Driving and exceptional cases: Supporting relicensing evaluation in patients whose visual fields fail to meet standards.

PURPOSE: The UK Driver and Vehicle Licensing Agency's (DVLA) visual field criteria mean that homonymous defects close to fixation are not usually acceptable for driving. Here, we illustrate cases where patients with field defects failing to meet standards had their licences revoked but subsequently were permitted to drive again through exceptional case provisions. METHODS: Clinical assessment of two patients with homonymous loss: a 62-year-old man (PWT) with a dense left upper homonymous quadrantanopia secondary to a right occipital lobe stroke and a 48-year-old woman (JC), only aware of right upper homonymous quadrantanopia following routine primary care assessment and subsequently attributed to left middle cerebral artery stroke from perinatal intracranial haemorrhage. RESULTS: PWT's Esterman test showed a significant central defect failing to meet the standard. His subsequent ophthalmic examination was otherwise unremarkable with excellent visual functions. Clinical evidence was provided supporting his relicensing application, and in time, a practical DVLA driving assessment indicated adaptation had been successful, and his licence was restored. JC's defect also failed to meet the standard, and her licence was revoked. Her ophthalmic examination was otherwise unremarkable, and her condition was attributed to a nonprogressive, isolated perinatal event. The DVLA accepted supporting clinical evidence; her subsequent practical driving assessment demonstrated successful adaptation and her licence was also restored. CONCLUSIONS: Conventional visual field tests are not necessarily predictive of real-world driving performance, with drivers' adaptive strategies not being accommodated. In the UK, individuals with visual field loss failing to meet the standard may be eligible for relicensing as exceptional cases if specific criteria can be met. For exceptional cases potentially licensable under these criteria, the DVLA requires clinician support and a satisfactory practical driving assessment. Similar provisions exist internationally. Clinicians need to be aware of the role they may play in such scenarios.

Routine versus As-Needed Bevacizumab with 12-Weekly Assessment Intervals for Neovascular Age-Related Macular Degeneration: 92-Week Results of the GMAN Trial.

PURPOSE: To evaluate the efficacy and safety of intravitreal bevacizumab (Avastin; Genentech, South San Francisco, CA) in patients with neovascular age-related macular degeneration (nAMD) using 2 different treatment regimens in which patients were assessed clinically at up to 12-week intervals. DESIGN: Randomized, controlled, noninferiority trial. PARTICIPANTS: A total of 331 patients with nAMD. METHODS: Patients were treated with 1.25 mg intravitreal bevacizumab and followed up to 92 weeks. They were randomized into 2 arms. All patients received 3 loading doses 4 weeks apart and thereafter were assessed every 12 weeks until the end of the study. One arm received a routine treatment at each 12-week assessment, and the other arm was treated at these assessments on an as-needed basis. After the loading doses, patients in either arm who showed signs of disease activity had an additional assessment after 6 weeks and at that visit had top-up treatments on an as-needed basis. MAIN OUTCOME MEASURES: Mean best-corrected visual acuity (BCVA) at 92 weeks. RESULTS: At 92 weeks, patients who had treatments every 12 weeks had superior BCVA to those treated on an as-needed basis every 12 weeks (P = 0.008), with the regular treatment arm gaining a mean BCVA of 5.5 letters and the as-needed treatment arm gaining 0.6 letters. The regular treatment arm of the study showed significantly improved outcomes with respect to 5-, 10-, and 15-letter changes in BCVA from baseline compared with the as-needed treatment arm, as well as superior reading speed. In patients who completed the study, up to but not including week 92, the mean number of treatments was 10.8 for the regular treatment arm and 9.1 for the as-needed treatment arm. CONCLUSIONS: A treatment regimen with regular bevacizumab injections every 12 weeks after loading doses supplemented with as-needed top-up treatments produced a stable improvement in BCVA from baseline. The improvement in BCVA was broadly similar to that obtained in other studies using anti-vascular endothelial growth factor drugs with more frequent assessments and treatments.

Repeatability of visual function measures in age-related macular degeneration.

PURPOSE: To assess repeatability of visual function measures in patients with early, intermediate or late age-related macular degeneration (AMD) without active neovascular disease in the study eye, but active neovascular AMD in the fellow eye. METHODS: One hundred subjects from an ongoing trial were screened for this study in which their LogMAR acuity, contrast sensitivity and reading performance were assessed using standardised protocols by trained optometrists. The same measures were repeated one month later and repeatability of the visual functions assessed. RESULTS: Data from 83 subjects satisfied inclusion criteria for analysis. Coefficient of repeatability was 14.9 letters for LogMAR visual acuity , 7.2 letters for Pelli Robson contrast sensitivity, 0.72 for LogMAR reading acuity, 110.4 words/ min for reading speed and 0.67 for LogMAR critical print size. Intraclass correlation coefficients allowed comparison between measures and were found to be 0.96 for LogMAR visual acuity, 0.93 for contrast sensitivity, 0.75 for LogMAR reading acuity, 0.79 for reading speed and 0.74 for LogMAR critical print size. Coefficients of variation were 9.4 %, 10.7 %, 48.4 %, 28.4 % and 31.8 % respectively. CONCLUSIONS: We found coefficients of repeatability that concurred with previous studies demonstrating variability of visual functions in patients with AMD. In addition, we found intraclass correlation coefficients to be better with visual acuity and contrast sensitivity than with measures of reading performance.