1117

WORLD VIEW

Prevalence and causes of blindness and low vision in Timor-

Leste
Jacqueline Ramke, Anna Palagyi, Thomas Naduvilath, Renee du Toit, Garry Brian
...................................................................................................................................

Br J Ophthalmol 2007;91:1117–1121. doi: 10.1136/bjo.2006.106559

Aim: To estimate the prevalence and causes of blindness and low vision in people aged >40 years in Timor-
Leste.
Method: A population-based cross-sectional survey using multistage cluster random sampling to identify 50
clusters of 30 people. A cause of vision loss was determined for each eye presenting with visual acuity worse
than 6/18.
See end of article for Results: Of 1470 people enumerated, 1414 (96.2%) were examined. The age, gender and domicile-adjusted
authors’ affiliations
........................ prevalence of functional blindness (presenting vision worse than 6/60 in the better eye) was 7.4% (95% CI
6.1 to 8.8), and for blindness at 3/60 was 4.1% (95% CI 3.1 to 5.1). The adjusted prevalence for low vision
Correspondence to: (better eye presenting vision of 6/60 or better, but worse than 6/18) was 17.7% (95% CI 15.7 to 19.7).
G Brian, FRANZCO, The
Fred Hollows Foundation Gender was not a risk factor for blindness or low vision, but increasing age, illiteracy, subsistence farming,
(New Zealand), Auckland unemployment and rural domicile were risk factors for both. Cataract was the commonest cause of blindness
1030, New Zealand; (72.9%) and an important cause of low vision (17.8%). Uncorrected refractive error caused 81.3% of low
grbrian@tpg.com.au
vision.
Accepted 9 December 2006 Conclusion: Strategies that make good-quality cataract and refractive error services available, affordable
........................ and accessible, especially in rural areas, will have the greatest impact on vision impairment.

I
n 1999, after more than 400 years of colonisation, Timor-
Leste, northwest of Australia at the eastern end of the
Indonesian archipelago, became an independent state. The
health of the Timorese population was poor at that time. This
was further compounded by the actions of anti-independence
forces, which resulted in population displacement, loss of
skilled health personnel, and almost total destruction of social
and physical infrastructure.1 Currently, Timor-Leste is also one
of the world’s poorest nations. Its rates of infant and maternal
mortality are among the highest. Malnutrition and infectious
diseases, such as tuberculosis, malaria and leprosy, are rife.2
The World Health Organization estimates that there are
currently 161 million people with vision impairment world-
wide, of whom 37 million are blind.3 Approximately 80% of
blind people live in the low-resource countries of Asia and
Africa, mostly in rural areas with few or underutilised eye-care
facilities.4–6 In many respects, Timor-Leste is typical of these
countries. With a predominantly rural population of 925 000
people, Timor-Leste has one referral hospital, in Dili, the
capital. This has an eye clinic and offers cataract surgery and
refraction services. Elsewhere, at the beginning of 2005, there
were two provincial eye clinics, including one in the Bobonaro
district. These provided primary eye-care and refraction.
In Timor-Leste’s current state of emergent independence and
reconstruction, its Ministry of Health is working to develop,
establish and maintain an appropriate, cost-effective and
equitable health system. Despite limited health resources, eye
health has been included in the Ministry’s strategic planning
framework. This is because of the significant personal and
economic impact of blindness; most blindness is either
preventable or treatable,3 and blindness prevention and
treatment interventions are cost-effective.7
As the Ministry prepared to develop a national eye health
strategy and implementation plan in accordance with the
World Health Organization’s Global initiative for the elimination of
avoidable blindness8 and the World Health Assembly’s Resolution
on the elimination of avoidable blindness,9 it became apparent that
no population vision and eye health data were available in
Timor-Leste. Given the limited resource setting, a rapid
assessment survey was identified as the most appropriate
method to obtain an estimation of the prevalence rates and
major causes of blindness and low vision in adults aged
>40 years, which is the age group most at risk.3 Additional
vision-related quality of life and willingness-to-pay data
relevant to the Timor-Leste National Eye Health Strategy were
also collected.
This paper reports the prevalence and causes of blindness and
low vision in Timor-Leste.
METHODS
The study protocol was based on the Rapid Assessment of
Cataract Surgical Services (RACSS).10–12 Among the modifica-
tions made, the entry age was reduced from 50 to 40 years, to
permit exploration of aspects of refractive error and presbyopia
correction.
Pilot
In November 2004, a pilot study (30 participants, representative
of the urban population to be screened in the main survey) was
undertaken to refine and validate the questionnaire, including
investigations of inter-observer and intra-observer variation,
and test–retest reliability. These data were not included in the
final survey analysis.
Sampling plan
The sample frame for this study included an urban district, Dili,
and one rural district, Bobonaro, 4K h from Dili by road. By
using an anticipated prevalence of vision impairment (present-
ing visual acuity worse than 6/18 in both eyes) of 11% in the
target population, absolute precision of ¡2.2% (20% relative),
with 95% CI, and a design effect of 1.5 and a response rate of
80%, the required sample size was estimated as 1500 persons.
Abbreviation: RACSS, Rapid Assessment of Cataract Surgical Services

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1118 Ramke, Palagyi, Naduvilath, et al

Table 1 Sample summary and demographic associations with low vision (presenting vision of 6/60 or better, but worse than
6/18, in the better eye) and blindness (presenting vision worse than 6/60 in the better eye)
Survey sample Low vision Blindness

Factor n (%) n (%) OR (95% CI) n (%) OR (95% CI)

Age (years)
40–49 602 (42.6) 29 (4.8) 1.0 7 (1.2) 1.0
50–59 343 (24.2) 51 (14.9) 3.5 (2.2 to 5.7) 11 (3.2) 2.8 (1.1 to 7.3)
60–69 254 (18.0) 68 (26.8) 8.8 (5.5 to 14.2) 36 (14.2) 14.0 (6.2 to 32.0)
>70 215 (15.2) 71 (33.0) 15.6 (9.6 to 25.3) 55 (25.6) 29.2 (13.1 to 65.4)

Gender
Male 721 (51.0) 109 (15.1) 1.0 56 (7.8) 1.0
Female 693 (49.0) 110 (15.9) 1.1 (0.8 to 1.4) 53 (7.6) 1.0 (0.7 to 1.5)

Domicile
Urban (Dili) 671 (47.5) 70 (10.4) 1.0 41 (6.1) 1.0
Rural (Bobonaro) 743 (52.5) 149 (20.1) 2.3 (1.7 to 3.1) 68 (9.2) 1.5 (1.0 to 2.3)

Literacy
Literate 463 (32.7) 36 (7.8) 1.0 8 (1.7) 1.0
Illiterate 951 (67.3) 183 (19.2) 3.2 (2.2 to 4.7) 101 (10.6) 6.8 (3.3 to 14.0)

Employment
Paid 200 (14.1) 15 (7.5) 1.0 1 (0.5) 1.0
Farming 490 (34.7) 94 (19.2) 3.1 (1.7 to 5.4) 18 (3.7) 7.6 (1.0 to 57.2)
Unemployed 724 (51.2) 110 (15.2) 2.6 (1.5 to 4.5) 90 (12.4) 28.3 (3.9 to 204)

Marital status
Married 1033 (73.1) 125 (12.1) 1.0 45 (4.4) 1.0
Single/widow/divorced 381 (26.9) 94 (24.7) 2.9 (2.1 to 4.0) 64 (16.8) 4.4 (3.0 to 6.6)
Total 1414 (100) 219 (15.5) 109 (7.7)

A total of 41 (2.9%) participants were using spectacles for distance vision.

From the sample frame, 50 clusters of 30 people were required
(25 from all 6 subdistricts of both Dili and Bobonaro). Within
each of the districts, the clusters were selected through
probability proportionate to size sampling,11 using preliminary
data from the 2004 national census.13
Enumeration
The survey was conducted from February to May 2005. Villages
comprising each cluster were attended by a single survey team.
Using a random process, the team leader (a population health
trained optometrist) identified the first household to be
targeted. Thereafter, consecutive households were approached
according to the RACSS protocol, and eligible people were
enumerated by trained Timorese fieldworkers until the 30
participants for that cluster were enrolled.
Clinical examination
Presenting visual acuity was measured in daylight for each eye
separately using a simplified 3 m chart with tumbling E
optotypes equal to standard Snellen sizes of 18, 60 and 120.
Vision assessment began at the 6/18 level and progressed to the
larger optotypes as required. A minimum of three out of five
correctly identified optotypes at the 6/18 and 6/60 level, or two
out of three at the 6/120 level, gave the final measurement.
Presenting binocular near visual acuity for each participant was
also measured. Any eye with visual acuity worse than 6/18 had
pinhole acuity measured and underwent an examination to
determine the cause of reduced vision.
Assessment of the anterior segment was made using loupe
magnification and a torch. The status of the central lens was
determined with a direct ophthalmoscope in a dimly lit room
through an undilated pupil. An intact red reflex was considered
indicative of a ‘‘normal’’ clear central lens. The presence of
obvious red reflex dark shading, but transparent vitreous, was
recorded as lens opacity. Where present, aphakia and pseudo-
phakia with and without posterior capsule opacification were
noted. The lens was determined to be not visible (‘‘no view’’) if
there were dense corneal opacities or other ocular pathologies,

Table 2 Prevalence of blindness and low vision by gender and domicile

Blindness* Low vision

Men Women Overall Men Women Overall

Age adjusted Age adjusted Age–gender adjusted Age adjusted Age adjusted Age–gender adjusted

Urban 5.39 (2.87 to 5.05 (2.79 to 5.24 (3.55 to 8.14 (5.09 to 9.39 (6.38 to 8.83 (6.68 to
7.91) 7.30) 6.92) 11.18) 12.39) 10.98)
Rural 6.50 (4.12 to 8.90 (5.83 to 7.73 (5.81 to 16.97 (13.35 to 21.09 (16.70 to 18.98 (16.16 to
8.88) 11.97) 9.65) 20.60) 25.49) 21.80)
Overall (domicile 6.59 (4.78 to 8.22 (6.18 to 7.41 (6.05 to 16.08 (13.40 to 19.31 (16.37 to 17.68 (15.70 to
adjusted) 8.41) 10.27) 8.78) 18.76) 22.25) 19.67)

Values are represented as % (95% CI).

*Worse than 6/60 in the better eye.

6/60 or better, but worse than 6/18, in the better eye.

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Blindness and low vision in Timor-Leste
such as phthisis bulbi, precluding any view of the lens.
Thereafter, the posterior segment was examined using a direct
ophthalmoscope.
Although any eye may have more than one condition
contributing to vision reduction, for the purposes of this study,
a single cause of vision loss was determined for each eye. In the
absence of any other findings, uncorrected refractive error was
the attributed cause of reduced vision if the acuity then
improved to 6/18 with pinhole. Allocation of other causes,
including corneal opacity and cataract, required clinical
findings of sufficient magnitude to explain the vision loss.
The attributed cause was always the condition most easily
treated if each of the contributing conditions were individually
treatable to a vision of 6/18 or better. Thus, for example, when
uncorrected refractive error and lens opacity coexisted, refrac-
tive error, with its easier and less expensive treatment, was
nominated as the cause. Where treatment of a condition
present would not result in 6/18 or better acuity, it was
determined to be the cause rather than any coincident or
associated conditions amenable to treatment. Thus, for
example, coincident retinal detachment and cataract would
be categorised as posterior segment pathology.
Study definitions
Presenting visual acuity is the habitual (with correction if
available) visual acuity of the individual. Blindness is reported
as presenting visual acuity worse than 6/60 in the better eye
(functional blindness), and also at the 3/60 level. Low vision is
defined as presenting visual acuity of 6/60 or better, but worse
than 6/18, in the better eye. Vision impairment is defined as
presenting visual acuity worse than 6/18 in the better eye (the
combination of low vision and functional blindness).
Data analysis
Data were entered into a specifically designed database daily
during the survey. Prior to analysis, missing data and outliers
were checked against the survey forms.
Point prevalence estimates of visual acuity and their 95% CIs
were calculated. Definitive data from the 2004 national census
became available after the survey.13 This was used to adjust the
prevalence estimates for distribution of age and gender. These
standardised estimates were then used to extrapolate to the
entire country.
The strength of association of demographic factors with
vision impairment was analysed and described using odds
ratios (ORs) and their 95% CIs. Major causes of vision
impairment were compared between demographic factors using
Fisher’s exact test. A p value (0.05, non-overlapping 95% CIs
or OR CIs without the value 1 were considered to be significant.
SPSS V.12 was used for data analysis.
Ethical considerations
Approval for this study and its methodology was sought from
the Timor-Leste Ministry of Health and granted by the Minister
of Health. Written consent was obtained from the village chiefs
prior to the commencement of the survey in each cluster.
Informed consent was obtained from each participant prior to
all data collection and examinations. Communications occurred
in Tetum, the local language or another, depending on the
participant’s preference.
All participants were advised of the availability of permanent
eye-care services in Dili and Bobonaro. Transport and accom-
modation arrangements were made for those with treatable
causes of low vision and blindness who were willing to be
referred to the Dili National Hospital.
1119
RESULTS
Sample
One selected cluster proved to be inaccessible, with no ready
adjacent substitute. Of the 1470 people enumerated, 1414
(96.2%) were examined. In all, 26 participants were not
available during the survey and 30 refused participation. Data
from these 56 people were not considered in the analysis.
The mean (SD) age of participants was 54.9 (20.1) years. In
all, 49% were women. Participants were more likely to be
younger, married, illiterate and not in paid employment
(table 1).
Prevalence of blindness and low vision
The crude prevalence of functional blindness for those aged
>40 years was 7.7% (109/1414), and of low vision was 15.5%
(219/1414). Increased probabilities of both were associated with
increasing age, illiteracy, not being married, farming and
unemployment (compared with paid employment) and rural
domicile (table 1).
The age, gender and domicile-adjusted prevalence of func-
tional blindness was 7.4% (95% CI 6.1 to 8.8). No gender
difference was detected in the age-adjusted prevalence of
blindness within the urban, rural or overall samples. Nor were
differences apparent in male, female and overall age-adjusted
prevalences between the urban, rural and overall populations
(table 2).
The age, gender and domicile-adjusted prevalence of low
vision was 17.7% (95% CI 15.7 to 19.7). No gender difference
was found within the urban, rural or overall groups. However,
the age-adjusted prevalence of low vision was significantly
higher in the rural area compared with the urban area for men,
women and both combined (table 2).
Using the definition of blindness as presenting acuity worse
than 3/60, the crude prevalence was 4.7%, and the age, gender
and domicile-adjusted prevalence was 4.1% (95% CI 3.1 to 5.1).
Causes of blindness and low vision
In the survey sample, cataract was the most common cause of
blindness, accounting for 76.1% (95% CI 68.1 to 84.1) of cases
at the 6/60 level (table 3) and 78.8% (95% CI 68.9 to 88.7) using
the 3/60 definition. Of the 83 cases worse than 6/60, 4.8% had
no perception of light, 16.9% perceived light, 41.0% counted
fingers and 37.3% read 3/60. Surgery-related and posterior
segment causes were the next most prevalent causes of
blindness (both 6.4%). No difference was demonstrated
between urban and rural residence for cataract (p = 0.818) or
refractive error (p = 1.0) as a cause of blindness.
Uncorrected refractive error was the most frequent cause of
low vision in the survey sample (table 4). It was responsible for
73.1% (95% CI 67.2 to 78.9) of cases overall, and was a more
probable cause among rural residents than among urban
residents (p,0.001). Cataract accounted for 25.1% (95% CI
19.4 to 30.9) of low vision, and was a more common cause for
urban dwellers than for rural dwellers (p,0.001).
The age, gender and domicile-adjusted prevalence of catar-
act-induced functional blindness was 5.4% (95% CI 4.2 to 6.6).
For low vision and vision impairment caused by refractive error,
this was 14.4% (95% CI 12.5 to 16.2) and 14.9% (95% CI 13.1 to
16.8), respectively.
DISCUSSION
The age, gender and domicile-adjusted prevalence of functional
blindness in the sample population was 7.4%. That for low
vision was 17.7%. Direct comparison with other prevalence
surveys from the region is difficult because of differences in
definitions and methodology, including age stratification.
However, a similar or higher prevalence of blindness has been
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1120 Ramke, Palagyi, Naduvilath, et al

Table 3 Causes of blindness (worse than 6/60 in the better eye) by gender, domicile and age
Cause

Uncorrected
Factor All Cataract refractive error Surgery related* Corneal opacity Posterior segment Other

Gender
Male 56 (51.4) 41 (73.2) 2 (3.6) 4 (7.1) 4 (7.1) 4 (7.1) 1 (1.8)
Female 53 (48.6) 42 (79.2) 4 (7.5) 3 (5.7) 1 (1.9) 3 (5.7) 0 (0.0)

Domicile
Urban 41 (37.6) 32 (78.0) 2 (4.9) 2 (4.9) 2 (4.9) 2 (4.9) 1 (2.4)
Rural 68 (62.4) 51 (75.0) 4 (5.9) 5 (7.4) 3 (4.4) 5 (7.4) 0 (0.0)

Age (years)
40–49 7 (6.4) 2 (28.6) 0 (0.0) 1 (14.3) 1 (14.3) 2 (28.6) 1 (14.3)
50–59 11 (10.1) 8 (72.7) 1 (9.1) 0 (0.0) 1 (9.1) 1 (9.1) 0 (0.0)
60–69 36 (33.0) 29 (80.6) 2 (5.6) 1 (2.8) 1 (2.8) 3 (8.4) 0 (0.0)
>70 55 (50.5) 44 (80.0) 3 (5.5) 5 (9.1) 2 (3.6) 1 (1.8) 0 (0.0)
Total 109 (100) 83 (76.1) 6 (5.5) 7 (6.4) 5 (4.6) 7 (6.4) 1 (0.9)

Values are given as n (%).

*Includes uncorrected aphakia, posterior capsule opacity and sequelae of intraoperative complications.

Includes age-related macular degeneration, retinal detachment and complications of diabetes.

reported for a similar age group in Indonesia,14 Papua New
Guinea15 and parts of India.16–19 A lower prevalence has been
described for Bangladesh,20 China,21 22 Malaysia,23 Mongolia,24
Nepal25 26 and Tibet.27 The overall estimate for South East Asia is
also lower.3 The relatively high prevalence of blindness in
Timor-Leste may, in part, be due to the historical lack of
permanent eye-care services, and low utilisation where they
have been available.28
The risk factors associated with blindness and low vision in
the current survey were in accordance with those in other
studies: increasing age,16 18–20 22 26 illiteracy or no formal educa-
tion16 18 20 22 26 and rural residence.16 19 20 However, despite
estimates that women are 1.4–2.2 times more likely to be
vision impaired in all regions of the world,3 29 this study did not
identify female gender as a risk factor. This apparent absence of
such gender disparity in Timor-Leste may be because of the
insufficient power of the sample size. Or, perhaps the past
profound lack of services has equally disadvantaged both men
and women. Future gender analyses will be telling, given that
the current (2004/5) male to female eye-care service utilisation
ratio is 60:40.2
As with other studies from other countries in the region,14–23 25–27
cataract was found to be the most prevalent cause of blindness in
Timor-Leste. Similarly, other studies using presenting rather than
best-corrected vision14 16–23 26 also found refractive error to be the
most frequent cause of low vision.
Extrapolating the age, gender and domicile-adjusted blind-
ness and low vision prevalences to the estimated 20% of Timor-
Leste’s population aged >40 years13 yielded a mean (SD) of
46 500 (6500) people vision impaired. Of these, 13 500 (2500)
are functionally blind. Uncorrected refractive error is respon-
sible for 27 500 (3500) people with vision impairment, and
cataract for 16 000 (3000). Cataract accounts for 10 000 (2000)
of those who are functionally blind. However, caution should
be exercised because, owing to the resource and logistic
restrictions of the survey, the rural sample may not be
representative of the entire rural population. A greater
prevalence of vision impairment may be expected in the more
remote communities in the eastern part of the country.
Use of a standardised validated population-based methodol-
ogy, together with good observer agreement and a high
response rate, is the strength of this study.11 However, pupil

Table 4 Causes of low vision (6/60 or better, but worse than 6/18, in the better eye) by gender, domicile and age
Cause

Uncorrected
Factor All Cataract refractive error Surgery related* Posterior segment Other

Gender
Male 109 (49.8) 23 (21.1) 82 (75.2) 1 (0.9) 2 (1.8) 1 (0.9)
Female 110 (50.2) 32 (29.1) 78 (70.9) 0 (0.0) 0 (0.0) 0 (0.0)

Domicile
Urban 70 (32.0) 31 (44.3) 36 (51.4) 0 (0.0) 2 (2.9) 1 (1.4)
Rural 149 (68.0) 24 (16.1) 124 (83.2) 1 (0.7) 0 (0.0) 0 (0.0)

Age (years)
40–49 29 (13.2) 1 (3.4) 26 (89.7) 1 (3.4) 1 (3.4) 0 (0.0)
50–59 51 (23.3) 12 (23.5) 39 (76.5) 0 (0.0) 0 (0.0) 0 (0.0)
60–69 68 (31.1) 23 (33.8) 44 (64.7) 0 (0.0) 0 (0.0) 1 (1.5)
>70 71 (32.4) 19 (26.8) 51 (71.8) 0 (0.0) 1 (1.4) 0 (0.0)
Total 219 (100) 55 (25.1) 160 (73.1) 1 (0.5) 2 (0.9) 1 (0.5)

Values are given as n (%).

*Includes uncorrected aphakia, posterior capsule opacity and the sequelae of intraoperative complications.

Includes age-related macular degeneration, retinal detachment and complications of diabetes.

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Blindness and low vision in Timor-Leste
dilatation and more sophisticated examination techniques and
grading criteria could have resulted in a more accurate
diagnosis of the cause of reduced vision. This is particularly
relevant to the potential overdiagnosis of cataract at 6/24, 6/36
and even 6/60 levels, and needs to be considered when these
data are used for planning. This potential loss of accuracy was
accepted because the examination was shorter, with reduced
participant discomfort. Also, the utility of the results may have
been improved by recording all conditions contributing to
vision loss in a single eye, rather than just the validated RACSS
convention of using the single most treatable condition.
Although a more rigorous, comprehensive and detailed
survey may have provided more accurate data, this simple
rapid assessment methodology has produced adequate infor-
mation with which to start planning eye-care services. It would
seem that a national eye health strategy initially concentrating
on high volume, high-quality cataract surgery and the correc-
tion of refractive error would go far to relieve the burden of
vision impairment in Timor-Leste.
ACKNOWLEDGEMENTS
We thank the Timor-Leste Ministry of Health, District Health
Management Bobonaro, and the survey teams of the Dili and
Bobonaro districts for their help.
.......................
Authors’ affiliations
Jacqueline Ramke, Anna Palagyi, Renee du Toit, The International Centre
for Eyecare Education, Sydney, New South Wales, Australia
Thomas Naduvilath, The Institute for Eye Research, Sydney, New South
Wales, Australia
Funding: This work was, in part, financially supported by the Australian
Federal Government through the Co-operative Research Centres Program
(Vision CRC).
Competing interests: The International Centre for Eyecare Education
distributes and receives financial benefit from the sale of ready-made
spectacles in developing countries. However, the authors, who were
previously employees of this organisation, have no personal pecuniary
interest in the manufacture, distribution or sale of spectacles. The authors
have no pecuniary interest in any product mentioned or in the outcome of
this survey.
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