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Glaucoma and On-Road Driving Performance

Article  in  Investigative Ophthalmology & Visual Science · August 2008

DOI: 10.1167/iovs.07-1609 · Source: PubMed

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Glaucoma and On-Road Driving Performance
Sharon A. Haymes, Raymond P. LeBlanc, Marcelo T. Nicolela, Lorraine A. Chiasson, and
Balwantray C. Chauhan
PURPOSE. To investigate the on-road driving performance of
patients with glaucoma.
METHODS. The sample comprised 20 patients with glaucoma
and 20 subjects with normal vision, all licensed drivers,
matched for age and sex. Driving performance was tested over
a 10-km route incorporating 55 standardized maneuvers and
skills through residential and business districts of Halifax, Nova
Scotia, Canada. Testing was conducted by a professional driv-
ing instructor and assessed by an occupational therapist certi-
fied in driver rehabilitation, masked to participant group mem-
bership and level of vision. Main outcome measures were total
number of satisfactory maneuvers and skills, overall rating, and
incidence of at-fault critical interventions (application of the
dual brake and/or steering override by the driving instructor to
prevent a potentially unsafe maneuver). Measures of visual
function included visual acuity, contrast sensitivity, and visual
fields (Humphrey Field Analyzer; Carl Zeiss Meditec, Inc., Dub-
lin, CA; mean deviation [MD] and binocular Esterman points).
RESULTS. There was no significant difference between patients
with glaucoma (mean MD ⫽ ⫺1.7 dB [SD 2.2] and ⫺6.5 dB [SD
4.9], better and worse eyes, respectively) and control subjects
in total satisfactory maneuvers and skills (P ⫽ 0.65), or overall
rating (P ⫽ 0.60). However, 12 (60%) patients with glaucoma
had one or more at-fault critical interventions, compared with
4 (20%) control subjects (odds ratio ⫽ 6.00, 95% CI, 1.46 –
24.69; higher still after adjustment for age, sex, medications
and driving exposure), the predominant reason being failure to
see and yield to a pedestrian. In the glaucoma group, worse-eye
MD was associated with the overall rating of driving (r ⫽ 0.66,
P ⫽ 0.002).
CONCLUSIONS. This sample of patients with glaucoma with slight
to moderate visual field impairment performed many real-
world driving maneuvers safely. However, they were six times
as likely as subjects with normal vision to have a driving
instructor intervene for reasons suggesting difficulty with de-
tection of peripheral obstacles and hazards and reaction to
From the Department of Ophthalmology and Visual Sciences,
Dalhousie University, Halifax, Nova Scotia, Canada.
Presented at the annual meeting of the Association for Research in
Vision and Ophthalmology, Fort Lauderdale, Florida, May 2007.
This study was conducted in collaboration with the Nova Scotia
Rehabilitation Centre Occupational Therapy Driver Program, Queen
Elizabeth II Health Sciences Centre, Halifax, Canada.
Supported by grants from the Glaucoma Research Society of
Canada, Canadian Glaucoma Clinical Research Council, Nova Scotia
Health Research Foundation, Fight for Sight, Capital Health Research
Fund, and Canadian Institutes for Health Research (MOP-11357).
Submitted for publication December 15, 2007; revised February
11 and 28, 2008; accepted April 30, 2008.
Disclosure: S.A. Haymes, None; R.P. LeBlanc, None; M.T.
Nicolela, None; L.A. Chiasson, None; B.C. Chauhan, None
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be marked “advertise-
ment” in accordance with 18 U.S.C. §1734 solely to indicate this fact.
Corresponding author: Sharon A. Haymes, Department of Oph-
thalmology and Visual Sciences, Dalhousie University, Room 2035, 2W
Victoria Building (VG site), 1278 Tower Road, Halifax, Nova Scotia,
Canada B3H 2Y9; sharon.haymes@dal.ca.
Investigative Ophthalmology & Visual Science, July 2008, Vol. 49, No. 7
Copyright © Association for Research in Vision and Ophthalmology
unexpected events. (Invest Ophthalmol Vis Sci. 2008;49:
3035–3041) DOI:10.1167/iovs.07-1609
G laucoma has been associated with increased risk of in-
volvement in motor vehicle collisions (MVCs).1– 6 Indeed,
previous research studies based on government records esti-
mate the risk to be increased by 1.7 to 3.6 times,1,2,4,6 a
significant finding, because MVCs are a major cause of injury,
hospitalization, and death7–10 and result in considerable eco-
nomic cost.11–13 To gain a better understanding of this health
burden, it is important to study the impact of glaucoma on
various components of driving performance.
Only a few relevant studies of driving performance have
been conducted, each with limitations. For example, Wood
and Troutbeck14 investigated the effect of visual field constric-
tion by having older persons, with otherwise normal vision,
wear goggles with restricted apertures while driving. On a
closed-road circuit free of other vehicles, reverse parking and
reaction to a peripheral LED stimulus were found to take
significantly longer with simulated visual-field constriction
compared with no constriction (P ⬍ 0.05).14 Differences in
speed, road position, maneuvering, central reaction time, and
sign detection were not statistically significant (P ⱖ 0.05).
However, the correlation between closed-road performance
and real-world performance is unknown. Moreover, driving
with simulated visual field constriction may not be represen-
tative of driving with glaucomatous visual field loss. In glau-
coma, visual field impairment is usually gradual, not concen-
tric, and defects vary with eye position. Szlyk et al.5 used an
interactive driving simulator to study patients with glaucoma.
These patients were found to have a higher accident rate than
that of normal vision control subjects, yet there were no
differences in other measures of performance, perhaps be-
cause the measures investigated had limited sensitivity to dif-
ferences in performance. Regardless, simulator performance
may not translate to real-world driving performance. Hitherto,
there has been only one real-world, open-road study of visual
field impairment that included patients with glaucoma.15 Most
were considered to be safe drivers; however, there was no
control group.
The purpose of the present study was to evaluate in a
real-world setting the on-road driving performance of patients
with glaucoma compared with that of control subjects with
normal vision.
METHODS
Participants
The sample comprised a group of patients with glaucoma and a group
of control subjects with normal vision, participating in a prospective
study of falls and MVCs in glaucoma.6 The patients with glaucoma
were recruited from the Glaucoma Clinic of the Eye Care Centre,
Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia [NS]).
The charts of consecutively scheduled patients were reviewed for
potential eligibility. After clinical consultation, patients who met the
eligibility criteria were provided with study information. Those inter-
ested were requested to telephone the coordinator for further expla-
nation and to schedule a visit. Normal-vision control subjects were
3035
3036 Haymes et al.
recruited by public notice within the Centre and by spoken commu-
nication and also responded by telephone. To be eligible, all partici-
pants had to be aged over 50 years. For the glaucoma group, the
inclusion criteria were a glaucoma specialist’s diagnosis of glaucoma,
glaucomatous optic nerve damage (e.g., notching or progressive thin-
ning of the neuroretinal rim), and corresponding visual field impair-
ment detected with standard automated perimetry (Humphrey Field
Analyzer [HFA]; Carl Zeiss Meditec Inc., Dublin, CA). Inclusion criteria
for the control group were normal findings in an ocular examination
and visual acuity (VA) better than 0.30 logMAR (20/40) in each eye.
Volunteers for the control group were ineligible if they were a patient
at the Eye Care Centre or were related to a participant with glaucoma.
Exclusion criteria for both groups were cataract (worse than grade II,
Lens Opacities Classification System II16), or other concomitant ocular
disease, systemic disease or medication known to affect the visual field,
cognitive impairment (more than two errors on the Short Portable
Mental Status Questionnaire),17 nursing home residency, and use of a
mobility device.
In addition, all participants were required to hold a current driver’s
license, meet the visual standard for driving a private motor vehicle in
NS (VA no less than 20/40 in at least one eye; field of vision no less than
120° with both eyes open),18 and drive at least 30 km per week. Of 35
patients with glaucoma enrolled in the prospective study who were
eligible and able to be contacted, 20 volunteered to participate. Forty-
three control subjects from the prospective study were eligible and
matched to the patients with glaucoma for age and sex. They were
invited in the order enrolled, and the first 20 to agree participated.
Thus, the final sample for this on-road driving substudy comprised 20
patients with glaucoma and 20 control subjects with normal vision.
Data Collection and Outcome Measures
Demographic, Medical, and Driving Exposure Data.
Demographic and medical data were collected from participants by
structured questions and checklists that included age, sex, medical
conditions, and systemic medications. For patients, number of years
since glaucoma diagnosis was obtained from clinical records. The
Driving Habits Questionnaire19 was used to estimate the driving expo-
sure (average kilometers per week) of all participants.
Vision Measures. Distance VA was measured monocularly with
logMAR charts with per-letter scoring.20,21 Contrast sensitivity (CS)
was measured with the Pelli-Robson CS Chart, also monocularly with
per-letter scoring.22,23 Visual fields were assessed with standard auto-
mated perimetry (HFA 24-2 program), and mean deviation (MD) was
used as the main global index of impairment.24 The HFA binocular
Esterman program was also administered,24,25 as it provides a direct
binocular measure of functional visual field (percentage of points
detected), and has been recommended for determining fitness to
drive.26 –28 In addition, the Useful Field of View test (UFOV; Visual
Awareness Inc., Birmingham, AL) was administered.29 –31 Also per-
formed under binocular conditions, the UFOV is an assessment of
cognitive as well as visual function that has been shown to be predic-
tive of at-fault MVCs.32,33 It comprises three subtests of increasing
difficulty (central vision and processing speed, divided attention, and
selective attention), each requiring identification of targets displayed
on computer for 17 to 500 ms with a double-staircase method. Subtests
are scored as the duration required for a 75% correct response rate, the
sum of which was used as a measure of overall visual information
processing speed.31 All vision tests were performed with optimal
refractive error correction, under standardized conditions, in accor-
dance with the manufacturer’s recommendations.
On-Road Driving Test and Main Outcome Measures.
Driving performance was assessed on a standardized 10-km route
through residential and business districts of Halifax. All participants
drove the same mid-size automatic-transmission vehicle, equipped
with a dual brake-control system, such that the brake could be applied
by either the driver or instructor. All tests were conducted by the same
professional driving instructor and assessed by the same occupational
IOVS, July 2008, Vol. 49, No. 7
therapist (a Certified Driver Rehabilitation Specialist from the NS Re-
habilitation Centre Occupational Therapy Driver Program, Queen Eliz-
abeth II Health Sciences Centre). The driving instructor gave directions
from the front passenger seat and was responsible for safety, whereas
the occupational therapist evaluated participant performance from the
rear seat and was responsible for assessment. Neither had prior knowl-
edge regarding the participant’s group or level of vision.
During the driving test, participants were instructed to perform
common driving maneuvers, such as entering traffic, turning, negoti-
ating intersections, exiting traffic, and parking. Skills assessed included
observation (vehicles, road signs, traffic signals, crosswalks, pedestri-
ans, cyclists, obstacles, and hazards), safety, signaling, steering control,
speed control, road position, and distance judgment. The test incor-
porated 34 maneuvers. The primary skills required for each were
evaluated as either satisfactory or unsatisfactory. The maneuvers and
skills were specified in a checklist, where one point was given for each
satisfactory performance (Fig. 1). The highest possible score was 55.
The maneuvers and skills were derived primarily in consultation with
the study occupational therapist and specialists from the NS Rehabili-
tation Centre Occupational Therapy Driver Program, after a review of
the provincial driver’s license testing protocol and the scientific liter-
ature.34 –36 In addition to the checklist assessment of maneuvers and
skills, overall driving performance was rated on a scale of 0 to 10,
where 0 is poor performance, and 10 is excellent performance.
Any critical interventions during the test were also recorded. Crit-
ical interventions were actions made by the driving instructor to avert
what he judged to be a potentially unsafe situation, and included
application of the dual brake, and/or taking over steering control. The
intention of the driving instructor was to implement caution and
maximize safety at all times. The cause of each intervention was
described and fault attributed, in the opinion of the assessing occupa-
tional therapist.
Protocol
Informed written consent was obtained before enrollment. The partic-
ipants were then interviewed and clinical records reviewed to obtain
demographic and medical data. Data collection was followed by re-
fraction, vision testing, and full ocular health examination. Next, par-
ticipants were given a short practice driving session to familiarize them
with the test vehicle and requirements, immediately followed by the
on-road test. All tests were conducted in fair-to-fine weather conditions
between 10 AM and 4 PM weekdays, from July to December, 2006. The
study adhered to the tenets of the Declaration of Helsinki and the
design, recruitment, consent, and procedures were approved by the
Capital Health Research Ethics Board.
Statistical Analysis
Data were analyzed with commercial software (SPSS, ver. 15.0; SPSS
Inc., Chicago, IL). Analyses were two-tailed, and P ⬍ 0.05 was consid-
ered statistically significant. Assumptions underlying all statistical tests
were verified. Descriptive statistics were calculated for demographic,
medical, vision, and driving performance data. Group differences were
evaluated with the Student’s t-test, Mann-Whitney U test, and ␹2 test for
continuous, ordinal, and nominal data, respectively. Logistic regression
analysis was used to calculate an odds ratio (OR) and corresponding
95% confidence interval (CI) for the association between glaucoma and
critical interventions during the driving test, with adjustment for the
possible confounding effects of age, sex, number of systemic medica-
tions, use of psychotropic medication, and driving exposure. For the
glaucoma group, associations between visual functions, number of
satisfactory driving maneuvers, and overall rating of driving skills were
evaluated using Spearman’s rank correlation coefficient. Associations
between visual functions and critical interventions were evaluated by
using logistic regression analysis to calculate ORs and 95% CIs, where
vision measures were dichotomized using cutoff criteria considered to
be clinically important (e.g., MD cutoff at 2 SD less than the control
IOVS, July 2008, Vol. 49, No. 7
FIGURE 1. Checklist of driving ma-
neuvers and skills tested and assessed.
group mean), with adjustment of statistically significant results for the
potentially confounding variables stated earlier.
RESULTS
Participant Characteristics
Differences in age, driving exposure, VA, and MD between
participants and eligible nonparticipants were nonsignificant,
for both the glaucoma and normal vision group (P ⱖ 0.07).
Characteristics of participants, by group, are presented in Ta-
ble 1. The mean age of patients with glaucoma was 68 years
(SD 7), and mean time since diagnosis 17 years (SD 8). There
were no significant differences between the glaucoma and
control groups with respect to age, sex, number of medical
conditions, number of systemic medications and driving expo-
sure (P ⱖ 0.49). As expected, the patients with glaucoma had
significantly decreased MD compared with the control subjects
(P ⬍ 0.01), which ranged from slight to moderate impairment
(better eye mean MD ⫽ ⫺1.66 dB [SD 2.19] and worse eye
mean MD ⫽ ⫺6.53 dB [SD 4.88]). In addition, worse eye
distance VA, worse eye CS, and UFOV total tended to be
slightly poorer for the glaucoma group (P ⫽ 0.07– 0.09). There
was no significant difference between groups for better eye
Glaucoma and Driving 3037
distance VA, better eye CS, and binocular Esterman visual field
(P ⱖ 0.30).
On-Road Driving Performance
Outcomes of the driving test for each group are given in Table
2. There was no significant difference in time to completion
(P ⫽ 0.24). The median number of driving maneuvers and skills
scored as satisfactory was 50 (range, 41–54) and 51 (range,
44 –53) of 55, for the glaucoma and control groups, respec-
tively, the difference being nonsignificant (P ⫽ 0.65). With
regard to individual maneuvers and skills, few discriminated
between subjects. Forty-one (75%) maneuvers and skills were
performed satisfactorily by at least 18 (90%) patients with
glaucoma and 18 (90%) control subjects. Five of 14 (36%)
maneuvers and skills performed unsatisfactorily were related to
poor practices that can develop in experienced drivers, (e.g.,
failure to use an indicator when pulling out from a parked
position and failure to shoulder check), with both groups
performing similarly. As with maneuvers and skills, there was
no significant difference between groups in overall rating of
driving performance (P ⫽ 0.60), with each group scoring
highly (median rating, 7 of 10, in the glaucoma and control
groups).
3038 Haymes et al. IOVS, July 2008, Vol. 49, No. 7

TABLE 1. Demographic, Medical, Driving and Vision Characteristics of Study Participants by Group

Glaucoma Normal Control

Characteristics (n ⴝ 20) (n ⴝ 20) P

Demographic
Age, mean (SD), y 68 (7) 67 (7) 0.62
Sex, male:female, n (%) 14 (70):6 (30) 14 (70):6 (30)
Medical
Medical conditions, median (range), count 3 (0–6) 3 (0–7) 0.90
Systemic medications, median (range), count 3 (0–7) 2 (0–6) 0.49
Use of psychotropic medication, n (%) 2 (10) 3 (15)
Driving
Exposure, median (range), km/wk 159 (40–1839) 119 (58–3050) 0.88
Distance visual acuity
Better eye, mean (SD), logMAR 0.05 (0.10) 0.05 (0.09) 0.85
Worse eye, mean (SD), logMAR 0.19 (0.18) 0.11 (0.10) 0.09
Contrast sensitivity
Better eye, mean (SD), log CS 1.62 (0.16) 1.66 (0.11) 0.30
Worse eye, mean (SD), log CS 1.49 (0.28) 1.61 (0.10) 0.07
HFA MD
Better eye, mean (SD), dB ⫺1.66 (2.19) 0.32 (1.48) 0.002
Worse eye, mean (SD), dB ⫺6.53 (4.88) ⫺0.48 (1.69) ⬍0.001
HFA binocular Esterman, median (range), % detected 99 (83–100) 99 (88–100) 0.51
UFOV total subtest scores, mean (SD), ms 391 (233) 275 (145) 0.07

However, a significantly greater proportion of patients with
glaucoma had one or more critical interventions during the test
(Table 2), that is, incidences where the driving instructor
applied the dual brake and/or took over steering to stop a
potentially unsafe maneuver. Twelve (60%) patients with glau-
coma had one or more at-fault critical interventions compared
with four (20%) control subjects (P ⫽ 0.01). Logistic regression
analysis indicated the odds of critical intervention in the glau-
coma group were six times that in the control group (OR ⫽
6.00; 95% CI, 1.46 –24.69), and greater still after adjustment for
age, sex, number of systemic medications, use of psychotropic
medication, and driving exposure (OR ⫽ 10.62; 95% CI, 1.46 –
77.35). In 11 of the 12 glaucoma cases, the intervention was
application of the dual brake, and in 1 case, the instructor took
over steering control. In comparison, in 2 of the 4 control
cases, the intervention was application of the dual brake, in 1
case steering override, and in the other case, both application
of the dual brake control and steering override. In 8 of the 12
glaucoma cases, the cause of intervention was failure to see
and yield to a pedestrian, whereas this occurred in only 1 of the
4 control cases. Other causes were failure to see and stop at a
stop sign and failure to yield to an oncoming vehicle.
Glaucoma and Vision Measures Associated with
Driving Performance
Associations between vision measures and continuous on-road
driving performance variables for the glaucoma group are in-
dicated by the correlation coefficients in Table 3. Vision mea-
sures most highly correlated with total satisfactory driving
maneuvers and skills were better eye CS (r ⫽ 0.60, P ⫽ 0.005)
and UFOV total (r ⫽ ⫺0.54, P ⫽ 0.01). For overall rating of
driving performance, the vision measure with the strongest
correlation was worse eye MD (r ⫽ 0.66, P ⫽ 0.002; Fig. 2),
followed by better eye CS (r ⫽ 0.54, P ⫽ 0.01).
The worse eye MD was the only vision measure associated
with critical intervention. Ten (77%) of 13 patients with glau-
coma with worse eye MD ⱕ ⫺4.0 dB had one or more at-fault
critical interventions compared with 2 (29%) of 7 with worse
eye MD ⬎ ⫺4.0 dB (OR ⫽ 8.33; 95% CI, 1.03– 67.14). How-
ever, the strength of the association was reduced after adjust-
ment for age, sex, number of systemic medications, use of
psychotropic medication and driving exposure (OR ⫽ 4.37;
95% CI, 0.26 –72.25).
Although correlation coefficients were also determined for
number of locations identified as outside normal limits in the
HFA pattern deviation plot, for the upper, lower, left, and right
visual field of each eye, none had a stronger association with
any of the driving performance measures than did MD.
DISCUSSION
Driving a private motor vehicle is of unquestionable impor-
tance in society today. It is the primary mode of transportation
for many people in many countries37 and is linked to one’s
autonomy, self-esteem, and quality of life.38 – 40 Studies have
shown that glaucoma may be associated with driving difficul-
ties,41– 44 avoidance of challenging driving conditions,45,46 ces-
sation of night driving,47 and increased risk of involvement in
motor vehicle collisions.1– 6 However, little is known about the
effect of glaucoma on actual driving performance and in what
way it may bring about these problems. To minimize difficul-
ties and plan risk reduction programs, further research is
needed. In this study, we have presented data comparing the

TABLE 2. On-Road Driving Performance by Group

Glaucoma Normal Control

Driving Performance Variable (n ⴝ 20) (n ⴝ 20) P

Time to completion, mean (SD), minutes 33 (3) 34 (4) 0.24

Total satisfactory driving maneuvers/skills, median (range), of 55 skills 50 (41–54) 51 (44–53) 0.65
Overall rating of driving performance, median (range), on a scale of 10 7 (3–9) 7 (2–9) 0.60
Critical interventions, n (%), ⱖ1 at-fault 12 (60) 4 (20) 0.01
IOVS, July 2008, Vol. 49, No. 7 Glaucoma and Driving 3039

TABLE 3. Correlation between Vision and On-Road Driving Performance in the Glaucoma Group

Total Satisfactory Overall Rating

Vision Variable Driving Maneuvers/Skills of Driving Performance

CS better eye 0.60 (0.005) 0.54 (0.01)

CS worse eye 0.42 (0.07) 0.50 (0.03)
HFA MD better eye 0.40 (0.08) 0.41 (0.08)
HFA MD worse eye 0.42 (0.07) 0.66 (0.002)
HFA binocular Esterman 0.31 (0.18) 0.30 (0.19)
UFOV total ⫺0.54 (0.01) ⫺0.28 (0.24)

Data are Spearman’s r (P); n ⫽ 20.

driving performance of patients with glaucoma to that of con-
trol subjects with normal vision in an on-road test.
We did not find a significant difference between patients
with glaucoma with slight to moderate visual field impairment
and control subjects in time taken to complete a standardized
test of driving performance (P ⫽ 0.24). In addition, there was
no significant difference between groups in the number of
maneuvers and skills passed and overall rating (P ⫽ 0.65 and
0.60, respectively), with each group scoring highly on both
measures. To our knowledge, there are no other on-road glau-
coma studies that have included a control group for compari-
son with our findings. However, our findings are consistent
with the closed-road study of simulated impairment by Wood
and Troutbeck,14 in which there was no significant effect of
moderate visual field constriction on several measures of per-
formance, including driving time, peripheral awareness (sign
detection), maneuvering time, maneuvering errors, reversing
angle, central reaction time, speed estimation, and road posi-
tion (P ⱖ 0.05). Furthermore, the high total number of maneu-
vers and skills passed and high overall ratings for patients with
glaucoma in this study are consistent with similarly high on-
road performance ratings noted by Bowers et al.15 Thus, we
might conclude that patients with glaucoma who meet the
visual standard for driving a private motor vehicle have good
FIGURE 2. Scatterplot of overall rating of performance on a standard-
ized, masked on-road driving test and worse-eye HFA MD, showing
better performance of patients with glaucoma with better residual
visual fields (Spearman r ⫽ 0.66, P ⫽ 0.002; n ⫽ 20).
general driving skills and perform standard driving maneuvers
as well as age-matched normal vision subjects do.
However, we found differences in other potentially impor-
tant aspects of driving performance, related to hazard detec-
tion and reaction to unexpected events, which were not cap-
tured by using a checklist count of standard maneuvers and
skills or a global rating. Patients with glaucoma in this study
were more than six times as likely as control subjects to have
the driving instructor intervene to avoid an unsafe maneuver.
In most cases, the instructor applied the dual brake or took
over steering control. Similarly, in a previous on-road study of
older licensed drivers, instructor interventions were required
for those with normal vision and those with slight visual im-
pairment (various causes); although the frequency of interven-
tion was different.48 The frequency of intervention may de-
pend on route difficulty, type and severity of visual
impairment, instructor safety threshold, and instructor bias.
Although the frequency of control case interventions in this
study suggests that the instructor may have had a low threshold
for intervening, he was masked to participant group member-
ship and level of vision. His criteria for intervening were the
same for all participants, and it is the difference between the
proportion of glaucoma and control group interventions that is
important (60% vs. 20%, respectively; P ⫽ 0.01). Whether the
incidence of instructor intervention for potentially unsafe ma-
neuvers during an on-road test is predictive of real-world col-
lisions is unknown and remains to be investigated.
Several measures of vision were associated with the driving
performance of patients with glaucoma in this study. The
strongest correlation was obtained between worse eye MD and
overall rating of driving (r ⫽ 0.66, P ⫽ 0.002). Moderately
strong correlations were also obtained for better eye CS and
UFOV total (P ⱕ 0.01). Likewise, significant correlations were
found for better eye CS and UFOV selective attention in the
on-road study conducted by Bowers et al.15 However, in that
study, the correlation between binocular visual field extent
(degrees), measured with Goldmann perimetry, and overall
driving performance was weak (r ⫽ 0.26, P ⫽ 0.19). Possibly
this is because such a measure is not sufficiently sensitive to
differences in visual field impairment between patients, which
was our experience with the binocular Esterman measure
(percentage of points detected).
In addition, we found an association between visual field
impairment and critical interventions. Patients with glaucoma
with worse eye MD ⱕ ⫺4 dB were more than four times as
likely as those with better visual fields to have the driving
instructor intervene, the predominant cause being failure to
see and yield to a pedestrian. Considering pedestrians are
relatively small and can quickly and unexpectedly emerge from
the periphery, it is not surprising that patients with glaucoma-
tous visual field impairment might experience difficulty in such
circumstances. From the findings of this study, we suggest that
it is possible that patients with glaucoma with even slight to
moderate visual field damage may be less able to detect and
3040 Haymes et al.
respond to peripheral obstacles and hazards, and unexpected
events. This hypothesis is further supported by the closed-road
study of moderate simulated visual field restriction by Wood
and Troutbeck,14 in which reaction to a small peripheral stim-
ulus was significantly slower than in the control condition, and
the on-road study of moderate real impairment by Bowers et
al.,15 which indicated a possible association between visual
field extent and reaction to unexpected events (r ⫽ 0.49, P ⫽
0.055).
Worse eye MD was more strongly correlated with all on-
road driving performance outcomes than better eye MD. In-
deed, other glaucoma studies have also found worse eye func-
tion to be more important in mobility (walking speed)49 and
driving (risk for involvement in MVCs).4,6 It is possible that
worse-eye MD better represents extent of glaucomatous dam-
age and overall functional binocular deficit. Location of visual
field defect correlated no better with any of the measures of
on-road driving performance investigated than MD. However,
this may be because our sample was limited to patients who
met the province visual standards for driving, having no more
than moderate visual field impairment. The importance of the
location of visual field damage may become apparent with a
larger sample of patients with a wider range of impairment.
These results are based on comparisons between a small
sample of clinical patients with glaucoma with slight to mod-
erate visual field impairment and a small sample of volunteer
control subjects. In addition, on-road driving tests were re-
stricted to nonpeak times and days with fair weather, in an
attempt to control for variations in vehicle and pedestrian
traffic, road condition, and visibility. The likely effect of these
limitations is that our results are conservative and underesti-
mate the impact of glaucoma on driving performance. The
limitations seem acceptable, and the findings important con-
sidering our partial understanding of the driving difficulty re-
ported by patients with glaucoma and the seriousness of their
increased risk for MVCs.
CONCLUSIONS
The results of this study indicate patients with glaucoma with
slight to moderate visual field impairment perform standard
driving maneuvers safely. However, peripheral obstacle and
hazard detection and unexpected events may present a prob-
lem for some, in particular those with worse visual field im-
pairment. These findings may be useful in providing guidelines
on driving and establishing programs to facilitate safe, lifelong
mobility for patients with glaucoma. We suggest that clinicians
discuss driving with all patients with glaucoma.
Acknowledgments
The authors thank Graeme Burke, driving instructor; Judy Brodie, OT
CDRS, for conducting and evaluating the driving tests; Paul Rafuse,
MD, Andrew Orr, MD, Lesya Shuba, MD (Glaucoma Clinic of the Eye
Care Centre, Queen Elizabeth II Health Sciences Centre, Halifax, Nova
Scotia), Paul Gray, OD (private practice, Halifax, Nova Scotia), and staff
of the Eye Care Centre for assistance with recruitment; and, particu-
larly, the participants for their commitment to the study.
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