
Interval)

4.1
6.4
5.3

0.77.5
0.015.8
0.011.9

194
217
411

1
2
3

0.5
0.9
0.7

(95%
Confidence
Interval)
0.03.0
0.02.4
0.21.2

Mixed Cataract

195
219
414

50
58
108

25.6
26.5
26.1

(95%
Confidence
Interval)
0.088.7
0.089.6
0.089.1

Husain et al Prevalence of Cataract in Rural Indonesia

Cataract, or Any Posterior Subcapsular Cataract by Age and Gender in Indonesia
Any Nuclear Cataract
N

101
124
94
50
50
419

1
0
20
11
34
66

1.0
0.0
21.3
22.0
68.0
15.8

171
104
95
59
64
493

0
6
19
18
45
88

272
228
189
109
114
912

1
6
39
29
79
154

95% Confidence
Interval

Any Cortical Cataract

N

0.05.1
0.00.0
0.098.1
0.087.8
9.1100.0
0.043.6
0.001

101
124
94
50
50
419

2
7
20
10
26
65

2.0
5.6
21.3
20.0
52.0
15.5

0.0
5.8
20.0
30.5
70.3
17.8

0.00.0
0.030.1
0.089.8
0.0100.0
11.3100.0
0.055.1
0.001

171
104
95
59
64
493

0
10
17
19
32
78

0.4
2.6
20.6
26.6
69.3
17.7

0.01.9
0.013.8
0.094.0
0.0100.0
10.1100.0
15.619.8
0.001

272
228
189
109
114
912

2
17
37
29
58
143

95% Confidence
Interval

Any Posterior Subcapsular Cataract

95% Confidence
Interval

0.09.7
0.029.7
0.098.1
0.088.2
0.0100.0
0.053.2
0.001

101
124
94
50
50
419

1
0
5
5
17
28

1.0
0.0
5.3
10.0
34.0
6.7

0.04.9
0.00.0
0.020.1
0.042.1
0.090.6
0.018.8
0.001

0.0
9.6
17.9
32.2
50.0
15.8

0.00.0
0.050.2
0.092.5
0.0100.0
9.790.3
0.051.9
0.001

171
104
95
59
63
492

0
4
4
5
26
39

0.0
3.8
4.2
8.5
41.3
7.9

0.00.0
0.020.1
0.021.8
0.049.1
20.562.0
0.021.0
0.001

0.7
7.5
19.6
26.6
50.9
16.3

0.03.7
0.039.1
0.095.5
0.0100.0
7.993.9
14.118.5
0.001

272
228
189
109
113
911

1
4
9
10
43
67

0.4
1.8
4.8
9.2
38.1
7.9

0.01.9
0.09.2
0.020.9
0.045.6
4.971.2
6.29.6
0.001

Discussion
From this large prevalence survey, the age-adjusted prevalence of cataract in adults aged 21 years and older in rural
Sumatra, Indonesia, was found to be 23%, whereas the
age-adjusted prevalence rate of cataract or any cataract
surgery was 23.1% (95% CI, 20.9 25.3). The cataract rates
decreased with increasing level of education and, as expected, increased with age. The predominant type of cataract was mixed, followed by nuclear only, cortical only, and
PSC only. Our findings reveal a relatively high rate of
cataract in a young adult population. In those aged younger
than 40 years, cortical cataract was the most common type.
Comparison of cataract prevalence rates between countries is important for several reasons. First, it allows a
quantitative assessment of the burden of the disease on the

population, which allows health care planners to allocate the

appropriate amount of resources. Second, if the prevalence
rate is found to be comparatively high, unique risk factors
may be identified, and interventions can be set in place to
lower the incidence of cataract. However, comparisons between surveys are notoriously difficult because of differences in subject selection, sampling strategies, and definitions of cataract. We have attempted to compare the
prevalence rate from our study with 4 other studies that have
used the LOCS III grading system. We have used our data,
but, in the case of the studies from India and Singapore, we
adjusted to their population census data to allow for a more
meaningful comparison. The results are shown in Table 6.
From these results it can be seen that the prevalence rate in
rural Indonesia is similar to the rate in Southern India9 and
higher than in Singapore,8 England,10 and Taiwan.11 The

Figure 1. Cataract and cataract surgery prevalence in different age groups.

1259

Ophthalmology Volume 112, Number 7, July 2005

Table 5. Prevalence of Nuclear Cataract Only, Cortical Cataract Only, Posterior Subcapsular Cataract Only, and Mixed Cataract by
Age and Gender in Indonesia
Nuclear Cataract Only

Men
2129
3039
4049
5059
60
All men
P for trend
Women
2129
3039
4049
5059
60
All women
P for trend
Total
2129
3039
4049
5059
60
All adults
(ageadjusted %
in bold)
P for trend

101
124
94
50
50
419

1
0
4
2
13
20

1.0
0.0
4.3
4.0
26.0
4.8

171
104
95
59
64
493

0
0
5
5
18
28

272
228
189
109
114
912

1
0
9
7
31
48

(95%
Confidence
Interval)

0.05.1
0.00.0
0.020.9
0.015.7
0.054.9
3.65.9
0.001

101
124
94
50
50
419

1
7
3
0
5
16

1.0
5.6
3.2
0.0
10.0
3.8

0.0
0.0
5.3
8.5
28.1
5.7

0.00.0
0.00.0
0.013.8
0.029.5
12.044.2
2.58.8
0.001

171
104
95
59
64
493

0
4
3
6
5
18

0.4
0.0
4.8
6.4
27.2
5.7

0.01.9
0.00.0
0.017.2
0.022.9
16.038.4
4.27.1

272
228
189
109
114
912

1
11
6
6
10
34

0.001

(95%
Confidence
Interval)

0.04.9
0.029.7
0.015.7
0.00.0
0.032.5
0.011.9
0.129

101
124
94
50
50
419

0
0
0
1
0
1

0.0
0.0
0.0
2.0
0.0
0.2

0.0
3.8
3.2
10.2
7.8
3.7

0.00.0
0.020.1
0.016.3
0.043.6
0.017.7
0.08.7
0.001

171
104
95
59
63
492

0
1
0
1
1
3

0.4
4.8
3.2
5.5
8.8
4.0

0.01.9
0.025.3
0.016.0
0.024.5
0.024.4
2.75.3

272
228
189
109
113
911

0
1
0
2
1
4

0.002

pattern of cataract is also similar, with most being of the

mixed type. However, in our survey, we found a greater
proportion of subjects with PSC cataract than in Singapore
or Taiwan and a similar proportion to that in southern India.
Often, the marked differences between cataract prevalence rates between countries can be attributed broadly to
differences in environment and/or differences in genetics
(i.e., race). There is evidence that race influences the type
and prevalence of cataract, but the extent of this is unclear
and warrants further investigation.12 In terms of environmental influences, a number of risk factors for cataract
development that have been examined by other studies may
explain the high rates of cataract in Indonesia. Ultraviolet
light is one of the most consistently cited risk factors for
development of opacity in all lens regions, especially cortical and PSC.1315 Indonesias location, straddling the
equator, in combination with the rural setting for this survey, makes it likely that our subjects were exposed to high
levels of sunlight.16 Smoking may also account for the high
cataract rates, because a history of smoking is particularly
associated with the development of nuclear opacity.17,18
Data published by the World Health Organization have
found that 31.4% of the Indonesian population smoke; this
prevalence rate is one of the highest in the world.
As expected, prevalence of cataract increased with age
for both genders. Age is likely to be representative of other
variables such as duration of exposure to ultraviolet light. A
trend toward higher prevalence in women was evident for

1260

Posterior Subcapsular
Cataract

Cortical Cataract Only

(95%
Confidence
Interval)

Mixed Cataract
(95% Confidence
Interval)

0.00.0
0.00.0
0.00.0
0.012.6
0.00.0
0.01.4
0.273

101
124
94
50
51
420

1
0
17
10
23
51

1.0
0.0
18.1
20.0
45.1
12.1

0.04.9
0.00.0
0.082.4
0.088.2
0.0100.0
0.042.2
0.001

0.0
1.0
0.0
1.7
1.6
0.6

0.00.0
0.05.0
0.00.0
0.09.8
0.07.4
0.02.0
0.137

171
104
95
59
65
494

0
6
14
13
31
64

0.0
5.8
14.7
22.0
47.7
13

0.00.0
0.030.1
0.076.1
0.0100.0
17.478.0
0.045.4
0.001

0.0
0.4
0.0
1.8
0.9
0.4

0.00.0
0.02.3
0.00.0
0.07.4
0.04.0
0.00.8

272
228
189
109
116
914

1
0.4
6
2.6
31 16.4
23 21.1
54 46.6
115 13.0

0.01.9
0.013.8
0.079.5
0.0100.0
0.094.6
11.015.0

0.069

0.001

all regions of the lens, although this was only statistically

significant for the nuclear region in the age group 30 to 39.
This female preponderance has been reported in many studies, and the reason is unclear. The link between hormone
replacement therapy use and cataract has been proposed
before, and although hormone replacement therapy use was
not assessed for this survey, it is unlikely that many subjects
were taking this medication.
The association that we found between cataract and level
of education has also been reported in studies from India,19
the United States,20 and Italy.21 Education may also act as a
surrogate for cataract lifestyle factors such as occupation,
outdoor activity, and smoking. Any initiative started by
health care organizations in terms of identifying at-risk
groups would need to consider those with low levels of
education, many of whom are illiterate.
Despite the high prevalence rate of cataract in rural
Indonesia and the fact that it is the leading cause of blindness in the region, there seems to be very little provision to
tackle this problem. Unoperated cataract in the developing
world remains ophthalmologys major unsolved problem.22
In our survey, we found only 6 subjects who had had
cataract surgery, only 2 of whom had had an intraocular lens
implanted. These 2 had posterior capsular opacification
develop and were likely to have poor vision. Approximately
5% of subjects examined in the Singapore survey had undergone cataract surgery compared with only 0.7% in our
study.8 This may not be surprising, given Singapores status

Husain et al Prevalence of Cataract in Rural Indonesia

Table 6. Cataract Prevalence Rates from Selected Studies
Study (Country)
Aravind
Comprehensive
Eye Study
(India)
Tanjong Pagar Eye
Survey
(Singapore)
Speedwell
Cardiovascular
Study (United
Kingdom)
Taiwan**

Definition of Cataract
using LOCS III

Population

Prevalence Rate

Present Study Prevalence

Rate*

NO3.0 and/or
CO3.0 and/or
PS2.0

40 yrs

61.9%

62.8% (95% CI, 58.767.0)

NO4.0 and/or
CO2.0 and/or
PS2.0 and/or
having had cataract
surgery
NO3.0 and/or
NC3.0 and/or
CO2.0 and/or
PS2.0
NO2.0 and/or
CO2.0 and/or
PS2.0 and/or
having had cataract
surgery

40 yrs

34.7%

43.4% (95% CI, 39.347.5)

4583 yrs and

male only

44.1%#

63.7% (95% CI, 0.6100.0)

65 yrs

59.2%#

97.4% (95% CI, 83.7100.0)

CI confidence interval; CO cortical score; LOCS Lens Opacities Classification System; NC lens color score; NO nuclear opalescence score;
PS posterior subscapsular score.
*Using the relevant studys definition of cataract and age range.

Nirmalan PK, Krishnadas R, Ramakrishnan R, et al. Lens opacities in a rural population of southern India; the Aravind Comprehensive Eye Study. Invest
Ophthalmol Vis Sci 2003;44:4639 43.

Age-adjusted to US population census 2000 (Indian population data not available).

Seah SK, Wong TY, Foster PJ, et al. Prevalence of lens opacity in Chinese residents of Singapore: The Tanjong Pagar survey. Ophthalmology
2002;109:2658 64.

Age-adjusted to Singapore population census 1997.

Stocks N, Patel R, Sparrow J, Davey-Smith G. Prevalence of cataract in the Speedwell Cardiovascular Study: a cross-sectional survey of men aged 45 83.
Eye 2002;16:275 80.
#
Crude (unadjusted) rate; age-adjusted rate unavailable.
**Tsai Sy, Hsu WM, Cbeng Cy, et al. Epidemiologic study of age-related cataracts among an elderly Chinese population in Shih-Pai, Taiwan.
Ophthalmology 2003;110:1089 95.

as a developed nation and its urban profile. Similar figures

of cataract surgery rates are found in Western countries,
such as in the Beaver Dam survey (7%) and in Australia
(6%). However, surveys in other rural Asian settings such as
India have revealed cataract surgery rates as high as 9.4%.9
The rate in Indonesia is comparable to rural Tanzania,
which had a cataract surgery prevalence rate of 0.3% to
0.4%.23 The high prevalence of PSC cataract in our population makes it likely that visual function was compromised
to a greater degree than in Tanzania or Singapore, which
had PSC prevalence rates of 1.9% and 7%.8,23 This puts the
low number of cataract surgeries being performed into
perspective and highlights the need to address this issue.
The high prevalence rate of cataract in Indonesia, the risk
factor profile, and the low rate of effective cataract surgeries
being carried out to tackle the problem have significant
public health implications for Indonesia. The impetus for
change must come from the Ministry of Health to set up an
effective and sustainable program. To this end, initiatives
have been made with the implementation of the Vision
20:20 The Right to Sight program. This has led to the
formation of a National Coordination Body and a National
Focal Person to address the issues involved. The Indonesian
Ophthalmologists Association has a scheme whereby if the
local health district manager can identify more than 25
subjects with cataract, a team is sent to perform surgery

(usually extracapsular) free of charge. The difficulty is in

identifying cases, and, therefore, in practice, this scheme is
not often implemented. Identification of suitable candidates
for cataract surgery and patient education and facilitating
access to ophthalmic services will probably best be achieved in
the rural setting with fully equipped mobile eye units.
The low number of trained ophthalmologists needs to be
increased and a skills transfer program set up. The use of
techniques such as extracapsular cataract extraction with
intraocular lens implantation needs to practiced such that
the quality of visual outcome is improved. The main restraint to the implementation of such a program in developing countries is cost. This can be reduced by actively
exercising cost-containment by using resources as efficiently as possible and using low-cost technologies. Subsidies, both internal and external, can be given to reduce costs
further.
This study is unique in the fact that we chose to examine
subjects older than 21 years of age. Most studies have
examined subjects 40 years of age or older, because cataract
is predominantly a disease of old age. We chose to examine
ages 21 to 39, because this age range is often neglected in
prevalence studies, and, yet, this is the age at which people
are most likely to be productive members of the workforce
and are likely to have dependents. In our study, 21 of 500
(4.2%) subjects aged 21 to 39 had cataract. Neglecting this

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Ophthalmology Volume 112, Number 7, July 2005

portion of the population may be underestimating the prevalence of cataract in the population.
For this survey, a number of methodologic issues need to
be addressed. The sample size was relatively small and
included all adults older than 21 years of age. Only 414
subjects were 40 years or older, a small number given the
predilection of cataract to affect the elderly. However, the
rates of cataract, even in younger adults, were not low. The
prevalence of opacities in the PSC region alone was low and
resulted in insufficient power to detect small differences in
subgroup analyses. We were unable to obtain demographic
data on the nonparticipants and were, therefore, unable to
assess any differences among the nonparticipants. The study
population was taken from only 3 villages and may not be
representative of entire rural Indonesia.
In conclusion, cataract prevalence in adults 21 years of
age and older in rural Indonesia is among the highest
reported in Southeast Asia. However, the rates of cataract
surgery are very low. The predominant type of cataract is
mixed, followed by nuclear only, cortical only, and PSC
only. Data on the prevalence of cataract in Indonesia, one of
the most populous countries in the world, will enable health
care planners to direct resources appropriately.

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