Objectives: To assess the efficacy and cost effectiveness of a home safety programme and a home exercise programme to reduce falls and injuries in older people with low vision. Design: Randomised controlled trial. Setting: Dunedin and Auckland, New Zealand. Participants: 391 women and men aged≥ 75 with visual acuity of 6/24 or worse who were living in the community; 92% (361 of 391) completed one year of follow-up. Interventions: Participants received a home safety assessment and modification programme delivered by an occupational therapist (n=100), an exercise programme prescribed at home by a physiotherapist plus vitamin D supplementation (n=97), both interventions (n=98), or social visits (n=96). Main outcome measures: Numbers of falls and injuries resulting from falls, costs of implementing the home safety programme. Results: Fewer falls occurred in people randomised to the home safety programme but not in those randomised to the exercise programme (incidence rate ratios 0.59 (95% confidence interval 0.42 to 0.83) and 1.15 (0.82 to 1.61), respectively). However, within the exercise programme, stricter adherence was associated with fewer falls (P=0.001). A conservative analysis showed neither intervention was effective in reducing injuries from falls. Delivering the home safety programme cost ＄ NZ650 (￡ 234; ＄ 432; ∈ 344) (at 2004 prices) per fall prevented. Conclusion: The home safety programme reduced falls and was more cost effective than an exercise programme in this group of elderly people with poor vision. The Otago exercise programme with vitamin D supplementation was not effective in reducing falls or injuries in this group, possibly due to low levels of adherence. Objectives: To assess the efficacy and cost effectiveness of a home safety program and a home exercise program to reduce falls and injuries in older people with low vision. Design: Randomized controlled trial. Setting: Dunedin and Auckland, New Zealand. Participants: 391 women and men aged ≥ 75 with visual acuity of 6/24 or worse who were living in the community; 92% (361 of 391) completed one year of follow-up. Interventions: Participants received a home safety assessment and modification program delivered by an occupational therapist (n = 100), an exercise program prescribed at home by a physiotherapist plus vitamin D supplementation (n = 97), both interventions (n ​​= 98), or social visits falls and injuries resulting from falls, costs of implementing the home safety program. Results: Fewer sets occurred in people randomized to the home safety program but not in those randomized to the exercise program (incidence rate 0.59 (95 % confidence interval 0.42 to 0.83) and 1.15 (0.82 to 1.61), respectively). However, within the exercise program, stricter adherence was associated with fewer falls (P = 0.001). A conservative analysis showed no intervention was effective in reducing injuries from Falls: the home safety program reduced falls and was more cost effective than an exercise program in this group of elderly people with poor vision. The Otago exercise program with vitamin D supplementation was not effective in reducing falls or injuries in this group, possibly due to low levels of adherence.