Aim: To estimate the rates of cataract blindness and cataract surgical coverage and to assess the visual outcome of cataract surgery among individuals aged > or =50 years in Orakzai Agency, Pakistan.

Methods: 1600 individuals aged > or =50 years were selected using probability proportional to size sampling. The main outcome measure was bilateral cataract blindness which was defined as visual acuity of <3/60 in the better eye with best available correction and with obvious central lens opacities/absence of red reflex in both eyes.

Results: A total of 1549 people were examined; the coverage rate was 96.8%. Of individuals who were examined, 958 (61.8%) were men. The overall prevalence of bilateral cataract blindness was 4.8% (95% CI: 3.8% to 5.9%). Women had a 2.1-fold greater prevalence of bilateral cataract blindness than men (7.1% (5.0% to 9.2%) v 3.4% (2.3% to 4.6%); p = <0.0001). However, cataract surgical coverage rates were lower for women than men. The overall quality of previous cataract surgery was poor: 43.1% eyes with cataract surgery had VA <6/60. 73.3% people with bilateral cataract blindness reported they could not undergo cataract surgery because they were too poor to afford its cost.

Conclusion: The unacceptably high rates of cataract blindness and poor affordability and visual outcome of cataract surgery calls for the establishment, in the agency, of static cataract surgical services that are high quality, affordable, and gender sensitive.