TSBVI Coffee Hour: Driving with Low Vision
An Overview from the Specialists
2020-05-06

>> Kaycee: Hello everybody. Welcome. We will wait just a few minutes as everybody comes in and joins us for today's session. While you're waiting, you can go ahead and set your chat, currently it should say all panelists in the drop down menu. If you'll change that to all panelists and attendees, then everyone will be able to see your questions and comments that come through. Again, in the chat next to where it says to and has a colon, change it to say all panelists and attendees and everyone will be able to see all your questions and comments. Also, we always love to see where you're joining us from if you want to put that in the chat while we're waiting to get started. We'll get started in about two minutes. Main, Montreal. Illinois. Austin. Austin. Pittsburgh. A bunch of cold places today. Pennsylvania, snowing there. Pittsburgh, Michigan, Texas. Western New York. South Carolina. More Pennsylvania. It's not snowing here. Pittsburgh. California. Fort Worth. Virginia. Oregon. More Philadelphia. Ohio. El Paso. Pittsburgh. (Greeting attendees.) We've got people from all over today. Great. Well, we can go ahead and get started. Thank you all so much for joining us today. If you have a question or comment during the time our presenters are speaking please post that in the chat box and make sure again that it says all panelists and attendees in your drop down menu. Your microphones and cameras are automatically muted so you don't need to worry about that. The handout for today's session is shared in the chat for immediate viewing and will also be available For later viewing and other Coffee Hour sessions shared through our TSBVI.EDU/Coffee Hour. Hit the section saying visit the archives. That will take you to the transcripts and chat information. To obtain your CEUs today you'll respond to the evaluation e-mailed to you from our registration website. You'll enter the code given at the end of today's session and the certificate will automatically generate upon completion of that evaluation. There's no opening code, only a closing code, and it will be given at the end of today's presentation. We'll stop the presentation at 3:55 to give you your code and announcements. I'm happy to introduce Dr. Cindy Bachofer who will introduce the rest of her panel for today. 

>> Cynthia: Thank you, Kaycee. I am pleased everyone can be here for this topic. This is our tenth year at TSBVI to be doing a weekend workshop that brings students and a family member, an adult, together to learn about this, and over 10 years we have had about 150 go through the workshop. And again and again we hear from families and the students getting information on this topic is so hard. They get different answers to the same question. So I'm really pleased we're able to record this. We have people from all over. And we can keep talking about this and people can access the recording for later. Because I know for so many of our teenagers with low vision, when their peers are heading to DPS or DMV for their driver's license, it's what about me? That question of will I be able to drive? And I think in this Coffee Hour session and in our workshop, the two things that we focus on is, first, that legal question: Does your state allow you to drive with the vision you have? And, second, the bigger topic is there are a whole lot of factors that go into deciding do I want to drive, do I want to pursue this? So this session and the workshop we do in early March is about that decision, having the conversation, discussing it with your key family members. And I'm going to let Cheryl Austin is in short term programs and let her say just a little bit about the in the driver's seat, the weekend workshop that will be coming up in about a month. 

>> Cheryl: Sure. Thank you, Cindy. This is Cheryl Austin. I am a teacher in the short term department here at the Texas school for the blind and visually impaired. We co-coordinate the driver's seat program that will be happening on Friday and Saturday March 5th and 6th for high school students in Texas who meet the visual requirements to drive. And as Cindy said, they come and learn an expanded version of the information you're going to hear today, talking not only about driving options, but how how to travel actively if you decide not to be a driver. So we can certainly entertain more questions about that later, if there are any, but, Cindy, I want to toss it back over to you so we can get to our presenters. 

>> Cynthia: Thank you. I'm going to put another plug in. In April, Cheryl and I who are co-coordinating this topic, but we are both non-drivers and we will be doing a Coffee Hour fully dedicated to that because today's session is, the bulk of the time is going to go to Dr. Laura Miller who is an optometrist at Northwest Hills Eye Care center here in Austin. She is so well known on our campus. The thing I love having her do is when she meets with a group of students for We used to call it stump the doctor on the students asking their questions, not a parent, during the appointment. And she has so many fans because she does such a great job of explaining this. And then Chad Strowmatt with Strowmatt rehabilitation services, Chad is a certified driving rehabilitation specialist and he will be talking about that, what's the training that can help build the confidence of learning to drive either with low vision or with a potential driving -- A driving candidate who needs to use a bioptic. Cheryl and I will come on towards the end and talk a little about that active traveler when you're not at the wheel and we're leaving time at the end for Q and A. Dr. Miller, I think we're right on time and you are up. >>: Dr. Miller, you're muted. 

>> Laura: There we go. Thank you. I'm so sorry. See, I'm in with patients, I'm not zooming, I apologize. I'll get this, I promise. I thank you guys for having me and I'll get my screen up here so we can share it. I know we have people from all over, but specifically today I'm going to be talking about some of the Texas DRIEFLG laws and things driving laws. In your state it could be a little different. Every state has different regulations for driving, I don't know all of the states specifically, so if you have questions on that you might have to do research on your own. We're going to talk about Texas, bioptics, and th. The things I'm looking for when a student comes to me and says I want to drive. This is what we're looking at and looking for. So the first thing is low vision, what is it? It can incorporate a lot of different things, but in essence it's an impairment to vision where we cannot be corrected with glasses, contact lenses, surgeries or medications to get someone to quote a normal level of vision. It can incorporate a loss of visual acuity, what you can actually read on a chart, loss of peripheral vision or loss of contrast. We all become low vision, just with aging and other things. When I'm doing a low vision evaluation the main thing I'm looking for is eligibility and then functionality. So for eligibility I've got to look at a few different things. We're going to go through a few of these things, but what they can read on a chart, by law that's what most of the laws go by. And then peripheral vision is another thing. We also don't want to look at eye pathologist that are more stable and not fluctuating and changing. We look at contrast. We look at by knock later, which means how the eyes are working together, we don't want someone seeing double and then color vision, we look at that also. These are all things in the evaluation when a patient comes to me and is wanting to drive that has low vision that I need to look at. In Texas, our unrestricted license is someone who has 20/40 best corrected aacuity. So that or better. They can be 20/40, 25, or 30. That means they can drive anytime day or night, any speeds they want and that is with their best glasses or contact lenses. We also have the rule of 140 degrees of uninterrupted field of view. So 140 degrees from center outwards is what we're looking at. There is also a restricted day time-only license in Texas. So if someone doesn't reach that 20/40 mark, if they're between 20/50 and 20/70, they can drive legally day time only. And again we have that restriction of the 140 degrees of visual field. Finally, we have the bioptic driver. And so if someone is lower than the 20/70, so between 20/80 but up to 20/200, they can still legally obtain a license to drive. They still have to have that 140 degrees of visual field, and they have to get to 20/40 levels of vision with no more than a 4 times telescope. They also need to have adequate cognitive ability and no physical problems that would preexclude driving. Chad will hit on those in his session. In all of those things, the one constant that we have is that visual field, and it's because we depend more on our peripheral vision when we're driving in an automobile than we really do on our central vision. The central vision is really just a very small portion, only 5 degrees, that gives us that sharp detail. But all the rest of the peripheral vision, 175 degrees is giving us the big picture, the lay of the land and the movement of people that might be running out in front of us or balls r All of those things are coming from our peripheral vision. So in this photograph I have here right now, essentially we're seeing a large wide scale view of an image of a highway and you can see directly in the center that central 5 degrees is blurred out. So there's a blue car, you can't really read the license plate on it, you can tell there's a car there. But as you can see the peripheral vision is unimpaired and that's how we're getting the lay of the land, what's coming to our right and l Again that peripheral visual field loss is the one most highly correlated with accidents and mortality when driving. So it's that central small section that we use for really reading on an eye chart, but visual field is what's really important. In this photograph that I have here, we have 4 little cubes of the same photograph and the bottom right shows someone with normal vision looking down a street. There's traffic coming in front of them. In a crosswalk there are cars in the road, there's traffic in front of us, looks like we're stopped at a red light. The bottom left photo shows we start to lose peripheral vision, the upper right is starting to tunnel down even more and the upper left is only if we're seeing down that central part. When you're just seeing down the center, we are missing people that are really almost directly in front of our path that if we were to roll forward or start to take off not realizing that person was in the crosswalk, we might take them out. So it's really important that that peripheral vision is good and full. Some people will ask me, well, what if I just have one eye? I have patients that see only out of one eye and can they legally drive? Yes, they can, because we do have overlap in visual fields. Someone that has normal vision, even with one blind eye, has visual field that's crossing over onto that blind side and that is what this photograph is showing us. The right eye can have from 60 degrees over to the left side all the way out to potentially 95 degrees to their right side so that would gi Even if they have just one eye that they're seeing with. We really don't have studies or established scientific guidelines that show us that 130 degrees of field is what's required to be a safe driver. We just -- we don't have those studies out there. However, we do know that since bioptic drivers do have generally that mild to moderate central vision loss, the overall consensus for really all states have been that they need to require reasonably wide peripheral vision fields. So in most all states there is some sort of peripheral visual field requirement for them to drive. Next thing I look at specifically is eye pathology. We want more eye diseases again that limit the central vision. Those tend to make better candidates again. Those that cause significant loss of peripheral vision, like rent pig, -- retinitis pigmentosa, they will be someone -- I've listed a few here. Albinism is a classic one, someone that just has congenital nystagmus, a macular hole, Stargardt'ses, early macular degeneration. These are early pathologist that make up better drivers just b The next thing we look at is what is the bioptic? People can drive with these things but what are they? It's a prescription eye wear. It has to be prescribed. It's got a small tally SKOP scope system mounted in the glasses. The eye wear can have a prescription in it, we call that the carrier. Then the telescope is basically there for quick spotting. Telescopes can come in different types. They can be permanently fused within the glasses, mounted above or clipped on. We have different types of options. Bioptic drivers, when they use these bioptics, they are using their carrier lens, their regular vision, 95 percent of the time or more. That bioptic is really for quick spotting, so look for a traffic sign down the road, it's really like how you and I might use a rear-view mirror. Just a quick spot and then we're in and out of that. That's what the bioptic is intended to be used for when people are driving with it, not looking through it the entire time. The bioptic system just allows us to increase someone's margin of safety, the time or distance that gets them to be able to detect something and make a prediction so they can change speed, lane positions, as they're approaching something from a greater distance. So that's what we look at. So viewing through a bioptic, as you can see in this photograph on the left, it brings things closer, makes them larger, but we're seeing less at one time, and that is why we want to have good peripheral vision and why we're not using it to drive all the time, looking through it the entire time. Because if we're looking through it the entire time we're limiting our peripheral vision through that scope and we don't want to do that. When we think of the bioptic particular system, we want to make sure when someone has a normal head position for driving that they are looking under the bioptic system, not looking through it all the time. They need to do a dip of their chin in order to be looking through the bioptics. When they're looking straight ahead they should not be looking through the bioptic. That telescope then is mounted a little bit tilted or higher so when they tip their chin down, they're looking through the sco Here's another image of someone driving chin up and they're not looking through the system. When their chin is down, they are looking through that bioptic system. We have lots of options too for our patients that have trouble with glare. We can put sunglasses to fit over the bioptic systems, that can go around the bioptic systems, or cover them completely if they're very light sensitive. So we have options there. We also have flip behind pieces that can help with glare on bright, sunny days. So really the main thing we're looking for or specifically I'm looking for when we are prescribing that bioptic is we want to make sure that someone is really competently using the bioptic. It's not just that they check all those boxes for driving with a bioptic legally, it's so they can competently use the bioptic. That's where the next portion of things comes into play which is the training for the bioptic system and the training in the car. Driving is dangerous for all of us and we want us to all be very safe, so the prescribing part of it is a small portion. The training part is really the most important part of it. All right. That kind of ends my section of things. I think I finished a little bit on time hopefully, so I'm going to stop my share. If there's any specific questions right now, I'm happy to answer. We're going to move on to Chad and do questions at the end, I'm not sure how that's going to flow. 

>> Cynthia: There's not specifically any questions in the chat right now, Dr. Miller. I think we can move to Chad. Each of these presenters typically gets an hour, so I'm very impressed. This is rapid speak and choose your most pertinent slides. 

>> Chad: All right. So basically what I do, as Cindy said earlier, I'm a certified driver rehab specialist. My background is actually occupational therapy. So many of the folks you see in the field across different parts of the United States, Canada, and other parts of Europe and Japan, most of us are OTs that got into the driving area only because in the OT world, driving is considered a daily living task and in many countries culturally driving makes a large difference when it comes to whe Or kind of where you select your job and things like that. We can move to the next one. So basically I am a licensed -- one of things that's unique about my practice is I'm a licensed private practice in occupational therapy and I'm a driving school. Some programs use drivers Ed folks in the front seat and the Ots are in the back. That's commonly how they do it in Canada, while in Texas we generally have the same person in front that's licensed as an ininstructor as well as an OT or an OT assistant. We can shift. Basically as OTs we require a referral from a physician. For example, if I get an example from a from Dr. Miller, I know this person has been through a screening program, they have had the bioptic custom fitted for them, and generally they're going to be more likely to be successful in the vehicle. When we see referrals from opt Tom TRIFTS that don't -- don't do a lot of low vision stuff, sometimes we may see bioptics that don't fit adequately. There may be a lot more chin dropping or the alignment is not correct. So we're all part of the same team. If I see issues that develop when we start doing behind the wheel training and we cannot resolve them through training, then frequently we will call the doctor's office, meet the client at their appointment and talk about the specific PRABS they're having. -- problems they're having. I would say 95 percent of the time when we're having issues and it's from a program that does it all the time it's usually related to glare protection or some type of way to reduce the glare coming through the carrier lenses somebody uses during driver training. Especially for conditions like albinism, our clients that are fighting light and what I call bleaching where things are just much brighter than they should be to have the contrast To see like the edge of the curve versus the side of the road, to look at traffic lights and such, those are all things we work closely with the medical team to make sure that we've given this person the maximum benefit of the background of that person so we can make sure they've got the tools they need to be successful. In our case, some of the other things we ask for, we ask them to fill out a questionnaire. Usually the questionnaire tells us what kind of vehicle they want to drive. My driving school has advance because I do a lot of physically impaired folks. I also have trucks and sedans, small and medium size sedans. So when we get a feel for what the person wants, we try to schedule them in one of those types of vehicles so they Can be successful or bought into the program. They have to have earned their permit before we see them. If they're a new driver and need to take drivers education, those are all the things people have to do before they come to our program. In Texas, there is a vision exam form the optometrist or ophthalmologist fills out, in our case it's the D L-63. That form, they explain to the clerk at the driver's license office telling that person why they can't pass the eye test in the machine. One of the interesting things about COVID-19 right now is that most of the eye exams done at the driver's license offices in Texas are an old eye chart so if somebody did have a bioptic, they would be able to use that bioptic to look at the eye chart. But historically when they use the machine, it's designed to simulate 20 foot distance and usually because of the size and structure of the device, it makes it difficult to get into the eye machine. Of course the other thing is a lot of times we have funds for these programs, so if we've got a vocational rehab, we have to -- of course depending on the condition they have to be seizure free. I would say that's pretty common in other populations like brain injuries and things we may get involved with. We can switch. This is the DL-63 form. This is something Dr. Miller would fill out for her patients. It basically talks about what the condition is, whether they have corrective lenses, even if they should drive day time only. These are all the things that are on this form. It really again is an explanation, because the clerk historically is just going to have the person try to read the eye machine and if they're unable to do it they're going to give them this form and send them back. We usually get this form ahead of time before we go to the drivers office. After their training and they're ready for their test, we need this form to be current so we can have that process go seamlessly. Click to the next one, which is the back of this page. This page basically defines what their vision is. It has the information on the specialists so that if they want to call that person, they can. As Dr. Miller said, the field of vision is listed on the lower aren't corner of the form. We do have cases where their vision is not quite the 140 degrees of uninterrupted field. It could be a TU more. We have some clients with conditions, you may read stuff if you look at pub med and things, people that are studying this, I do have a little success with situations where somebody has had more of an acute trauma that has resulted in a problem compared to a metabolic issue like stroke or severe diabetes, the effect on their vision tends to be more global As opposed to affecting just their vision. So this form is designed to again let us take this with us to the driver's license office the day the person takes their driving test. Let's go ahead and switch. In our case, if they're under 18 there are certain rules that apply. We used to have a rule, it was really ridiculous. We only had 14 hours of drivers Ed, behind the wheel time, that was required up until about 2015. And the assumption that the DPS made in our case, the Department of Public Safety, made was that people were going to practice on their own before they took the driving test in or before they got their certificate of completion from a driving school. The reality was, some people that was the only amount of training they got. So at some point they used some common sense and said, okay, we need to have at least a certain amount of classroom hours and a minimum of 44 hours of driver training behind the wheel and of that 44 at least 10 need to be at night. We have some situations where we've got a low vision driver that Dr. Miller or one of our local doctors at the University of Houston has a big optometry school and they send us a lot of referrals in the Houston area, they will say this person is not eligible to drive at night. In that case we would just do all 44 hours of behind the wheel training and not include night driving. We generally take everybody out at least once at night. Sometimes with albinism they see a lot better at night, better contrast. So in those situations we do take them out so we can see how they are functionally. So if they do pretty well and we feel like they are a descent candidate to drive at night, we get the form changed so it won't say day time only. In many cases DPS in our state will have them take the driving test either twice, once in the day time to get their license, and they may take it again when it's dark to show that they can drive in the dark also. And in some cases we still get overruled when it comes to the medical advisory board which is in our case the kind of final word as far as who can and can't drive with medical conditions, but basically the point here is that if we've got somebody that does do okay at night, the doctor didn't think they were going to be able to do okay at night, we will try to get their form made so they have the functional options to drive with at little restrictions as is reasonably possible. Then of course I've got a link here to our website. You can go ahead and switch. These are some of the tests that if you referred somebody that has any type of medical condition to a driver rehab specialist, these are some of the tests we do. Switch to the next one. One of the big things, I have any doctorate now and the big push these days is to have evidence -based practice, so a lot of those tests have at least some studies that are written and talked about as far as their predict ability for success behind the wheel. So I've tried to revamp our program. I've been in practice for over 30 years and I have students all the time, so it's commonly a student mission to upgrade either one of our clinical tests or right now we're trying to improve our driver evaluation route so that it includes all the elements we should really look for when we do a driver evaluation. The only time we cannot necessarily have a perfectly comprehensive evaluation is if I'm in an area that it doesn't -- you know, they're not coming to my office. I do a lot of traveling. I see kids in their home towns I would say 80 percent of the time. So if they lived in, let's say, junction, Texas, I would go out to Junction and do the driver training out there so I can really see them drive in areas that they're familiar with and/or where they're going to really drive. So sometimes it would be rural areas. We've had cases where they needed to have a speed restriction, but they lived in the country and the highway to the town was a 70 mile an hour zone, so some of those kids were unable to drive from their home in the town but they were really functional in town. So we can help them make decisions about their living arrangements based on the functional use of their vision. Now this slide is showing the bioptic. This one gives us the best field of vision when it comes to driving and so I really like this tool, this bioptic. ACUTECH. I would say probably these two slides I've got to bioptics, I would say 85 percent of the clients that we see have one of those two types. Then if we don't have one of these two types, then it will be a version of this. Let's go to the next slide. We've used the by lateral bioptics before. For years and years I used a single bioptic, it was mounted over one carrier lens that was of 3 or 4 power. Usually we don't do more than 4 power partly because the medical advisory board and Dr. Laura's people decided that anything stronger than that was going to restrict the field too much, and that's been my functional experience. I had a guy that came one time with a 6 power on one eye and a 5 power on the other eye, and he missed like six stop signs in a row in the Houston area. So I do strongly believe that the 4 power, even that bioptic is the strongest that we should really allow when it comes to functional success. And I bet -- you know, it's interesting, people ask me how many patients do we see a year. I would say we probably see 15 to 20 in a year, and of those 15 to 20, I would say 18 of those folks are really successful. The ones that are not either do not have family support and they really don't want their kid to drive or they are for whatever reason life has just gotten in the way and they have not committed to the time it takes It does take longer than a traditional teenager to drive this way. So when we talk about 44 hours, that's really the minimum. We had a kid with a certain condition and I bet we spent over 100 hours, over a year and a half, and we were eventually able to get him to be successful. Things like the glare in the evening and the glare in the morning were challenges for him and we had to work through all of those things. Let's switch. So obviously when we do behind the wheel assessments or training we're going from simple to complex. We are different than a regular driving school when it comes to that. Some driving schools have a curriculum. We have a curriculum also, but they have a curriculum that says day 1 we're going to do this, day 2 this, day 3 that. In our case it's developmental. So until you master lesson 1, we don't go on. Sometimes our kids have been to a regular school, they have been put on the freeway, b So we kind of have to back track and get them back to the area where they're functional and build from there. All right. Next one. . Some of the outcomes. When we do an evaluation, do driver training, obviously we're trying to clear them to drive independently. When it comes to low vision, if we're doing an assessment and it's somebody that has, say, developed macular degeneration and they're losing some independent, we do an evaluation and take them to the DPS. They take the road test and we sometimes report to the medical advisory board if they shouldn't drive. We're not really in the business of taking their license away. In some cases we have them return later if we feel their condition is going to improve or there are some outside therapies they can participate in to improve their skills. I would say usually those are cases where we've got a field limitation of some kind and they're not scanning well. Those are the kind of cases that come back after they have done some outside therapy and come back. Go ahead and switch. Obviously with new drivers we recommend additional therapy if they need it. We do training. We take them to the DPS. When their car is done, we have frequently spent sometime with them in their own car to make sure they feel comfortable. When it comes to low vision, sometimes the speedometer and the ability to see it is critical to success and comfort. So we will work with them with all those different apps and things you can put on your phone or if they purchase a vehicle that has like a digital speedometer. Next one. Like I said, the length of training depends. If we've got someone struggling, we will do training and make a decision as to if there has been improvement. And we will talk about restrictions. Most of them will be based on function. They have struggled in a certain area and say it doesn't make a lot of sense if you're struggling above 55 miles an hour. Let's get you some years of experience and then if you feel comfortable with the next layer, we can do that. This link is something I wanted you guys just to have so you can click because as Dr. Miller said every state has a different requirement. There are some states that do not allow bioptics to drive, so this is a pretty comprehensive list. I think it's pretty up to date that has a lot of the standards for driving. Let's switch to the last one. And again, the purpose of this is just to say this is a team effort. We find as much success when families have bought in and we get good therapy stuff, good low vision folks, good O&M work that's done before they get to us. If we've got somebody that has success and is not afraid to use their bioptic in other situations like in class or walking around or going to a concert, they will tend to do much better behind the wheel than if they only wear it for driving. So I've said that many, many times over the years. If they don't care about the aesthetics and they care about the function, they typically do much, much better. All right. Questions? Somebody asked early in the presentation about funding. I would say the funding issue, vocational rehab, we do some stuff with some of the Medicaid-based programs, or in our state they call them independent living programs. Sometimes ILS services will pay for driver training or driver evaluations. It really depends. The only other -- typically health insurance does not cover these kinds of services, so I rarely have somebody that has blue cross blue shield and their parents have a good job or what have you and this is one of the services that are covered. Even though I'm an OT, blue cross blue SCHEELD especially does not consider what we do medically based. So whenever we have cases or referrals like that we usually refer them to a vocational rehab person that has some experience with low vision to try to help them navigate that program. I've served clients in Arkansas, Louisiana, Oklahoma and Texas, and each one of those states has a really different set of rules for vocational rehab. But as long as the person wants to be independent and live independently and have a job at some point, get their degree, vocational rehab will help. 

>> Cynthia: And I think we'll be able to maybe have a couple other questions at the end. Thank you, Chad. 

>> Chad: You're welcome. 

>> Cynthia: And I've got a slide up here. This is the phrase, for about 20 years I've been doing either presentations with students or conversations with them and it's that idea if I'm not at the wheel, I'm still getting in charge of getting around. And I think that phrase, it shows that responsibility in picking this up. And I'm glad that the term now "Active traveler" is being used as opposed to non-driver, because active traveler says what I am doing. And I think this Coffee Hour topic applies to our students with low vision who may get their license and get a bioptic, but they may not be driving on bad weather days or in The phrase I would hear, wow, you don't drive? You just don't have any independence. That's got to be tough. And it took me a long time to develop the response of, yes, I do. Yes, I am independent in my travel. I'm able to get where I want to go. And I think even like drivers we say repeatedly in our workshop, drivers have frustrations too just as those who are active travelers have frustrations, And that feeling positive about my active traveler status, Cheryl and I had a discussion on this earlier in the week and the three that come up in my mind most often when I know I'm using multiple modes of transportation to get around, environmentally friendly and not putting another car on the road in some instances, community contacts because I'm at street level when I'm doing my travel and I'm meeting people, seeing businesses. And that owning and operating a vehicle has a significant price tag on it, which everyone who is a driver recognize s I've made a decision to go this route. But by being an active traveler, more funds and less stress is another feature that I feel positive about my status. I think there are so few role models. There's a lot of images that being at the wheel is -- if we have a student who doesn't drive and gets around independently, that's a huge point. This slide is one that's most important to me, I have a few others I'm going to move through quickly, and they're more about lesson ideas or conversation topics for those who are in this KAED goer of low vision -- category of low vision and looking at being a driver or being an active traveler. I think that developing those active traveler skills, that first phrase, active passenger challenge, in our workshop we throw that out a lot because parents will comment to us, you know, my son can't even tell us how to get to grandma's and we go there 5 times a month. It's that if you are a passenger in a car and a teenager that's considering this, your eyes should be up and directing the driver. Here's where we turn. Okay. The light's green. Watch that potential collision. Where you are starting to recognize and I think comes do this a lot with their students is starting to understand traffic patterns and what's key to paying attention here whether you're a pedestrian or a driver. And then setting up that practice time for am I going to ride gray hound, take a trip to the near by town or practice using LIFT or Uber. Doing that with an adult. To just get that habit started where you're kind of learning the ropes of how to do this. And when not being at the wheel, probably the biggest responsibilities I've learned here is that I have a role to play in this. Am I helping to direct the driver? Am I responsible for getting the directions? Am I choosing what our stops are along the way? I have a role in this. And I especially have a role in reciprocating whether it's through money, paying for lunch, getting gas. And another really big lesson was making good use of wait time, whether I have hired a driver and they got way laid and I have 20 minutes, how can I going to use that time well? Or the bus is late. What am I going to do to make the use of that time where it cuts down on my frustration. I think there are multiple skills that students should be working on along the way. Here's a short list. I think one of the biggest is building that skill of getting good travel directions and noting how many major intersections are we going through along the route? Is my -- the location on the left side or the right side of the street, east or west side? Is it a brown building or a yellow building? So you're getting those visual markers that help you be an efficient traveler. And then practicing the problem solving. I would sometimes just throw out scenarios to a student. What happens if this? What happens, you know, if your phone dies and you've been relying on that for your GPS, what's your backup plan? So there's a short list of those. I have an image here, 1957, a property type of a autonomous vehicle, it has 4 people playing SKRAB bell because nobody is having to be at the wheel. In the past year one of our students in the workshop said I'm waiting for the Google car. I can still be an independent traveler, but me doing it the way that has been demonstrated for 100 years, that's not going to be my way. And I know the development of that vehicle is slower than we first expected, that autonomous vehicle was supposed to be out this year, but it is still something of the future. So I've listed here alternate modes of transportation. And even if you're in a very small town, even rural, the top three I think apply to all of us of any size, whether I am walking or biking, whether I am setting up rides with family or friends, or whether I hire a driver. And Cheryl and I will be able to discuss some of these more in that Coffee Hour coming up in April. I have a quick promo here for through TSBVI curriculum, the second edition of finding wheels has come out and it is a very, very teacher-friendly, family-friendly, student-friendly publication that gives lesson ideas and quick topics for students to be considering if they're choosing to not be at the wheel at this time. So Cheryl's and my e-mails are on this slide and one of the things we had talked about was the -- we've been doing this for 10 years and we've even be able to take it on the road where essentially we could bring together a group of students and parents. We would have a low vision specialist talk, just as what Dr. Miller demonstrated. We would find a driving rehab specialist who could summarize what Chad did, and our third key element of a short one-day workshop was bringing in panelists, bioptic drivers who could talk to the room about here's where my concerns were, here's what it took MR foe to build my confidence. It's very, very doable to set this up. And as I said at the beginning, we hear from so many parents and families this is a tough topic to get reliable information on. So I'm glad we could do this Coffee Hour today. I haven't been monitoring if another questions have come in the chat. We have about 5 minutes. 

>> Kaycee: Let's see how many questions we can power through. How often does a customer need to upgrade the bioptic? You're on mute, Dr. Miller. 

>> Laura: Thank you. I would say sometimes these will last decades. So truly it's how much they take care of it, how well it's taken care of, and really the biggest issue is changing prescriptions. So if the prescription needs to be changed and the carrier, that's generally when we do have to do an update. Not necessarily to the whole bioptic system, but maybe just change the lenses in the carrier. 

>> Kaycee: Chad, is there a course to become a driver rehabilitation therapists for O&Ms or is there a prerequisite required? 

>> Chad: ADD if you type that in on Google there's a whole website that goes into the all the things that are required. One of my staff members is not an OT, so it's kind of like an apprenticeship program. If you start as an OT, even being an OT doesn't automatically make you qualified. You have to do time and pass an exam. So it's an apprenticeship. The more medical background you have when you start, the less behind the wheel or PREN advertise time you need to be qualified. Like an OT assistant needs two years of experience whereas an OT needs one. So an O&M specialist, because of that medical background probably would just need 1 to 2 years max. Again, all those kinds of specific questions are answered on the website and we have courses done online, we have courses that every year we have a big conference in different cities. In fact, chuck house is probably the premier person when it comes to driving and he's an O 

>> Kaycee: We have several questions come in about where to go to find the 140 degree rule in Texas and also the 20/200 as the max acuity. Is there a reliable place to find that information? 

>> Chad: That one slide I had that had the link, it broke down. What happens there's a page and you click the state, it shows the vision and acuity requirement -- 

>> Cynthia: When I looked at that, it only had the 20/70 cut off. 

>> Chad: The first one I sent you had that, but the second one was in more detail. I think. 

>> Cynthia: We'll hear back if it isn't. 

>> Kaycee: Another question is are the insurance premiums higher if an individual uses a bioptic for driving? 

>> Chad: In my experience it has not been. It's more about whether you're a male versus female. It's more about whether you're married. It's all the typical actuarial data and the value of your vehicle is what really determines the insurance rates. If I've got a new driver and they're 29 years old and married, it may be less than it would have been if they were learning when they were 16 but it would still be high because they don't have a lot of experience. The value of a bioptic, like we do a lot of vehicles that are extremely expensive that are modified for spinal injury drivers and those are more expensive because the value of their car is higher. But when it comes to bioptic drivers or low vision drivers, it should not be any higher than a regular driver until they get the years of experience under their belt. 

>> Kaycee: Dr. Miller, do you ever perform cognition testing especially on older drivers wanting to bioptic drive prior to referring to a certified driving instructor? 

>> Laura: I do have an OT on my staff that will do some cognitive testing to see if that's playing into things and I'll refer them to a primary care, a neurologist, to get that if it's more an issue. We do need to make sure cognitively they can get from point A to B, there's a whole other aspect we need to work out. 

>> Kaycee: And can you -- 

>> Laura: All of us have trouble with contrast on a rainy or cloudy, foggy day. If you already have low KRON traditions and low vision, we talk about do you need to ride with a friend or have a backup plan? For contrast we need to really talk about other alternatives. With color there's really no issues with color perception. You can't get a CDL, which our low vision drivers are not going to be able to qualify to get one anyway. The only color vision issue might be with stoplights, red, yellow green, but you'd learn those by memory. So it doesn't become an issue with driving with color. 

>> Kaycee: Perfect and that brings us to the end. I know there are some more questions we didn't get to. Check your handouts for our presenters' contact information. Please join us on the 4th because we have canvass accessibility with John rose followed by coaching versus consulting what's the difference with McCormick. And then we have story time on the 11th with Peterson and Kathi Garza. Check our Coffee Hour website for the registration information. To get your CEUs for today respond to the evaluation e-mailed to you from our registration website. Also the handouts and recordings from this and past sessions are available through a link on our Coffee Hour page TSBVI/EDU/Coffee Hour. Once you're on the page scroll down to visit the new archives. That is the link and it will take you to the recordings, handouts, transcripts and chat information. On the evaluation you receive from ESC works there are two boxes, 10 and 11, that ask for additional comments you'd like to share with the presenters and the planning committee. Pleat let us know in those boxes if the day and time we're offering work for your schedule or if you have other suggestions. We'd also like to hear your ideas for future coffee hours. The symposium for deaf-blind is coming up. That's April 22nd and 23rd. Registration information is in the chat right now. And a huge thank you to you, Dr. Cindy Bachofer, and her panel today. Thank you guys so much for joining us.