Visual Impairment and Driving in Older Adults: A Narrative Review.

Purpose of Review: This narrative review synthesizes current evidence on the relationship between visual impairment and driving safety in older adults, with a focus on the visual functions required for safe driving, the impact of common visual deficits, and current approaches to clinical evaluation and management. Recent Findings: Recent studies have strengthened evidence that visual functions beyond high contrast visual acuity--particularly visual field sensitivity, contrast sensitivity, and visual processing speed--are associated with driving performance and crash risk. Emerging studies also highlight the role of higher-order visuospatial processing and the integration of visual input with cognitive, multisensory, and motor systems. Advances in functional assessment tools and in-vehicle technologies, such as advanced driver-assistance systems, may further enhance evaluation and support driving safety. Summary: Driving safety in older adults with visual impairment is multifactorial and cannot be adequately assessed by a single visual measure. A multidomain approach incorporating visual, cognitive, and functional assessment is essential for clinical decision-making. Management should emphasize treatment of reversible conditions, patient-centered counseling, and referral for functional driving evaluation when appropriate. Future research should focus on developing functionally relevant, real-world measures to better guide clinical practice and policy. Opinion Statement: Driving is a visually intensive activity that plays a central role in maintaining independence, mobility, and social participation for older adults. As global populations age, the number of older drivers is increasing, making safe mobility an important public health concern. Visual impairment is common in later life and may arise from both ocular disease and neurologic conditions affecting the visual pathways or higher-order visual processing. Although driver licensing systems worldwide rely heavily on visual acuity thresholds to determine visual fitness to drive, growing evidence indicates that visual acuity alone provides an incomplete assessment of driving safety. Safe driving depends on the coordinated function of multiple visual domains, including central vision, peripheral vision, contrast sensitivity, motion and depth perception, visual processing speed, and higher-order visuospatial processing. Impairments in these domains may compromise hazard detection, situational awareness, and timely responses to changing traffic conditions, even when central visual acuity remains relatively preserved. In addition, driving performance requires integration of visual input with cognitive, multisensory, and motor systems, which may be affected by neurologic disease and age-related changes in sensory processing. Clinical evaluation of older drivers with visual impairment should therefore extend beyond visual acuity to incorporate multidomain assessment of visual and neurologic function when concerns arise. Management strategies should prioritize treatment of reversible visual conditions, patient counseling regarding adaptive driving behaviors, and referral for functional driving evaluation when appropriate. Ultimately, decisions regarding driving must balance preservation of independence with public safety. Continued research is needed to develop evidence-based screening strategies and policies that better reflect the complex visual demands of real-world driving.