Download A Review of Visual Functions and Their Impact on Driving Behavior

A Review of Visual Functions and Their Impact on Driving Behavior
Chris A. Johnson, Ph.D., D.SC., FAAO
Professor, Department of Ophthalmology and Visual Sciences
University of Iowa Hospitals and Clinics
It has often been reported that vision is an important component of operating a
motor vehicle. However, which properties of vision are most important for safe
and effective driving ? In this presentation I will provide a summary of what is
currently known about the significance of specific visual performance factors on
driving tasks.
Visual Acuity – Visual acuity is the most common visual function that is tested for
driver’s license applicants. Fine detail, such as traffic signs, road hazards highway
markings and related information requires a best-corrected visual acuity of 20/40
or better (which is the requirement for many states). However, each state in the
USA has variations (both eyes, the better eye, use of optical devices such as a
bioptic telescope, etc). Many investigations have demonstrated that poor visual
acuity is a risk factor for safe driving.
Contrast Sensitivity – Several studies have indicated that contrast sensitivity is an
important visual feature for safe driving, particularly for detection and
identification of low contrast objects under impoverished visual conditions (rain,
snow, fog, nighttime, etc.). Contrast sensitivity has become a topic of greater
interest in driving studies recently, and there are now several rapid test procedures
that are available for population based testing.
Glare disability – Investigating the influence of glare on driving is a complicated
task. There is glare disability and glare recovery. Some aspects of glare are
related to road conditions and weather and some are due to lighting conditions and
other oncoming vehicles. (Question: are the new high intensity headlights a good
thing [for drivers] or a bad thing [a hazard for oncoming vehicles because of glare]
?). Glare can certainly disrupt safe driving abilities, and changes in a driver’s lens
with increasing age produce greater problems with glare with older drivers.
However, there is currently no consensus among experts as to what test procedure
is appropriate for assessing this property in drivers, and no standardized test is
currently available for performing this test.
Visual Fields – Early investigations found no relationship between visual field
extent and driving performance (evaluated by accident and conviction records).
However, these studies were performed with visual field test procedures that had
not been validated and were known to have poor performance characteristics (low
sensitivity and specificity and high false positive and false negative rates). A large
population-based study of licensed drivers applying for renewal (using a clinically
validated visual field screening procedure) found that a small percentage of these
drivers had visual field abnormalities, that the prevalence was greater in older
populations, and that there was no difference in accident and conviction records in
drivers with normal visual function and those with visual field loss in only one eye.
However, the accident and conviction rate was more than double this amount for
drivers with visual field loss in both eyes. More recent studies have confirmed that
visual field reductions are a risk factor for safe driving. Initial investigations
reported that the visual field of the better eye was the primary determinant and that
moderate to advanced loss was associated with driving problems. However, the
latest investigations have found that even mild visual field losses are associated
with driving problems, even if it is only in one eye.
Stereoacuity - Although stereopsis has been examined as a potential visual
function that may affect driving, there is no compelling evidence that it plays an
important role. There are many individuals without stereopsis (amblyopia or “lazy
eye” is present in more than 2% of the population, and these drivers are not worse
than those with normal visual function). Stereopsis is a rather slow visual response
that has its primary benefits for near work (less than 4 feet), so it would not be
effective for high-speed activities requiring quick responses to distant objects. It
should also be kept in mind that stereoacuity is not equivalent to depth perception
– it is only one of many visual cues for determining depth.
Color Vision – The literature indicates that color vision is important for being able
to properly detect and recognize traffic signals, and the ability to recognize
illuminated taillights from a distance at night. Approximately 8% of the male
population has some form of congenital color vision deficiency, and only a small
percentage of women have this condition (less than 0.1%). However, many eye
diseases produce color vision problems. Devices that are reported to “correct”
color vision loss have not been shown to be effective. However, driving
performance and related studies have demonstrated that it is only those individuals
with moderate to sever color vision loss that have an impairment in their driving
abilities (less than 2% of the population). The automotive industry has altered
their color designations for tail lights (less red and more orange) to improve their
design for individuals with red (protanope) color vision problems.
Vernier Acuity – Vernier acuity, or the ability to align the position of adjacent
objects, is one of the most sensitive and precise visual functions. It is useful for
tasks for measurement (using a ruler or other measuring device) or for obtaining
accurate readings from a dial or other indicator. However, it does not appear to be
important for driving, and there are no known studies that have demonstrated that
this is an important component of the driving task.
Dark Adaptation, Night Vision – Dr. Fred Owens will present a summary of the
role of vision for night driving and some of the complications that it creates. There
are more accidents that occur at night, visibility is less at night than in the daytime,
many drivers do not adjust their speed of driving for night conditions, and there is
tremendous individual variability in night vision among drivers. Moreover, it is a
challenge to design a test that could be rapidly administered to prospective drivers
to test for night vision. Some eye diseases specifically reduce the ability to see at
night, or result in greatly prolonged times to adapt from a light environment to
darkness.
Flicker and Motion (Temporal visual processing) – Although visual changes
produced by flicker and motion are important factors related to driving (selfmotion and motion of other objects), there is little that is currently known about
these factors related to driving safety. Exceptions to this include the study of
biological motion, time to collision, judging the relative speed of other vehicles,
and spatial orientation related to motion influences. More work is needed in this
area.
Dynamic Visual Acuity – Because drivers are mostly moving when operating a
motor vehicle and many outside objects are also in motion, the ability to identify
fine detail under these conditions (dynamic visual acuity) is important. However,
this is also a topic that has not received as much attention as other visual functions,
partly because it is again a complicated issue with many variations, making it
difficult to achieve a standardized, quantifiable approach.
Other Visual Functions – There are additional issues that are important for
driving (visual search, “pop-out” phenomena, eye-hand coordination, multitasking,
visual-auditory compatibility, etc.) that require additional exploration, as well as
issues related to the use of one eye (monocular) or two (binocular), visual
capabilities of individuals with differing levels of function between the two eyes,
etc.
Summary
Although there are many other factors related to the task of driving (e.g., decision
making, cognition, attention, multitasking, etc.) there are many aspects of vision
that are important for safe and effective driving abilities. Visual acuity, contrast
sensitivity, glare, visual fields, color vision, night vision, motion perception and
dynamic visual acuity are all important for being able to successfully perform the
driving task.
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State-of-the-Art Review
Section Editors: Grant T. Liu, MD
Randy H. Kardon, MD, PhD
Vision and Driving: The United States
Chris A. Johnson, PhD, Mark E. Wilkinson, OD
Abstract: Minimal visual standards for obtaining driving
licensure in the United States principally use 2 measures:
visual acuity and visual field. Although research studies
have established a correlation between performance on
these measures and safe driving, the correlations are
weak and mostly retrospective. These measures remain in
place in screening centers largely because they (especially visual acuity) are practical. A newer test of visual
attention, called the useful field of view, may be more
predictive of safe driving than the traditional measures,
but it has not been widely applied in licensing bureaus.
Journal of Neuro-Ophthalmology 2010;30:170–176
doi: 10.1097/WNO.0b013e3181df30d4
! 2010 by North American Neuro-Ophthalmology Society
D
riving is a complex multifaceted activity in which
visual performance is a critical feature. Research
projects utilizing more detailed and thorough approaches
have produced new insights into the role of vision during
the driving task and the use of technological advances to
improve the driving experience for individuals with visual
impairments. We review the research directed toward vision
and driving with an emphasis on visual acuity, contrast
sensitivity, color vision, and visual fields. Although attention, visual search, decision making, and other cognitive
functions are also clearly involved with driving performance, these components are reviewed elsewhere (1,2).
While it is a fundamental responsibility of licensing
bodies to identify drivers with impairments that place them
at an unacceptable risk for crashes, the decisions they make
about licensing must be legally and morally defensible and
must not unfairly restrict the mobility of disabled or aging
drivers. It is important, therefore, that the licensing criteria
for visual fitness be based on scientific evidence establishing
their effectiveness and predictive value for unsafe driving
performance, particularly for older drivers (1). Surprisingly,
there is no rigorous evidence to support the hypothesis that
Department of Ophthalmology and Visual Sciences, University of
Iowa Hospitals and Clinics, Iowa City, Iowa.
170
vision screening leads to a reduction in motor vehicle
crashes involving older drivers or that a specific cutoff value
for vision performance improves safety (2). This seeming
conundrum is probably resolved by acknowledging that
driving safety depends less on what the driver sees than
on how quickly, adequately, and accurately he responds to
what is seen (2).
Many review articles have evaluated the relationships
among driving performance, vision, decision-making behavior, risk-benefit analysis, and related factors (3–9); but
few have incorporated these issues within the context of
visual performance, driving demands, and visual and cognitive impairment questions that arise during the course
of an eye examination. Following a brief review of visual
factors affecting driving, we discuss the issues directly
pertinent to eye care providers.
HISTORICAL PERSPECTIVE
The foundations of research on vision and driving can be
traced back to the Transactions of the Section on
Ophthalmology of the American Medical Association’s
Seventy Sixth Annual Session in Atlantic City, New Jersey,
on May 25–29, 1925 (10). The Committee on Visual
Standards for Drivers of Motor Vehicles recommended that
driver license applicants demonstrate a visual acuity of at
least 20/50 in one eye and at least 20/100 in the fellow eye,
with or without glasses. Applicants with visual acuity worse
than 20/100 in the poorer eye could be qualified to drive
a motor vehicle by a special board under certain circumstances. Diplopia would disqualify an applicant from obtaining a license to operate a motor vehicle.
The next formal report concerning vision standards for
driving appeared on October 16, 1937 in the Organization
Section of the Journal of the American Medical Association
(Vision Standards for Licensure to Operate a Motor Vehicle)
(11), which indicated that the 1925 recommendations for
a board of physical licensure in each county had proved to
be impracticable and had therefore not been embodied into
law or practice. The report also indicated that standards of
good vision necessary for efficient operation of a motor
Johnson and Wilkinson: J Neuro-Ophthalmol 2010; 30: 170-176
Copyright © North American Neuro-ophthalmology Society.Unauthorized reproduction of this article is prohibited.
State-of-the-Art Review
vehicle could not be arbitrarily fixed because the problem of
safety also depended on factors such as the driver’s natural
aptitude, experience, and general mental and physical fitness. The lack of good vision might be compensated for by a
high degree of efficiency in aptitude, experience, and mental
and physical fitness. The report modified the vision standard for driving licensure to 20/40 or better in one eye (with
or without glasses) and 20/100 or better in the fellow eye
(with or without glasses). It recommended a horizontal
extent of the visual field of at least 45" to both sides of the
point of fixation; a binocular single vision; and the ability to
distinguish red, green, and yellow. A limited driving license
could be obtained with a visual acuity of at least 20/65 in the
better eye, a field of vision extending at least 125" horizontally in one eye, and the absence of diplopia. Personal
qualities that could compensate for minor defects of vision
would have to be highly rated in those to whom a limited
license was to be issued.
The 1937 report was followed by investigations performed by Burg (12–15) in landmark studies published in
the 1960s. These studies evaluated a large population of
California drivers on an extensive battery of vision, reaction
time, and decision-making tests. This work served as a basis
for establishing vision requirements for a driving license,
although many questions arose concerning the individuals
selected for inclusion in the study, the methodology used in
some of the test procedures, and the analysis procedures
used in evaluation of the data. Burg’s work (12–15) was
a retrospective study of the association of vision and cognitive
properties with driving accidents and convictions; no validation or prospective evaluations were performed. Subsequent
studies of vision and driving have explored the influence of
visual impairment on driving, the use of devices to accommodate disabilities, and cognitive and decision-making aspects of driving (1,2,7,16–93). Using driving simulators,
population-based studies, closed road tracks, and retrospective
reviews of driving accidents and convictions, they have provided more sophisticated information on visual performance
and driving behavior, as described in a later section of this
article. The factors most often considered are visual acuity,
contrast sensitivity, visual fields, and color vision.
Despite much research on these topics, there remain
significant differences in vision requirements for driving
licensure throughout the world. In fact, each of the 50 states
in the United States has its own requirements.
establishing the relationship between vision and driving
among individuals with normal vision. Only recently, there
have been efforts toward evaluating the driving abilities of
individuals with vision impairments (1,44–55).
VISUAL FUNCTIONS AND OTHER FACTORS
RELATED TO DRIVING
At night, highways and intersections are not as well delineated. The span of useable vision is smaller due to
nonuniform lighting of the highway and the short distance
for which the headlights of a vehicle can illuminate the
roadway. Paradoxically, drivers tend to maintain nighttime
driving speeds at nearly the same level as daytime driving
speeds (56–60). Accidents are more than twice as frequent
at night (56–60). Regrettably, there has been very little
useful research on night time driving.
Most studies indicate that visual acuity, contrast sensitivity,
visual fields, and color vision have the strongest relationship
to driving performance (12–43). We will provide a summary of results from these investigations, and direct the
interested reader to the more comprehensive reviews
(6–11). In the past, most research was directed at
Johnson and Wilkinson: J Neuro-Ophthalmol 2010; 30: 170-176
Visual Acuity
Visual acuity is the most universal vision requirement for
obtaining a driving license. Tests of visual acuity can be
administered rapidly with a standardized test procedure by
personnel with minimal visual testing skills. It is acknowledged as critical for interpreting traffic signs and
detecting road hazards. In the United States, most jurisdictions require an unaided or best-corrected visual acuity of
20/40 in the better eye (7). Most of the signage and other
roadside information have been designed to be read by
individuals with 20/40 or better visual acuity who are operating a motor vehicle at or below the speed limit.
A number of studies have evaluated the consequences of
driving with reduced visual acuity produced by cataract or
other ocular and neurologic diseases or by artificially degrading vision by means of lenses or translucent devices in
persons with normal visual acuity (46,49,50,53–55).These
studies have mostly been performed retrospectively by reviewing visual acuity status and traffic accidents and convictions in the general population, the elderly, the young,
and those with physical or mental impairments. Prospective
studies have measured driving performance on a closed road
track or in a driving simulator (1,46–55). Reductions in
visual acuity produce impairments in certain aspects of
driving related to specific driving tasks, such as recognition
of road signs, road hazards, highway markings, and objects
entering the roadway (29).
Contrast Sensitivity
Evans and Ginsburg (17) and Ginsburg (18) have reported
that contrast sensitivity is an important factor in being able
to distinguish the legibility of highway signs and other
properties of functional vision that are associated with
driving, such as recognition of road signs, hazards, traffic
signals, and indicator markers. In bad weather and in night
driving, highway signs, road hazards, animals, and pedestrians have low contrast. For this reason, many studies have
incorporated the detection and discrimination of lowcontrast objects as part of their driving research (44).
Night Vision
171
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State-of-the-Art Review
Visual Fields and Attention
Early investigations did not find a meaningful relationship
between peripheral vision and accident and conviction
reports (13). Among the many factors responsible for this
lack of a relationship are the low prevalence of visual field
loss in the general population; self-restriction of driving by
individuals with ocular or neurologic disorders; the use of
peripheral vision test equipment with high false-positive
and false-negative rates; and the lack of reproducibility,
confirmation, and validation of test findings (19).
But with a visual field instrument of known performance
characteristics, a study (19) finally found that drivers with
significant visual field loss in both eyes had more than twice
as many accidents and convictions as drivers with normal
visual fields or loss in only one eye. Subsequently, many
studies reported a relationship between visual field loss and
driving performance (20–31). When the binocular visual
field was reduced to 50"–60" in diameter, impairments
in driving performance were noted (19,20,22). However,
more recent investigations have found that even relatively
minor amounts of visual field loss are related to deficits in
driving performance (22,23).
The devices that perform clinical visual field testing rely
on the subject’s ability to detect a single stimulus superimposed on a uniform background. Because driving is much
more complex, investigators (32–37) have developed a test
known as the useful field of view (UFOV), which combines
peripheral target detection with measurements of reaction
time, the ability to perform multiple tasks (including
simultaneous central and peripheral target recognition), and
the ability to localize targets and distinguish one from another
(see Anticipated Future Developments). The intent of the
UFOV test is to provide a more powerful surrogate of the
visual and cognitive tasks encountered during driving. Studies
(32–37) have verified that this test is useful in identifying task
performance difficulties associated with driving impairments.
Color Vision
The role of color vision in safe driving is complex because
deficient color vision can be congenital or acquired, stable
or progressive, partial or complete, and affect primarily red
(protan), green (deutan), blue (tritan), or all color sensitive
visual mechanisms. Moreover, color is not the only visual
attribute used to distinguish a critical visual target. Individuals with red (protan) deficiencies have greater difficulty seeing red traffic signals and automobile tail lights at
night, thereby producing a higher risk of traffic accidents
(39–41). Individuals with protan (red) and deutan (green)
deficits have greater difficulty recognizing traffic signal
colors and the conspicuity of signs and signals (39,41–43).
Many sunglass manufacturers do not adhere to the
recommended specifications for tint colorations and produce spectacles that create significant difficulties for colordeficient observers (38).
172
Although color vision performance is not a component
of the standard for obtaining a standard driving license in
the United States, it is a component for obtaining a commercial vehicle driving license. To obtain a US commercial
driving license, the driver must be able to distinguish traffic
control signals and devices showing red, green, and amber
colors. Some European countries use it as a component for
obtaining a standard driving license.
Other Factors
Even if visual modalities are intact, their integration with
auditory, memory, and other sensory information can be an
especially difficult task for youthful, elderly, or neurologically impaired individuals. This lack of integration may lead
to an increase in vehicular accidents (61–64). For example,
studies have shown that cellular telephone use during driving
disrupts sensory tasks and driving performance (61–64).
The effect of instruction, rehabilitation, and the use of
assistive devices on driving performance has been controversial
(11,24,25,30,44,48–50,54,55,58,61–64,70,71,77,83,92).
For example, the use of bioptic telescopes by drivers who are
visually impaired has been advocated by some vision specialists but considered hazardous by others (65–67). Among
those who favor them, the assumption is that these devices
will be used according to the instructions provided by the
manufacturer and the eye care specialist prescribing them.
Although there is evidence that drivers use them mostly to
spot signs (65–67), they will experience inattention blindness as they switch their fixation from the carrier lens to the
bioptic. A talking global position system might be a safer
option for older drivers with visual impairments. Adaptive
cruise control, lane alert warnings, and self-parking cars may
also be a boon to drivers with visual impairments, but
studies are yet to be forthcoming on these issues.
Aging
Driving accidents and convictions are higher in youths and
in the elderly (2,68–77), but there are large individual
differences. No consistent factors, such as cognitive decision
making, attention, driving experience, or training programs,
have been identified.
Stereopsis
Investigations of stereopsis and driving performance
(78–80) have failed to disclose any important impact of
reduced function.
TRADITIONAL VISION TESTING
Visual Acuity
Visual acuity has traditionally been evaluated by reading
a series of progressively smaller letters or symbols on a chart.
For the most part, this procedure has been shown to be
effective in providing a quick, accurate, and easily
Johnson and Wilkinson: J Neuro-Ophthalmol 2010; 30: 170-176
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State-of-the-Art Review
administered test that is relevant to the driving task. The
methodology for visual acuity assessment has been standardized, and it is unlikely that meaningful improvements
to the procedure will be achieved through more extensive
research. This procedure therefore appears to be adequate
for vision screening for a driving license.
Contrast Sensitivity
Contrast sensitivity is measured in many different ways with
no consensus as to which method is most appropriate for
driving. At the present time, contrast sensitivity is regarded
as an important visual factor for driving, but the use of
a specific screening procedure has not yet been achieved.
Moreover, a determination of the amount and quality of
information that it can provide beyond visual acuity needs
further investigation.
Visual Fields
Visual field testing is time consuming. Rapid screening
techniques such as the Humphrey matrix have been able to
generate a screening procedure that takes 20–30 seconds per
eye in those without defects and 60 seconds per eye in those
with defects. However, this procedure only evaluates the
central 30" radius of the visual field, thereby limiting its
utility for evaluation of the full visual field. There are
a number of other rapid screening techniques, but they have
not been subjected to a rigorous investigation in this setting.
CURRENT ISSUES IN VISION AND DRIVING
As of 2004, all drivers licensed in Florida who are 80 years
and older are required to meet a minimum visual acuity
requirement to renew their driver licenses. They are required to pass a letter acuity test of 20/40 or better at the
time of renewal or provide a certificate from a licensed
allopathic physician, osteopathic physician, or optometrist
demonstrating that they have passed a vision test within the
past year. When comparing prelaw and postlaw periods, the
all-cause fatality rate, adjusted for age, race, and sex, among
all aged drivers increased by 6% but decreased by 17%
among drivers aged 80 years and older (88). Prior research
done by Shipp and others (89–93) had suggested that states
with mandated visual acuity tests have lower motor vehicle
collision fatality rates among older individuals. Grabowski
et al (88) found that in-person license renewal was related
to a significantly lower fatality rate among the most elderly
drivers. More stringent state licensure policies related to
vision or road tests and more frequent license renewal cycles
were not independently associated with additional benefits.
After controlling for middle-aged daytime driver deaths, the
only policy related to significantly lower driving fatality
rates was the requirement for in-person license renewal.
License renewal included a visual acuity test or a referral to
a medical practitioner for further medical screening in some
states.
Johnson and Wilkinson: J Neuro-Ophthalmol 2010; 30: 170-176
PHYSICIAN REPORTING OF VISUALLY
IMPAIRED DRIVERS
Physicians working in jurisdictions where reporting a patient who is at high risk for a motor vehicle accident is not
mandatory still have a moral and ethical obligation to report
in order to preserve patient and public safety (83,84). The
Duty to Warn is a legal rationale intended to provide
a means of protecting the patient from an unreasonable risk
of harm. Failure to warn patients of conditions that create
a risk of injury will be upheld as a cause of action against eye
care providers when it can be shown that the failure to warn
is the proximate cause of an injury. Patients may argue that
they had insufficient warning of their impairment, and
because of their impairment, their operation of a motor
vehicle or other machinery resulted in an injury. Thus,
patients whose vision no longer legally qualifies them to
operate a motor vehicle should be warned not to drive and
a notation to this effect should be entered into the patient’s
record (86,87).
In 1999, the American Medical Association (AMA)
House of Delegates approved a recommendation that calls
on doctors to breach patient confidentiality for the good of
both the patient and the society. The AMA stated that it is
desirable and ethical for physicians to notify the Department
of Motor Vehicles or an equivalent agency if an impaired
patient fails to restrict driving appropriately (87).
Mandatory reporting concerns include the question of
relative benefit, and different states have varying legal
opinions about mandatory reporting. If mandatory reporting detours someone from confiding or getting necessary
care, because he or she fears losing driving privileges, then
reporting statutes could backfire, creating more hazardous
drivers. There has been a long-standing controversy as to
whether driving is a privilege or a right. Driving is subject to
reasonable regulations in the interest of public safety and
welfare. The suspension or revocation of an operator’s license is not intended as a punishment to the driver but is
designed solely for the protection of the public. The AMA
Physician’s Plan for Older Drivers’ Safety (2003) (3) states
that every physician (we would include optometrists) should
assess risk factors for older patients who drive (4). For those
individuals at risk of unsafe driving, the practitioner should
recommend a formal assessment of vision, cognition, and
motor skills and also refer for a road test when appropriate.
ANTICIPATED FUTURE DEVELOPMENTS
The UFOV is a specialized visual field test that has been
developed for evaluation of driving and peripheral vision
(32–37). It differs from other tests of peripheral visual
function by incorporating measures of reaction time,
stimulus localization, simultaneous central and peripheral
visual tasks (multitasking), target identification, and complex decision making. The UFOV provides a means of
173
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State-of-the-Art Review
evaluating the driver’s ability to perform multiple tasks
accurately and quickly to simulate the driving task. Studies
performed with this procedure indicate that it correlates
with driving performance (32–37). This procedure is now
being used by a greater number of health care professionals
who are concerned with driving and other mobility tasks;
but careful research has been limited to only a few laboratories, and there is a strong need for additional work.
Currently, the UFOV test is considered too costly and time
consuming to be used for screening on a widespread population basis.
The rapid increase in vision and driving research has
generated a number of questions as to the impact on safe
driving of multisensory integration of information and
assimilation of sensory, cognitive, decision making, and
attentional properties. Also, important are validation of
laboratory studies when applied to population implementation and public policy, rehabilitation and training
regimens to compensate for disabilities, evidence-based
guidelines, and legal liabilities. No single group is capable of
addressing all relevant issues, and a consolidation of this
information through meta-analysis or overviews can
sometimes be difficult. The Cochrane Report (69) provides
a comprehensive objective assessment of current findings
and directed efforts primarily toward identifying the importance of vision screening for prediction of traffic accidents and fatalities. The authors concluded that 1) no
studies to date met their inclusion criteria (randomized
controlled trial before and after studies comparing vision
screening to nonscreening of drivers aged 55 and older), 2)
there is insufficient evidence to assess the effect of vision
screening on elderly drivers, and 3) valid and reliable vision
screening tools need to be developed to properly evaluate
this topic in a more thorough fashion.
CONCLUSIONS
Our knowledge concerning the relationship between visual
performance and driving has increased in recent years.
Highly competent laboratories and research teams have
conducted a number of research studies and evaluations.
However, policy decisions, accuracy and efficiency of testing
large populations, interpretation of test results, legal ramifications, and risk assessment currently determine the requirements for a driving license. A procedure that is highly
effective in a research project has not yet been found applicable for general use in screening drivers.
The United Kingdom and other countries have adopted
a uniform vision standard for driving licensure. The United
States has not, with the result that there are 50 standards of
visual performance needed to obtain a driving license. There
are also meaningful variations in the licensing requirements
among different countries in Europe, Asia, and South
America. We propose that the United States adopt a national vision standard for driving personal vehicles similar to
174
that of the United Kingdom. Such a standard would place
the responsibility on drivers rather than eye care providers to
know if they are visually qualified to drive, and enforcement
would be conducted by departments of motor vehicles and
law enforcement agencies. This approach would also remove concerns about mandatory reporting of impaired
drivers by health care professionals. It would be an application of the principle used in qualifying for a commercial
driving license.
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