Characteristics of Glaucoma Patients Attending a Vision Rehabilitation Service

Associations between vision impairment and vision-related interventions on crash risk and driving cessation: systematic review and meta-analysis

OBJECTIVES

To systematically investigate the associations between vision impairment and risk of motor vehicle crash (MVC) involvement, and evaluate vision-related interventions to reduce MVCs.

DESIGN

Medline (Ovid), EMBASE and Global Health electronic databases were systematically searched from inception to March 2022 for observational and interventional English-language studies. Screening, data extraction and appraisals using the Joanna Briggs Institute appraisal tools were completed by two reviewers independently. Where appropriate, measures of association were converted into risk ratios (RRs) or ORs for meta-analysis.

PARTICIPANTS

Drivers of four-wheeled vehicles of all ages with no cognitive declines.

PRIMARY AND SECONDARY OUTCOMES

MVC involvement (primary) and driving cessation (secondary).

RESULTS

101 studies (n=778 052) were included after full-text review. 57 studies only involved older drivers (≥65 years) and 85 were in high-income settings. Heterogeneity in the data meant that most meta-analyses were underpowered as only 25 studies, further split into different groups of eye diseases and measures of vision, could be meta-analysed. The limited evidence from the meta-analyses suggests that visual field defects (four studies; RR 1.51 (95% CI 1.23, 1.85); p<0.001; I2=46.79%), and contrast sensitivity (two studies; RR 1.40 (95% CI 1.08, 1.80); p=0.01, I2=0.11%) and visual acuity loss (five studies; RR 1.21 (95% CI 1.02, 1.43); p=0.03, I2=28.49%) may increase crash risk. The results are more inconclusive for available evidence for associations of glaucoma (five studies, RR 1.27 (95% CI 0.67, 2.42); p=0.47; I2=93.48%) and cataract (two studies RR 1.15 (95% CI 0.97, 1.36); p=0.11; I2=3.96%) with crashes. Driving cessation may also be linked with glaucoma (two studies; RR 1.62 (95% CI 1.20, 2.19); p<0.001, I2=22.45%), age-related macular degeneration (AMD) (three studies; RR 2.21 (95% CI 1.47, 3.31); p<0.001, I2=75.11%) and reduced contrast sensitivity (three studies; RR 1.30 (95% CI 1.05, 1.61); p=0.02; I2=63.19%). Cataract surgery halved MVC risk (three studies; RR 0.55 (95% CI 0.34, 0.92); p=0.02; I2=97.10). Ranibizumab injections (four randomised controlled trials) prolonged driving in persons with AMD.

CONCLUSION

Impaired vision identified through a variety of measures is associated with both increased MVC involvement and cessation. Cataract surgery can reduce MVC risk. Despite literature being highly heterogeneous, this review shows that detection of vision problems and appropriate treatment are critical to road safety.

PROSPERO REGISTRATION NUMBER

CRD42020172153.

Vision rehabilitation in glaucoma patients

PURPOSE OF REVIEW

Vision rehabilitation services are important but underutilized resources for patients with glaucoma. Glaucoma and its impact on vision can affect patients' abilities to read and drive, two activities of daily living that are associated with quality of life and functional independence. In this review, we provide an overview of low vision, discuss barriers to vision rehabilitation, and outline various strategies and interventions to optimize visual function and quality of life in patients with glaucoma.

RECENT FINDINGS

Studies have shown that glaucoma negatively impacts reading, driving and overall quality of life. Decreased visual acuity, visual field loss and reduced contrast sensitivity play a role. Low vision services and interventions can help patients maximize visual function and improve their quality of life. Barriers to receiving these services exist at multiple levels and an increased awareness and integration into routine ophthalmic care are needed to deliver comprehensive care.

SUMMARY

Glaucoma is one of the leading causes of low vision. Ophthalmologists who treat glaucoma often tend to focus on objective measures to monitor progression and disease severity, but the functional impact of glaucoma should also be addressed. Low vision services can benefit patients, particularly for reading and driving, and should be considered as an essential component of patient care.

Assessment of Low Vision Referrals before and after Establishment of a Low Vision Program at an Academic Medical Center

SIGNIFICANCE

We assessed the number of referrals for low vision (LV) services to determine if establishing an LV program at a large academic medical center impacted referral rates. Visual acuity (VA), referral outcome, location, and specialty were examined as factors that could impact referrals.

PURPOSE

This study aimed to identify gaps in the referral process to LV services.

METHODS

Electronic medical records of patients were reviewed to ascertain the referral rate among those who qualified for services, both before (2014 to 2016) and after (2017 to 2019) the establishment of an LV program. The medical records were further subdivided into two categories based on VA in the better-seeing eye: 20/70 to 20/200 and 20/200 to worse vision.

RESULTS

A total of 2014 patient records with VA qualifying for LV services were reviewed. The proportion of patients who had a VA of 20/70 to 20/200 inclusive in their better eye was 91.7%. A majority (89.8%) of patients with VA of 20/70 to 20/200 and 74.4% of patients with VA worse than 20/200 were never referred. Before establishing an LV program, only 2.2% of patients with VA of 20/70 to 20/200 were referred for services on their first visit, which improved to 8% after the program was established (odds ratio [OR], 3.88; 95% confidence interval [CI], 2.37 to 6.33; P < .001). Also, before the program's establishment, 12.5% of patients with VA worse than 20/200 were referred on their first visit, which increased to 31.9% after the program's establishment (OR, 3.29; 95% CI, 1.50 to 7.19; P = .002). Patients with VA worse than 20/200 were more likely to be referred (before: OR, 6.34 [95% CI, 3.03 to 13.28; P < .001]; after: OR, 5.38 [95% CI, 3.09 to 9.37; P < .001]). Our data also showed that 10.3% of patients in this study declined referral to LV services.

CONCLUSIONS

Referral rates to LV services are low among patients who qualify. The establishment of an LV program at the medical center significantly increased referral rates. However, more improvement is necessary to connect patients to LV services.

Charles Bonnet Syndrome in patients with open-angle glaucoma - prevalence and correlation to visual field loss

PURPOSE

To determine the prevalence and characteristics of Charles Bonnet Syndrome (CBS) and its relation to visual field loss (VFL) in patients with open-angle glaucoma (OAG).

DESIGN

Prospective, cross-sectional study.

PARTICIPANTS

Adult patients (n=337) with manifest OAG with verified VFL and without significant macular disease or extraocular conditions known to cause visual hallucinations.

METHODS

Patients attending the glaucoma outpatient department of the Skåne University hospital, Malmö, Sweden, between April 1^st 2018 and December 31^st 2018 were consecutively evaluated for inclusion. Potentially eligible patients admitting to having complex visual hallucinations were interviewed to explore the characteristics of their hallucinatory experiences. Recent automated visual field examinations were available for all participants and swept source optical coherence tomography was performed in participants with CBS to rule out previously undiagnosed macular pathology. The correlation between potential risk factors and CBS was evaluated with logistic regression analysis.

MAIN OUTCOME MEASURE

Prevalence of CBS in patients with OAG.

RESULTS

CBS was found in 7.1% (95% CI: 4.7% - 10.6%) of patients with OAG. Participants with CBS were more likely to have at least one eye with a visual field index (VFI) of ≤ 30% compared to those without CBS (71% vs. 34.2%; P = 0.001). Although the best-corrected visual acuity (BCVA) in the worse eye was significantly lower in participants with CBS (decimal equivalent of Snellen BCVA: 0.25 vs. 0.6, P = 0.003), 33% of these participants had a BCVA of ≥ 0.5 in the worse eye. In multivariable analysis, CBS was correlated to the VFI of the better eye (odds ratio 0.984; 95% CI: 0.969 - 0.998, P = 0.030) and the BCVA of the worse-seeing eye (odds ratio 0.210; 95% CI: 0.046 - 0.952, P = 0.043).

CONCLUSIONS

CBS was not a rare condition in patients with glaucoma. Patients with a combination of advanced VFL and low BCVA had the highest risk of CBS; however, one out of three patients with CBS had a BCVA of ≥ 0.5 in both eyes. These findings emphasize the importance of being attentive to symptoms of CBS in patients with glaucomatous VFL even when visual acuity is preserved.