Objective: To assess the prevalence and major causes of visual impairment (VI) in elderly residents of 'home for the aged' institutions in the Prakasam district in India. Design: Cross-sectional study. Setting: 'Home for the aged' institutions in the Prakasam district in the South Indian state of Andhra Pradesh. Participants: All 524 residents in the 26 'homes for aged' institutions in the district were enumerated. Primary and secondary outcome measures: Prevalence and causes of VI; visual acuity (VA) was assessed using a Snellen chart at a distance of 6 m. Pinhole VA was assessed if presenting VA was <6/18. Torchlight examination and direct ophthalmoscopy were performed. VI was defined as presenting VA <6/18 in the better eye. Results: Of the 494 participants examined (response rate 94.3%), 78.1% were women, 72.1% had no formal schooling. The mean age of participants was 70 years (SD ±8.6 years). VI was present in 280/494 individuals (56.9%; 95% CI 52.3 to 61.3). Over 80% of the VI was due to avoidable causes including cataract (57.1%) and uncorrected refractive errors (26.4%). Among 134 individuals who had undergone bilateral cataract surgery, only 78 (58.2%) individuals had presenting VA =6/18 and 13/134 (9.7%) participants were blind. Conclusions: There is high prevalence of VI in the institutionalised elderly population in the Prakasam district in India. A significant proportion of this elderly population with VI can benefit from spectacles and cataract surgery. Strategies are required to provide highquality services to this population.