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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. Introduction. For most people, driving is a very important privilege and a necessary part of maintaining independent living

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Driving and Visual Impairment

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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 Association’s 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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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

Variations in VA Requirements


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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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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 

Variations in VF Requirements


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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 AllowedBioptic Can Be UsedBioptic 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 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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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 OD’s 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/


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