Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
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Diplopia and driving: A problematic issue Stefano Righi a, Paolo Boffano a, *, Valeria Guglielmi b, Paolo Rossi a, Massimo Martorina b a b
Division of Otolaryngology, Maxillofacial Surgery and Dentistry, Aosta Hospital, Aosta, Italy Division of Ophthalmology, Aosta Hospital, Aosta, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 11 November 2013 Accepted 21 March 2014
The aim of this article was to review the literature regarding diplopia and driving license and to review the West European legislations about this topic, in order to obtain appropriate indications for hospitals specialists and patients. A systematic review of articles published about diplopia and driving was performed. In addition a review of West European national legislations about driving license regulations for medical illnesses was performed, in addition to the European Union Directive on driving licenses. In the literature, the presence of diplopia has not been considered a reliable predictor of the safety of driving behavior, or it has not appeared to be a contraindication for driving according to some authors who were unable to demonstrate significant differences on driving simulator performance between subjects with chronic stable diplopia and control subjects. Nevertheless, in all western European legislations, acute diplopia constitutes an important limitation for driving, thus making the knowledge of current regulations fundamental for specialists involved in managing patients with diplopia. Ophthalmologists and maxillofacial/head and neck surgeons, may advise patients before hospital discharge about current legislations in their respective countries. 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Diplopia Orbital fracture Driving License Driving license
1. Introduction Driving is a highly visual task. Visual acuity examination is the most frequent screening test for a driver’s license, although several further features of visual function are fundamental for a safe and effective control of a vehicle. Visual field, contrast sensitivity, glare sensitivity, color vision and night vision should also be assessed. Furthermore, diplopia is a crucial problem for a driver as it can compromise safe driving, thus it should be carefully evaluated (International Council of Ophthalmology, 2005; Owsley and McGwin, 2010). Diplopia is a symptom that is frequently associated with orbital wall fractures (Roccia et al., 2011; Karabekir et al., 2012; Polligkeit et al., 2013; Boffano et al., 2013a; Boffano et al., 2013b; Ristow et al., 2013; Boffano et al., 2014). Posttraumatic diplopia may be commonly caused by extrusion of the extraocular muscles or orbital soft tissues, injury of the extraocular muscles, edema of the intraorbital fat tissue, or vertical deviation of the eyeball. In the literature, few articles discuss the problem of posttraumatic diplopia in relation to the driving license.
Jurisdictions may widely differ regarding contraindications to drive in the presence of diplopia. Therefore, a thorough knowledge of driving contraindications is nescessaryl for both ophthalmologists and maxillofacial/head and neck surgeons so that they can advise patients before hospital discharge. The aim of this article was to review the literature regarding diplopia and driving license and to review the West European legislations about this topic, in order to obtain appropriate indications for hospitals specialists and patients. 2. Materials and methods A systematic review of articles published between January 1990 and August 2013 using Medline and the MeSH Term ‘Diplopia’ and “double vision” in combination with the following terms ‘drive’ and “Driving license”. Furthermore, a review of national legislations of West countries belonging to the European Union about driving license regulations as for medical illnesses was performed, in addition to the European Union Directive on driving licenses. 3. Results
* Corresponding author. Viale Ginevra 3, 11100, Aosta, Italy. Tel.: +390165543990. E-mail address: [email protected] (P. Boffano).
The literature regarding diplopia and driving included very few articles, that is two letters regarding United Kingdom, a Canadian
http://dx.doi.org/10.1016/j.jcms.2014.03.022 1010-5182/ 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Righi S, et al., Diplopia and driving: A problematic issue, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.03.022
2
S. Righi et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
experimental study involving a driving simulator, and an Australian study with a small population (White et al., 2001; Jolly and Clunas, 2010; Singh et al., 2011, 2012). West European legislations and European Union Directive are resumed in Table 1. In all countries, contraindications vary according to driving license class that are classified in group 1 (including drivers of vehicles of categories A, A1, A2, AM, B, B1 and BE) and group 2 (drivers of vehicles of categories C, CE, C1, C1E, D, DE, D1 and D1E). Group 1 includes mopeds, motorcycles, motor vehicles, and tractors, whereas group 2 includes large goods vehicles and buses. 4. Discussion Maxillofacial/head and neck surgeons and ophthalmologists often deal with patients who present with a sudden diplopia that can appear because of trauma or neurological causes. The implications of diplopia in everyday life are important in reading, walking, working and driving, as well as in every activity. For example, diplopia in downgaze can prevent accurate and fluid reading or it can make it difficult to go down ladders or staircases. Walking may become difficult as depth of field of vision is impared, thus facilitating falls. Finally, while driving, diplopia may lead to the perception of false images that make it difficult to drive safely, particularly during night and along narrow streets. In conclusion, diplopia may determine severe functional disability and a psychosocial worsening with a more severe impact in the psychosocial well-being as the area of single binocular vision became smaller. Orbital wall fractures, even if appropriately treated, may cause a permanent, even if mild, diplopia in external fields. Furthermore, a few patients can have important medical contraindications for general anesthesia: because of that, surgical interventions for orbital fractures may become a high risk surgery, thus having to be avoided and leaving a permanent diplopia. In all these situations, the involved specialists may be asked by the patient about the possibility of driving or returning to drive. Therefore, it is crucial that specialists know the current rules that widely vary among countries in the Western Europe. Clinicians’ awareness of driving license guidelines may be poor and the patients may not receive appropriate driving advice (Singh et al., 2011). In the literature, the presence of diplopia has not been considered a reliable predictor of the safety of driving behavior (Jolly and Clunas, 2010), or it has not appeared to be a contraindication for driving according to some authors who failed to demonstrate significant differences on driving simulator performance between subjects with chronic stable diplopia and control subjects (White et al., 2001). Nevertheless, in all western European legislations, acute diplopia constitutes an important limitation for driving (Table 1), thus making the knowledge of current regulations important for the involved specialists. It is important to remember that, in spite of a common European Union (EU) Directive (2009/113/EC Directive) (European Union, 2009) which suggests general advice, all EU countries may decide a different and particular legislation. In almost all considered countries, more severe contraindications and prescriptions are applied to group 2 (professional) drivers, i.e. drivers of vehicles of categories (C, CE, C1, C1E, D, DE, D1 and D1E). In all countries but Italy, Germany and Belgium, driving licenses are not issued or renewed in cases of diplopia, according to the EU Directive. In Italy, after a 6 months adaptation period, a local medical commission, having consulted an ophthalmologist, may allow the patient to drive under special prescriptions and limitations.
In Germany, driving licences are not issued to or renewed for patients with a specified diplopia: 25 or less in the upper vision, 30 or less in the lateral vision, 40 in the inferior vision. Finally, in Belgium, patients need permission of an ophthalmologist to continue to drive and a monocular vision may be compulsory. As for group 1 drivers, regulations widely vary among countries. Generally, driving is prohibited for an adaptation period of some months. After that an ophthalmological assessment is necessary and a monocular vision may be prescribe for driving. These regulations are quite similar in Austria, Finland, Germany, Ireland, Italy, Luxembourg, Netherlands, Portugal, and United Kingdom, with some small variations. Monocular vision is preferable to diplopia if restoring functional binocularity is impossible because, as aforementioned, the implications of diplopia in everyday life are important in reading, walking, working and driving, as well as in every activity with severe functional disability. Binocularity may be achieved with traditional ground-in prisms and Fresnel prisms. Prisms correct diplopia by altering the pathway of light, moving images onto the fovea of the deviated eye or within a range to allow fusion of the images if possible. In general, prisms are considered effective for small, comitant deviations (Gunton and Brown, 2012). Instead, in adults who have intractable diplopia a filter or a patch can be considered to obtain monocular vision. Some filters vary in strength from the most dense, which produce severe reduction in visual acuity, to the barely occlusive, in which nearly normal visual acuity is possible. Partially occlusive filters that determine sector occlusion of a spectacle lens of the pathologic may be utilized (Rutstein, 2010). Monovision decreases symptoms of diplopia and improves patients’ quality of life with fewer disturbances in daily activities from diplopia and improved speed in everyday activities. In Denmark, no adaptation period seems to be necessary and diplopia has to be controlled by and opaque glass or by a patch which the license holder undertakes to wear on the low seeing eye while driving. Driving licenses can then be issued or renewed when the patient has a visual acuity of 0.6 (6/10) or more in the best seeing eye. In France and in Spain, a severe legislation prohibits driving licenses for patients suffering from permanent diplopia that cannot be surgically or medically resolved. Iin Greece, driving licenses are allowed if an eye is excluded by glasses (with or without a prism) or by a patch which the license holder undertakes to wear while driving. Corrected visual acuity in the uncovered eye has to be at least 8/10 and visual field has to be normal. Finally, in Sweden, driving is allowed if the patient has no diplopia inside the central 30 degrees of the visual field. Diplopia inside the central 30 degrees of the visual field precludes driving. In this case driving is prohibited for an adaptation period to monocular vision (by glasses with or without a prism or by a patch) of at least 6 months. Exceptionally a stable uncorrected diplopia of 6 months’ duration or more may be compatible with driving if there is consultant support indicating satisfactory functional adaptation. Considering all aforementioned regulations, it is obvious that different kinds and degrees of diplopia exist and that patients vary greatly in the degree to which they are bothered by diplopia (International Council of Ophthalmology), Some patients are able to suppress the unattended image when looking through a monocular telescope or other monocular device, others close one eye (International Council of Ophthalmology, 2005). The most important limitation of current laws and guidelines seems to be the absence of consideration for the field of diplopia and the degree of disability the patient is suffering from (Singh
Please cite this article in press as: Righi S, et al., Diplopia and driving: A problematic issue, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.03.022
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Table 1 Prescriptions and prohibitions in West European countries to patients with a recent sudden diplopia as for driving license. Country
Group 1
Austria, 2013
Driving licences shall not be issued or renewed. The patient needs a permission by an ophthalmologist. Diplopia has to be controlled by glasses (with or without a prism) or by a patch which the licence holder undertakes to wear while driving. Therefore, requirements for monocularity must be met. Maximum time for driving license: 5 years. Patients who suffer from a sudden diplopia in the primary vision cannot drive. The patient needs a permission by an ophthalmologist to drive again. An opaque glass or a patch can be used in case of diplopia Driving licences shall not be issued or renewed. Driving licences can be issued or renewed when the patient has a visual acuity of 0.6 (6/10) or more in the best seeing eye. Diplopia has to be controlled by and opaque glasse or by a patch which the licence holder undertakes to wear on the low seeing eye while driving. Driving licences shall not be issued or renewed. Driving is prohibited for an adaptation period of 6 months, then an ophthalmological and eventually neurological assessment is necessary, then driving examination Driving licences shall not be issued or renewed. Driving licences shall not be issued to or renewed for patients suffering from permanent diplopia that cannot be surgically or medically solved. Driving licences shall not be issued to or renewed for patients with a Driving is prohibited for an adaptation period of at least 3 months, specified diplopia: 25 or less in the upper vision, 30 or less in the then an ophthalmological assessment is necessary. Driving is allowed if the patient has no diplopia inside the central 20 lateral vision, 40 in the inferior vision. degrees of the visual field. Driving licences shall not be issued or renewed. Driving licences are allowed if an eye is excluded by glasses (with or without a prism) or by a patch which the license holder undertakes to wear while driving. Corrected visual acuity in the uncovered eye has to be at least 8/10 and visual field has to be normal. Drivers with diplopia need a periodical revision every 3 years. Driving licences shall not be issued or renewed. Driving is prohibited for an adaptation period of at least 6 months, then an ophthalmological or optometrist (“vision experts”) assessment is necessary. An eye has to be excluded by glasses (with or without a prism) or by a patch which the licence holder undertakes to wear while driving. Corrected visual acuity in the uncovered eye has to be at least 5/10 and a sufficient visual field. The competent medical authority must certify that this condition of monocular vision has existed for a sufficiently long time to allow adaptation. Driving is prohibited for an adaptation period of at least 6 months. Driving is prohibited for an adaptation period, that is decided by an After that, a local medical commission, having consulted an ophthalmologist; after that period, a local medical commission, ophthalmologist, may allow the patient to drive under special having consulted an ophthalmologist, may allow the patient to prescriptions and limitations. drive under special prescriptions and limitations. Driving licences shall not be issued or renewed. Driving is prohibited for an adaptation period of a maximum of 6 months, that is decided by a medical commission and an ophthalmologist; after that period, driving is allowed only if an ophthalmologist certifies that the patient is adapted to monocular vision. Driving licences shall not be issued or renewed. Driving is prohibited for an adaptation period to monocular vision of 3 months, then an ophthalmological assessment is necessary to allow the patient to drive. Driving licences shall not be issued or renewed. Driving is prohibited for an adaptation period of at least 6 months, then an ophthalmological assessment is necessary to allow the patient to drive. However, some restrictions are applied to the patient: - An eye has to be excluded - Driving in highways is prohibited - A maximum validity of 3 years is granted Driving licences shall not be issued or renewed. Driving licences shall not be issued or renewed. Driving licences shall not be issued or renewed. Driving is allowed if the patient has no diplopia inside the central 30 degrees of the visual field. A diplopia inside the central 30 degrees of the visual field does not allow driving. In that case, driving is prohibited for an adaptation period to monocular vision (by glasses with or without a prism or by a patch) of at least 6 months. Exceptionally a stable uncorrected diplopia of 6 months’ duration or more may be compatible with driving if there is consultant support indicating satisfactory functional adaptation. Driving licences shall not be issued or renewed. Driving is prohibited until the Licensing Authority has a confirmation that diplopia is controlled by glasses or by a patch which the licence holder undertakes to wear while driving. (If patching, requirements for monocularity are applied). Exceptionally a stable uncorrected diplopia of 6 months’ duration or more may be compatible with driving if there is consultant support indicating satisfactory functional adaptation.
Belgium, 2002
Denmark, 2009
Finland, 2011
France, 2005
Germany, 2013
Greece, 2010
Ireland, 2013
Italy, 2011
Luxembourg, 2011
Netherlands, 2010
Portugal, 2012
Spain, 1997 Sweden, 2013
United Kingdom, 2013
Group 2
(continued on next page)
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Table 1 (continued ) Country
Group 1
Group 2
European Union, 2009 2009/113/EC Directive
Applicants for a driving licence, or for the renewal of such a licence, who have total functional loss of vision in one eye or who use only one eye (e.g. in the case of diplopia) must have a visual acuity of at least 0,5, with corrective lenses if necessary. The competent medical authority must certify that this condition of monocular vision has existed for a sufficiently long time to allow adaptation and that the field of vision in this eye meets the requirements. After any recently developed diplopia or after the loss of vision in one eye, there should be an appropriate adaptation period (for example, six months), during which driving is not allowed. After this period, driving is only allowed following a favorable opinion from vision and driving experts.
Driving licences shall not be issued or renewed.
et al., 2011), which is present in almost all western UE countries, with the exception of Germany and Sweden. In Germany the field of diplopia limits are described for group 2 drivers, whereas in Sweden driving is allowed if the patient has no diplopia inside the central 30 degrees of the visual field. Knowledge of the extent of diplopia would be theoretically be very important as a mild form of diplopia in extreme peripheral gaze might allow a safe and effective driving (Singh et al., 2011). As aforementioned, current EU legislations frequently do not specify such extent, thus creating a crucial dilemma: should all diplopic group 2 drivers have such an important prohibition, even if their diplopia is minimal? It would be helpful to have a method of quantifying severity of diplopia, particularly when evaluating recovery after the first injury or intervention. Most of the various methods available for assessing diplopia severity include questionnaires that obviously present a subjective bias, whereas other techniques (such as CROM) require special equipment and are limited to capturing a patient’s diplopia at a specific point in time on a specific day (Holmes et al., 2013). A revision of current regulations may be needed, but in the meantime we suggest that every patient who has suffered from a temporary or permanent diplopia undergoes an ophthalmological assessment before returning to drive. 5. Conclusion Ophthalmologists and maxillofacial/head and neck surgeons, may advise patients before hospital discharge about current legislations in their respective countries, reminding them that if they choose to ignore advice to cease driving, there could be consequences with respect to their insurance. Disclosure statement No disclosures. References Austria: Bundesrecht konsolidiert: Gesamte Rechtsvorschrift für Führerscheingesetz-Gesundheitsverordnung, Fassung vom 11.10.2013. Available online at: http://www.ris.bka.gv.at/GeltendeFassung.wxe?Abfrage¼Bundesnormen& Gesetzesnummer¼10012726; October 2013 Belgium: Normes minimales relatives à l’aptitude physique et psychique à la conduite d’un véhicule à moteur. Arrêté royal du 5 septembre 2002 modifiant l’arrêté royal du 23 mars 1998 relatif au permis de conduire et l’arrêté royal du 1er décembre 1975 portant règlement général sur la police de la circulation routière. Available online at: http://www.ejustice.just.fgov.be/cgi_loi/change_lg. pl?language¼fr&la¼F&table_name¼loi&cn¼2002090535; September 2002 Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Infraorbital nerve posttraumatic deficit and displaced zygomatic fractures: a double-center study. J Craniofac Surg 24: 2044e2046, 2013a Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Bicycle-related maxillofacial injuries: a double-center study. Oral Surg Oral Med Oral Pathol Oral Radiol 116: 275e280, 2014b
Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Diplopia and orbital wall fractures. J Craniofac Surg 25: e183ee185, 2014 Denmark: Cirkulære om kørekort. Ministerialtidende. Available online at: https:// www.ministerialtidende.dk/pdf.aspx?id¼123639; April 2009 European Union: Commission directive 2009/113/EC of 25 August 2009 amending Directive 2006/126/EC of the European Parliament and of the Council on driving licences. Off J Eur Union. Available online at: http://eur-lex.europa.eu/ LexUriServ/LexUriServ.do?uri¼OJ. L:2009:223:0031:0035:EN: PDF Finland: Sosiaali- ja terveysministeriön asetus ajoterveydestä. Annettu Helsingissä 25 päivänä marraskuuta 2011. Available online at: http://www.silmalaakariyhdistys. fi/fin/lainsaadanto/ajokorttilainsaadanto/; November 2011 France: Arrêté du 21 décembre 2005 fixant la liste des affections médicales incompatibles avec l’obtention ou le maintien du permis de conduire ou pouvant donner lieu à la délivrance de permis de conduire de durée de validité limitée. Available online at: http://www.legifrance.gouv.fr/affichTexteArticle.do; jsessionid¼4B36119F161F12FDB1D400E4E5E59F8C.tpdjo09v_1?cidTexte¼ JORFTEXT000000265763&idArticle¼LEGIARTI000022817769&dateTexte¼ 20131011&categorieLien¼id#LEGIARTI000022817769; December 2005 Germany: Fahrerlaubnis-Verordnung vom 13. Dezember 2010 (BGBl. I S. 1980), die durch Artikel 2 Absatz 14 des Gesetzes vom 3. Mai 2013 (BGBl. I S. 1084) geändert worden ist. Available online at: http://www.gesetze-im-internet.de/ bundesrecht/fev_2010/gesamt.pdf; May 2013 Greece: UA 292//2010 (UA 29240/3729 FEK B 1409 2010): ODG 91/439/EOK(Trop/sh Parars/so2 III,PD 19/1995(΄Adεiε2 odήghsh2) (523285). Available online at: http://www.ekpaideftis.gr/frontend/decisions/3_9_10_YA_29240_trop_pds_.doc; September 2010 Gunton KB, Brown A: Prism use in adult diplopia. Curr Opin Ophthalmol 23: 400e 404, 2012 Holmes JM, Liebermann L, Hatt SR, Smith SJ, Leske DA: Quantifying diplopia with a questionnaire. Ophthalmology 120: 1492e1496, 2013 International Council of Ophthalmology: Vision requirements for driving safety, http://www.icoph.org/enhancing_eyecare/standards_for_eyecare_and_vision. html; December, 2005 Ireland: Sláinte agus Tiomáint. Medical fitness to drive guidelines. Available online at: http://www.rsa.ie/Documents/Licensed%20Drivers/Medical_Issues/Sl%C3% A1inte_agus_Tiom%C3%A1int_Medical_Fitness_to_Drive_Guidelines.pdf; February 2013 Italy: Decreto legislativo 18 aprile 2011, n. 59: Attuazione delle direttive 2006/126/ CE e 2009/113/CE concernenti la patente di guida. GU Serie Generale n.99 del 30-4-2011. Available online at: http://www.gazzettaufficiale.it/atto/serie_ generale/caricaDettaglioAtto/originario?atto.dataPubblicazioneGazzetta¼201104-30&atto.codiceRedazionale¼011G0104&elenco30Giorni¼false; April 2011 Jolly N, Clunas N: Assessment of diplopia using saccades and pursuits and its relation to driving performance. Clin Exp Ophthalmol 38: 79e81, 2010 Karabekir HS, Gocmen-Mas N, Emel E, Karacayli U, Koymen R, Atar EK, et al: Ocular and periocular injuries associated with an isolated orbital fracture depending on a blunt cranial trauma: anatomical and surgical aspects. J Craniomaxillofac Surg 40: e189ee193, 2012 Luxembourg: Règlement ministériel du 27 janvier 2011 fixant les modalités du certificat médical pour l’obtention, la transcription et le renouvellement d’un permis de conduire. Available online at: http://www.legilux.public.lu/leg/a/ archives/2011/0019/a019.pdf; January 2011 Netherlands: Wijziging van de Regeling eisen geschikheid 2000 in verband met implementatie van de richtlijnen 2009/112/EG en 2009/113/EG. Available online at: https://zoek.officielebekendmakingen.nl/stcrt-2010-2588.html; February 2010 Owsley C, McGwin Jr G: Vision and driving. Vision Res. 50: 2348e2361, 2010 Polligkeit J, Grimm M, Peters JP, Cetindis M, Krimmel M, Reinert S: Assessment of indications and clinical outcome for the endoscopy-assisted combined subciliary/transantral approach in treatment of complex orbital floor fractures. J Craniomaxillofac Surg 41: 797e802, 2013 Portugal: Decreto-Lei n. 138/2012. D.R. n. 129, Série I de 2012-07-05. Available online at: http://dre.pt/pdf1s/2012/07/12900/0342603475.pdf; July 2012
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S. Righi et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5 Ristow O, Pautke C, Kehl Victoria, Koerdt S, Schwärzler K, Hahnefeld L, et al: Influence of kinesiologic tape on postoperative swelling, pain and trismus after zygomatico-orbital fractures J Craniomaxillofac Surg. http://dx.doi.org/10.1016/ j.jcms.2013.05.043, 2013 Jul 4 pii: S1010e5182(13)00177-7 Roccia F, Boffano P, Guglielmi V, Forni P, Cassarino E, Nadalin J, et al: Role of the maxillofacial surgeon in the management of severe ocular injuries after maxillofacial fractures. J Emerg Trauma Shock 4: 188e193, 2011 Rutstein RP: Use of Bangerter filters with adults having intractable diplopia. Optometry 81: 387e393, 2010 Singh RP, Malik H, Carter LM: Driving advice for patients with double vision following zygomatico-orbital complex fractures. Br J Oral Maxillofac Surg 49: 586, 2011 Singh RP, Bhuva K, Bustin J, Carter LM: Diplopia, driving and DVLA. Br J Oral Maxillofac Surg 50: 791, 2012
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Spain: Real Decreto 772/1997, de 30 de mayo, por el que se aprueba el Reglamento General de Conductores. Available online at: https://www.boe.es/boe/dias/ 1997/06/06/pdfs/A17348-17393.pdf; June 1997. Sweden: Föreskrifter om ändring i Transportstyrelsens föreskrifter och allmänna råd (TSFS 2010:125) om medicinska krav för innehav av körkort m.m. (omtryck). Available online at: https://www.transportstyrelsen.se/tsfs/TSFS%202013_2.pdf; 2013 United Kingdom: Guide to the current medical standards of fitness to drive. Edition. Available online at: https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/232964/At_a_glance.pdf; 2013 White JE, Marshall SC, Diedrich-Closson KL, Burton AL: Evaluation of motor vehicle driving performance in patients with chronic diplopia. J AAPOS 5: 184e188, 2001
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Contents lists available at ScienceDirect
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Diplopia and driving: A problematic issue Stefano Righi a, Paolo Boffano a, *, Valeria Guglielmi b, Paolo Rossi a, Massimo Martorina b a b
Division of Otolaryngology, Maxillofacial Surgery and Dentistry, Aosta Hospital, Aosta, Italy Division of Ophthalmology, Aosta Hospital, Aosta, Italy
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 11 November 2013 Accepted 21 March 2014
The aim of this article was to review the literature regarding diplopia and driving license and to review the West European legislations about this topic, in order to obtain appropriate indications for hospitals specialists and patients. A systematic review of articles published about diplopia and driving was performed. In addition a review of West European national legislations about driving license regulations for medical illnesses was performed, in addition to the European Union Directive on driving licenses. In the literature, the presence of diplopia has not been considered a reliable predictor of the safety of driving behavior, or it has not appeared to be a contraindication for driving according to some authors who were unable to demonstrate significant differences on driving simulator performance between subjects with chronic stable diplopia and control subjects. Nevertheless, in all western European legislations, acute diplopia constitutes an important limitation for driving, thus making the knowledge of current regulations fundamental for specialists involved in managing patients with diplopia. Ophthalmologists and maxillofacial/head and neck surgeons, may advise patients before hospital discharge about current legislations in their respective countries. 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Diplopia Orbital fracture Driving License Driving license
1. Introduction Driving is a highly visual task. Visual acuity examination is the most frequent screening test for a driver’s license, although several further features of visual function are fundamental for a safe and effective control of a vehicle. Visual field, contrast sensitivity, glare sensitivity, color vision and night vision should also be assessed. Furthermore, diplopia is a crucial problem for a driver as it can compromise safe driving, thus it should be carefully evaluated (International Council of Ophthalmology, 2005; Owsley and McGwin, 2010). Diplopia is a symptom that is frequently associated with orbital wall fractures (Roccia et al., 2011; Karabekir et al., 2012; Polligkeit et al., 2013; Boffano et al., 2013a; Boffano et al., 2013b; Ristow et al., 2013; Boffano et al., 2014). Posttraumatic diplopia may be commonly caused by extrusion of the extraocular muscles or orbital soft tissues, injury of the extraocular muscles, edema of the intraorbital fat tissue, or vertical deviation of the eyeball. In the literature, few articles discuss the problem of posttraumatic diplopia in relation to the driving license.
Jurisdictions may widely differ regarding contraindications to drive in the presence of diplopia. Therefore, a thorough knowledge of driving contraindications is nescessaryl for both ophthalmologists and maxillofacial/head and neck surgeons so that they can advise patients before hospital discharge. The aim of this article was to review the literature regarding diplopia and driving license and to review the West European legislations about this topic, in order to obtain appropriate indications for hospitals specialists and patients. 2. Materials and methods A systematic review of articles published between January 1990 and August 2013 using Medline and the MeSH Term ‘Diplopia’ and “double vision” in combination with the following terms ‘drive’ and “Driving license”. Furthermore, a review of national legislations of West countries belonging to the European Union about driving license regulations as for medical illnesses was performed, in addition to the European Union Directive on driving licenses. 3. Results
* Corresponding author. Viale Ginevra 3, 11100, Aosta, Italy. Tel.: +390165543990. E-mail address: [email protected] (P. Boffano).
The literature regarding diplopia and driving included very few articles, that is two letters regarding United Kingdom, a Canadian
http://dx.doi.org/10.1016/j.jcms.2014.03.022 1010-5182/ 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Righi S, et al., Diplopia and driving: A problematic issue, Journal of Cranio-Maxillo-Facial Surgery (2014), http://dx.doi.org/10.1016/j.jcms.2014.03.022
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S. Righi et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5
experimental study involving a driving simulator, and an Australian study with a small population (White et al., 2001; Jolly and Clunas, 2010; Singh et al., 2011, 2012). West European legislations and European Union Directive are resumed in Table 1. In all countries, contraindications vary according to driving license class that are classified in group 1 (including drivers of vehicles of categories A, A1, A2, AM, B, B1 and BE) and group 2 (drivers of vehicles of categories C, CE, C1, C1E, D, DE, D1 and D1E). Group 1 includes mopeds, motorcycles, motor vehicles, and tractors, whereas group 2 includes large goods vehicles and buses. 4. Discussion Maxillofacial/head and neck surgeons and ophthalmologists often deal with patients who present with a sudden diplopia that can appear because of trauma or neurological causes. The implications of diplopia in everyday life are important in reading, walking, working and driving, as well as in every activity. For example, diplopia in downgaze can prevent accurate and fluid reading or it can make it difficult to go down ladders or staircases. Walking may become difficult as depth of field of vision is impared, thus facilitating falls. Finally, while driving, diplopia may lead to the perception of false images that make it difficult to drive safely, particularly during night and along narrow streets. In conclusion, diplopia may determine severe functional disability and a psychosocial worsening with a more severe impact in the psychosocial well-being as the area of single binocular vision became smaller. Orbital wall fractures, even if appropriately treated, may cause a permanent, even if mild, diplopia in external fields. Furthermore, a few patients can have important medical contraindications for general anesthesia: because of that, surgical interventions for orbital fractures may become a high risk surgery, thus having to be avoided and leaving a permanent diplopia. In all these situations, the involved specialists may be asked by the patient about the possibility of driving or returning to drive. Therefore, it is crucial that specialists know the current rules that widely vary among countries in the Western Europe. Clinicians’ awareness of driving license guidelines may be poor and the patients may not receive appropriate driving advice (Singh et al., 2011). In the literature, the presence of diplopia has not been considered a reliable predictor of the safety of driving behavior (Jolly and Clunas, 2010), or it has not appeared to be a contraindication for driving according to some authors who failed to demonstrate significant differences on driving simulator performance between subjects with chronic stable diplopia and control subjects (White et al., 2001). Nevertheless, in all western European legislations, acute diplopia constitutes an important limitation for driving (Table 1), thus making the knowledge of current regulations important for the involved specialists. It is important to remember that, in spite of a common European Union (EU) Directive (2009/113/EC Directive) (European Union, 2009) which suggests general advice, all EU countries may decide a different and particular legislation. In almost all considered countries, more severe contraindications and prescriptions are applied to group 2 (professional) drivers, i.e. drivers of vehicles of categories (C, CE, C1, C1E, D, DE, D1 and D1E). In all countries but Italy, Germany and Belgium, driving licenses are not issued or renewed in cases of diplopia, according to the EU Directive. In Italy, after a 6 months adaptation period, a local medical commission, having consulted an ophthalmologist, may allow the patient to drive under special prescriptions and limitations.
In Germany, driving licences are not issued to or renewed for patients with a specified diplopia: 25 or less in the upper vision, 30 or less in the lateral vision, 40 in the inferior vision. Finally, in Belgium, patients need permission of an ophthalmologist to continue to drive and a monocular vision may be compulsory. As for group 1 drivers, regulations widely vary among countries. Generally, driving is prohibited for an adaptation period of some months. After that an ophthalmological assessment is necessary and a monocular vision may be prescribe for driving. These regulations are quite similar in Austria, Finland, Germany, Ireland, Italy, Luxembourg, Netherlands, Portugal, and United Kingdom, with some small variations. Monocular vision is preferable to diplopia if restoring functional binocularity is impossible because, as aforementioned, the implications of diplopia in everyday life are important in reading, walking, working and driving, as well as in every activity with severe functional disability. Binocularity may be achieved with traditional ground-in prisms and Fresnel prisms. Prisms correct diplopia by altering the pathway of light, moving images onto the fovea of the deviated eye or within a range to allow fusion of the images if possible. In general, prisms are considered effective for small, comitant deviations (Gunton and Brown, 2012). Instead, in adults who have intractable diplopia a filter or a patch can be considered to obtain monocular vision. Some filters vary in strength from the most dense, which produce severe reduction in visual acuity, to the barely occlusive, in which nearly normal visual acuity is possible. Partially occlusive filters that determine sector occlusion of a spectacle lens of the pathologic may be utilized (Rutstein, 2010). Monovision decreases symptoms of diplopia and improves patients’ quality of life with fewer disturbances in daily activities from diplopia and improved speed in everyday activities. In Denmark, no adaptation period seems to be necessary and diplopia has to be controlled by and opaque glass or by a patch which the license holder undertakes to wear on the low seeing eye while driving. Driving licenses can then be issued or renewed when the patient has a visual acuity of 0.6 (6/10) or more in the best seeing eye. In France and in Spain, a severe legislation prohibits driving licenses for patients suffering from permanent diplopia that cannot be surgically or medically resolved. Iin Greece, driving licenses are allowed if an eye is excluded by glasses (with or without a prism) or by a patch which the license holder undertakes to wear while driving. Corrected visual acuity in the uncovered eye has to be at least 8/10 and visual field has to be normal. Finally, in Sweden, driving is allowed if the patient has no diplopia inside the central 30 degrees of the visual field. Diplopia inside the central 30 degrees of the visual field precludes driving. In this case driving is prohibited for an adaptation period to monocular vision (by glasses with or without a prism or by a patch) of at least 6 months. Exceptionally a stable uncorrected diplopia of 6 months’ duration or more may be compatible with driving if there is consultant support indicating satisfactory functional adaptation. Considering all aforementioned regulations, it is obvious that different kinds and degrees of diplopia exist and that patients vary greatly in the degree to which they are bothered by diplopia (International Council of Ophthalmology), Some patients are able to suppress the unattended image when looking through a monocular telescope or other monocular device, others close one eye (International Council of Ophthalmology, 2005). The most important limitation of current laws and guidelines seems to be the absence of consideration for the field of diplopia and the degree of disability the patient is suffering from (Singh
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Table 1 Prescriptions and prohibitions in West European countries to patients with a recent sudden diplopia as for driving license. Country
Group 1
Austria, 2013
Driving licences shall not be issued or renewed. The patient needs a permission by an ophthalmologist. Diplopia has to be controlled by glasses (with or without a prism) or by a patch which the licence holder undertakes to wear while driving. Therefore, requirements for monocularity must be met. Maximum time for driving license: 5 years. Patients who suffer from a sudden diplopia in the primary vision cannot drive. The patient needs a permission by an ophthalmologist to drive again. An opaque glass or a patch can be used in case of diplopia Driving licences shall not be issued or renewed. Driving licences can be issued or renewed when the patient has a visual acuity of 0.6 (6/10) or more in the best seeing eye. Diplopia has to be controlled by and opaque glasse or by a patch which the licence holder undertakes to wear on the low seeing eye while driving. Driving licences shall not be issued or renewed. Driving is prohibited for an adaptation period of 6 months, then an ophthalmological and eventually neurological assessment is necessary, then driving examination Driving licences shall not be issued or renewed. Driving licences shall not be issued to or renewed for patients suffering from permanent diplopia that cannot be surgically or medically solved. Driving licences shall not be issued to or renewed for patients with a Driving is prohibited for an adaptation period of at least 3 months, specified diplopia: 25 or less in the upper vision, 30 or less in the then an ophthalmological assessment is necessary. Driving is allowed if the patient has no diplopia inside the central 20 lateral vision, 40 in the inferior vision. degrees of the visual field. Driving licences shall not be issued or renewed. Driving licences are allowed if an eye is excluded by glasses (with or without a prism) or by a patch which the license holder undertakes to wear while driving. Corrected visual acuity in the uncovered eye has to be at least 8/10 and visual field has to be normal. Drivers with diplopia need a periodical revision every 3 years. Driving licences shall not be issued or renewed. Driving is prohibited for an adaptation period of at least 6 months, then an ophthalmological or optometrist (“vision experts”) assessment is necessary. An eye has to be excluded by glasses (with or without a prism) or by a patch which the licence holder undertakes to wear while driving. Corrected visual acuity in the uncovered eye has to be at least 5/10 and a sufficient visual field. The competent medical authority must certify that this condition of monocular vision has existed for a sufficiently long time to allow adaptation. Driving is prohibited for an adaptation period of at least 6 months. Driving is prohibited for an adaptation period, that is decided by an After that, a local medical commission, having consulted an ophthalmologist; after that period, a local medical commission, ophthalmologist, may allow the patient to drive under special having consulted an ophthalmologist, may allow the patient to prescriptions and limitations. drive under special prescriptions and limitations. Driving licences shall not be issued or renewed. Driving is prohibited for an adaptation period of a maximum of 6 months, that is decided by a medical commission and an ophthalmologist; after that period, driving is allowed only if an ophthalmologist certifies that the patient is adapted to monocular vision. Driving licences shall not be issued or renewed. Driving is prohibited for an adaptation period to monocular vision of 3 months, then an ophthalmological assessment is necessary to allow the patient to drive. Driving licences shall not be issued or renewed. Driving is prohibited for an adaptation period of at least 6 months, then an ophthalmological assessment is necessary to allow the patient to drive. However, some restrictions are applied to the patient: - An eye has to be excluded - Driving in highways is prohibited - A maximum validity of 3 years is granted Driving licences shall not be issued or renewed. Driving licences shall not be issued or renewed. Driving licences shall not be issued or renewed. Driving is allowed if the patient has no diplopia inside the central 30 degrees of the visual field. A diplopia inside the central 30 degrees of the visual field does not allow driving. In that case, driving is prohibited for an adaptation period to monocular vision (by glasses with or without a prism or by a patch) of at least 6 months. Exceptionally a stable uncorrected diplopia of 6 months’ duration or more may be compatible with driving if there is consultant support indicating satisfactory functional adaptation. Driving licences shall not be issued or renewed. Driving is prohibited until the Licensing Authority has a confirmation that diplopia is controlled by glasses or by a patch which the licence holder undertakes to wear while driving. (If patching, requirements for monocularity are applied). Exceptionally a stable uncorrected diplopia of 6 months’ duration or more may be compatible with driving if there is consultant support indicating satisfactory functional adaptation.
Belgium, 2002
Denmark, 2009
Finland, 2011
France, 2005
Germany, 2013
Greece, 2010
Ireland, 2013
Italy, 2011
Luxembourg, 2011
Netherlands, 2010
Portugal, 2012
Spain, 1997 Sweden, 2013
United Kingdom, 2013
Group 2
(continued on next page)
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Table 1 (continued ) Country
Group 1
Group 2
European Union, 2009 2009/113/EC Directive
Applicants for a driving licence, or for the renewal of such a licence, who have total functional loss of vision in one eye or who use only one eye (e.g. in the case of diplopia) must have a visual acuity of at least 0,5, with corrective lenses if necessary. The competent medical authority must certify that this condition of monocular vision has existed for a sufficiently long time to allow adaptation and that the field of vision in this eye meets the requirements. After any recently developed diplopia or after the loss of vision in one eye, there should be an appropriate adaptation period (for example, six months), during which driving is not allowed. After this period, driving is only allowed following a favorable opinion from vision and driving experts.
Driving licences shall not be issued or renewed.
et al., 2011), which is present in almost all western UE countries, with the exception of Germany and Sweden. In Germany the field of diplopia limits are described for group 2 drivers, whereas in Sweden driving is allowed if the patient has no diplopia inside the central 30 degrees of the visual field. Knowledge of the extent of diplopia would be theoretically be very important as a mild form of diplopia in extreme peripheral gaze might allow a safe and effective driving (Singh et al., 2011). As aforementioned, current EU legislations frequently do not specify such extent, thus creating a crucial dilemma: should all diplopic group 2 drivers have such an important prohibition, even if their diplopia is minimal? It would be helpful to have a method of quantifying severity of diplopia, particularly when evaluating recovery after the first injury or intervention. Most of the various methods available for assessing diplopia severity include questionnaires that obviously present a subjective bias, whereas other techniques (such as CROM) require special equipment and are limited to capturing a patient’s diplopia at a specific point in time on a specific day (Holmes et al., 2013). A revision of current regulations may be needed, but in the meantime we suggest that every patient who has suffered from a temporary or permanent diplopia undergoes an ophthalmological assessment before returning to drive. 5. Conclusion Ophthalmologists and maxillofacial/head and neck surgeons, may advise patients before hospital discharge about current legislations in their respective countries, reminding them that if they choose to ignore advice to cease driving, there could be consequences with respect to their insurance. Disclosure statement No disclosures. References Austria: Bundesrecht konsolidiert: Gesamte Rechtsvorschrift für Führerscheingesetz-Gesundheitsverordnung, Fassung vom 11.10.2013. Available online at: http://www.ris.bka.gv.at/GeltendeFassung.wxe?Abfrage¼Bundesnormen& Gesetzesnummer¼10012726; October 2013 Belgium: Normes minimales relatives à l’aptitude physique et psychique à la conduite d’un véhicule à moteur. Arrêté royal du 5 septembre 2002 modifiant l’arrêté royal du 23 mars 1998 relatif au permis de conduire et l’arrêté royal du 1er décembre 1975 portant règlement général sur la police de la circulation routière. Available online at: http://www.ejustice.just.fgov.be/cgi_loi/change_lg. pl?language¼fr&la¼F&table_name¼loi&cn¼2002090535; September 2002 Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Infraorbital nerve posttraumatic deficit and displaced zygomatic fractures: a double-center study. J Craniofac Surg 24: 2044e2046, 2013a Boffano P, Roccia F, Gallesio C, Karagozoglu KH, Forouzanfar T: Bicycle-related maxillofacial injuries: a double-center study. Oral Surg Oral Med Oral Pathol Oral Radiol 116: 275e280, 2014b
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S. Righi et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2014) 1e5 Ristow O, Pautke C, Kehl Victoria, Koerdt S, Schwärzler K, Hahnefeld L, et al: Influence of kinesiologic tape on postoperative swelling, pain and trismus after zygomatico-orbital fractures J Craniomaxillofac Surg. http://dx.doi.org/10.1016/ j.jcms.2013.05.043, 2013 Jul 4 pii: S1010e5182(13)00177-7 Roccia F, Boffano P, Guglielmi V, Forni P, Cassarino E, Nadalin J, et al: Role of the maxillofacial surgeon in the management of severe ocular injuries after maxillofacial fractures. J Emerg Trauma Shock 4: 188e193, 2011 Rutstein RP: Use of Bangerter filters with adults having intractable diplopia. Optometry 81: 387e393, 2010 Singh RP, Malik H, Carter LM: Driving advice for patients with double vision following zygomatico-orbital complex fractures. Br J Oral Maxillofac Surg 49: 586, 2011 Singh RP, Bhuva K, Bustin J, Carter LM: Diplopia, driving and DVLA. Br J Oral Maxillofac Surg 50: 791, 2012
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Spain: Real Decreto 772/1997, de 30 de mayo, por el que se aprueba el Reglamento General de Conductores. Available online at: https://www.boe.es/boe/dias/ 1997/06/06/pdfs/A17348-17393.pdf; June 1997. Sweden: Föreskrifter om ändring i Transportstyrelsens föreskrifter och allmänna råd (TSFS 2010:125) om medicinska krav för innehav av körkort m.m. (omtryck). Available online at: https://www.transportstyrelsen.se/tsfs/TSFS%202013_2.pdf; 2013 United Kingdom: Guide to the current medical standards of fitness to drive. Edition. Available online at: https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/232964/At_a_glance.pdf; 2013 White JE, Marshall SC, Diedrich-Closson KL, Burton AL: Evaluation of motor vehicle driving performance in patients with chronic diplopia. J AAPOS 5: 184e188, 2001
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