Knowledge of the age-specific causes of blindness and visual impairment elucidates the increase in the prevalence of impaired vision and may facilitate adequate management. In this study, most of the disorders responsible for blindness and visual impairment were age related, mostly of unknown cause, and, as yet, unpreventable. We confirm the observation that age-related macular degeneration is the leading cause of blindness among white populations,8,18,19 but this was true only for subjects aged 75 years or older. Then it became the main contributor to the steep increase in the prevalence of blindness, leading to bilateral blindness as a single cause in 12 (3%) of 408 subjects aged 85 years or older in the present study. In common with other studies, age-related cataract was the most important cause of bilateral visual impairment5,20 and the second most frequent cause of blindness. The visual-impairing effect of cataract was highly associated with age, causing a larger proportion of visual impairment with increasing age. Successful treatment for this disorder is readily available; cataract extraction is one of the most frequent surgical procedures in the Netherlands (Netherlands Foundation of Information Systems for Health Care [SIG-Zorginformatie], National Medical Registration, Utrecht, the Netherlands; written communication; August 9, 1997). If adequate facilities and personnel are not a logistic constraint to treatment, why does cataract still impair vision to such a great extent in the elderly? Before we enlarge on this issue, we emphasize that 62 (15%) of 408 subjects aged 85 years or older were "saved" from bilateral blindness or visual impairment by cataract extraction, a much greater proportion than the 32 (8%) who were blind or visually impaired by cataract. Most of the subjects in the latter category received no eye care. Our study provides limited information on possible barriers, but old age, unawareness of treatment possibilities, and comorbidity (with other disabling disorders) seem to hamper access to appropriate care. Policies to implement referrals on a more uniform basis are needed, for even in the very old or disabled, the restoration of visual function may improve the quality of life and reduce the nursing care required.