Driving and Visual Impairment

1
Driving and Visual Impairment

• Lori L. Grover, O.D., F.A.A.O.
• Assistant Professor
• Chief, Low Vision Rehabilitation Service
• Southern California College Of Optometry

2
Introduction

• For most people, driving is a very important
  privilege and a necessary part of maintaining
  independent living
• When vision is lost as a result of disease,
  trauma or congenital condition, specific visual
  requirements needed for driving may be
  compromised
• Results in an inability to meet requirements for
  legal driving, and restriction or loss of
  licensure

3
Learning Objectives

• Understand importance of accessibility to, and
  involvement in, the bioptic driving process
• Understand licensure options and national driving
  standards
• Recognize patient populations where driving is a
  critical factor
• Identify the optometric role in driving-related
  issues
• Advocate driving privileges based on clinical
  findings

4
Clinical Care Objectives

• Promote comprehensive clinical rehabilitation to
  include treatment options and patient/family
  counseling for driving-related issues
• Advocate the privilege of gaining and/or
  maintaining safe and legal drivers licensure for
  low vision patients of driving age
• Provide clinical leadership and expertise through
  direct or referral services

5
Twentieth Century Demographics

• Americans 65 and older more than tripled
• 4.1 in 1900 vs. 12.7 in 1997
• Older Americans have more than tripled
• 3.1 million to 34.1 million
• By 2030 it is projected that there will be 70
  million 65 or more living in U.S.A.
• Americans 65 and over 12 of population 33 of
  national health care expenditures

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Not only growing, but AGING!

• Number of people 85 or older is 31 times greater
  than that in 1900
• Sixteen fold increase in 75-84 age group
• Eight fold increase in 65-74 age group

CONCLUSION Older persons need comprehensive
optometric care, including driving-related
issues, to maintain a self-reliant, independent
and enhanced life style!
7
Driving and the Low Vision Rehabilitation Practice

• Within our field, remains area of frustration
• Modern society demands independence and freedom
  of mobility
• Inability to drive often results in limitations
  in vocational and avocational options
• Realistic goals of financial and social
  independence depend upon drivers licensure

8
Non-Driver Fallout for Youth...

• Psychological studies have shown young adults
  with visual impairment have strongly linked
  conflicts between transportation problems and
  dependence/emergence of independence
• Results in major negative impact on emerging
  self-concept

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and for the Mature Patient

• Adults who lose driving privileges due to
  acquired vision loss experience decreased
  self-esteem, declining social status and
  increased isolation
• Results in negative impact on relationships with
  friends and family as well as employment-related
  issues

10
Did you know

• It is estimated that 59 of those people ages
  65-69 earn regular wages?
• And
• 95 of all 40 year olds have at least one living
  parent
• 80 of all 50 year olds have at least one living
  parent
• 25 of all female caregivers have been forced to
  take time off from a job to care for aging
  parents
• 12 of these women have had to leave employment
  to render elder-care services

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Is There Licensure Discrimination?

• Licensure issued to wide range of physically
  challenged individuals
• Individuals with VI frequently denied due to
  inability to meet high visual standards developed
  by regulatory agencies throughout the nation
• Denial occurs in spite of consistent data showing
  favorable ranking of VI drivers

12
Example Texas MAB

• Comparison of accident ratios per hundred
  drivers
• 8.50 neurological impairments
• 5.63 cardiovascular impairments
• 4.86 visual impairments

13
and do WE contribute?

• Thorough understanding of state licensure
  requirements and law
• Issues related to driving vision routinely
  discussed with patients and family members
• Provision of appropriate low vision
  rehabilitation care OR referral to colleagues for
  LVR, bioptic driving evaluation, etc.

14
Vision And Driving

• Most states require best corrected VA of 20/40 or
  better but.no standardization
• Recommendation from a 1925 report by American
  Medical Associations Section on Ophthalmology
• Lack of standardization for non-restricted
  licensure as well

15
Vision and Driving

• 20/40 vs. 20/200 (Fonda, Weiss)
• Arbitrary standard based on signage at 20/40, not
  actual visual demands
• Maintained that person with 20/200 at 40 mph can
  drive safely
• Static vs. Dynamic Acuity (Burg)
• Accident rates have a 10 times higher correlation
  with dynamic acuity than static acuity
• Peripheral Image Quality (Feinbloom)
• 12 fully sighted drivers fogged to 20/200 with
  3.00D
• Interesting for central vs. overall loss

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Drivers Licensure Options

• Standard Licensure
• 20/40 20/70 varies greatly between states may
  require VF, phoria, color vision minimums
• Restricted Licensure
• 20/50 20/200 may have VF component and can
  include time of day geographical area no
  freeways side mirrors driving skills exam
  highway restriction TS use
• Commercial Licensure
• conservative may require VF, color vision,
  stereopsis

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Variations in VA Requirements

• Louisiana
• 20/40 best eye without lenses full driving
• 20/50 daylight only
• 20/60 20/70 daytime within 25 mile radius of
  residence

• West Virginia
• 20/40 no restrictions monocular or binocular,
  with or without lenses
• 20/100 minimum or better for licensure

18
Visual Field and Driving

• There is an even greater disparity between states
  with regards to visual field requirements
• One of the most important functions of peripheral
  vision when driving is motion detection
• Objects 3-10 times smaller than those resolved by
  the fovea can be detected in the periphery
  through motion, therefore intact peripheral field
  is critical

19
Variations in VF Requirements

• Louisiana
• 150 degree fields measured with a 10 mm white
  test object at 330mm without corrective lenses in
  the horizontal meridian no restrictions
• 140 but at least 110 degrees restriction for
  outside mirrors and license must display an
  active VF impairment sticker

• West Virginia  
• 20 degree minimum field required from center of
  at least one eye for licensure
• 70 degree field required for non- restricted
  licensure 

20
Current Licensure Regulations

• 18 states have no visual field requirements

21
A Look to the Past

• Statement On The Use Of Bioptic Telescopes For
  Driving AOA Low Vision Section September, 1994
• Articles reports on driving and telescopes
  visual field/acuity deficits role of vision in
  driving bioptic drivers training model
  programs visual performance and accident
  records driving skills diseases and driving,

22
A Look to the Past

• cognitive function and driving psychosocial
  issues restrictions and limitations on driving
  safe and legal driving color perception,
  contrast sensitivity, glare recovery,
  photosensitivity, oculomotor skills and driving
• Independent state regulations and requirements
• La Resistance - those who advocate no driving
  with visual loss under any circumstances

23
Thank you Dr. Feinbloom!

• First developed bioptic telescopic spectacle to
  allow full-time use of telescope

24
Korb - 1969

• First used bioptics (32 out of 67 patients with
  low vision in Massachusetts)
• 26 ultimately received licensure
• Compiled 32 person-years of automobile operation
  without any incidents

25
Bioptic Driving in 1982

• 13 states permitted bioptic driving licensure
• 13 states considered bioptic licensure on an
  individual basis
• 34 states did not allow bioptic driving
• (Janke, Journal of Safety Research, 1983) 

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Bioptic Driving In 1995

• 17 states permitted bioptic driving
• 8 states permitted bioptic licensure on an
  individual basis
• 25 states did not permit bioptic driving

(Fishbaugh, 1995 Appel et al., 1990)
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Bioptic Driving In 2000

• 34 states allow bioptic driving
• 14 states do not allow bioptic driving
• 5 states allow bioptic telescope use
  after passing DMV evaluation

Note District Of Columbia included Note
TS use OK but no bioptic licensure in two states
(Grover, Barnes, 2000)
28
Bioptic Driving In The U.S.A.
Bioptic Driving Allowed Bioptic Can Be Used
Bioptic Driving Not Allowed
(Grover Barnes, 2000)
29
AOA Statement on Bioptic Driving (1994)

• The AOA acknowledges driving is not a right but
  a privilegepublic safety issues are a primary
  concernaccess to driving privilege should not be
  categorically denied to individuals who have
  reduced acuity

30
AOA LVS Statement

• The Driving Population
• What Are Bioptic Telescopes
• How Bioptic Telescopes Are Used
• Vision Criteria
• Other Factors Influencing Driving
• Driving Research

31
AOA LVS Statement

• How ODs Can Help To Clarify Issues Related To
  Bioptic Drivers
• Provide OR refer for comprehensive evaluations
  encompassing factors related to driving
• Know traditional and new TS design technology
• Contribute to related research studies
• Provide expertise to DMV Advisory Committees

32
Potential Problems

• Restricted field and ring scotomas
• Jack-in-the-Box effect
• Inconsistencies with acuity when in motion
• Lack of instruction and training
• Other factors

33
The Bioptic Driving Population

• 670 California
• 4-6 Idaho
• 345 (96), 296 (97), 137 (98) Illinois
• 236 (as of 5/99) Ohio
• 1259 Nevada
• 7-8 Wyoming

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Additional Notes

• All data are as of 2000 - more recent information
  has shown additional states allowing driving with
  visual loss and/or bioptic TS since 2000
• AOA Vision and Driving Symposium to be held at
  the AOA Mid Year Planning Meeting 1-26-03 (I
  will update after mtg.)

35
Summary of Clinical Care

• Promote comprehensive rehabilitation to include
  treatment options and patient/family counseling
  for driving-related issues
• Advocate the privilege of gaining and/or
  maintaining safe and legal drivers licensure for
  low vision patients of driving age
• Provide clinical leadership and expertise through
  direct or referral services
• Also see http//www.biopticdriving.org/