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The impact of presbyopic spectacles and
contact lenses on driving performance
Byoung Sun Chu
Dip (Optom), BEng, MOptom, FIACLE
Thesis submitted to fulfill the requirements of
Doctor of Philosophy
School of Optometry & Institute of Health and Biomedical Innovation
Queensland University of Technology
Brisbane, Australia
2010
Vision & Driving Research, School of Optometry, QUT
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Statement of original authorship
The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the
best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made.
Signed ………………………………….………………………. Date ………………………………….……………………….
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Abstract
Presbyopia affects individuals from the age of 45 years onwards, resulting in difficulty in
accurately focusing on near objects. There are many optical corrections available
including spectacles or contact lenses that are designed to enable presbyopes to see
clearly at both far and near distances. However, presbyopic vision corrections also
disturb aspects of visual function under certain circumstances. The impact of these
changes on activities of daily living such as driving are, however, poorly understood.
Therefore, the aim of this study was to determine which aspects of driving performance
might be affected by wearing different types of presbyopic vision corrections. In order
to achieve this aim, three experiments were undertaken.
The first experiment involved administration of a questionnaire to compare the
subjective driving difficulties experienced when wearing a range of common presbyopic
contact lens and spectacle corrections. The questionnaire was developed and piloted,
and included a series of items regarding difficulties experienced while driving under day
and night-time conditions. Two hundred and fifty five presbyopic patients responded to
the questionnaire and were categorised into five groups, including those wearing no
vision correction for driving (n = 50), bifocal spectacles (BIF, n = 54), progressive
addition lenses spectacles (PAL, n = 50), monovision (MV, n = 53) and multifocal contact
lenses (MTF CL, n = 48). Overall, ratings of satisfaction during daytime driving were
relatively high for all correction types. However, MV and MTF CL wearers were
significantly less satisfied with aspects of their vision during night-time than daytime
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driving, particularly with regard to disturbances from glare and haloes. Progressive
addition lens wearers noticed more distortion of peripheral vision, while BIF wearers
reported more difficulties with tasks requiring changes in focus and those who wore no
vision correction for driving reported problems with intermediate and near tasks.
Overall, the mean level of satisfaction for daytime driving was quite high for all of
the groups (over 80%), with the BIF wearers being the least satisfied with their
vision for driving. Conversely, at night, MTF CL wearers expressed the least
satisfaction.
Research into eye and head movements has become increasingly of interest in
driving research as it provides a means of understanding how the driver responds to
visual stimuli in traffic. Previous studies have found that wearing PAL can affect eye
and head movement performance resulting in slower eye movement velocities and
longer times to stabilize the gaze for fixation. These changes in eye and head
movement patterns may have implications for driving safety, given that the visual tasks
for driving include a range of dynamic search tasks. Therefore, the second study was
designed to investigate the influence of different presbyopic corrections on driving-
related eye and head movements under standardized laboratory-based conditions.
Twenty presbyopes (mean age: 56.1 ± 5.7 years) who had no experience of wearing
presbyopic vision corrections, apart from single vision reading spectacles, were
recruited. Each participant wore five different types of vision correction: single
vision distance lenses (SV), PAL, BIF, MV and MTF CL. For each visual condition,
participants were required to view videotape recordings of traffic scenes, track a
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reference vehicle and identify a series of peripherally presented targets while their
eye and head movements were recorded using the faceLAB® eye and head tracking
system. Digital numerical display panels were also included as near visual stimuli
(simulating the visual displays of a vehicle speedometer and radio). The results
demonstrated that the path length of eye movements while viewing and
responding to driving-related traffic scenes was significantly longer when wearing
BIF and PAL than MV and MTF CL. The path length of head movements was greater
with SV, BIF and PAL than MV and MTF CL. Target recognition was less accurate
when the near stimulus was located at eccentricities inferiorly and to the left, rather
than directly below the primary position of gaze, regardless of vision correction
type.
The third experiment aimed to investigate the real world driving performance of
presbyopes while wearing different vision corrections measured on a closed-road
circuit at night-time. Eye movements were recorded using the ASL Mobile Eye, eye
tracking system (as the faceLAB® system proved to be impractical for use outside of
the laboratory). Eleven participants (mean age: 57.25 ± 5.78 years) were fitted with
four types of prescribed vision corrections (SV, PAL, MV and MTF CL). The measures
of driving performance on the closed-road circuit included distance to sign
recognition, near target recognition, peripheral light-emitting-diode (LED)
recognition, low contrast road hazards recognition and avoidance, recognition of all
the road signs, time to complete the course, and driving behaviours such as braking,
accelerating, and cornering. The results demonstrated that driving performance at
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night was most affected by MTF CL compared to PAL, resulting in shorter distances
to read signs, slower driving speeds, and longer times spent fixating road signs.
Monovision resulted in worse performance in the task of distance to read a signs
compared to SV and PAL. The SV condition resulted in significantly more errors
made in interpreting information from in-vehicle devices, despite spending longer
time fixating on these devices. Progressive addition lenses were ranked as the most
preferred vision correction, while MTF CL were the least preferred vision correction
for night-time driving.
This thesis addressed the research question of how presbyopic vision corrections
affect driving performance and the results of the three experiments demonstrated
that the different types of presbyopic vision corrections (e.g. BIF, PAL, MV and MTF
CL) can affect driving performance in different ways. Distance-related driving tasks
showed reduced performance with MV and MTF CL, while tasks which involved
viewing in-vehicle devices were significantly hampered by wearing SV corrections.
Wearing spectacles such as SV, BIF and PAL induced greater eye and head
movements in the simulated driving condition, however this did not directly
translate to impaired performance on the closed- road circuit tasks.
These findings are important for understanding the influence of presbyopic vision
corrections on vision under real world driving conditions. They will also assist the
eye care practitioner to understand and convey to patients the potential driving
difficulties associated with wearing certain types of presbyopic vision corrections
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and accordingly to support them in the process of matching patients to optical
corrections which meet their visual needs.
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Key words
Vision and driving
Presbyopia
Presbyopic vision correction
Progressive addition lenses
Bifocal spectacle lenses
Monovision
Multifocal contact lenses
Eye and head movements
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Acknowledgments
“Are you ready?” ………. “Are you ready?” ……….
There was one person saying “Are you ready?” using a walki-talki on every
single night of our experiments. It was simply to confirm whether our team
was ready to go, but it means much more for me as from it I can feel the
passion and dedication of Professor Joanne Wood towards the research.
Passion, dedication, encouragement and generosity!
These are the words which describe my supervisors, Professor Joanne Wood and
Professor Michael Collins. My tentative ideas for a research project in the beginning
of this journey would never have been brought to fruition without their support and
wisdom and it has been a privilege to work with them. Thanks again to Joanne for
your dedication, helping me collect data until very late at night and guiding me to
think and write in scholarly ways. I am very sure Laura might not like me as you
have put too much time for me during day and night-time. Thanks to Michael for
your generous guidance and being a subject even at night-time. Thanks also to Dr
Peter Hendicott for being supportive and for your constructive comments on the
draft of this thesis.
Thanks must go to the vision and driving research team, Trent Carberry and Ralph
Marszalek, who have been with me throughout my journey, even till very late at
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night. It was very enjoyable to work with you and I thank you for your support,
positive energy and sharing memory.
I would like to thank the optometrists who helped with recruiting participants for
Experiment 1: Phillip Hong, Sonia Shin, Lucy Hsieh, Damien Fisher, Celia Bloxsom,
Kate Johnson, Luke Arundel, Mark Hinds, Jonathan Shaw, Oliver Woo, and Malinda
Halley. Importantly, I would like to thank my participants for their time and effort. I
also thank Dr. Philippe Lacherez for his valuable advice on data analysis. I also would
like to thank the contact lens & visual optics laboratory team, with special thanks to
Brett Davis who always provided the right tools whenever I needed them, and Dr
Scott Read who always answered my simple and sophisticated questions. You are
great people to be with. Also, thanks to John Stephens who made all the electric
devices (near display panels) despite the many modifications. Thanks to Cliff
McCarty for making all the spectacles and ordering contact lenses. I am also grateful
to the friendly administration staff, Catherine Foster, Fiona Lauder and Yvonne
Kenwrick who always welcome me at the School office. It was the most pleasant
place for me to be.
I would like to especially thank Associate Professor Barbara Junghans (UNSW), who
has witnessed my journey from the beginning to this moment and always gives me
a huge hug and encouragement.
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This thesis is also dedicated to my family; especially my parents, wife Mei Ying and a
little adorable distractor, Seung Woo (Harry) who came out into the world at the
most busiest moment of Dad’s PhD journey causing lack of sleep and a twilight
state, but you are still the biggest bonus in my life.
I will miss the moments lying on the driving circuit waiting for the research vehicle
to come, changing bio-motion clothes, walking like a Robot, running and loading
stuff to the fleet vehicle, watching the sparkling stars in the dark sky, the sweat of
hard work and the sound of “Are you ready?”. Thanks again for everyone for
giving me this invaluable memory which I loved and will love forever.
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Publications Arising from this Research
Journal articles
1. Chu, B. S., Wood, J. M. and Collins, M. J. (2009) Effect of presbyopic vision
corrections on perceptions of driving difficulty. Eye and Contact Lens, 35(3),
133-143.
2. Chu, B. S., Wood, J. M. and Collins, M. J. (2009) Influence of presbyopic
corrections on driving-related eye and head movements. Optometry and Vision
Science, 86 (11), 1267-1275
Published abstract
1. Chu, B. S., Wood, J. M. and Collins, M. J. (2009) Effect of presbyopic vision
corrections on eye and head movements. Clinical Experimental and
Optometry, 92(1), 61.
2. Chu, B. S., Wood, J. M. and Collins, M. J. (2009) Driving-Related Eye and
Head Movements Are Changed by the Type of Presbyopic Correction.
Invest. Ophthalmol. Vis. Sci. 2009 50: E-Abstract 3982.
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Table of Contents
Chapter 1. Introduction ...................................................................................... 31
1.1 Background .................................................................................................. 31
1.2 Aims of the study ......................................................................................... 32
1.3 Significance .................................................................................................. 35
Chapter 2. Literature review............................................................................... 37
2.1 Ageing population and driving ..................................................................... 37
2.2 Presbyopia and implications for driving ...................................................... 40
2.3 Visual function change with age and driving ............................................... 42
2.3.1 Visual acuity ........................................................................................ 43
2.3.2 Contrast sensitivity ............................................................................. 45
2.3.3 Visual field ........................................................................................... 47
2.3.4 Stereopsis ............................................................................................ 49
2.3.5 Glare disability .................................................................................... 50
2.3.6 Summary of visual functions and driving ............................................ 51
2.4 Presbyopic vision corrections ...................................................................... 52
2.4.1 Bifocal spectacle lenses .................................................................... 53
2.4.2 Progressive addition spectacle lenses .............................................. 54
2.4.3 Monovision contact lenses ............................................................... 56
2.4.4 Multifocal contact lenses .................................................................. 60
2.4.5 Summary of presbyopic vision corrections ......................................... 62
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2.5 Presbyopic vision corrections and driving ................................................... 63
2.6 Day and night-time driving........................................................................... 64
2.7 Eye and head movements for driving .......................................................... 65
2.8 The effect of in-vehicle devices for driving .................................................. 67
2.9 Different approaches for assessing driving performance ............................ 69
2.9.1 Simulator driving research .................................................................. 69
2.9.2 Open-road driving research ................................................................ 71
2.9.3 Closed-road circuit driving research ................................................... 71
2.10 Summary of literature review ...................................................................... 72
Chapter 3. Rationale and research design ........................................................... 75
Chapter 4. Experiment 1: Questionnaire - perceptions of driving difficulty when
wearing presbyopic vision corrections ................................................................. 79
4.1 Introduction ................................................................................................. 79
4.2 Methods ....................................................................................................... 81
4.2.1 Design and development of questionnaire ........................................ 81
4.2.2 Participants ......................................................................................... 84
4.2.3 Scoring of questionnaires ................................................................... 85
4.2.4 Analysis ................................................................................................ 86
4.3 Results ......................................................................................................... 87
4.4 Discussion ..................................................................................................... 98
4.5 Conclusion .................................................................................................. 105
xxiii
Chapter 5. Experiment 2: Influence of presbyopic corrections on driving-related
eye and head movement .................................................................................. 107
5.1 Introduction ............................................................................................... 107
5.2 Methods ..................................................................................................... 109
5.2.1 Participants ....................................................................................... 109
5.2.2 Presbyopic vision corrections ........................................................... 111
5.2.3 Distance targets ................................................................................ 113
5.2.4 Near targets ...................................................................................... 116
5.2.5 Laboratory set-up and procedures ................................................... 117
5.2.6 Recording of eye and head movements ........................................... 119
5.2.6 Analysis ............................................................................................. 120
5.3 Results ....................................................................................................... 122
5.4 Discussion................................................................................................... 125
5.5 Conclusion .................................................................................................. 131
Chapter 6. Experiment 3: Night-time driving performance while wearing
different presbyopic vision corrections ............................................................. 133
6.1 Introduction ............................................................................................... 133
6.2 Methods ..................................................................................................... 135
6.2.1 Participants ....................................................................................... 135
6.2.2 Vision corrections and fitting methods ............................................ 138
6.2.3 Visual performance measures .......................................................... 140
6.2.4 Night-time driving performance and fixations ................................. 144
6.2.5 Analysis ............................................................................................. 162
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6.3 Results ....................................................................................................... 163
6.3.1 Visual performance measures .......................................................... 163
6.3.2 Night-time driving performance and fixations measures ................. 166
6.3.3 Correlations between visual performance, driving performance and
fixation measures ............................................................................. 176
6.4 Discussion ................................................................................................... 179
6.5 Conclusion .................................................................................................. 188
Chapter 7. Conclusions ..................................................................................... 191
7.1 Implications for driving safety ................................................................... 193
7.1.1 Visbility of traffic-related objects at distance ................................... 193
7.1.2 Day and night-time driving................................................................ 194
7.1.3 In-vehicle devices and dashboard ..................................................... 195
7.1.4 Eye and head movements and fixation duration .............................. 196
7.2 Subjective perceptions of driving difficulty and objective driving
performance ....................................................................................................... 197
7.3 Clinical implications .................................................................................... 199
7.3.1 Visual function of presbyopic vision correction ................................ 199
7.3.2 Fitting approach of presbyopic contact lenses ................................. 201
7.3.3 The effect of adaptation ................................................................... 202
7.4 Summary .................................................................................................... 203
References ................................................................................................... 205
Appendices ................................................................................................... 221
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List of Figures
Figure 2.1. Projected increase in drivers aged 60 years and above. ......................... 38
Figure 2.2.Effect of age and relative accident involvement ratio .............................. 40
Figure 2.3. The predicted number of people worldwide with presbyopia, and the
number of people with uncorrected presbyopia. ............................................... 41
Figure 2.4. Diagram of zones in a typical progressive addition lens .......................... 55
Figure 2.5. Pupil size and relative coverage of optic zone of MTF CL. ....................... 61
Figure 2.6. Average severity rates at day and night-time by different road type ..... 64
Figure 4.1. Mean (SE) score of each group on clarity of street directory. ................. 92
Figure 4.2. Mean (SE) score of each group on peripheral distortion. ....................... 93
Figure 4.3. Mean (SE) score of each group on disturbance of glare. ......................... 96
Figure 4.4. Mean (SE) score of each group on disturbance of halo. .......................... 96
Figure 4.5. Mean (SE) score of each group on overall satisfaction. ........................... 97
Figure 5.1. Example of a captured scene from the video recording. ....................... 114
Figure 5.2. Digital numeric display panels for near targets. .................................... 117
Figure 5.3. Experimental set-up and relative location of screen and near targets. 118
Figure 5.4. Photograph of faceLAB® system. ........................................................... 120
Figure 5.5. Captured eye and head movement path lengths .................................. 121
Figure 5.6. Mean (SE) of path lengths of eye and head movements. ...................... 123
Figure 5.7. Mean (SE) of accuracy of identification of near targets. ....................... 125
Figure 6.1. Photograph of spectacle frame used for SV and PAL. ........................... 138
Figure 6.2. Photographs of the Berkeley Glare Tester. ............................................ 144
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Figure 6.3. Schematic diagram of the closed-road circuit. ...................................... 145
Figure 6.4. Stationary vehicle with headlight beam to create glare from on-coming
vehicle ................................................................................................................ 145
Figure 6.5. Low contrast road hazard on the closed-road circuit during night-time. ....
................................................................................................................. 146
Figure 6.6. Photograph of the research vehicle used in the study. ......................... 146
Figure 6.7. Screenshot of the VigilVanguard™ system output. ............................... 147
Figure 6.8. Eye tracking system – ASL Mobile Eye. .................................................. 149
Figure 6.9. Road signs along the driving circuit ....................................................... 151
Figure 6.10. Location of near targets (radio and speedometer) and LEDs .............. 152
Figure 6.11. Electronic circuit of LED display ........................................................... 153
Figure 6.12. Captured video footage from VigilVanguard™ system for assessment of
lane crossing time. ............................................................................................. 155
Figure 6.13. Captured video footage when the vehicle crossed the right lane. ...... 155
Figure 6.14. Captured video footage when the vehicle crossed the left lane. ........ 155
Figure 6.15. The task of measuring the distance to recognize a standard street sign. .
................................................................................................................. 156
Figure 6.16. Photograph of the four standard street signs used in the study. ........ 157
Figure 6.17. Procedure for measuring distance VA on the closed-road circuit. ...... 158
Figure 6.18. The types of distance signs used. ......................................................... 160
Figure 6.19. Distance VA under different viewing conditions. ................................ 165
Figure 6.20. Mean (SE) of percentage of near targets correctly identified. ............ 170
Figure 6.21. Mean (SE) of distance to recognize standard street signs. .................. 172
xxvii
Figure 6.22. Mean (SE) of the total fixation duration when observing near targets. ....
................................................................................................................. 173
Figure 6.23 Mean (SE) of the total fixation duration when observing distance targets
................................................................................................................. 175
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List of Tables
Table 4.1. Characteristics of each group. ....................................................................88
Table 4.2. Mean scores for each question ..................................................................89
Table 5.1. Mean unaided distance VA of participant under photopic condition .... 110
Table 6.1. Inclusion criteria for participants. ........................................................... 136
Table 6.2. Characteristics of participants. ................................................................ 137
Table 6.3. Details of monovision and multifocal contact lenses. ............................. 140
Table 6.4. Types of road signs on the closed-road circuit. ....................................... 151
Table 6.5. Mean (SD) of visual performance measures. .......................................... 164
Table 6.6. Mean (SD) of driving performance measures. ........................................ 167
Table 6.7. Mean (SD) of eye movement fixations. ................................................... 168
Table 6.8. Correlation coefficients (r) between visual performance measures and
driving performance measures. ........................................................................ 178
Table 7.1. Summary of results from experimental Chapters 4, 5 and 6. ................. 192
xxix
List of Abbreviations
BIF: Bifocal spectacle lenses
D: Dioptre
HVID: Horizontal Visible Iris Diameter
LE: Left eye
LED: Light-Emitting-Diode
MTF CL: Multifocal contact lenses
MV: Monovision
PAL: Progressive addition lenses
RE: Right eye
SD: Standard Deviation
SE: Standard Error
Sec: Second
Sec of arc: Seconds of arc
SV: Single vision distance lenses
VA: Visual acuity
xxx
Chapter 1
31
Chapter 1. Introduction
This chapter provides an overview of the research involved in this thesis, including the
background, aims, and significance.
1.1 Background
Interest in research on the driving safety of older drivers has increased over recent
years as a result of the increasing age of the general population. The decline in
visual function with age is likely to have a significant negative effect on driving
performance, as 90% of the driving task is believed to be dependent on vision (Hills,
1980). One of the physiological changes in visual function that occurs with ageing is
difficulty with focusing on near objects, known as presbyopia, which usually
becomes apparent when people are in their mid forties. Therefore, persons aged
over 45 years typically need corrective lenses to be able to focus at near distances.
Many studies have investigated the impact of presbyopic corrections on tasks such as
reading, visual performance and head movements (Gupta, Naroo, & Wolffsohn, 2009;
Han, Ciuffreda, Selenow, Bauer et al., 2003; Proudlock, Shekhar, & Gottlob, 2004).
However, the effect of presbyopic vision corrections on driving has received only
limited attention in previous studies. Even though previous surveys have reported the
subjective problems of glare and haloes experienced when wearing monovision (MV)
or multifocal contact lenses (MTF CL) for night-time driving (Back, Grant, & Hine, 1992;
Chapter 1
32
Papas, Young, & Hearn, 1990), it is not clear to what degree different presbyopic
corrections impair driving performance.
The only study that has investigated the impact of presbyopic vision corrections was
reported by Wood et al., (1998). This involved a comparison of objective measures
of driving performance for adapted monovision wearers when wearing their
monovision correction compared to their habitual correction (spectacles or
unaided). They reported that sign recognition, mirror checks, lane deviation, driving
time, parking angle and speed estimation were not adversely affected when wearing
MV during the daytime under real world in-traffic driving conditions.
Currently, there are increasing numbers of presbyopic vision corrections available, with
new materials and designs of spectacles and contact lenses. Therefore, it is important
to determine the effect of different types of the latest presbyopic vision correction
designs on driving. The assessment of unadapted wearers of presbyopic vision
corrections is also useful, given that the initial performance of presbyopic corrections
may be problematic and is a key factor in estimating the success of presbyopic
corrections.
1.2 Aims of the study
The overall aim of this study was to investigate the effects of various forms of
commonly used presbyopic corrections (e.g. bifocal spectacle lenses (BIF),
progressive addition lenses (PAL), MV and MTF CL) on day and night-time driving
Chapter 1
33
performance. In order to achieve the aim of the study, three studies were
conducted. These studies, along with their specific aims are described below.
Experiment 1. Questionnaire study on perceptions of driving difficulties
when wearing presbyopic vision corrections
The aim of Experiment 1 was to determine the subjective driving difficulties
experienced by adapted wearers of five different vision correction types (no vision
correction, BIF, PAL, MV and MTF CL) by mail-out questionnaire. A questionnaire
was developed to establish the level of satisfaction with aspects of each correction
type for driving and to identify any problems experienced when wearing these
vision corrections while driving. Based on the aims of this study, the following
hypotheses were developed.
1) The PAL group will notice more peripheral blur while driving.
2) The BIF group will have difficulty changing gaze from the forwards driving
scene to in-vehicle devices.
3) The MV group will have difficulty judging distances while driving.
4) The MTF CL group will have less clear vision which could reduce visibility of
the road environment and traffic.
5) The visibility of all vision corrections will be poorer at night-time and the
effect of glare will be greater with MV and MTF CL.
Experiment 2. Influence of presbyopic corrections on driving-related eye
and head movements
Chapter 1
34
The aim of Experiment 2 was to investigate the eye and head movement patterns
adopted when wearing presbyopic vision corrections (single vision distance lenses
(SV), BIF, PAL, MV and MTF CL) while viewing dynamic visual stimuli (videos of
traffic scenes) in a laboratory situation. These traffic scene videos included day and
night-time driving and freeway and suburban roads.
The following hypotheses were developed based on the aims of this study.
1) Wearing PAL will produce greater eye and head movement than any other
type of vision correction due to peripheral blur.
2) Wearing SV will result in experiences of difficulty viewing near in-vehicle
devices.
3) Eye and head movements will differ between day and night-time conditions.
Experiment 3. Effect of different types of presbyopic vision corrections on
real world driving performance under night-time conditions
The aim of Experiment 3 was to determine whether driving performance is affected
by wearing presbyopic vision corrections. The results of Experiment 1 and 2 were
considered in the design of Experiment 3 so that issues such as night-time glare,
reduced clarity of distance targets, and difficulty in focusing on near targets were
specifically tested. In addition, another type of eye tracking system was used to
record fixation patterns while driving, given that the tracking system used in
Experiment 2 was not found to be practical for use when driving in the field. In
order to investigate which visual measures predicted any differences in driving
Chapter 1
35
performance, a range of visual performance measures were assessed with these
presbyopic corrections prior to assessment of driving performance.
Based on the aims of the study, the following hypotheses were developed.
1) Driving performance tasks which are dependent on distance visual acuity
(VA) will be affected by wearing MV and MTF CL due to reduced VA.
2) Recognition of targets viewed in the side mirrors will be affected by wearing
PAL due to peripheral blur.
3) The clarity of viewing in-vehicle devices will be affected by wearing SV.
4) Efficiency viewing in-vehicle devices will be modulated by the limited near
segments of PAL lenses
1.3 Significance
The onset of presbyopia at around 45 years of age inevitably means that all drivers will
face the question of whether to wear a presbyopic vision correction, which provides
the convenience of clear distance and near vision, when driving and which type should
be worn. Extensive research on the effect of vision on driving has confirmed that vision
provides the major sensory input for driving, however, the effect of presbyopic vision
corrections, which modify visual experience, has not been investigated. This is an
important gap in the literature as currently available presbyopic vision corrections do
not provide completely natural vision and may disturb aspects of visual function which
could be detrimental to safe driving. Therefore, this research is important to determine
whether wearing presbyopic vision corrections affect driving performance and in what
Chapter 1
36
way. The results of this research will help quantify differences in driving performance
when wearing different presbyopic corrections and provide valuable information for
understanding the benefits and limitations of wearing different presbyopic vision
corrections when driving. In addition, the information gained from this study can be
used to advise presbyopic drivers about what they can realistically expect with regards
to visual performance while driving with different kinds of presbyopic corrections, and
to assist in the design of optimum presbyopic corrections. The presbyopic vision
corrections investigated in this study were those that are commonly used, therefore
the results are relevant to optometry practitioners and their presbyopic patients.
Chapter 2
37
Chapter 2. Literature review
2.1 Ageing population and driving
Over the past half-century, there has been rapid growth in the aged population
worldwide. It has been reported that the current growth rate of the population
aged 60 years or over is significantly higher than that of the total population, with
predictions that the growth rate will be 3.5 times as rapid as that of the total
population by 2030 (UN, 2001). While almost one in five persons in developed
countries was aged 60 years or over in 2000, one in every three persons will be 60
years or over by 2050 (UN, 2001).
This demographic transition into an ageing society will have a profound effect on a
range of community issues, such as economic, health and social activities (Restrepo
& Rozental, 1994). Of these, driving safety has become an important focus of
research because of the projected increase in the number of older drivers on our
road systems.
Driving a private vehicle can enable drivers to fulfil many essential needs including
driving to the shops, accessing medical services, participating in social activities and
visiting friends (Rosenbloom, 1993). Thus driving is a means of maintaining
independence and quality of life for the elderly population (Banister & Bowling,
2004; Cvitkovich & Wister, 2001). Given the importance of driving to everyday living,
Chapter 2
38
driving cessation has potential detrimental effects on the mobility of older people
and may result in a reduction in well-being, limited community access and increased
depressive symptoms (Davey, 2007; Fonda, Wallace, & Herzog, 2001). Thus older
drivers wish to continue to drive as long as possible into old age in order to
maintain their quality of life (Jette & Branch, 1992).
With the convenience and importance of driving for the aged population, it is
anticipated that there will be a greater number of older drivers on our roads in the
future (Eberhard, 1996). It has been reported that the licensure rate for those aged
65 years and older has increased steadily from 63% in 1983 to 75% in 1995 in the
United States (Lyman, Ferguson, Braver, & Williams, 2002). Another report
estimated that 73% of persons aged 60 years and above had a driver’s licence in
2001, and predicted that this will increase to 96% by 2031 in the state of Victoria in
Australia (Figure 2.1) ("Older drivers," 2008)
Figure 2.1. Projected increase in drivers aged 60 years and above
(Based on the data “Traffic Accident Commission, Victoria, 2008”).
Chapter 2
39
This increase in the number of older drivers on our road systems poses a potential
risk for road safety, as the abilities required for safe driving, including cognitive,
motor and sensory function, can be affected by normal ageing processes. Studies
indicate that older drivers adjust their driving behaviour through self-regulation to
reduce the risk of accidents such as avoiding peak hour traffic, night-time driving,
unfamiliar routes, poor weather conditions and also driving fewer miles than other
age groups (Lyman, McGwin, & Sims, 2001; McGwin, Chapman, & Owsley, 2000).
While these driving patterns should reduce the rate of crash involvement per driver
in this age group (Lyman et al., 2002), crash statistics indicate that older drivers
have higher crash rates per distance travelled than either young or middle-aged
drivers (Alvarez & Inmaculada, 2008; Langford & Koppel, 2006). Increasing age has
also been shown to be significantly associated with increased crash involvement
resulting in severe injuries (Hanrahan, Layde, Zhu, Guse, & Hargarten, 2009; Skyving,
Berg, & Laflamme, 2009) (Figure 2.2). Accordingly, the issue of safe and efficient
mobility for older drivers has become an important social problem. The high crash
rate of older drivers may arise from a range of factors including restriction of
physical movement, impaired cognitive functions, and the visual deterioration that
occurs with age (Owsley, 1994; Wood, 1998, 2002b). Among the factors affecting
driving safety, vision is considered to be a key factor as it makes up approximately
90% of the sensory input required to drive (Hills, 1980).
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40
Figure 2.2. Effect of age and relative accident involvement ratio.
(Reprinted from Accid Anal and Prev., 27(4), Stamatiadis, N., and Deacon, J. “Trends in
highway safety: Effects of an aging population on accident propensity”, 443-459., 1995
with permission from Elsevier)
2.2 Presbyopia and implications for driving
Presbyopia is an age-related change in the function of the eye which results in an
inability to see near objects clearly. Presbyopia is the most common physiological
change occurring in adults after about 45 years of age, with the exact onset
depending on a range of factors such as individual refractive error, climate or
geographic location (Holden et al., 2008; Miranda, 1979), and importantly, it is
irreversible. The most widely accepted explanation of how presbyopia develops is
Helmholtz’s theory, which suggests that presbyopia is due to a loss of elasticity of
the crystalline lens and capsule combined with changes in the ciliary muscle and
choroid which become less efficient with ageing. This decrease in the flexibility and
elasticity of the lens means that the lens cannot change shape to focus on near
Chapter 2
41
objects when the ciliary muscle contracts (Marmer, 2001; Strenk, Strenk, & Koretz,
2005).
With the demographic transition toward an ageing population, the number of
people with presbyopia is increasing worldwide, and they need adequate near
vision for the many tasks they perform, including reading or viewing computers.
However, it has been reported that approximately half of people with presbyopia
are either uncorrected or undercorrected (Holden et al., 2008) (Figure 2.3). A lack of
adequate optical correction in presbyopes has been found to have negative effects
on health-related quality of life when measured by a self-administered
questionnaire, the National Eye Institute Refractive Error Quality of Life (NEI-RQL)
Instrument (McDonnell, Lee, Spritzer, Lindblad, & Hays, 2003).
Figure 2.3. The predicted number of people worldwide with presbyopia, and the number of
people with uncorrected presbyopia from 2005 to 2050
(Based on the data from Holden et al., 2008).
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42
Another survey study using a different questionnaire by Patel et al. (2006) also
found that near vision-related quality of life such as reading, writing, cooking and
threading a needle were significantly affected by uncorrected presbyopia.
Considering the in-vehicle environment, it is possible that uncorrected presbyopia
may also disturb viewing the dashboard and in-vehicle devices such as navigation
and entertainment systems. However, the effect of presbyopia on driving, which
involves both near and distance vision, has not been investigated. In addition, the
effect of wearing vision corrections for presbyopia while driving is also unknown.
Therefore, investigation of the impact of corrected and uncorrected presbyopia on
driving is an important research area, particularly with the increasing use of in-
vehicle devices.
2.3 Visual function change with age and driving
In addition to presbyopia, a number of other changes in the eye and visual system
accompany normal ageing in healthy older adults. The declines in VA, contrast
sensitivity, and increased susceptibility to disability glare are thought to be due to
the combined effects of several factors including loss of media transparency,
changes in pupil size (senile miosis), and neuronal and receptor loss in the visual
pathways (Owsley, Sekuler, & Siemsen, 1983; Spear, 1993; Weale, 1975). However,
senile miosis also increases depth of field by occluding peripheral rays which are the
most affected by refractive blur, which can be advantageous, resulting in less
reliance on spectacle and contact lens corrective power (Schwartz, 2002).
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43
The relationship between driving and vision has been widely researched in
recognition of the importance of vision for driving. In particular, the decline in visual
function with age has been considered in relation to the role of visual capability and
driving performance in older drivers (Cole, 2002; Wood, 2002b). In this section, the
literature on the relationship between the changes in visual function with age and
driving will be discussed.
2.3.1 Visual acuity
Visual acuity is the most commonly measured visual function and is a measure of
the finest detail that can be seen (spatial resolution). A decrease in VA with age has
been found in several large population-based studies (Foran, Mitchell, & Wang,
2003; Klein, Klein, Lee, Cruickshanks, & Gangnon, 2006; Rubin et al., 1997), and this
decline has been shown to accelerate with increased age. However, in early
presbyopia, distance VA is relatively normal (Foran et al., 2003; Haegerstrom-
Portnoy, 2005).
To obtain a driver’s license in the Australia, private drivers must obtain a minimum
corrected VA of 6/12 in the better eye or binocularly, whereas a commercial driver
must obtain a minimum 6/9 in the better eye and a minimum of 6/18 in the other
eye (Horton & Joseph, 2002). Despite the fact that VA is the most commonly
adopted visual standard for licensing in most developed countries, the relevance of
VA to road safety remains unclear, as only a limited number of studies have shown
Chapter 2
44
an association between VA and crash rates, whereas others have failed to find any
association.
Burg (1967) examined the crash records of 17,500 drivers in the United States
America (USA), and found no significant correlations between VA and crash rates
for drivers below 54 years of age, and only weak correlations for those drivers over
54 years of age. Other studies have similarly failed to report a significant association
between VA and crash involvement (Ball, Owsley, Sloane, Roenker, & Bruni, 1993;
Decina & Staplin, 1993; McCloskey, Koepsell, Wolf, & Buchner, 1994). These studies
suggested that reductions in VA may have little effect on the risk of injurious
crashes for drivers in this age group. While Owsley et al. (1998) did find a slight
trend, suggesting that drivers with a VA of less than 6/12 might have more crashes
than those with VA better than 6/12, the relationship was not statistically significant.
Hunt et al. (1993) also failed to find an association between VA and performance on
an on-road driving assessment.
Conversely, Davison (1985) analysed 1,000 drivers’ accident history and visual
functions and found that monocular and binocular VA were significantly correlated
with crash rates, with the effect being stronger for older drivers. Hofstetter (1976)
also found that those drivers with poor VA (defined as VA below the lower quartile)
reported a significantly higher number of accidents (three or more) compared with
those with good VA. Similarly, Ivers, Mitchell and Cumming (1999) showed that a
reduction in two lines of VA (0.20 logMAR) was associated with an increased risk of
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accidents. In an experimental study, Higgins, Wood and Tait (1998) examined the
effect of artificially blurring vision to VA levels of 6/6 to 6/12, 6/30 and 6/60 on
driving performance measured on a closed-road. They showed that the percent of
road signs detected and the number of road hazards hit deteriorated significantly
with reductions in VA, however, measures such as lane keeping were not affected
by reductions in VA.
2.3.2 Contrast sensitivity
Contrast sensitivity is considered to be a more comprehensive measure
representing visual function in real world conditions than VA (Elliott, 1987), as
contrast thresholds are measured for different spatial frequencies. This better
represents vision in a natural environment which consists of a diversity of contrasts,
textures, borders and spatial frequencies. Therefore, measurement of the human
contrast sensitivity function provides a more complete assessment of visual
capability, by assessing both spatial resolution and contrast sensitivity (Woods &
Wood, 1995).
Many studies have used the Pelli-Robson chart to measure contrast sensitivity,
showing that there is little change in contrast sensitivity throughout adulthood until
approximately 60 to 65 years of age (Haegerstrom-Portnoy, Schneck, & Brabyn,
1999), thereafter declining 0.1 log contrast sensitivity per decade (Rubin et al.,
1997). Mean log contrast sensitivity was approximately 1.8 to 1.9 log contrast
Chapter 2
46
sensitivity in the 20’s age group and around 1.8 log contrast sensitivity in the 60’s
age group (Elliott & Bullimore, 1993; Elliott, Sanderson, & Conkey, 1990).
Given that the driving environment includes a range of objects of different sizes and
contrasts, the relationship between contrast sensitivity and driving safety has been
considered as a more relevant factor to safe driving (Schmidt, 1961), and many studies
have demonstrated an association between contrast sensitivity and crashes and
driving-related tasks.
Evans and Ginsburg (1985) compared road sign discrimination ability between younger
and older drivers. In their study, both groups had VA better than 6/6, however, the
older drivers showed significantly poorer contrast sensitivity and performed worse on
the road sign discrimination task. A similar relationship between contrast sensitivity
and sign legibility distance was found by Kline et al. (1990). Contrast sensitivity has also
been shown to predict drivers’ recognition performance (signs, hazards and
pedestrians) under day and night conditions in closed road studies (Wood & Owens,
2005). Reduced contrast sensitivity has been associated with difficulty driving under
night-time conditions, in the accuracy of distance judgements (Rubin, Roche, Prasada-
Rao, & Fried, 1994), and under high-risk driving situations such as rush hour or heavy
traffic (McGwin et al., 2000).
Decina and Staplin (1993) reported that a combined visual screening battery that
included contrast sensitivity, VA and visual fields was significantly related to increasing
Chapter 2
47
crash involvement in older drivers. More recently, a study by Owsley, Stalvey, Wells,
Sloane and McGwin (2001) found that cataract patients with a history of crash
involvement were eight times more likely to have reduced contrast sensitivity than
controls. Their finding was supported by closed-road studies which showed that poor
contrast sensitivity was associated with poor driving performance measures in drivers
with simulated (Wood, Dique, & Troutbeck, 1993) and real cataracts (Wood, 2002a)
and that driving performance improved following cataract surgery (Wood & Carberry,
2006).
2.3.3 Visual field
Visual fields are a measure of visual sensitivity across the field of view and are
known to decline with age (Johnson & Keltner, 1983; Klein, 1991). Visual fields are
commonly tested with short duration stimuli presented across a person’s central
and peripheral vision while the person is fixating straight centrally. The reduction in
visual fields with age have been reported in people over 64 years (Haegerstrom-
Portnoy et al., (1999). Similarly, Spry and Johnson (2001) reported that reductions in
the visual field with age increased among those aged 70 years and over.
The evidence from studies relating visual field loss to either crash risk or indices of
driving performance has been inconclusive. In a study involving 10,000 drivers with
automated visual field testing, Johnson and Keltner (1983) found that drivers with
binocular vision field loss had crash and conviction rates twice as high as those of
drivers with normal visual fields, while those with monocular field loss and
Chapter 2
48
monocular drivers with normal visual fields, had similar crash rates to the control
drivers.
Early studies showed a weak relationship between visual field and crash
involvement (Burg, 1967; Council & Allen, 1974). More recent studies also failed to
find a relationship between the extent of visual field and crashes (Ball et al., 1993;
Decina & Staplin, 1993). McGwin et al. (2004) found that there was no difference
between drivers with glaucoma and drivers without glaucoma on collision and at-
fault crash rates, however, when the extent of the visual field loss was further
classified, those with moderate or severe visual field defects were found to have an
increased crash risk even though the association was not significant (McGwin et al.,
2005). Similarly, a study of on road driving performance showed that drivers with
glaucoma had one or more at-fault critical interventions due to failure to see and
yield to a pedestrian, while the level of satisfactory manoeuvres and skills were
equivalent to the controls (Haymes, LeBlanc, Nicolela, Chiasson, & Chauhan, 2008).
A closed-road study which simulated binocular visual field restrictions showed that
driving performance was impaired only when extensive visual field loss was
simulated (Wood & Troutbeck, 1992). On road driving assessment of drivers with
visual field defects also demonstrated that driving skills were adversely affected
with drivers who had severe binocular visual field defects (Bowers, Peli, Elgin,
McGwin, & Owsley, 2005). In another on-road driving assessment study, Racette
and Casson (2005) showed that extent of visual field defects is related to driving
performance, but there were large individual differences in the driving safety rating
Chapter 2
49
of those with visual field defects. Together, these findings suggest that while minor
or moderate visual field loss may not pose a significant risk factor for driving safety,
a fact supported by both closed and open road studies of driving performance and
crash data, severe visual field loss appears to be an important risk factor for unsafe
driving.
2.3.4 Stereopsis
Stereopsis represents the ability to detect the relative depth of objects using
binocular disparity and is important in undertaking many activities of daily living
(Norman et al., 2008). Haegerstrom-Portnoy et al. (1999) found a decrement in
stereoacuity with increasing age using a Frisby stereotest. Similarly, Garnham and
Sloper (2006) showed that while there is some decline in stereoacuity with age, the
magnitude of the stereoacuity reduction was dependent upon the stereoscopic
tests used. However, considering the driving environment, the role of stereopsis in
safe driving is unclear, as there are many other cues for judging depth or distance,
such as the road narrowing in the distance (an example of a perspective cue),
overlapping of objects and relative size.
A large study of 1,801 drivers by Rubin et al. (2007) found no correlation between
stereoacuity and self-reported crash involvement. In a study of 10 drivers with
convergent strabismus and reduced stereopsis, only driving through the slalom
course was significantly worse than that for the control drivers, while the ability to
stop in front of obstacles, reverse into a parking space and estimate the relative
Chapter 2
50
positions of two cars was not affected (Bauer, Dietz, Kolling, Hart, & Schiefer, 2001).
Bauer et al. (2001) concluded that stereopsis may be most important under
dynamic situations at intermediate distances. The role of stereoacuity on braking
responses was also explored using a custom-built go-cart on a linear track by Tijtgat,
Mazyn, De Laey and Lenoir (2008). The group with poorer stereoacuity (400 sec of
arc or worse) actually exhibited more cautious braking behaviour, including earlier
onset of braking, longer stopping distances and an earlier time of peak deceleration
compared to the control group (stereoacuity better than 40 sec of arc), suggesting
that reduced stereoacuity may not be related to an increase in rear-end collisions.
2.3.5 Glare disability
Glare disability describes the impairment of visual function resulting from the
presence of a bright light source in the field of vision (Babizhayev, 2003). Disability
glare is commonly assessed by determining the extent of VA loss that occurs with
the introduction of a bright light source. The difference in the number of letters
read between the no glare condition and glare conditions is known as the disability
glare index (Bailey & Bullimore, 1991). Previous studies have reported that there is
a linear increase in the reduction in VA in the presence of glare with increasing age
(Bailey & Bullimore, 1991; Haegerstrom-Portnoy et al., 1999; Rubin et al., 1997).
Elderly drivers more commonly report problems with glare and driving compared to
young drivers, possibly because of their higher prevalence of cataracts, which
Chapter 2
51
increases their glare sensitivity (Babizhayev, 2003) and results in difficulty in
detecting low contrast objects (Van der Berg, 1991).
A study by Theeuwes, Alferdinck and Perel (2002) found that glare has a
detrimental effect on real world driving performance, such that drivers found it
more difficult to detect simulated pedestrians along the roadside in the presence of
glare and also reduced their speed on winding roads. Similarly, a study by Gray
(2007) using a driving simulator, found that the presence of simulated glare reduced
the safety margin for making a safe turn across traffic at an intersection, thus
increasing the risk for a collision, and that the older drivers exhibited a reduction
in the safety margin compared to younger drivers.
2.3.6 Summary of visual functions and driving
The importance of vision for driving has been emphasised for decades and many
studies have demonstrated that poorer visual functions are associated with reductions
in driving safety for a range of driving measures. Retrospective crash studies have
shown limited evidence between specific visual function measures and crash
involvement, while more recent studies involving a combination of visual function
measures have found them to be associated with crash involvement and unsafe driving.
One of the difficulties in establishing the extent of the relationship between visual
function and crash involvement may be because drivers with degraded visual function
may compensate for their visual loss by driving more defensively and reducing their
driving exposure.
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2.4 Presbyopic vision corrections
Correcting presbyopia can be achieved by several methods including surgical and
non-surgical options which allow near objects to be seen clearly. Options for
presbyopic surgical correction include laser surgery to produce monovision and
multifocal effects, anterior ciliary sclerostomy, scleral expansion bands, corneal
inlays and implantation of artificial intraocular lenses (IOLs) (Hamilton, Davidorf, &
Maloney, 2002; Jacobi, Dietlein, Lüke, & Jacobi, 2002; Jain, Ou, & Azar, 2001;
Malecaze, Gazagne, Tarroux, & Gorrand, 2001; Yilmaz et al., 2008). Non-surgical
options include spectacles and contact lenses. These options have different optical
characteristics which aim to provide functional near vision while also providing clear
distance vision. As the aim of this research was to investigate the effects of non-
surgical optical correction (contact lenses and spectacle lenses) on driving
performance, surgical options will not be included in this literature review. The non-
surgical options for the correction of presbyopia include several spectacle and
contact lens designs such as BIF and PAL, and MV and MTF CL.
The use of presbyopic vision corrections will increase as the number of people aged
45 years and above in the population increases. It has been reported that the
majority of presbyopes are prescribed PAL (37% of presbyopes) and bifocal/trifocal
spectacles (16% of presbyopes) (Nichols, 2009). Another study by Sheedy, Hardy and
Hayes (2006) estimated that approximately 50% of spectacles dispensed for
presbyopes are PAL. The prescription of MTF CL has increased steadily over the 10-
year period between 1996 to 2005 in the United Kingdom (UK), from approximately
Chapter 2
53
3% to 6% (Morgan & Efron, 2006). In a seven year survey of contact lens prescribing
patterns in Canada, 9.7% of all soft contact lens fitted were MTF CL (Woods, Jones,
Jones, & Morgan, 2007), which is in accord with another recent study reporting that
soft MTF CL represented 10% of fitting or refitting of all types of contact lenses
(Nichols, 2009). A recent report showed that the use of MV and MTF CL soft lenses
increased by 7% during 2008 worldwide. In particular, the use of MV and MTF CL in
Australia has increased in the last three years from, 7% in 2006 to 12% in 2007 and
14% in 2008 (Morgan et al., 2007, 2008; 2009). It has also been suggested that the
use of contact lenses for correcting presbyopia will further increase as the next
generation of presbyopes, who currently prefer to wear contact lenses to spectacles
in daily work or sport, wish to continue wearing contact lenses once they become
presbyopic (Bennett, 2006).
2.4.1 Bifocal spectacle lenses
The invention of the BIF is attributed to Benjamin Franklin in the mid 1700s, and is
the most basic method for correcting presbyopia to provide near and distance
vision within the same lens (Callina & Reynolds, 2006). The main advantage of BIF is
that they provide clear vision with two distinctive correction zones which have
different optical characteristics within the same lens.
An important disadvantage of BIF is the presence of a visible line which divides the
lens into the distance and near portions. When wearing BIFs, reflections from the
top of flat top bifocal segment designs can result in vertical streak reflections which
Chapter 2
54
have been reported to be “disconcerting” during night driving (Jalie, 2003). In
addition, due to prismatic effects at the top of the reading segment and the
absence of an intermediate viewing range, wearers may experience apparent
displacement of objects known as “prism jump” when their gaze switches between
the distance and near zones (Alonso & Alda, 2003). Additionally, although clear
vision is obtained through both the distance and near portions, there are
intermediate distances at which objects cannot be focused clearly, known as the
intermediate viewing zone. Another disadvantage of wearing BIF is that
psychologically, the visible line is commonly associated with the appearance of
ageing and imperfection (Glass, 2001).
2.4.2 Progressive addition spectacle lenses
Progressive addition lenses are characterised by a gradual increase in power along
the lens surface from the upper to the lower portion, enabling continuous clear
vision at all distances: distance vision, intermediate (which is not offered by BIF) and
near vision (Callina & Reynolds, 2006; Sheedy, 2004a). Additionally, unlike BIF, PAL
have a seamless appearance which is similar to that of SV. With these advantages,
PAL have been shown to be the preferred presbyopic correction with high success
rates in the range of 80% to 97% (Boroyan et al., 1995; Cho, Barnette, Aiken, &
Shipp, 1991; Sullivan & Fowler, 1989). One study demonstrated that up to 92% of
previous BIF wearers preferred PAL when given a choice between PAL and BIF
following a trial of PAL (Boroyan et al., 1995).
Chapter 2
55
Progressive addition lenses consist of four main zones (Figure 2.4): a distance zone
that provides the distance viewing power, a near zone that provides the near power,
an intermediate power progression for viewing objects at intermediate distances
and the peripheral zone (Atchison, 1987). The area of the lens where optimum and
unaberrated vision can be obtained through the progressive change in power is
called the “corridor” (Callina & Reynolds, 2006). The corridor varies in shape, width,
and length depending on the manufacturer’s design (Sheedy et al., 2006). However,
image quality through the corridor can be slightly blurry, as the light rays pass
through a range of different dioptric powers resulting in a less sharp image (Burns,
1995). In addition, in order to provide clear vision for all distances, the dioptric
power of PAL needs to be varied across the lens surfaces, which induces unwanted
aberrations, resulting in distorted vision through the peripheral zones of the lenses
(Sheedy, 2004a). These unwanted aberrations are affected by the power of the
addition, such that a higher addition results in increased astigmatism in the
peripheral zone due to greater change in lens curvature (Sheedy et al., 2006).
Figure 2.4. Diagram of zones in a typical progressive addition lens.
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56
Selenow, Bauer, Ali, Spencer and Ciuffreda (2002) compared the visual performance
of PAL with that of SV in a computer-based reading task at an intermediate distance
(64 cm). They found that PAL presented only a limited intermediate zone resulting
in reduced visual performance compared to SV. In addition, PAL have been found to
induce longer durations of eye and head movements compared to SV in reading
tasks, due to the smaller zone of clear vision of PAL (Han, Ciuffreda, Selenow, Bauer
et al., 2003). Thus PAL wearers need to learn to indentify where the clear zone of
the lens is and how to coordinate eye and head movements to ensure that they are
viewing through the required lens power at a given working distance (Pedrono,
Obrecht, & Stark, 1987). If the eyes are not directed through the correct portion of
the PAL, the wearer will experience a sensation of distortion, or apparent motion of
the visual field (“swim effect”) which is either due to changes in the amount of
astigmatism, or to variations in the axis of the astigmatism in the infero-lateral
zones of the lens (Pedrono et al., 1987; Simonet, Papineau, & Lapointe, 1986).
2.4.3 Monovision contact lenses
Monovision refers to an optical technique, where one eye is corrected for distance
vision while the other eye is corrected for near vision. This approach has been
widely adopted as a presbyopic vision correction, with advantages including the use
of conventional single vision contact lenses, ease of fitting and immediate
judgement of success by the wearer (Bennett, 2008).
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57
Studies have also reported high success rates for MV wear. Back, Holden and Hine
(1989) indicated that MV was the most successful contact lens option compared to
bifocal contact lenses, showing a 67% success rate. Another study by Harris, Sheedy
and Gan (1992) found that 90% of subjects chose to wear MV after a 6-week period
of wear while only 10% of subjects preferred to wear diffractive bifocal contact
lenses. Collins, Bruce and Thompson (1994) reported that 78% of subjects were
satisfied with MV at the completion of 8 weeks wear. In a review of a number of MV
studies, Jain, Arora and Azar (1996) found that the mean success rate for wearing
MV was 76% and rose to 81% after the exclusion of contact lens related intolerant
individuals.
Even though wearing MV is a highly successful option to correct presbyopia, there
have been concerns regarding the adverse consequences of wearing MV which
include reduced stereopsis, VA and contrast sensitivity, while peripheral VA is
unaffected (Collins, Brown, Verney, Makras, & Bowman, 1989). These reductions in
visual function resulting from MV wear have been found to affect near performance
on tasks such as card filing and letter editing compared to controls (distance contact
lenses with reading glasses) (Sheedy, Harris, Busby, Chan, & Koga, 1988). In the
incident of Delta Airline Flight 554’s collision with the ground while landing at
LaGuardia Airport in 1996, the pilot wore MV and this was considered by the
Federal Aviation Administration (FAA) to be one of the contributing factors to the
crash because of resulting misperceptions and visual illusions while flying
(Nakagawara, Montgomery, & Wood, 2001).
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Reduced stereopsis is a well known disadvantage of MV. Papas et al. (1990)
reported that stereoacuity was reduced with MV compared to diffractive bifocal
contact lenses and other studies have reported decreased stereoacuity with MV
compared to MTF CL (Back et al., 1992; Kirschen, Hung, & Nakano, 1999; Richdale,
Mitchell, & Zadnik, 2006). Similarly, a study by Situ, Du Toit, Fonn and Simpson
(2003) found that near stereoacuity with MV was 109 sec of arc while it was 43 sec
of arc with bifocal contact lenses. This reduction in stereoacuity has been shown to
be positively correlated with increasing magnitude of the power of the addition
(Gutkowski & Cassin, 1991).
Due to monocular blur, wearing MV also affects visual functions such as distance VA
and contrast sensitivity. Binocular VA with MV has also been shown to be slightly
reduced compared to that with a spectacle correction. A study by Back et al. (1992)
found that there was a 0.10 logMAR reduction with MV compared to spectacles in
low illumination, and an 0.04 logMAR reduction under high illumination conditions.
However, a recent study showed that distance VA with MV is actually better than
MTF CL, given that the distance VA with MV was -0.01 logMAR compared with 0.05
logMAR for MTF CL (Gupta et al., 2009).
A study by Collins, Brown and Bowman (1989) found binocular contrast sensitivity
with MV was decreased compared to that with a spectacle correction. Rajagopalan,
Bennett and Lakshminarayanan (2006) also found contrast sensitivity at higher
spatial frequencies with MV to be worse compared to PAL. The decrease in contrast
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59
sensitivity is related to the magnitude of defocus. If monocular defocus is more than
+2.50D, binocular contrast sensitivity becomes equivalent to monocular contrast
sensitivity due to the effect of suppression of the defocused eye (Pradhan &
Gilchrist, 1990).
For MV wearers, it is unclear if a period of adaptation is required. Sheedy, Harris
and Gan (1993) found that there was no significant improvement in VA and
stereoacuity after commencing MV wear over a period of eight weeks. Similarly,
Collins et al. (1994) reported no significant changes in VA, near stereoacuity and
blur suppression over eight weeks of MV wear. However MV wearers do report
subjective improvements in visual satisfaction over this period (Collins et al., 1994).
In prescribing MV, the practitioner needs to determine which eye should be
corrected for distance and which corrected for near. The most commonly used
method is to prescribe the distance correction for the “dominant” or “sighting” eye
and the non-dominant eye for near vision (Evans, 2007). In determining the
“dominant” or “sighting” eye, the participant is asked to extend their arms, forming
a small hole with both hands and binocularly centre a given distance target in that
hole. When the examiner occludes either eye, the eye aligned with the target is
defined as the dominant eye (Bennett, 2008). Despite many practitioners using tests
of sighting ocular dominance to prescribe the distance lens in monovision,
controversy still exists over whether such tests should be used, particularly as there
are so many possible tests for ocular dominance (Evans, 2007; McMonnies, 1974).
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2.4.4 Multifocal contact lenses
The concept of MTF CL is to combine two or more different dioptric powers within
the optical zone of a contact lens to provide clear vision across a range of focal
distances. Generally, MTF CL are classified as either simultaneous or alternating
vision designs. Simultaneous designs are based upon several different design
concepts such as multi-zone concentric, diffractive design, or aspheric designs.
Aspheric designs are commonly available and utilise an aspheric curvature within
the optical zone on the front or back surface providing a progressive power change
from the centre to the periphery of the optical zone. The centre-distance aspheric
design consists of a centre positive power that is less than the peripheral area,
whereas centre near type have more positive power in the centre of the lens
(Guillon, Maissa, Cooper, Girard-Claudon, & Poling, 2002).
The principle of simultaneous vision is to use near and distance optic zones which
are located within the entrance pupil, enabling partial focus of near and distant
objects at the same time. Consequently, the visual system is able to use the clear
image of the object at the desired viewing distance while ignoring the out-of-focus
image (Bennett, 2006). However, the in-focus image is present simultaneously with
the out-of-focus image, resulting in a reduction in the contrast of the focused image
(Koffler, 2002). Gupta et al. (2009) found that wearing MTF CL resulted in
significantly poorer distance and near VA compared to MV when the prescription
power was equivalent to the best spectacle prescription and no modification of the
prescription was made. Other studies have found that distance VA with MTF CL was
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approximately 1 line worse (0.10 logMAR) than with spectacles (Fisher, Bauman, &
Schwallie, 2000; Kirschen et al., 1999; Richdale et al., 2006). Contrast sensitivity was
also poorer when wearing MTF CL than with spectacles (Rajagopalan et al., 2006)
for medium and high spatial frequencies (Collins, Brown, & Bowman, 1989). The
extent of contrast loss is dependant on the relative amounts of in-focus to out-of-
focus image on the retina and is closely related to pupil size (Borish, 1988) (Figure
2.5). For instance, when wearing a centre-near design and when the pupil is small,
distance vision will be less clear than near vision. On the other hand, when the pupil
is large, proportionally more light will pass through the distance viewing portion
than the near viewing portion), resulting in compromised near vision.
Figure 2.5. Pupil size and relative coverage of optic zone of MTF CL.
(A; small pupil with centre-near (CN) design, distance vision is compromised
B; large pupil with centre-near design, near vision is compromised).
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2.4.5 Summary of presbyopic vision corrections
Presbyopia is an inevitable physiological change that occurs with age, resulting in a
reduction in the clarity of near vision. While there are many interventions available
to address the problems of presbyopia, wearing spectacles and contact lenses are
easy and effective interventions for individuals who require clear distance and near
vision within one optical correction. However, as there are many presbyopic vision
corrections with different optical characteristics that affect visual function in
different ways, individuals need to prioritise their visual tasks, including outdoor
activities, reading, working with a computer and driving, and select the vision
correction which works best for their visual requirements.
When distance tasks are a priority, spectacles options such as BIF and PAL may be
good options as their distance VA is usually better than with MV and MTF CL (Back
et al., 1992; Collins, Brown, & Bowman, 1989; Papas et al., 1990). However, motion
sickness with PAL needs to be considered and the appearance with the visible line is
a limitation of BIF. If depth perception is important, MV may not be a good option
as MV induces anisometropia which reduces stereopsis and affects near vision-
related tasks. With its advantage of no adverse effects on binocular visual function,
the use of MTF CL is steadily increasing. However, degraded VA is a limitation unless
modifications to the MTF CL power is prescribed (e.g. one lens is prescribed with
over plus or less plus). In addition, increased haloes and glare are common
complaints of MV and MTF CL wearers regarding night-time driving.
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2.5 Presbyopic vision corrections and driving
Most studies that have investigated the association between wearing presbyopic
vision corrections and driving difficulties have been based on self-report using
questionnaires that provide data about participants’ previous driving experience. A
study by Josephson and Caffery (1987) found that 80% of presbyopic contact lenses
wearers reported driving difficulties at night-time with MV and MTF CL (aspheric
bifocal) and Back et al. (1992) also found that patients wearing bifocal contact
lenses experienced more haloes than wearers of MV. Schor, Landsman and Erickson
(1987) found that haloes were reported by MV wearers at lower levels of
illumination and that the haloes reduced with increasing illumination. In addition, as
the size of the light source increased, blur suppression was enhanced compared to
that with smaller light sources. In addition, 17% of MV wearers were not satisfied
with MV for driving and this level of dissatisfaction was greater at night-time due to
distance vision blur and ghosting around lights (Collins, Goode, Tait, & Shuley, 1994).
The only objective measurement of driving performance with MV was conducted by
Wood et al. (1998) with thirteen MV wearers on the open road under daytime
conditions. No adverse effects on sign recognition, mirror checks, lane-keeping
deviations, driving time and speed estimation were found with MV.
However, little is known about how other presbyopic vision corrections affect real
world measures of driving performance, nor the effect on driving performance
when patients are unadapted to their presbyopic vision correction.
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2.6 Day and night-time driving
Environmental lighting conditions have significant implications for driving as visual
performance varies under different levels of illumination. Several studies have
provided evidence that drivers’ ability to avoid collisions is impaired under dim
lighting conditions (Owens and Sivak, 1996; Elvik, 1995). In addition, the injury crash
rate for drivers increases during night-time hours (Rice et al,. 2003). According to
Plainis, Murray and Pallikaris (2006), the severity of fatal collisions almost doubled
at night between 1996 and 2005 for different types of roads in the UK (Figure 2.6).
In addition, they indicated that the average injury severity rates at night-time were
almost three times higher for situations where there was no street lighting
compared to those where street lighting was present.
Figure 2.6. Average severity rates at day and night-time by different road type (1995 to
2004). (Reproduced from “Road traffic casualties: understanding the night-time death toll,
Plainis, Murray and Pallikaris., 12(125-128), 2006 with permission from BMJ Publishing
Group Ltd.”)
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Target detection was shown to become poorer with decreasing background
luminance at night (0.01cd/m2) (Alferdinck, 2006), and it became even worse in the
presence of oncoming headlight beams (Anderson & Holliday, 1995). In addition, in
closed road driving studies, driving speeds and road sign recognition were reduced
under conditions of decreased illumination and for older drivers (Owens, Wood, &
Owens, 2007). The decrease in visual function under low illumination conditions
(e.g. night-time) and increased glare sensitivity with increasing age are likely
contributing factors to the increased risk of crashes at night-time. Increased pupil
size at night also causes more haloes around lights due to refraction of light into
peripheral parts of pupil which may not be the optical portion of the lens (Stone,
1970) and problems with haloes at night is a common complaint from MV and MTF
CL wearers compared to spectacles wearers.
2.7 Eye and head movements for driving
Research into head and eye movements has become of increasing interest in driving
research as it provides insight into how the driver responds to visual stimuli in
traffic. During driving, eye and head movements are important to monitor the
forward traffic scene to avoid potential hazards, allowing the driver to obtain
information from their visual field that is useful for driving (Land, 2006).
However, eye and head movements are potentially affected by wearing presbyopic
vision corrections. In particular, PAL are known to affect head movements due to
restriction of the intermediate viewing zone. For example, Han et al. (2003)
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investigated eye and head movements in a simulated computer-based environment
and found that reading tasks, as well as eye and head movements, were adversely
affected by the use of PAL compared to SV. PAL resulted in slower eye movement
velocities and stabilization of gaze occurred later than for SV. A study by Jones,
Phillips, Kenyon, Kors and Stark (1982) found that head movements increased when
reading with PAL compared to BIF, and that this difference persisted after months
of adaptation to the PAL. However, a study by Proudlock et al. (2004) found no
significant difference in head movements between a group of SV wearers and a
group of BIF or PAL wearers. This failure to find between gr