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Association of Cataract Surgery With Traffic Crashes

Educational Objective
To conduct a comprehensive longitudinal analysis testing whether cataract surgery is associated with a reduction in serious traffic crashes where the patient was the driver.
1 Credit CME
Key Points

Question  Is cataract surgery associated with reduced serious traffic crashes as a driver?

Findings  In this population-based, study of 559 546 patients who received at least 1 eye cataract surgery, the crash rate decreased from 2.36 per 1000 patient-years in the baseline interval to 2.14 per 1000 patient-years after surgery, representing a 9% reduction in serious traffic crashes.

Meaning  These results suggest cataract surgery is associated with a patient’s reduced subsequent risk of serious traffic crash as a driver.

Abstract

Importance  Cataracts are the most common cause of impaired vision worldwide and may increase a driver’s risk of a serious traffic crash. The potential benefits of cataract surgery for reducing a patient’s subsequent risk of traffic crash are uncertain.

Objective  To conduct a comprehensive longitudinal analysis testing whether cataract surgery is associated with a reduction in serious traffic crashes where the patient was the driver.

Design, Setting, and Participants  Population-based individual-patient self-matching exposure-crossover design in Ontario, Canada, between April 1, 2006, and March 31, 2016. Consecutive patients 65 years and older undergoing cataract surgery (n = 559 546).

Interventions  First eye cataract extraction surgery (most patients received second eye soon after).

Main Outcomes and Measures  Emergency department visit for a traffic crash as a driver.

Results  Of the 559 546 patients, mean (SD) age was 76 (6) years, 58% were women (n = 326 065), and 86% lived in a city (n = 481 847). A total of 4680 traffic crashes (2.36 per 1000 patient-years) accrued during the 3.5-year baseline interval and 1200 traffic crashes (2.14 per 1000 patient-years) during the 1-year subsequent interval, representing 0.22 fewer crashes per 1000 patient-years following cataract surgery (odds ratio [OR], 0.91; 95% CI, 0.84-0.97; P = .004). The relative reduction included patients with diverse characteristics. No significant reduction was observed in other outcomes, such as traffic crashes where the patient was a passenger (OR, 1.03; 95% CI, 0.96-1.12) or pedestrian (OR, 1.02; 95% CI, 0.88-1.17), nor in other unrelated serious medical emergencies. Patients with younger age (OR, 1.27; 95% CI, 1.13-1.14), male sex (OR, 1.64; 95% CI, 1.46-1.85), a history of crash (baseline OR, 2.79; 95% CI, 1.94-4.02; induction OR, 4.26; 95% CI, 2.01-9.03), more emergency visits (OR, 1.34; 95% CI, 1.19-1.52), and frequent outpatient physician visits (OR, 1.17; 95% CI, 1.01-1.36) had higher risk of subsequent traffic crashes (multivariable model).

Conclusions and Relevance  This study suggests that cataract surgery is associated with a modest decrease in a patient’s subsequent risk of a serious traffic crash as a driver, which has potential implications for mortality, morbidity, and costs to society.

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Article Information

Corresponding Author: Matthew B. Schlenker, MD, MSc, FRCSC, Kensington Eye Institute, 340 College St, Ste 400, Toronto, ON M5T 3A9, Canada (matt.schlenker@utoronto.ca).

Accepted for Publication: May 4, 2018.

Published Online: June 28, 2018. doi:10.1001/jamaophthalmol.2018.2510

Author Contributions: Drs Redelmeier and Thiruchelvam had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Schlenker, Redelmeier.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Schlenker.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Supervision: Redelmeier.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: Dr Redelmeier is supported by a Canada Research Chair.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the following for helpful comments: Michael Fralick, MD, MSc, FRCPC, St Michael’s Hospital, University of Toronto; Husayn Gulamhusein MD, MPH, Department of Ophthalmology, McMaster University; Ann Lvin, COMT, MSc, Kensington Vision and Research Centre; Marko Popovic, MD(C), University of Toronto; Sheharyar Raza, MD(C), University of Toronto; Jay Udell, MD, MPH, FRCPC, Women’s College Research Institute, Institute for Clinical Evaluative Sciences, University Health Network, University of Toronto; and Jason Woodfine, MD, Department of Internal Medicine, University of Ottawa. No compensation was received from a funding sponsor for these contributions.

References
1.
Centers for Disease Control (CDC).  Cost of injury: United States: a report to Congress, 1989.  MMWR Morb Mortal Wkly Rep. 1989;38(43):743-746.PubMedGoogle Scholar
2.
Safety Research Office, Ministry of Transportation.  Ontario Road Safety Annual Report 1994. Downsview, Ontario: Safety Research Office, Ministry of Transportation; 1994.
3.
World Health Organization.  World Report on Road Traffic Injury Prevention. Geneva, Switzerland: World Health Organization; 2004.
4.
McFarland  RA, Moore  RC.  Human factors in highway safety; a review and evaluation.  N Engl J Med. 1957;256(19):890-897. doi:10.1056/NEJM195705092561906PubMedGoogle ScholarCrossref
5.
Li  G, Braver  ER, Chen  LH.  Fragility versus excessive crash involvement as determinants of high death rates per vehicle-mile of travel among older drivers.  Accid Anal Prev. 2003;35(2):227-235. doi:10.1016/S0001-4575(01)00107-5PubMedGoogle ScholarCrossref
6.
Owsley  C, Stalvey  B, Wells  J, Sloane  ME.  Older drivers and cataract: driving habits and crash risk.  J Gerontol A Biol Sci Med Sci. 1999;54(4):M203-M211. doi:10.1093/gerona/54.4.M203PubMedGoogle ScholarCrossref
7.
Kline  DW, Kline  TJ, Fozard  JL, Kosnik  W, Schieber  F, Sekuler  R.  Vision, aging, and driving: the problems of older drivers.  J Gerontol. 1992;47(1):27-34. doi:10.1093/geronj/47.1.P27PubMedGoogle ScholarCrossref
8.
Curtis  LH, Hammill  BG, Schulman  KA, Cousins  SW.  Risks of mortality, myocardial infarction, bleeding, and stroke associated with therapies for age-related macular degeneration.  Arch Ophthalmol. 2010;128(10):1273-1279. doi:10.1001/archophthalmol.2010.223PubMedGoogle ScholarCrossref
9.
Hatch  WV, Campbell  EdeL, Bell  CM, El-Defrawy  SR, Campbell  RJ.  Projecting the growth of cataract surgery during the next 25 years.  Arch Ophthalmol. 2012;130(11):1479-1481. doi:10.1001/archophthalmol.2012.838PubMedGoogle ScholarCrossref
10.
Defined  C. National Eye Institute. https://nei.nih.gov/eyedata/cataract#1. Published 2010. Accessed May 18, 2018.
11.
Bourne  RR, Stevens  GA, White  RA,  et al; Vision Loss Expert Group.  Causes of vision loss worldwide, 1990-2010: a systematic analysis.  Lancet Glob Health. 2013;1(6):e339-e349. doi:10.1016/S2214-109X(13)70113-XPubMedGoogle ScholarCrossref
12.
Asbell  PA, Dualan  I, Mindel  J, Brocks  D, Ahmad  M, Epstein  S.  Age-related cataract.  Lancet. 2005;365(9459):599-609. doi:10.1016/S0140-6736(05)70803-5PubMedGoogle ScholarCrossref
13.
Owsley  C, McGwin  G  Jr.  Vision and driving.  Vision Res. 2010;50(23):2348-2361. doi:10.1016/j.visres.2010.05.021PubMedGoogle ScholarCrossref
14.
Owsley  C, Stalvey  BT, Wells  J, Sloane  ME, McGwin  G  Jr.  Visual risk factors for crash involvement in older drivers with cataract.  Arch Ophthalmol. 2001;119(6):881-887. doi:10.1001/archopht.119.6.881PubMedGoogle ScholarCrossref
15.
Agramunt  S, Meuleners  LB, Fraser  ML, Morlet  N, Chow  KC, Ng  JQ.  Bilateral cataract, crash risk, driving performance, and self-regulation practices among older drivers.  J Cataract Refract Surg. 2016;42(5):788-794. doi:10.1016/j.jcrs.2016.02.023PubMedGoogle ScholarCrossref
16.
Kanthan  GL, Wang  JJ, Rochtchina  E,  et al.  Ten-year incidence of age-related cataract and cataract surgery in an older Australian population: the Blue Mountains Eye Study.  Ophthalmology. 2008;115(5):808-814. doi:10.1016/j.ophtha.2007.07.008PubMedGoogle ScholarCrossref
17.
Cullen  KAHM, Golosinskiy  A.  Ambulatory Surgery in the United States, 2006. Hyattsville, MD: National Center for Health Statistics; 2009.
18.
Bellan  L.  The evolution of cataract surgery: the most common eye procedure in older adults.  Geriatr Aging. 2008;11(6):328-332.Google Scholar
19.
Riley  AF, Grupcheva  CN, Malik  TY, Craig  JP, McGhee  CN.  The waiting game: natural history of a cataract waiting list in New Zealand.  Clin Exp Ophthalmol. 2001;29(6):376-380. doi:10.1046/j.1442-9071.2001.d01-25.xPubMedGoogle ScholarCrossref
20.
Leinonen  J, Laatikainen  L.  The decrease of visual acuity in cataract patients waiting for surgery.  Acta Ophthalmol Scand. 1999;77(6):681-684. doi:10.1034/j.1600-0420.1999.770615.xPubMedGoogle ScholarCrossref
21.
Laidlaw  DA, Harrad  RA, Hopper  CD,  et al.  Randomised trial of effectiveness of second eye cataract surgery.  Lancet. 1998;352(9132):925-929. doi:10.1016/S0140-6736(97)12536-3PubMedGoogle ScholarCrossref
22.
Wood  J, Chaparro  A, Hickson  L.  Interaction between visual status, driver age and distracters on daytime driving performance.  Vision Res. 2009;49(17):2225-2231. doi:10.1016/j.visres.2009.06.017PubMedGoogle ScholarCrossref
23.
Wood  J, Chaparro  A, Carberry  T, Chu  BS.  Effect of simulated visual impairment on nighttime driving performance.  Optom Vis Sci. 2010;87(6):379-386.PubMedGoogle Scholar
24.
Wood  JM, Tyrrell  RA, Chaparro  A, Marszalek  RP, Carberry  TP, Chu  BS.  Even moderate visual impairments degrade drivers’ ability to see pedestrians at night.  Invest Ophthalmol Vis Sci. 2012;53(6):2586-2592. doi:10.1167/iovs.11-9083PubMedGoogle ScholarCrossref
25.
Wood  JM, Carberry  TP.  Bilateral cataract surgery and driving performance.  Br J Ophthalmol. 2006;90(10):1277-1280. doi:10.1136/bjo.2006.096057PubMedGoogle ScholarCrossref
26.
Owsley  C, McGwin  G  Jr, Sloane  M, Wells  J, Stalvey  BT, Gauthreaux  S.  Impact of cataract surgery on motor vehicle crash involvement by older adults.  JAMA. 2002;288(7):841-849. doi:10.1001/jama.288.7.841PubMedGoogle ScholarCrossref
27.
Lotfipour  S, Patel  BH, Grotsky  TA,  et al.  Comparison of the visual function index to the Snellen Visual Acuity Test in predicting older adult self-restricted driving.  Traffic Inj Prev. 2010;11(5):503-507. doi:10.1080/15389588.2010.488494PubMedGoogle ScholarCrossref
28.
Keay  L, Munoz  B, Turano  KA,  et al.  Visual and cognitive deficits predict stopping or restricting driving: the Salisbury Eye Evaluation Driving Study (SEEDS).  Invest Ophthalmol Vis Sci. 2009;50(1):107-113. doi:10.1167/iovs.08-2367PubMedGoogle ScholarCrossref
29.
Okonkwo  OC, Crowe  M, Wadley  VG, Ball  K.  Visual attention and self-regulation of driving among older adults.  Int Psychogeriatr. 2008;20(1):162-173. doi:10.1017/S104161020700539XPubMedGoogle ScholarCrossref
30.
Ontario Ministry of Transportation. Ontario road safety annual report. http://www.mto.gov.on.ca/english/publications/pdfs/ontario-road-safety-annual-report-2011.pdf. Published 2011. Accessed May 18, 2018.
31.
Bell  CM, Hatch  WV, Fischer  HD,  et al.  Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery.  JAMA. 2009;301(19):1991-1996. doi:10.1001/jama.2009.683PubMedGoogle ScholarCrossref
32.
Rapoport  MJ, Zagorski  B, Seitz  D, Herrmann  N, Molnar  F, Redelmeier  DA.  At-fault motor vehicle crash risk in elderly patients treated with antidepressants.  Am J Geriatr Psychiatry. 2011;19(12):998-1006. doi:10.1097/JGP.0b013e31820d93f9PubMedGoogle ScholarCrossref
33.
Williams  J, Young  W. A summary of studies on the quality of health care administrative databases in Canada. https://www.ices.on.ca/flip-publication/patterns-of-health-care-2d-edition/files/assets/common/downloads/ICES%20.pdf. Accessed May 18, 2018.
34.
Ontario Population Projections. 2008-2036 Ontario and its 49 Census Divisions. http://www.mississauga.ca/file/COM/Ontario_Population_Projections_2008-2036.pdf. Published 2009. Accessed May 18, 2018.
35.
Canada  S. Focus on Geography Series, 2011 Census Ottawa: Statistics Canada. http://www12.statcan.gc.ca/census-recensement/2011/as-sa/fogs-spg/Facts-pr-eng.cfm?Lang=eng&GC=35. Published 2011. Accessed May 18, 2018.
36.
CIHI Data quality study of emergency department visits for 2004-2005. Canadian Institute for Health Information. https://secure.cihi.ca/free_products/vol1_nacrs_executive_summary_nov2_2007.pdf. Accessed May 18, 2018.
37.
Levy  AR, O’Brien  BJ, Sellors  C, Grootendorst  P, Willison  D.  Coding accuracy of administrative drug claims in the Ontario Drug Benefit database.  Can J Clin Pharmacol. 2003;10(2):67-71.PubMedGoogle Scholar
38.
Juurlink  D, Preyra  C, Croxford  R,  et al. Canadian Institute for Health Information Discharge Abstract Database: a validation study. August 19th, 2014. Available from: Available at http://www.ices.on.ca/~/media/Files/Atlases-Reports/2006/CIHI-DAD-a-validation-study/Full%20report.ashx. Accessed May 18, 2018.
39.
Campbell  RJ, Bronskill  SE, Bell  CM, Paterson  JM, Whitehead  M, Gill  SS.  Rapid expansion of intravitreal drug injection procedures, 2000 to 2008: a population-based analysis.  Arch Ophthalmol. 2010;128(3):359-362. doi:10.1001/archophthalmol.2010.19PubMedGoogle ScholarCrossref
40.
Hatch  WV, Cernat  G, Wong  D, Devenyi  R, Bell  CM.  Risk factors for acute endophthalmitis after cataract surgery: a population-based study.  Ophthalmology. 2009;116(3):425-430. doi:10.1016/j.ophtha.2008.09.039PubMedGoogle ScholarCrossref
41.
Hatch  WV, Cernat  G, Singer  S, Bell  CM.  A 10-year population-based cohort analysis of cataract surgery rates in Ontario.  Can J Ophthalmol. 2007;42(4):552-556. doi:10.3129/i07-090PubMedGoogle ScholarCrossref
42.
Campbell  RJ, Gill  SS, Bronskill  SE, Paterson  JM, Whitehead  M, Bell  CM.  Adverse events with intravitreal injection of vascular endothelial growth factor inhibitors: nested case-control study.  BMJ. 2012;345:e4203. doi:10.1136/bmj.e4203PubMedGoogle ScholarCrossref
43.
Hux  JE, Ivis  F, Flintoft  V, Bica  A.  Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm.  Diabetes Care. 2002;25(3):512-516. doi:10.2337/diacare.25.3.512PubMedGoogle ScholarCrossref
44.
Tu  K, Campbell  NR, Chen  ZL, Cauch-Dudek  KJ, McAlister  FA. Accuracy of administrative databases in identifying patients with hypertension. CORD Conference Proceedings. 2007;1(1):e18-e26.
45.
Gershon  AS, Wang  C, Wilton  AS, Raut  R, To  T.  Trends in chronic obstructive pulmonary disease prevalence, incidence, and mortality in ontario, Canada, 1996 to 2007: a population-based study.  Arch Intern Med. 2010;170(6):560-565. doi:10.1001/archinternmed.2010.17PubMedGoogle ScholarCrossref
46.
World Health Organization.  International Statistical Classification of Diseases and Related Health Problems. Geneva, Switzerland: World Health Organization; 2004.
47.
Redelmeier  DA.  The exposure-crossover design is a new method for studying sustained changes in recurrent events.  J Clin Epidemiol. 2013;66(9):955-963. doi:10.1016/j.jclinepi.2013.05.003PubMedGoogle ScholarCrossref
48.
Schlenker  MB, Thiruchelvam  D, Redelmeier  DA.  Intravitreal anti-vascular endothelial growth factor treatment and the risk of thromboembolism.  Am J Ophthalmol. 2015;160(3):569-580.e5. doi:10.1016/j.ajo.2015.06.011PubMedGoogle ScholarCrossref
49.
Redelmeier  DA, Yarnell  CJ, Thiruchelvam  D, Tibshirani  RJ.  Physicians’ warnings for unfit drivers and the risk of trauma from road crashes.  N Engl J Med. 2012;367(13):1228-1236. doi:10.1056/NEJMsa1114310PubMedGoogle ScholarCrossref
50.
Maclure  M.  The case-crossover design: a method for studying transient effects on the risk of acute events.  Am J Epidemiol. 1991;133(2):144-153. doi:10.1093/oxfordjournals.aje.a115853PubMedGoogle ScholarCrossref
51.
Box  G, Jenkins  G, Reinsel  G.  Time Series Analysis: Forecasting and Control. Prentice Hall: Upper Saddle River, NJ; 1994.
52.
Hodge  W, Horsley  T, Albiani  D,  et al.  The consequences of waiting for cataract surgery: a systematic review.  CMAJ. 2007;176(9):1285-1290. doi:10.1503/cmaj.060962PubMedGoogle ScholarCrossref
53.
Wait Times for Priority Procedures in Canada. https://secure.cihi.ca/estore/productFamily.htm?pf=PFC2839&lang=fr&media=0. 2015. Accessed May 18, 2018.
54.
Redelmeier  DA, Yarnell  CJ.  Lethal misconceptions: interpretation and bias in studies of traffic deaths.  J Clin Epidemiol. 2012;65(5):467-473. doi:10.1016/j.jclinepi.2011.09.007PubMedGoogle ScholarCrossref
55.
Suissa  S.  Immortal time bias in pharmaco-epidemiology.  Am J Epidemiol. 2008;167(4):492-499. doi:10.1093/aje/kwm324PubMedGoogle ScholarCrossref
56.
Vahabzadeh  A, McDonald  WM, Tibshirani  RJ.  Physicians’ warnings for unfit drivers and risk of road crashes.  N Engl J Med. 2013;368(1):86-87. doi:10.1056/NEJMc1212928PubMedGoogle ScholarCrossref
57.
McNemar  Q.  Note on the sampling error of the difference between correlated proportions or percentages.  Psychometrika. 1947;12(2):153-157. doi:10.1007/BF02295996PubMedGoogle ScholarCrossref
58.
Wang  M.  Generalized estimating equations in longitudinal data analysis: a review and recent developments.  Adv Stat. 2014. doi:10.1155/2014/303728Google Scholar
59.
Evans  L.  Traffic safety measures, driver behaviour responses, and surprising outcomes.  J Traf Med. 1996;24:5-15.Google Scholar
60.
Hedlund  J.  Risky business: safety regulations, risks compensation, and individual behavior.  Inj Prev. 2000;6(2):82-90. doi:10.1136/ip.6.2.82PubMedGoogle ScholarCrossref
61.
Underwood  G, Jiang  C, Howarth  CI.  Modelling of safety measure effects and risk compensation.  Accid Anal Prev. 1993;25(3):277-288. doi:10.1016/0001-4575(93)90022-OPubMedGoogle ScholarCrossref
62.
Subzwari  S, Desapriya  E, Scime  G, Babul  S, Jivani  K, Pike  I.  Effectiveness of cataract surgery in reducing driving-related difficulties: a systematic review and meta-analysis.  Inj Prev. 2008;14(5):324-328. doi:10.1136/ip.2007.017830PubMedGoogle ScholarCrossref
63.
Meuleners  LB, Lee  AH, Ng  JQ, Morlet  N, Fraser  ML.  First eye cataract surgery and hospitalization from injuries due to a fall: a population-based study.  J Am Geriatr Soc. 2012;60(9):1730-1733. doi:10.1111/j.1532-5415.2012.04098.xPubMedGoogle ScholarCrossref
64.
Bates  LJ, Davey  J, Watson  B, King  MJ, Armstrong  K.  Factors contributing to crashes among young drivers.  Sultan Qaboos Univ Med J. 2014;14(3):e297-e305.PubMedGoogle Scholar
65.
Dischinger  PC, Ho  SM, Kufera  JA.  Medical conditions and car crashes.  Annu Proc Assoc Adv Automot Med. 2000;44:335-346.PubMedGoogle Scholar
66.
Margolis  KL, Kerani  RP, McGovern  P, Songer  T, Cauley  JA, Ensrud  KE; Study Of Osteoporotic Fractures Research Group.  Risk factors for motor vehicle crashes in older women.  J Gerontol A Biol Sci Med Sci. 2002;57(3):M186-M191. doi:10.1093/gerona/57.3.M186PubMedGoogle ScholarCrossref
67.
McDonough  CM, Jette  AM.  The contribution of osteoarthritis to functional limitations and disability.  Clin Geriatr Med. 2010;26(3):387-399. doi:10.1016/j.cger.2010.04.001PubMedGoogle ScholarCrossref
68.
Kahneman  D, Tversky  A.  On the psychology of prediction.  Psychol Rev. 1973;80:237-251. doi:10.1037/h0034747Google ScholarCrossref
69.
Redelmeier  DA, Tibshirani  RJ, Evans  L.  Traffic-law enforcement and risk of death from motor-vehicle crashes: case-crossover study.  Lancet. 2003;361(9376):2177-2182. doi:10.1016/S0140-6736(03)13770-1PubMedGoogle ScholarCrossref
70.
Horswill  MS, Waylen  AE, Tofield  MI.  Drivers’ ratings of different components of their own driving skill: a greater illusion of superiority for skills that relate to accident involvement.  J Appl Soc Psychol. 2004;34(1):177-195. doi:10.1111/j.1559-1816.2004.tb02543.xGoogle ScholarCrossref
71.
Janke  MKM.  Accidents, mileage, and the exaggeration of risk.  Accid Anal Prev. 1991;23(2-3):183-188. doi:10.1016/0001-4575(91)90048-APubMedGoogle ScholarCrossref
72.
Langford  J, Methorst  R, Hakamies-Blomqvist  L.  Older drivers do not have a high crash risk:a replication of low mileage bias.  Accid Anal Prev. 2006;38(3):574-578. doi:10.1016/j.aap.2005.12.002PubMedGoogle ScholarCrossref
73.
Tseng  VL, Yu  F, Lum  F, Coleman  AL.  Risk of fractures following cataract surgery in Medicare beneficiaries.  JAMA. 2012;308(5):493-501. doi:10.1001/jama.2012.9014PubMedGoogle ScholarCrossref
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