15. California Motor Vehicle Research Branch - the state’s first licensed Bioptic Driver in 1971 – and others

California has a long history of low vision and bioptic driving with many critical events in evolution. In this blog I interview various people about California's history and current practice and reflect on the similarities and differences of success factors and barriers for Australia. Of particular interest in California is the controversy around studies done in 1983 and 1996 on motor vehicle collision rates of bioptic drivers. Interviews with:

• California's first licensed bioptic driver Dr Dennis Kelleher
• California DMV Research and Development Branch
• University of Berkeley - Professor Bailey and Associate Professor Chu
• The Association for Driver Rehabilitation Specialist 
• Dr Deemer, Assistant Professor Low Vision Rehabilitation Services, Southern California College of Optometry Marshall B. Ketchum University

California's first licensed bioptic driver Dr Dennis Kelleher

Meet Dr Dennis Kelleher, California's first legal bioptic driver in 1971! Listen to his story on how he became a bioptic driver and the history of bioptic driving in California. Dennis's was born with Albinism with the type that presents without pigment in the skin, hairs and eyes. His vision acuity is able to read the top letter of the eye chart but not the second line (20/200 to 20/100). At the time of recoding this video in 2023 he is in his 70s and still a safe driver.

Dennis talks to the barriers and enablers of bioptic driving in California and the USA in general. In 1975 Dennis wrote a contributing chapter to a book about titled Low Vision. The chapter is 23 titled "Experience of a Low Vision Patient Driving With a Bioptic Telescope" discusses prerequisites for driving. Here is that chapter:

Image of cover of book

In 1975 he was invited by the state medical assessing fitness to drive working group to develop procedures for determining bioptic driving assessment. The form is still used today with variations and can be downloaded here (DL 62 2.6.17 Report of Vision Examination):

Image of form

Here are the California DMV procedures for licensing bioptic drivers from this time:

image of first page of procedure

Dennis talks to two conferences held in Washington D.C. in 1975 and then 1976. The 1975 conference held by the New York DMV as they have been licensing bioptic drivers from assessment by William Feinbloom O.D. who invented bioptic for driving and created the company Designs for Vision. Here is the proceedings document from that meeting.

image of front page of document

People for and against bioptic driving engaged in healthy dialogue but those opposed could not be convinced. The people who still opposed bioptic driving (Dr Arthur Keeney from Kentucky, Dr Gerald Fonda from New York, Dr Otto Lippman from Texas, George Hellenger from New York) wanted another meeting so organised this for the next year with the American Association of Motor Vehicle Administrators (AAMVA). At the breakfast after the 1976 conference, some of the attendees got together to develop the recommendations. Dennis says the recommendations agreed to at the breakfast was not what came out in the publication which said bioptic can only be used by those who can meet the vision standard in the carrier lens (which Dennis and I discuss this effectively negates the use of the bioptic). Dennis says Dr Arthur Keeney was adamantly opposed and he had a lot of power. You can view that publication at this link. In addition, Dennis says Dr Keeney, Dr Fonda, Dr Lippman and Mr Hellenger also attempted to convince the AAMVA to request all states of the USA to prohibit the use of bioptics to drive. Eventually the decision was left up to each state and many did not prohibit their use but some did. 

Image of document BTS AAMVA 6.76 pp 19-23 pp33-34

In 1982 the American Optometric Association refuted the above saying it was not was agreed to outlining what was agreed to, seen below. Dennis said the AAMVA lost the battle in the end as bioptic driving is now legal in most states in the USA and those that don't allow it you can still drive with low vision without the bioptic to acuity down to 20/200 (6/60). Paper can be seen at this link.

image of 1982 paper from AOA

Dennis reveals one of the above Ophthalmologist who opposes bioptic driving and who has written several papers to this effect was Dennis's childhood ophthalmologist. Dennis recalls Dr Fonda telling him that he is one in a million (referring to being able to drive safely with a bioptic) which Dennis replied he is just an average person who had a need to drive.

As a member of the California DMV Driver Licence Authority Board, Dennis wrote this journal article  in the Journal of Visual Impairment and Blindness that addresses some of the misunderstanding around bioptics for driving:

image of journal cover

Controversy of the 1983 & 1996 California studies

Dennis requested the following two presentations to be added to the public record. The first is a presentation prepared by Dr David Hennessy who was a career road safety expert working in the Motor Vehicle Research Branch of the California Department of Motor Vehicles. 

image of first page of presentation

In this presentation, Dr Hennessy analysis why Ms Mary Janke's 1983 study into bioptic drivers (BTS - Bioptic Telescopic Systems) is flawed and therefore why the California Department of Motor Vehicles does not use it to ban bioptic drivers as Ms Janke has demanded. He first points out Ms Janke's data used in the report available on the DMV website (Janke, M. & Kazarian, G. 1983, DMV Report #86) is not the same as that published (Janke, M. 1983, Journal of Safety Research, Volume 14, pp. 159-165). This controversy found:

"When the Janke 1983 analysis was confined to only validly licensed drivers, the adjusted mean accident rates for BTS drivers are not significantly higher than the general driving population."

This controversy revealed bias used in research reporting to make bioptic drivers look more risky then they actually are.

Dr Hennessy goes on further to point out the following flaws in research methodology that rely on the BTS - which would be the same as saying all wears of spectacles (glasses).

Dr Hennessy says there are two main errors for BTS studies:

 - its not known if the bioptic is actually worn or used at time of being involved in the accident (therefore the contributing factor) and,

 - amalgamation errors. 

As an example of an amalgamation error, Dr Hennessy uses the example of people sitting in an ophthalmologist waiting room:

 - 50% designated drivers with best corrected vision acuity (VA) = 20/20

 - 50% patients best correct VA = 20/80

 - Overall mean VA = 20/40

Conclusion: the people sitting in the ophthalmologist's waiting room meet the California 20/40 screening standard for an unrestricted driver licence. This is an amalgamation error because clearly those with 20/80 VA do 'not' meet.

Therefore, treating all bioptic drivers as though they are a functionally unitary group is no less an amalgamation error.

E.g. 

Congential and stable (Albinism)

+

Progressive (age related macular degeneration)

=

Amalgamation Error

E.g.

Reduced central vision only (Albinsim)

+

Both reduced central vision and peripheral fields (retinitis pigmentosa)

=

Amalgamation Error

The Overall Mean accident rates for bioptic drivers are artefacts produced by amalgamating entirely different subgroups. It can be extrapolated that this amalgamation error issue may be why studies of this sort cannot be found for wheelchair users and users of other assistive technology disability devices. Studies of wheelchair users seem to focus on the impact on the wheelchair user if they are in a crash rather than whether the effect of improper restraint or other issue about the assistive technology devices/s would be a contributing factor to at fault accidents. Studies also look at reaction times.

Result:

Conclusions based on the Overall Mean accident rates of BTS licensed drivers are as misguided as concluding that people sitting in ophthalmologists’ waiting rooms meet the California DMV 20/40 screening standard for an unrestricted driver licence.

In 2017 Dennis gave this presentation to the Schepens Eye Harvard which discusses Bioptic Driving in California and further elaborations by Dr Hennessy on the 1983 study by Janke and therefore why that research is not used to ban bioptic drivers. Ms Clarke's same study published 1996 demanding the same ban for Bioptic Driving. However the outcome of that is the California DMV decided to no longer allow people to drive whose vision acuity through the carrier lens is legally blind and below (20/200 or 6/60). Therefore people with visual acuity of better than legally blind today can hold a drivers licence and drive even without the bioptic telescope. You can view the presentation here. 

image of front page of presentation

Current bioptic laws for California:

·      Visual Acuity: A driving license will not be issued to a driver whose best corrected visual acuity is 20/200 or worse in that person’s better eye, as verified by an optometrist or ophthalmologist.

·      No person may use a bioptic telescope or similar lenses to meet the 20/200 visual acuity standards.  

·      Bioptic telescope acuity must be 20/40 or better. 

·      No visual field requirements are mentioned. 

Additional assessment techniques are available through a new pilot program in Northern California. This covers any physical impairments that may impair safe driving, as well as a cognitive exercise that requires you to recall your social security number or zip code in writing if you have never been awarded one. If you don’t do well on the traditional exams or the new assessment tools, you’ll be tested for contrast sensitivity and a Perceptual Response test. See http://www.biopticdrivingusa.com/bioptic-driving-laws-californi/  and https://lowvisionaids.org/blog/bioptic-driving-laws-by-state/

California DMV Research and Development Branch

Some member of the California DMV Research and Development Branch: Bayliss Camp, Daniel Bederian-Gardner, Jamie Davis, Mark Fox, Mattie Jette, Peter LaRue, Andrew McCullough, Ainsley Mitchum, Dario Sacchi, Sam Stevens, Steven Villafranca (not all in photo)

It was truely a privilege to meet with people working in the motor vehicle research and development branch of California Department of Motor Vehicles (DMV). This team is the equivalent of Australia's MUARC (Monash University Accident Research Centre). The branch has been producing studies and reports since the 1950s which help the DMV to measure the impact of new laws on making drivers safer. California has around 25 million licensed drivers with an estimated 500 bioptic drivers. There are around 233 million licensed drivers in the USA and it is estimated there are around 10,000 bioptic drivers. In Australia there are around 19 million licensed drivers.

For our meeting I gave a presentation on my Churchill Fellowship and the findings to date and they presented overviews of their current research priorities. We discussed the bioptic reports of 1983 and 1996 which are still available for download on their website and Dr Hennessy's rebuttal. The researchers discussed how to appropriately do research in small groups in that the methodology needs to be qualitative rather than the mean aggregated method used. We discussed the goal for bioptic drivers is not to ban them but rather, just like all drivers, implement measures to make drivers safer. The branch confirmed there are no plans for further research around bioptic drivers in California.

University of Berkeley

Ian Bailey - Co-Founder, Emeritus Professor, Herbert Wertheim School of Optometry and Vision Science

Marlena Chu - Health Sciences Associate Clinical Professor, School of Optometry and Chief of Low Vision Services 

Professor Bailey began his optometric career in 1967 in Australia working at the University of Melbourne and then the National Vision Research Institute (NVRI) and since 1976 moved to the USA. Professor Bailey and Jan Lovie did the foundational work at the NVRI in Australia in the 1970s developing the "logMAR" design principles for visual acuity charts and introducing the methods of scoping visual acuity as logMAR. These charts are the now the standard for eye care and clinical research in Australia and globally. It is the measure used in the Australian Fitness to Drive Guidelines. Professor Bailey for decades has contributed to practice, research and authored papers on bioptics for driving. As discussed in the blog for Australia, Dr Alan Johnston who brought the Ocutech bioptic to Australia in the 1980s studied under Professor Bailey.

Professor Bailey also received push back from the ophthalmology community, including Dr Fonda. Here is an example posted as letter to the editor:

To the Editor. —The August Archives carried two letters expressing divergent attitudes toward allowing some visually handicapped drivers to use bioptic telescope systems for driving. 12 Dr Fonda1 clearly expressed his view that it is dangerous to drive while wearing a bioptic telescope system. His principal objection is that when the wearer looks through the telescope, a substantial and important part of the visual field is obstructed, blocking access to key visual information about traffic and its flow. At first glance, this argument seems clear and undeniable, but, in reality, the proposition is not valid. Almost invariably, bioptic telescopes for driving are fitted to two-eyed patients, are mounted before one eye only, and are positioned as superiorly as possible in the spectacle lens carrier. If both eyes are open, the bioptic telescope creates no scotoma at all. Bioptic telescope wearers should be taught or trained to have both eyes open.

https://www.researchgate.net/publication/19183609_Bioptic_Telescopes 

Professor Bailey and Associate Clinical Professor Chu discuss history and current practice of Bioptic Driving, including through Berkeley University's Optometry Clinic. Professor Bailey serviced on the DMV panel about 20 years ago to review and revise policies on impaired vision and driving. Associate Clinical Professor Chu is involved in current practice. Bailey and Chu admit to similar views on visual impairment and driving and th use of bioptic telescopes for driving. 

I discussed in preparing for our meeting I had conducted a Freedom of Information request to Australia's national body with responsibility for review of the Assessing Fitness to Drive Guidelines. This revealed a paper from persons with the interest to ban bioptic driving in Australia. I shared that paper which we discussed. The paper talked to only three (above mentioned 1983 & 1996 plus a 1988 study by Lippman in Texas) studies on bioptics being useful evidence and based on those studies the use of bioptics for driving must be banned. Much of what is noted above was covered noting whilst the writer has academic promise, the paper appears 'naive' as it is clear it is written by people with little to no prior exposure to the research topic. 

In considering learnings from my research and travels, I wondered if the authors of paper and those who approved it truly do not understand appropriate methodological construction for studies and research or, if there was any intent to mislead regulatory authorities. 

The Association for Driver Rehabilitation Specialist 

ADED - The Association for Driver Rehabilitation Specialist is the registry of driver trainers including CDRS (Certified Driver Rehabilitation Specialists) some whom have training and experience in low vision and bioptic driver training. A search of the website can find any driver trainer who advertises for such services and seminars. One such seminar held in California in 2023 can be seen here: EventDetails.aspx 

I contacted several CDRS on the list to discuss their experience in delivering driver training to people with low vision and/or bioptic drivers. They requested to remain annonymous. One issue identified was receiving contact from people who were given a bioptic by an optometrist but received no formal training protocol by that optometrist on how to learn to use the bioptic nor practice sitting, on-foot or passenger in car. They had turned away clients to seeks such training before they would allow them to commence the driving process. This issue was not identified in other states and points that there are no formalised bioptic driving programs in California. Another CDRS spoke that clients with stable congenital eye conditions, particularly those with Albinism, who were younger, highly motivated and no other comorbidities tended to learn quicker and do better in performance. From my travels this observation concurs with what has been said in other jurisdictions.

Dr Ashley Deemer, Assistant Professor Low Vision Rehabilitation Services, Southern California College of Optometry Marshall B. Ketchum University

Working in California in for the past years and in Maryland before (which allows down to 20/200 as a soft rule - if you are going to get benefits for legally blindness or are you able to drive), not required to drive with a bioptic but is an option for visually impaired. So clients can try it but you don't have to use it pass the road test. Clients try to not use the bioptic first. Some people can get the bioptic financially covered for vocational rehabilitation if the device will be used for other purposes as well such as for work and study purposes. Larger majority of clients are age related so don't qualify for vocational rehabilitation and most have poor contrast sensitivity. Those most successful are those who are self motivated to drive as opposed to hose who say they are thinking about it. It is a long process that requires time and dedication. I discussed in other places like Quebec and West Virgina that such motivation is a criteria to be part of the bioptic driving programs. 

We discussed is if the client how has been given the training and not motivated or who are the optometrists who are just giving the bioptic and not giving the training. Said the process is:

1) check acuity (20/40 in better eye), visual field, contrast sensitivity (if this is poor she will not recommend unless can demonstrated compensatory behaviour).

2) discuss client motivation and barriers to seeing if genuine interest.

3) when prescribe and dispense make sure filtered properly and have them walk around hallway to spot exit signs and then refer to occupational therapy (OT) and/or CDRS. In most optemetric practice there is usually no training protocol as this is a need to hire an O&M or OT (e.g. static, dynamic, sitting, walking/on-foot, passenger in car). 

4) will send to the medical review board, if approved

5) behind the wheel driving test (particularly those with prior experience)

5) seeks client feedback.

We talked where Dr Deemer sees clients who have had an accident. She said those who are bioptic drivers have less problems then those with low vision who choose not to use the bioptic. Dr Deemer says they are more proficient in their rehabilitation process as seems to be more motivation. She rarely prescribes for a person who has lost their vision in older age as learning a whole seperate process and unless they are extremely motivated to adapt. We discussed my findings so far from other states has been consistent with this in those that are congenitally vision impaired or had the condition a long time tend to have less of a need of hours with the CDRS. She noted the older drivers tend to stick to familiar areas.

Travel to California was a worthwhile visit that allowed me to transfer knowledge and deep dive into areas to explore further. I stayed in a comfortable self contained room of a motel in Sacramento. With the beautiful hot weather I would often sit at or in the outdoor pool to read, write or rest. On occasion there was a weird cigarette smell (even with a non smoking sign). One day I overhead a conversation near me about 'weed' being legal in California. So I guess you could say my visit provided a cultural insight into recreational cannabis consumption and its role in the community's social fabric! I didn't have 'the munchies' or the need to stare onto space so I am confident I was far enough away and there was enough open space to negate secondary effects.

Additional resources from Dr Dennis Kelleher

Ameican Optometric association Video on Bioptic Driving

http://biopticdrive.biopticdriving.org/

Biooptic Driving Network

http://www.biopticdriving.org/

Driving with Low Vision (Kelleher)

http://www.biopticdriving.org/DKelleher.htm

Controversies About Driving with Bioptic (Kelleher)

http://www.biopticdriving.org/driving.htm

Bioptic Driving Pioneers

http://www.biopticdrivingusa.com/pioneers-in-bioptic-driving/

Bioptic Driving USA

http://www.biopticdrivingusa.com/

Driving with Bioptics

http://www.ocutech.com/bioptic-driving.aspx

Bioptic Driving in Indiana

http://www.eyeassociates.com/bioptic_driving_blue.htm

Bioptic Driving Laws by State

http://www.biopticdrivingusa.com/state-laws/

Low Vision, Bioptic Driving Publications of Dennis Kelleher

Kelleher, Mehr & Hirsch (1971) Motor Vehicle Operation by a Patient with Low Vision.

American Journal of Optometry and Archives of the American Academy of Optometry 48 (9) pg

773-776

Kelleher (1974) Driving with the aid of a bioptic telescope: Training booklet, School of

Optometry, University of California, Berkeley

Kelleher (1974) A Pilot study to determine the effect of the bioptic telescope on the young low

vision patient’s attitude and achievement. American Journal OF Optometry and Physiological

Optics. 51 (3) Pg 198-205

Kelleher (1975). “Experience of a Low Vision Patient Driving with a Bioptic Telescope” in Low

Vision edited by Fay & Hood. Springfield, Ill. Thomas Publishers

Kelleher, Levin (1975) Driving with a Bioptic Telescope: An Interdisciplinary approach

American Journal of Optometry and Physiological Optics 52 (3) pg 200-206

Kelleher (1975) Teaching the low vision patient: A new Optometric area of responsibility.

Optometry Weekly 66 pg 655-657

Kelleher (1976) “Adaptation and other considerations in driving with low vision” in Proceedings:

National Conference on Telescopic Devices and Driving, June 11-12, 1976. American

Association of Motor Vehicle Administrators

Kelleher (1976). Driving with Low Vision from the Patient’s Perspective. Optometry and Physiological Optics 53 (8) pg 440-442

Kelleher (1976) Training Low Vision Patients Journal of the American Optometry Association 47

(11) pg 1425-1427

Kelleher (1979) Orientations to Low Vision Aids. 166

Kelleher (1979). Driving with Low Vision. Journal of Visual Impairment 73 (9) pg 345-350

Kelleher (1983) The Bioptic Lens California Optometry 9 (1) pg 15

Kelleher (1983) Driving with Bioptics. VHS Video training tape produced in conjunction with the

American Optometric Association and the California Department of Motor Vehicles

Kelleher (1984) Driving with Bioptics – a personal viewpoint. Journal of Rehabilitative

Optometry. Summer pg 8-9

Kelleher, McMillan (1999) Driving with Albinism. National Organization for Albinism & Hypopigmentation web site

 

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/