OBJECTIVE: To determine the effectiveness of screening for visual impairment in people aged 75 or over as part of a multidimensional screening programme. DESIGN: Cluster randomised trial. SETTING: General practices in the United Kingdom participating in the MRC trial of assessment and management of older people in the community. PARTICIPANTS: 4340 people aged 75 years or over randomly sampled from 20 general practices, excluding people resident in hospitals or nursing homes. INTERVENTION: Visual acuity testing and referral to eye services for people with visual impairment. Universal screening (assessment and visual acuity testing) was compared with targeted screening, in which only participants with a range of health related problems were offered an assessment that included acuity screening. MAIN OUTCOME MEASURES: Proportion of people with visual acuity less than 6/18 in either eye; mean composite score of 25 item version of the National Eye Institute visual function questionnaire. RESULTS: Three to five years after screening, the relative risk of having visual acuity < 6/18 in either eye, comparing universal with targeted screening, was 1.07 (95% confidence interval 0.84 to 1.36; P = 0.58). The mean composite score of the visual function questionnaire was 85.6 in the targeted screening group and 86.0 in the universal group (difference 0.4, 95% confidence interval -1.7 to 2.5, P = 0.69). CONCLUSIONS: Including a vision screening component by a practice nurse in a pragmatic trial of multidimensional screening for older people did not lead to improved visual outcomes.