17. Bioptic driving in The Netherlands and the European Union
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| Picture 1: driving on freeway Picture 2: sculpture of cycling clogs Picture 4: crossing showing car, pedestrian and bike lanes Picture 5: moped on cycle path and walk path next to it both separated by tree lined refuge then car lane Picture 5 shows shared streets Picture 6 shows shared streets. |
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2453517/
The bioptic driving program is a small sub element of the Royal Dutch Visio’s Mobility Program meaning should someone be a candidate for bioptic driving, that modality of travel is but one option of a mix of modalities available to that person. The client is given training on mobility options through a framework of decisions they apply each time they chose to travel. In my training to be an Orientation and Mobility (O&M) Specialist it is this decision-making process we train a client which forms the main of my education. In doing my Churchill travels I have seen how that training has been applied to include bioptic driving as an option. Bioptic driving is an emerging field for O&M service delivery all over the world. Traditionally that training is given in house once qualified/ certified but increasing its become part of the curriculum and I was certainly introduced to it as part of my O&M training.
The Netherlands has an extraordinarily comprehensive and effective public transport system of train, trams, buses. Other options available for private use:
- Cars / motorbikes and scooters with an extensive and well-maintained road network
- Mini cars and scooters that are limited to 45km/h with different colour number plates and available without medical restrictions with their own licence code – these can be used on the bike paths.
- Bicycles and trikes of all forms that can be ridden on the extensive bike path network including extensive separated bike lanes, road shoulder bike lanes, shared roads (particularly in town centres) and some standard roads.
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| Map of The Netherlands |
The availability of travel modalities to all people, including those without medical restrictions (e.g., mini car) works very well for a small country that is heavily populated in areas and narrow streets. No person is more than 30-minute drive from a train station. So people can get anyway, it just might take them longer with certain modalities. That the mini car has no medical conditions and people with low vision can get a scooter, both go up to 45km/h is a great example of the culture that everyone has personal responsibility of choice and where that choice and freedom to set their low limits and be personally responsible for their decision. In contrast to a system that sets strict limits taking away functional mobility options to people who could be safe drivers/ riders.
Visit to the Royal Dutch Visio - Haren
Today my visit to the centre in Haren including meetings these people, discussion, and observations of the mobility assessment process for two clients.
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| Visit to the Royal Dutch Visio: Centre of Expertise for Blind and Partially Sighted People – Haren: left to right: Hanneke Ferehrmann, Occupational Therapist and Orientation and Mobility Specialist, Dr. Bart J.M. Melis-Dankers, Clinical Physicist Visual System, Josien Zeeman, Optometrist, Anne Vrijling, Clinical Physicist. |
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| Belinda holding a bike she road to Haren standing out the office of Visio in Haren |
The Functional Vision and Mobility Assessment
Bioptic driving is simply one option of mobility that may be available to a person. People with a vision condition are referred by an ophthalmologist or other person/ organisation to Visio to assess their functional vision, determine everyday living goals then, to receive services and visual aids to meet those goals. In this way Visio is a multidisciplinary centre for vision and hearing conditions.
Today I had opportunity to follow two clients including functional vision assessments by the Low Vison Optometrist (LVO) and the Occupational Therapist/ Orientation and Mobility Specialist (OT/O&M). Both clients had expressed interest in being able to drive again using bioptics. Both had middle age onset vision conditions. The day started with the multidisciplinary team of Clinical Physicist, LVO and OT/O&M siting together to review each client’s ophthalmology report to determine client specific strategy for that day. The team come together again after the LVO assessment to revise where needed and then after the OT/O&M to determine outcomes. The Clinical Physicist provides a verbal exit report to the client on findings, mobility options and rights and responsibilities on the road around those mobility options. This process usually runs from 9am to 12pm. The client will then be sent a report in writing from that verbal exit report.
The Functional Vision Assessment
The ophthalmology report will detail the function deficits of the eye organ and where relevant, brain/ neurological pathways and if known, the diagnosis and prognosis of the eye/ brain e.g. if stable or progressive. The low vision functional assessment seeks to understand how the client’s vision operates in the world and how the client uses their vision. Tests used will be targeted based on the ophthalmology report and the client’s goals for everyday living including mobility.
Some of the client’s goals today included: being able to once again read the music sheet while playing an instrument, reading books and reading when out in the community both up close and at distance, mobility options including walking, bike, mobility scooter, mini car (described above with no vision standard but personal responsibility) or a car (with bioptic).
Today I saw the LVO perform tests including acuity on a computer screen and on paper stand, refraction, contrast sensitivity, glare adaption and visual field analysis. See some photos below.
Where a bioptic telescope is part of the client’s goals whether for driving or other activities, the trial set of glasses with six different types of telescopes can be used with varying magnifications and options for Galilean and Keplerian telescopes. Not all six are used, only those considered by the LVO as relevant to that client.
Both client’s I saw today were middle aged with onset eye conditions, one stable one progressive. One client with the progressive condition presented with results that did not make them eligible for bioptic driving. The other client was trialled with two different bioptics for distance acuity. The later part of the functional assessments identified field loss not mentioned in the ophthalmology report. An online review of the characteristics of the pathology identified such could be consistent but it is not the role of the LVO to diagnose with the thought that such could alternatively mean the client has both an ocular/ eye condition plus a neurological/ brain condition that is undiagnosed. This client did not progress to the OT/O&M stage rather at that point given the exit interview and referred to their Ophthalmologist and a Neurologist for further testing and diagnosis. Due to privacy laws Visio must ask for in writing permission to give their report to a person/ medical professional which was to be sort. The client will also be given the Visio written report and test results. At this time a decision could not be made on bioptic driving. Their law and rules means if the client’s ocular condition has resulted in the scotoma (that was only two separate dots) then the client may still be a candidate for bioptic driving. However, if the diagnosis comes back with an additional condition that is a field loss condition the client will be prohibited from bioptic driving.
The Functional Mobility Assessment
Again, the type of testing done by the OT/O&M will be governed by the ophthalmology report and the outcome of the functional OLV assessment. This client presented with significant acuity and horizontal field loss. So the testing focused on how the client uses their residual vision in the room and then outside as a passenger in car and walking the streets in addition what insight the client has to their functional vision and how they use that information. This client is not a bioptic driving candidate but could be considered for a mobility scooter as a transport option to get to social activities and do shopping/ medical appointments. The in room exercises included table top placement of objectives and moving in the client’s known deficit area. Repeating such on the wall at a distance and with larger objects and spatial awareness of a moving person. The client was observed walking to the car to see if there were balance issues and visual processing issues. The passenger in car conversation to the town was to see how the client saw road signs and moving objects. The walking route observed the client’s ability to manage a walking line of travel, negotiate static and moving obstacles and general road sense. The client was observed demonstrating neglect and late recognition of road crossings and occasionally startled by objects appearing into field. The exit interview will report the findings and make recommendations for training to help the client develop better insight into using their vision including visual scanning exercises for walking mobility.
These were very interesting sessions which were very familiar to me both as a person who has had both sorts of assessments as a vison impaired person and in my training to certify as an orientation and mobility specialist. Consistent with all places I visited, the professionals have developed their skills as mostly add-ons to their formal qualifications. The processes, skills and professional judgements are shared within professionals and across professionals of the multidisciplinary setting. Also assisting with succession planning and transference outside Visio.
Discussion on personal choice for independent travel
In discussions with Dr Melis-Dankers we set out what a decision-making framework might look like the below as a very basic example. The client will consider, how should I today travel to work or study:
1) Strategic: What travel modalities are available to me, and which will I chose and why? Where am I going? Consider the factors that may influence which modality I take today: how long will each take? Travel route conditions today for time of day? Whether such as very hot or snow? What limits do I have or things I don’t like to do e.g. if driving I don’t like roundabouts so planning my route before I get in the car. Is there anything affecting me today that may make me decide not to drive e.g. medication issues or didn’t sleep well.
a. With the modality selected, how do I best prepare that choice for that task? E.g. if choose the car or mini car, make sure the windscreen is always clean, my GSP is in a suitable position.
2) Tactical: decisions I make when driving such as, use of a car’s ADAS (Advanced Driver Assist Systems) features, defensive driving considerations such as following distance, lane choice, environmental scanning.
3) Operational: if I have made good choices for strategic and tactical on the most part I will stay out of trouble of avoidable situations. But I have also been trained that the driving environment can be unexpected where some of the above safe practices can compensate but so too can the bioptic. The bioptic is like a time machine – it brings things in the distance closer to you to allow you to take action when and if needed.
In being a time machine for the low vision driver, the bioptic compensates. Road signs are designed for people with 6/6 vision to see at 300 meters away having six seconds to read. If the person has 6/12 vision (e.g. though the bioptic) they will see the sign at 150 meters away at three seconds. These signs are repeated four times in Europe at 1,200, 600, 300 and exit. In addition to knowing this, the driver can use their GSP as a backup to verify. Road signs letters are very big and detailed acuity is not needed for objects. The person only needs to be able to identify the sign shape and symbol such as give way or stop or one way. The person only needs to see the cyclist or pedestrian, not know if it is their neighbour. The person can anticipate intentions at road crossings, see cars, pedestrians.
Community training
It was interesting to learn every two years Visio runs training workshops for professionals across The Netherlands to share expertise, make referrals known, assist private practice and fill gaps as people move on. This includes:
· Eye health: ophthalmologists, optometrists, opticians, neurologist
· OT/O&Ms
· CBR specialist trainers to perform the on-road driving test for bioptic drivers.
· Driving instructors – at present there are 25 driving instructors that have been trained by Visio. Most are regular driving instructors, some with special training in first responder driver training and some with disability driver training.
Visit to the Dutch CBR (Dutch agency for issuing driving licenses and certificates of fitness to drive) – Rijswijk in The Hague (head office)
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| Visit to the Dutch CBR (Dutch agency for issuing driving licenses and certificates of fitness to drive) – Rijswijk in The Hague: left to right: Helmut van der Smitte, Driving Examiner Marcel J. Strik BSc, Senior Policy Advisor, Belinda O’Connor, Ruud A. Bredewoud MD, Chief Medical Officer (retiring), Rob Kok PhD, Chief Medical Officer (incoming). |
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| Display in foyer including old models and pictures of transport items. |
I am grateful to have had opportunity to visit key personnel at CBR involved in decision making for all driver licences in the Netherlands. We had a productive discussion on bioptic driving in Australia and my observations along the way for this Churchill Fellowship. I was given a presentation by Marcel and Helmut of the development of the bioptic driving program and its operation from the CBR perspective. Those presentations can be seen here:
Bioptic Driving CBR procedures July 2023
Learning to Drive in The Netherlands
· Person turns 18 years of age, finds a driving instructor and must do 30 hours of driving lessons
· Go to CBR to do written test and on road test, if pass
· For one year can only drive with a fully licenced driver in the passenger seat.
Bioptic driving process fits in this standard process for new drivers. For those who have previously held a drivers licence, it is the discretion of the driving instructor when they consider the client ready to CBR on road test. The CBR on road test for bioptic drivers can only be performed by a tester who has been specially trained by the Visio bioptic driving.
Before the bioptic driver goes through the standard process for a driver’s licence and after they have had their assessment, they are given at least six lessons over six weeks each 1.5 hours in duration for bioptic use including:
· Two in classroom for static and dynamic exercises and homework
· Four static and dynamic exercises in the community
· Last two sessions include passenger in car with the OT/O&M in the back seat reinforcing bioptic use.
The client then goes through the above process with a driving instructor trained by Visio and sits the CBR exam with an examiner trained by Visio. The client if passes is issued with a licence for five years with a requirement to provide an ophthalmology report at renewal. That report gives the ophthalmologist’s opinion on the diagnosis and progress and not that the client is ‘fit to drive’, that is the role of the CBR. If the client’s condition is progressive, they may have an annual review.
Privacy laws prohibit collection of personal characterises and thus reporting of medical conditions for accidents and infringements cannot be done on that basis. However, the numbers of bioptic drivers are low, around 300 with no known death or serious injury associated.
What is unique and in my view crucial to any mobility/ bioptic driving program, we see here in The Netherlands is the emphasis on succession planning and ongoing professional development on the Mobility program as applied to relevant professionals.
Visit with Orientation and Mobility Specialists and a Bioptic Driver – Royal Dutch Visio, The Hague
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Visit to Royal Dutch Visio: Centre of Expertise for Blind and Partially Sighted People - Koninklijke Visio in The Hague. Nadiye (bioptic driver), Belinda O’Connor, Nanda van der Burg Occupational Therapist and Orientation and Mobility Specialist
| My last official meeting for The Netherlands was with a bioptic driver Nadiye and her Orientation and Mobility Specialist / Occupational Therapist Nanda. In this video we talk about the process Nadiye went through to get her driver’s licence and how Nanda’s role supported. In addition to a bioptic driver, Nadiye has a licence for a scooter, per the above the type that is limited to 45km/h and she doesn’t need/use the bioptic, she uses a push bike and catches public transport. |
Visio has recently released promotional material to advertise the services they can provide to support people with low vision to drive. You can see the video here – it is in Dutch:
AutO-Mobiliteit: autorijden met een visuele beperking - YouTube
Nadiye is currently studying and will be living in another EU country to do her work placement. Because she holds an EU licence, she is allowed to drive in any EU country. Whether she does, she will make that decision later based on her mobility training from Visio on how to make good and safe choices for independent travel. And just like most EU citizens, she has holidayed in various EU countries so has been exposed to variations in road infrastructure and travel conditions.
Yes, we can! Ride bikes!
Nadyie and I spent the next day together when she picked me up from the hotel and we drove about 1.5 hours in the rural area to go to indoor mountain biking. As people reading my blogs will know, I am a keen mountain biker.
This was Nadyie’s first time, and she did really well. We talked about the impact on visual perception and riding, that she relied on me first to show the way and she thought I could see better to do biking but see the same as her when looking at our phones or written things. I explained that my experience mounting biking has much to do with my confidence to ride through trails because I have spent many years learning how the mountain bike ground is shaped and sloped and how the dynamics of different types of bikes impact how you ride the terrain and this means I already know what to expect but more importantly, how to control my bike for expected and unexpected travels. After I explained to her how to position the bike on various trail features, she applied that and to my surprise tried some more advance things like riding the seesaw and unprotected / skinny bridges.
We had a lot of fun! Pretty good for yet another person with low vison told by an eye doctor she can never ride a bike!
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| Nadyie and I riding bikes in the indoor mountain bike park |
I wish to extend my gratitude to everyone in The Netherlands who accepted my request to attend and observe and who imparted their expertise. There is a lot of goodness here. This was an exceptional visit that will contribute much towards my final recommendations.
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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