ORIGINAL ARTICLE  
Association of Serum Vitamin D Levels  
with Senile Cataract  
Yasir Iqbal Malik1, Aqsa Malik2, Atteya Zaman3, Rabia Shabbir4, Masooma Talib5  
1,5Watim Medical College, Rawat, Islamabad, 2Mohtarma Benazir Bhutto Shaheed Medical College Mirpur-AJK,  
3Federal Medical and Dental college, Islamabad, 4Hitec Medical and dental college, Wah Cantt,  
ABSTRACT  
Purpose: To determine vitamin D levels in patients of senile cataract and compare them with age related control  
patients.  
Study Design: Case control observational study.  
Place and Duration of Study: Naseer Memorial Hospital, Dadhyal Azad Kashmir from March 2016 to June  
2017.  
Material and Methods: Three hundred patients were selected and two groups were designed for the study.  
Group I included patients having senile cataract of any morphological type. The inclusion criteria were age of 50  
years or more. Group II was control in which age matched controls that had no cataract were enrolled from the  
outpatient clinic. Vitamin D levels were measured by radioimmunoassay technique with Diasorin SR® kit following  
the user’s manual. The collected data was entered in the statistical package for social sciences (SPSS) version  
21 for analysis. Independent t –test was used to determine the significant difference of means between controls  
and patients. P value less than 0.05 was considered as significant.  
Results: Group I consisted of 65.33 % females and 35.66% males whereas in group II were 68% females and  
32% males. The mean age of patients was 63.20 ± 9.5 years in group I and 65.5 ± 8.9 years in group II.  
Statistically no significant difference (p>0.05) was found between mean Vitamin D levels in cataract patients  
(25.95 ± 3.75 ng/mL vs. and age matched control (29.02 ± 5.11ng/mL).  
Conclusion: There was no statistically significant difference between the vitamin D levels of cataract patients  
and the age matched controls.  
Key Words: Vitamin D, Cataract, Oxidative stress.  
How to Cite this Article: Malik YI, Malik A, Zaman A, Shabbir R, Bilal M. Association of Vitamin D Levels with  
Senile Cataract. Pak J Ophthalmol. 2020; 36 (3): 258-262.  
Doi: 10.36351/pjo.v36i3.1037  
INTRODUCTION  
leading cause of severe visual loss in year 2017  
Cataract is a one of the leading causes of reversible  
according to the statistics of the Global Burden of  
blindness and is estimated to be affecting 94 million  
Disease (GBD)2. The treatment of cataract is surgical  
people of the world population1. In Pakistan, it was the  
removal with implantation of artificial intraocular lens,  
which is the commonest procedure being performed in  
all ophthalmic centers.3  
Correspondence to: Yasir Iqbal Malik  
Watim Medical College, Rawat, Islamabad  
Email: yazeriqbal@gmail.com  
Cataract is defined as any opacification or  
cloudiness in the otherwise clear crystalline ocular  
lens. The normal lens is made up of water and protein  
fibers and when these proteins clump together an  
opacity is formed which affects the lens ability to  
Received: April 13, 2020  
Accepted: May 4, 2020  
Revised: May 4, 2020  
258  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 258-262  
Association of Serum Vitamin D Levels with Senile Cataract  
refract light. The causes of cataract are multiple. It can  
be senile due to normal aging process or secondary to  
trauma, drugs, ocular diseases, systemic diseases,  
ultraviolet light exposure and oxidative stress4.  
Alcohol abuse, smoking and obesity lead to an  
increase in oxidative stress and this increase in  
oxidative stress is a preventable cause of cataract5.  
50 years or older and of any gender. The exclusion  
criteria were history of smoking, alcohol use, cataract  
secondary to ocular or systemic disease, having  
glaucoma or any other retinal pathology, history of  
ocular surgery, oral steroid or calcium supplements  
use, any history of ocular trauma or any systemic  
disease. Group II was control in which age matched  
subjects who had no cataract were enrolled from the  
outpatient clinic having the same exclusion criteria.  
The patients underwent complete eye examination like  
visual acuity assessment with the Snellen chart,  
pupillary reflexes, slit lamp examination, intraocular  
pressure measurement with applanation tonometry and  
detailed Biomicroscopic fundoscopy. Cataract  
diagnosis and grading was done by Lens opacity  
classification system (LOCS) on slit lamp using  
retroillumination technique.  
Like all cellular cytoplasm of the body, oxidation  
is being inhibited in the lens and it is kept in a reduced  
environment but it can be oxidized6. Ultraviolet light  
absorption from sunlight can create free radicals such  
as hydrogen peroxide and hydroxyl radical leading to  
increased oxidative damage and cataract formation.  
This free radical formation can be prevented by  
nutritional factors such as vitamin C, vitamin E and  
xanthine6.  
Vitamin D, once a vitamin, has now been declared  
as a hormone due to its proven anti-inflammatory  
properties and immune regulation. Researchers have  
found association of vitamin D in cardiovascular  
diseases, neurogenesis, autoimmune disorders and  
infectious diseases in preventing oxidative stress7. Due  
these properties researchers have debated its role in  
prevention of senile cataract by preventing oxidative  
stress.  
For the assessment of vitamin D levels 3 ml  
peripheral venous blood sample was collected from  
300 patients of both groups in the laboratory. Serum  
was obtained after centrifugation of whole blood, after  
clot formation had taken place at 3000 rpm for 5  
minutes and were stored at −20 °C for further analysis.  
25-OH D levels were measured by radioimmunoassay  
technique with Diasorin SR® kit following the user’s  
manual.  
The source of vitamin D is dual. Most of it is  
synthesized in the skin after being exposed to  
ultraviolet light and the rest is from dietary source8.  
Vitamin D after absorption in the intestines and  
synthesis by skin is converted into 25(OH) D in the  
liver which is the measuring parameter of vitamin D.  
The subject is considered to be vitamin D deficient if  
the serum 25 (OH) D levels are less than 30ng/ml8.  
The collected data was entered in the statistical  
package for social sciences (SPSS) version 21 for  
analysis. Gender was expressed as percentages and  
frequency whereas numerical variable e.g. age was  
expressed as mean and standard deviation.  
Independent t–test was used to determine the  
significant difference of means between controls and  
patients. P value less than 0.05 was considered  
significant.  
To find out whether serumvitamin D levels are  
related tocataract formation or not we measured  
vitamin D levels in patients of senile cataract and  
compared them with age-matched controls.  
RESULTS  
The study was completed in 1 year and 3 months.  
During the study period 24,759 patients were  
examined out of which 1,874 (7.5%) patients were  
diagnosed with cataract. Cataract patients consisted of  
956 (51.01%) males with mean age of 57 ± 11.4 years  
and 918 (48.9%) females with mean age of 55 ± 8.4  
years. For the study one hundred and fifty patients,  
fulfilling the inclusion and exclusion criteria, were  
included in the group I from these diagnosed patients  
having cataract.  
MATERIAL AND METHODS  
This comparative prospective observational study was  
conducted at Naseer memorial hospital, Dadyal, Azad  
Jammu and Kashmir during a period of one year and  
three months after approval from the ethical review  
committee and following the guidelines of Declaration  
of Helsinki. Three hundred patients were selected by  
convenient non-probability sampling technique and  
two groups were designed for the study. Group I  
included patients having senile cataract of any  
morphological type. The inclusion criterion was age of  
In group I, we found cataract involving the right  
eye in 29.3% males vs. 22.6% females. Bilateral  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 258-262  
259  
Yasir Iqbal Malik, et al  
cataract was seen in 16.8% males and 8% females.  
Morphological classification revealed that majority of  
the patients had nuclear cataract (37.3% in males vs.  
34.6% in females) followed by posterior subcapsular  
cataract (8% in males vs. 13.3% in females) with no  
significant statistical difference (Table 1). Group I  
consisted of 65.33% females and 35.66% males  
Cataract not only makes the patient himself  
handicapped but adds people to the non functional  
community. It is a burden for the developing world for  
its increasing incidence10. We found bilateral cataract  
in 16.8% males and 8% females compared to a study  
conducted in Chakwal district reporting prevalence of  
bilateral cataract in 5.1% of the study group11.  
Similarly, different prevalence of cataract has been  
reported according to morphology. Naseer1 reported  
posterior sub capsular cataracts as being the most  
common in 56.8% of the study group, followed by  
nuclear cataract in 26.4% and cortical cataract in  
16.8% whereas we found nuclear cataract (37.3% in  
males vs. 34.6% in females) followed by posterior  
subcapsular cataract (8% in males vs. 13.3% in  
females). The variation in frequency of cataract may  
be attributed to variation in sample sizes and settings  
of the studies. This was endorsed by a study by Sasaki  
H et al12 who reported more percentage of cortical  
cataract in northern region of Japan and China while  
nuclear cataracts predominating in the southern  
regions.  
Table 1: Morphological types of cataract in group I (n =  
150).  
Cataract  
Cortical  
Males  
4%  
Females  
2.6%  
Type  
Nuclear  
Posterior Subcapsular  
Right  
37.3%  
8%  
29.3%  
8%  
34.6%  
13.3%  
22.6%  
15.3%  
8%  
Unilateral  
Bilateral  
Left  
16.8%  
whereas in group II there were 68% females and 32%  
males. The mean age of patients was 63.20 ± 9.5 years  
in group I and 65.5 ± 8.9 years in group II. Patients in  
both groups were matched for age and gender  
revealing no significant difference (Table 2).  
According to the guidelines of the endocrine  
society, serum vitamin D levels less than 30 ng/dL is  
declared as vitamin D deficiency13. In our study we  
found vitamin D levels as 25.95 ± 3.75 ng/mL in  
patients with cataract and as 29.02 ± 5.11ng/mL in the  
control group falling in the vitamin D deficiency  
group. This finding is in correspondence to reports by  
other researches done in our settings. According to  
Mansoor S et al14 90% of the employees in a tertiary  
care unit had low vitamin D levels in his study. Iqbal  
R et al15 also reported prevalence of vitamin D  
deficiency in 74% of the study group. This deficiency  
in vitamin D levels has been equated to a worldwide  
epidemic and has been postulated to be due to decrease  
in outdoor activities and sun exposed work  
professions16. Furthermore, people have become more  
inclined to television, computer usage and deliberate  
sun prevention16.  
Table 2: Descriptive statistics of cataract and control  
group.  
Group I  
(Cataract)  
n = 150  
Group II  
(Control) p value  
n = 150  
Mean Age (Years ± SD) 63.20 ± 9.5 65.5 ± 8.9  
0.94  
Female  
Male  
65.33%  
34.66%  
68%  
32%  
0.414  
0.617  
Gender  
Serum Vitamin D Levels  
(ng/mL)  
25.95 ± 3.75 29.02 ± 5.11 0.921  
Statistically no significant difference was found  
between mean 25-OH D levels in cataract patients  
(25.95 ± 3.75ng/ mL vs. 29.02 ± 5.11 ng /mL) and age  
matched control.  
Vitamin D, a new revolution in hormone therapy,  
is a breakthrough for the medical community.  
Numerous systemic diseases of the body are proven to  
be associated with vitamin D levels like the skeletal  
system, teeth and the cardiovascular system.17 Vitamin  
D has been detected in aqueous and vitreous humor of  
the eye and because of its antioxidant properties by  
preventing free radical formation, it has been  
associated to uveitis18, macular degeneration19 and dry  
eye syndrome20. Researchers are exploring association  
DISCUSSION  
Cataract has a high reported incidence worldwide  
which has been related to oxidative stress induced by  
light with photochemical generation of reactive  
oxygen species such as superoxide, hydrogen peroxide  
and hydroxyl radical.9 We found frequency of cataract  
as 7.5% but during a survey it has been reported as  
high as 20.9% in Pakistan1. Similarly, in another  
study, cataract was reported as 4% and 50% in the  
ages of 50-65 years and 75 – 85 years respectively2.  
260  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 258-262  
Association of Serum Vitamin D Levels with Senile Cataract  
of vitamin D with cataract formation but there are  
conflicting results. In our study we found no  
statistically significant difference in levels of vitamin  
D in control and cataract patients and found no role of  
vitamin D in cataract development. This is in  
accordance to the findings of Rao P et al21who also  
stated that vitamin D levels were not related to  
cataract. On the other hand, Park S22 reported that  
serum vitamin D levels were inversely associated to  
the risk of developing cataract. Similarly, Jee D23  
reported that age related cataracts were significantly  
decreased in patients with high serum vitamin D  
levels.  
Aqsa Malik; Assistant Professor: Manuscript review.  
Atteya Zaman; Assistant Professor: Interpretation of  
data, Manuscript review.  
Rabia Shabbir; Assistant Professor: Interpretation of  
data, Manuscript review.  
Masooma Bilal; Assistant Professor: Critical appraisal  
of findings with literature, Manuscript review.  
REFERENCES  
1. Alam M, Idris M, Hussain M. Frequency of Different  
Types of Age Related Cataracts (Study of 250 cases).  
Ophthalmology Update, 2013; 11 (1): 25.  
Supporters of vitamin D deficiency leading to  
cataract have postulated some pathways. According to  
Brown CJ16 vitamin D regulating systemic calcium  
also regulates calcium levels in aqueous humor.  
Vitamin D levels were negatively correlated to  
parathyroid. Cataract is associated with parathyroid  
hormone disorders; therefore, when vitamin D levels  
decrease, parathyroid hormone levels are increased  
leading to cataract formation.16 Another pathway is  
disruption of calcium homeostasis caused by vitamin  
D deficiency producing lens opacification by lens  
protein aggregation and abnormal differentiation of  
lens epithelial cells into fibrocytes24.  
2. Hassan B, Ahmed R, Li B, Noor A, ul Hassan Z. A  
comprehensive study capturing vision loss burden in  
Pakistan (1990-2025): Findings from the Global Burden  
of Disease (GBD) 2017 study. PloS one, 2019; 14 (5).  
3. Iqbal Y, Zia S, Khan QA. Post operative Anterior  
Chamber Reaction in Adult Cataract Surgery after  
Adding Heparin in Irrigating Solution. Pak  
J
Ophthalmol. 2014; 30 (4).  
4. García-Layana A, Ciufo G, Toledo E, Martínez-  
González MA, Corella D, Fitó M, et al. The effect of  
a Mediterranean diet on the incidence of cataract  
surgery. Nutrients, 2017; 9 (5): 453.  
5. Kuruvilla A. Background Causes of Human Cataract.  
Indian JApp Res. 2019; 10; 9 (7).  
6. Rakete S, Nagaraj RH. UVA Lightmediated  
Ascorbate Oxidation in Human Lenses. Photochem  
photobiol. 2017; 93 (4): 1091-5.  
7. Hussain F, Malik A, Qureshi MS, Imran M,  
Waquar S, Shafique H, et al. Homeostatic relevance  
of vitamin D in maintaining male fertility in human:  
Down–regulation of oxidative stress and up-regulation  
of anti-oxidative defense and steroidal hormones. Asian  
Pac J Reprod. 2018; 7 (2): 56.  
Limitations of our study were that it was an  
observational study and it was confined to a particular  
area. Confounders like time spent outdoors, sunlight  
exposure, dietary habits and ethnicity were not taken  
into account. Furthermore, linear analysis was not  
done but we still we feel that this study will be a new  
milestone in cataract and vitamin D association.  
8. Udani SK, Qureshi SA, Lateef T, Jafri L, Effendi  
MU, Raheem A, et al. Vitamin D and bone metabolism  
in breast cancer patients in Karachi, Pakistan. Pak J  
Pharm Sci. 2019; 32 (2) (Supplementary): 875-880.  
9. Varma SD, Kovtun S, Hegde KR. Role of UV  
irradiation and oxidative stress in cataract formation.  
Medical prevention by nutritional antioxidants and  
metabolic agonists. Eye contact lens, 2011; 37 (4): 233.  
10. Baig MA, Mahmood S, Munir R, Shahid S. To study  
the Visual Outcome and Complications of Small  
Incision Cataract Extraction (SICS) with Intra Ocular  
Lens implantation (IOL). Pak J Med Health Sci. 2017;  
11 (1): 237-9.  
CONCLUSION  
There was no statistically significant difference  
between the vitamin D levels of cataract patients and  
the age matched controls.  
Ethical Approval  
The study was approved by the Institutional review  
board/Ethical review board.  
Conflict of Interest  
Authors declared no conflict of interest.  
11. Haider S, Hussain A, Limburg H. Cataract blindness  
in Chakwal District, Pakistan: results of a survey.  
Ophth Epidemiol. 2003; 10 (4): 249-58.  
Authors’ Designation and Contribution  
Yasir Iqbal Malik; Associate Professor: Concept and  
drafting of article, Manuscript review.  
12. Sasaki H, Jonasson F, Shui YB, Kojima M, Ono M,  
Katoh N, Cheng HM, et al. High prevalence of  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 258-262  
261  
Yasir Iqbal Malik, et al  
nuclear cataract in the population of tropical and  
subtropical areas. Dev Ophthalmol. 2002; 35: 60-9.  
13. Holick MF, Binkley NC, Bischoff-Ferrari HA,  
Gordon CM, Hanley DA, Heaney RP, et al. Weaver  
CM. Evaluation, treatment, and prevention of vitamin D  
deficiency: An endocrine society clinical practice  
guideline. J Clin Endocrinol Metab. 2011; 96: 1911-  
1930.  
14. Mansoor S, Habib A, Ghani F, Fatmi Z, Badr-ud-  
Din S, Mansoor S, et al. Prevalence and significance  
of vitamin D deficiency and insufficiency among  
apparently healthy adults. Clin Biochem. 2010; 43 (18):  
1431-5.  
15. Iqbal R, Jafri L, Haroon A, Habib A. Illuminating  
the dark side-vitamin D status in different localities of  
Karachi. J Coll Phys Surg. 2013; 23 (8): 604.  
16. Brown CJ, Akaichi F. Vitamin D deficiency and  
posterior subcapsular cataract. Clin Ophthalmol.  
(Auckland, NZ). 2015; 9: 1093.  
18. Grotting LA, Davoudi S, Palenzuela D, Papaliodis  
GN, Sobrin L. Association of low vitamin d levels  
with  
noninfectious  
anterior  
uveitis.  
JAMA  
ophthalmology, 2017; 135 (2): 150-3.  
19. Millen AE, Voland R, Sondel SA, Parekh N, Horst  
RL, Wallace RB, et al. Vitamin D status and early age-  
related macular degeneration in postmenopausal  
women. Archive Ophthalmol. 2011; 129 (4): 481-9.  
20. Yildirim P, Garip Y, Karci AA, Guler T. Dry eye in  
vitamin  
D deficiency: more than an incidental  
association. Int J Rheum Dis. 2016; 19 (1): 49-54.  
21. Rao P, Millen AE, Meyers KJ, Liu Z, Voland R,  
Sondel S, et al. The Relationship between Serum 25-  
Hydroxyvitamin D Levels and Nuclear Cataract in the  
Carotenoid Age-Related Eye Study (CAREDS), an  
Ancillary Study of the Women's Health Initiative.  
Invest Ophthalmol Vis Sci. 2015; 56 (8): 4221-30.  
22. Park S, Choi NK. Serum 25-hydroxy vitamin D and  
age-related cataract. Ophth Epidemiol. 2017; 24 (5):  
281-6.  
23. Jee D, Kim EC. Association between serum 25-  
hydroxy vitamin D levels and age-related cataracts. J  
Cat Refract Surg. 2015; 41 (8): 1705-15.  
24. Vrensen GF, de Wolf A. Calcium distribution in the  
human eye lens. Ophth Res. 1996; 28 (Suppl. 2): 78-  
85.  
17. Jee D, Kang S, Yuan C, Cho E, Arroyo JG.  
Epidemiologic Survey Committee of the Korean  
Ophthalmologic Society. Serum 25-hydroxy vitamin D  
levels and dry eye syndrome: differential effects of  
vitamin D on ocular diseases. PloS one. 2016; 11 (2):  
e0149294.  
.…….  
262  
Pakistan Journal of Ophthalmology, 2020, Vol. 36 (3): 258-262