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Eur J Ophthalmol 2010 ; 20 ( 5 ): 892 - 901

Original Article

Cataract and pseudophakia in elderly European

drivers
Christian Nischler1, Ralph Michael2, Christine Wintersteller1, Patrick Marvan1, Martin Emesz1,
Laurentius J. Van Rijn3, Thomas J.T.P. van den Berg4, Helmut Wilhelm5, Tanja Coeckelbergh6,
Rafael I. Barraquer2, Gnther Grabner1, Wolfgang Hitzl1,7
1
Department of Ophthalmology, Paracelsus Private Medical University Salzburg, Salzburg - Austria
2
Institut Universitari Barraquer, Barcelona - Spain
3
Department of Ophthalmology, Vrije Universiteit Medical Centre, Amsterdam - Netherlands
4
Netherlands Ophthalmic Research Institute, Amsterdam - Netherlands
5
Department of Ophthalmology, University of Tbingen, Tbingen - Germany
6
Department of Ophthalmology, Universitair Ziekenhuis Antwerpen, Antwerpen - Belgium
7
Research Office, Paracelsus Private Medical University Salzburg, Salzburg - Austria

Purpose. To evaluate the prevalence and association of different types and severities of cataract or
pseudophakia with visual impairments in older European drivers.
Methods. In this prospective European multicenter study, 2211 active drivers, 45 years of age and
older, participated in an ophthalmologic examination, the measurement of visual functions, and were
asked to fill in the NEI-VFQ-25 and another questionnaire about driving habits, driving difficulties, and
self-reported accidents.
Results. Prevalence of moderate and severe forms of cataract in an active driving population is lower
than that in the general population, but could be found in both eyes in 20% (95% confidence interval
[CI] 16%25%) and 17% (95% CI:13%21%) of subjects 75 years of age and older. In addition, there
is a strong relationship between severity of cataract and parameters such as age, visual acuity, intrao-
cular straylight, and contrast sensitivity.
Conclusions. Cataract is not as highly prevalent in the elderly active driving population as in the general
population, but is frequently present in drivers over 65 years of age. Lower prevalence of severe bilate-
ral cataracts in countries with mandatory tests of visual functions of drivers suggest that this could be
a suitable measure to detect and to reduce the number of active drivers with severe bilateral cataracts.
(Eur J Ophthalmol 2010; 20: 892-901)

Key Words: Cataract, Contrast sensitivity, European drivers, Intraocular straylight

Accepted: January 14, 2010

Introduction older population. From 2000 to 2030, the number of re-

Older adults are the fastest growing age group in western
countries, and they tend to continue to drive automobiles
through late life (1, 2). Official population projections provi-
ded by EUROSTATthe Statistical Office of the European
Communitypredict a considerable increase of Europes
sidents over 70 years will increase by 48% in Germany,
50% in Norway, 54% in Greece, 55% in Switzerland, 80%
in Luxembourg, and 81% in the Netherlands (EUROSTAT,
Statistical Office of the European Communities 2005;
http://epp. eurostat.cec.eu.int/portal). In Austria, 1 out of
5 residents was over the age of 60 years in 2001, but it is

892 2010 Wichtig Editore - ISSN 1120-6721

Nischler et al
estimated that every third resident will be over 60 years
old in 2035 (3). These developments will lead to a large
variety of consequences for the European Unions health
and social system that cannot be neglected for diseases
with age-dependent prevalences.
Although responsible for a small percentage of overall
crashes, older people have crash rates that are 4 times
higher than those of middle-aged adults, after adjustment
for mileage (4). Several studies suggest that these higher
crash rates are due in part to deteriorating vision (5-7).
One of the most common causes for decreasing visual
function with age is cataract. Several population-based
studies showed that cataract is a highly prevalent condi-
tion among older persons. Early and late age-related lens
opacities were found in the Blue Mountains Eye Study in
46.8% and 21.6% and in the Beaver Dam Eye Study in
50.3% and 24.0% of persons between the ages of 65 and
74 years (8, 9). Both studies showed a prevalence of late
stages of cataract in persons of age 75 years and older of
more than 50%.
However, not much is known about the prevalence of ca-
taract in a population of active driving persons in Europe.
Studies have indicated that older drivers with cataract re-
port more driving difficulties than those without cataract
(10-12), and that they avoid visually challenging situations
such as driving at night, during inclement weather, and at
rush hour, or reduce their driving exposure (4, 10, 13, 14).
Furthermore, drivers with cataract are more likely to stop
driving compared with those without cataract (15). Howe-
ver, not all older drivers with cataract-related reduction of
vision stop driving. As we showed in a previous study of
cataract patients in Austria, 26% of drivers license hol-
ders who underwent cataract surgery and admitted to still
driving a motor vehicle had a legally unsatisfactory visual
acuity (16).
Therefore, it is the aim of this large prospective study to
evaluate the prevalence of cataract and pseudophakia
and their related changes of visual impairments in Euro-
pean drivers. This is important for assessing the relation
of vision impairments with driver safety and to understand
whether and how drivers with cataract of different intensi-
ties or types or pseudophakic drivers change their driving
behavior. Compared with most of the previous studies,
which were conducted on small, selective samples of pa-
tients, the relatively large number of observations used for
the present study should increase the generalizability and
validity of our findings.
2010 Wichtig Editore - ISSN 1120-6721
METHODS
In this prospective clinical study, 2211 drivers 45 years of
age and older were tested in 5 participating clinics of diffe-
rent European countries (Austria, Germany, Spain, Nether-
lands, and Belgium). Inclusion criteria were the possession
of a valid class 1 driving license and that participants con-
sidered themselves as active drivers, according to their
own judgment. We intended to recruit an equal number of
participants in the following age categories: 4554 years,
5564 years, 6574 years, or 75 years of age and older.
Subjects with a history of ocular surgery (n=48), corneal
scars (n=63), age-related macular degeneration (n=30),
diabetic retinopathy (n=48), retinal vascular occlusions
(n=15), glaucoma (n=43), or amblyopia (n=58) had to be
excluded from analysis of visual impairments, but not for
prevalence calculations. The study was approved by an
ethics committee (Tubingen, Germany) and conforms to
the provisions of the Declaration of Helsinki. Every parti-
cipant gave written informed consent and anonymity was
preserved.
Recruitment strategies
Participants were recruited among drivers in the general
population in a wide area around the 5 participating clinics.
For each clinic, the recruitment strategy was chosen that
best fitted with the particular circumstances in the invol-
ved clinic and the cultural circumstances in the involved
country with the aim to reduce selection bias as much as
possible. The most common methods of inclusion were as
follows: sending out letters to all inhabitants of one nei-
ghboring village (Salzburg), random selection of telephone
numbers in vicinity of clinic (Amsterdam), advertisement
in local newspaper (Tuebingen), recruitment at public pla-
ces (Antwerpen), and randomly by telephone contacted
volunteers from an automobile club (Barcelona). Subjects
recruited directly in a clinic or outpatient department were
excluded from prevalence calculations.
Slit-lamp examination and cataract grading
A slit-lamp examination of the anterior segment and the
lens and funduscopy were performed by an ophthalmolo-
gist to exclude abnormalities of the optic nerve head and
macular region. Cataracts were graded at the slit lamp
with respect to nuclear opalescence (NO: 0.16.9), nuclear
893
Cataract and pseudophakia in elderly European drivers
color (NC: 0.16.9), and cortical (C: 0.15.9) and posterior
subcapsular (P: 0.15.9) cataract, using the Lens Opacities
Classification System (LOCS) III (17). According to the ave-
rage LOCS III value (average of NO, NC, C, P), lens opaci-
ties were defined as no cataract (avLOCS<1.5), mild cata-
ract (1.5avLOCS<2), moderate cataract (2avLOCS<3),
and severe cataract (avLOCS3).
In addition, lens opacities were categorized into 5 groups
of different types. To compare outcome between different
types of cataracts, only cataracts with a defined range of
intensity were used for this evaluation: nuclear (2NO4,
2NC4, C<2, P1.5), cortical (NO<2, NC<2, 2C4,
P1.5), posterior subcapsular ((NO<2, NC<2, C<2,
1.5P4), mixed nuclear-cortical (2NO4, 2NC4,
2C4, P1.5), and mixed nuclear-cortical-posterior
subcapsular (2NO4, 2NC4, 2C4, 1.5P4). The son-Clopper intervals. The Kruskal-Wallis test was used to
presence of surgical aphakia or an intraocular lens was re-
corded as well as the presence of posterior capsule opa-
cification.
Vision measurement
Driving visual acuity (DVA) with habitual glasses and best-
corrected distance visual acuity (BCDVA) were measured
monocularly using the Early Treatment of Diabetic Retino-
pathy Study (ETDRS) chart (18). Both were determined as
the smallest completed line read correctly by the examinee
at a test distance of 4 meters and a constant luminance of
80 to 90 cd/m2, and expressed as logarithm of the minimal
angle of resolution (logMAR) units. Contrast sensitivity (CS)
was measured in each eye with the Pelli-Robson (PR) chart
and expressed as log (percentage contrast) (19). A compu-
terized straylight meter was used for measuring intraocular
straylight (IOSL). For the purpose of traffic studies, it has
been modified from the conventional straylight meter. Ma-
jor modifications included measurement by means of a 2
alternative force choice strategy and the inclusion of com-
puter routines to allow calculation of measurement quality
(20, 21). Trial glasses were provided according to the di-
stance correction of the subject, with a near addition ac-
cording to age. Each eye was measured twice. Data were
also expressed as log (straylight parameter).
Perceived driving disability and medical history
Subjects were asked to fill in 2 questionnaires. One que-
stionnaire that was used in previous studies (22, 23) was
894 2010 Wichtig Editore - ISSN 1120-6721
about driving habits, driving difficulties, and self-reported
accidents. The other questionnaire was the NEI-VFQ-25
about quality of life and quality of vision (24, 25). In ad-
dition, all subjects were asked for a brief medical and
ophthalmologic history.
Statistical analysis
Analysis of variance (ANOVA) was used to test for signi-
ficant differences between means. Categorized whisker
plots together with 95% confidence intervals (CI) for the
corresponding means were used to illustrate results. Pear-
son chi square tests were used to test for significance of
the relationship between categorical variables. 95% CIs for
age-specific prevalences were computed based on Pear-
compare 3 or more samples as a nonparametric alternative
to one-way (between-groups) ANOVA for continuous and
ordinal scaled variables. The Z-test was used to test for
significance between 2 sample proportions. All results of
statistical analysis refer to right eyes. If left eyes differed
significantly, these differences were reported. All statisti-
cal analyses and illustrations were done with STATISTICA
6.0 (StatSoft, Inc., STATISTICA for Windows, Tulsa, OK:
StatSoft, Inc., 1999.).
Results
Prevalence of cataract and pseudophakia
Figure 1 shows the frequencies of different types of cata-
ract and their overlap in our study population. The most
common type of cataract in active driving persons of ol-
dest age category IV was a nuclear opacification of the
lens (NO2), which could be found in 68% of female and
80% of male participants (Tab. I). A cortical opacification
(CO) of 2 in the LOCS III classification system could be
detected in 56% (female) and 68% (male) and posterior
subcapsular cataract of a intensity 2 in 12% (female) and
36% (male) of the oldest age category. For all 3 types of
lens opacification, a positive relation between age and pre-
valence could be found, indicating increasing prevalence
with increasing age. In age categories IIIV, more male than
female persons could be recruited.
In addition, we categorized eyes of examined subjects by
Nischler et al

II (5564 years), a significant increase of persons with the-

se intensities of cataract could be found in persons over 64
years of age. Prevalence of moderate and severe cataracts
on both eyes in age category IV (75 years and more) was
20% (95% CI 16%25%) and 17% (95% CI 13%21%).
Bilateral pseudophakia could be found in 16% (95% CI
12%20%) of active drivers in age category IV.

Differences between European countries

Overall prevalence of severe cataracts in both eyes of acti-

Fig. 1 - Frequencies of different types of cataract and their overlap
in our study population.
cataract severity according to the mean LOCS III value.
Table II shows the overall prevalence of cataract of diffe-
rent severities and the prevalence of pseudophakic eyes
in European drivers by age. Whereas moderate (2avLO-
CS<3) and severe (avLOCS3) cataracts were observed
very rarely in participants of age category I (4554 years) or
ve drivers 45 years of age and older differed between Euro-
pean countries. Amsterdam (0.8%) and Barcelona (1.6%)
detected an about 6 times lower prevalence of dense bi-
lateral lens opacities than Antwerpen (4.7%), Tuebingen
(6.5%), and Salzburg (7.6%).
It is of importance to note that in the Netherlands (over 70
years of age) and in Spain (every 10 years under the age of
45, every 5 years between 45 and 60 years, and every 2 ye-
ars over 60 years of age), regular test procedures for visual
functions of drivers are obligatory. Prevalence of bilateral
pseudophakia in active drivers of age category IIV was lo-
west in Salzburg (2.5%) and highest in Amsterdam (6.1%).

TABLE I - NUMBER OF ACTIVE DRIVERS [PREVALENCE (%)] WITH LENS OPACITIES BY AGE AND SEX

LOCS III Nuclear opalescence Cortical opalescence Posterior subcapsular opalescence

and age
No. No. (%) female No. No. (%) male No. No. (%) female No. No. (%) male No. No. (%) female No. No. (%) male

2.0 <3.0
4554 323 44 (13.6) 293 38 (13.0) 323 25 (7.7) 291 40 (13.7) 240 4 (1.7) 222 3 (1.4)
5564 296 79 (26.7) 355 106 (29.9) 296 68 (23.0) 355 84 (23.7) 233 16 (6.9) 276 20 (7.2)
6574 179 58 (32.4) 268 93 (34.7) 178 49 (27.5) 266 113 (42.5) 153 17 (11.1) 200 35 (17.5)
75 79 23 (29.1) 151 46 (30.5) 79 27 (34.2) 151 60 (39.7) 71 15 (21.1) 132 35 (26.5)
3.0 <4.0
4554 6 (1.9) 7 (2.4) 0 (0.0) 0 (0.0) 1 (0.3) 1 (0.3)
5564 29 (9.8) 25 (7.0) 10 (3.4) 11 (3.1) 1 (0.3) 3 (0.8)
6574 34 (19.0) 50 (18.7) 18 (10.1) 29 (10.9) 5 (1.9) 7 (2.6)
75 21 (26.6) 44 (29.1) 11 (13.9) 34 (22.5) 1 (0.7) 17 (11.3)
4.0
4554 0 (0.0) 1 (0.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
5564 5 (1.7) 6 (1.7) 0 (0.0) 1 (0.3) 1 (0.3) 1 (0.3)
6574 14 (7.8) 19 (7.1) 7 (3.9) 2 (0.8) 3 (1.1) 0 (0.0)
75 10 (12.7) 31 (20.5) 6 (7.6) 9 (6.0) 2 (1.3) 3 (2.0)
2.0
4554 50 (15.5) 46 (15.7) 25 (7.7) 40 (13.7) 5 (1.7) 4 (1.4)
5564 113 (38.2) 137 (38.6) 78 (26.4) 96 (27.0) 18 (5.1) 24 (6.8)
6574 106 (59.2) 162 (60.4) 74 (41.6) 144 (54.1) 25 (9.4) 42 (15.8)
75 54 (68.4) 121 (80.1) 44 (55.7) 103 (68.2) 18 (11.9) 55 (36.4)

LOCS = Lens Opacities Classification System.

2010 Wichtig Editore - ISSN 1120-6721 895

Cataract and pseudophakia in elderly European drivers
mild cataract
mild cataract
Association between cataract or pseudophakia
and visual functions
Cataract intensity or pseudophakia.With or without age
adjustment, we found significant differences (p<0.01) for all
groups of cataract of different severity, in DVA, BCDVA, IOSL,
PR, and age (Fig. 2). Additionally, within each group a signifi-
cant difference (p<0.0001) between DVA and BCDVA existed.
BCDVA in the no and mild cataract group was on average
0.07 logMAR units lower than the DVA and in the moderate
and severe cataract group on average 0.10 logMAR units.
Visual functions of pseudophakic eyes did not differ from
eyes with moderate (2avLOCS<3) cataract severity, whe-
reas mean age was similar to subjects with severe forms of
cataract. The outcome of visual functions test of persons
with recorded posterior capsule opacification (PCO) (n=16)
did not significantly differ from that of persons without PCO
(n=68) or persons with reported YAG laser capsulotomy in
the past (n=12) (data not shown).
Cataract type.In unadjusted groups, no statistically signi-
ficant differences on visual impairments between different
types of cataract could be found. However, after adjustment
896 2010 Wichtig Editore - ISSN 1120-6721
Fig. 2 - Age, driving, and best-
corrected distance visual acu-
ity, intraocular straylight, and
contrast sensitivity of right
eyes differed significantly
between groups of different
cataract severity. Pseudopha-
kic eyes performed similarly to
eyes with moderate cataract.
mild cataract
mild cataract
of groups by cataract intensity (Fig. 3), several significant
differences were found. Nuclear cataracts had a significan-
tly (p<0.0001) better DVA, BCDVA, and IOSL than mixed
cataracts and better values of CS than nuclear-cortical-po-
sterior subcapsular cataracts (p<0.0001). In addition, pure
cortical cataracts differed significantly (p=0.005) from mi-
xed cataracts in DVA and BCDVA and from mixed cataracts
with posterior subcapsular component in IOSL (p<0.0001)
and CS (p=0.03). Posterior subcapsular cataracts showed
significantly better values of BCDVA (p=0.049) than mixed
cataracts and better values of CS (p<0.0001) than mixed ca-
taracts with posterior subcapsular component. In addition,
persons with mixed cataract with posterior subcapsular opa-
cities showed a significantly (p<0.0001) worse performance
at the Pelli-Robson CS chart than those without. Only 23
participants with pure posterior subcapsular cataract who
had the lowest mean age (57 years [95% CI 5461]) of all
groups (p<0.001) were recruited.
Driving behavior and NEI-VFQ-25 questionnaire
Cataract severity and pseudophakia.The age-corrected
Table III compares the driving behavior of persons with dif-
Nischler et al

Fig. 3 - Age, driving, and best-

corrected distance visual acu-
ity, intraocular straylight, and
contrast sensitivity of right
eyes differed significantly
between some types of cata-
ract. For this evaluation, only
cataracts with a defined range
of intensity were used.

TABLE II - NUMBER OF ACTIVE DRIVERS [PREVALENCE (%)] WITH CATARACT OR PSEUDOPHAKIA BY SEVERITY OF
CATARACT AND AGE

Cataract classification (LOCS III) Age I (4554 y), Age II (5564 y), Age III (6574 y), Age IV (75 y), All (45 y),
n (%) n (%) n (%) n (%) n (%)

No cataract (<1.5)
OD 508 (82.5) 361 (55.0) 144 (29.1) 51 (15.6) 1064 (50.9)
OS 501 (81.3) 361 (55.0) 144 (29.1) 56 (17.2) 1062 (50.8)
OU 491 (79.7) 343 (52.3) 135 (27.3) 43 (13.2) 1012 (48.4)
Mild cataract (1.5 <2)
OD 84 (13.6) 178 (27.1) 134 (27.1) 42 (12.9) 438 (20.9)
OS 84 (13.6) 179 (27.3) 128 (25.9) 39 (12.0) 430 (20.6)
OU 75 (12.2) 175 (26.7) 116 (23.5) 27 (8.3) 393 (18.8)
Moderate cataract (2 <3)
OD 17 (2.8) 93 (14.2) 128 (25.9) 92 (28.2) 330 (15.8)
OS 18 (2.9) 94 (14.3) 135 (27.3) 85 (26.1) 332 (15.9)
OU 14 (2.3) 79 (12.0) 114 (23.1) 66 (20.2) 273 (13.0)
Severe cataract (3)
OD 1 (0.2) 4 (0.6) 49 (9.9) 67 (20.6) 121 (5.8)
OS 1 (0.2) 6 (0.9) 49 (9.9) 72 (22.1) 128 (6.1)
OU 1 (0.2) 4 (0.6) 41 (8.3) 55 (16.9) 101 (4.8)
Pseudophakia
OD 2 (0.3) 7 (1.1) 37 (7.5) 66 (20.2) 112 (5.4)
OS 4 (0.6) 8 (1.2) 36 (7.3) 67 (20.6) 115 (5.5)
OU 2 (0.3) 5 (0.8) 28 (5.7) 52 (16.0) 87 (4.2)

LOCS = Lens Opacities Classification System; OD = right eye; OS = left eye; OU = both eyes.

2010 Wichtig Editore - ISSN 1120-6721 897

Cataract and pseudophakia in elderly European drivers

ferent intensities of lens opacities or pseudophakia in both
eyes. Increasing density of cataract resulted in a significant
(p<0.01) reduction of kilometers driven per year and a re-
duction of self-reported driving speed. Driving during bad
weather or at night causes problems for about half of all
the subjects, with no difference between groups.
Self-reported accident rate of persons with bilateral severe
forms of cataract did not differ significantly from all other
groups. Participants with bilateral severe cataract or pseu-
dophakia had the highest self-reported accident rate, with
4.3 accidents per million driven kilometers. Additionally, it
is of interest to note that the percentage of subjects who
did not answer the question about involvement in traffic
accidents, but did answer the other questions of the dri-
ving habits questionnaire, was also the highest in the se-
vere cataract and pseudophakic group. Driving behavior of
persons with bilateral pseudophakic eyes was, even after
age adjustment, related to reduced kilometers per year and
more frequently reported accidents per driven million kilo-
meters, but not related to subjective difficulties in parking
or driving during rush hour and not related to self-reported
reduced speed.
In the NEI-VFQ-25 questionnaire, statistically significant
differences (Pearson chi square) between different groups
of cataract severity could be found for questions about
general health (p<0.0001), general vision (p<0.0001), dif-
ficulties seeing and enjoying programs on TV (p<0.03), li-
mitations in kinds of activities the persons can participate
in because of vision (p<0.02), and staying in home alone
because of the persons eyesight (p<0.004).
Cataract type.With or without adjustment for age or cata-
ract intensity, no statistically significant difference between
groups was found for questions about driving behavior or
the NEI-VFQ-25 questionnaire (data not shown).
DISCUSSION
The development of lens opacities is a concomitant of
aging in every human population study. Up until now, our
knowledge about prevalence of cataract in a population
is based mainly on 4 major studies that were not perfor-
med in European countries: The Blue Mountains Study, the
Melbourne Visual Impairment Project, the Beaver Dam Eye
Study, and the Framingham Eye Study (8, 9, 26, 27). Ho-
wever, very little is known about the prevalence of cataract
and pseudophakia and their effects on visual functions and
driving behavior in an active driving population.
The strengths of this study are the high number of inclu-
ded subjects and the participation of different clinics in a
variety of European countries. If we compare our results,
found in active drivers, with prevalence studies of cataract
in the general population, which used different cataract
grading methods, we can find similar results for frequen-
cy of mild/early cataract in patients between the ages of

TABLE III - DRIVING HABITS AND DRIVING DIFFICULTIES OF SUBJECTS WITH THE SAME INTENSITY OF LENS OPACIFICA-
TION IN BOTH EYES AFTER CORRECTION FOR AGE, MEAN (95% CONFIDENCE INTERVAL)

Cataract severity (OU) Km per year, Accidents Reduced Bad Self-reported driving Night
(LOCS III) mean per million speed weather difficulties
km
Parking Highway Rush hour

No cataract (<1.5) 12,000 3.2 (3.4*) 7 40 6 5 13 41

(10,00015,000) (2.93.6) (410) (3545) (48) (37) (1016) (3746)
Mild cataract (1.5 <2) 10,000 2.9 (3.2*) 9 38 9 5 11 48
(800013,000) (2.63.3) (514) (3244) (612) (28) (715) (4353)
Moderate cataract (2 <3) 8500 2.6 (3.1*) 18 38 15 4 15 56
(700010,000) (2.33.0) (1422) (3145) (1119) (27) (1120) (4963)
Severe cataract (3) 8000 4.3 (4.8*) 28 42 9 8 18 45
(700010,000) (3.64.9) (2132) (3252) (315) (215) (1126) (3655)
Pseudophakia 7800 4.3 (5.0*) 15 50 9 7 15 47
(65009000) (3.35.2) (921) (3862) (216) (012) (723) (3659)

*Indicates corrected number of accidents per million driven kilometers when subjects who did not answer this question but did answer all other questions were
counted.
LOCS = Lens Opacities Classification System; OD = right eye; OS = left eye; OU = both eyes.

898 2010 Wichtig Editore - ISSN 1120-6721

Nischler et al
45 and 64 years. However, our results clearly demonstrate
that advanced stages of cataract in drivers have a preva-
lence that is significantly lower than that in the general po-
pulation. Vision impairment by dense cataract could also
be a reason to abandon driving, which seems to be more
likely for female subjects and for inhabitants of countries
with mandatory visual function tests for drivers. Whether
they stopped driving by their own judgment or they had
to stop because of not passing tests for visual functions
which have to be performed regularly and are obligatory in
counties like Spain or the Netherlands could not be evalua-
ted in this study.
Cataract classification was performed in our study without
pupillary dilatation, which could lead to an underestimation
of cataract severity, especially for cortical and posterior
subcapsular types of cataract.
As we show in this study, there is a strong correlation
between impairment of visual functions and intensity of
lens opacification independent of age. In addition to other
studies, we showed that visual acuity alone is not always
well related to vision impairment. Other aspects of visual
functions (IOSL, CS) may be as important even with reaso-
nably good visual acuity (28-30).
Interestingly, patients with pseudophakic eyes showed
comparable performance on visual function tests as per-
sons with moderate cataract severity. One would expect
that after cataract surgery and implantation of a clear lens,
visual functions of this group would be much better than
we found. The main reasons for this limited improvement
or decrease of visual functions after cataract surgery are
pseudophakia-related changes, such as posterior capsular
fibrosis or intraocular lens decentration, and most impor-
tantly age-related changes of the eye. Decreasing visual
functions with age are not only lenticular of origin, but also
influenced by age-related pigmentation changes, such as
migration of uveal pigment from iris, or loss of melanin in
the retinal pigment epithelium (31-33). In a previous study,
we showed that noncataractous straylight values increa-
se strongly with age to the power of 4 (34). On average,
straylight doubles in noncataractous eyes by the age of 65
years and triples by the age of 77 years as compared with
the young eye (34). Therefore it is not surprising that the
pseudophakic group with a mean age of 76 years does not
have similar visual functions as our no cataract group with
a mean age of 59 years. If we compare visual functions of
the noncataractous age group IV (mean age of 77 years)
with the pseudophakic group we do not find any differen-
2010 Wichtig Editore - ISSN 1120-6721
ces in BCDVA (0.06 vs 0.05 logMAR), intraocular straylight
(1.29 vs 1.27 log [IOSL]), or contrast sensitivity (1.47 vs
1.48 log [PR]), underscoring that reduced visual functions
in pseudophakic eyes are mainly age-related.
Because lens opacities are heterogeneous, which could
influence the optical quality of the retinal image and con-
sequently visual functions, we additionally evaluated our
data according to different types of cataract. We have
found statistically significant differences in visual impai-
rment between nuclear or cortical types of cataract and
mixed types of cataract. Mean values between nuclear
and cortical or posterior subcapsular cataracts differed for
all evaluated visual functions, but were not statistically si-
gnificant. However, the infrequent occurrence of pure PSC
(only 23 eyes were available for this study) suggests that
the data relating to this type of cataract must be interpre-
ted cautiously.
Differences of visual function between different types of ca-
taracts have been shown in many studies (35-39). Several
studies suppose that a perfectly uniform, constant density
of a medium, often seen in nuclear opacities, exhibits only
a small amount of scattered light away from the forward
direction (40). However, in cortical or posterior subcapsular
opacities, the medium contains more special fluctuations
in density, discontinuities in the refractive index, or sharp
limited ruptures of lens fibers, which can lead to a signi-
ficant increase in light scatter, and consecutively decrea-
se of visual functions (40, 41). Additionally, the correlation
between forward scatter that causes disability glare and
backscatter derived from slit-lamp image seems to be low.
Backscatter is clearly largest for nuclear cataract, but very
small for cortical, and intermediate for posterior subcapsu-
lar cataract (42).
Contrary to a report of Owsley et al., we could not detect
any significant difference between crash rates of subjects
with severe bilateral cataract and bilateral pseudophakia
(5). Although these 2 groups did not differ in age, driven
kilometers per year, or reported difficulties during challen-
ging driving situations, they differed significantly in visual
functions and subjectively estimated speed compared to
the other traffic. It seems that the high self-reported crash
rate we found in pseudophakic patients results from lower
self-awareness of driving difficulties due to improved vi-
sual functions after cataract surgery, which may result in
driving at higher speed, one common risk factor for vehicle
accidents in general (43).
In summary, we found that cataract is not as highly pre-
899
Cataract and pseudophakia in elderly European drivers
valent in the elderly active driving population than in the
general population, but is still very frequent in drivers over
the age of 65 years. Interestingly, there were significant dif-
ferences in prevalence of bilateral severe forms of cataract
in active drivers between European countries. The regular
and mandatory testing of visual functions of active drivers
in Spain and the Netherlands seems to result in a signi-
ficantly lower percentage of drivers with severe forms of
bilateral cataract that impaired visual functions greatly. In
order to detect and reduce the number of these impaired
active drivers in other countries, regular and mandatory
eye examinations of drivers performed by ophthalmolo-
gists should be considered.
ACKNOWLEDGEMENTS
This study was supported by grant SUB-B27020B-E3-GLA-
RE-2002-S07.18091 from the European Commission. The
REFERENCES
1. Eberhard JW. Driving is transportation for most older adults.
Geriatrics 1998; 53 (Suppl 1): S53-5.
2. Foley DJ, Heimovitz HK, Guralnik JM, Brock DB. Driving life
expectancy of persons aged 70 years and older in the United
States. Am J Public Health 2002; 92: 1284-9.
3. Statistics Austria. Bevoelkerung Oesterreichs im 21 Jahrhun-
dert. Statistische Nachrichten 2004; 12: 1030-4.
4. Freeman EE, Munoz B, Turano KA, West SK. Measures of
visual function and their association with driving modification
in older adults. Invest Ophthalmol Vis Sci 2006; 47: 514-20.
5. Owsley C, McGwin G Jr, Sloane M, Wells J, Stalvey BT, Gau-
theraux S. Impact of cataract surgery on motor vehicle crash
involvement by older adults. JAMA 2002; 288: 841-9.
6. Owsley C, McGwin G Jr, Ball K. Vision impairment, eye dis-
ease, and injurious motor vehicle crashes in the elderly. Oph-
thalmic Epidemiol 1998; 5: 101-13.
7. Owsley C, Stalvey BT, Wells J, Sloane ME, McGwin G Jr. Vi-
sual risk factors for crash involvement in older drivers with
cataract. Arch Ophthalmol. 2001; 119: 881-7.
8. Klein BEK, Klein R, Linton KLP. Prevalence of age-related
lens opacities in a population: the Beaver Dam Eye Study.
Ophthalmology 1992; 99: 546-52.
9. Mitchell P, Cumming RG, Attebo K, Panchapakesan J. Preva-
lence of cataract in Australia. Ophthalmology 1997; 104: 581-8.
10. Owsley C, Stalvey B, Wells J, Sloane ME. Older drivers and
900 2010 Wichtig Editore - ISSN 1120-6721
Salzburg part was supported by the Ernst Fuchs Stiftung. The
Belgian part was supported and the Dutch part cosupported
by Pearle BV. The German part was cosupported by Vistech
GmbH. The RACC Automvil Club supported recruitment of
subjects in Barcelona.
The Netherlands Ophthalmic Research Institute has a proprietary in-
terest in the straylight meter. None of the authors has any proprietary
or financial interest in any of the tests that were used or in any of the
results that were obtained in this study.
Address for correspondence:
Christian Nischler, MD
Department of Ophthalmology
Paracelsus Medical University Salzburg
Muellner Hauptstrasse 48
5020 Salzburg, Austria
c.nischler@salk.at
cataract: driving habits and crash risk. J Gerontol Med Sci
1999; 54: M203-11.
11. McGwin G, Chapman V, Owsley C. Visual risk factors for driv-
ing difficulty among older drivers. Accid Anal Prev 2000; 32:
735-44.
12. Mangione CM, Phillips RS, Seddon JM, et al. Development of
the activities of daily vision scale: a measure of visual func-
tional status. Med Care 1992; 30: 1111-26.
13. Ball K, Owsley C, Stalvey B, Roenker DL, Graves M. Driving
avoidance and functional impairment in older drivers. Accid
Anal Prev 1998; 30: 313-22.
14. Szlyk JP, Seiple W, Viana M. Relative effects of age and com-
promised vision on driving performance. Hum Factors 1995;
37: 430-6.
15. Marottoli RA, Mendes de Leon CF, Glass TA, et al. Driving
cessation and increased depressive symptoms: prospec-
tive evidence from the New Haven EPESE. J Am Geriatr Soc
1997; 45: 202-6.
16. Ruckhofer J, Grabner G. Driving behavior of patients before
cataract operation - is an unlimited drivers license justifiable?
Results of an analysis of 1,124 patients of the ophthalmology
department of a central hospital. Klin Monatsbl Augenheilkd
1998; 212: 106-10.
17. Chylack LT Jr, Wolfe JK, Singer DM, et al. The lens opacities
classification system III. The Longitudinal Study of Cataract
Study Group. Arch Ophthalmol 1993; 111: 831-6.
18. Ferris FL, Kassoff A, Bresnick GH, Bailey IL. New visual acu-
Nischler et al
ity charts for clinical research. Am J Ophthalmol 1982; 94:
91-6.
19. Pelli DG, Robson JG, Wilkins AJ. The design of a new letter
chart for measuring contrast sensitivity. Clin Vis Sci 1988; 2:
187-99.
20. Van den Berg TJTP, Coppens JE, Franssen L. New Approach
for Retinal Straylight Assessment: Compensation Compari-
son. Invest Ophthalmol Vis Sci 2005; 46: E-Abstract 4315.
21. Franssen L, Coppens JC, van den Berg TJTP. Compensa-
tion comparison method for assessment of retinal straylight.
Invest Ophthalmol Vis Sci 2006; 47: 768-76.
22. Nischler C, Emesz M, Hufnagl C, et al. Driving habits of pa-
tients with glaucoma. Klin Monatsbl Augenheilkd 2005; 222:
1002-7.
23. Emesz M, Egger SF, Nitsch S, Ruckhofer J, Hitzl W, Grabner
G. Automobile drivers with retinal diseases: a prospective
analysis. Klin Monatsbl Augenheilkd 2001; 218: 670-6.
24. Mangione CM, Lee PP, Gutierrez PR, et al. Development of
the 25-item National Eye Institute Visual Function Question-
naire. Arch Ophthalmol 2001; 119: 1050-8.
25. Mangione CM, Lee PP, Pitts J, et al. Psychometric properties
of the National Eye Institute Visual Function Questionnaire
(NEI-VFQ). NEI-VFQ Field Test Investigators. Arch Ophthal-
mol 1998; 116: 1496-504.
26. Kahn HA, Leibowitz HM, Ganlez JP, et al. The Framingham
Eye Study: outline and major prevalence findings. Am J Epi-
demiol 1977; 106: 17-41.
27. Livingston PM, Carson CA, Stanislavsky YL, Lee SE, Guest
CS, Taylor HR. Methods for a population-based study of eye
disease: the Melbourne visual impairment project. Ophthal-
mic Epidemiol 1994; 1: 139-48.
28. Van Rijn LJ, Nischler C, Gamer D, et al. Measurement of stray
light and glare: comparison of Nyktotest, Mesotest, stray
light meter, and computer implemented stray light meter. Br J
Ophthalmol 2005; 89: 345-51.
29. Rubin GS, Adamsons IA, Stark WJ. Comparison of acuity,
contrast sensitivity, and disability glare before and after cata-
ract surgery. Arch Ophthalmol 1993; 111: 56-61.
30. Meacock WR, Spalton DJ, Boyce J, Marshall J. The effect
of posterior capsule opacification on visual function. Invest
Ophthalmol Vis Sci 2003; 44: 4665-9.
on line
This paper has been selected to appear on the
EJOWEB page free of charge
www.eur-j-ophthalmol.com
2010 Wichtig Editore - ISSN 1120-6721
View publication stats
31. Ijspeert JK, de Waard PWT, van den Berg TJTP, de Jong
PTVM. The intraocular straylight function in 129 healthy vol-
unteers; dependence on angle, age and pigmentation. Vision
Res 1990; 30: 699-707.
32. Van den Berg TJTP, Ijspeert JK, de Waard PWT, Meire F.
Functional quantification of diaphany. Doc Ophthalmol 1990;
75: 239-46.
33. Sarna T, Burke JM, Korytowski W, et al. Loss of melanin from
human RPE with aging: possible role of melanin photooxida-
tion. Exp Eye Res 2003; 76: 89-98.
34. Van den Berg TJTP, Van Rijn LJ, Michael R, et al. Straylight ef-
fects with aging and lens extraction. Am J Ophthalmol 2007;
144: 358-63.
35. Stifter E, Sacu S, Weghaupt H, et al. Reading performance
depending on the type of cataract and its predictability on the
visual outcome. J Cataract Refract Surg 2004; 30: 1259-67.
36. Stifter E, Sacu S, Benesch T, Weghaupt H. Impairment of
visual acuity and reading performance and the relationship
with cataract type and density. Invest Ophthalmol Vis Sci
2005; 46: 2071-5.
37. Stifter E, Sacu S, Weghaupt H. Functional vision with cata-
racts of different morphologies: Comparative study. J Cata-
ract Refract Surg 2004; 30: 1883-91.
38. Maraini G, Rosmini F, Graziosi P, et al, and the Italian Ameri-
can Study Group. Influence of type and severity of pure forms
of age-related cataract on visual acuity and contrast sensitiv-
ity. Invest Ophthalmol Vis Sci 1994; 35: 262-7.
39. Rouhiainen P, Rouhiainen H, Salonen JT. Contrast sensitiv-
ity in different types of early lens opacities. Acta Ophthalmol
Scand 1996; 74: 379-83.
40. Pau H. Cortical and subcapsular cataracts: Significance of
physical forces. Ophthalmologica. 2006; 220: 1-5.
41. Tang D, Borchman D, Schwarz AK, et al. Light scattering
of human lens vesicles in vitro. Exp Eye Res 2003; 76:
605-12.
42. De Waard PWT, Ijspeert JK, Van den Berg TJTP, De Jong
PTVM. Intraocular light scattering in age-related cataracts.
Invest Ophthalmol Vis Sci 1992; 33: 618-25.
43. Blows S, Ameratunga S, Ivers RQ, Lo SK, Norton R. Risky
driving habits and motor vehicle driver injury. Accid Anal
Prev 2005; 37: 619-24.
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