Driving%20and%20Visual%20Impairment

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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

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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

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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

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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

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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!
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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

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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

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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

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Example Texas MAB

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

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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.

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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

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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

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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

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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 

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Current Licensure Regulations

• 18 states have no visual field requirements

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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,

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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

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Thank you Dr. Feinbloom!

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

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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

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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)
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Bioptic Driving In The U.S.A.
Bioptic Driving Allowed Bioptic Can Be Used
Bioptic Driving Not Allowed
(Grover Barnes, 2000)
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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

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AOA LVS Statement

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

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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

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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

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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.)

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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/