In the Driver's Seat - Dr. Laura Miller Description of graphical content is included between Description Start and Description End. Transcript Start Fade up from black. Animation: Text for TSBVI transform into braille cells for TSBVI. [Music face out] Fade to black. [ Music ] [Title start:] Description start: In the Driver's Seat A Conversation with Dr. Laura S. Miller, O.D. Considerations from the Low Vision Specialist Description end: [ Music ] [Title end:] Cindy Bachofer: Dr. Miller has been our Low Vision Specialist who presents each year at the In the Driver Seat, our introduction to safe driving, and this morning we want to talk about use of bioptics and visual factors. With bioptics-- this is part of an interview set with some of our other presenters, such as Chuck Huss, that are on the bioptic driving website. So, I'll let Dr. Miller maybe say a little more about herself. Dr. Miller: Alright. Yeah, my name is Dr. Laura Miller and... I have a practice here in Austin. I'm a Therapeutic Optometrist and an Optometric Glaucoma Specialist, but I do specialize in working with low vision, so I specialize in working with those who are legally blind and visually impaired; and I've been the consulting optometrist, here, for the Texas School for the Blind, oh, since about 1998, I believe, so it's been a while. So I enjoy the-- working with the visually impaired and I enjoy working with your students, and so I'm excited to be able to do this with you today. Yeah. Bachofer: Wonderful. Why don't we start with... showing some samples of bioptics? Dr. Miller: Sure, absolutely. Bachofer: And get that information out first. Dr. Miller: Out there. There are a few different types of bioptic designs that are out there. [Title start:] Description start: Ocutech VES-Explorer ocutech.com Description end: This one is the Ocutech design, so this is a Keplerian design, which means that it gives it just a little bit more... magnification, so. [Title end:] Bachofer: And Keplerian is a type of telescope. Dr. Miller: Type of telescope. Bachofer: That has a prism inside of it. Dr. Miller: That is correct. Dr. Miller: That's right. So yeah. So, light does come in from this side of the scope, passes through across some prisms, and the light goes into the eye over here. These are also focusable, so they are adjustable. So, they can also not be used just for driving, but have uses, like in the classroom, or when you need your hands free to see things off at a distance. So, this design, again, is made by Ocutech. They have a-- this is kind of their sporty design, so it's a little bit smaller, a little less bulky. And then their standard design looks like this. [Title start:] Description start: Ocutech VES-II ocutech.com Description end: So, same type of design but as you can see it is a little bit more... bulky, but this does come in just the black. [Title end:] The sporty, now newer design, you can get in a variety of colors. So, for those that want a blue one, or a pink one, or a red one, they can do that, too. So, if you want to have more fun with it. These do go all the way across. So, for some patients they feel like that's a little bit... maybe too noticeable. So, some of the designs that we look at have to do with cosmesis, and some of them have to do with actual functionality. So, that's why we have a couple different options there. So, those are these two designs here, that are by Ocutech. Ocutech has just come out with this newer version called the SightScope. [Title start:] Description start: Ocutech SightScope Flip ocutech.com Description end: The SightScope is a very low powered scope, though. So, this is not intended for, in general, most of those patients that need a true bioptic to drive, and we'll talk, I'm sure, about the criteria for driving. [Title end:] Bachofer: Mm-hmm, yep. Dr. Miller: But these scopes can go from three times up to six or seven times magnification. This only comes in a one point seven and a two point two. So, can't even get up to the three power. This doesn't' have the ability to focus or adjust, it just has some ability to adjust for the width and distance between your eyes, only. This does have a little bit of a wider field of view on it, because of the way that it's designed. So, it can still be used for those drivers that maybe are just off the cusp of driving, but want a little bit of extra help to just key in when they need-- Bachofer: Give that bump of vision, yeah. Dr. Miller: That little bump of-- little bit of magnification when they need it to see that street sign off at a distance. It can be flipped up to get out of the way, and then flipped back down to be used. So-- so, these are the three types of designs that we have from Ocutech. Bachofer: And I-- I'm betting somebody is thinking how much is that. Dr. Miller: Yes. Yes. So, these start at about $1300 to $1400 and go up around $1800s, in these. The SightScope is a little less; this one is just under 1000 for this type of design. But these are all customizable. You can have your prescription put into the bottom part of the lens, because you do generally look through the bottom portion of the glass most of the time while you're driving. You're not looking through this scope all the time. So, the way that this works is you would be using just the bottom portion with your prescription. When you needed to spot, or see something off at a distance that you're not able to, then you're in and you're out of the scope, very quickly. So, I like to describe using these as almost like we, as normal drivers, use a rear-view mirror in our car. We're not looking through it all the time to see what's going on around us, but when you do need to spot something, or see what's behind you, or to the side of you, you're checking out your mirrors. And you're in and out of them very quickly, and that's how this scope is supposed to be used. So, the prescription can be incorporated here. We can also make those transitions, or the ones that darken and lighten, for those that have glare troubles. And or you could have some slip in filters added, in order to have some consistent glare control, because a lot of the transitions may not change as dark as some people may need, even in a car. So... so that's why the price is a little variable depending on prescriptions and customizability that we do with these types of designs. [Title start:] Description start: Bioptic Telescope DesignsForVision.com Description end: The other type of design that we have is one by Designs for Vision. These have the scope actually ground into and mounted into the glass. These also, again, are focusable so you can change and adjust the focus. This is a Galilean design, which is just another different type of design. The Galilean design gives us a little bit less magnification but a little bit wider field of view. [Title end:] Again the prescription in the surround of the glass can be done to the prescription... and you can have filters added or the transitions. Now, because this is kind of ground in, of course, the transitions is not through the scope. So, if someone's very light sensitive, we want to add that filter behind it in order to control the glare. So, these come right eye or left eye. So, they're pretty much the standard kind of 'stick out designs,' is how these are mounted. Bachofer: And it's always in front of the lens. Dr. Miller: Always-- Bachofer: They don't do the behind the lens anymore. Dr. Miller: Correct. Correct. Yeah. The behind the-- there used to be a behind the lens design. A gentleman actually did it and designed it, but he has retired and so we're unable to really get that design anymore. So, used to kind of hide behind the lines which helped it cosmetically, but it was a little more awkward, people had to get used to it. Bachofer: Okay. Dr. Miller: Yeah. Yeah. So those are pretty much our designs that we have of the types of scopes that we can use for driving. And again these come anywhere from three, to six, or seven times power; although there are some limitations as to what powers we can use for driving in Texas, yeah. Bachofer: So, let's talk a little about the visual criteria to drive in Texas. Dr. Miller: Perfect, yeah. So, for Texas to get an unrestricted license where there's no-- absolutely no restrictions-- you have to have at least 20/40 or better on the chart. And what that would mean is that you could see something from... 20 feet that someone with normal vision could see from 40 feet. So, very close in similar proximity to quote normal levels of vision. So, that would be an unrestricted license. You could get that with or without glasses, so of course you could-- if you get to 20/40, at least with a pair of glasses, you could still qualify for that unrestricted, meaning you could drive at any speed limit, at any time of day that you wanted to. Bachofer: And that's even if just one eye has the-- Dr. Miller: Correct, even if just one eye has that vision, that is correct. For... the other levels for visual acuity, you can get from 20/50 to 20/70 levels of vision, and still just drive with standard glasses, although that license does limit you to daytime only driving, no nighttime driving. Bachofer: Okay. Dr. Miller: So... Bachofer: Are there typically other restrictions that go on that or is it just the time of day? Dr. Miller: No, just the time of day are restricted for that. Now, when we start stepping into the bioptics, that's when the vision goes below 20/80, so it's between 20/80 and 20/160, or 20/200 level of vision. And that still allows you to legally drive in the state of Texas, although you would have to start driving with one of these systems... at that level of vision. Now, the state, right now, says you can drive with no more than a four times power of telescope. So, you can have a three times-- two times, three times, or four times level of telescope. And through that telescope you do have to get to at least 20/40 vision with that. So, in general those that have 20/200 vision, with a four times scope, can get to that 20/40 20/50 level of vision pretty comfortably. And that is why that 20/200 is kind of the peak, because as we get worse and worse in our vision you need a stronger and stronger power of telescope in order to see more at a distance. Bachofer: Right. Dr. Miller: With that stronger and stronger telescope we are limiting, and limiting the field of view that someone can drive with. And so... we're going to discuss the fields here in a minute, but that also is a limiting factor for driving. Now, the other part that we have is field of vision, which talks about our peripheral vision, how much we see out to the sides. And there are some restrictions that the law does put on that, also. They want us to have essentially 140 degrees of continuous field of vision. Now you think, "Oh okay, if I have one eye I'm limiting half of my vision, but in essence our nose does cross over and can do up to about 50 to 60 degrees of vision, even to our blind side. So, from 60 degrees here, and out to 90 degrees out here, you could cover 140 degrees of vision still with just one eye. Bachofer: Okay. Dr. Miller: Now when we start looking through these scopes we are limiting the field of vision to just about, usually, 20 to 30 degrees. So, it's a very narrow limited field of view. And that's why, also, the scope is just placed on one eye. If you were looking through both at the same time you'd be looking through tunnel vision, through both, and that is much more dangerous. So, we will generally apply the scope to the... better seeing eye, and then we use the peripheral vision for the other eye for maintaining good peripheral vision, when we're driving all the time. And so, that is why you see these just with one eyed. Now of course this scope, because it's a lower power, in the lower power we are getting a wider field of view. And the way that this design it does allow it to have a wider field of view, so you can be looking through both eyes... and still get that field of view with this. So- so, that's what the state does require-- it's not my requirement, it's the state's requirement. [laughing] And so, when I have to fill out paperwork I have to put both the information with regard to vision and visual fields, so... Bachofer: So, a patient would come to your office, meets the criteria, fitted with a scope, you test in the office that they are meeting that. Dr. Miller: Correct. Bachofer: And then the patient can take that bioptic and-- Dr. Miller: And their DL-63 form, which is the standard state vision form... which I will-- I will fill out and they take that, they take their bioptic, and they can proceed with, then, taking their test. Bachofer: Permit. Dr. Miller: the Permit and, then, taking the test. I tell every patient come and see me every time you need to go in for anything at DPS, I need to fill you out a new vision form. One, they're going to want to have to see it current, and they're just going to want to see a new form every time you go in, so... Bachofer: To get your license renewed? Dr. Miller: To get the license renewed-- or yeah, so, you go get your permit, when you go to get your license, when you need any renewals, or anything like that it's good to come in. Let's double check all the information, also make sure your scope is fitting properly and aligned properly. Bachofer: Good good. Dr. Miller: And we can get you a new form. So, yeah. Bachofer: When you consider... driving and the visual demands of that-- over the years I have-- drivers to me always make it look so easy. Dr. Miller: Right. Bachofer: But it is visually demanding. Dr. Miller: It is. Bachofer: What would you most want to emphasize with, say, teenagers or young adults who are just pursuing their license in that-- Dr. Miller: Right. Bachofer: Those visual demands. Dr. Miller: Yeah. I think that it's very important that... they realize that, you know, this is definitely something that is... potentially a hazard and a danger. They need to take this very very seriously. And I do find that my visually impaired drivers are a little more cautious, and are definitely more... take this much more seriously than say your typical teenage driver that just wants to get in the car and go. But there are a lot of things that have to be done, and requirements that have to be met in order to get this when you are visually impaired. And so, definitely, I think that the things that I want to emphasize most are, one is to always have a backup plan. This definitely can allow you some independence, and these scopes can allow you to be able to be an independent driver. However, there may be days that it's a beautiful day when you leave, and you-- your day runs away from you, and then it's dark when you go-- are going home, or you have a horrible storm, and the lights are poor. And so, we need to have a backup plan, because there may be times that you do not feel comfortable nor confident driving, even with one of these scopes. If weather conditions change, lighting conditions change, sometimes just visual fluctuations that may change throughout the day; visual fatigue if you've been using your eyes all day on a computer. So, that's one of the things that's very important, is always considering a backup plan and having kind of that backup plan. Do I have a parent? Do I have a friend, that can, maybe, pick me up if things change, or if the lighting changes. From fall time when it gets dark earlier to springtime where we have a little more light in the evenings, those are also things to take into consideration. Bachofer: Okay. Dr. Miller: So. So... so, that's one big emphasis. Another is to... just... really get a lot of practice with the scope I think. Using it not just for your driving. So, using it in a classroom, using it as a passenger when you are just riding with other friends, or things to get you-- or with your parents-- to get used to using the scope. It's not something you just put on, and like, "Okay I'm ready to drive." Bachofer: It's building a skill. Dr. Miller: It is building a skill. And so, using it while riding a bike, or... those kind of things, to get used to the motion and how this works. So, there is a lot of preparation that goes into it, and I think that that's one thing that's a little bit underestimated. They think that, "I'll put this on, let's go," and they haven't been using monocular in the classroom for years, maybe since they were, you know, nine or ten, because it's embarrassing and they keep it in the drawer. So, pulling that handheld monocular out. Starting with that in the car, as a passenger, even when you're 13, 14, 15, before you're getting your permit to get used to how it- how it-- the scope works again. And then, getting just a lot of practice with this. And you need to have very good scanning skills, and good... just observation skills with using this, so. Bachofer: What are some examples of eye conditions that would prevent a patient from meeting the visual criteria, or... possibly not appropriate to pursue a license? Dr. Miller: Yeah. So, in general we want to make sure that someone has one, you know, the visual acuity requirements; so that 22/100. So, that's the first thing that we kind of look at is that. And we also want to make sure, secondarily, that this is more of a stable condition. So, there are certain conditions, such as, maybe, Stargardt's, optic atrophies, some... different conditions like that. Maybe some mild retinopathy of prematurity, different things like that, where these people can usually have fairly stable vision... and can generally qualify for the license. Now... field is the other issue. And so, in general Retinitis Pigmentosa, a condition that causes a tunneling of the field of view, and it is progressive disease, is someone that probably should not look at pursuing a license. And there are some variations in that; there are some people that have very slower progressions, but the field changes are more what we look, and how quickly that field is changing. Generally the central vision isn't the limiting factor, but it is the peripheral vision that's the limiting factor for those. So, also conditions where, again, there might be instability, those with maybe diabetes where their vision may fluctuate wildly, from day to day, or from week to week. So, those are really the types of conditions that we look at. So, those with major retinal detachments, or retinal disease where their peripheral vision may be severely affected, or specifically retinitis pigmentosa, which is a progressive non-stable disease, would be one that would probably be eliminated, right off the bat, for driving. Yeah. Bachofer: What... changes or improvements do you see coming in bioptic design? Dr. Miller: Yeah. Bachofer: Because these show some of that progression of how the tool has improved. Dr. Miller: Right, absolutely. I think, you know, with technology we're going to get more, probably, auto-focusing capabilities. There have been some auto-focusing designs, in the past, but they've been very bulky and cumbersome, and not very useful. And not, definitely, user friendly for all of the changes that you're zooming in and out, for for driving specifically. So, I think that some auto-focus... type of designs. And also, just, somewhat, minimizing some of the bulkiness. As you can see, we've gone from this, even to this design, to make it just appear a little cosmetically better, and make it a little more lightweight. We have had some improvements, too, in the frame designs; the old frames were those typical old just black heavy duty looking-- military looking designs. And so, we have gotten some that are lighter weight, that are more-- less cumbersome and more comfortable to wear. So, I do think those are probably the major changes we'll see coming with that. You know, we've also got auto-drive cars, maybe, coming; things like that can-- that can maybe-- Bachofer: It's happening, yes. Dr. Miller: I know. Bachofer: In the future. Dr. Miller: Get rid of even some of these things in the future, right. Right. Bachofer: What words of advice would you have for a parent who is very nervous about their child driving. Especially, when I think it's that the child is-- or student is on that borderline of meeting the criteria? Dr. Miller: Right. Bachofer: And parents can-- there's a lot of anxiety around that. Dr. Miller: Right. Absolutely, and that's understandable, absolutely. I have two normal sighted children that drove, and it was very nerve racking just to send them out into the world on their own. But I think that one of the main things that... that I would say is that, you know, this does require a lot of practice, and a lot of thoroughness to be able to achieve that license. And if their student is willing to go through all of those things, I think that... that should help at least to settle some of the nerves. In general, again, for the driving, the field of vision is the most important thing, and those of us even with normal vision do not have 20/20 out in our peripheral vision; only our central vision has that good detailed acuity, and all of our vision drops off as we go off center. And so, their peripheral vision would be the same sight as our peripheral vision, and we have seen lots of research and lots of studies, that have shown that... really, peripheral vision problems are the ones that cause most accidents, and most harm and damage... Bachofer: Most of driving is being aware of that side. Dr. Miller: That's exactly-- Bachofer: What's happening on the side, yeah. Dr. Miller: Absolutely correct, and theirs is-- should be, if they qualify to drive, exactly like ours. Or close to ours. And so, enhancing just that center of vision is just what the scopes are providing for them. And it's not like they're not seeing anything out there. I think that's one of the fears, parents have never seen how their child has seen, and they hear that number 20/200, and it sounds like a horrible number. It's you know-- but they are seeing cars, they are seeing obstacles, they are seeing all those things. They just might not be seeing what's written on the side of the car, you know, or the license plate number. So, that's what these are enhancing, giving them that little bit of extra bump up to- to bring the acuity to a normal level. So, I think that, in knowing that... all of these things really have... a lot of-- they have to have a lot of experience with these in order to achieve that license that-- Bachofer: So, a student might start out... neighborhood routes only, practicing, getting used to this, it's not heading straight to downtown. Dr. Miller: Exactly. Bachofer: And helping the parent understand that that we're... building that skill. Dr. Miller: Baby steps. Baby steps, absolutely, and building that skill. And again, I think the more the parents can encourage their child to use it as a passenger in a car. I know most kids are-- they're on their phone, just not paying attention to anything that's going on, when they're in a car as a passenger. So, putting that phone away, making them help you determine the route that you're going to take, and, also, helping observe the- the route as we're going, finding those street signs and-- Bachofer: Showing the parent, right, that I can read that, you know, as it's approaching, I'm getting better as the car is moving to be able to pull the information off that sign. Dr. Miller: Absolutely. Bachofer: And demonstrating that to the parent, hopefully, helps both sides that this is a good decision. Dr. Miller: Absolutely. Bachofer: Pursing. Dr. Miller: Absolutely, yeah yeah. Bachofer: Okay. Thank you very much. I appreciate that we've been able to share more information on bioptics. Dr. Miller: Absolutely, thank you for having me. 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