Purpose: To determine the prevalence and causes of blindness and visual impairment in people 40 years of age and older in Budni, Peshawar, Pakistan. Methods: A population-based cross-sectional study was carried out involving 1,106 men and women 40 years of age and older in a rural area in Pakistan's North West Frontier Province (NWFP). All subjects with a presenting visual acuity < 6/18 in either eye were referred to a centralized clinic for a standardized eye examination that included refraction and dilated fundal examination. The main outcome was blindness (presenting visual acuity < 3/60 in the better eye) and low vision (presenting VA < 6/18–3/60 in the better eye). Results: Of 1,106 people examined, 21 (1.9%; 95% CI: 1.1—2.7%) were blind, while another 27 (2.4%) and 62 (5.5%) subjects had severe visual impairment (< 6/60–3/60) and visual impairment (< 6/18–6/60), respectively. Women, as compared to men, had a higher prevalence of visual impairment and severe visual impairment; but they had a lower prevalence of blindness (1.6 vs. 2.2%); however, the difference was not statistically significant (0.6%; 95% CI: −0.9–2.1%). Similarly farmers had the highest prevalence of blindness. The leading cause of blindness and low vision was cataract, which accounted for 14 of 21 (66.6%) cases of blindness and 49 of 89 (55.5%) cases of low vision. The second leading cause of blindness was uncorrected aphakia. Conclusion: Much of the blindness was due to unoperated cataract and uncorrected aphakia. Thus, there is an urgent need to develop ways in which cataract surgical output could be increased, and glasses provided to those who need them.