10. Iowa Low Vision Driving without Bioptics in conversation with Dr Mark Wilkinson
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| Picture: Mark left, Belinda right |
Mark E Wilkinson, OD is Clinical Professor of Ophthalmology and Director, Vision Rehabilitation Service for Carver College of Medicine, Department of Ophthalmology and Visual Sciences at University of Iowa. Dr. Wilkinson's research interests are in two general areas; inherited eye diseases and driving with a reduction in visual functioning. I contacted Dr Wilkinson because I wanted an alternative view to bioptic driving in the USA and to learn more about his views on individuals who are visually impaired using GPS (global positioning systems) and ADAS (advance driver assist systems) instead of a bioptic telescope. Additionally, Iowa is one of only two states that does not permit the use of the bioptics for licensure, however, it does permit individuals with reduced acuity, down to 20/200 (6/60), to be licensed to drive if they can safely pass a behind the wheel test. The vision standard is:
Iowa
Visual Acuity | |
> 20/40 in one or both eyes | No restrictions |
20/41-20/70 in one or both eyes | No driving when headlights are required
|
20/71 – 20/199 in one or both eyes | Discretionary issuance
|
< 20/200 in one or both eyes | License denied |
Bioptic Telescopes: Not allowed to achieve the visual acuity standards noted above
Visual Field (uninterrupted is not specified) | |
≥ 140 degrees binocular | No restrictions |
< 140 degrees but >110 degrees binocular or≥100 degrees monocular | Will be required to have a left and right outside mirror |
<110 degrees binocular or <100 degrees monocular, but ≥75 degrees monocular or binocular | Discretionary issuance
|
<75 degrees binocular or monocular | Discretionary issuance
|
<20 degrees binocular or monocular | License denied |
Source: Iowa Department of Transport. https://iowadot.seamlessdocs.com/f/DriversVisualAcuityReport
I started out summarising my fellowship journey thus far and Dr Wilkinson gave me some history of low vision and bioptic driving. He stated before 1922 there was no restriction on who could drive and that vision standards originally were introduced in 1922 by the American Medical Association at the 76th Annual Session. Not 1937 as commonly reported being ‘Visual Standards for Licensure to Operate Motor Vehicles’ in Journal of the American Medical Association. In reviewing these standards after our meeting, I cited they say 20/50 and 20/40 respectively with no less than 20/100 and 20/65 respectively in the worse eye. The change reason stated was due to road deaths and injuries and speeding with a desire to reduce these and a statement that ‘good vision’ is required for driving but that a person’s ability to compensate can vary from person to person. No evidence or reference was made as to what portion of these deaths and injuries were attributed even at all, to vision issues. The document also stresses that good vision is not the only factor but rather how someone uses their vision. Dr Wilkinson stated that since these early times that advice has not changed, nor has it been validated scientifically.
In referring to the early research papers on bioptics for driving Dr Wilkinson states that Dr Feinbloom stated bioptic were not needed to see other cars, nor to see pedestrians. The bioptic was mostly used for wayfinding e.g. reading street signs (as road/ traffic signs were created for people who see 20/40 or better as that was the unrestricted vision standard). Mark stated what we have learned from a distracted driver standpoint is using your mobile phone is problematic, even hands free, so is changing your radio. Activities such as these creating attentional blindness. When you're attending to one thing and blind to the other. So Dr Feinbloom’s original thought was that using bioptics would not be problematic for driving because when the driver is looking through the small field of view of the bioptic to see something in the distance, their other eye would be aware of what's going on around them. Yet Mark states that human factors research has provided this to not be true. Mark related this to talking on the phone in conversation having both eyes open looking at the road but distracted by the conversation whether hands free or holding the phone.
Mark stated his other issue with the use bioptics is their use is mandated by rules added for each state, and these rules are different from state to state in the same way that there is variation in vision standards across states. It is also a financial burden to acquire a bioptic system, so only those who can afford it can drive with vision loss. He noted some people are price gouging. Additionally, in some states, drivers using a bioptic telescope then have to go through an extensive training process, that adds additional cost, yet it has not been proven definitively the training makes them a safer driver.
Mark stated despite operating out of Iowa that does not allow bioptics to meet the vision standard, he does fit bioptic telescopes for clients in surrounding states that require the use of a bioptic telescope for licensure to drive for the past 40 years.
Laws vary between these states and places like Nebraska don’t have restrictions on the person visual acuity without the telescope. Privileges are based on the acuity through the scope. This is despite the fact that the person using the bioptic is only using it for about 2% of the time when driving so they are driving with their regular vision the vast majority of the time, yet, the person’s driving privileges’ are being decided based on their visual acuity through the bioptic. Mark stated he has patents who tell him for the majority of the time the bioptic sits on the seat next to them and they use their talking GPS for wayfinding.
Dr Wilkinson stated for Iowa being the most “aggressive state” allowing people to drive with acuity better than 20/200 and visual field better than 20 degrees to “as the doctors say”, let the client show they can drive through an on road test and they can prove they are safe drivers.
Mark has patients with 20/160 who are very safe drivers’ day and night. These patients have gone through the on-road testing by the DOT (Department of Transportation), including day, night, gravel roads and everything else and they did not have to spend $1,000 or more to do special training. Dr Wilkinson said for him this is the ultimate position and non-discriminatory.
Dr Wilkinson stated he regularly talks to parents of children who are visually impaired who are wondering if their child can drive. He asks the parent to look at what their child sees on the eye chart and then asks what in a driving settings is smaller than that.
Mark says eyes on the road is the most important thing. When you're looking through a bioptic telescope your eyes are not on the road. He gave an example of his wife being rear ended by a normally sighted, younger person trying to read a street sign and not recognizing that the three cars ahead, were all stopped for somebody to make a turn. He states this may have been helped by wayfinding, which would have allowed the driver to listen for the direction to turn right at the next intersection and not having to read the signs, so everyone is safer. I stated I agree that in my experience I don’t read signs and instead use my talking GPS to complement my driving.
Dr Wilkinson then moved onto discussing the advanced safety features on cars. So automatic braking, lane departure warning, adaptive cruise control, all those things are going to make everybody safer and I agreed with his views. Mark reflected that his grandfather had polio and had an adapted car in 1950 with hand controls. He moved on to say these days with these ADAS features, that make the car an adapted car, individuals who are visually impaired should be allowed to show they can drive safely using these systems in the same way individuals with physically disabilities have been able to be licensed for decades. When using ADAS and GPS especially living in regional areas and where there is limited distances and speed. Mark argues ‘why do you have to have to acquire a bioptic telescope if you are using a GPS and you've got an adapted car? On this basis he feels requiring a bioptic telescope is discriminatory because it requires a person to buy an unproved device to acquire driving privileges, when these more proven systems of talking GPS and ADAS have been shown to result in less attentional blindness and greater driving safety. Mark stated using a bioptic nor training in its use has never been proven in 50 years to make somebody a safer driver and both are a financial cost to the person. However, if a person wants to use a bioptic for driving then let them, but don’t require it for the vision test and don’t put it in the law. Mark reiterated that the USA has 50 states with 50 different vision standards for passenger car drivers. The differences with the use of a bioptic system versus no bioptic use are not scientifically based. Dr Wilkinson says for individuals who are visually impaired, with visual acuities better than 20/200 in one or both eyes and a visual field of greater than 20 degrees, just let them prove they can drive safely with an on the road test.
I discussed with Dr Wilkinson my curiosity on not being able to locate much on driver safety research for low acuity drivers without the bioptic, e.g. crashes, moving violations etc., noting most states that allow low vision driving only do so with the use of the bioptic, but Iowa is different.
Dr Wilkinson explained that although they Iowa Department of Transport (DOT) allows driving down to 20/200 this is not advertised so the average person would be told they failed the vision test. However, some licensing offices will refer the person to Dr Wilkinson for assessment. Dr Wilkinson certifies and recertifies 400-500 people a year.
Dr Wilkinson reiterated that there is no vision standard that says you are safe at a certain level of vision and unsafe at another level. I said I have not been able to find research that shows a point of acuity someone is a safe driver. Mark said he has some people with 30 degree field that are consistently safe drivers including a lady who’s been seeing him for 17 years and keeps taking the behind the wheel test every year, who keeps driving safely. He’s had others with much wider field who are not safe drivers. You can’t generalise. Mark recalled there was a general statement out of New York state that said visually impaired drivers were safer than those who weren’t because they are more conscientious, less risk taking, limit their driving.
Dr Wilkinson discussed the need for a nationally consistent standard across the USA and more studies. He suggested this is something that could be looked by the America Association of Motor Vehicle Administrators. Mark said people move to Iowa so they can drive because they cannot in their state. He stated they are the same person regardless of the state they live and it’s frustrating for citizens.
Mark noted that in 2007 The Federal Highway Transportation Safety Administration (FHTSA) said someone with a 70 degree or better field of view can drive a commercial vehicle down the interstate. He noted this standard allows drivers to drive commercial vehicles with standards that are more liberal than many passenger car licenses in many states. Mark noted there is no science to support the 120 to 140 degree field of view standards for passenger car licensure. In fact, a study done in 2019 by the FHTSA found that there had been no increase in accidents by commercial licensed drivers with the lesser visual field standards than in the past.
Dr Wilkinson said people don’t understand what a certain level of visual acuity means, from a functional standpoint, including some eye doctors. They don’t think about what the numbers mean on an eye chart in comparison to functioning in the real world or behind the wheel. Mark said he asks people in his office to tell him what’s the difference between 20/100 and 20/200 from a functional standpoint.
I wish to thank Dr Wilkinson for his time and willingness to be so open to discuss these matters and particularly to provide me with an alternative view to bioptic driving.
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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