Visual field testing and fitness to drive in Europe: A cross-country comparison against a potential reference standard

Purpose: The purpose of this study was to assess the agreement between the European Driving Test (EDT)-a new perimetry test designed to comply with the visual field requirements for Group 1 drivers outlined in the European Commission Directive 2009/113/EC-and the manner in which these standards are applied across European countries. Methods: This was a cross-sectional study of patients with visual field loss who underwent fitness-to-drive visual field assessments at the University Hospital Zürich between 2023 and 2025. Patients completed monocular static and kinetic perimetry, as well as binocular perimetry with the Esterman test and the EDT, all performed using an Octopus 900 perimeter. We determined pass/fail outcomes according to Swiss, Swedish, Norwegian and British criteria. We analysed inter-country agreement and diagnostic accuracy of national criteria relative to the EDT using Fleiss' kappa, sensitivity and specificity. Results: The study enrolled 243 patients. Pass rates were 65% (Switzerland), 76% (Sweden), 74% (Norway) and 86% (UK). Inter-country agreement was moderate (Fleiss' κ = 0.56), with lower agreement in central (κ = 0.57) than peripheral (κ = 0.69) visual fields. Compared to EDT results, national standards demonstrated high specificity (0.87-1.00) but variable and low sensitivity (0.39-0.76), particularly for the central visual field. Conclusion: The application of common visual field standards for driver licensing varies across European countries, especially concerning central visual field criteria. Our findings support adopting a uniform perimetry algorithm to ensure consistent visual field evaluation in fitness-to-drive assessments.