BIOPTIC DRIVERS AUSTRALIA

Kooijman AC1, Melis-Dankers BJ, Peli E, Brouwer WH, Pijnakker P, Van Delden G, Van Pluuren E, Van Iddekinge B, Derksen P, Busscher RB, Bredewoud RA, Van Rosmalen JH, Postema FJ, Wanders I, De Vries J and Witvliet JM

In many states of the U.S.A., people with moderately reduced visual acuity e.g., 20/50 - 20/200) can legally drive with the aid of a small, spectacle-mounted ("bioptic") telescope. In this paper, we describe the framework of the project from conception through to realization of BDA's primary objective - the introduction of bioptic driving as a legal option for visually impaired people in The Netherlands.

Robert Chun, Maria Cucuras, Walter.M Jay

In this review, the authors discuss the current perspectives of spectacle-mounted telescopes (bioptics) used for driving among patients with vision impairments. The history, design, driving laws surrounding bioptic use, and developing programs in The Netherlands and Canada are discussed. Patients who have certain visual requirements and stable disease status may be eligible candidates to consider using a bioptic aid for driving. Given the high prevalence of depression among visually impaired patients, low vision specialists can work with neuro-ophthalmologists to maximise the independence and visual function of patients who have permanent vision impairments but capable of maintaining driving privileges.

Bioptic Driving Movie by Low Vision Centers of Indiana

In March 1971, California licensed the first bioptic driver.

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Produced by the Low Vision Centers of Indiana , this movie explains the steps in becoming a bioptic driver, who is a good candidate and the training to become licensed. Animations explain how the bioptic is used. The movie is an ideal starting point for someone interested in bioptic driving. It features Dr. Laura K Windsor, patients of the Low Vision Centers of Indiana, and Sue Henderson, a driving rehabilitation specialist from South Bend Memorial Hospital. The movie is designed to present a good overview of the process of becoming a bioptic driver and the impact it has on patients lives. The doctors of the Low Vision Centers of Indiana have fit hundreds of bioptic drivers.

By Dr Eli Peli

This articles discusses low vision driving using a bioptic telescope. The author introduces the subject be reinforcing 'Driving is a privilege not a right'. Discussing the USA context talks to the impact of inability to obtain a licence, such as "...social isolation, economic difficulties, and limits access to healthcare and other services... increase depression amongst the elderly... younger people loss or inability to gain driving privileges limits job opportunities, social interactions, and may severely restrict location of housing and life style." The author argues "...one would not like to withhold driving privileges unless absolutely necessary. Interpretation of the American with Disabilities Act prohibits unjustified limiting of a driving license as discrimination against the disabled."

The author further states "The idea of low vision driving evokes emotional objections from lay people and professionals alike... Many people believe that low-vision driving will lead to an increase in these already frightening accident statistics. This belief, however, is not founded on scientific data, and indeed is frequently in direct contradiction to such data. The visual requirements for driving are frequently misunderstood due to reliance on driving regulations that appear to have been arbitrarily established in the face of a dearth of scientific evidence. As a result, the vision requirements for driving regulations vary widely from state to state and also differ significantly from regulations in other countries, most notably with respect to the regulations regarding restricted driving with low vision, with or without visual aids."

Oberstein SL, Boon MY, Chu BS, Wood JM

Background: Eye-care practitioners are often required to make recommendations regarding their patients' visual fitness for driving, including patients with visual impairment. This study aimed to understand the perspectives and management strategies adopted by optometrists regarding driving for their patients with central visual impairment.

Method: Optometrists were invited to participate in an online survey (from April to June 2012). Items were designed to explore the views and practices adopted by optometrists regarding driving for patients with central visual impairment (visual acuity [VA] poorer than 6/12, normal visual fields, cognitive and physical health), including conditional driver's licences and bioptic telescopes. Closed- and open-ended questions were used.

Results: The response rate was 14 per cent (n = 300 valid responses were received). Most respondents (83 per cent) reported that they advised their patients with visual impairment to 'always' or 'sometimes' stop driving. Most were confident in interpreting the visual licensing standards (78 per cent) and advising on legal responsibilities concerning driving (99 per cent). Respondents were familiar with VA requirements for unconditional licensing (98 per cent); however, the median response VA of 6/15 as the poorest VA suggested for conditional licences differed from international practice and Australian medical guidelines released a month prior to the survey's launch. Few respondents reported prescribing bioptic telescopes (two per cent). While 97 per cent of respondents stated that they discussed conditional licences with their patients with visual impairment, relatively few (28 per cent) reported having completed conditional licence applications for such individuals in the previous year. Those who had completed applications were more experienced in years of practice (p = 0.02) and spent more time practising in rural locations (p = 0.03) than those who had not.

Conclusion: The majority of Australian optometrists were receptive to the possibilities of driving options for individuals with central visual impairment, although management approaches varied with respect to conditional licensing.

Bradley E. Dougherty, Roanne E. Flom, Mark A. Bullimore, and Thomas W. Raasch

The purpose of this study was to determine significant associations among previous driving experience, vision, and motor vehicle collisions (MVCs) for bioptic drivers in Ohio.

Method: We conducted a retrospective study of patients who received a vision examination and subsequently obtained bioptic licensure. We obtained driving records from the Ohio Bureau of Motor Vehicles in order to determine MVC involvement. Relationships among vision measures, age, sex, previous experience, and MVCs were investigated using time-to-event analysis and the Cox proportional hazards regression model. 

Results: We identified 237 bioptic drivers (65% male). Age at initial exam ranged from 16 to 81 years, and mean visual acuity was approximately 20/120. The number of MVCs per driver ranged from 0 to 11, with 124 (52%) drivers having had at least one MVC. Visual acuity and contrast sensitivity were not significant predictors of MVC. Drivers without previous driving experience were significantly more likely to have been involved in an MVC (P < 0.001), and this association remained significant after adjusting for age and sex (P = 0.01). The rate of MVC per year decreased steadily over a 10-year period for drivers without previous experience.

Conclusion: Previous nonbioptic driving experience, but not visual acuity or contrast sensitivity, was associated with yearly MVC rate in bioptic drivers.

Howard Larkin

Because driving is so dependent on out for restriction, Dr Peli points out.vision, common sense dictates that driving must be unsafe beyond a certain threshold of visual impairment. This idea is so compelling that traffic authorities worldwide restrict or prohibit driving by persons with defects in visual acuity and often in visual field. Problem is, the scientific evidence linking these clinical measures of vision to unsafe driving performance is weak to non-existent, says Eli Peli, OD, professor of ophthalmology at Harvard Medical School in Boston, US. The correlation with visual acuity is especially tenuous. “There are no firm, evidence-based standards, so people make decisions based on weak reasoning,” Dr Peli says. “Legislators look at the state next door and they adopt similar standards because that is what people are used to and what they will accept.” 

The 2005 International Council of Ophthalmology report, “Vision Requirements for Driving Safety,” recommends that countries worldwide adopt 0.5 visual acuity and 120o horizontal visual field as a screening point for an unrestricted licence. The report recommends such requirements “not because one becomes

A person spotting through a monocular bioptic telescope. Shown is a 3.0X Keplerian telescope (Mini, manufactured by Ocutech, inc). This telescope was used by some of the subjects in the Dutch study unsafe at 0.4 but it includes a safety margin for adverse conditions.” In other words, anyone who has 0.5 visual acuity is likely to retain enough vision to drive safely in the dark, rain, fog or other poor conditions.

However, the report further recommends that individual consideration be given to those in the 0.5-0.1 range, with additional vision, cognitive, and functional tests, including a road test, if there is any doubt. Restricted licences also should be available for the purpose of “improv[ing] the safety margin (inherent in the standard requirements) through avoidance of hazardous conditions, especially for those who have prior experience and a good driving record.” 

Cynthia Owsley, Gerald McGwin, Jr, Jennifer Elgin and Joanne M. Wood

This article compares self-assessed driving habits and skills of licensed drivers with central visual loss who use bioptic telescopes to those of age-matched normally sighted drivers, and to examine the association between bioptic drivers' impressions of the quality of their driving and ratings by a “backseat” evaluator. Conclusions revealed that bioptic drivers show insight into the overall quality of their driving and areas in which they experience driving difficulty. They report using the bioptic telescope while driving, contrary to previous claims that it is primarily used to pass the vision screening test at licensure.

Claude Vincent PhD, OT(c), Jean-Paul Lachance OD, MEd & Isabelle Deaudelin BSc

Research out of Canada, this study sought to compare road safety of new drivers with low vision who have followed a specific pilot bioptic training program with other groups of drivers all matched for age and driving experience. The number of new drivers involved in at least one accident and who committed at least one offense is not greater for users of a bioptic telescope than for drivers of in the other groups. The results of this study indicate that driving with a bioptic telescope does not increase the risk of accidents and offenses, with more scientific evidence than in previous studies, among drivers aged between 25 and 35 who have a congenital visual impairment and who have completed an eight-week pilot bioptic training program.

Alex R. Bowers, Doris H. Apfelbaum and Eliezer Peli

​Purpose: Visually impaired people are permitted to use bioptic telescopes for driving in many states in the United States. However, it has been suggested that the telescope is used only to meet the visual acuity criteria for licensure. In this study, a survey was used to establish the extent to which bioptic telescopes are used by and meet the driving needs of people with moderately reduced visual acuity.

Conclusion: The bioptic telescope met the (self-reported) driving needs of the majority of visually impaired drivers in this survey and was found to be a useful aid for tasks requiring resolution of detail.

Eliezer Peli and Fernando Vargas-Martin

This document (US patent) addresses the importance of the bioptic telescope system. It provides images of the bioptic telescope’s design, a detailed description of the invention’s field, background, and also a general summary of the product.

Joanne M. Wood, Gerald McGwin, Jr, Jennifer Elgin, Karen Searcey, and Cynthia Owsley

Professor Wood as an Australian expert in bioptic research, conducted this study in the United States with fellow above researcher.

Purpose: To compare the on-road driving performance of visually impaired drivers using bioptic telescopes with age-matched controls. 

Method: Participants included 23 persons (mean age = 33 ± 12 years) with visual acuity of 20/63 to 20/200 who were legally licensed to drive through a state bioptic driving program, and 23 visually normal age-matched controls (mean age = 33 ± 12 years). On-road driving was assessed in an instrumented dual-brake vehicle along 14.6 miles of city, suburban, and controlled-access highways. Two backseat evaluators independently rated driving performance using a standardized scoring system. Vehicle control was assessed through vehicle instrumentation and video recordings used to evaluate head movements, lane-keeping, pedestrian detection, and frequency of bioptic telescope use.

Results: Ninety-six percent (22/23) of bioptic drivers and 100% (23/23) of controls were rated as safe to drive by the evaluators. There were no group differences for pedestrian detection, or ratings for scanning, speed, gap judgments, braking, indicator use, or obeying signs/signals. Bioptic drivers received worse ratings than controls for lane position and steering steadiness and had lower rates of correct sign and traffic signal recognition. Bioptic drivers made significantly more right head movements, drove more often over the right-hand lane marking, and exhibited more sudden braking than controls.

Szlyk JP1, Seiple W, Laderman DJ, Kelsch R, Stelmack J and McMahon T

This study evaluates a vision rehabilitation program aimed at training persons with central vision loss to use a bioptic telescope for improving life skills, including driving. It also compares the outcomes of subjects who are given bioptic telescopes and training, with subjects who are prescribed telescopic lenses without training. Conclusions revealed there was significant improvement in visual skills with the use of a bioptic telescope. This improvement was greater with training in the use of the lenses in a number of visual skills categories including driving-related skills.

Politzer MR. Erratum in J Am Optom Assoc 1995 Oct;66(10):602.

Background: The use of a bioptic telescope for driving purposes has been controversial. This controversy has been fueled by confusion over which vision skills are needed for driving and how they are measured and developed. To make this issue even more complex, there are no standardized programs for evaluating patients and teaching basic vision skills needed to drive safely.

Methods: This paper will address vision skills and abilities which, intuitively, play an important role in driving. We will also propose a training program for the successful development of these skills since they relate to active driving, specifically, with a bioptic telescope.

Results: Our experience in working with patients who are partially sighted in the driving program seems to indicate that these patients have confidence in using their bioptic telescopic lens system for driving purposes. They appreciate and recognize the responsibility that comes with the independence that is gained from driving with the bioptic system.

Conclusions: It is our hope that by providing these patients with appropriate care and training, we afford them the opportunity to adjust to their bioptic driving lens system and enjoy more years of independence and safe driving.

C.Owsley

Being a licensed driver in the United States and many other countries facilitates health and well-being. Based on the vision standards in most states, individuals with worse than 20/40 visual acuity who desire licensure are denied through the usual licensure application process. However, >40 states have bioptic telescope licensing programs where applicants can gain licensure contingent on meeting specific requirements. Despite the existence of the bioptic telescope and these licensing programs since the 1970s, there has been little rigorous scientific study of this topic. Here, I offer an organizing perspective for a research agenda on driving with bioptic telescopes, with the long-term practical goal being to provide an evidence basis for licensure policies and training programs.

Amy L. Doherty Eli Peli Gang Luo

Purpose: The safety of bioptic telescopes for driving remains controversial. The ring scotoma, an area to the telescope eye due to the telescope magnification, has been the main cause of concern. This study evaluates whether bioptic users can use the fellow eye to detect in hazards driving videos that fall in the ring scotoma area.

Conclusions: Detection of driving hazards is impaired by the addition of a secondary reading like task. Detection is further impaired when reading through a monocular telescope. The effect of the partially‐occluding bioptic supports the role of the non‐occluded fellow eye in compensating for the ring scotoma.

Dougherty BE, Flom RE, Bullimore MA, Raasch TW

Purpose: Bioptic telescopic spectacles (BTS) can be used by people with central visual acuity that does not meet the state standards to obtain an unrestricted driver’s license. The purpose of this study was to examine the relationships among visual and demographic factors, training hours, and the results of road testing for bioptic drivers.

Conclusion: New bioptic drivers without previous nonbioptic driving experience required more training and performed more poorly on road testing for licensure than those who had previous nonbioptic licensure. No visual factor was predictive of road testing results after adjustment for previous experience. The hours of training received remained predictive of road testing outcome even with adjustment for previous experience. These results suggest that previous experience and trainer assessments should be investigated as potential predictors of road safety in bioptic drivers in future studies.

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Lisa Kamino, OD, San Diego, California

Driving, often a goal for patients with low vision, is associated with personal independence for many individuals. Oftentimes, an optometrist may be the first person who informs a patient that they do not meet visual acuity requirements for driving. In this respect, it is important for optometrists to be familiar with the laws in their individual states and if permitted, to consider whether their patients may be candidates for bioptic telescope systems for driving. 

Individuals are often directed to cease driving when their acuity becomes reduced below a certain level. In many states, however, these individuals may qualify for licensure with a bioptic telescope system. Therefore, optometrists have the opportunity to change lives through identifying, evaluating, and/or prescribing bioptic telescope systems for potential bioptic driving candidates, thereby enabling certain individuals to continue driving and thus to maintain their independence. 

Cucuras M, Chun R, Lee P, Jay WM, Pusateri G

Purpose: We surveyed bioptic and non-bioptic low-vision drivers in Illinois, USA, to determine their usage of global positioning system (GPS) devices. 

Conclusions: Since non-GPS users were significantly older than GPS users, it is likely that older participants would benefit from GPS technology training from their low-vision eye care professionals.

Chuck Huss and Anne Corn

Abstract: This article presents an overview of driving for adolescents and adults who meet their states’ visual requirements for low vision driving using bioptic lenses. It also discusses the outcomes of two studies of bioptic driver education. 

Alex R. Bowers, Sarah S. Sheldon, Dawn K. DeCarlo, and Eli Peli

Purpose: To investigate the telescope use and driving patterns of bioptic drivers with age-related macular degeneration (AMD).

Results: Bioptic usage patterns of AMD drivers did not differ from those of the younger bioptic drivers and greater visual difficulty without the bioptic was strongly correlated with greater bioptic helpfulness. Bioptic AMD drivers were more likely to report avoidance of night driving than the age-similar NV drivers (P = 0.06). However, they reported less difficulty than the nonbioptic AMD drivers in all driving situations (P ≤ 0.02). Weekly mileages of bioptic AMD drivers were lower than those of the younger bioptic drivers (P < 0.001), but not the NV group (P = 0.54), and were higher than those of the nonbioptic AMD group (P < 0.001).

Conclusions: Our results suggest that bioptic telescopes met the visual demands of drivers with AMD and that those drivers had relatively unrestricted driving habits.

Amy L. Doherty, BA; Alex R. Bowers, PhD; Gang Luo, PhD; et al

Objective  To evaluate the ability of the fellow eye to detect stimuli in the area corresponding to the ring scotoma (blind area) of a monocular bioptic telescope in simple conditions (conventional perimetry) and in more visually demanding conditions.

Conclusions  To our knowledge, this is the first study to demonstrate fellow-eye detection in the area of the ring scotoma with a monocular bioptic telescope under more realistic and visually demanding conditions than conventional perimetry. These results should ease the concern that the monocular ring scotoma might cause blindness to traffic outside the field of the telescope.

Melis-Dankers, B. J. M., Kooijman, A. C., Brouwer, W. H., Busscher, R. B., Bredewoud, R. A., Derksen, P. H., Amersfoort, A., IJsseldijk, M. A. M., Delden, G. W. V., Grotenhuis, T. H. P. A. & Witvliet, M. D. 2008 In : Visual Impairment Research: The official publication of the International Society for Low-vision Research and Rehabilitation ISL. 10, 1, p. 7-22 16 p.

Background: In Europe, driving a passenger car is prohibited if binocular best corrected visual acuity (BCVA) is below 0.5 (20/40). Some US states allow people with reduced visual acuity to use a bioptic telescope system when driving. The aim of our study is to introduce a bioptic telescope system for driving in the Netherlands and to investigate whether it enables people with reduced visual acuity to gain sufficient practical fitness to drive in a European setting.

Conclusion: This is the first study in Europe to prepare subjects with reduced visual acuity to drive with the use of a bioptic telescope system. About 55% of the preselected subjects fulfilled all inclusion criteria. Half of the subjects who entered the bioptic training program passed the official fitness to drive test, demonstrating that they could drive smoothly and safely in Dutch traffic using a bioptic telescope system.

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Results confirm our 6 hypothesis. Results regarding the number of offences and accidents show that drivers using a bioptic telescope and having completed an eight-week training are similar to drivers of the same age, with the same driving experience and who drive with a license, with or without restrictions, in Quebec. Our results can thus be generalized for all new drivers aged 25-35. They are hence different with the results of the four American studies conducted with non comparable control groups, e.g. representing all drivers of all ages with various driving experiences [1,3]. The positive results in terms of the social participation of drivers using a bioptic telescope are similar to [9] in terms of dependency, social function and role difficulties. Results concerning satisfaction towards the technical aid (bioptic telescope) show that the aid is comfortable, efficient and durable, and that customer services were always accessible and adequate. The fact that the satisfaction level is so high shows that users are well trained and adapted very well. This study has few limitations.

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The purpose of this study was to investigate the telescope use behaviors in
natural daily driving of people with reduced visual acuity licensed to drive with a bioptic (a small spectacle-mounted telescope).

Conclusions: In daily driving, the bioptic drivers mostly (>98% of driving time) drove under low visual acuity conditions. The bioptic telescope was mainly used for observing road and traffic conditions in the distance for situational awareness. Only a small portion of usage was for road sign reading.
Translational Relevance: This study provides new insights into how the vision rehabilitation device—bioptic telescopes are used in daily driving. The findings may be helpful for designing bioptic driving training programs.

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