Prevalence and associated factors of cataract in Ethiopia: a systematic review and meta-analysis

Abstract

Background:

Cataract poses a significant burden in Ethiopia and was given priority in the WHO’s VISION 2020 program. However, there is limited pooled information on the extent of cataract and determinant factors in Ethiopia.

Objective:

The objective of the study is to provide updated data on the pooled prevalence of cataract and associated factors to develop effective intervention strategies, particularly for addressing modifiable risk factors.

Design:

The study utilized a systematic review and meta-analysis design.

Data source and methods:

The study was registered with the International Prospective Register of Systematic Reviews. Relevant published articles were searched in PubMed, EMBASE, Wiley Online Library, CINAHL/EBSCO, Wolters Kluwer, Cochrane Library, Science Direct, Google Scholar, and African Journal Online. Data were extracted using Microsoft Excel, and Meta-analysis was performed using STATA version 17.

Results:

In this study, the pooled prevalence of cataract in Ethiopia is estimated to be 32.30% (95% CI: 20.72−43.89, I² = 99.2%). Age ⩾ 70 years old (Pooled odds ratio; POR = 9.03, 95% CI: 2.21–36.85), diabetes mellitus (POR = 3.31, 95% CI: 1.61–6.82), sunlight exposure (POR = 1.95, 95% CI: 1.53–2.47) and hypertension (POR = 4.09, 95% CI: 2.98–5.61) were associated with cataract.

Conclusion:

Despite progress in cataract control, the pooled prevalence of cataract in Ethiopia remains high. The pooled estimates for associated factors were based on a limited number of studies, including diabetes mellitus (two studies), hypertension (two studies), sunlight exposure (two studies), and age ⩾70 years (three studies); therefore, these findings should be interpreted cautiously.

Trial registration:

CRD42022377695.

Plain language summary

Understanding cataracts in Ethiopia: a summary of studies

Cataracts are a common eye problem that can make vision cloudy or blurry and may eventually lead to blindness if untreated. In Ethiopia, many people are affected by cataracts, but the exact number and outcomes of treatment have not been clear. This study looked at all the research done in Ethiopia on cataracts to understand how common they are, who is most affected, and how well treatments, like surgery, are working. By combining the results from many studies, we provide a clearer picture of the cataract situation in the country. Our findings highlight the need for better access to eye care, earlier detection, and effective treatment to prevent vision loss in Ethiopia.

Keywords

associated factors cataract Ethiopia meta-analysis systematic review

Introduction

Cataract is the main cause of vision loss and the second most common cause of visual impairment in the world.¹ Cataract is characterized by progressive reduction of lens transparency.² When the entire cortex of the lens, extending from the nucleus to the capsule, turns opaque, it obstructs light passage, leading to progressive reduction in vision.³ There are four types of cataracts, namely traumatic, congenital, age-related or senile cataracts, and secondary cataracts.⁴ Among these, age-related cataract is the most prevalent type of cataract globally.⁵ In many developing countries, a significant number of cataract patients remain blind due to limited access to appropriate surgical services.¹

Cataracts are a significant cause of visual impairment, affecting individuals across all age groups, thereby placing an escalating strain on healthcare systems.⁶ More than 100 million individuals living in the world suffer from cataracts.⁷ Approximately 70 million people globally suffer from bilateral blindness caused by cataracts.⁸ As the population ages, the incidence of cataract-related blindness is increasing.⁹ In 2020, an estimated 15.2 million people aged 50 and older were blind, with an additional 78.8 million individuals globally experiencing moderate to severe vision impairment due to cataracts.¹⁰ In low- and middle-income countries, where the majority of individuals with cataract-related visual impairment live, access to simple and affordable cataract treatment is limited.¹¹ Currently, cataract surgery is the only treatment that can effectively treat all types of cataracts, but people living in developing countries have limited access to eye care services due to a shortage of facilities, high fees, and transportation costs.¹¹ Cataracts represent a significant public health problem in sub-Saharan Africa, responsible for more than 46% of blindness cases.⁵

Cataract causes high economic loss, mortality, and decreased mobility and quality of life.¹² Preventing cataract occurrence in developing countries is a big problem.¹³ An estimated $5733 million investment is needed to eliminate cataract-related blindness.⁵

Cataract poses a significant burden in Ethiopia and was given priority in the WHO’s VISION 2020 program.¹⁴ Cataract remains one of the leading causes of visual impairment and blindness in Ethiopia, contributing substantially to the national burden of avoidable blindness. Despite the availability of effective surgical treatment, access to cataract services is limited in many parts of the country, resulting in a significant unmet surgical need and preventable visual disability. However, there is limited pooled information on the extent of cataract and determinant factors in Ethiopia. As a result, it is vital to provide updated data on the pooled prevalence of cataract and associated factors to develop effective intervention strategies and to provide evidence for policymakers in the significant allocation of health budgets for cataract treatment to eliminate cataracts. Therefore, the objective of this systematic review and meta-analysis was to determine the pooled prevalence and associated factors of cataract in Ethiopia.

Methods

Study design and protocol registration

This systematic review and meta-analysis were conducted following the protocol that was registered with International Prospective Register of Systematic Reviews (PROSPERO) (Reference number: CRD42022377695). The report was presented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA-2020) checklists¹⁵ (Supplemental File 1).

Data sources and searching strategy

Relevant published articles were searched in PubMed, EMBASE, Wiley Online Library, CINAHL/EBSCO, Wolters Kluwer, Cochrane Library, Science Direct, Google Scholar, and African Journal Online. The literature search was conducted from database inception to September 1, 2025, to identify all relevant studies reporting the prevalence and associated factors of cataract in Ethiopia. EndNote X7 reference manager software was used to collect, filter, and remove duplicate articles. In the search process, Medical Subject Headings (MeSH) were used. Keywords that were used in the search process were “cataract,” “lens opacity,” “visual disorders,” “clouding of lens,” “near opacity,” “crystalline opacity,” “determinants,” “associated factors,” “predictors,” and “Ethiopia.” The disagreements between the authors were resolved by group discussion. Two authors (W.C.T. and Y.A.F.) screened articles based on their title, abstract, and/or full text, utilizing Boolean operators “AND” and “OR” to combine search terms. The literature search was conducted using predefined search terms and Boolean operators tailored to each database. The full electronic search strategies for all databases are provided in the Supplemental Material to ensure transparency and reproducibility of the review process (Supplemental File 2).

Eligibility criteria

This review included published observational studies conducted in Ethiopia up to September 1, 2025, that reported cataract prevalence in community or health facility settings and were written in English. Unpublished, qualitative studies, case reports, conference papers, and prior reviews were excluded.

PICO

P (Population): Ethiopian population

I/E (Exposure): Associated/risk factors of cataract

C (Comparison): Individuals without exposure/risk factors

O (Outcome): Prevalence of cataract and associated factors.

Outcome of interest measurement/definition

Cataract was defined as clouding or loss of transparency of the lens within the posterior capsule, nucleus, and/or cortex of the eye, which is revealed with slit-lamp examination of the crystalline lens. A nuclear cataract (NC) was identified with a Lens Opacities Classification System III (LOCS III) score greater than 4 for nuclear opalescence or greater than 4 for NC. Similarly, a cortical cataract (CC) was indicated by an LOCS III score greater than 2 for CC, while a significant posterior sub-capsular cataract was identified with an LOCS III score greater than 2.¹⁶

Quality assessment

The quality assessment of the included studies was evaluated using the Joanna Briggs Institute (JBI) critical appraisal checklist.^17,18 Using the tool as a protocol, the authors (Y.A.F. and G.W.A.) used the blinded review approach to assess the quality of the primary articles. Those articles score 5 or more in the JBI criteria were included in the review. Further discrepancies in the quality assessment were resolved through another author (W.C.T.; Supplemental File 3).

Data extraction

After identifying articles for inclusion, two independent authors (G.W.A. and W.C.T.) conducted data extraction, using a standardized data abstraction template created in Microsoft Excel. The JBI tool was used for the data extraction. Extracted data items included the general information (primary author’s name, publication year, region/setting, study design, response rate, sample size, sampling technique, prevalence of cataract, and associated factors. Odds ratios of each variable were extracted from studies to determine factors associated with cataract. Each variable was associated with more than two primary studies to pool the odds ratios with each corresponding confidence interval. Any discrepancies between the two independent reviewers during data extraction were resolved through discussion and consensus; if disagreement persisted, a third reviewer was consulted to make the final decision.

Data synthesis

Data were extracted using Microsoft Excel, and Meta-analysis was performed using STATA version 17 (StataCorp LLC, College Station, TX, USA). Heterogeneity of studies was assessed by Cochran’s Q test and I² statistics. A p-value less than 0.05 represents the presence of statistically significant heterogeneity among the included studies.¹⁹ Heterogeneity was classified as no (I² = 0.0%), low (I² < 25%), moderate (25% ⩽I² ⩽ 75%), or high (I² > 75%).²⁰ The pooled prevalence of cataract along their corresponding 95% CI was presented using a forest plot. Because of the presence of heterogeneity among the included studies, a random-effects model was employed to estimate the pooled prevalence of cataract in Ethiopia.²¹ Specifically, among the methods of random effect, Der-Simonian–Laird random-effects models (D+L) were used to determine the pooled prevalence of cataract.²¹

Subgroup and sensitivity analysis

To identify the source of heterogeneity between the included studies, subgroup analysis was done using different parameters. In addition, meta-regression analysis was conducted using sample size, response rate, and publication year as covariates. Sensitivity analysis was also performed to check the effect of each study on the pooled prevalence of cataract.

Publication bias

In this meta-analysis, the presence of publication bias was evaluated using funnel plots and statistical Egger’s test.^22,23 A p-value less than 0.05 from Egger’s test indicated notable publication bias, implying that studies with larger effects (either positive or negative) are more likely to be published.²⁴ A trim and fill analysis was performed to address this publication bias.²⁵

Results

Study selection

About 1784 studies were retrieved from initial electronic searches using international databases. The database included 505 studies from PubMed, EMBASE (92), Wiley Online Library (129), CINAHL/EBSCO (50), Wolters Kluwer (12), Cochrane Library (16), Science Direct (17), African Journal Online (22), and Google Scholar (941). About 986 duplicate articles were removed, along with an additional 243 articles that were excluded as they did not conduct a similar study population. In addition, 523 articles were excluded during the title and abstract screening. The full texts of the remaining 32 articles were then assessed by two authors (W.C.T. and Y.A.F.) against the eligibility criteria and quality. In addition, some articles were excluded because they did not report the outcome of interest or the prevalence of cataract. Finally, 10 (10) studies with a total sample size of 5673 conducted on the prevalence of cataract were included in the analysis (Figure 1).

Overview of included studies

A total of 10 studies were included in the review. The studies included, published up until 2025, and comprised a total of 5673 participants, with sample sizes varying from 174 to 1121 participants. Five articles were obtained from the Amhara region,^26
–30 four were from the South region,^31,32 and the remaining were from Addis Ababa.^33,34 All the included articles were published in peer-reviewed journals. Regarding the study design, four studies utilized a facility-based cross-sectional study design. The prevalence of cataract ranged from 7.8% to 57% (Table 1).

Table 1.

Overview of included studies in the systematic review and meta-analysis of prevalence and associated factors of cataract in Ethiopia (n = 10).

Author name	Pub year	Region	Sampling technique	Sample size	Prevalence (%)	Study design	Diagnosis method
Wale et al.	2021	Amhara	Simple random	158	57	FBCS	Slit-lamp
Ferede et al.	2023	South	Simple random	734	29.16	CBCS	Visual acuity
Kentayiso et al.	2022	South	Simple random	359	7.8	CBCS	Visual acuity
Shumye et al.	2025	Amhara	systematic random	1100	42.2	FBCS	Slit-lamp
Tegegn et al.	2022	Amhara	Simple random	821	29.1	CBCS	Slit-lamp
Ahmed et al.	2021	Amhara	Simple random	528	20.1	CBCS	Snellen test
Abebe et al.	2021	Amhara	systematic random	325	20.8	FBCS	Slit-lamp + visual acuity
Getachew et al.	2024	South	systematic random	655	30.48	CBCS	Visual acuity
Cherinet et al.	2018	AA	systematic random	881	20.5	FBCS	Slit-lamp + visual acuity
Woldeyes et al.	2011	AA	systematic random	1100	66.7	CBCS	WHO criteria + visual acuity

Pooled prevalence of cataract

In this study, the pooled prevalence of cataract in Ethiopia is estimated to be 32.30% (95% CI: 20.72−43.89, I² = 99.2%, p-value = 0.000). Due to the presence of heterogeneity, a random-effects model was used to determine the pooled prevalence of cataract (Figure 2).

Subgroup analysis

The subgroup analysis based on study design revealed that the highest pooled prevalence of cataract is observed in studies that used facility-based cross-sectional studies, 34.84% (95% CI: 20.30–49.39, I² = 98.3%, p-value = 0.000). The subgroup analysis based on sampling technique revealed that the highest pooled prevalence of cataract was reported from studies that utilized systematic random sampling, 36.16% (95% CI: 18.13–54.19, I² = 99.4%, p-value = 0.000). For studies including adults aged ⩾40 years, the pooled prevalence of cataract was 28.6% (95% CI: 18.7–38.4). This suggests a relatively high burden of cataract in older adults, which is consistent with the known age-related nature of the disease. However, there was substantial variability across studies, indicating differences in study populations and settings. For studies that included adults aged ⩾18 years, the pooled prevalence was higher at 37.6% (95% CI: 15.2–59.9). This wider confidence interval and higher estimate suggest greater heterogeneity in this subgroup, likely driven by inclusion of studies with different population structures, including hospital-based samples and studies with older subpopulations.

The regional subgroup analysis shows variation in cataract prevalence across Ethiopia. The pooled prevalence was 33.5% in Amhara, 22.5% in the Southern region, and 43.6% in Addis Ababa. However, the estimate for Addis Ababa is unstable because of the small number of studies and the wide confidence interval. Overall, the findings indicate regional differences in cataract burden, with higher and more stable estimates in Amhara compared to other regions. After excluding the diabetic-only study, the pooled prevalence among adult populations is 31.2% (95% CI: 18.4–44.0). This indicates that cataract remains highly prevalent in the general adult population in Ethiopia, even without the influence of high-risk diabetic patients. The result suggests that diabetes may contribute to higher cataract burden, but it is not the sole driver of the overall prevalence.

Publication bias

The funnel plot displayed an even distribution of studies, suggesting the absence of publication bias. This observation was supported by Egger’s test, which yielded a statistically nonsignificant p-value of 0.373 at the 5% significance level, providing further evidence of the absence of publication bias (Figure 3).

Meta-regression

We further fitted meta-regression using the random-effects model on the aggregated study variables to assess heterogeneity. According to the meta-regression analysis, the number of participants and publication year were not significant, indicating the heterogeneity was not a result of these variables.

Sensitivity analysis

The subgroup analysis showed the presence of heterogeneity across the included studies. To assess the effect of each study on the overall estimate, a sensitivity analysis was performed. The results indicated that none of the individual primary studies significantly affected the pooled prevalence of cataract.

Factors associated with cataract

In the present analysis, the pooled effect of three studies showed that the odds of respondents in the age ⩾70 years were 9.03 times (Pooled odds ratio; POR = 9.03, 95% CI: 2.21–36.85) more likely to develop cataract than in the age of less than 70 years old. In addition, the pooled effect of two studies showed that the odds of having cataract were 3.31 (POR = 3.31, 95% CI: 1.61–6.82) times higher among diabetic participants when compared with participants who did not have diabetic mellitus. This study showed that those adults who spend ⩾6 h per day on average sunlight had odds of having cataract was 1.95 (POR = 1.95, 95% CI: 1.53–2.47) times higher compared with those adults who spend less than 6 hours per day. Finally, the pooled effects of two studies indicated that the odds of having cataract were 4.09 (POR = 4.09, 95% CI: 2.98–5.61) times higher among hypertensive participants when compared with participants who did not have hypertension (Figure 4).

Discussion

Despite ongoing efforts to reduce avoidable blindness, cataract remains highly prevalent in Ethiopia, partly due to limited access to cataract surgical services, shortages of trained ophthalmic personnel, and delayed health-seeking behavior among affected individuals. In addition, regional disparities in health service availability and sociocultural factors, including traditional beliefs and low awareness of eye health, may contribute to differences in cataract burden across the country. In this study, the pooled prevalence of cataract in Ethiopia is estimated to be 32.30% (95% CI: 20.72−43.89, I² = 99.2%, p-value = 0.000). The result of this review is higher than the results of studies done in Iran 9.27%,³⁵ Taiwan (10.7%),³⁶ China 27.45%,³⁷ Singapore (9.7%),³⁸ Indonesia (2.2%),³⁹ and Nepal (5.3%).⁴⁰ This may be due to differences in the type of studies, sample sizes, and accessibility to effective eye-care services. The other reason for the discrepancy might be due to the difference in economy and education between developed and low-income countries; the awareness of disease and the desirability of treatment are relatively low in low-income countries. This suggests that cataract screening to popularize the knowledge of cataract and the latest research progress is an effective method to reduce the prevalence of cataract in low-income countries, and carrying out cataract surgery camps in the local setting is the best and most efficient method for the reduction of cataract.

Compared with other African countries, the prevalence of cataract in Ethiopia is comparable or higher in some settings, reflecting a similar regional burden of avoidable blindness across sub-Saharan Africa. However, differences in health system capacity, cataract surgical coverage, and access to eye care services contribute to variability in reported estimates across countries. Ethiopia’s cataract surgical rate remains below the level required to address the existing burden of disease, indicating a substantial unmet need for cataract surgery. Strengthening surgical outreach services, increasing the ophthalmic workforce, and improving equitable access to eye care are essential to reduce avoidable blindness in the country

However, the pooled prevalence of cataract is lower than the findings of studies done in South India (44.6%), (47.5%),^16,41 and Myanmar (40.39).⁴² The reported prevalence rates of cataracts differ because of several factors. One reason is the lack of a clear definition for when a lens is opaque enough to be diagnosed as a cataract. In some studies, individuals were considered to have cataracts if lens opacities were detected through retro-illumination with indirect ophthalmoscopy, and these findings were also visible during slit-lamp bio-microscopy. This method likely underestimates the prevalence of cataracts compared to photographic techniques. A standardized grading system for lens opacity, such as LOCS III, should be favored in cataract population surveys. In addition, the age of the population being studied varies between studies, and age is a significant risk factor for cataract development. Lastly, including individuals who have had cataract surgery could influence the reported prevalence rates.

The pooled effect of three studies showed that the odds of respondents aged ⩾70 years or older were more likely to develop cataract than age of less than 70 years old. This finding was similar to studies conducted in Ghana, Nigeria, India, and China.^43
–46 As people age, the cell membranes, including the lens epithelial cells, which are responsible for maintaining the balance of ions and metabolism of the entire lens, may become damaged. This can lead to an accumulation of fluid inside the lens. Additionally, abnormal differentiation of lens fibers and the occurrence of an amino acid plug can occur, both of which contribute to the development of cataracts.⁴⁷

Additionally, the pooled effect of two studies showed that the chance of cataract development was higher among diabetic participants when compared with participants who did not have diabetic mellitus. The finding is similar to the result of studies done in South Africa,⁴⁸ Malaysia,⁴⁹ and Poland.⁵⁰ The possible reason for this result might be due to the metabolic changes and complications associated with diabetes over time, which can significantly contribute to the occurrence of cataract in older individuals. This could also be because of high blood sugar (blood glucose) levels, which can create an imbalance of water content in the crystalline lens that can accelerate the development of cataracts.

The study found that adults who spend 6 or more hours per day in sunlight had a higher likelihood of developing cataracts compared to those who spent less than 6 h daily in sunlight, which aligns with a study conducted in Korea.⁵¹ This is because ultraviolet radiation can damage lens proteins and cells, triggering oxidative stress that contributes to the formation of cataracts. Finally, the pooled effects of two studies indicated that the odds of having cataract were higher among hypertensive participants when compared with participants who did not have hypertension. This result is consistent with the findings of the Korean study.⁵¹ The development of cataracts is strongly associated with systemic inflammation and hypertension. Inflammation can cause structural changes in the proteins within the lens capsules, which worsens cataract formation. Additionally, some antihypertensive medications have been known to contribute to cataract development.⁵² The associated factors were pooled from a small number of studies, which may limit the precision and reliability of the estimates. Therefore, the observed associations should be interpreted with caution and should not be considered evidence of causality.

Limitations

A key strength of this study is the use of major databases for article retrieval. However, it has limitations: First, the meta-analysis showed extreme heterogeneity among included studies, which may affect the precision and interpretability of the pooled estimates. Second, the number of studies included for some risk factor analyses was small, limiting the robustness of these pooled associations. Third, the inclusion of both facility-based and community-based studies may have introduced potential overestimation of prevalence, particularly from facility-based samples. Fourth, the inclusion of a diabetic-only study may have influenced the overall pooled estimates. Finally, the assessment of publication bias was limited due to the small number of included studies, which may reduce the reliability of these tests.

Although 10 studies were included in this meta-analysis, the studies were not uniformly distributed across all regions of Ethiopia. This may limit the national representativeness of the findings and suggests the need for additional high-quality community-based studies in underrepresented areas of the country.

Conclusion and recommendations

Despite progress in cataract control, the pooled prevalence of cataract in Ethiopia remains high. These findings highlight the need to strengthen Ethiopia’s national eye health strategies, including expanding cataract surgical outreach programs, improving equitable access to services across regions, and enhancing community awareness to reduce preventable blindness. The pooled estimates for associated factors were based on a limited number of studies, including diabetes mellitus (two studies), hypertension (two studies), sunlight exposure (two studies), and age ⩾70 years (three studies); therefore, these findings should be interpreted cautiously.

Strengthening public awareness, improving access to affordable surgery, and promoting regular vision screening could significantly reduce preventable cataract cases. The findings of this study provide important evidence for policymakers and eye health program planners in Ethiopia. The high pooled prevalence of cataract highlights the need to strengthen national eye health strategies, expand cataract surgical services, and improve equitable access across regions. In addition, the identified associated factors can help guide targeted prevention strategies, early screening, and health education programs. Overall, the results support the prioritization of cataract control within national blindness prevention programs to reduce avoidable visual impairment in Ethiopia.

Supplemental Material

sj-docx-1-oed-10.1177_25158414261465593 – Supplemental material for Prevalence and associated factors of cataract in Ethiopia: a systematic review and meta-analysis

Supplemental material, sj-docx-1-oed-10.1177_25158414261465593 for Prevalence and associated factors of cataract in Ethiopia: a systematic review and meta-analysis by Worku Chekol Tassew, Yeshiwas Ayale Ferede and Getaw Wubie Assefa in Therapeutic Advances in Ophthalmology

Supplemental Material

sj-docx-2-oed-10.1177_25158414261465593 – Supplemental material for Prevalence and associated factors of cataract in Ethiopia: a systematic review and meta-analysis

Supplemental material, sj-docx-2-oed-10.1177_25158414261465593 for Prevalence and associated factors of cataract in Ethiopia: a systematic review and meta-analysis by Worku Chekol Tassew, Yeshiwas Ayale Ferede and Getaw Wubie Assefa in Therapeutic Advances in Ophthalmology

Supplemental Material

sj-docx-3-oed-10.1177_25158414261465593 – Supplemental material for Prevalence and associated factors of cataract in Ethiopia: a systematic review and meta-analysis

Supplemental material, sj-docx-3-oed-10.1177_25158414261465593 for Prevalence and associated factors of cataract in Ethiopia: a systematic review and meta-analysis by Worku Chekol Tassew, Yeshiwas Ayale Ferede and Getaw Wubie Assefa in Therapeutic Advances in Ophthalmology

Footnotes

Acknowledgements

The author would like to thank the authors of the included primary studies, which were used as sources of information to conduct this systematic review and meta-analysis.

Declarations

ORCID iD

Worku Chekol Tassew

Supplemental material

Supplemental material for this article is available online.

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