Association of Sociodemographic Characteristics with Pediatric Vision Screening and Eye Care: An Analysis of the 2021 National Survey of Children's Health.

PURPOSE: Vision screening and regular eye care can help detect and treat potentially irreversible vision impairment. This study aims to investigate the associations between sociodemographic and health characteristics and the receipt of eye care among children aged 17 years and younger in the United States. DESIGN: This cross-sectional study used data from the National Survey of Children's Health (NSCH), a nationally representative and population-based survey of randomly sampled households. PARTICIPANTS: Participants were children aged 0 to 17 years, residing in all 50 states and the District of Columbia, whose caregivers or parents answered an address-based survey by mail or online. METHODS: Weighted prevalence calculations were applied to analyze the data, and logistic regression was performed to explore associations between reported eye care and demographic, health, and parent-related variables. MAIN OUTCOME MEASURES: Caregiver-reported vision screenings, referral to an eye doctor after vision screening, eye doctor visits, and prescription of corrective lenses. RESULTS: Caregivers reported that 53.2% of children had a vision screening at least once (if child ≤ 5 years) or within the past 2 years (if child > 5 years). Of those screened, 26.9% were referred to an eye doctor. Overall, 38.6% of all children had a previous eye doctor visit, and among them, 55.4% were prescribed corrective lenses during the visit. Factors associated with decreased odds of vision screening included younger age, lack of health care visits, no insurance coverage, parent education high school or less, and lower household income. Non-White ethnicities, households with a non-English primary language, and lower incomes were more likely to be referred to an eye doctor after vision screening. Lower rates of eye doctor visits were associated with younger age, lack of insurance coverage, and primary household languages other than English. CONCLUSIONS: Children from disadvantaged backgrounds are less likely to receive vision screening and eye care. Targeted strategies are needed to increase vision screening and access to eye care services in these vulnerable groups. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

A Scoping Review of Intervention for Pediatric Cerebral Visual Impairment: Calling All Pediatric Occupational Therapists.

Cerebral visual impairment is the leading cause of low vision in children, and functional gains can be achieved with intervention. To date there exists no evidence-based intervention protocol to guide rehabilitation therapists. This scoping review was conducted to synthesize the evidence currently available and explore current interventions in order to guide future research. This review identified five types of interventions for cerebral visual impairment; habilitation, visual stimulation, video game, color tent, and medical and also evidenced the need for standardized, objective measures of function for this population.

Cortical plasticity in central vision loss: Cortical thickness and neurite structure.

Late-stage macular degeneration (MD) often causes retinal lesions depriving an individual of central vision, forcing them to learn to use peripheral vision for daily tasks. To compensate, many patients develop a preferred retinal locus (PRL), an area of peripheral vision used more often than equivalent regions of spared vision. Thus, associated portions of cortex experience increased use, while portions of cortex associated with the lesion are deprived of sensory input. Prior research has not well examined the degree to which structural plasticity depends on the amount of use across the visual field. Cortical thickness, neurite density, and orientation dispersion were measured at portions of cortex associated with the PRL, the retinal lesion, and a control region in participants with MD as well as age-matched, gender-matched, and education-matched controls. MD participants had significantly thinner cortex in both the cortical representation of the PRL (cPRL) and the control region, compared with controls, but no significant differences in thickness, neurite density, or orientation dispersion were found between the cPRL and the control region as functions of disease or onset. This decrease in thickness is driven by a subset of early-onset participants whose patterns of thickness, neurite density, and neurite orientation dispersion are distinct from matched control participants. These results suggest that people who develop MD earlier in adulthood may undergo more structural plasticity than those who develop it late in life.

Objective Vision-related Indications for Clear and Tinted Football Helmet Visors.

SIGNIFICANCE: Football helmet visors are popular among players and may increase safety. However, they may also be costly or impractical, or impair the evaluation of head and neck injury. Determining an objective list of vision-related clinical conditions may help meet risk-benefit ratios while increasing access to care to athletes with special needs. PURPOSE: The purpose of this study was to determine an objective list of vision-related conditions that may benefit from clear and tinted football helmet visor use in athletes. METHODS: After comprehensive dilated eye examinations on 58 Division I collegiate football players at the University of Alabama at Birmingham between February 2017 and June 2018, an expert panel in vision care, sports medicine, and football equipment convened to determine vision-related conditions most important for clear or tinted football helmet visor use. RESULTS: In August 2018, the list drafted by the expert vision and sports medical panel in which a clear football helmet visor might be justified included conditions associated with retinal detachment and unilateral or binocular vision loss as well as high refractive error, refractive surgery, corneal compromise, and other conditions, which would necessitate additional eye protection. Of the 58 players examined, 3 (5%) were determined to have eye conditions that would require a clear visor as deemed by the expert panel, and 3 (5%) were determined to have eye conditions for which a clear visor was recommended. No players met indications for a tinted visor including congenital eye conditions that limit useful vision in daylight or bright-light environments, acquired conditions that may increase light sensitivity, and light-induced systemic conditions. CONCLUSIONS: This objective list of eye and vision-related systemic conditions is intended to mitigate the risk of long-term eye damage and/or vision deprivation. Clear and especially tinted football helmet visors require the sports medicine team to evaluate factors that will maximize the vision, head, and neck health of the athlete while increasing accessibility to sports for individuals with unique abilities.

Reliability and validity of the PedsQL 4.0 Generic Core Scales in pediatric vision impairment.

BACKGROUND: The PedsQL 4.0 is a generic health-related quality-of-life (HRQoL) instrument that has been used across many pediatric health conditions. The purpose of this study was to investigate its use in children with vision impairment and to test its ability to distinguish between visually impaired and normally sighted children. METHODS: Children with vision impairment and age-matched controls underwent vision testing, including binocular best-corrected distance visual acuity. They completed the PedsQL 4.0 Generic Core Scale Child Report (ages 8-12) or Teen Report (ages 13-18), as appropriate. Parents completed the Parent Proxy Report in a room separate from their children. Analyses included descriptive statistics, intraclass correlations, t tests, and determination of Cronbach's α for subscales. RESULTS: A total of 70 study subjects and 44 controls were included. Groups were similar with regard to age, race, and sex. PedsQL 4.0 subscales showed no floor effects; however, some scales had ceiling effects of up to 28% in certain groups. Cronbach's α was excellent (0.88) for all subscales and reports. PedsQL 4.0 total score for children with vision impairment differed significantly from that for normally sighted children for both age groups and for both parent and child reports. Total score was also significantly associated with visual acuity. Parent and child reports correlated poorly (ICC, <0.5), highlighting the importance of both perspectives. CONCLUSIONS: The PedsQL 4.0 can be used to assess HRQoL in children and teens with low vision. It has internal consistency reliability, and construct validity.

Repeatability and Validity of MNREAD Test in Children With Vision Impairment.

Purpose: To evaluate the test-retest reliability and validity of the MNREAD test for use in children with vision impairment (VI) and to compare their performance on the test to that of normally sighted children. Methods: Children with VI (n = 62) and without VI (n = 40) were administered the MNREAD test and the Basic Reading Inventory (BRI) on two study visits, 1 to 3 weeks apart. The maximum reading rate, critical print size, and reading acuity were determined for the MNREAD test, and test-retest reliability was evaluated. The reading rate for the MNREAD test was compared to the BRI results. Results: Strong correlations between visits were found for all MNREAD parameters (0.68-0.99). Older, but not younger, children with VI read significantly more slowly on both the MNREAD and the BRI than children with normal vision (P < 0.05). Reading rates between the two tests were strongly correlated (r = 0.88). For the MNREAD test, the reading rate increased 4.4 words per minute (wpm) per year for VI and 10.6 wpm/y for those with normal vision. For the BRI, the reading rate increased by 5.9 wpm/y for VI and 9.7 wpm/y for those with normal vision. Poorer visual acuity was associated with slower reading rates on the MNREAD test but not on the BRI, as the MNREAD relies largely on visual factors but the BRI also relies on linguistic and grammar skills. Conclusions: The MNREAD test are reliable and valid for use in children with vision impairment. Translational Relevance: The MNREAD test can be utilized by clinicians, as they are a quick, easy-to-administer method for evaluating reading vision in children with VI.

Rehabilitation Referral for Patients With Irreversible Vision Impairment Seen in a Public Safety-Net Eye Clinic.

Importance: The prevalence of irreversible vision impairment in the United States is expected to increase by 2050. Vision rehabilitation is the primary treatment option. Clinical trials have established its efficacy in improving quality of life. Yet studies indicate that patients experience many barriers to accessing low-vision care. Objectives: To examine the rate of referral for low-vision rehabilitation services by resident and attending ophthalmologists for adults with irreversible vision impairment and to assess the knowledge, attitudes, and beliefs of patients about vision rehabilitation. Design, Setting, and Participants: Cross-sectional study with enrollment from June 20, 2016, to January 31, 2017, of 143 adults 18 years or older seen in a publicly funded, comprehensive eye clinic in Jefferson County, Alabama, and having 1 or both eyes with irreversible vision impairment (visual acuity was defined as 20/60 or worse) per the electronic health record. Exposures: Demographic characteristics; patient questionnaire on knowledge, attitudes, and beliefs about vision rehabilitation; general cognitive status (Short Orientation-Memory-Concentration test); depressive symptoms (Patient Health Questionnaire-9); health literacy (Rapid Estimate of Adult Literacy in Medicine, Revised [REALM-R]); and self-reported difficulty in everyday activities. Main Outcomes and Measures: Proportion of patients with irreversible vision impairment who were referred by ophthalmologists to low-vision rehabilitation services per the electronic health record. Results: Of 143 patients enrolled with irreversible vision impairment in 1 or both eyes, the mean (SD) age was 55.4 (11.1) years and 68 (47.6%) were women. Most patients were African American (123 [86.0%]), uninsured (88 [61.5%]), and unemployed (92 [64.3%]); on average, they had normal cognitive status, minor depressive symptoms, and limited health literacy. As noted in the electronic health record, the rate of referral for low-vision rehabilitation services was 11.4% for patients with irreversible bilateral vision impairment (4 of 35 patients) and 1.9% for those with unilateral impairment (2 of 108). Most patients with bilateral (31 of 34 [91.2%]) and unilateral (90 of 97 [92.8%]) impairment indicated that they were bothered by their vision impairment, and most reported difficulty with reading (33 of 34 patients [97.1%] who were bilaterally impaired vs 85 of 104 [81.7%] who were unilaterally impaired). Conclusions and Relevance: Results of this study suggest a need to better educate ophthalmologists and residents in ophthalmology about referrals to low-vision rehabilitation services for patients with irreversible vision impairment.

Bioptic Telescope Use and Driving Patterns of Drivers with Age-Related Macular Degeneration.

PURPOSE: To investigate the telescope use and driving patterns of bioptic drivers with age-related macular degeneration (AMD). METHODS: A questionnaire addressing telescope use and driving patterns was administered by telephone interview to three groups of bioptic drivers: AMD (n = 31; median 76 years); non-AMD first licensed with a bioptic (n = 38; 53 years); and non-AMD first licensed without a bioptic (n = 47; 37 years). Driving patterns of bioptic AMD drivers were also compared with those of normal vision (NV) drivers (n = 36; 74 years) and nonbioptic AMD drivers (n = 34; 79 years). RESULTS: Bioptic usage patterns of AMD drivers did not differ from those of the younger bioptic drivers and greater visual difficulty without the bioptic was strongly correlated with greater bioptic helpfulness. Bioptic AMD drivers were more likely to report avoidance of night driving than the age-similar NV drivers (P = 0.06). However, they reported less difficulty than the nonbioptic AMD drivers in all driving situations (P ≤ 0.02). Weekly mileages of bioptic AMD drivers were lower than those of the younger bioptic drivers (P < 0.001), but not the NV group (P = 0.54), and were higher than those of the nonbioptic AMD group (P < 0.001). CONCLUSIONS: Our results suggest that bioptic telescopes met the visual demands of drivers with AMD and that those drivers had relatively unrestricted driving habits. TRANSLATIONAL RELEVANCE: Licensure with a bioptic telescope may prolong driving of older adults with AMD; however, objective measures of bioptic use, driving performance, and safety are needed.

Health Literacy in Older Adults With and Without Low Vision.

OBJECTIVE: In this study, we investigated whether older adults with low vision (LV) from age-related macular degeneration (AMD) demonstrated lower functional health literacy than older adults without LV. METHOD: Fifty adults with AMD were matched with adults without LV on age, gender, education, and income. We measured visual acuity, contrast sensitivity, and reading speed and administered the Test of Functional Health Literacy in Adults (TOFHLA) using two test time conditions, standard and unlimited, to measure health literacy levels. RESULTS: The group with LV had considerably lower TOFHLA scores for both time conditions (p < .001) and took notably longer to complete the test (p < .001). Poorer acuity correlated with lower TOFHLA scores in the group with LV. CONCLUSION: Older adults with LV may take longer to read and understand health information, which has important implications for providing health education to support self-management. Modifying components of the reading task may facilitate reading performance and understanding of health education materials.

Validation of a Reading Assessment for Persons With Homonymous Hemianopia or Quadrantanopia.

OBJECTIVE: To preliminarily validate the Visual Skills for Reading Test (VSRT) for assessing reading performance in persons with homonymous hemianopia (HH) or quadrantanopia. DESIGN: Retrospective chart review. SETTING: University-based outpatient low vision rehabilitation center. PARTICIPANTS: Persons (N=38) with HH or quadrantanopia who completed the VSRT. INTERVENTIONS: Validation procedures included testing for equivalence of the 3 test versions, estimation of internal consistency reliability, and known-group comparison using VSRT results from previous studies of adults with normal vision and central field loss. MAIN OUTCOME MEASURES: Corrected reading rate, reading accuracy rate, type and number of reading errors, and completion time were recorded and evaluated. RESULTS: Cronbach α for the VSRT across all participants was .80, which indicated good internal consistency. A known-group comparison showed that persons with a visual field deficit read significantly slower than did normally sighted adults (t580=10.13; P<.0001). Persons with quadrantanopia read significantly faster than did persons with HH (t36=2.25; P=.03) or those with central field loss (t48=3.17; P=.0027). These findings confirmed that the VSRT correctly discriminated between groups in terms of reading performance. CONCLUSIONS: Preliminary validation results indicate that the VSRT demonstrates adequate evidence of reliability and validity to evaluate reading performance in adults with HH or quadrantanopia.

Cortical thickness in human V1 associated with central vision loss.

Better understanding of the extent and scope of visual cortex plasticity following central vision loss is essential both for clarifying the mechanisms of brain plasticity and for future development of interventions to retain or restore visual function. This study investigated structural differences in primary visual cortex between normally-sighted controls and participants with central vision loss due to macular degeneration (MD). Ten participants with MD and ten age-, gender-, and education-matched controls with normal vision were included. The thickness of primary visual cortex was assessed using T1-weighted anatomical scans, and central and peripheral cortical regions were carefully compared between well-characterized participants with MD and controls. Results suggest that, compared to controls, participants with MD had significantly thinner cortex in typically centrally-responsive primary visual cortex - the region of cortex that normally receives visual input from the damaged area of the retina. Conversely, peripherally-responsive primary visual cortex demonstrated significantly increased cortical thickness relative to controls. These results suggest that central vision loss may give rise to cortical thinning, while in the same group of people, compensatory recruitment of spared peripheral vision may give rise to cortical thickening. This work furthers our understanding of neural plasticity in the context of adult vision loss.

ADHD and Vision Problems in the National Survey of Children's Health.

PURPOSE: To compare the prevalence of attention deficit/hyperactivity disorder (ADHD) in children with normal vision and with vision problems not correctable with glasses or contact lenses (vision problems) as determined by parent report in a nationwide telephone survey. METHODS: This cross-sectional study included 75,171 children without intellectual impairment aged 4 to 17 years participating in the 2011 to 2012 National Survey of Children's Health, conducted by the U.S. Centers for Disease Control and Prevention. Demographic information and information regarding vision and ADHD status were obtained by parent interview. Questions asked whether they had ever been told by a doctor or health care provider that the child had a vision problem not correctable with glasses or contact lenses, ADHD, intellectual impairment, or one of 13 other common chronic conditions of childhood. A follow-up question asked about condition severity. The main outcome measure was current ADHD. RESULTS: The prevalence of current ADHD was greater (p < 0.0001) among children with vision problems (15.6%) compared with those with normal vision (8.3%). The odds of ADHD compared with those of children with normal vision were greatest for those with moderate vision problems (odds ratio [OR], 2.6; 95% confidence interval [95% CI], 1.7 to 4.4) and mild vision problems (OR, 1.8; 95% CI, 1.1 to 2.9). Children with severe vision problems had similar odds of ADHD to those of children with normal vision perhaps because of the small numbers in this group (OR, 1.6; 95% CI, 0.8 to 3.1). In multivariable analysis adjusting for confounding variables, vision problems remained independently associated with current ADHD (OR, 1.8; 95% CI, 1.2 to 2.7). CONCLUSIONS: In this large nationally representative sample, the prevalence of ADHD was greater among children with vision problems not correctable with glasses or contacts. The association between vision problems and ADHD remains even after adjusting for other factors known to be associated with ADHD.

Nystagmus in pediatric patients: interventions and patient-focused perspectives.

Nystagmus refers to involuntary, typically conjugate, often rhythmic oscillations of the eyes. The most common cause of nystagmus in children is infantile nystagmus syndrome (INS). INS presents within the first few months of life and is sometimes accompanied by an ocular condition associated with sensory impairment. Because this condition affects a person throughout life, it is important to understand the options available to manage it. This review focuses on the underlying nystagmus etiology, psychosocial and functional effects of nystagmus, as well as current principles of management, including optical, pharmacological, surgical, and rehabilitative options. Currently, the neural mechanisms underlying INS are not fully understood. Treatment options are designed to increase foveation duration or correct anomalous head postures; however, evidence is limited to mainly pre- and post-study designs with few objective comparisons of treatment strategies. Management of INS should be individualized. The decision on which treatment is best suited for a particular patient lies with the patient and his/her physician.

Prevalence of attention-deficit/hyperactivity disorder among children with vision impairment.

PURPOSE: To evaluate the prevalence of parent-reported attention-deficit/hyperactivity disorder (ADHD) in two clinics in Alabama serving children with vision impairment. METHODS: The medical records of children 4-17 years of age attending the Alabama School for the Blind (ASB) during the 2010-2011 school year or seen at the University of Alabama at Birmingham (UAB) Center for Low Vision Rehabilitation between 2006 and 2010 were retrospectively reviewed. Sociodemographics, ocular characteristics, and parental report of ADHD diagnosis were obtained. The prevalence of ADHD was compared to national and state figures for age-similar children regardless of comorbidities. The prevalence of ADHD, sociodemographic, and ocular characteristics was also compared between clinical sites. RESULTS: A total of 264 children participated in the study (95 from ASB and 169 from UAB). The prevalence of ADHD among children with visual acuity better than hand motion (n = 245) was 22.9%, which is higher than reported state (14.3%) and national prevalence (9.5%) for children in this age range. The prevalence was similar at ASB (22.4%) and UAB (23.1%). Those with ADHD were similar to those without ADHD with respect to age, sex, and race. Children with ADHD were significantly less likely to have nystagmus and more likely to have better visual acuity (P < 0.05). The prevalence of ADHD among the 19 participants with total or near total vision loss (all from ASB) was 10.5%. CONCLUSIONS: Our analyses suggest that children with vision impairment may be more likely to be diagnosed with ADHD than children in the general population.

Trial frame refraction versus autorefraction among new patients in a low-vision clinic.

PURPOSE: To determine the relationship between refractive error as measured by autorefraction and that measured by trial frame refraction among a sample of adults with vision impairment seen in a university-based low-vision clinic and to determine if autorefraction might be a suitable replacement for trial frame refraction. METHODS: A retrospective chart review of all new patients 19 years or older seen over an 18-month period was conducted and the following data collected: age, sex, primary ocular diagnosis, entering distance visual acuity, habitual correction, trial frame refraction, autorefraction, and distance visual acuity measured after trial frame refraction. Trial frame refraction and autorefraction were compared using paired t-tests, intraclass correlations, and Bland-Altman plots. RESULTS: Final analyses included 440 patients for whom both trial frame refraction and autorefraction data were available for the better eye. Participants were mostly female (59%) with a mean age of 68 years (SD = 20). Age-related macular degeneration was the most common etiology for vision impairment (44%). Values for autorefraction and trial frame refraction were statistically different, but highly correlated for the spherical equivalent power (r = 0.92), the cylinder power (r = 0.80) and overall blurring strength (0.89). Although the values of the cross-cylinders J(0) and J(45) were similar, they were poorly correlated (0.08 and 0.15, respectively). The range of differences in spherical equivalent power was large (-8.6 to 4.9). CONCLUSIONS: Autorefraction is highly correlated with trial frame refraction. Differences are sometimes substantial, making autorefraction an unsuitable substitute for trial frame refraction.

Use of prescribed optical devices in age-related macular degeneration.

PURPOSE: To evaluate prescribed optical device use in terms of frequency and perceived usefulness among people with age-related macular degeneration (AMD). We also sought to determine the tasks for which they were using their prescribed low vision device(s). METHODS: One hundred ninety-nine patients with AMD presenting for the first time to the low vision service were recruited from a university-based clinic. Prior to the low vision evaluation and device prescription, they completed the National Eye Institute Visual Function Questionnaire 25, Center for Epidemiological Studies Depression Scale, Short Portable Mental Status Questionnaire, and a general health questionnaire. The low vision evaluation included best-corrected Early Treatment of Diabetic Retinopathy Study visual acuity, MNREAD testing, microperimetry, prescription, and dispensing of optical low vision devices. Telephone follow-up interviews were conducted about device usage 1-week, 1-month, and 3-months postintervention. RESULTS: One hundred eighty-one participants were prescribed low vision devices. Of them, 93% completed all 3 follow-up interviews. Intensive users (≥1 hours/day) of devices were similar in demographic and visual characteristics to non-intensive users (<1 hours/day), except for habitual reading acuity and speed as well as contrast sensitivity. Overall, device use increased slightly over 3 months of follow-up. Magnifiers were reported to be moderately-to-extremely useful by >80% of participants at all time points except the 1-month follow-up for hand magnifiers (75%). High plus spectacles were the least frequently prescribed device and rated as moderately-to-extremely useful by 70%, 74%, and 59% at 1 week, 1 month, and 3 months, respectively. Most participants used their devices for leisure reading, followed by managing bills. Very few devices (n = 3, <1%) were not used at any time point. CONCLUSIONS: Patients with AMD who are provided with prescribed optical low vision devices do use them and perceive them as useful, especially for leisure reading activities. High rates of usage were maintained over 3 month.

Impact of pediatric vision impairment on daily life: results of focus groups.

PURPOSE: To identify through focus groups of visually impaired children and their parents, relevant content for a vision-targeted health-related quality of life (HRQoL) questionnaire designed for children aged 6 to 12 years. METHODS: Six focus groups of children with vision impairment aged 6 to 12 years and six focus groups of their parents were conducted by trained facilitators using a guided script. Sessions were recorded, transcribed, and coded as per a standardized protocol for content analysis. Comments were placed in thematic categories and each was coded as positive, negative, or neutral. RESULTS: Twenty-four children (mean age: 9.4 years) with vision impairment from a variety of causes and 23 parents participated in the study. The child focus groups generated 1,163 comments, of which 52% (n = 599) were negative, 12% (n = 138) were neutral, and 37% (n = 426) were positive. The three most common topical areas among children were: glasses and adaptive equipment (18%), psychosocial (14%), and school (14%). The parent focus groups generated 1952 comments of which 46% (n = 895) were negative, 16% (n = 323) were neutral, and 38% (n = 734) were positive. The three most common topical areas among parents were: school (21%), expectations or frustrations (14%), and psychosocial (13%). CONCLUSIONS: Pediatric vision impairment has significant effects on HRQoL, as reported by children with vision impairment and their parents in their own words. These findings will provide the content to guide construction of a survey instrument to assess vision-specific, HRQoL in children with vision impairment.

Hemianopic and quadrantanopic field loss, eye and head movements, and driving.

PURPOSE: To compare eye and head movements, lane keeping, and vehicle control of drivers with hemianopic and quadrantanopic field defects with controls, and to identify differences in these parameters between hemianopic and quadrantanopic drivers rated safe to drive by a clinical driving rehabilitation specialist compared with those rated as unsafe. METHODS: Eye and head movements and lane keeping were rated in 22 persons with homonymous hemianopic defects and 8 with quadrantanopic defects (mean age, 53 years) who were ≥6 months post-injury and 30 persons with normal fields (mean age, 53 years). All were licensed to drive and were current drivers or aimed to resume driving. Participants drove a 6.3-mile route along non-interstate city roads under in-traffic conditions. Vehicle control was assessed objectively by vehicle instrumentation for speed, braking, acceleration, and cornering. RESULTS: As a group, drivers with hemianopic or quadrantanopic defects drove slower, exhibited less excessive cornering or acceleration, and executed more shoulder movements than the controls. Those drivers with hemianopic or quadrantanopic defects rated as safe also made more head movements into their blind field, received superior ratings regarding eye movement extent and lane position stability, and exhibited less sudden braking and drove faster than those rated unsafe. CONCLUSIONS: Persons with hemianopic and quadrantanopic defects rated as safe to drive compensated by making more head movements into their blind field, combined with more stable lane keeping and less sudden braking. Future research should evaluate whether these characteristics could be trained in rehabilitation programs aimed at improving driving safety in this population.

Evaluation of on-road driving in people with hemianopia and quadrantanopia.

OBJECTIVE: To examine whether some drivers with hemianopia or quadrantanopia display safe driving skills on the road compared with drivers with normal visual fields. METHOD: An occupational therapist evaluated 22 people with hemianopia, 8 with quadrantanopia, and 30 with normal vision for driving skills during naturalistic driving using six rating scales. RESULTS: Of drivers with normal vision, > 90% drove flawlessly or had minor errors. Although drivers with hemianopia were more likely to receive poorer ratings for all skills, 59.1%-81.8% performed with no or minor errors. A skill commonly problematic for them was lane keeping (40.9%). Of 8 drivers with quadrantanopia, 7 (87.5%) exhibited no or minor errors. CONCLUSION: This study of people with hemianopia or quadrantanopia with no lateral spatial neglect highlights the need to provide individual opportunities for on-road driving evaluation under natural traffic conditions if a person is motivated to return to driving after brain injury.

On-road driving performance by persons with hemianopia and quadrantanopia.

PURPOSE: This study was designed to examine the on-road driving performance of drivers with hemianopia and quadrantanopia compared with age-matched controls. METHODS: Participants included persons with hemianopia or quadrantanopia and those with normal visual fields. Visual and cognitive function tests were administered, including confirmation of hemianopia and quadrantanopia through visual field testing. Driving performance was assessed using a dual-brake vehicle and monitored by a certified driving rehabilitation specialist. The route was 14.1 miles of city and interstate driving. Two "back-seat" evaluators masked to drivers' clinical characteristics independently assessed driving performance using a standard scoring system. RESULTS: Participants were 22 persons with hemianopia and 8 with quadrantanopia (mean age, 53+/-20 years) and 30 participants with normal fields (mean age, 52+/-19 years). Inter-rater agreement for back-seat evaluators was 96%. All drivers with normal fields were rated as safe to drive, while 73% (16/22) of hemianopic and 88% (7/8) of quadrantanopic drivers received safe ratings. Drivers with hemianopia or quadrantanopia who displayed on-road performance problems tended to have difficulty with lane position, steering steadiness, and gap judgment compared to controls. Clinical characteristics associated with unsafe driving were slowed visual processing speed, reduced contrast sensitivity and visual field sensitivity. CONCLUSIONS: Some drivers with hemianopia or quadrantanopia are fit to drive compared with age-matched control drivers. Results call into question the fairness of governmental policies that categorically deny licensure to persons with hemianopia or quadrantanopia without the opportunity for on-road evaluation.