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

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

Learning Objectives

Understand importance of accessibility to, and involvement in, the bioptic driving processUnderstand licensure options and national driving standardsRecognize patient populations where driving is a critical factor Identify the optometric role in driving-related issuesAdvocate driving privileges based on clinical findings

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

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

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!

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

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

…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*

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

Is There Licensure Discrimination?

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

Example: Texas MAB

Comparison of accident ratios per hundred drivers:8.50% neurological impairments5.63% cardiovascular impairments4.86% visual impairments

…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.

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 Association’s Section on Ophthalmology

Lack of standardization for non-restricted licensure as well…

Vision and Driving20/40 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

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

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

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

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 

Current Licensure Regulations

18 states have no visual field requirements

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, …

…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

Thank you Dr. Feinbloom!

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

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

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) 

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)

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)

Bioptic Driving In The U.S.A.

Bioptic Driving Allowed Bioptic Can Be Used Bioptic Driving Not Allowed

(Grover & Barnes, 2000)

AOA 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…”

AOA LVS Statement

The Driving Population

What Are Bioptic Telescopes

How Bioptic Telescopes Are Used

Vision Criteria

Other Factors Influencing Driving

Driving Research

AOA LVS Statement How OD’s Can Help To Clarify Issues Related To Bioptic Drivers:Provide OR refer for comprehensive evaluations

encompassing factors related to drivingKnow traditional and new TS design technologyContribute to related research studiesProvide expertise to DMV Advisory Committees

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

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

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.)

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/