June 2007

 

OPHTHALMOLOGY NEWS

 

When should glaucoma patients stop driving?


by Tony Realini, M.D.

   

The doctor’s role in this difficult decision

DrivingBeing a safe driver requires both adequate central visual acuity and sufficient peripheral vision. Until its late stages, glaucoma steals the latter and spares the former. As a result, patients with glaucoma may have excellent central visual acuity and yet be unsafe behind the wheel.

A glaucoma patient with a valid driver’s license who no longer meets the minimum visual requirements to drive safely represents a significant conundrum to the ophthalmologist. Balancing our patient’s personal needs with the greater issue of public safety in the community is a meaningful challenge.

For the patient who is faced with surrendering a driver’s license, the consequences can be enormous.

According to Cynthia Owsley, MSPH, Ph.D., professor of ophthalmology at the University of Alabama at Birmingham, “Not driving is much more than a personal inconvenience. Driving is inextricably linked to quality of life.” Robert Fechtner, M.D., professor of ophthalmology, the University of Medicine and Dentistry of New Jersey, Newark, agreed.

“One of the great fears for my aging patients is the loss of independence,” he said. “Nothing seems to underline this loss to them more than the loss of driving privileges. When I served on a medical advisory board to the division of motor vehicles, it was a little scary to see who was still driving.”

Dr. Owsley pointed out that the personal automobile is the primary mode of travel in the United States. Without the privilege of driving one’s self, most people have no alternate means of getting around. “Public transportation in most areas of the United States is either inadequate or nonexistent.”

Losing the ability to drive often leads to significant side effects such as depression and social isolation. In addition, overall health may deteriorate as an unexpected consequence. “In a number of surveys, the number one problem in getting to routine eyecare is lack of transportation,” she said. This likely generalizes to seeking other forms of health care as well, which can leave seniors effectively cut off from health care.

Clearly, not every patient with glaucoma poses a driving risk. “Crash rates in people with glaucoma are not increased compared to people without glaucoma,” said Dr. Owsley. “There’s no association with being diagnosed with glaucoma and having an increased risk of a motor vehicle crash.”

Instead, risk is associated with the extent to which glaucoma has affected an individual patient’s visual function. At what stage in the disease process does the ability to drive a car deteriorate? “Those with moderate visual field loss in at least one eye do pose a threat,” she said. She defined moderate visual field loss as having an AGIS [Advanced Glaucoma Intervention Study] score of greater than 12. “And people with visual field limitations to within 30° of fixation have trouble detecting obstacles in the roadway.”

In contrast, she said, patients with minor binoculars visual field loss, but still possessing 100° or more of horizontal field, are not likely to have increased crash risk.

“Clearly, recommendations to give up driving are not to be made or taken lightly,” she said. She suggested initiating a conversation about driving once the patient has developed moderate visual field loss in one eye. “Document this conversation and any recommendations in the medical record,” she advised.

Dr. Fechtner also takes a proactive approach. “I routinely ask my patients if they are still driving. Often, a family member will bring up the subject. They know their loved one should not be driving, but do not want to be the one to take away his or her independence. I’ll ask about driving with moderate to advanced field loss on the SITA [Swedish Threshold Interactive Algorithm] standard 24-2 visual field,” he said. He doesn’t limit this conversation to his glaucoma patients, and often initiates the conversation with patients who have deteriorating vision from any cause. “From the standpoint of central visual acuity, I usually ask about driving once acuity reaches 20/60 or worse.”

Dr. Owsley pointed out that some states have mandatory reporting laws regarding impaired drivers. “It’s important to know the laws of your state,” she said.

As an interesting example of the importance of knowing the laws of your state, the state of West Virginia incorporates a vision test into the initial licensure process, but does not retest vision at any subsequent licensure renewals. This adds an additional layer of responsibility onto the shoulders of eye care professionals.

Reporting a potentially impaired driver to the Department of Motor Vehicles (DMV) is the beginning of a process, not the end. “Just because you do report someone, this does not mean that their license will be revoked.” She pointed out that an independent evaluation may take place, and that an appeals process exists for patients who feel that their license has been unjustly revoked. “People with visual impairments sometimes appeal non-licensure decisions on the basis of the Americans with Disabilities Act.” These appeals can be successful.

In addition, some patients may be able to retain their driving privileges through additional training. “Consider referring your patients to a driving assessment clinic,” Dr. Owsley advised. She pointed out that the Association for Driver Rehabilitation Specialists is an organization of professionals working in the field of driver education and driver training for persons with disabilities. More information can be obtained at their website (www.driver-ed.org).

When faced with the patient who should probably no longer be driving, Dr. Fechtner takes a patient-centered approach to this difficult discussion.

“When I discuss stopping driving with my patients, I first confirm to them that I believe they are responsible and would drive with great care. However, the loss of vision from their glaucoma will now prevent them from seeing the other drivers or hazards in the road to allow them to drive safely. I always try to have this discussion with another family member in the room. More often than not,” he said, “the family member is grateful to have the doctor confirming what they already know.”

Editors’ note: Dr. Fetchner has no financial interests related to his comments. Dr. Owsley has an affiliation with Pfizer (New York).

Contact information
Fechtner: fechtner@umdnj.edu
Owsley: owsley@uab.edu

When should glaucoma patients stop driving? When should glaucoma patients stop driving?
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