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Giving up your driving privilege is one of the most difficult realities to come to terms with if you have a problem that leads to permanent visual decline.
The legal requirements vary from state to state. For example, in New Jersey the legal requirement to drive, based on vision, is 20/50 vision or better with best correction in one eye for a “pleasure” driving license. For a commercial driving license, the requirement is 20/40 vision or better in both eyes.
In some states there is also a requirement for a certain degree of visual field (the ability to see off to the sides).
According to the Insurance Institute for Highway Safety, the highest rate of motor vehicle deaths per mile driven is in the age group of 75 and older (yes, even higher than teenagers). Much of this increased rate could be attributable to declining vision. There are also other contributing factors such as slower reaction times and increased fragility but the fact remains that the rate is higher, so when vision problems begin to occur with aging it is extremely important to do what is necessary to try to keep your vision as good as possible.
That means regular eye exams, keeping your glasses prescription up to date, dealing with cataracts when appropriate and staying on top of other vision-threatening conditions such as macular degeneration, glaucoma and diabetes.
It is our responsibility to inform you when you are no longer passing the legal requirement to drive. Although there is no mandatory reporting law in all states, it is recorded in your medical record that you were informed that your vision did not pass the state requirements to maintain your privilege. And, yes, it is a privilege - not a right - to drive.
If you have a significant visual problem and your vision is beginning to decline, you need to have a frank discussion with your eye doctor about your driving capability. If you are beginning to get close to failing the requirement you need to start preparing with family and love ones about how you are going to deal with not being able to drive, preferably before it becomes absolutely necessary.
We have had the very unfortunate occurrence of having instructed a patient that he should stop driving because his vision no longer met the requirements only to have him ignore that advice and get in an accident. Don’t be that guy. Be prepared, have a plan.
Article contributed by Dr. Brian Wnorowski, M.D.
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Closed or Narrow Angle Glaucoma, which will be discussed in another article, is treated differently from Open Angle Glaucoma
In the U.S., Primary Open Angle Glaucoma (POAG) is by far the most common type of Glaucoma we treat.
Glaucoma is a disease where the Optic Nerve in the back of the eye deteriorates over time, and that deterioration has a relationship to the Intraocular Pressure (IOP). Most - but not all - people diagnosed with Glaucoma have an elevated IOP. Some people have fairly normal IOP’s but show the characteristic deterioration in the Optic Nerve. Regardless of whether or not the pressure was high initially, our primary treatment is to lower the IOP. We usually are looking to try to get the IOP down by about 25% from the pre-treatment levels.
The two mainstays of initial treatment for POAG in the U.S. are medications or laser treatments. There are other places in the world where Glaucoma is initially treated with surgery. However, while surgery can often lower the pressure to a greater degree than either medications or laser treatments, it comes with a higher rate of complications. Most U.S. eye doctors elect to go with the more conservative approach and utilize either medications - most often in the form of eye drops - or a laser treatment.
Drops
There are several different classes of medications used to treat Glaucoma.
The most common class used are the Prostaglandin Analogues or PGA’s. The PGA’s available in the U.S. are Xalatan (latanaprost), Travatan (travapost), Lumigan (bimatoprost) and Zioptan (tafluprost).
PGA’s are most doctors’ first line of treatment because they generally lower the IOP better than the other classes; they are reasonably well tolerated by most people; and they are dosed just once a day, while most of the other drugs available have to be used multiple times a day.
The other classes of drugs include beta-blockers that are used once or twice a day; carbonic anhydrase inhibitors (CAI’s ), which come in either a drop or pill form and are used either twice or three times a day; alpha agonists that are used either twice or three times a day; and miotics, which are used three or four times a day. All of these other medications are typically used as either second-line or adjunctive treatment when the PGA’s are not successful in keeping the pressure down as single agents.
There are also several combination drops available in the U.S. that combine two of the second-line agents (Cosopt, Combigan, and Symbrinza).
Laser
The second option as initial treatment is a laser procedure.
The two most common laser treatments for Open Angle Glaucoma are Argon Laser Trabeculoplasty (ALT) or Selective Laser Trabeculoplasty (SLT). These treatments try and get an area inside the eye called the Trabecular Meshwork - where fluid is drained from the inside of the eye into the venous system - to drain more efficiently.
These treatments tend to lower the pressure to about the same degree as the PGA’s do with over 80% of patients achieving a significant decrease in their eye pressure that lasts at least a year. Both laser treatments can be repeated if the pressure begins to rise again in the future but the SLT works slightly better as a repeat procedure compared to the ALT.
Article contributed by Dr. Brian Wnorowski, M.D.
