Abstract
Purpose
To describe the patterns and causes of adult blindness in patients attending a tertiary ophthalmic center in Somalia, to examine age- and gender-related associations with major causes of blindness, and to assess the contribution of trauma-related visual loss.
Methods
A retrospective cross-sectional study was conducted using medical records of all eligible patients aged 16 years and older evaluated at a tertiary ophthalmic center in Mogadishu, Somalia, between January and December 2025. Demographic characteristics, blindness laterality, and clinical causes were extracted from electronic medical records jointly by the two investigators and recorded in a Microsoft Excel spreadsheet. Descriptive analyses and multivariable logistic regression were performed to evaluate the distribution of blindness and age- and gender-related associations with major causes of blindness.
Results
Of 10,000 patient records screened, 9740 met the eligibility criteria and were included in the analysis. Among these, blindness was identified in 1236 patients (12.7%), of whom 77.9% had unilateral blindness and 22.1% had bilateral blindness. Cataract was the leading cause of blindness overall, followed by trauma-related ocular disease, glaucoma, and corneal opacity. Trauma-related conditions predominated among younger adults, whereas cataract and glaucoma were more common in older age groups. Corneal opacity related to microbial keratitis or undetermined corneal scarring remained among the leading causes of unilateral blindness across age groups.
Conclusions
Adult blindness in this hospital-based population reflected distinct age-related patterns, with trauma-related visual loss predominating among younger adults and age-related ocular diseases among older individuals. Corneal opacity remained an important cause of unilateral blindness across age groups. These findings have important implications for ophthalmic care in resource-limited settings.
Keywords: blindness, age-related cataract, traumatic cataract, corneal opacity, Somalia
Introduction
Blindness and visual impairment remain major causes of disability worldwide. Recent global estimates suggest that at least 2.2 billion people live with some form of vision impairment, of whom nearly one billion have visual loss that could have been prevented or remains untreated.1,2
The epidemiology of blindness shows substantial variation across geographic regions. Cataract and uncorrected refractive error remain leading causes of blindness and vision impairment worldwide.3 In Sub-Saharan Africa, the age-standardised prevalence of blindness has been estimated at 1.3%, with higher levels reported in some sub-regions of the continent.4 Studies from the region have shown that a substantial proportion of blindness is avoidable through timely prevention and treatment, underscoring the importance of reliable epidemiological data for planning effective eye-care services.5
Despite these findings from Sub-Saharan Africa, published data on adult blindness in Somalia remain limited, with only a single hospital-based study from Mogadishu available to date.6 That study identified trauma-related complications, cataract, and diabetic retinopathy as the leading causes of unilateral blindness, while cataract, diabetic retinopathy, and glaucoma predominated in bilateral blindness. However, these findings were reported across all age groups without age-specific analysis, despite the likelihood that the relative contribution of different etiologies varies substantially with age.
The present study aimed to describe the patterns and causes of adult blindness among patients attending a tertiary ophthalmic center in Mogadishu, Somalia, and to examine age- and gender-related associations with major etiologies. Particular attention was given to assessing the contribution of trauma-related visual loss.
Materials and Methods
Study Design and Setting
This retrospective cross-sectional study was conducted at the Department of Ophthalmology, Mogadishu Somalia Turkey Training and Research Hospital, Mogadishu, Somalia, a tertiary ophthalmic center providing services for a large urban and peri-urban population. Patients aged 16 years and older who were evaluated at the ophthalmology department between January and December 2025 were eligible for inclusion. Medical records were identified and jointly reviewed by the two investigators using the hospital’s electronic medical record system, and the extracted data were recorded in a Microsoft Excel spreadsheet.
Study Population and Definitions
A total of 10,000 patients aged 16 years and older were evaluated at the ophthalmology department during the study period. Patients with incomplete clinical evaluation, insufficient follow-up to determine stabilized visual acuity when required, or inadequate clinical information relevant to the study were excluded (n = 260). The remaining 9740 patients were included in the final analysis. As all eligible patient records during the predefined study period were included, no a priori sample size calculation was performed. Demographic characteristics and relevant medical and family history were reviewed when pertinent to the clinical assessment and etiologic classification of blindness.
Best-corrected visual acuity (BCVA) was measured using a standard Snellen chart. In patients presenting with acute ocular trauma, infection, or inflammation, visual acuity recorded after clinical stabilization following appropriate medical or surgical management was used. In all other patients with multiple visits, the BCVA recorded at the initial examination was used in the analysis.
All patients underwent a comprehensive ophthalmic examination, including slit-lamp biomicroscopy and, when indicated, fundus examination following pharmacologic pupil dilation. Additional ophthalmic and systemic investigations, including ocular ultrasonography, optical coherence tomography, visual field testing, imaging studies, and relevant laboratory tests, were performed when clinically indicated, and patients requiring systemic evaluation were referred to the appropriate departments.
Blindness was classified according to WHO criteria.7 Bilateral blindness was defined as BCVA worse than 3/60 in both eyes, and unilateral blindness as BCVA worse than 3/60 in one eye with BCVA of 3/60 or better in the fellow eye.
In most patients, a single ocular diagnosis accounted for blindness. When multiple ocular pathologies were present, the condition considered most responsible for visual loss was recorded as the principal cause of blindness.8 In patients with bilateral blindness but discordant causes between eyes (n < 10), the etiology of the eye with worse BCVA was used for classification, and these cases were analyzed within the unilateral blindness group to maintain analytical consistency. Age was categorized into four predefined groups: 16–35, 36–55, 56–75, and ≥76 years. Trauma-related cases were further categorized according to the recorded trauma-related ocular condition.
Statistical Analysis
Statistical analyses were performed using IBM SPSS Statistics, version 23 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize demographic characteristics and causes of blindness, with categorical variables presented as frequencies and percentages. Differences in the distribution of blindness across age groups and gender were assessed using the chi-square test. To explore associations between major causes of unilateral blindness and demographic variables, separate multivariable binary logistic regression models were performed. In each model, the presence of the specific etiology was treated as the dependent variable (1 = presence of the etiology, 0 = other etiologies), while age group and gender were included as independent variables. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and a p value < 0.05 was considered statistically significant. Because of sparse data and small cell counts across age strata in the bilateral blindness group, multivariable regression analysis was not performed for these cases to avoid unstable estimates.
Ethics Approval
The study adhered to the tenets of the Declaration of Helsinki and received ethical approval from the institutional ethics committee (Protocol No. MSTH/24985). Because the study involved retrospective analysis of anonymized medical records, the requirement for informed consent was waived.
Results
A total of 9740 patients aged 16 years and older were evaluated during the study period. Among them, 1236 patients (12.7%) met the criteria for blindness. Of these, 963 (77.9%) had unilateral blindness and 273 (22.1%) had bilateral blindness. The distribution of blindness across age groups and gender is presented in Table 1. The proportion of blindness increased markedly with age, ranging from 5.1% in patients aged 16–35 years to 62.3% in those aged ≥76 years (p < 0.001). Blindness was also more common among males than females (13.8% vs 11.8%, p = 0.004).
Table 1.
Distribution of Adult Blindness by Age Group and Gender (n = 9740) Overall Blindness: 1236/9740 (12.7%)
| Variable | Total n | Blind n (%) | p-valuea |
|---|---|---|---|
| Age group (Years) | <0.001 | ||
| 16–35 | 5597 | 286 (5.1) | |
| 36–55 | 2387 | 270 (11.3) | |
| 56–75 | 1456 | 493 (33.9) | |
| ≥76 | 300 | 187 (62.3) | |
| Gender | 0.004 | ||
| Female | 5369 | 634 (11.8) | |
| Male | 4371 | 602 (13.8) |
Notes: a P-values were calculated using the chi-square test. Values < 0.05 are shown in bold.
The etiologic distribution of unilateral blindness according to age group is shown in Table 2. Overall, the most common causes were age-related cataract (31.7%), trauma (16.9%), and corneal opacity related to microbial keratitis or undetermined corneal scars (11.0%). Other notable causes included glaucoma (7.7%) and pseudophakic bullous keratopathy (7.3%). Trauma represented the leading cause of unilateral blindness in younger patients aged 16–35 years, accounting for 41.7% of cases in this age group, whereas age-related cataract predominated in older age groups, particularly among patients aged 56–75 years (49.6%).
Table 2.
Causes of Unilateral Adult Blindness by Age Group
| Cause | 16–35 (Years) (n=247) |
36–55 (Years) (n=214) |
56–75 (Years) (n=369) |
≥76 (Years) (n=133) |
Total (n=963) |
|---|---|---|---|---|---|
| Age-related cataract | 1 (0.4%) | 73 (34.1%) | 183 (49.6%) | 48 (36.1%) | 305 (31.7%) |
| Trauma | 103 (41.7%) | 40 (18.7%) | 17 (4.6%) | 3 (2.3%) | 163 (16.9%) |
| Corneal opacity (microbial keratitis scar/undetermined corneal scar) | 22 (8.9%) | 30 (14.0%) | 39 (10.6%) | 15 (11.3%) | 106 (11.0%) |
| Glaucoma | 12 (4.9%) | 11 (5.1%) | 38 (10.3%) | 13 (9.8%) | 74 (7.7%) |
| Pseudophakic bullous keratopathy | 1 (0.4%) | 9 (4.2%) | 33 (8.9%) | 27 (20.3%) | 70 (7.3%) |
| Phthisis bulbi/Eviscerated eye | 5 (2.0%) | 14 (6.5%) | 17 (4.6%) | 9 (6.8%) | 45 (4.7%) |
| Secondary optic nerve atrophy | 28 (11.3%) | 6 (2.8%) | 2 (0.5%) | 1 (0.8%) | 37 (3.8%) |
| Uncorrected aphakia | 7 (2.8%) | 4 (1.9%) | 8 (2.2%) | 5 (3.8%) | 24 (2.5%) |
| Undetermined macular scar | 15 (6.1%) | 3 (1.4%) | 2 (0.5%) | 0 (0.0%) | 20 (2.1%) |
| Diabetic retinopathy | 2 (0.8%) | 10 (4.7%) | 7 (1.9%) | 0 (0.0%) | 19 (2.0%) |
| Deep amblyopia | 19 (7.7%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 19 (2.0%) |
| Retinal detachment | 5 (2.0%) | 4 (1.9%) | 6 (1.6%) | 0 (0.0%) | 15 (1.6%) |
| Uveitis | 5 (2.0%) | 1 (0.5%) | 4 (1.1%) | 1 (0.8%) | 11 (1.1%) |
| Keratoconus | 9 (3.6%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 9 (0.9%) |
| Toxoplasma chorioretinitis | 7 (2.8%) | 1 (0.5%) | 0 (0.0%) | 0 (0.0%) | 8 (0.8%) |
| Age-related macular degeneration | 0 (0.0%) | 0 (0.0%) | 1 (0.3%) | 5 (3.8%) | 6 (0.6%) |
| Other | 6 (2.4%) | 8 (3.7%) | 12 (3.3%) | 6 (4.5%) | 32 (3.3%) |
Notes: Percentages represent column percentages.
The causes of bilateral blindness are summarized in Table 3. The most frequent cause was age-related cataract (50.5%), followed by glaucoma (15.8%) and diabetic retinopathy (6.6%). Cataract was the leading cause of bilateral blindness in all age groups above 36 years and accounted for 65.9% of cases among patients aged 56–75 years. In younger adults aged 16–35 years, trauma represented a relatively larger proportion of bilateral blindness (28.9%).
Table 3.
Causes of Bilateral Adult Blindness by Age Group
| Cause | 16–35 (Years) (n=38) |
36–55 (Years) (n=54) |
56–75 (Years) (n=129) |
≥76 (Years) (n=52) |
Total (n=273) |
|---|---|---|---|---|---|
| Age-related cataract | 0 (0.0%) | 24 (44.4%) | 85 (65.9%) | 29 (55.8%) | 138 (50.5%) |
| Glaucoma | 1 (2.6%) | 8 (14.8%) | 20 (15.5%) | 14 (26.9%) | 43 (15.8%) |
| Diabetic retinopathy | 1 (2.6%) | 7 (13.0%) | 9 (7.0%) | 1 (1.9%) | 18 (6.6%) |
| Secondary optic nerve atrophy | 7 (18.4%) | 5 (9.3%) | 3 (2.3%) | 0 (0.0%) | 15 (5.5%) |
| Trauma | 11 (28.9%) | 2 (3.7%) | 0 (0.0%) | 0 (0.0%) | 13 (4.8%) |
| Pseudophakic bullous keratopathy | 0 (0.0%) | 0 (0.0%) | 3 (2.3%) | 4 (7.7%) | 7 (2.6%) |
| Hereditary retinal dystrophies | 3 (7.9%) | 2 (3.7%) | 1 (0.8%) | 0 (0.0%) | 6 (2.2%) |
| Age-related macular degeneration | 0 (0.0%) | 2 (3.7%) | 3 (2.3%) | 1 (1.9%) | 6 (2.2%) |
| Corneal opacity (microbial keratitis scar/undetermined corneal scar) | 0 (0.0%) | 1 (1.9%) | 2 (1.6%) | 2 (3.8%) | 5 (1.8%) |
| Hereditary optic nerve atrophy | 4 (10.5%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 4 (1.5%) |
| Hypertensive retinopathy | 4 (10.5%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 4 (1.5%) |
| Keratoconus | 4 (10.5%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 4 (1.5%) |
| Other | 3 (7.9%) | 3 (5.6%) | 3 (2.3%) | 1 (1.9%) | 10 (3.7%) |
Notes: Percentages represent column percentages.
Associations between major causes of unilateral blindness and demographic variables were evaluated using multivariable logistic regression (Table 4). Trauma-related blindness was strongly associated with younger age groups compared with patients aged 56–75 years (OR = 13.83, 95% CI: 7.97–24.00 for ages 16–35; OR = 4.75, 95% CI: 2.61–8.63 for ages 36–55). Male gender was also associated with higher odds of trauma-related blindness (OR = 1.77, 95% CI: 1.21–2.59). Corneal opacity showed a significant association with male gender (OR = 2.48, 95% CI: 1.61–3.82). Pseudophakic bullous keratopathy was more frequent in patients aged ≥76 years (OR = 2.58, 95% CI: 1.48–4.48). Secondary optic nerve atrophy was strongly associated with younger age groups, particularly patients aged 16–35 years (OR = 26.80, 95% CI: 6.28–114.44).
Table 4.
Factors Associated with Major Causes of Unilateral Adult Blindness
| Cause | Age 16–35 vs 56–75 | Age 36–55 vs 56–75 | Age ≥76 vs 56–75 | Male vs Female |
|---|---|---|---|---|
| Age-related cataract | <0.01 (0.00–0.03) | 0.53 (0.37–0.75) | 0.59 (0.39–0.89) | 0.54 (0.39–0.73) |
| Trauma | 13.83 (7.97–24.00) | 4.75 (2.61–8.63) | 0.46 (0.13–1.61) | 1.77 (1.21–2.59) |
| Corneal opacity | 0.71 (0.41–1.24) | 1.36 (0.81–2.27) | 1.03 (0.54–1.94) | 2.48 (1.61–3.82) |
| Glaucoma | 0.43 (0.22–0.85) | 0.47 (0.23–0.94) | 0.94 (0.48–1.82) | 1.15 (0.71–1.86) |
| Pseudophakic bullous keratopathy | 0.04 (0.01–0.30) | 0.45 (0.21–0.95) | 2.58 (1.48–4.48) | 1.16 (0.70–1.91) |
| Phthisis bulbi/Eviscerated eye | 0.41 (0.15–1.12) | 1.44 (0.69–2.98) | 1.48 (0.64–3.41) | 1.34 (0.73–2.45) |
| Secondary optic nerve atrophy | 26.80 (6.28–114.44) | 5.40 (1.08–27.00) | 1.44 (0.13–16.04) | 0.49 (0.24–0.98) |
Notes: Each model compares the specified etiology (coded as 1) vs all other etiologies (coded as 0). Reference age group = 56–75 years; reference gender = female. Results with p <0.05 are shown in bold.
Abbreviations: OR, odds ratio; CI, confidence interval.
The distribution of trauma-related ocular conditions among blind young adults aged 16–35 years is illustrated in Figure 1. Corneal scarring, traumatic cataract, and eviscerated eyes were among the most frequent clinical outcomes in this subgroup.
Figure 1.
Distribution of trauma-related ocular conditions among blind young adults aged 16–35 years (n = 114).
Discussion
In this retrospective cross-sectional study of adult patients attending a tertiary eye center in Mogadishu, trauma-related ocular disease emerged as an important contributor to blindness, particularly among young adults. Although age-related cataract remained the leading cause of blindness overall and the predominant cause of bilateral blindness in older individuals, trauma accounted for a substantial proportion of blindness in the youngest age group. In addition, unilateral blindness constituted the majority of cases (77.9%), reflecting the contribution of potentially preventable conditions such as ocular trauma and non-traumatic corneal opacity related to microbial keratitis or undetermined corneal disease.
The proportion of adult patients meeting the criteria for blindness in this tertiary eye center population was substantial (12.7%), reflecting the concentration of patients with advanced ocular disease typically seen in referral hospitals. Comparable hospital-based studies from the region have reported similar proportions of blindness among patients attending tertiary ophthalmic services, including 9.8% in Somalia,6 14.3% in Ethiopia,5 and approximately 14% in Sudan.9 While cataract remained the leading cause of blindness in both the present study and previous reports from the region, the relative contribution of other causes differed. In several studies from neighboring countries, glaucoma and age-related macular degeneration have often been reported as the second and third leading causes of blindness among adults.5,9 In contrast, when all cases of blindness were considered together in the present study, trauma-related ocular disease represented the second most common cause of blindness, followed by glaucoma and corneal opacity. This difference may partly reflect variations in the age distribution of study populations as well as the burden of ocular trauma and infectious corneal disease in this setting.
Ocular trauma represented a major contributor to blindness, particularly among younger adults. In the 16–35 year age group, trauma accounted for the largest proportion of unilateral cases (41.7%), highlighting the impact of ocular injury on visual loss in economically active populations. This finding is consistent with previous studies indicating that ocular trauma disproportionately affects younger individuals and is more common among males.10,11 The multivariable analysis also demonstrated a strong association between trauma-related blindness, younger age groups, and male gender. The trauma-related conditions observed in young adults, including corneal scarring, traumatic cataract, and eviscerated eyes (Figure 1), reflect the severe consequences of ocular injuries. In this setting, a substantial proportion of these severe ocular injuries may be attributable to the long-standing conflict environment and explosive incidents reported in the region.12,13 Studies from different countries have similarly reported that trauma-related corneal scarring and traumatic cataract are among the most frequent causes of monocular visual loss following ocular injury.10,11,14
Secondary optic nerve atrophy was also strongly associated with younger age groups in the regression analysis. A previous report from Somalia described epidemic optic neuropathy affecting predominantly young individuals, with nutritional deficiencies suggested as a possible contributing factor.15 This regional observation may provide additional context for the age-related pattern observed in the present study.
Corneal opacity related to microbial keratitis or undetermined corneal scarring also represented a leading cause of unilateral blindness in this cohort and consistently ranked among the three leading causes across all age groups. Similar findings have been reported in several studies from low- and middle-income countries, where infectious keratitis frequently results in unilateral corneal scarring and subsequent monocular visual loss.16–18 In resource-limited settings, delayed access to ophthalmic care, limited availability of early antimicrobial treatment, and inadequate eye health awareness may contribute to the progression of corneal infections to visually significant scarring.19
Age-related ocular diseases accounted for the majority of blindness among older adults. Cataract was the leading cause of both unilateral and bilateral blindness and remained the predominant cause of bilateral blindness in older age groups, consistent with findings from many studies conducted in other low- and middle-income countries, including several regions of Africa.2,5,20,21 Glaucoma also contributed substantially to blindness in older age groups, reflecting its well-recognized role as a major cause of irreversible visual loss worldwide.22 Diabetic retinopathy accounted for a notable proportion of bilateral blindness, likely reflecting the high prevalence of diabetic eye disease and ongoing challenges in diabetes management reported across several East African countries.23 An additional observation was the relatively high proportion of pseudophakic bullous keratopathy among the oldest patients with unilateral blindness, which may reflect delayed access to cataract surgery, limited surgical infrastructure and trained personnel, higher rates of surgery-related complications, and restricted availability of corneal transplantation services.24
The findings of this study have important implications for ophthalmic care in similar resource-limited settings. The prominent contribution of trauma-related blindness among younger adults highlights the need for strengthened injury prevention strategies and improved access to emergency ophthalmic care. At the same time, the contribution of corneal opacity across all age groups underscores the importance of early detection and treatment of infectious keratitis. The continued dominance of cataract among older adults indicates the need to improve cataract surgical coverage and the capacity of eye-care services.24
Because the study was conducted in a tertiary center, the findings may over-represent more severe ocular conditions and may not fully reflect the distribution of blindness in the general population. Furthermore, the retrospective design relied on the accuracy and completeness of medical records, which may introduce some degree of information bias. Despite these limitations, the study included a large cohort of adult patients and provided age-stratified analyses of unilateral and bilateral blindness. In addition, the use of clinical records covering an entire calendar year may have helped minimize seasonal variation in disease presentation.
In conclusion, this study provides additional clinical insight into the patterns and causes of adult blindness in a hospital-based population in Somalia. Ocular trauma emerged as a major contributor to visual loss among younger adults, while corneal opacity remained an important cause of unilateral blindness across all age groups. In contrast, age-related ocular diseases, particularly cataract and glaucoma, accounted for the majority of blindness among older individuals.
Acknowledgments
Generative artificial intelligence assistance (ChatGPT, GPT-5.3, OpenAI) was used for language editing, manuscript organization, and stylistic refinement during manuscript preparation. No artificial intelligence tools were used for data collection, analysis, interpretation of results, or generation of study findings. The authors reviewed and approved all final content and take full responsibility for the accuracy and integrity of the manuscript.
Funding Statement
No funds, grants, or other financial support were received for this study. The authors declare that no funding bodies had any role in the design of the study, data collection, analysis, interpretation of data, or in writing the manuscript.
Abbreviation
BCVA, best-corrected visual acuity.
Data Sharing Statement
The datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality and institutional data protection policies but are available from the corresponding author on reasonable request.
Ethics Approval and Informed Consent
The study adhered to the tenets of the Declaration of Helsinki and received ethical approval from the Ethics Committee of Mogadishu Somalia Turkey Training and Research Hospital (Protocol No. MSTH/24985). Because the study involved retrospective analysis of anonymized medical records, the requirement for informed consent was waived.
Consent for Publication
Not applicable. The study did not include identifiable patient images, videos, or personal information requiring publication consent.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
The authors declare that they have no financial or non-financial competing interests related to this work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality and institutional data protection policies but are available from the corresponding author on reasonable request.