Sex Differences In Early-Onset Cataract: Reproductive Aging, Betel Quid Use, And Socioeconomic Disadvantage In A South Indian Cohort

Women experience disproportionate cataract blindness, but whether this reflects earlier disease expression rather than delayed access is unclear. To quantify sex differences in age at cataract surgery and determine whether the age gap persists across preoperative vision‑impairment severity. To identify determinants of presenile cataract in midlife women, focusing on menopausal stage and region‑specific exposures.

We retrospectively analyzed 3.3 million adult cataract surgeries performed within a high-volume eye-care network in South India (2010–2023) and conducted a prospective case–control study of women aged 35–50 years. 

Retrospective analysis of adult cataract surgeries (≥18 years). Age at surgery and preoperative best‑corrected visual acuity (BCVA) were extracted. BCVA was grouped into WHO categories. Age distributions and medians were compared by sex overall and within BCVA strata; female:male surgery ratios were calculated by single year of age. Prospective case–control study of women aged 35–50 years. Cases had any lens opacity on slit‑lamp examination and photography; controls had clear lenses bilaterally. Menopausal stage was classified using the STRAW +10 criteria. Exposures included socioeconomic status , betel quid use, and clinical/lifestyle covariates. Associations were assessed using age‑adjusted logistic regression.

Among 3,347,285 surgeries, 54.6% were in women. Women were younger at surgery than men (median 60 vs 64 years; mean 60.6 vs 62.9). Female: male surgery ratios exceeded 1.0 from ages 30–59 and peaked at 1.69 in ages 40–49. Of 340 participants, 86 were cases and 254 controls. Cases were older (median 45 vs 40 years; p<0.0001) and more often natural postmenopausal (25.6% vs 3.5%). After age adjustment, natural postmenopause was strongly associated with cataract vs premenopause (OR 5.92, 95%CI 2.27–15.46). Regular betel quid use increased odds (OR 2.55, 95%CI 1.01–6.48). Lower socioeconomic class showed a graded association (class IV OR 2.44, 95%CI 1.34–4.44; class V OR 7.15, 95%CI 1.18–43.24; ref class III).

In a high‑volume low‑ and middle‑income country (LMIC) surgical network, women reach cataract surgery at younger ages than men, with a pronounced midlife shift that is not explained by worse presenting vision. In women ≤50 years, presenile cataract is linked to natural postmenopause, regular betel quid use, and socioeconomic disadvantage. Targeted midlife screening and prevention should incorporate reproductive aging and modifiable cultural exposures.