1. Montreal's Bioptic Driving Program-Québec
Institut Nazareth et Louis-Braille (INLB)
CISSS de la Montérégie-Centre – Longueuil, Montréal, Canada
Visit date: Monday, 29 May 2023
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Left to right: Véronique Small (Optometrist), Anyk Bélair (Optician), Annik Gemme (Driving Program Coordinator and orientation and mobility specialist), Vincent Moore (Optometrist), Belinda O’Connor (Bioptic Drivers Australia), Maude Gravel (Orientation and Mobility Specialist), Nicholas Leroux (Orientation and Mobility Specialist)
Today’s Agenda
8h30 à 10h30 Vincent Moore (optometrist) / Anyk Bélair (optician)
· Presentation of the Quebec's low vision rehab services
· External reference to the bioptic driving program
· Inclusion criteria
· Most frequent diagnosis of our patients
· Choice of the bioptic telescope
· Fitting/Customization of the telescope
· Photophobia/glare management
10h45-12h00 Annik Gemme (Driving program coordinator)
· History of the bioptic driving program in Quebec
· Collaboration with the SAAQ and existing regulations
· Statistics of the bioptic program since 2012
12h00-13h00 Lunch with the whole team where Belinda presented the historical and current context of bioptic driving in Australia
13h00-14h00 Maude Gravel (orientation and mobility specialist)
· Presentation of the bioptic driving program
· Virtual driving simulator
· Commentary driving.
Belinda's Reflections
See this supporting presentation video that describes the bioptic driving program's criteria.
Low Vision Services
The province of Québec, Canada has 14 Multidisciplinary Low Vision clinics which are government funded (province/state) giving free access to rehab specialist to all Quebec Province residents. There are long waiting lists in some clinics, and not all specialized services are provided in every clinic, especially in remote regions. Some private practice optometry clinics also provide basic low vision services at a fee for service. The inclusion criteria (this is different to the inclusion criteria for the bioptic driving program see presentation at above link):
1. VA below 6/21
2. VA equal or below 6/18 if degenerative visual pathology or associated motor or intellectual deficiency
3. VF below 60°
4. Complete hemianopia
This service provides many elements around low vision rehabilitation. This can include assessment by an optometrist, provision of optical aids, orientation and mobility services.
In Australia, examples of the equivalent of this type of centre would be Vision Australia, Guide Dogs, VisAbility. With the introduction of the NDIS (National Disability Insurance Scheme), these vision rehabilitation centres in Australia are no longer government funded directly. Rather the funding is given to the person who can then choose their service or service provider based on that person’s goals in their NDIS plan. With the change in funding model the NDIS has restricted access to vision services to only 6/60 and below. This means 10s of thousands of Australians no longer have government funded access to services to assist for work and study to be productive citizens. The only exception is people diagnosed with a degenerative condition that is on an NDIS list given by those who can advocate so no everyone eligible is included.
Here are pictures of some low vision aids for purchase and same that can be found in Australia.
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| low vision aids such as books and talking devices |
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| talking clocks |
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| large print books |
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| kitchen vision aids |
Bioptic Driving Program
The Bioptic driving program is offered only in two clinics so people travel from all over Québec province to visit either of these facilities to undertake the program, which can sometimes be up to an eight hour drive away: Longueuil, Montreal and Quebec city since 2012. There were earlier funded by bioptic assessment and training processes, and I will talk about that in later blogs. Referrals to the bioptic driving program can come from INLB or other Low Vision clinics. Each year each of the two clinics have 2 groups of candidates (4-7). One cohort starts in the fall and one in the spring, for a total of around 12 per year in Montreal and 12 per year in Quebec city. The waiting time for the bioptic program is 3-4 years. Of the government funding for low vision services there is specific appropriation for bioptic driving and only for 12 candidates per year per centre.
An important induction criteria is a psychological assessment to determine that the person has the motivation to undertake the program for the full duration, because resources are limited, and they want to ensure success for all clients who enter the program. This is a key factor as to this program’s success. Psychological support is also available for clients throughout the program to help manage anxiety if needed for some clients throughout the driving process.
Regarding barriers to access to bioptic driving in Québec Province, access to funding constrains the number of bioptic drivers who could potentially be driving at this time. Another barrier is access to health professionals who will work in the government funded sector because pay parity is better in the private sector. Despite this, the people who work in the sectors are motivated by the outcomes, they see of independence for people with low vision. See here a video by Dr Moore who discusses one of the barriers to access to low vision services is the need for education for ophthalmologists and optometrist of low vision options, including bioptic driving.
This is the same barrier based in Australia for people with low vision. On a personal note, I have been told by eye doctors (ophthalmologists and some optometrists) that “nothing more can be done” and I have been in countless discussions with other people living with low vision who have heard the same statement. This commentary is too often told to people with low vision, when, in fact what can be done is in the rehabilitation field by low vision specialists in the multidisciplinary settings. It is important that education of this sort is continued to be provided in learning institutions for upcoming ophthalmologists, orthoptists, optometrists etc.
Like other places around the world, bioptic driving started in Canada in the 1980s and I will talk in another blog about what happened in the interim period. The success factor that allowed bioptic driving to re-commence in a formal way in Canada, was the result of a court case where the Supreme Court of Canada determined that the transportation department must allow people with low vision to demonstrate that they have compensatory skills. Prior to this, the compensatory skills only applied to other physical disabilities and not vision. There was an earlier court case in the 1980s that was with bioptic drivers and determined that they should be given the privilege with government support which will talked about in a later blog. Therefore, if a person with low vision, even just above 20/200 or 6/60 (this is the world accepted, definition of legally blind), is able to demonstrate compensatory skills, they may be able to hold a drivers license with or without a bioptic.
As is the same in Australia and other countries around the world, it is the driving licensing authority who makes the final decision as to whether somebody should or should not hold a drivers license. The reason for this authority is that the driving licensing authority has access to all the information regarding the clients’ medical records of different body systems, including not just the eye, but whether the person has other medical conditions in addition to a driving record or not. The SAAQ (Societe d’aaurances automobile du Quebec) will receive a recommendation for a driver’s license from a health professional. The next step for a person who does not meet the standard for vision criteria will be for the SAAQ driving Instructor to do a onroad driving test with the person with low vision to see if that person can demonstrate compensatory skills. If they can do this, then the person will receive a driver’s license. The person has to provide an annual Vision report and the SAAQ will do a onroad driver test to re-evaluate the client every two years.
One of the barriers to low vision and bioptic driving In Australia is over the last two reviews of the medical guidelines for vision, there has been inclusion of progressively more restrictive commentary on not to allow people with low vision to do an onroad assessment by an occupational therapy driving instructor. No evidence has been provided to support this position, and there is no definition as to the meanings of what vision issue would not be a safe driver. Yet, this is a common practice around the world and these tests can be done in a dual break car where the instructor can cease the test at any time if they find the person is unsafe. Further, the research supports that this is an Important step for assessing whether a person with low vision, including a person who uses a bioptic, could be a safe driver.
Some interesting points from discussion is that the program only allows people with stable conditions. This means that any person with a progressive eyesight condition cannot be eligible for the program. An example of a progressive condition maybe something like Stargardt disease and Age related Macular Degeneration (ARMD). These conditions are very commonly included in bioptic driving programs in the USA and the Netherlands. Candidates for the programs in Québec Province are people who were born with their eyesight condition, e.g. Albinism.
Another interesting point is that people are issued a daytime only driving license. They can however, apply to the SAAQ for a license that will allow them to have night time driving after holding a licence for one year and again sitting an onroad test but at night. Ancedotally however most of the INLB clients don’t seek this. These points are items of concession made to the SAAQ so they could be satisfied to allow introduction of bioptic driving into Québec.
This above is an example that the development of regulations in countries for driving and assessing fitness to drive are not evidence based rather are evidence informed and political will decisions.
Using a Multidisciplinary Team
The presentation that can be accessed above includes the eligibility criteria and utilisation of a multidisciplinary team for the bioptic driving program. This gives the program the capacity to look at people in-depth on a case by case basis, and this is clearly one of the factors as to why the program is so successful and why the outcomes for bioptic drivers are so successful in ensuring that they are safe drivers and continue to drive.
Before getting in the car it is important that every person is considered as a person. After the assessment by the low vision optometrist, the optician fits the bioptic for the client. This includes determining the best frame and glasses, including whether there is a prescription in the lens or a prescription for contact lenses. Although a client may have been diagnosed with a certain eye condition, e.g. Albinism, the way that condition affects the person and how that person responds or functions in the world with the condition is always different between people. As an example, an optician might provide a different set of coloured tints to one person with the same condition. Here are some photos of tints that have been made up for a person with Achromatopsia. One lens is red, and the other lens Is green, and they have used a 3-D printing machine to create a lens cap for the bioptic so that a polarise tint can be added to the scope. For this client side frame filters were bought and dyed and painted darker to cut glare but still be transparent. This rehabilitation is life changing to this person and is the difference between being able to drive or not because it accommodates for that person’s glare sensitivity and allows for better colour discrimination of traffic lights.
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| red and green lens and 3-D printed lens cap |
As this is my eyesight condition, we had an interesting discussion in comparison of my bioptic and fit over setup. We were able to exchange ideas of techniques I have not thought of and could use in the future for myself. I also provided them with this blog, which is where I obtained my setup: http://suzannegermano.blogspot.com/2015/05/one-light-two-light-red-light-green.html
Commentary Driving and Driving Simulator
At many stages of the Quebec Province program there are tests that the client will go through. That may mean that the client has to take a few steps back to re-learn to be able to pass and progress. One example is how the driving simulator is used. Whilst it is acknowledged that driving simulators are not the real-world environment and provide a clear view rather than a low contrast of a typical world. For people with low vision, especially who are told that they will never drive this is a real opportunity to get in the driver seat and be able to simulate their first ever driving experience. The driving simulator is used in the first phase of four phases of the bioptic driving program. And these drivers are not allowed to go driving with family members or friends until they have reached at least stage three of the bioptic driving program. Until then, they must be in a dual break car with the driving instructor.
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| Nicolas demonstrating use of the simulator |
As per the eligibility criteria clients must be able to afford to pay the fees, and in this case they must pay for the driving instructor at the stage they start driving (but the commentary driving sessions are government funded) which is about $2000 for 10 lessons. The driving instructor is used for this program and not rehabilitation or OTDI however, they have been trained by the INLB in bioptic driving techniques. The client is introduced to commentary, driving in about session 5 of stage one of the four stage driving program.
The commentary driving technique is recommended worldwide (including Australia) for every new driver, disability or not so the everyday person will see reference to this technique, but not the name in training programs for their teenager. The technique all learners would be familiar with is they sit in the passenger seat of the car and tell mum or dad (the driver) what traffic signs are ahead and what action needs to be taken. There are red or green lights, stop or give way, anticipating other and vulnerable road users and on how to proceed. This is an essential part of any bioptic driving program. And in this context, a checkpoint test is that the client must pass a session where no instruction is given and the client must tell the instructor who is driving how to proceed based on the road conditions and signage around them.
Using Orientation and Mobility Specialists
The driving simulator and commentary driving sections of the bioptic driving program is supported by an orientation and mobility specialist. They sit in the back seat to give instruction to the client about how to do the commentary driving, what they might be missing and how to use vision techniques to improve their driving performance. The O&M will sit in every second or third session to assess progress and they continue to support through the driving instructor phase until the client is determined by the instructor and O&M that client is ready to have the ‘driver instructor only’ (S condition) lifted. At that stage the client can start driving with family and friends.
One of the barriers to the bioptic driving programs is that O&Ms only in last 15 years are being taught how their skill set can be applied to the bioptic and low vision driving context. In addition, there is still limited education given to Occupational Driving Instructors (OTDIs) for vision and driving. The vision science theory and vision rehabilitation techniques taught to O&Ms makes them very well positioned to teach and assess people with low vision for driving simulators and as a back seat commentary driver educator. They are not however, driving instructors. We discussed that in Australia we too experience the same barrier that education can provide O&Ms with the framework on how to apply their current skill, set to a bioptic driving program. This context, however, is different to the USA where they have driving instructors who are rehabilitation specialists, who do have explicit training for low vision and bioptic driving.
This was a fascinating visit and I am extremely gratified to the team at INLB setting aside the time and imparting their expertise. The knowledge I have gained from this visit far outweighs anything I could have obtained by email or by zoom meeting. I hope you have enjoyed reading this blog and gained some knowledge in this topic. Questions are always welcome.
Keep an eye out for my next set of blogs which will be in Québec City:
- videos and discussion on the vision habilitation process done by the orientation in mobility specialist in the classroom and using the driving simulator.
- videos and discussion of bioptic drivers driving the car in all settings with the driving instructor and orientation and mobility specialist in the back seat.
- the history of bioptic driving in Québec and how the program fits into the standard settings for driving licensure.
You’re welcome to follow my/ this blog for updates. And join our Facebook group Bioptic Drivers Australia: https://m.facebook.com/groups/BiopticDriversAus/?ref=share&mibextid=S66gvF
To learn about the reasons for this blog, go to my Churchill Trust Australia webpage to read about the fellowship I was awarded being "The NRMA - ACT Road Safety Trust Churchill Fellowship to identify success factors and barriers for low vision and telescopic glasses driving" The page is here: https://www.churchilltrust.com.au/fellow/belinda-oconnor-act-2022/
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