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Editors Selection IGR 11-3

Progression: Progression and drivers license

Comment by George Lambrou on:

21373 Glaucoma and fitness to drive: using binocular visual fields to predict a milestone to blindness, Owen VM; Crabb DP; White ET et al., Investigative Ophthalmology and Visual Science, 2008; 49: 2449-2455

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Managing POAG ‐ especially of advanced or progressing cases ‐ is essentially a race against time. At every visit, the patient-physician tandem must make a therapeutic decision based on educated gues-ses and reasonable bets as to the progression of the disease under the various possible therapeutic regimens. Although one usually thinks of blindness occurring within the expected lifespan of the patient as the main endpoint of this race, it is equally important to consider other milestones that affecting the quality of life of the ‐ usually elderly ‐ POAG patient. One such milestone is the loss of the ability to drive. It is indeed established that loss of the driver's license is a particularly significant life event resulting in loss of mobility, social independence and self-esteem. It affects quality of life considerably and exposes the elderly patient to the risk of worsening depressive symptoms.

The parameters best associated with driving cessation during follow-up were IVF sensitivity at presentation and the rate of IVFdeterioration over two years

But how can one predict whether a given glaucoma patient is at risk of losing their driver's license several years down the line? This is the problem that Owen et al. (490) have chosen to investigate in a longitudinal study based on repeated visual fields (at least seven per patient) from glaucoma patients with normal IOP followed over several years in a Moorfields clinic. As there was no actual information on which patients had indeed lost their driving license, the authors developed a surrogate measure of the Driver and Vehicle Licensing Agency (DVLA) test failure, based on the binocular Integrated Vi-sual Field (IVF). IVF, a computer-generated combination of the two monocular fields, estimates the central binocular visual field, where the sensitivity at each location is the highest of the two monocular sensitivities at that location. Out of 299 patients initially included in the study, 60 (20%) failed the surrogate DVLA test during an average follow-up of seven years. The ten-year estimate of driving survival was 77%. This indicates that although the probability of blindness in an elderly glaucoma patient under treatment is low, the probability of driving cessation within the expected lifespan is much higher and should be considered as a meaningful endpoint on which to base clinical management decisions. Having studied several monocular and binocular measures of visual fi eld loss, the authors concluded that mean IVF sensitivity in the central 20° at presentation and the rate of IVF deterioration over two years were the parameters best associated with driving cessation during follow-up, and suggested that these may help identify patients who could benefit from intensified treatment.

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