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The Introduction of Bioptic Driving in The Netherlands

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BACKGROUND: 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. We conducted a demonstration project to assess the viability of implementing bioptic driving in The Netherlands. In this paper we describe the framework of the project from conception through to realization of our primary objective - the introduction of bioptic driving as a legal option for visually impaired people in The Netherlands. METHODS: The project was based on bioptic driving programs in the U.S.A., which were adapted to fit within current driving training and assessment practices in The Netherlands. The project convened a consortium of organizations including the Netherlands Bureau of Driving Skills Certificates (CBR), service organizations for the visually impaired, and research departments at universities investigating driving and vision. All organizations were educated about bioptic driving and participating professionals were trained in their specific aspects of the project. Media publicity led to significant interest and helped recruitment that enabled the screening and selection of potential participants. OUTCOMES: The project demonstrated that people with moderately reduced visual acuity can be trained to achieve an adequate level of proficient and safe driving (as assessed by the local official driving licensing professionals) when using a bioptic telescope for the road conditions in the Netherlands. Based on the successful project outcomes, a request was made to the Minister to allow bioptic driving in the Netherlands. This request has been accepted; the legal procedures for implementation are in process.
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The Introduction of Bioptic Driving in The Netherlands
Aart C. Kooijman1,2,3, Bart J.M. Melis-Dankers3,1, Eli Peli4, Wiebo H. Brouwer2,5,6, Petra
Pijnakker3, Geert Van Delden3, Eelko Van Pluuren3, Birgit Van Iddekinge3, Peter Derksen3,
Rens B. Busscher5, Ruud A. Bredewoud7, Jose H.M. Van Rosmalen8, Fokke Jan Postema9,
Irene Wanders3, Jos De Vries7, and Jaap M.D. Witvliet3
1 Laboratory of Experimental Ophthalmology, University Medical Center Groningen, University of
Groningen, Groningen, The Netherlands 2 School of Behavioral and Cognitive Neurosciences (BCN),
University of Groningen, Groningen, The Netherlands 3 Royal Visio, National Foundation for the Visually
Impaired and Blind, Huizen, The Netherlands 4 Schepens Eye Research Institute, Harvard Medical School,
Boston, MA, U.S.A 5 Department of Psychology, University of Groningen, Groningen, The Netherlands 6
Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The
Netherlands 7 Netherlands Bureau of Driving Skills Certificates (CBR), Rijswijk, The Netherlands 8 Viziris,
Utrecht, The Netherlands 9 Ophthalmology Clinic, Isala Klinieken, Zwolle, The Netherlands
Abstract
Background—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.
We conducted a demonstration project to assess the viability of implementing bioptic driving in The
Netherlands. In this paper we describe the framework of the project from conception through to
realization of our primary objective – the introduction of bioptic driving as a legal option for visually
impaired people in The Netherlands.
Methods—The project was based on bioptic driving programs in the U.S.A., which were adapted
to fit within current driving training and assessment practices in The Netherlands. The project
convened a consortium of organizations including the Netherlands Bureau of Driving Skills
Certificates (CBR), service organizations for the visually impaired, and research departments at
universities investigating driving and vision. All organizations were educated about bioptic driving
and participating professionals were trained in their specific aspects of the project. Media publicity
led to significant interest and helped recruitment that enabled the screening and selection of potential
participants.
Outcomes—The project demonstrated that people with moderately reduced visual acuity can be
trained to achieve an adequate level of proficient and safe driving (as assessed by the local official
driving licensing professionals) when using a bioptic telescope for the road conditions in the
Netherlands. Based on the successful project outcomes, a request was made to the Minister to allow
bioptic driving in the Netherlands. This request has been accepted; the legal procedures for
implementation are in process.
INTRODUCTION
Bioptic telescopes are small telescopes mounted at the top of a regular spectacle lens that are
permitted as a driving aid in 36 of 51 jurisdictions in the USA 1. They are used by people with
moderately reduced visual acuity to enable them to see the details of distant objects such as
traffic signs and street names. Most of the time the user looks through the regular spectacle
lens, taking occasional glances through the telescope to examine distant objects when
necessary.
NIH Public Access
Author Manuscript
Vis Impair Res. Author manuscript; available in PMC 2009 January 1.
Published in final edited form as:
Vis Impair Res. 2008 ; 10(1): 1–16.
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The use of a bioptic telescope for driving was first suggested by William Feinbloom in
19582, and the results of the earliest study of bioptic driving were published by Korb in
19703. An overview of the developments of bioptic driving in the USA and Canada is presented
in the accompanying review article.4
Although bioptic driving is well established in the USA and is a rehabilitation option that has
the potential to significantly improve quality of life for people with visual acuity loss5, it is
currently not permitted in any country in Europe, and has never been evaluated within a
European setting. We designed and implemented the first demonstration project of bioptic
driving in The Netherlands. The primary objective was to establish an evidence base that could
be used to demonstrate the viability of introducing bioptic driving in Europe.
A pilot bioptic driving training program in The Netherlands
Building on earlier research on driving with impaired vision carried out in collaboration with
the Netherlands Bureau of Driving Skills Certificates (CBR)6,7,8,9, we developed a pilot
bioptic driving training program in the Netherlands to determine whether visually impaired
people were able to achieve satisfactory driving performance using a bioptic telescope in an
on-road fitness-to-drive test. The purpose of this paper is to describe the process needed to set
up such a demonstration project with a fair chance to get the rules changed. Of course the
project had to demonstrate that bioptic drivers could be considered to be safe drivers by the
local driving evaluation experts. We describe the framework of the demonstration project from
conception through the realization of our primary objective – the introduction of bioptic driving
as a legal option for visually impaired people in The Netherlands. Details of the assessment
and training procedures used in the project, along with study results are presented in the
accompanying paper10.
METHODS
Because professionals in Europe had no prior experience with bioptic driving, the project
required, adequate education and training of all relevant professionals and to ensure inclusion
of all appropriate organizations and authorities. Initial reaction was frequently that bioptic
driving was not feasible because the traffic in the U.S.A. was considered to be more relaxed
and less aggressive than in The Netherlands.
Project consortium formation
The project manager JMDW, together with the Project Supervision Team WHB, BJMM-D and
ACK, initiated the project. They consulted with RAB, head of the Medical Department of the
CBR, regarding the prospects of bioptic driving in the Netherlands and ask for the
recommended procedure to gather convincing evidence that people with reduced visual acuity
could drive safely with the aid of a bioptic telescope. Professionals from all of the involved
disciplines were invited to become partners in the project. In particular, the participation of the
CBR was essential to assure an approach that would fit within the current practice of assessing
practical fitness to drive of people with impairments. The project consortium included: Viziris
(Joint Societies of the Visually Impaired and Blind People in the Netherlands), CBR, the
Netherlands Society of Ophthalmology, Visio, and the University of Groningen.
Professionals
The roles of each of the professionals involved in the project are summarized in Table 1. To
educate the collaborating professionals about bioptic driving and to train them in the various
aspects of preparing visually impaired clients to become a bioptic driver, we organized an
obligatory two-day course in March 2004. This comprehensive course attended by the 20
project members addressed the theory and the practical procedures of bioptic driving, as well
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as the legal and social aspects of driving with low vision. Project members also received
information and practical training about their specific role within the project, including lectures
and workshops on fitting bioptic telescopes, vision and neuropsychological assessments
relevant to bioptic drivers, and techniques for training patients how to use bioptic telescopes
for general and daily activities as well as when driving.
Project management
A project of such wide scope required careful and continuous monitoring and evaluation, with
mutually agreed adjustments. The supervision of this process was carried out by the project
manager. The project group met every two months to synchronize the activities and the training
phases of all members and to discuss intermediate results. Biannual meetings of a Feedback
Committee assured that the development of the project complied with current practice and
expectations in the involved organizations. The Feedback Committee consisted of members
from each of the organizations in the project consortium
Participants
We preferred to stay close to the current vision requirements for driving in The Netherlands
and the E.U., requiring a decimal visual acuity of 0.5 (20/40) or better, and a visual field width
of at least 140 degrees horizontally (E.U.: 120 degrees). Therefore our main inclusion criteria
were: a visual acuity of 0.5 (20/40) or better while using the telescope, the standard visual field
requirement, and demonstration of adequate driving skills in a preliminary driving proficiency
test.
Early in the project we added criteria to exclude participants with nystagmus. This was based
on the driving instructors’ observation that these patients had difficulty maintaining stable
steering; also subjects who showed a “low aptitude for driving” were excluded. The reason for
adding these criteria was to limit the number of driving lessons a participant needed to prepare
for a successful driving test.
Project Phases and Protocols
The bioptic driving training project included 10 phases, summarized in Table 2. The following
sources were used to guide protocol development: reports of bioptic driving training programs
in the USA, observation of the longstanding bioptic driving training program at the School of
Optometry, University of California, Berkeley, and discussions with experts in the field and
bioptic users during the International Bioptic Driving Conference 2004 in London, UK.
Project’s procedures were designed to fit within current vision rehabilitation and driving
training and assessment practices in the Netherlands. Protocols were developed for each phase
of the project. Additionally, entrance and exit criteria were defined for each phase, determining
whether a participant could progress to the next phase.
Phase 1: Press releases and recruitment—We established a dedicated telephone line
and an E-mail address to enable potential participants, interested ophthalmologists,
optometrists and journalists to obtain up-to-date information about the project. Organizations
of visually impaired people were informed about the project, either by information leaflets or
by oral presentations, and were asked to inform potential candidates about the project. Because
many potential candidates were not in contact with one of these organizations, we used press
releases to gain newspaper, radio and TV exposure. The project manager coordinated all
communications with journalists. The publicity in the newspapers, radio, and TV also served
to inform the general public about driving with vision impairment and the opportunity for
drivers with reduced visual acuity to use bioptic telescopes.
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Phase 2: Screening of potential candidates—All people who expressed interest in
participating in the project were called by one of the counselors. The nature of bioptic driving
was explained and they were told about the vision criteria for inclusion, the phases of the project
and the criteria to advance to consecutive phases. It was very important that the candidates
realized the high investments in time and money required for participation. Before candidates
decided to participate, the counselor also ensured that they understood that a positive
recommendation in the final driving test might not provide them with a legal driver’s license,
unless the legal rules were changed to allow bioptic driving. Following completion of the
project, the counselors remained available for the participants while the new rules to allow
driving with a bioptic were under consideration.
During the telephone interviews we determined that 30% of callers did not meet the inclusion
criteria, and an additional 20% were not interested in participation once they had heard the
details. The remaining 160 persons were registered as candidates.
Phases 3–9—Details of phases 3–9 of the protocol are described in the accompanying paper.
Project funding
All expenses related to the assessments and the O&M training were paid by Visio, as well as
the travel expenses to the driving lessons, but the individual driving lessons and the bioptic
device had to be paid for by the participants themselves. In some cases participants were
reimbursed by their health insurance for the cost of the bioptic. The fitness-to-drive test of the
bioptic driver was paid for by the state.
OUTCOMES
Thirty six (~22%) of the registered candidates completed the training program and took the
fitness-to-drive test. At the end of the project, 9 out of the 36 (25%) demonstrated satisfactory
driving safety and fluency with a bioptic telescope, sufficient to warrant a driver’s license.
Implementation of bioptic driving in the legal rules
In September 2006, we sent a report describing the study results, titled “Fitness to drive with
the use of a bioptic telescope”11 to the Minister of Traffic, Public Works and Water
Management. The report also recommended a revision of the current rules for vision
requirements to include a conditional opportunity to use a bioptic telescope while driving.
Included in the report was a proposed revised interpretation of the rule relating to visual acuity
requirements (Fig. 1). Based on the report, the Minister has decided that “bioptic driving” will
be allowed in the Netherlands under the conditions described in the revised interpretation of
the rules. The official legal texts of the decision and regulations are expected to be published
in the Staatscourant (State Newspaper) in 2007. This expected publication will be the official
legal act enabling a drivers’ license to be issued to a bioptic driver in the Netherlands.
DISCUSSION
We designed and executed a demonstration project that has validated the viability of
introducing bioptic driving in The Netherlands. We found that 25% of carefully selected
candidates could be trained and were able to demonstrate satisfactory driving safety and fluency
with a bioptic telescope to warrant a driver’s license. All participating professionals of the
various disciplines were able to carry out their respective part of the program within their
regular work schedule, and the final test of practical fitness to drive was the regular test used
by the CBR to evaluate people with other impairments.
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Though rather uncommon in a study, we introduced two major changes to the exclusion criteria
during the execution of the project. We added “nystagmus” and “low aptitude to drive” as
exclusion criteria that might bias our study population toward participants who could achieve
higher success rates. The decision to exclude people with nystagmus was based on the
observations of our driving instructors. However, there is no evidence in the bioptic driving
literature that people with nystagmus require more driving training or have particular difficulty
maintaining a stable lane position (as was suggested by our driving instructors); evaluating
these aspects was beyond the scope of our study. In fact, nystagmus is a very common diagnosis
among bioptic drivers in the USA. When evaluating the suitability of visually impaired clients
for bioptic driving, it may be helpful to advise that clients with previous driving experience
take a preliminary driving test to evaluate their general driving skills. If the result of this pretest
suggests a low aptitude to drive, the client might want to reconsider whether to proceed with
bioptic training. However, a low aptitude to drive should not necessarily be considered as an
exclusion criterion; a client especially one with no prior driving experience might still be a
successful bioptic driver after additional driving skills training.
Our project demonstrated that some drivers with impaired vision can be trained to an adequate
level of proficient and safe bioptic driving in the roads and traffic conditions common in a
European country. This first bioptic-driving project in the E.U. might serve as a template for
initiatives to introduce bioptic driving in other countries.
Acknowledgements
ACK received invaluable information about all aspects of bioptic driving from Ian Bailey, Helen Dornbusch, School
of Optometry, UC Berkeley, CA, Derrick Scott, driving school San Francisco, CA and Dave Hennessy, DMV,
Sacramento, CA. We highly appreciated the enthusiastic cooperation in this project with Anoeska Amersfoort, client
counselor Visio, Thea Grotenhuis, and Martin IJsseldijk, mobility instructors Visio, Ludolf Niemeijer; driving
instructor, Bert Van Osch, driving instructor Welzorg, Sander Bison, Rene Stofkooper, and A Zwijgers: driving
assessors CBR. Alex Bowers provided valuable comment on a draft manuscript. EP was supported in part by NIH
grant # EY12890.
References
1. Peli, E.; Peli, D. Driving with confidence, a practical guide to driving with low vision. New Jersey:
World Scientific; 2002.
2. Feinbloom, W. The bioptic telescopic system; a paper read before the Session on Contact Lenses and
Subnormal Vision. American Academy of Optometry meeting; December 1958; reference in Korb
1970
3. Korb DR. Preparing the visually handicapped person for motor vehicle operation. Am J Optom Arch
Am Acad Optom 1970;47:619–628. [PubMed: 5273102]
4. Melis-Dankers, et al. Review on Driving with Reduced Visual Acuity and a Bioptic Telescope. Visual
Impairment Research. 2007submitted
5. Bowers AR, Apfelbaum DH, Peli E. Bioptic telescopes meet the needs of drivers with moderate visual
acuity loss. Invest Ophthalmol Vis Sci 2005;46:66–74. [PubMed: 15623756]
6. Coeckelbergh TM, Cornelissen FW, Brouwer WH, Kooijman AC. Training compensatory viewing
strategies: Feasibility and effect on practical fitness to drive in subjects with visual field defects. Vis
Impair Res 2001;3:67–83.
7. Coeckelbergh TRM, Brouwer WH, Cornelissen FW, Kooijman AC. Predicting practical fitness to
drive in drivers with visual field defects caused by ocular pathology. Hum Factors 2004;46:748–760.
[PubMed: 15709335]
8. Tant MLM, Brouwer WH, Cornelissen FW, Kooijman AC. Prediction and evaluation of driving and
visuo-spatial performance in homonymous hemianopia after compensational training. Visual
Impairment Research 2001;3:133–145.
9. Kooijman AC, Brouwer WH, Coeckelbergh TRM, Tant MLM, Cornelissen FW, Bredewoud RA,
Melis-Dankers BJM. Compensatory viewing training improves practical fitness to drive of subjects
with impaired vision. Visual Impairment Research 2004;6:1–27.
Kooijman et al. Page 5
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10. Melis-Dankers BJM, Kooijman AC, Brouwer WH, Busscher RB, Bredewoud RA, Derksen PH,
Amersfoort A, IJsseldijk MAM, van Delden GW, Grotenhuis THPA, Witvliet JMD. A Demonstration
Project on Driving with Reduced Visual Acuity and a Bioptic Telescope in the Netherlands. Visual
Impairment Research. 2007submitted
11. Kooijman AC, Brouwer WH, Keunen JEE. Rijgeschiktheid bij gebruik van een bioptische telescoop.
Een advies tot herziening van de regelgeving. 13 september 2006;
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Figure 1.
Translation of the revised explanation of the Rules to enable bioptic driving (visual acuity
values are given in decimal form: 0.5 = 20/40; 0.125 = 20/160).
(*) Group 1 indicates drivers of motor cycles and private cars
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Kooijman et al. Page 8
Table 1
Summary of professionals involved in the project
Professional Role Organization
Project manager Project supervision, assisted by project supervision team Visio and University
of Groningen
2 counselors Maintained a registration system of all candidates’ information; main contact for the
participants as well as candidates who applied for the project; maintained the
continuity of communication between the participants and the project; addressed
problems in cooperation with other members of the project group
Visio
2 psychologists Assessed speed of processing and divided attention (may be relevant to ability to use
telescope while driving) Visio
Low vision optometrist Fit participants with the bioptic and assessed visual function with and without the
telescope Visio
4 orientation and mobility
(O&M) instructors Pre-driving bioptic training: Training in use of the bioptic in general mobility
situations including using the bioptic as a passenger but not behind-the-wheel Visio
Driving instructors Instructors with special interests and skills in training people with limited physical or
mental abilities instructed participants in driving with a bioptic Driving schools
Driving assessment Examiners specialized in assessing driving with special adaptations to compensate
for various physical impairments CBR
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Table 2
Summary of the 10 phases of the project
Phase Description
1 Press releases to raise public awareness and aid recruitment
2 Candidate screening, based on information provided by the candidate. Selected candidates who passed the screening and were interested
to participate were registered
3 Selected candidates received written information about all aspects of the project, and signed an informed consent to be included as a
participant in the study
4 Functional assessment, including evaluation with clip-on bioptic telescope and preliminary driving evaluation
5 Bioptic telescope fitting
6 Pre-driving bioptic training
7 Driving training
8 Driving assessment
9 Data processing and analysis
10 Advice to the Ministery.
Vis Impair Res. Author manuscript; available in PMC 2009 January 1.
... In collaboration with bioptic driving researchers, trainers, and administrators in the United States, researchers in the Netherlands conducted a study of a training program for bioptic licensure. 5 The goal was to determine whether people with moderate visual impairment could be trained to drive safely enough to be licensed in the Netherlands, a country that had not previously allowed for bioptic licensure. Nine of 36 (25%) people who underwent training were eventually licensed after a road test. ...
... We also examined the relationship between nystagmus and Highway Patrol test for licensure outcomes, as there is reason to believe that nystagmus could make accessing the bioptic telescope more difficult, and others have speculated that people with nystagmus should not be bioptic drivers. 5 We hypothesized that prospective bioptic drivers without previous nonbioptic licensure would be younger, have more documented training hours, and be more likely to fail the Highway Patrol test for licensure. We also hypothesized that prospective bioptic drivers with poorer vision (visual acuity and contrast sensitivity) or nystagmus would require more training and perform worse on the Highway Patrol test, even after adjusting for previous driving experience. ...
... Whether nystagmus may be detrimental to driving ability has been a subject of interest for some time among those interested in vision and driving. 5 Because of the nature of nystagmus, it is reasonable to consider whether the lateral movement of the eyes might cause difficulty accessing the telescope in BTS. We have previously shown that nystagmus was independently associated with a greater number of training hours but that the association was no longer significant if we controlled for previous driving experience. ...
Article
Full-text available
Bioptic telescopic spectacles 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. A retrospective study of patients who received an initial daylight bioptic examination at the Ohio State University and subsequently received a bioptic license was conducted. Data were collected on vision including visual acuity, contrast sensitivity, and visual field. Hours of driver training and results of Highway Patrol road testing were extracted from records. Relationships among vision, training hours, and road testing were analyzed. Ninety-seven patients who completed a vision examination between 2004 and 2008 and received daylight licensure with bioptic telescopic spectacles were included. Results of the first Highway Patrol road test were available for 74 patients. The median (interquartile range) hours of training before road testing was 21 (17) hours (range, 9 to 75 hours). Candidates without previous licensure were younger (p < 0.001) and had more documented training (p < 0.001). Lack of previous licensure and more training were significantly associated with having failed a portion of the Highway Patrol test and points deducted on the road test. 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.
... 7,8 When visual acuity falls below the requirement for an unrestricted license (e.g., 20/40 in many states and countries), individuals will automatically be denied a license, which may lead to social isolation, loss of independence, depression, and decreased quality of life. [9][10][11][12] In many states in the United States, 13,14 the province of Quebec in Canada, 15 and the Netherlands, 16 people with moderately reduced visual acuity may be permitted to drive on a restricted license with the aid of a bioptic telescope. This small telescope, which is usually mounted at the top of the spectacle lens before one eye (although occasionally bioptic telescopes are mounted binocularly), 17 is used intermittently for tasks such as reading road signs and determining the status of traffic light signals. ...
... In prior surveys, [18][19][20][21][22] retrospective chart reviews 23 and on-road studies of bioptic drivers, 15,16,24,25 the majority of participants were under 60 years of age suggesting that bioptic telescopes are more likely to be prescribed for people with congenital, juvenile, or middle-aged vision loss than seniors with AMD. In a recent retrospective review of 237 licensed bioptic drivers who received their initial evaluation to determine visual eligibility for bioptic driving in a university-based clinic, only 4% had a diagnosis of AMD. 26 Yet, AMD is a major cause of central vision impairment in the United States. ...
Article
Full-text available
Purpose: To investigate the telescope use and driving patterns of bioptic drivers with age-related macular degeneration (AMD). Methods: A questionnaire addressing telescope use and driving patterns was administered by telephone interview to three groups of bioptic drivers: AMD (n = 31; median 76 years); non-AMD first licensed with a bioptic (n = 38; 53 years); and non-AMD first licensed without a bioptic (n = 47; 37 years). Driving patterns of bioptic AMD drivers were also compared with those of normal vision (NV) drivers (n = 36; 74 years) and nonbioptic AMD drivers (n = 34; 79 years). 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. Translational relevance: Licensure with a bioptic telescope may prolong driving of older adults with AMD; however, objective measures of bioptic use, driving performance, and safety are needed.
... Bioptic telescopes are small, spectacle-mounted telescopes ( Fig. 1) used by people with reduced visual acuity (VA) to see the details of distant objects. They can be used as driving aids 1,2 in 48 US states, 3 The Netherlands, 4,5 and the province of Quebec, Canada. 6 When people with reduced VA drive wearing bioptic telescopes, they spend most of the time looking through the carrier lens below the telescope. ...
Article
Full-text available
Purpose: In most states, people with reduced visual acuity may legally drive with the aid of a bioptic telescope. However, concerns have been raised that the ring scotoma may impair detection of peripheral hazards. Using a driving simulator, we tested the hypothesis that the fellow eye would be able to compensate for the ring scotoma when using a monocular telescope. Methods: Sixteen bioptic users completed three drives with binocular viewing interleaved between three drives with monocular viewing. Forty pedestrians appeared and ran on the road for 1 second, including 26 within the ring scotoma, while participants were reading road signs through their own monocular telescopes. Head movements were analyzed to determine whether the pedestrian appeared before or only while using the telescope. Results: For pedestrians that appeared only during bioptic use and were likely in the area of the ring scotoma, detection rates were significantly higher in binocular (fellow eye can compensate) than monocular (fellow eye patched) viewing (69% vs. 32%; P < 0.001); this was true for both current and noncurrent drivers. For pedestrians appearing before or after bioptic use, detection rates did not differ in binocular and monocular viewing. However, detection rates were even higher and reaction times shorter when the telescope was not being used. Conclusions: Both current and noncurrent drivers' fellow eyes were able to compensate, at least in part, for the ring scotoma. Translational relevance: When using monocular telescopes, the fellow eye reduces the impact of the ring scotoma on hazard detection in binocular viewing.
... In the United States alone, about 3.9 million visually impaired adults (>45 years old) are estimated to have corrected visual acuity worse than 20/40. 1 They may lose their driving privilege when their visual acuity falls below the requirement for an unrestricted license (typically 20/40 in many US states), which may significantly restrict their independence and mobility, especially for those living in rural and suburban areas. [2][3][4][5] However, those with moderately reduced visual acuity may be permitted to drive on a restricted license with the aid of a bioptic telescope in most states in the United States, 6,7 the province of Quebec in Canada, 8 the Netherlands, 9 and Australia. 10 The bioptic telescope is small and usually mounted at the top of the spectacle lens in front of one eye (Fig. 1). ...
Article
Full-text available
Purpose: 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). Methods: A large dataset (477 hours) of naturalistic driving was collected from 19 bioptic drivers (visual acuity 20/60 to 20/160 without the telescope). To reduce the data volume, a multiloss 50-layer deep residual neural network (ResNet-50) was used to detect potential bioptic telescope use events. Then, a total of 120 hours of selected video clips were reviewed and annotated in detail. Results: The frequency of looking through their telescopes ranged from 4 to 308 times per hour (median: 27, interquartile range [IQR], 19-75), with each bioptic use lasting median 1.4 seconds (IQR, 1.2-1.8). Thus, participants spent only 1.6% (IQR, 0.7%-3.5%) driving time with their telescopes aiding their vision. Bioptic telescopes were used most often for checking the road ahead (84.8%), followed by looking at traffic lights (5.3%), and reading road signs (4.6%). 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.
... Bioptic telescopes are small, spectacle-mounted telescopes ( Fig. 1) used by people with reduced visual acuity (VA) to see the details of distant objects. They can be used as driving aids 1,2 in 48 US states, 3 The Netherlands, 4,5 and the province of Quebec, Canada. 6 When people with reduced VA drive wearing bioptic telescopes, they spend most of the time looking through the carrier lens below the telescope. ...
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Purpose: Recently we developed a driving simulator paradigm to evaluate detection of road hazards when using a bioptic telescope and conducted an initial study using normally-sighted observers with simulated vision loss. We now extend our investigation to quantifying the extent to which visually impaired bioptic users are able to use their fellow (non-telescope) eye to compensate for the ring scotoma of a monocular bioptic telescope. We tested the hypothesis that detection rates would be higher in binocular viewing (fellow eye could potentially compensate) than monocular viewing (fellow eye patched so it could not compensate) for pedestrian hazards present in the scene only while the telescope was being used. Methods: Sixteen bioptic telescope users (17-80 y) completed six test drives, including three with binocular viewing interleaved between three with monocular viewing. While driving, they used their own monocular bioptic telescopes to read information on highway road signs (n = 71) and pressed the horn when they saw a pedestrian hazard (n = 50). Twenty-six of the pedestrians were programed to appear, run on the road ahead of the driver for 1s within the ring scotoma and then disappear, within the period when participants were reading signs through the bioptic. The timing of the head movement to look into and out of the bioptic was determined and events were then categorized by whether or not the pedestrian hazard was present in the scene only while using the bioptic. Results: When pedestrian hazards were in the scene only while subjects were using the bioptic to read a sign, detection rates were significantly higher in binocular than monocular viewing (68% vs. 40%). However, when pedestrians when subjects had a brief view of the pedestrian either beforeor after looking through the bioptic, then detection rates did not differ in binocular and monocular viewing (78% vs. 79%). By comparison, when not using the bioptic detection rates were higher (> 90%) and reaction times were shorter (without 0.95 s vs. with 1.25 s) Conclusions: Our results suggest that under binocular viewing conditions the fellow eye was able to compensate for the ring scotoma to a certain extent when subjects used a monocular telescope to read road signs; however, performance was not as good as without the bioptic.
... 9 When VA is worse than 6/24, other restrictions such as the use of bioptic telescopes may be applied in the USA 11 and in the Netherlands. 36 Views and practices of Australian optometrists Oberstein, Boon, Chu and Wood Respondents reported limited familiarity and little experience with the prescription and use of bioptic telescopes (Figure 3). Respondents stated that a VA of 6/15 should be the minimum VA through the carrier lens, when a bioptic telescope is prescribed, while non-Australian jurisdictions allow VA between 6/24 to 6/60 through the carrier lens. ...
Article
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.
... There is some evidence for their safe use for driving, 1,2 and also reports to the contrary. 3,4 Despite their controversial use, bioptic telescopes are permitted for driving in 43 states in the US, 5 the Netherlands, 6,7 and Quebec, Canada. The number of jurisdictions permitting them has increased substantially over the last decade. ...
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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. Twelve visually impaired bioptic users watched a series of driving hazard perception training videos and responded as soon as they detected a hazard while reading aloud letters presented on the screen. The letters were placed such that when reading them through the telescope the hazard fell in the ring scotoma area. Four conditions were tested: no bioptic and no reading, reading without bioptic, reading with a bioptic that did not occlude the fellow eye (non-occluding bioptic), and reading with a bioptic that partially-occluded the fellow eye. Eight normally sighted subjects performed the same task with the partially occluding bioptic detecting lateral hazards (blocked by the device scotoma) and vertical hazards (outside the scotoma) to further determine the cause-and-effect relationship between hazard detection and the fellow eye. There were significant differences in performance between conditions: 83% of hazards were detected with no reading task, dropping to 67% in the reading task with no bioptic, to 50% while reading with the non-occluding bioptic, and 34% while reading with the partially occluding bioptic. For normally sighted, detection of vertical hazards (53%) was significantly higher than lateral hazards (38%) with the partially occluding bioptic. 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. © 2015 The Authors Ophthalmic & Physiological Optics © 2015 The College of Optometrists.
Article
Significance: A new driving simulator paradigm was developed and evaluated that will enable future investigations of the effects of the ring scotoma in bioptic drivers with diverse vision impairments and different telescope designs. Purpose: The ring scotoma may impair detection of peripheral hazards when viewing through a bioptic telescope. To investigate this question, we developed and tested a sign-reading and pedestrian-detection paradigm in a driving simulator. Methods: Twelve normally sighted subjects with simulated acuity loss (median 20/120) used a 3.0× monocular bioptic to read 36 road signs while driving in a simulator. Thirteen of 21 pedestrian hazards appeared and ran on the road for 1 second within the ring scotoma while participants were reading signs through the bioptic. Head movements were analyzed to determine whether the pedestrian appeared before or only while using the bioptic. Six subjects viewed binocularly, and six viewed monocularly (fellow eye patched). Two patients with real visual acuity loss in one eye and no light perception in the other performed the same tasks using their own telescopes. Results: For the monocular simulated acuity loss group, detection rates were significantly higher when the pedestrian appeared before using the bioptic than when it appeared while using the bioptic and was likely within the area of the ring scotoma (77% vs. 28%, P < .001). For the binocular simulated acuity loss group, there was no significant difference in detection rates for pedestrians that appeared before or while using the bioptic (80% vs. 91%, P = .20). The two monocular patients detected only 17% of pedestrians that appeared while looking through the bioptic. Conclusions: Our results confirm the utility of the testing paradigm and suggest that the fellow eye of normally sighted observers with simulated acuity loss was able to compensate for the ring scotoma when using a monocular bioptic telescope in a realistic driving task.
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Fifty-one subjects with visual field defects were trained to use compensatory viewing strategies.The subjects were referred to the training program by an official driving examiner of the Dutch Central Bureau of Driving Licenses. Three training programs were compared: laboratory training, mobility training, and motor traffic training. Viewing behavior, visual attention, and practical fitness to drive were assessed before and after training. Practical fitness to drive was assessed on the road as well as in a driving simulator. It was observed that compensatory viewing behavior and practical fitness to drive could be improved by training. Subjects in the motor traffic training showed a small advantage with regard to practical fitness to drive, suggesting that training is task-specific and that generalization is limited. The effect of visual field defect on viewing behavior and practical fitness to drive was analyzed separately for subjects with central or peripheral visual field defects. It was observed that none of the outcome measures differed between the central and peripheral visual field defect groups.
Article
In many countries strict legal requirements for obtaining a driver’s license are in effect for visual acuity and visual field.We studied the relationship between these characteristics and driving safety and driving proficiency in an on-the-road test of practical fitness to drive in subjects with visual disorders, including many subjects scoring below current criteria. We further studied how far the relationship between the on-the-road test and visual measures improved if compensatory eye movements and visual attention were included in the criteria. Lastly, we studied the effects of training compensatory viewing strategiesformed the on-the-road test before and after training. Training consisted of laboratory and mobility training, including driving instruction. Visual function assessment included acuity, visual field, contrast sensitivity, visual attention, compensatory viewing efficiency, and visuospatial tests. In one study an advanced driving simulator was used besides the on-the-road assessment. Two models were compared to predict the on-the-road score. Results: 13–62% of the subjects passed the on-the-road test before training. After training, an additional 15–45% passed. The power of both models to predict the on-the-road score rose to about 45% by adding viewing behavior in the driving simulator. Discussion: A considerable percentage of the subjects, legally not allowed to drive, passed the on-the-road test. Sensitivity and specificity of vision tests and driving simulator tests are still too low to decide upon unfitness to drive. Training of compensatory viewing improved the performance in the on-the-road test.
Article
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. A cross-sectional survey of a convenience sample of 58 bioptic drivers was administered by telephone interview. Bioptic telescope usage patterns were quantified with questions designed specifically for the study. Driving patterns were quantified by use of the Driving Habits Questionnaire. Subjects were recruited from four sources across the United States to ensure a range of bioptic training and driving experience. The majority (74%) rated the bioptic telescope as very helpful, and almost all (90%) would continue to use it for driving, even if it were not required for driving licensure; however, only 62% reported always wearing the bioptic when driving. Subjects had relatively unrestricted driving habits, driving a mean of 222 +/- 211 miles per week, and 85% aged < or =65 years drove to work. With the exception of driving in rain, in bright sunlight, and at night, there was little difficulty with driving in a variety of situations, and levels of driving avoidance due to vision impairment were low (<10%). 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.
Article
Vision, viewing efficiency, visual attention, and on-road driving performance were assessed in 100 participants with central and/or peripheral visual field defects caused by ocular pathology. Driving was evaluated by the Dutch driving license authority making use of the protocol for investigating practical fitness to drive. A smaller percentage of participants with central visual field defects passed the on-road driving test, in comparison with participants with peripheral or mild field defects. The predictive power of a model based on the current vision requirements for driving significantly increased when taking compensatory viewing efficiency into account. The results of the latter model were comparable to those of a model based on tests of visual attention and contrast sensitivity. Despite the increased explained variance of practical fitness to drive when taking higher-order visual functions into account, sensitivity and specificity remained quite low, limiting the use of these tests in identifying unfit drivers. Actual or potential applications of this research include the development of training programs to improve practical fitness to drive in drivers with visual field defects.
Review on Driving with Reduced Visual Acuity and a Bioptic Telescope
  • Melis
  • Dankers
Melis-Dankers, et al. Review on Driving with Reduced Visual Acuity and a Bioptic Telescope. Visual Impairment Research. 2007submitted
Compensatory viewing training improves practical fitness to drive of subjects with impaired vision Kooijman et al. Page 5 Vis Impair Res Author manuscript; available in PMC 2009 January 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript 10
  • Ac Kooijman
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Kooijman AC, Brouwer WH, Coeckelbergh TRM, Tant MLM, Cornelissen FW, Bredewoud RA, Melis-Dankers BJM. Compensatory viewing training improves practical fitness to drive of subjects with impaired vision. Visual Impairment Research 2004;6:1–27. Kooijman et al. Page 5 Vis Impair Res. Author manuscript; available in PMC 2009 January 1. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript 10. Melis-Dankers BJM, Kooijman AC, Brouwer WH, Busscher RB, Bredewoud RA, Derksen PH, Amersfoort A, IJsseldijk MAM, van Delden GW, Grotenhuis THPA, Witvliet JMD. A Demonstration Project on Driving with Reduced Visual Acuity and a Bioptic Telescope in the Netherlands. Visual Impairment Research. 2007submitted
The bioptic telescopic system; a paper read before the Session on Contact Lenses and Subnormal Vision
  • W Feinbloom
Feinbloom, W. The bioptic telescopic system; a paper read before the Session on Contact Lenses and Subnormal Vision. American Academy of Optometry meeting; December 1958; reference in Korb 1970