North Carolina Board of Examiners in Optometry
Policy Statement on Window Tinting and other North Carolina Department of Motor Vehicles (DMV) Issues:
This Policy covers the following three issues:
Window Tinting and Window Tinting Waivers
Completing DMV Form DL-77 - Question 18
Requirement to Report Visually Impaired Drivers
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1. Window Tinting and Window Tinting Waivers.
Executive Summary On Window Tinting and Waivers:
Maximum window tinting allowed by waiver decreases a driver’s detection threshold over standard window tinting, particularly at night, and thereby increases the potential for a motor vehicle accident.
DMV regulations specifically state that photosensitivity (not photophobia) is a basis for a window tinting waiver. However, the Tinted Window Waiver Application Form states the “patient suffers from a medical condition that is sensitive to visible light” as the criteria for a physician signing the Application Form. Photosensitivity is a dermatological sign not an ocular sign. However, patients interpret the form to mean light sensitivity as an eye condition and request their optometrist to sign the Application Form. In the Board’s view, photophobia is not an appropriate basis for an OD signing a window tinting waiver as a patient can simply wear protective sunglasses that can be removed for limited light environments such as night driving.
Given the above, should an OD still decide to provide a window tinting waiver, the OD must have an established ocular diagnosis and have substantiated that this condition is severe enough to cause a chronic photophobic condition. The Board requires that this condition and its clinical findings be well documented in the patient record. Conditions such as chronic uveitis or severe dry eye disease, such as seen in Sjogren’s Syndrome, etc. could be such conditions.
Detailed Statement on Window Tinting and Waivers
The following two questions are examples of concerns expressed about patients who seek window tinting waivers when they have little or no pathology to justify such a waiver by the optometrist that can be documented in the patient’s medical record.
We keep having patient requests for us to sign a waiver for car windshield tint restrictions. We have refused to do so in the past unless there was a valid medical reason for it (so far, none). Does the Board have a position? Those laws are in place for a reason and should not be circumvented. This would lessen the pressure on us to appease the patient if we could show a Board policy to them.
I was wondering if the NC board has any guidance on determining eligibility for tinted windows? We have had quite a few patients request this. The form does not clearly define what constitutes a medical condition that causes light sensitivity, and many of these are not diagnosed by us as optometrists. For example, migraines, epilepsy and TBI are diagnosed typically by neurologists.
As optometrists, we understand that most window tinting waiver requests are more about the car's cosmetics than legitimate medical issues. Since there are better alternatives to tinting, such as light protective eyewear, the Board hopes this Policy will assist you in communicating with your patients seeking these waivers.
The primary question the Board must address is what is in the best interest of the public and the patients we serve, given the current policy of the DMV based on the governing regulations.
The DMV regulation that governs window tinting states:
“Individuals with a photosensitivity to light (emphasis added) who need darker window tints can apply for a medical exception permit with the N.C. Division of Motor Vehicles' Medical Review Program.”
Remember that the Regulation does not mention photophobia or the eyes being sensitive to light.
The regulation states photosensitivity to light. Photosensitivity is a sign of a dermatological condition with an immune origin (abnormal skin reaction to sunlight). More details on photosensitivity and how it applies to an NC DMV waiver (here).
Photophobia is a symptom of an ocular condition with a neurological origin. Since photophobia has no relationship to photosensitivity and photophobia is not mentioned in the regulation, the answer seems simple: photophobia is not a basis\ to issue a window tinting waiver under the current DMV Regulation.
However, the application for a window tinting waiver to North Carolina’s DMV Medical Review Program requires the physician to state, “Yes, I certify that the above patient suffers from a medical condition that is sensitive to visible light, such being: __________.” Because of this description, patients seek window tint waivers from optometrists for photophobia, not from dermatologists for photosensitivity. NC DMV Tinted Window Waiver Application Form
The Optometry Board believes this to be a significant error that should be addressed by the DMV’s Medical Review Program. In the Board’s opinion, there is a much better and safer alternative to managing patients with photophobia than window tinting. Wrap-around sunglasses can offer protection from problematic light in the daytime and can offer different levels of light transmission. Sunglasses can be removed at night or in low-light environments. On the other hand, window tinting greater than the standard obviously cannot be removed. Window tinting decreases a patient's detection threshold, thereby increasing accident potential, especially at night.
Given the current interpretation of the criteria for window tinting, when a patient requests that an optometrist sign a window tinting waiver, the Board requires that there be an associated ocular medical condition appropriately documented in the patient's medical record as well as the clinical finding leading to this diagnosis. Ordinarily, the Board requires that such a medical condition be a chronic photophobia serious enough that the patient is and likely will remain under the continuous care of the optometrist.
There is no inclusive list of ocular conditions an optometrist can use to justify this decision. The optometrist must use their professional judgment. Photophobia is a symptom, and the waiver should not be written on the basis of a symptom but rather for a documented medical condition as outlined above.
By way of example, If a patient has an ocular condition such as chronic uveitis or severe dry eye disease (Sjogren’s patient, for example) with corneal epitheliopathy, these would be acceptable diagnoses. The diagnosis should be clearly documented in the patient's medical record and in the treatment plan, along with the follow-up appointment for the condition.
There are conditions where photophobia can be associated with a neurological condition, such as traumatic brain injury. However, waivers in such situations should be provided by the patient's treating physician, PCP, neurologist, etc., as the case may be—not an optometrist.
Accordingly, it is good medical-legal practice to discuss with the patient how darker than standard window tinting increases accident potential and, importantly, to document your discussion in the patient’s record.
If an optometrist signs a window tinting waiver without appropriate medical justification—and without consideration and explanation of why sunglasses were not a better alternative—if the patient subsequently should have a motor vehicle accident, it is possible the optometrist could be alleged to be a causal factor of the accident.
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2. DMV Form 77 Question 18 – Statement on patient’s medical condition(s) and potential effect on safe driving ability.
Here is Question 18 from DMV Form 77 (DL-77 Rev. 2/2019 - North Carolina Department of Motor Vehicles - Vision Specialist) with a considered statement regarding the extent of the optometrist’s evaluation of the patient.
18. Has the driver been involved in a recent motor vehicle accident because of their medical conditions? Yes ___ No ___
Give your overall assessment of this patient's medical condition and any potential effect on safe driving.
Please comment on all medical conditions and any over-the-counter or prescription medications that might exacerbate the risk of driving. ________________________________________________________________
My comments are related to my examination of the patient’s ocular and visual status. The patient’s overall medical status would best be addressed by the patient’s PCP.
A typical question from a licensee regarding Form 77, Question 18:
How am I supposed to comment on all of the patient’s medical conditions when I am only examining the patient’s eyes and being asked to complete the DMV form DL-77?
In the first section of question Question 18, where it asks for a history of a motor vehicle accident, it asks for a yes or no answer. If the answer to that question is unknown, the Board would suggest answering the question by writing “unknown” as the response.
As to the second set of directions [overall assessment], absent the OD’s knowledge of any pertinent ocular or visual information, the Board believes an appropriate response might be what is stated above in red ink.
A similar response was found on the internet:
As an eye care specialist, my care and evaluation of this patient is related to their ocular health and vision, and it would be inappropriate to comment on this patient’s overall medical status under the care of their PCP or otherwise. My comments are related to my examination of the patient’s ocular and visual status.
AMA Code of Ethics Opinion 8.2 also may provide guidance:
Impaired Drivers & Their Physicians:
“Not all physicians are in a position to evaluate the extent or effect of a medical condition on a patient’s ability to drive, particularly physicians who treat patients only on a short-term basis. Nor do all physicians necessarily have appropriate training to identify and evaluate physical or mental conditions in relation to the ability to drive. In such situations, it may be advisable to refer a potentially at-risk patient for assessment.”
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3. Requirement to report a patient with a visual disability that you believe may affect the patient's ability to operate a motor vehicle safely.
Question from an optometrist sent to the Board:
Are optometrists obligated in North Carolina to report to the DMV regarding who should have driving privileges removed or recommend glasses for driving? Also, are optometrists held liable if an accident were to occur?
REPORTING A CONDITION THAT MAY AFFECT A PERSON’S ABILITY TO DRIVE SAFELY
North Carolina General Statute section 20-9.1 contains guidance on this issue:
”Notwithstanding…any other law relating to confidentiality of communications between physicians…or other medical providers and their patients…a physician…or other medical provider duly licensed in the State of North Carolina may disclose after consultation with the patient to the Commissioner information about a patient who has a physical or mental disability or disease that the physician…or medical provider believes may affect the patient’s ability to operate a motor vehicle safely. This information shall be limited to the patient’s name, address, date of birth, and diagnosis.” G.S. 20-9.1(a) (underlining added).
“A physician…or other medical provider disclosing or not disclosing information pursuant to this section, or conducting an evaluation and making a recommendation to the Division regarding a person’s ability to operate a motor vehicle safely, is immune from any civil or criminal liability that might otherwise be incurred or imposed based on the disclosure or lack of disclosure provided that the physician…or other medical provider was acting in good faith and without malice. In any proceeding involving liability, good faith and lack of malice are presumed.” G.S. 20-9.1(c).
If you are asked by the North Carolina DMV or a patient to complete DMV Form DL-77, you obviously should state accurately your clinical findings for that patient and your impression of the patient's ability to drive based on such clinical findings.
However, If you examine a patient who is not requesting that Form DL- 77 be completed and you do observe findings that would limit or disqualify the patient from meeting the NC DMV visual standards for driving, you are under no legal obligation to report your findings to the DMV. See the “may” underlined in G.S. 20-9.1(a) above: North Carolina is not a mandatory reporting state. North Carolina has no statutory provision requiring physicians to report to a central state agency patients diagnosed with conditions that could limit or affect the patient’s driving ability. However, while you are not legally obligated to report a disqualifying condition, you have the option to do so and you are protected from civil liability if you choose to do so (assuming you otherwise comply with G.S. 20-9.1). G.S. 20-9.1(c).
You should use your professional judgment in deciding whether to report a situation or condition you believe may affect the patient’s ability to operate a motor vehicle safely. For example, a patient presents with a history of a recent stroke, and your finding shows a right or left homonymous hemianopsia. That patient’s driver’s license does not expire for three years, and the patient intends to continue driving. Arguably, you have moral and ethical considerations in deciding whether to report: a failure to report the patient’s condition could jeopardize not only your patient but also other drivers and pedestrians. Regardless of your decision on whether to report such a condition, you are obligated to have a frank discussion with the patient and document the medical record that you informed the patient of your findings and how that would limit or disqualify them from driving by NC DMV standards.
If you decide to report your findings to the DMV, you would do so on the North Carolina DMV Request for Driver Re-Examination Form.
If reporting a patient, I would do so following a review of G.S. 20-9.1 and the AMA’s Code of Ethics Impaired Drivers & Their Physicians, which provides sound advice on how to fulfill your professional responsibility and at the same time, respect the patient’s privacy and confidentiality.
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