G360 2024: Steering patients and ECPs in the right direction regarding driving with glaucoma

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Reviewed by Robert L Stamper, MD

A recognized fact is that patients with glaucoma, even early-stage disease, are at increased risk of involvement in car accidents. Once diagnosed, physicians are advised to initiate discussions about driving and coping mechanisms and to continue those discussions going forward.

Robert L Stamper, MD, Distinguished Professor of Clinical Ophthalmology and Director Emeritus of the Glaucoma Service at University of California, San Francisco, discussed the challenges for physicians and patients at the Glaucoma Symposium during the Glaucoma 360 annual meeting in San Francisco.

Stamper recounted the case of an 80-year-old pseudophakic man who complained of slow, progressively blurred vision that interfered with golf, driving, and reading. The best-corrected visual acuity was 20/40 bilaterally and intraocular pressures 25 mmHg bilaterally. The patient had clear media, a cup-to-disc ratio of 0.9, and bilateral small central islands (~10 degrees). The patient agreed to stop driving.On the trip home from the examination, he was involved in an accident that resulted in the death of a child.

This case raises the question of physician liability for allowing the patient to drive.

Glaucomatous effects

Glaucoma can decrease contrast sensitivity, motion detection, color perception, peripheral vision, and depth perception, all relatively early in the disease process.

In addition, because most patients with glaucoma are older, their reaction times may be decreased. Finally, comorbidities and medications can compound the problem, Stamper explained.

Numerous studies have been undertaken to identify the effects of glaucoma on driving ability. Almost 2 decades ago, researchers reported that patients with advanced glaucoma are 3.6 times more likely to have a motor vehicle accident (MVA) compared to those with no visual fields defects,¹ while another study found that that risk to be almost doubled.²

Another group reported that visual field loss exceeding 20 points on binocular visual fields and increased glare sensitivity were significant predictors of MVAs.³

A study of moderate-to-advanced glaucoma found that 52% patients had marginal/failed road tests compared to 21% of age-matched controls,⁴ specifically decreased braking response time, and decreased ability to identify traffic signs.

Coping behaviors

The following, Stamper noted, can help compensate for reduced visual function: head movements; increased saccades; slower driving, avoiding heavy traffic, bad weather, higher speeds; and instituting defensive driving tactics. He also suggested that glaucoma patients take a senior driving course or hire Uber and Lyft services.

Legal responsibilities

Stamper said that 6 states mandate the reporting of patients to the respective divisions of motor vehicles: California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania. In 24 states, it is okay to report patients, and in 20 there are no laws.

The take-home messages are the following:

• Early-stage glaucoma puts patients at increased risk of a motor vehicle accident.
• Physicians should begin discussions about glaucoma and driving early in disease course and follow-up with occasional reminders.
• Coping behaviors, such as senior driving courses and increased use of taxi and ride-sharing services, can mitigate risks.
• When both central and peripheral vision have deteriorated, risks increase significantly.
• Comorbidities like diabetes, heart disease, and medications, can have negative visual effects.
• Patients should be advised of the effects of their reduced visual function on driving, that advice should be documented in the patient chart, and, if the visual loss, in the doctor’s opinion, might increase the risk of an MVA, a report should be filed with the division of motor vehicles.

“The patient’s, the public’s, and your own safety are at stake,” Stamper concluded.

References

1. Swanson MW, Scilley K, Liu B, et al. The nursing home minimum data set for vision and vision function. Invest Ophthalmol Vis Sci. 2007;48:1176. ARVO meeting abstract.

2. Haymes SA, LeBlanc RP, Nicolela MT, et al. Risk of falls and motor vehicle collisions in glaucoma.Invest Ophthalmol Vis Sci. 2007;48:1149-1155; https://doi.org/10.1167/iovs.06-0886

3. Rubin GS, Ng ESW, Bandeen-Roche K, et al., the SEE Project Team. A prospective, population-based study of the role of visual impairment in motor vehicle crashes among older drivers: The SEE Study. Invest Ophthalmol Vis Sci. 2007;48:1483-1491. doi:https://doi.org/10.1167/iovs.06-0474

4. Bhorade AM, Ym VH, Barco P, et al. On-road driving performance of patients with bilateral moderate and advanced glaucoma. Am J Ophthalm