Questions And Answers Proposed About Driving With A Visual Impairment: A Literature of Controversy

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Questions And Answers Proposed About Driving With
A Visual ImpairmentA Literature of Controversy

• Gregory L. Goodrich, Ph.D., F.A.A.O.
• Research Psychologist Optometric Research
  Fellowship Director
• VA Palo Alto Health Care System
• Palo Alto, CA

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Goals of this Paper

• Review the history of driving and low vision
  driving literature (i.e., 1930 1990?)
• Need and context
• Expert opinion
• Evidence for/against increased accident rate
• Evidence for/against bioptic lenses
• Summary
• A Personal Conclusion (She had it right in 1970)!

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The Context of Bioptic Driving

• The question of who should drive and under what
  conditions is not new
• These questions affect many people with various
  conditions including visual impairments
• In a good society the answers would reflect
  equitable treatment of all people

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Why Drive At All?

• The flip answer - to get from here to there
• It is in societys interests that all people be
  able to do this safely, efficiently, and
  equitably - Its the economy stupid
• For many its an economic, medical, and practical
  necessity

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A Legacy of Danger

• June 10, 2004 was the anniversary of the one and
  only automobile race Henry Ford participated in
• After successfully winning his first automobile
  race at Grosse Point, New York Henry Ford gave it
  up as too dangerous

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Some Context

• The first automobile accident probably involved a
  horse and a horseless carriage
• Both the horse rider and horseless carriage
  driver blamed the other
• Prior to World War I US automobile accidents had
  killed over 36,000 people
• To put these fatality statistics into context
  consider that the American Revolutionary War, the
  War of 1812, the Mexican War, and the
  Spanish-American War combined killed less than
  23,000

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Just Another Statistic

• Steam, electric, or internal combustion
  automobiles have been with us for well over 120
  years
• Property damage, injury and death due to
  automobiles have always been with us
• It is societys responsibility to regulate their
  use in a safe and equitable manner
• Historically, determining what regulations to
  apply has been problematic

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Doing Is Inherently Dangerous(or how to prevent
2/3 of all accidents)

• Do NOT ride in automobiles they cause 20 of all
  fatal accidents. 
• Do NOT stay home 17 of all accidents do occur
  in home. 
• Do NOT walk on the streets or sidewalks 14 of
  all accidents happen to pedestrians. 
• Do NOT travel by air, rail, or water 16 of all
  accidents happen on these.

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Driving is a Recent Issue

• For 99 of the time since human beings developed
  civilization the predominate form of transport
  was walking
• If you didnt need to leave your village you were
  okay, today that is usually not an option

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Driving Is An Important Issue

• Because of the cost, the experience of indignity
  and lack of freedom related to transportation
  many (disabled) individuals do not enter into or
  remain in employment.
• 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.

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Low Vision is Even More Recent

• It has only been in the last 30 to 40 years that
  there have been sizeable numbers of people with
  low vision
• 80 of all low vision publications have been
  written in the last 2 yrs.
• 40 in the last 10 yrs.

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The Blindness Thing

• Most people dont understand that vision isnt
  just sighted or blind nor what vision is
  required to accomplish visual tasks
• Historically, less than normal vision viewed as
  useless (i.e., partially blind, legally blind,
  defective vision, etc.)

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To Overly Simplify (a bit)

• Driving an automobile has historically involved
  risk and accidents
• Its a visually oriented task and a major part of
  testing for a license is a visual acuity test
• Road testing may occur only once
• People with defective vision are therefore
  suspect and often denied the privilege to drive
• What historical evidence has there been for
  current criteria of what vision is needed for
  safe driving?

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The Early Years in Our Literature

• In 1927 McFadden wrote on the driver licensing
  laws
• In 1938 DeSilva wrote about one eyed drivers
• But it wasnt until the 1950s that limitations of
  vision gained greater prominence (visual fields
  formed a significant topic area)
• In the 1960s a wide variety of factors were
  studied (i.e., night driving, medical records,
  relationships between psychological and
  ophthalmic factors, etc.)

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Relevant Issues in the 1960s - 1

• Writing in the British Journal of Physiological
  Optics Kite and King noted
• Need for research on effect of reduced visual
  field on driving
• No consistent measurement for licensing standard
• Basis for visual field standards (in US) unclear

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Relevant Issues in the 1960s - 2

• Arthur Keeney, writing in a 1967 US ophthalmology
  publication, recommended
• those receiving aid to the needy blind have
  their drivers licenses removed. Similarly people
  who get income tax deductions for visual loss
  should not be licensed
• Acuity should be 20/40 or 20/50 (6/12, 6/15)
• Fields should be at least 140

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Relevant Issues in the 1960s - 3

• Burg, writing in 1967, noted
• Considerable variation in the vision-driving
  record relationship is found as a function of sex
  and age group studied
• With regard to vision teststhe relationships
  with the driving record are small
• That is good vision is associated with poor
  records (when considering accidents per miles
  driven)

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Relevant Issues in the 1960s - 3

• Julian Waller, publishing in JAMA (1969), noted
  that medical conditions impair highway
  performance
• Chronic medical problems believed to be
  contributing factors in up to 25 of crashes
• In regard to vision he noted that dynamic visual
  acuity most closely correlated with crash rate
• Alcoholism may be a factor in 33 of crashes
• Yet curiously he stated No more than a quarter
  of these drivers should have their licenses
  revoked.

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Relevant Issues in the 1960s - 4

• Committee on Medical Aspects of Automotive Safety
  (Archives of Ophthalmology) 1969
• Disqualifying eye diseases (for licensing)
• Corneal opacities
• Lens opacities
• Pigmentary degeneration of the retina
• Optic Atrophy
• Degeneration of the macula
• Diabetic retinopathy
• Hypertensive retinopathy with macular involvement
• Obscure or etiologically undetermined pigmentary
  disturbances

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Summary of the 1960 Contradictory Views

• Decreased vision, while poorly correlated with
  accident rate, probably contributes to many
  accidents and should disqualify for licensure
• Dynamic visual acuity should be measured, but
  isnt
• Acuity should be 6/12 to 6/15 although no solid
  evidence to support this criteria
• Visual fields should be 140 or maybe less
• Some eye pathologies should automatically
  preclude licensing and blindness should
  certainly disqualify the individual - although
  there was little data to back this up
• Other medical conditions cause more accidents
  than vision loss, but little concerted effort to
  deny licensing based upon those conditions

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In 1970 It Happened

• In 1970 a seminal article by Donald Korb appeared
• Provided detailed guidance on selection and
  rejection of candidates
• Reported on 26 telescopic lens wearing drivers
  licensed in Massachusetts he also reported
  others licensed in New Hampshire, Maine, New
  York, Florida, and two Canadian provinces.

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One Drivers Influence

• In 1971 Dennis Kelleher coauthored a case report
  with Edwin Mehr and Monroe Hirsch describing his
  experiences as a bioptic driver (American Journal
  of Optometry and Physiological Optics, 48, 773-6)
• Dennis subsequently published about a dozen
  articles including a training manual on teaching
  driving to people with low vision using bioptics

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In the UK

• G. T. Chashell, an ophthalmic surgeon, published
  on visual function in relation to road accidents
  finding
• The number of visual defects that occur in
  drivers who have been involved in accidents is
  negligible
• The extrinsic factors should be considered as
  important as, if not more so than, visual
  function

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Also In 1970

• Joan Bardach published on 520 disabled patients
  participating in a driver training program at the
  Institute of Rehabilitation Medicine in New York,
  noted
• the saliency of some factors is different in
  the one group from that of the other suggests
  that studying the pattern of interaction of
  variables is more relevant than the study of each
  variable separately if one wishes to understand
  the nature of the driving task.

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The Contrary View

• While the view against bioptic driving was widely
  held the two most vocal advocates of banning
  bioptic driving (at this time) were two
  ophthalmologists Arthur Keeny and Gerald Fonda.
  Both correctly pointed out that bioptic lenses
• create a ring scotoma
• magnification restricts field of view, and
• a nearness illusion
• there is induced displacement of the magnified
  image
• increased effect of vibration, and
• altered head posture

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A Genuine Concern

• Gerald Fonda, M.D. wearing bioptic telescopic
  spectacles (1991)
• The BTS is good for the greedy ophthalmologist
  or optometrist, and the BTS is a hazard for the
  handicapped using it.

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The Literature 1970 to 1990

• In this two decade time frame the literature can
  be divided into three categories
• Those articles advocating training qualified
  drivers with low vision
• Those advocating against the use of bioptics in
  driving and/or licensing individuals with less
  that 20/40 (6/12) visual acuity
• Those studying the relationship between vision,
  driving performance, and/or accidents

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The Link Between Measures of Vision and Driving
Performance

• Brian Hills summed up the literature relating
  vision to automobile accidents in a 1980 article
  in the journal Perception by stating
• the available evidence suggests that few of
  these (accidents) are attributable to reduced or
  defective vision

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The Literature from 1990 On

• Much like this Jaguar of the future I will leave
  it to my colleagues to bring you up to date on
  research and clinical experience
• But I feel history gives us some take home
  messages

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Bioptic Driving Is

• Controversial Pro or con beliefs are strongly
  held (few have no opinion)
• The question may not be to drive, or not to
  drive but independence if society prohibits
  driving should it be obligated to provide equal
  alternatives?
• Driving (or an alternative) is very important
• Employment
• Access to medicine, food, society, etc.
• Quality of life

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Less Than Normal Vision

• Does have an effect on driving - based on over 30
  years driving experience of many individuals with
  low vision
• Devices and training may compensate for this
• Empirically based driver selection is critical
• Driver training (which is important for all
  drivers) is probably more important for drivers
  with some degree of low vision

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And

• The degree of vision loss sufficient to prevent
  driving is not well understood, and visual acuity
  and/or visual field tests may not be the best
  determinants
• Joan Bardach in 1970 may have gotten it right
  we need to study the pattern of interaction of
  the variables of the individual in driving which
  suggests that realistic driver simulators may be
  critical in determining who should/should not be
  licensed

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A Societal Question

• Given that
• Some visually impaired drivers have done so
  safely and effectively
• That some groups of drivers are known to be at
  greater risk of accidents (i.e., stroke patients,
  young males, drivers with prior driving under the
  influence convictions, etc.) than normals
• And that current licensing exams are not based
  upon a scientific foundation

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We Can Then Ask

• Is it reasonable for society to restrict driving
  based solely upon a persons visual acuity or
  field using arbitrary criteria? The historical
  literature would suggest it isnt
• Is the question then a civil rights question?
• Is society willing to develop and commit the
  resources necessary to develop rational tests so
  that people with some level of visual impairment
  can determine if they can drive safely and
  effectively (even if this involves limited
  licensing)?
• If society arbitrarily prohibits driving is it
  obligated to provide an equal alternative?

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Thank you!

• And whatever your vision and whether you drive,
  walk, stroll, jog, skate, bicycle, or roll do it
  safely Its a jungle out there!