Caring for the Driver With Vision Loss in the USA

1
Caring for the Driver With Vision Loss in the
USA

• Lori L. Grover, O.D., F.A.A.O
• Scottsdale, Arizona
• www.azvisionrehab.com

2
Learning Objectives

• Describe the treatment of individuals with vision
  loss whose goals includes driving
• Highlight factors that can impact driving status
  
• Review the role of the Vision Rehabilitation
  Optometrist and involvement in the bioptic
  driving process
• Discuss available treatment options, highlighting
  bioptic telescopic systems and achieving
  licensure with the use of a bioptic telescope
• Review medico-legal issues involving the patient,
  provider and other stakeholders

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Level of Problem Service Provider
OD, MD/DO OD (MD,DO) OT PT Blind Rehab
O M Social Work Others

• Visual system disorders (disease)
• ?
• Visual impairment
• ?
• Visual disabilities
• ?
• Visual handicaps
• ?
• Altered quality of life

• Medical
• Surgical
• LVR
• ADLs
• O M
• Voc. Rehab.
• Human Services

?

?

?
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Vision RehabilitationCommon Clinical Programs

• Macular Degeneration
• Diabetic Retinopathy
• Head Injury/Stroke
• Glaucoma
• Albinism
• Retinitis Pigmentosa
• Pediatric/Youth
• Special Needs
• Inpatient Care
• Driving with Vision Impairment

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To Drive or Not to DriveThis is the First
Question

• Current Driving Status
• Driving History Experience
• Patient Goals, Motivation Expectations
• Visual Status
• State Legal Guidelines
• Bioptic Requirement
• Recommendation of Eye Doctor
• If answer is YES, then

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Qualification for Bioptic Driving Is Dependent
Upon

• Results of Eye Examination
• Diagnosis of Vision Impairment
• Status of Visual Acuity and Field
• Medical History Health Status
• State Specific Guidelines
• Is a bioptic required? Recommended?
• State Dept./Bureau of Motor Vehicles
• KEY POINT State ultimately controls licensure
  (grants or denies final licensure status), not
  the Doctor!

7
Visual Impairment Description/Classification

• ICD-9-CM (diagnosis codes)
• WHO
• Social Security Administration
• Visual Impairments Determining Eligibility for
  Social Security Benefits, National Research
  Council, Committee on Disability Determination
  for Individuals with Visual Impairments (2002)
• Legal blindness
• Visual acuity, contrast sensitivity, color
  vision, glare sensitivity, stereopsis
• Visual field defects (central, peripheral,
  hemianopic)

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ICD-9-CM
9
Visual Field and Driving

• There is a greater disparity between states
  with regards to visual field requirements as
  compared to those for visual acuity
• 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
  becomes critical
• Most states requiring peripheral visual field
  specify a minimum field requirement of between 75
  degrees (temporal) to 120 degrees (total
  horizontal) without the use of prism

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Driving and Vision ImpairmentClinical 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
  patients with vision loss who are of driving age
• Provide clinical leadership and expertise through
  direct or referral services

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Driving and the Vision Rehabilitation Optometrist

• Within our field, remains area of frustration and
  inconsistencies
• 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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Licensure Discrimination?

• Licensure issued to wide range of
  physically challenged individuals
• Individuals with vision impairment frequently
  denied licensure 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 drivers with vision
  impairment
• 2000 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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Ensuring Access to Drivers Licensure

• How Optometrists Help To Clarify Issues Related
  To Bioptic Drivers
• Provide (or refer) for comprehensive examinations
  and programming which encompassing factors
  related to driving
• Know traditional and new telescope design
  technology, and when to use it
• Contribute to related research studies
• Provide expertise to Department of Motor Vehicles
  Advisory Committees (or parallel entity)

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Licensure Options

• Standard Licensure
• 20/4020/70 varies greatly between states may
  require minimum visual fields, phoria, color
  vision minimums
• Restricted Licensure
• 20/50 20/200 may have VF component and can
  include spectacle Rx time of day geographical
  area no freeways side mirrors driving skills
  exam medical certification highway restriction
  telescopic system use
• Commercial Licensure
• conservative may require VF, color vision,
  stereopsis

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American Optometric Association Statement on
Bioptic Driving (1994)

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

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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 TS use OK but no bioptic licensure in
two states
(Grover, 2000)
Since 2000, several states have introduced
legislation which provides for bioptic licensure,
most recently Louisiana, in April, 2004
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Commonly PrescribedBioptic Telescopic Systems
20
Cosmesis
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Assisting the Bioptic Driver

• In addition to the Bioptic, other factors for
  safe driving include
• Viewing dashboard
• Controlling glare
• Inclement weather
• Reading maps, etc.
• EX Compact - a new portable video scanning
  system from Optelec (Tieman, Netherlands)

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Examples of Bioptic DrivingProfessional
Experiences

• Michigan
• well-established program
• Ohio
• pilot program now established
• California
• bioptic driving not mandated
• Arizona
• there is work to be done on my end
• Thank you so very much!
• www.azvisionrehab.com