Visual fields and driving

Dr Stephanie Kearney
 Describe the defect
A. Left superior arcuate defect:
inferior retinal nerve fibre
bundles in left eye affected
B. Left superior arcuate defect:
superior retinal nerve fibre
bundles in left eye affected
C. Left superior arcuate defect:
inferior retinal nerve fibre Retinochoroiditis: Destroys retinal nerve
bundles in right eye affected
fibre bundles
D. Left superior arcuate defect:
superior retinal nerve fibre Field defect similar to glaucoma
bundles in right eye affected
https://www.ncbi.nlm.nih.gov/books/NBK10944/#:~:text=Corresponding%20vertical%20and%20horizontal%20lines,quadrant
s%20of%20the%20visual%20field.

Purves D, Augustine GJ, Fitzpatrick D, et al., editors. Neuroscience. 2nd edition. Sunderland (MA): Sinauer Associates; 2001.
The Retinotopic Representation of the Visual Field. Available from: https://www.ncbi.nlm.nih.gov/books/NBK10944/
 Learning objectives
1) To be able to describe the expected visual field and visual acuity
requirements for group 1 and group 2 drivers

2) To understand how the Esterman visual field test is conducted and how
to interpret the results

3) To have an awareness of your duties as an optometrist when discussing

vision and driving with pxs
Vision and driving
There is more to safe driving ability than good vision:
• Visuospatial perception
• hearing
• attention and concentration
• memory
• insight and understanding
• judgement
• adaptive strategies
• good reaction time
• planning and organisation
• ability to self-monitor
• sensation
• muscle power and control
• coordination
Vision and driving
• Vision is the primary sensory input required for driving

• It is the ONLY sense tested prior to granting a license

• Even at that, UK has lowest testing standards
https://www.ecoo.info/wp-content/uploads/2017/01/Visual-Standards-for-Driving-in-Europe-Consensus-Paper-January-
2017....pdf
https://www.aop.org.uk/ot/science-and-vision/research/2019/10/01/uncorrected-
defective-eyesight-a-factor-in-196-uk-road-accidents
Vision standards
Group 1 (car, motorbike): VA
The px must be able to:
Read (with glasses or contact lenses, if necessary) a car number plate
made after 1 September 2001 from 20 metres

Optom must check:

Binocular VA (with glasses or contact lenses) of at least 6/12 Snellen
Group 2 license: Bus, coach, lorry: VA
• Medical and vision check when first applying for bus or lorry licence,
and then every five years from age 45 and every year from age 60.

• Visual acuity at least 0.8 (6/7.5) measured on the Snellen scale in the
best eye and at least 0.1 (6/60) on the Snellen scale in the other eye.
Group 2 license: Bus, coach, lorry: VA
• Glasses with a corrective power not more than
(+) 8 dioptres (restricted field of view)

• There’s no specific limit for the corrective power

of contact lenses.
 Group 2

• Group 2 drivers
• Complete form after eye
examination
• Practices may charge a fee to
complete form
• H&S must include: Diplopia, glare,
ocular conditions, GH and
medications
• Full refraction
• Full health check
Self-declaration
Px must inform the DVLA of any eye condition which may affect
VA:

• Px can fill out V1 form online from DVLA

• Failure to declare can result in fine of up to £1,000 and px may
be prosecuted if involved in an accident as a result

• For group 1: must declare if condition affects both eyes

• For group 2: must declare if condition affects either eye
• The px must self declare
Exceptions
• Don’t need to declare cataracts if VA within standards and not
affected by increased sensitivity to glare

• Full list below:

https://www.gov.uk/health-conditions-and-driving
Glaucoma
• Group 1: Don’t need to inform if in 1 eye. However, if below vision
standards or if the other eye is affected by a different eye condition
then DVLA must be informed.
• Group 2: Need to inform the DVLA is affected in one eye
Macular degeneration
• Group 1:Don’t need to inform the DVLA if still within driving
standards and affects 1 eye. Need to inform the DVLA if affects both
eyes
• Group 2:If it affects the ability to drive
What happens after DVLA has been informed
by px?
• Regular visual acuity and visual field testing completed at DVLA
approved Opticians
• Specsavers currently has the DVLA vision testing services contract up
until April 2023 (may then be extended)
Visual fields: Esterman
DVLA requires:

• the method to be a binocular Esterman field test

• may request monocular full field charts in specific conditions
Visual field: Esterman
• DVLA: must be completed on Humphrey (gold standard)

• Test is also available on Henson

• Distance spectacles are worn (assumes stimuli is bright enough to be

seen without near addition)
Visual field: Esterman
• Completed binocularly

• A size III white stimulus is presented at 10 dB over a Esterman grid

covering >130° field

• 35⁰ superiorly and 55 ⁰ inferiorly

• Greater focus on the inferior field
Visual field: Esterman
Monocular
Visual field: Esterman
• Each location is tested once

• Any location with a fail is re-tested

• If the location fails twice = a defect

• the false-positive score and fixation losses must be no more than

20%.
Visual field: Esterman
Pros:
• Quick and easy
• Can be done using equipment in community optometry practices

Cons:
• correlates poorly with other measures of visual function (Jampel et al
2002)
• the testing pattern may miss central defects
• lacks accuracy since it is not based on threshold data
 Group 1 (car, motorbike): Visual fields
1) At least 120° horizontally minimum with not less then 50 ° on
each side of the centre
2) No significant defect encroaching within 20° radius of fixation
3) No significant defect in the binocular field that encroaches
within 20° of the fixation above or below the horizontal meridian
4) any central loss that is an extension of hemianopia or
quadrantanopia of size greater than 3 missed points

https://www.gov.uk/guidance/visual-disorders-assessing-fitness-to-drive#minimum-standards-for-field-of-vision--all-drivers
Group 1 (car, motorbike): Visual fields
Letterbox
Group 1:Esterman: Central field
Defects affecting the central area only (within 20 degree radius of
fixation)
• the following are generally regarded as acceptable central loss
• scattered single missed points
• a single cluster of up to 3 adjoining points
Group 1: Esterman: peripheral field
• Defect affecting the peripheral areas – width assessment
the following will be disregarded when assessing the width of field
• a cluster of up to 3 adjoining missed points, unattached to any other area of
defect, lying on or across the horizontal meridian
• a vertical defect of only single-point width but of any length, unattached to
any other area of defect, which touches or cuts through the horizontal
meridian
 Esterman: Pass or fail? (Group 1)

20⁰
120⁰

https://www.researchgate.net/publication/7930553_Integrated_visual_fields_A_new_approach_to_measuring_the_b
inocular_field_of_view_and_visual_disability/figures?lo=1&utm_source=google&utm_medium=organic
 Esterman: Fail (Group 1)

20⁰
120⁰

https://www.researchgate.net/publication/7930553_Integrated_visual_fields_A_new_approach_to_measuring_the_b
inocular_field_of_view_and_visual_disability/figures?lo=1&utm_source=google&utm_medium=organic
Group 1:Esterman: Central field
• the following are generally regarded as unacceptable (‘significant’)
central loss:
• a cluster of 4 or more adjoining points that is either wholly or
partly within the central 20° area
• any central loss that is an extension of hemianopia or
quadrantanopia of size greater than 3 missed points
Group 1: Esterman: peripheral field
• Defect affecting the peripheral areas – width assessment
the following will be disregarded when assessing the width of field
• a cluster of up to 3 adjoining missed points, unattached to any other area of
defect, lying on or across the horizontal meridian
• a vertical defect of only single-point width but of any length, unattached to
any other area of defect, which touches or cuts through the horizontal
meridian
Group 1: exceptional cases
defect must have been
• present for at least 12 months
• caused by an isolated event or a non-progressive condition
• there must be no other condition or pathology regarded as
progressive and likely to be affecting the visual fields
• sight in both eyes
• no uncontrolled diplopia
Group 1: exceptional cases
• no other impairment of visual function, including
no glare sensitivity, contrast sensitivity or impairment of
twilight vision

• For exceptional cases, the DVLA will then require a

satisfactory practical driving assessment at an approved
centre (see Appendix G).
Group 2 license: Bus, coach, lorry:
Visual fields
• A horizontal visual field of at least 160 degrees, the extension should
be at least 70 degrees left and right and 30 degrees up and down.
• No defects should be present within a radius of the central 30
degrees
 Group 2 license: Bus, coach, lorry:
Visual fields
• no significant defect (more than 3 points) within 70° right and 70° left
between 30° up and 30° down

• no other impairment of visual function, including no glare sensitivity,

contrast sensitivity or impairment of twilight vision.

https://www.gov.uk/guidance/visual-disorders-assessing-fitness-to-drive#higher-standards-of-field-of-
vision--bus-and-lorry-drivers
 Group 2: Visual fields Letterbox

30⁰
160⁰

https://www.racp.edu.au/docs/default-source/fellows/resources/congress-2017-presentations/racp-17-mon-dr-guillermo-ruggeri.pdf?sfvrsn=9c4a3c1a_2
Group 2: Exceptions
• Maximum of a total of 3 missed points – can be adjoining–outside the
central 30° radius.
• it would be acceptable for a defect on visual field charts to have an
upper limit of a total of 3 missed points – which may be contiguous –
within the letterbox but outside the central 30° radius.
 Esterman: Pass or fail? (Group 2)

30⁰

160⁰

http://www.mrcophth.com/mock/mock8/stationseven.html
 Esterman: Fail(Group 2)

30⁰

160⁰

http://www.mrcophth.com/mock/mock8/stationseven.html
Group 2 license: Bus, coach, lorry:
Visual fields
• A horizontal visual field of at least 160 degrees, the extension should
be at least 70 degrees left and right and 30 degrees up and down.
• No defects should be present within a radius of the central 30
degrees
• no significant defect (more than 3 points) within 70° right and 70° left
between 30° up and 30° down
Decision making
• The optometrist undertaking the DVLA test must not comment on the
results of the test to the px

This is entirely the responsibility of the DVLA who may also take into
consideration other aspects of the px’s medical history

The vision panel DVLA:

7 Ophthalmologists, 2 optometrists, 2 lay members, one member of
Forum of Driving Assessment Centres
The AOP and driving standards
• The AOP believe that the current system of checking vision for driving
which relies on self- reporting and a simple initial number plate test is
not adequate.
• The distance number plate test is neither standardised nor validated,
meaning that results are not reliably repeatable.
• Environmental factors can affect an individual’s ability to complete
the test
The AOP and driving standards
• The number plate test and the Snellen scale of visual acuity are not
comparable.
• The number plate test cannot be used to satisfactorily check if drivers
meet the 6/12 (Snellen, decimal 0.5) standard and vice versa
Being allowed to drive is a big deal…
Cessation of driving has been associated with:
• decreased health-related quality of life
• increased likelihood of depression and social isolation,
• reduced access to healthcare services
• and increased likelihood of placement in long-term-care
To report or not to report?
Doctors and other healthcare professionals should:
• Advise the individual on the impact of their medical condition for safe
driving ability
• Advise the individual on their legal requirement to notify the DVLA of
any relevant condition

• Notify the DVLA when fitness to drive requires notification but an

individual cannot or will not notify the DVLA themselves
However…
• DVLA:“…this may pose a challenge to issues of consent and the
relationship between patient and healthcare professional.”

• Data protection act: ‘You cannot discuss the information given to you
by a patient with anyone who is not involved in the patient’s care ‘
 College optometrists guidelines

https://guidance.college-optometrists.org/guidance-contents/knowledge-skills-and-performance-domain/
College of Optometrists
• If you think the patient may pose a very real risk of danger to the
public, but you are not sure whether you should act, ask yourself:

what might the outcome be in the short or longer term if I do not

raise my concern?

And,
how could I justify why I did not raise the concern?
College of Optometrists:
If you decide that the patient is unfit to drive, you should:

• first tell the patient that they are unfit to drive and give the reasons
• Tell the patient that they have a legal duty to inform the DVLA or DVA
about their condition
• put your advice in writing to the patient
• record your advice and keep a copy of any correspondence to the
patient on the patient record, and
• notify the patient’s GP, if appropriate, with the patient’s consent.
College of Optometrists
• If you conclude the public interest outweighs the duty of
confidentiality, you should:

notify the appropriate authority (DVLA or DVA) in writing, and, if

appropriate, provide evidence of clinical findings (see useful
information below)

CONTACT AOP OR LEGAL BODY FOR ADVICE BEFORE TAKING ACTION

AOP: legal responsibilities
• Ensure you’ve fully considered the issues involved and have good
reasons to support your decision
• Public interest: good reasons include a HGV driver, a bus driver etc
who continues to drive and pose a significant risk to the public.
• Always discuss the case with the AOP before acting
GOC: Standards
You should inform the DVLA/DVA where: you have assessed that a patient
may not be safe to drive;
And
you consider that they will not or cannot inform the DVLA/DVA themselves;
And
you have a concern for road safety in relation to the patient and/or the wider
public.

https://standards.optical.org/vision-and-safe-driving-what-to-do-if-a-patients-vision-means-they-
may-not-be-fit-to-drive/
• This must be a
considered decision and
not taken lightly
• Form ref: DOM 3854
Keep accurate records
Case scenarios
 Case scenario 1
• Bilateral
moderate/severe
glaucoma
• 57 year old male
• Group 1 driver
• Full time carer for wife

Is the visual field within

standards?

Ayala, M. Comparison of the monocular Humphrey visual field

and the binocular Humphrey esterman visual field test for driver
licensing in glaucoma subjects in Sweden. BMC
Ophthalmol 12, 35 (2012). https://doi.org/10.1186/1471-2415-
12-35
 Case scenario 1

• Bilateral
moderate/severe
glaucoma
• 57 year old male
• Group 1 driver 20⁰
• Full time carer for wife
120⁰
Is the visual field within
standards?

Ayala, M. Comparison of the monocular Humphrey visual field

and the binocular Humphrey esterman visual field test for driver
licensing in glaucoma subjects in Sweden. BMC
Ophthalmol 12, 35 (2012). https://doi.org/10.1186/1471-2415-
12-35
 Case scenario 1

Is the visual field within

standards?

Yes 20⁰

120⁰

Ayala, M. Comparison of the monocular Humphrey visual field

and the binocular Humphrey esterman visual field test for driver
licensing in glaucoma subjects in Sweden. BMC
Ophthalmol 12, 35 (2012). https://doi.org/10.1186/1471-2415-
12-35
 Case scenario 2
• RE moderate
glaucoma
• LE advanced glaucoma
• 69 year old female
• Group 1 driver
• Lives alone but needs
to drive to get to
bingo

Is the visual field within

standards?
Case scenario 2

• RE moderate
glaucoma
• LE advanced
glaucoma
20⁰
• 69 year old female
120⁰
• Group 1 driver
• Lives alone but
needs to drive to
get to bingo

Is the visual field

within standards?
Case scenario 2

Is the visual field

within standards? 20⁰
120⁰

No
Group 1:Esterman: Central field
• the following are generally regarded as unacceptable (‘significant’)
central loss:
• a cluster of 4 or more adjoining points that is either wholly or
partly within the central 20° area
• any central loss that is an extension of hemianopia or
quadrantanopia of size greater than 3 missed points
 Learning objectives
1) To be able to describe the expected visual field and visual acuity
requirements for group 1 and group 2 drivers

2) To understand how the Esterman visual field test is conducted and how
to interpret the results

3) To have an awareness of your duties as an optometrist when discussing

vision and driving with pxs
Questions?
Useful resources
• AOP membership:
• https://www.aop.org.uk/advice-and-support/for-patients/driving-
and-vision-standards

• College of Optometrists: Guidance for professional practice:

https://guidance.college-optometrists.org/home/

• DVLA:https://www.gov.uk/driving-eyesight-rules
• DVLA: https://www.gov.uk/guidance/visual-disorders-assessing-
fitness-to-drive#minimum-standards-for-field-of-vision--all-drivers
• Henry D. Jampel, David S. Friedman, Harry Quigley, Rhonda Miller;
Correlation of the Binocular Visual Field with Patient Assessment of
Vision. Invest. Ophthalmol. Vis. Sci. 2002;43(4):1059-1067.

• Victoria M. F. Owen, David P. Crabb, Edward T. White, Ananth C.

Viswanathan, David F. Garway-Heath, Roger A. Hitchings; Glaucoma
and Fitness to Drive: Using Binocular Visual Fields to Predict a
Milestone to Blindness. Invest. Ophthalmol. Vis. Sci. 2008;49(6):2449-
2455. doi: https://doi.org/10.1167/iovs.07-0877.