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Questions And Answers Questions And Answers Proposed About Driving With Proposed About Driving With
A Visual Impairment:A Visual Impairment:A Literature of ControversyA Literature of Controversy
Gregory L. Goodrich, Ph.D., F.A.A.O.Gregory L. Goodrich, Ph.D., F.A.A.O.
Research Psychologist & Optometric Research Psychologist & Optometric Research Fellowship DirectorResearch Fellowship Director
VA Palo Alto Health Care SystemVA Palo Alto Health Care System
Palo Alto, CA Palo Alto, CA
Goals of this PaperGoals of this Paper
Review the history of driving and low Review the history of driving and low vision driving literature (i.e., 1930 – 1990?)vision driving literature (i.e., 1930 – 1990?)– Need and contextNeed and context– ““Expert” opinionExpert” opinion– Evidence for/against increased accident rateEvidence for/against increased accident rate– Evidence for/against bioptic lensesEvidence for/against bioptic lenses
SummarySummary A Personal Conclusion (She had it right in A Personal Conclusion (She had it right in
1970)!1970)!
The Context of Bioptic DrivingThe Context of Bioptic Driving
The question of who The question of who should drive and under should drive and under what conditions is not newwhat conditions is not new
These questions affect These questions affect many people with various many people with various conditions including conditions including visual impairmentsvisual impairments
In a “good” society the In a “good” society the answers would reflect answers would reflect equitable treatment of all equitable treatment of all peoplepeople
Why Drive At All?Why Drive At All?
The flip answer - to get The flip answer - to get from here to therefrom here to there
It is in society’s interests It is in society’s interests that all people be able to that all people be able to do this safely, efficiently, do this safely, efficiently, and equitably - “It’s the and equitably - “It’s the economy stupid”economy stupid”
For many its an economic, For many its an economic, medical, and practical medical, and practical necessitynecessity
A Legacy of “Danger”A Legacy of “Danger”
June 10, 2004 was the June 10, 2004 was the anniversary of the one anniversary of the one and only automobile and only automobile race Henry Ford race Henry Ford participated inparticipated in
After successfully After successfully winning his first winning his first automobile race at automobile race at Grosse Point, New Grosse Point, New York Henry Ford gave York Henry Ford gave it up as too dangerousit up as too dangerous
Some ContextSome Context
The first automobile accident probably involved a The first automobile accident probably involved a horse and a horseless carriagehorse and a horseless carriage
Both the horse rider and horseless carriage driver Both the horse rider and horseless carriage driver blamed the otherblamed the other
Prior to World War I US automobile accidents had Prior to World War I US automobile accidents had killed over 36,000 peoplekilled over 36,000 people– To put these fatality statistics into context consider that To put these fatality statistics into context consider that
the American Revolutionary War, the War of 1812, the the American Revolutionary War, the War of 1812, the Mexican War, and the Spanish-American War Mexican War, and the Spanish-American War combined killed less than 23,000combined killed less than 23,000
Just Another StatisticJust Another Statistic
Steam, electric, or internal combustion – Steam, electric, or internal combustion – automobiles have been with us for well over automobiles have been with us for well over 120 years120 years
Property damage, injury and death due to Property damage, injury and death due to automobiles have always been with usautomobiles have always been with us
It is society’s responsibility to regulate their It is society’s responsibility to regulate their use in a safe and equitable manneruse in a safe and equitable manner
Historically, determining what regulations Historically, determining what regulations to apply has been problematicto apply has been problematic
Doing Is Inherently DangerousDoing Is Inherently Dangerous(or how to prevent 2/3 of all accidents)(or how to prevent 2/3 of all accidents)
Do NOT ride in automobiles: they cause Do NOT ride in automobiles: they cause 20% of all fatal accidents. 20% of all fatal accidents.
Do NOT stay home: 17% of all accidents Do NOT stay home: 17% of all accidents do occur in home. do occur in home.
Do NOT walk on the streets or sidewalks: Do NOT walk on the streets or sidewalks: 14% of all accidents happen to 14% of all accidents happen to pedestrians. pedestrians.
Do NOT travel by air, rail, or water: Do NOT travel by air, rail, or water: 16% of all accidents happen on these.16% of all accidents happen on these.
Driving is a Recent IssueDriving is a Recent Issue
For 99% of the time For 99% of the time since human beings since human beings developed civilization developed civilization the predominate form the predominate form of transport was of transport was walkingwalking
If you didn’t need to If you didn’t need to leave your village you leave your village you were okay, today that were okay, today that is usually not an is usually not an optionoption
Driving Is An Important IssueDriving Is An Important Issue
““Because of the cost, the experience of indignity Because of the cost, the experience of indignity and lack of freedom related to transportation many and lack of freedom related to transportation many (disabled) individuals do not enter into or remain (disabled) individuals do not enter into or remain in employment.” in employment.”
» Meyer Siegel (1970). Meyer Siegel (1970). Driver training, transportation, and vocational adjustment of the handicapped in an urban setting. Psychological Aspects of Disability, 17, 9-10.
Today an additional issue is elderly, visually impaired individuals seeking means of travel for food, medicines, medical care, socialization, and other necessary activities lack safe, effective transportation.
Low Vision is Even More RecentLow Vision is Even More Recent It has only been in It has only been in
the last 30 to 40 the last 30 to 40 years that there have years that there have been sizeable been sizeable numbers of people numbers of people with low visionwith low vision– 80% of all low vision 80% of all low vision
publications have publications have been written in the been written in the last 2 yrs.last 2 yrs.
– 40+% in the last 10 40+% in the last 10 yrs.yrs.
0
500
1000
1500
2000
2500
3000
3500
4000
4500
1901
-10
1911
-20
1921
-30
1931
-40
1941
-50
1951
-60
1961
-70
1971
-80
1981
-90
1991
-200
0
The “Blindness” ThingThe “Blindness” Thing
Most people don’t understand Most people don’t understand that vision isn’t just ‘sighted’ that vision isn’t just ‘sighted’ or ‘blind’ nor what vision is or ‘blind’ nor what vision is required to accomplish “visual required to accomplish “visual tasks”tasks”
Historically, less than normal Historically, less than normal vision viewed as useless (i.e., vision viewed as useless (i.e., partially blind, legally blind, partially blind, legally blind, defective vision, etc.)defective vision, etc.)
To Overly Simplify (a bit)To Overly Simplify (a bit)
Driving an automobile has historically involved Driving an automobile has historically involved risk and accidentsrisk and accidents
It’s a visually oriented task and a major part of It’s a visually oriented task and a major part of testing for a license is a visual acuity testtesting for a license is a visual acuity test– Road testing may occur only onceRoad testing may occur only once
People with “defective” vision are therefore People with “defective” vision are therefore suspect and often denied the privilege to drivesuspect and often denied the privilege to drive
What historical evidence has there been for What historical evidence has there been for current criteria of what vision is needed for safe current criteria of what vision is needed for safe driving?driving?
The Early Years in Our The Early Years in Our LiteratureLiterature
In 1927 McFadden wrote on the driver licensing In 1927 McFadden wrote on the driver licensing lawslaws
In 1938 DeSilva wrote about one eyed driversIn 1938 DeSilva wrote about one eyed drivers But it wasn’t until the 1950s that limitations of But it wasn’t until the 1950s that limitations of
vision gained greater prominence (visual fields vision gained greater prominence (visual fields formed a significant topic area)formed a significant topic area)
In the 1960s a wide variety of factors were studied In the 1960s a wide variety of factors were studied (i.e., night driving, medical records, relationships (i.e., night driving, medical records, relationships between psychological and ophthalmic factors, between psychological and ophthalmic factors, etc.)etc.)
Relevant Issues in the 1960s - 1Relevant Issues in the 1960s - 1
Writing in the Writing in the British Journal of Physiological British Journal of Physiological OpticsOptics Kite and King noted: Kite and King noted:– Need for research on effect of reduced visual field Need for research on effect of reduced visual field
on drivingon driving– No consistent measurement for licensing standardNo consistent measurement for licensing standard– Basis for visual field standards (in US) unclearBasis for visual field standards (in US) unclear
Relevant Issues in the 1960s - 2Relevant Issues in the 1960s - 2
Arthur Keeney, writing in a 1967 US Arthur Keeney, writing in a 1967 US ophthalmology publication, recommended:ophthalmology publication, recommended:– ““those receiving aid to the needy blind have those receiving aid to the needy blind have
their driver’s licenses removed. Similarly their driver’s licenses removed. Similarly people who get income tax deductions for people who get income tax deductions for visual loss should not be licensed”visual loss should not be licensed”
– Acuity should be 20/40 or 20/50 (6/12, 6/15)Acuity should be 20/40 or 20/50 (6/12, 6/15)– Fields should be at least 140Fields should be at least 140°°
Relevant Issues in the 1960s - 3Relevant Issues in the 1960s - 3
Burg, writing in 1967, noted:Burg, writing in 1967, noted:– ““Considerable variation in the vision-driving Considerable variation in the vision-driving
record relationship is found as a function of sex record relationship is found as a function of sex and age group studied”and age group studied”
– ““With regard to vision tests…the relationships With regard to vision tests…the relationships with the driving record are small”with the driving record are small”
– ““That is ‘good’ vision is associated with ‘poor’ That is ‘good’ vision is associated with ‘poor’ records” (when considering accidents per miles records” (when considering accidents per miles driven)driven)
Relevant Issues in the 1960s - 3Relevant Issues in the 1960s - 3
Julian Waller, publishing in JAMA (1969), noted Julian Waller, publishing in JAMA (1969), noted that medical conditions impair highway that medical conditions impair highway performanceperformance– Chronic medical problems believed to be contributing Chronic medical problems believed to be contributing
factors in up to 25% of crashesfactors in up to 25% of crashes» In regard to vision he noted that dynamic visual acuity most In regard to vision he noted that dynamic visual acuity most
closely correlated with crash rateclosely correlated with crash rate
– Alcoholism may be a factor in 33% of crashesAlcoholism may be a factor in 33% of crashes
– Yet curiously he stated “No more than a quarter of Yet curiously he stated “No more than a quarter of these drivers should have their licenses revoked.”these drivers should have their licenses revoked.”
Relevant Issues in the 1960s - 4Relevant Issues in the 1960s - 4
Committee on Medical Aspects of Automotive Committee on Medical Aspects of Automotive Safety (Archives of Ophthalmology) 1969:Safety (Archives of Ophthalmology) 1969:– Disqualifying eye diseases (for licensing):Disqualifying eye diseases (for licensing):
» Corneal opacitiesCorneal opacities» Lens opacitiesLens opacities» Pigmentary degeneration of the retinaPigmentary degeneration of the retina» Optic AtrophyOptic Atrophy» Degeneration of the maculaDegeneration of the macula» Diabetic retinopathyDiabetic retinopathy» Hypertensive retinopathy with macular involvementHypertensive retinopathy with macular involvement» Obscure or etiologically undetermined pigmentary Obscure or etiologically undetermined pigmentary
disturbancesdisturbances
Summary of the 1960 Summary of the 1960 Contradictory “Views”Contradictory “Views”
Decreased vision, while poorly correlated with accident rate, probably Decreased vision, while poorly correlated with accident rate, probably contributes to many accidents and should disqualify for licensurecontributes to many accidents and should disqualify for licensure
Dynamic visual acuity should be measured, but isn’tDynamic visual acuity should be measured, but isn’t Acuity should be 6/12 to 6/15 although no solid evidence to support Acuity should be 6/12 to 6/15 although no solid evidence to support
this criteriathis criteria Visual fields should be 140Visual fields should be 140° or maybe less° or maybe less Some eye pathologies should automatically preclude licensing and Some eye pathologies should automatically preclude licensing and
“blindness” should certainly disqualify the individual - although there “blindness” should certainly disqualify the individual - although there was little data to back this upwas little data to back this up
Other medical conditions cause more accidents than vision loss, but Other medical conditions cause more accidents than vision loss, but little concerted effort to deny licensing based upon those conditionslittle concerted effort to deny licensing based upon those conditions
In 1970 “It” HappenedIn 1970 “It” Happened
In 1970 a seminal article by Donald Korb In 1970 a seminal article by Donald Korb appearedappeared– Provided detailed guidance on selection and Provided detailed guidance on selection and
rejection of candidatesrejection of candidates– Reported on 26 telescopic lens wearing drivers Reported on 26 telescopic lens wearing drivers
licensed in Massachusetts; he also reported licensed in Massachusetts; he also reported others licensed in New Hampshire, Maine, New others licensed in New Hampshire, Maine, New York, Florida, and two Canadian provinces.York, Florida, and two Canadian provinces.
One Driver’s InfluenceOne Driver’s Influence
In 1971 Dennis Kelleher coauthored a case In 1971 Dennis Kelleher coauthored a case report with Edwin Mehr and Monroe Hirsch report with Edwin Mehr and Monroe Hirsch describing his experiences as a bioptic describing his experiences as a bioptic driver driver (American Journal of Optometry and (American Journal of Optometry and Physiological Optics, 48, 773-6)Physiological Optics, 48, 773-6)
Dennis subsequently published about a Dennis subsequently published about a dozen articles including a training manual dozen articles including a training manual on teaching driving to people with low on teaching driving to people with low vision using biopticsvision using bioptics
In the UKIn the UK
G. T. Chashell, an ophthalmic surgeon, G. T. Chashell, an ophthalmic surgeon, published on visual function in relation to published on visual function in relation to road accidents finding:road accidents finding:– The number of visual defects that occur in The number of visual defects that occur in
drivers who have been involved in accidents is drivers who have been involved in accidents is “negligible”“negligible”
– ““The extrinsic factors should be considered as The extrinsic factors should be considered as important as, if not more so than, visual important as, if not more so than, visual function”function”
Also In 1970Also In 1970
Joan Bardach published on 520 disabled Joan Bardach published on 520 disabled patients participating in a driver training patients participating in a driver training program at the Institute of Rehabilitation program at the Institute of Rehabilitation Medicine in New York, noted:Medicine in New York, noted:– “…“…the saliency of some factors is different in the saliency of some factors is different in
the one group from that of the other suggests the one group from that of the other suggests that studying the pattern of interaction of that studying the pattern of interaction of variables is more relevant than the study of variables is more relevant than the study of each variable separately if one wishes to each variable separately if one wishes to understand the nature of the driving task.”understand the nature of the driving task.”
The Contrary ViewThe Contrary View
While the view against bioptic driving was widely held the While the view against bioptic driving was widely held the two most vocal advocates of banning bioptic driving (at two most vocal advocates of banning bioptic driving (at this time) were two ophthalmologists: Arthur Keeny and this time) were two ophthalmologists: Arthur Keeny and Gerald Fonda. Both correctly pointed out that bioptic Gerald Fonda. Both correctly pointed out that bioptic lenses:lenses: – create a ring scotomacreate a ring scotoma– magnification restricts field of view, andmagnification restricts field of view, and– a nearness illusiona nearness illusion– there is induced displacement of the magnified image there is induced displacement of the magnified image – increased effect of vibration, and increased effect of vibration, and – altered head posturealtered head posture
A Genuine ConcernA Genuine Concern
Gerald Fonda, M.D. Gerald Fonda, M.D. wearing bioptic wearing bioptic telescopic spectacles telescopic spectacles (1991)(1991)
““The BTS is good for The BTS is good for the greedy the greedy ophthalmologist or ophthalmologist or optometrist, and the optometrist, and the BTS is a hazard for the BTS is a hazard for the handicapped using it.”handicapped using it.”
The Literature 1970 to 1990The Literature 1970 to 1990
In this two decade time frame the literature In this two decade time frame the literature can be divided into three categoriescan be divided into three categories– Those articles advocating training qualified Those articles advocating training qualified
drivers with low visiondrivers with low vision– Those advocating against the use of bioptics in Those advocating against the use of bioptics in
driving and/or licensing individuals with less driving and/or licensing individuals with less that 20/40 (6/12) visual acuitythat 20/40 (6/12) visual acuity
– Those studying the relationship between vision, Those studying the relationship between vision, driving performance, and/or accidentsdriving performance, and/or accidents
The Link Between Measures of The Link Between Measures of Vision and Driving PerformanceVision and Driving Performance
Brian Hills summed up the literature Brian Hills summed up the literature relating vision to automobile accidents in a relating vision to automobile accidents in a 1980 article in the journal 1980 article in the journal PerceptionPerception by by stating:stating:– “…“…the available evidence suggests that few of the available evidence suggests that few of
these (accidents) are attributable to reduced or these (accidents) are attributable to reduced or defective vision…”defective vision…”
The Literature from 1990 OnThe Literature from 1990 On
Much like this Jaguar Much like this Jaguar of the future I will of the future I will leave it to my leave it to my colleagues to bring colleagues to bring you up to date on you up to date on research and clinical research and clinical experienceexperience
But I feel history gives But I feel history gives us some “take home” us some “take home” messages …messages …
Bioptic Driving Is:Bioptic Driving Is:
Controversial – Pro or con beliefs are strongly Controversial – Pro or con beliefs are strongly held (few have no opinion)held (few have no opinion)
The question may not be “to drive, or not to drive” The question may not be “to drive, or not to drive” but independence – if society prohibits driving but independence – if society prohibits driving should it be obligated to provide equal should it be obligated to provide equal alternatives?alternatives?
Driving (or an alternative) is very important – Driving (or an alternative) is very important – – Employment Employment – Access to medicine, food, society, etc.Access to medicine, food, society, etc.– Quality of lifeQuality of life
““Less Than Normal Vision”:Less Than Normal Vision”:
Does have an effect on driving - based on Does have an effect on driving - based on over 30 years driving experience of many over 30 years driving experience of many individuals with low visionindividuals with low vision– Devices and training may compensate for thisDevices and training may compensate for this– Empirically based driver selection is criticalEmpirically based driver selection is critical– Driver training (which is important for all Driver training (which is important for all
drivers) is probably more important for drivers drivers) is probably more important for drivers with some degree of low visionwith some degree of low vision
And…And…
The degree of vision loss sufficient to prevent The degree of vision loss sufficient to prevent driving is not well understood, and visual acuity driving is not well understood, and visual acuity and/or visual field tests may not be the best and/or visual field tests may not be the best determinantsdeterminants
Joan Bardach in 1970 may have gotten it right – Joan Bardach in 1970 may have gotten it right – we need to study the pattern of interaction of the we need to study the pattern of interaction of the variables of the individual in driving which variables of the individual in driving which suggests that realistic driver simulators may be suggests that realistic driver simulators may be critical in determining who should/should not be critical in determining who should/should not be licensedlicensed
A Societal QuestionA Societal Question
Given that:Given that:– Some visually impaired drivers have done so Some visually impaired drivers have done so
safely and effectivelysafely and effectively– That some groups of drivers are known to be at That some groups of drivers are known to be at
greater risk of accidents (i.e., stroke patients, greater risk of accidents (i.e., stroke patients, young males, drivers with prior driving under young males, drivers with prior driving under the influence convictions, etc.) than “normals”the influence convictions, etc.) than “normals”
– And that current licensing exams are not based And that current licensing exams are not based upon a scientific foundation …upon a scientific foundation …
We Can Then Ask:We Can Then Ask:
Is it reasonable for society to restrict driving based Is it reasonable for society to restrict driving based solely upon a person’s visual acuity or field using solely upon a person’s visual acuity or field using arbitrary criteria? The historical literature would arbitrary criteria? The historical literature would suggest it isn’tsuggest it isn’t
Is the question then a civil rights question?Is the question then a civil rights question?– Is society willing to develop and commit the resources Is society willing to develop and commit the resources
necessary to develop rational tests so that people with necessary to develop rational tests so that people with some level of visual impairment can determine if they some level of visual impairment can determine if they can drive safely and effectively (even if this involves can drive safely and effectively (even if this involves limited licensing)?limited licensing)?
– If society arbitrarily prohibits driving is it obligated to If society arbitrarily prohibits driving is it obligated to provide an equal alternative?provide an equal alternative?
Thank you!Thank you! And whatever And whatever
your vision and your vision and whether you whether you drive, walk, drive, walk, stroll, jog, skate, stroll, jog, skate, bicycle, or roll do bicycle, or roll do it safely… It’s a it safely… It’s a jungle out there!jungle out there!
