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Global issues

Prevalence of corneal diseases in the rural Indian

population: the Corneal Opacity Rural
Epidemiological (CORE) study
Noopur Gupta,1 Praveen Vashist,1 Radhika Tandon,1 Sanjeev K Gupta,2
Sadanand Dwivedi,3 Kalaivani Mani3
1

Dr Rajendra Prasad Centre for

Ophthalmic Sciences, All India
Institute of Medical Sciences,
New Delhi, India
2
Centre for Community
Medicine, All India Institute of
Medical Sciences, New Delhi,
India
3
Department of Biostatistics,
All India Institute of Medical
Sciences, New Delhi, India
Correspondence to
Dr Praveen Vashist,
Dr Rajendra Prasad Centre for
Ophthalmic Sciences, All India
Institute of Medical Sciences,
Room No. 787, 7th oor,
Ansari Nagar, New Delhi
110029, India;
PRAVEENVASHIST@YAHOO.
COM
Received 4 August 2014
Revised 30 September 2014
Accepted 26 October 2014
Published Online First
13 November 2014

ABSTRACT
Objective The present population-based study was
undertaken to estimate the prevalence, determinants and
causes of corneal morbidity and blindness in a rural
North Indian population.
Design Population-based study in India with 12 899
participants of all ages.
Methods Participants were recruited from 25 village
clusters of district Gurgaon, Haryana, India using random
cluster sampling strategy. All individuals were examined
in detail with a portable slit lamp for evidence of any
corneal disease during the door-to-door examination.
Comprehensive ocular examination including logMar
visual acuity, slit lamp biomicroscopy, non-contact
tonometry and dilated retinal evaluation was performed
at a central clinic site in the respective villages.
Results Overall, 12 113 of 12 899 people (93.9%
response rate) were examined during the household
visits. Prevalence of corneal disease was 3.7% (95%
CI 3.4% to 4.1%) and that of corneal blindness was
0.12% (95% CI 0.05% to 0.17%). Multivariable
analysis demonstrated that corneal disease was
signicantly higher in the elderly ( p<0.0001) and
illiterates ( p<0.0001). Common causes of corneal
opacity in the study population were pterygium (34.5%),
ocular trauma (22.3%) and infectious keratitis (14.9%).
Corneal diseases contributing to blindness were postsurgical bullous keratopathy (46.2%) and corneal
degenerations (23.1%).
Conclusions The study ndings demonstrate that
currently ocular trauma, infectious keratitis, post-surgical
bullous keratopathy, and corneal degenerations are
responsible for the major burden of corneal blindness
and morbidity in the Indian population. The prevalence
of corneal morbidity due to vitamin A deciency and
trachoma was low in this rural population.

INTRODUCTION

To cite: Gupta N, Vashist P,

Tandon R, et al. Br J
Ophthalmol 2015;99:147
152.

Corneal blindness, including corneal opacity and

trachoma, contribute to 7% of the blindness
burden globally.1 2 This translates to nearly 2.7
million blind people worldwide due to corneal diseases.2 The global burden of corneal blindness is
concentrated in emerging and developing countries.
The major causes of corneal blindness include
corneal ulceration, ocular trauma, trachoma,
bullous keratopathy, corneal degenerations and
vitamin A deciency. It has been reported that
nearly 90% of the global cases of ocular trauma
and corneal ulceration leading to corneal blindness
occur in developing countries.3 Being a developing
country with a predominantly rural population,

India faces a signicant challenge in eliminating

corneal blindness. A meta-analysis of various
population-based blindness studies conducted in
India demonstrated that the prevalence of corneal
blindness was 0.45% (95% CI 0.27% to 0.64%) in
adults.4
There is an absence of representative communitybased data on the magnitude of corneal diseases in
the general population, especially in North India.
To the best of our knowledge, this study is the rst
of its kind to reect the magnitude of corneal
opacity in a large sample of the Indian population.
Available literature on corneal blindness in India is
either hospital-based5 or extrapolated data from
blindness surveys that were not specically designed
for studying corneal morbidity.612 Hence, this
population-based study provides new insights into
the prevalence, risk factors and causes of corneal
blindness and morbidity across all age groups in a
rural Indian population.

METHODS
Study design and population
The Corneal Opacity Rural Epidemiological
(CORE) study is a cross-sectional study involving
cluster random sampling. It was conducted from
July 2011 to January 2013 to determine the prevalence and determinants of corneal opacity in the
rural regions of Gurgaon district, state of Haryana,
India. A sample size of 9640 was calculated assuming 4% prevalence of corneal opacity,13 design
effect of 2, 0.6% absolute precision, and response
rate of 85%. It was planned to cover a sample of
10 000 people from 25 randomly selected rural
clusters. A computerised simple random sampling
approach was used to select 25 clusters from a sampling frame of 910 clusters generated from the
total rural population of 472 085 from 229 villages
of District Gurgaon.14 The study protocol received
ethical approval from the Institutional Ethics
Committee, All India Institute of Medical Sciences,
New Delhi in April 2010. Written informed
consent for enrolment and examination was
obtained from all adults for their own participation
and from parents or appropriate guardians of all
eligible children before they were included in the
study in accordance with the principles of the
Declaration of Helsinki.
A house-to-house visit was made to each family
in the selected village cluster. All eligible individuals
were examined by an experienced ophthalmologist
for the presence of corneal opacity using a portable
slit-lamp. Individuals detected with corneal

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Global issues
opacication during the house-to-house examination were
invited for a detailed ocular examination at a temporary makeshift clinic utilising the local infrastructure of the village that
was easily accessible to the enumerated study population of the
concerned village. People who were bedbound or those who
failed to attend the central clinical facility in the village were
examined at home.
The comprehensive ocular examination of patients with
corneal opacity included visual acuity estimation with the
logMAR tumbling E chart for distance and near, noncycloplegic refraction and prescription (cycloplegic refraction
for children), non-contact tonometry, lens examination and cataract assessment by the Lens Opacity Classication System III, slit
lamp biomicroscopy with uorescein staining, and detailed
retinal evaluation. The corneal examination was performed
under high magnication and emphasis was laid on the aetiopathogenesis, morphological characteristics and management of
the corneal disease. In the present study, blindness was dened
as visual acuity <3/60 in the better eye with available
correction.
Quality assurance and standardisation of all study procedures
and equipments was maintained throughout the period of the
study. A single cornea specialist conducted the ophthalmic
examination on the entire study population. The items of ophthalmic equipment were calibrated and standardised at regular
intervals. Any potential observer or measurement bias was thus
reduced.

Statistical analysis
The data were entered into a specially designed Microsoft
Access based platform with inbuilt validation and consistency
checks. Data analysis was carried out using Stata V.12.0 (Stata,
College Station, Texas, USA). Qualitative data has been
described as number (%) and quantitative data has been
described as meanSD and median (range) as appropriate. The
multivariable logistic regression analysis was done to nd the
association between sociodemographic factors and the presence

of corneal opacity and corneal blindness. The results for the

same were reported as OR (95% CI). A value of p<0.05 was
considered statistically signicant.

RESULTS
The total enumerated population in the 25 clusters of Rural
Gurgaon was 12 899. Out of these, 12 113 individuals completed all the study procedures, with a coverage of 93.9%. The
synopsis of the study participants recruited at each step has been
summarised in gure 1.

Sociodemographic prole
The age and gender distribution of the enumerated and the
covered population was similar and it matched the national
demographic prole of the Indian population. Although 6.1%
of the sample population could not be covered, the enumerated
population and the covered population had comparable sociodemographic characteristics. Males comprised 51% of the study
population (table 1).

Prevalence of corneal opacity

The prevalence of corneal opacity in this study population was
3.7% (95% CI 3.4% to 4.1%). During house-to-house examination, 452 people were detected with corneal opacity and comprehensive ocular examination was possible for 435 participants
(96.2%). The prevalence increased with age and was highest for
elderly patients (26.1%, 95% CI 23.4% to 28.8%). The prevalence of corneal opacity was higher among females (4.1% 95%
CI 3.6% to 4.6%) compared to males (3.4%, 95% CI 2.9% to
3.8%), the difference being statistically signicant ( p=0.025).
With multivariable analysis, the odds of having corneal
opacity increased with age and decreasing literacy status, and
were higher for females and unemployed participants (table 2).
After adjustment, females were at higher odds of having corneal
opacity, though the difference was not statistically signicant
(p=0.53).

Figure 1 Flow chart summarising

number of participants at various steps
of the study.

148

Gupta N, et al. Br J Ophthalmol 2015;99:147152. doi:10.1136/bjophthalmol-2014-305945

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Global issues
Table 1 Sociodemographic profile of the enumerated and covered
study population in rural Gurgaon

Sociodemographic parameters
Age (years)
015
1639
4059
60
Gender
Male
Female
Occupation
Housework
Agricultural work
Non-agricultural work
Indoor work
Not working
Students and children
Education profile
Illiterate
Primary education*
Schooling (Std. 612)
Graduate and above
Children <7 years
Marital status
Married
Unmarried
Divorced/separated/
widow/widower
Religion
Hindu
Muslim
Total

Enumerated
population
n=12 899
n

Covered
population
n=12 113
n (%)

Uncovered
population
n=786
n (%)

4194
5632
2041
1032

4000 (95.4)
5276 (93.7)
1840 (90.2)
997 (96.6)

194
356
201
35

(4.6)
(6.3)
(9.8)
(3.4)

6745
6154

6173 (91.5)
5940 (96.5)

572 (8.5)
214 (3.5)

3435
709
1337
1263
692
5463

3349 (97.5)
653 (92.1)
1162 (86.9)
1080 (85.5)
668 (96.5)
5201 (95.2)

86
56
175
183
24
262

(2.5)
(7.9)
(13.1)
(14.5)
(3.5)
(4.8)

1949
2267
6292
641
1750

1862 (95.5)
2143 (94.5)
5828 (92.6)
575 (89.7)
1705 (97.4)

87
124
464
66
45

(4.5)
(5.5)
(7.4)
(10.3)
(2.6)

6303
5968
628

5847 (92.8)
5674 (95.1)
592 (94.3)

456 (7.2)
294 (4.9)
36 (5.7)

12 726
173
12 899

11 951 (93.9)
162 (93.6)
12 113 (93.9)

775 (6.1)
11 (6.4)
786 (6.1)

*Includes participants educated up to class 5 of formal schooling and people who

could read and write.

Prevalence of corneal blindness

The overall prevalence of corneal blindness in our study population, including both unilateral and bilateral cases, was 0.55%
(95% CI 0.42% to 0.69%); the prevalence of bilateral cases was
0.12% (95% CI 0.05% to 0.17%) and that of unilateral corneal
blindness was 0.45% (95% CI 0.33% to 0.56%). The majority
of the corneal blind patients were females (61.5%) and were
aged 60 years (84.6%).
Logistic regression analysis was conducted for individuals who
had corneal blindness in any (54) or both eyes (13). In this subgroup, comprising 67 people with either unilateral or bilateral
corneal blindness, the odds of having corneal blindness increased
with age and were higher for females and unemployed participants (table 3). Similar results were obtained after adjustment for
age, gender and other demographic parameters (table 3). The
elderly had 4.7 times more risk of developing corneal blindness
when compared to the younger age group after adjustment for
other demographic factors.

Causes of corneal opacity

Common causes of corneal opacity included pterygium
(34.5%), trauma (22.3%) and infectious keratitis (14.9%). In

the 150 cases with pterygium, 89 (59.3%) had normal vision

and 61 (40.7%) had mild to moderate visual impairment.
Table 4 lists the various corneal diseases prevalent in the study
population. Corneal involvement due to trachomatous infection
and its sequelae was seen in 33 eyes of 21 participants (table 4).

Causes of corneal blindness

Corneal diseases contributing to blindness were aphakic and
pseudophakic bullous keratopathy following cataract surgery,
corneal degenerations, and trauma. Unilateral corneal blindness
was mostly caused by ocular trauma, infectious keratitis, and
post-surgical bullous keratopathy (table 4).

DISCUSSION
The CORE study is the rst detailed, population-based study on
corneal diseases in the Indian population. To the best of our
knowledge, our study is the largest epidemiological study on
corneal opacities worldwide. This study provides reliable epidemiological data on the prevalence and risk factors of corneal
blindness and morbidity across all age groups in a rural North
Indian population.
In the present study, the prevalence of corneal opacity was
3.7% (95% CI 3.4% to 4.1%). There are a few published
studies on ocular morbidity conducted in the Indian population,
which report the prevalence rate of corneal opacity as 4.2% in
people aged 20 years and 3% in people aged 50 years.13 15
These studies involved a very small sample of the population
and hence do not represent accurate estimations of the prevalence of corneal opacity. In a hospital-based study in Haryana,
11.6% of patients with a visual acuity of 6/9 or worse were
found to have corneal disease.16 As these studies did not include
all age groups, they failed to provide comprehensive and representative data on the burden of corneal diseases in the general
population.
The prevalence of corneal blindness in this rural population
was 0.12%, and 0.45% of people were unilaterally blind due to
corneal disease. This amounts to a signicant burden on the
health system in general, and the blindness programme in particular. In another Indian study, the prevalence of corneal blindness (dened as presenting visual acuity <6/60 in the better eye
in this study) was reported to be 0.10% and that of unilateral
corneal blindness was 0.56%.17 A Chinese study also reported a
similar prevalence of corneal blindness of 0.1%.18
The common causes of corneal opacity in this rural population were pterygium (34.5%) followed by trauma (22.3%) and
infectious keratitis (14.9%). The aetiological factors responsible
for corneal disease were reported to be different in the late 19th
century, wherein trachoma was the most common corneal
disease reported (30%) in a hospital-based study.16 The impact
of community trachoma control programmes and nutritional
education together with a measles immunisation programme has
resulted in a reduction of the burden of corneal blindness due
to trachoma and vitamin A deciency.
The main aetiological diseases responsible for corneal blindness in our study population were post-surgical bullous keratopathy (46.2%), corneal degenerations (23.1%) and trachoma
(15.4%). In the South Indian population, corneal blindness was
predominantly due to infectious keratitis (59.5%) and trauma
(23.2%).17 Studies from Thailand and Gambia also report the
common causes of corneal blindness.19 20 In Thailand, these
were infections (35.6%), surgical bullous keratopathy (27.8%),
and trauma (14%).19 In Gambia, vitamin A deciency (7.8%)
was an important cause of corneal blindness in addition to
infectious keratitis (22.7%) and trauma (14.3%).20 Thus,

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149

Global issues

150

Table 2

Effect of sociodemographic factors on the prevalence of corneal opacity by logistic regression analysis
Corneal opacity

Age group (years)

015
1639
4059
60
Gender
Male
Female

No
n=11 661

Yes
n=452

Prevalence
% (95% CI)

3997
5247
1680
737

3
29
160
260

0.08 (0.01 to 0.16)

0.55 (0.35 to 0.75)
8.70 (7.41 to 9.98)
26.08 (23.35 to 28.81)

5966
5695

207
245

3.35 (2.90 to 3.80)

4.12 (3.62 to 4.63)

No
n=7664

Yes
n=449

Prevalence
% (95% CI)

1554
831
4715
564

271
63
105
10

14.85 (13.22 to 16.48)

7.05 (5.37 to 8.73)
2.18 (1.77 to 2.59)
1.74 (0.67 to 2.82)

3167
616
1118
1041
1722

182
37
44
39
147

5.43
5.67
3.79
3.61
7.87

Unadjusted OR
(95% CI)

p Value

Adjusted OR (95% CI)

p Value

1.0
7.36 (2.24 to 24.19)
126.89 (40.44 to 398.17)
470.02 (150.20 to 1470.83)

0.001
<0.001
<0.001

1.0
7.34 (2.23 to 24.11)
126.23 (40.22 to 396.14)
467.64 (149.42 to 1463.52)

0.001*
<0.001*
<0.001*

0.025*

1.0
1.24 (1.03 to 1.49)

0.025

1.0
1.07 (0.87 to 1.31)

0.533

p Value

Unadjusted OR
(95% CI)

p Value

Adjusted OR (95% CI)

p Value

<0.001*

1.0
0.43 (0.33 to 0.58)
0.13 (0.10 to 0.16)
0.10 (0.05 to 0.19)

<0.001
<0.001
<0.001

1.0
0.80 (0.58 to 1.10)
0.47 (0.34 to 0.64)
0.52 (0.25 to 1.06)

0.168
<0.001*
0.071

1.0
1.04 (0.72 to 1.50)
0.68 (0.49 to 0.96)
0.65 (0.46 to 0.93)
1.5 (1.19 to 1.86)

0.812
0.027
0.017
0.001

1.0
1.02
1.21
1.59
1.48

0.937
0.417
0.056
0.015*

p Value

<0.001*

Corneal opacity

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Risk Factors
Education
Illiterate
Primary education
Schooling (Std. 612)
Graduate and above
Occupation
Housework
Agricultural work
Non-agricultural work
Indoor work
Not working and students

(4.67
(3.89
(2.69
(2.50
(6.64

to
to
to
to
to

6.20)
7.44)
4.89)
4.73)
9.09)

<0.001*

*Statistically significant difference between groups.

In the multivariable analysis, age and gender were adjusted for each other.
Children aged 05 years were excluded.
Education and occupation were adjusted for all the variables including age and gender and was done excluding children aged 015 years.
Includes participants who could read and write.

(0.63 to
(0.77 to
(0.99 to
(1.08 to

1.64)
1.88)
2.57)
2.03)

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Risk Factors

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Global issues
Table 3 Effect of sociodemographic factors on the prevalence of corneal blindness by logistic regression analysis
Corneal blind
Risk factors
Age (years)
<60
60
Gender
Male
Female
Education
Up to primary
Above primary (>Std. 5)
Occupation
Housework
Agricultural work
Non-agricultural work
Indoor work
Not working/retired
Students and children

No
(n=12 046)

Yes
(n=67)

Prevalence
% (95% CI)

11 093
953

23
44

0.21 (0.12 to 0.29)

4.41 (3.14 to 5.69)

p Value

Unadjusted OR (95% CI)

p Value

Adjusted OR (95% CI)

p Value

1.0
22.27 (13.39 to 37.03)

<0.001*

1.0
4.70 (2.38 to 9.26)

<0.001*

1.0
1.64 (1.00 to 2.69)

0.048*

1.0
1.13 (0.58 to 2.19)

0.720

1.0
0.19 (0.10 to 0.36)

<0.001*

1.0
0.30 (0.15 to 0.62)

0.001*

1.0
0.41
0.69
0.25
6.47
0.03

0.224
0.416
0.057
<0.001*
<0.001*

1.0
0.58
1.38
0.73
2.81
0.04

0.505
0.584
0.679
0.003*
0.002*

<0.001*

0.046*
6147
5899

26
41

0.42 (0.26 to 0.58)

0.69 (0.48 to 0.90)
<0.001*

5655
6391

55
12

0.96 (0.71 to 1.22)

0.19 (0.08 to 0.29)
<0.001*

3324
651
1156
1078
637
5200

25
2
6
2
31
1

0.75
0.31
0.52
0.19
4.64
0.02

(0.45
(0.12
(0.10
(0.07
(3.04
(0.01

to
to
to
to
to
to

1.04)
0.73)
0.93)
0.44)
6.24)
0.06)

(0.10
(0.28
(0.06
(3.79
(0.01

to
to
to
to
to

1.73)
1.69)
1.04)
11.03)
0.19)

(0.12
(0.47
(0.15
(1.41
(0.01

to
to
to
to
to

2.75)
3.99)
3.53)
5.59)
0.32)

*Statistically significant difference between groups.

Includes participants educated up to class 5 of formal schooling and people who could read and write.
Includes children <7 years of age.

contrary to popular belief and previous studies,17 19 20 the predominant cause of corneal blindness in the current study was
not infectious keratitis but corneal decompensation following
cataract surgery. Addressing the issue of improving the quality
of cataract surgical services in the country will help reduce the
requirement for corneal transplantation. There is a need for
implementing monitoring mechanisms so that good quality cataract surgery is available at all levels of healthcare delivery,
thereby reducing the load of corneal complications after cataract
surgery.
The study highlights the changing trends in the pattern of
corneal diseases in the rural Indian population. The success of
prevention programmes related to keratomalacia and trachoma
have led to marked reductions in their prevalence, as exemplied in the present study. We need to be cautious about the

Table 4

increasing prevalence and occurrence of corneal complications

due to high-volume cataract surgery, which is shifting the
burden from cataract blindness to corneal blindness in a developing country like India.
It is important to interpret the results of our study keeping in
view the few limitations. Rural data cannot be directly extrapolated to urban populations and further surveys in urban regions
are required to achieve a comprehensive picture. Though the
overall participation rate in the present study was high, the
coverage of individuals aged 4059 years and the male population was comparatively lower than other sub-groups. This could
be attributed to the non-availability of males and people aged
4059 years in their households during daytime, as they constitute the productive population and were out at work when the
house-to-house visits were conducted. Although the present

Causes and age distribution of corneal opacities and corneal blindness in the study population (n=435)

Corneal pathology

Age of participants (years)

Median (range)

People with CO
n=435
n (%)

Bilateral blind*
n=13
n (%)

Unilateral blind
n=54
n (%)

Pterygium associated CO
Traumatic CO
Infectious keratitis
Corneal dystrophy and degenerations
Trachomatous keratopathy
Aphakic/pseudophakic bullous keratopathy
Post-exanthematous CO
Iatrogenic CO
Vitamin A deficiency associated CO
Glaucoma with corneal decompensation
Miscellaneous
Unknown aetiology

55 (1895)
60 (1190)
65 (3094)
72.5 (5192)
68 (3299)
75 (6294)
65 (4282)
68 (6098)
45.5 (1458)
63.5 (6364)
65 (284)
62 (2274)

150 (34.5)
97 (22.3)
65 (14.9)
26 (6.0)
21 (4.8)
17 (3.9)
15 (3.5)
13 (3.0)
4 (0.9)
2 (0.5)
16 (3.8)
9 (2.1)

0
0
1
3
2
6
0
0
1
0
0
0

0 (0.0)
14 (25.9)
12 (22.2)
4 (7.4)
6 (11.1)
8 (14.8)
7 (13.0)
1 (1.9)
1 (1.9)
1 (1.9)
0 (0.0)
0 (0.0)

(0.0)
(0.0)
(7.7)
(23.1)
(15.4)
(46.2)
(0.0)
(0.0)
(7.7)
(0.0)
(0.0)
(0.0)

*Blindness defined as presenting visual acuity <3/60 in better eye.

CO, corneal opacity.

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Global issues
study involved a large sample population which was larger than
any previously published study on corneal blindness, the sample
size was not adequate for ascertaining the true prevalence of
corneal blindness.17 18 However, the sample size was appropriate for assessing the primary objective of the study which was to
determine the population prevalence of corneal opacity.
The major strengths of this study are the high response rate
(93.9%) in a large sample population covering all age groups,
and that it is the rst reported population-based study, specically designed to study the prevalence of corneal opacity in
India, outlining all determinants and aetiological factors responsible for its occurrence. This study will prove useful in planning
blindness programme initiatives and estimating resources
required to provide comprehensive corneal services for the community, thereby helping to eliminate the causes of avoidable
corneal blindness and visual impairment.
Contributors NG: Literature search and compilation, study conception and design,
data collection and acquisition, data analysis and interpretation, drafting and writing
of manuscript. PV: Study conception and design, critical revision of manuscript,
administrative, technical and material support, supervision. RT: Study conception and
design, data interpretation, revision of manuscript for important intellectual content,
supervision. SKG: Study conception and design, data collection and acquisition,
revision of manuscript for important intellectual content, technical support. SD:
Statistical expertise, data analysis and interpretation, revision of manuscript for
important intellectual content. KM: Study design, statistical expertise, data analysis
and interpretation.
Competing interests None.

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Patient consent Obtained.

Ethics approval Institute Ethics Committee, All India Institute of Medical Sciences,
New Delhi, India.

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Provenance and peer review Not commissioned; externally peer reviewed.

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Gupta N, et al. Br J Ophthalmol 2015;99:147152. doi:10.1136/bjophthalmol-2014-305945

Downloaded from http://bjo.bmj.com/ on February 2, 2015 - Published by group.bmj.com

Prevalence of corneal diseases in the rural

Indian population: the Corneal Opacity Rural
Epidemiological (CORE) study
Noopur Gupta, Praveen Vashist, Radhika Tandon, Sanjeev K Gupta,
Sadanand Dwivedi and Kalaivani Mani
Br J Ophthalmol 2015 99: 147-152 originally published online November
13, 2014

doi: 10.1136/bjophthalmol-2014-305945
Updated information and services can be found at:
http://bjo.bmj.com/content/99/2/147

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