How to support and advise patients on sight loss and driver safety
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How to support and advise patients on sight loss and driver safety

Erin Dean Health journalist

Nurses can advise patients with eye health problems on the common conditions that affect driving and when they should inform the DVLA

Almost one in five drivers (18%) say they have missed a turning because they were unable to see the road sign, and more than one in ten (12%) have never had an eye test, according to statistics published by the College of Optometrists.

Nursing Older People. 34, 6, 10-12. doi: 10.7748/nop.34.6.10.s5

Published: 29 November 2022

Eye health plays a critical part in safe driving, and nurses’ can help patients maintain this by being aware of signs that could indicate a problem.

In the UK, more than 2 million people are living with some sight loss, which can have a profound effect on their lives.

RCN ophthalmic nursing forum chair Penelope Stanford, a senior lecturer in adult nursing at the University of Manchester, says: ‘Eye health is fundamental to driving safety, and while eye problems increase with age, they can also affect younger people. Assumptions shouldn’t be made that someone’s vision is fine just because they are younger.

‘Nurses don’t need to be able to diagnose specific eye problems, but they need to be aware of signs someone has a problem, be asking about eye health and know where to direct them for more specialist support.’

Poor vision was involved in ten fatal and 56 serious road accidents in Great Britain in 2020, according to official government figures.

‘I found myself making little mistakes while on a familiar route’

Before he lost his sight, Richard Hart worked as a train operator for London Underground and loved driving. Diagnosed with diabetes a decade ago, Mr Hart, 64, has been blind for six years as a result of diabetic retinopathy, in which the light-sensitive cells at the back of the eye are damaged.

‘Before I lost my sight, I was a keen driver,’ he says. ‘When on hot summer nights I couldn’t sleep, I would always go out for a drive. I noticed my sight deteriorating when I found myself making little mistakes while doing a familiar route.’

When he realised his sight was failing, he stopped driving immediately and was referred to Newham General Hospital.

Dangers of driving

‘My vision continued to deteriorate and I eventually lost my sight,’ he says. ‘I was frustrated at not being able to drive, but understood the dangers of driving with

Mr Hart has embraced technology to help maintain his independence since retiring, and has gained valuable support from the Royal National Institute of Blind People, but urges others to protect their sight.

‘My advice is for people to check their sight regularly. I understand that for people losing their sight there will be periods of depression, but you have to push against boundaries and keep pushing.’

Standards of vision

Guidance for nurses published by the RCN in 2021 highlights the eye problems that could affect driving for older people and the steps to take. It includes details on eye health, visual impairment and ageing, as well as nurses’ responsibilities and signposting for further information.

There is a long list of conditions that drivers must inform the Driver and Vehicle Licensing Agency (DVLA) about, but nurse experts say the most common ones for nurses to be aware of are glaucoma, macular degeneration, diabetic retinopathy and cataracts.

Asking patients about their eye health and encouraging individuals to have eye tests is an important part of the holistic assessments carried out by nurses in a wide range of settings, including hospital outpatient departments and wards, primary and community care and emergency departments (EDs).

In England, Wales and Scotland, the DVLA must be informed if a patient has a problem with their eyesight that affects both of their eyes, or the remaining eye if they only have one eye, that prevents them meeting the standards for vision.

There is a different service in Northern Ireland, the Driver & Vehicle Agency (DVA), but the standards are the same.

A driver, wearing glasses or contact lenses if needed, must be able to read a car number plate from 20 metres, have a visual acuity of at least decimal 0.5 (6/12) measured on the Snellen scale (using the letter eye test chart that features capital letters in rows of descending sizes), and have an adequate field of vision.

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Picture credit: iStock

Advising on sight loss

The RCN guidance says healthcare professionals should advise people with sight loss that the driver licensing authority should be informed if they have a problem that affects their eyes, or their single remaining eye.

Patients should not drive while waiting to hear back from the DVLA or DVA.

‘Health professionals should inform patients of the importance of wearing glasses or contact lenses, if prescribed, every time they drive,’ says Dr Stanford.

‘But nurses don’t have a duty to report to the DVLA directly. It should be recorded in patient notes that a nurse has advised them to contact the DVLA and this should be shared with the consultant or GP.’

A nurse can report someone to the DVLA if they believe that they are still driving when they should not be, although nurses working in the field say this is not a situation that arises often.

Even if a person did continue to drive when they should not, a healthcare professional would be unlikely to know, adds Dr Stanford.

Cataracts, when the lens of the eye becomes cloudy, obscuring vision, is common in either one or both eyes as people age. However, it is a condition that the DVLA does not need to be informed of if someone is waiting for surgery, says Dr Stanford.

The patient should be told not to drive until after they have had their surgery if they do not meet the standards for vision.

Moorfields Eye Hospital adnexal nurse consultant Nicola Dunlop says that listening carefully to what a patient is saying can help you pick up indications that more investigation is needed.

Advising people on eye health and driving: points to remember

  • » It is advisable to have an eye test every two years

  • » In the event of sudden loss of vision, patients should be advised to attend an eye centre or eye unit

  • » To maintain the standards of vision for driving, healthcare professionals should inform patients of the importance of wearing glasses or contact lenses, if prescribed, every time they drive

  • » Healthcare professionals should advise people with sight loss that the driver licensing authority should be informed if they have a problem that affects both their eyes or their remaining single eye

  • » It is not necessary for people with long or short sightedness or those having eye surgery to inform the driver licensing authority

  • » Healthcare professionals should inform individuals of their responsibility to inform their driver licensing authority of double vision, reduced sharpness (visual acuity) or field of vision that affects driving

Source: RCN (2021)

Listening for cues

‘Listening to the cues that the patient gives you and examining them properly can help determine if they need further assessment by a specialist service,’ says Dr Dunlop.

‘Ask about their vision, if they have noticed any changes, if they are using additional visual aids, such as a magnifier on top of their glasses, and if they have had an eye test in the past two years.’

Someone mentioning they are having difficulty driving or have had recent trips or falls could also indicate problems.

Asking patients to trace the lines on a simple Amsler grid can identify problems, including macular degeneration, as the lines will no longer appear straight. The lines become distorted, blurry or disappear, and can flag up the need for expert advice, says Dr Dunlop.

Anyone who could be experiencing difficulties should generally be referred to an optometrist for an eye test, unless it is a sudden loss or change in vision, or a dark curtain, shadow or flashing lights appear, in which case they should go to their local ED.

This could signal a detached retina, which would require emergency treatment to save the person’s sight.

Discussing a potential pause in a person’s driving experience, or the end of it entirely, is not an easy issue, says Dr Dunlop.

‘It can be a terrible thing for a patient to hear,’ she says. ‘Driving is important for people to maintain their social life, their self-confidence, and being mobile helps prevent loneliness for older people.

How common eye conditions can affect people’s ability to drive

Glaucoma This term covers a range of eye conditions where the optic nerve, which connects the eye to the brain, becomes damaged.

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Picture credit: SPL

It is usually caused by fluid building up in the front part of the eye (pictured), which increases pressure inside the eye.

It tends to develop slowly over many years, often starting on the periphery of someone’s vision, and may cause the person to experience blurring or rainbow-coloured circles around lights.

Glaucoma can lead to loss of vision if not diagnosed and treated early. It can affect people of all ages, but is most common in adults in their seventies and eighties.

Treatment, which can include laser treatment and surgery, cannot reverse damage but can prevent it getting worse. If one eye is affected and the other has a normal field of vision, an individual can usually drive but must be advised to inform their driver licensing authority if they have a condition in their other eye and cannot meet the visual standards for driving.

Macular degeneration Age-related macular degeneration (AMD) is a common condition that affects the centre of a person’s vision. AMD has a number of forms and its exact cause is unknown, but it has been linked to unhealthy lifestyles.

It often starts with the vision being distorted or blurred then, as symptoms worsen, people may not be able to see anything in the middle of their vision. It usually first affects people in their fifties and sixties and is a leading cause of blindness in people aged over 65.

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Picture credit: Alamy

Healthcare professionals should check visual distortion with an Amsler grid (pictured), a grid of horizontal and vertical lines used to monitor a person’s central visual field. If undiagnosed patients have blurred vision and dark spots, or gaps or problems with bright lights or glare, healthcare professionals should advise them to see an ophthalmologist.

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Picture credit: iStock

Diabetic retinopathy This is a common complication of diabetes, caused by high blood sugar levels damaging the back of the eye, or retina (pictured). Symptoms include blurred or patchy vision, floaters and gradually worsening vision.

It can cause blindness if left undiagnosed and untreated. However, it usually takes several years for diabetic retinopathy to reach a stage where it can threaten sight.

Healthcare professionals should ensure that all patients with diabetes are referred to the Diabetic Eyes Screening Service and encourage regular attendance. If patients with diabetes have, or have had, retinopathy in both eyes or in their only functioning eye, healthcare professionals should advise them to inform their driver licensing authority.

Source: RCN (2021) and NHS (2021)

Visual impairment support

‘The loss of driving can mean losing independence and leaves someone more vulnerable to abuse, as they have to ask someone else to do it for them.’

People diagnosed with a new or worsening visual impairment should be directed to support that is available, which includes social care and rehabilitation for visual impairment to help maintain independence.

A Royal National Institute of Blind People eye clinic liaison officer can also provide advice and emotional support.

Nurses have a responsibility to discuss visual health issues and act on concerns, says Dr Dunlop.

‘We have a duty of care as healthcare professionals to inform people that they should report to the DVLA. It can be an emotional issue to discuss, but it is part of our safeguarding role.

‘Our actions can help individuals remain safe and not incur DVLA fines or prosecution if an accident occurs as a result.’

See expert advice, page 18

Find out more

College of Optometrists (2021) Almost half of Brits unaware they could be fined for driving without prescribed glasses. tinyurl.com/CO-news-optomerists

gov.uk (2021) Eye Conditions and Driving. www.gov.uk/eye-conditions-and-driving

NHS (2021) Blindness and Vision Loss. www.nhs.uk/conditions/vision-loss

NHS (2021) What is Diabetic Eye Screening? www.nhs.uk/conditions/diabetic-eye-screening

RCN (2021) Eyes Right: Older People and Driving. tinyurl.com/RCN-eyes-right

RNIB www.rnib.org.uk

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