PURPOSE: To examine the impact of cataract surgery on older adults' self-reported visual difficulties and compare them with those of patients with cataract who declined surgery over the same period. SETTING: Twelve area practices. METHODS: This was a consecutive chart review over a 6-month period. Primary inclusion criteria were 55 years or older, cataract in 1 or both eyes with 20/40 visual acuity or worse (best corrected, distance), and no previous cataract surgery in either eye. The Activities of Daily Vision Scale (ADVS) and visual acuity, contrast sensitivity, and disability glare tests were administered at baseline and at a 1-year follow-up visit. RESULTS: This study comprised 245 patients, 156 of whom elected to have cataract surgery and 89 of whom declined. Those electing surgery were more likely to be white, female, and have worse visual acuity and no ocular comorbidities. At baseline, ADVS subscale scores ranged from 53 to 76 in the surgery group and from 72 to 89 in the no-surgery group. In the surgery group, subscale scores improved by 15 to 21 points on average at the 1-year follow-up; scores were unchanged or worse in the no-surgery group over this period. This difference between the groups remained statistically significant after adjustment for group baseline differences in demographics, vision, and ADVS score. In the surgery group, visual acuity improvement in the first eye was an independent predictor of increases in the ADVS overall score and night driving and glare disability subscales; contrast sensitivity was an independent predictor of improvement in the night driving subscale. A reduction in disability glare in the second eye was independently linked to increases in the overall ADVS score and the night driving, near vision, and glare disability subscales. CONCLUSIONS: Baseline findings suggest that cataract patients who have surgery have more difficulty in visual tasks than those who decline surgery. After surgery, patients reported less difficulty with visual tasks. In the no-surgery group, no change was reported. Improvements in visual acuity and contrast sensitivity and reductions in disability glare after surgery were independently linked to improvements in ADVS scores.