Bioptic Telescope Drivers License


The following document is intended to serve as a resource as well as the recommended guidelines when prescribing bioptic spectacle mounted telescopes for driving. This should be in addition to any comprehensive eye evaluation you would do which could include but is not limited to a thorough history, eye-movement evaluation, pupil evaluation, slit lamp assessment, IOP measurement, and dilated assessment. 

1. Best corrected visual acuity of at least 20/200 in the best corrected eye per a complete vision exam. 
2. Plotted visual field of 120° uninterrupted binocular visual field across the horizontal. 
3. Color vision sufficient to respond correctly to the presence of or changes in traffic light color, pavement markings, road signs, turn indicators, brake lights, or emergency flashers with the presence of other road users including emergency vehicles.
4. Telescopes must be in the bioptic position (superior mount and angled up) and firmly fixed in the glasses or attached permanently to the bridge of the frame and no greater than 6.X. The bioptic telescope can be monocular or binocular.
5. The patient must own the bioptic telescope spectacle for 3 months, and practice  and complete at least 10 hours of front seat passenger in car instruction while wearing a bioptic telescope by a low vision rehabilitation professional. 
6. After ownership for 3 months and passenger in car instruction, patient is eligible to apply for a permit to complete behind the wheel instruction.  A letter of proof of this step by the low vision professional will be required for application.
7. Once the individual has the permit, behind the wheel instruction must take place as follows: 20 hours with a certified driver instructor or a certified driver rehabilitation specialist followed by an additional 45 hours (5 of which must be in adverse weather) with a licensed driver of at least 21 years of age.  Note that the permit authorizes the patient to drive only while wearing the bioptic telescope and only during 30 minutes after sunrise through 30 minutes before sunset.  The permit is valid for 12 months.  Once this step is complete, the patient is reevaluated by the driving instructor who did the original behind the wheel training.  That driving instructor will recommend that PennDOT schedule the individual for an on-road driving exam administered by the department.
8. Note that a bioptic driver's license will always be limited to driving on roads other than freeways and to passenger vehicles weighing no more than 10,000 pounds.  Furthermore, it always excludes operation of a motorcycle. It may be limited to a radius of the individual's residence as determined by the individual's low vision rehabilitation professionals, certified driving professionals or the department.  
9. Note that if the patient achieves 20/50 or less through the telescope, the license is limited to daytime driving only.  If the patient can achieve 20/40 or better through the telescope, the patient can apply for a nighttime driver's license after one year of original bioptic licensure, provided that there has been no violation of bioptic driving rules/law, no accidents during that year and that the patient is reevaluated by the certified driving professional who agrees and recommends it.
10. An annual vision assessment will be required to determine if the vision continues to meet the bioptic telescope license vision standards.
11. The department will annually review the individual's accident and violation history. The law states that the bioptic telescope license may be recalled if the department determines that the patient was involved in an at-fault accident or convicted of two moving violations committed in a one year period.  Also, a violation of a condition or limitation of the license shall result in the recall of the bioptic telescope license. 

Talking points to remember during this assessment:
1. Prescribing a bioptic and learning to use one to drive is a process that will take time.
2. Getting a bioptic does not guarantee a license.
3. Discuss other uses for a bioptic.
4. This process will require a financial investment. Support from OVR, BVS, or other sources might be available and should be discussed.

A comprehensive history should be performed as with any comprehensive eye evaluation, investigating ocular and systemic history, and functional visual abilities and needs.  Listed below are some additional questions that would be pertinent for bioptic driving.
1. Have you ever driven or held a learner's permit?
a. If you have driven before, have you ever had a motor vehicle accident?
2.  When riding in a car, are you able to identify the following:  Signs (stop, yield, road markings, construction signs, etc)?  Traffic signals? Oncoming traffic?  Pedestrians?  Animals?  
3.  At what distances are you able to see details most clearly? 
4.  Do you have any issues with glare?
5.  Do you have any issues with color perception/discrimination?
6.  Do you have any issues with contrast sensitivity?
7.  Do you have any issues with light to dark or dark to light adaptation?
8.  Do you have any perceived issues with judging distances?
9.  Do you have any issues with not seeing objects on either side?

Visual Acuity
Distance and near visual acuities must be assessed. Information about onset of vision loss, diagnosis of ocular condition causing the vision loss, and stability of vision should be explored.
Although not specifically stated in the current law, visual acuities can be assessed utilizing one of the following testing measures:
1. Standard Snellen acuity with projected, computerized, or paper chart
2. ETDRS chart
3. Feinbloom Low Vision Acuity Chart (test distance should be properly measured)
a. If using a low vision chart at non-standard distances, the vision should also be tested with a traditional Snellen chart to verify accuracy.

Room lighting should be consistent (would be determined by the chart being used)
Although near vision measurement is not required, it will be necessary to note as it relates to functional ability such as seeing the dashboard.
1. Single letter or number
2. Continuous text

Determination of refractive status is critical for obtaining the best corrected visual acuity which will determine the bioptic telescope selected.
As with any visually impaired patient, a trial frame refraction with loose lenses is highly recommended.
(Trial frame refraction allows the patient to best use an eccentric viewing position which may be critical in their success when reading the visual acuity chart.)
The concept/theory of just noticeable difference should be utilized in determining spherical and cylindrical powers.

Visual Fields
The following testing strategies may be used:
1. Humphrey Binocular Esterman
2. Binocular Esterman- like visual field 
3. Goldmann bowl perimetry (paying closest attention to the III4e isopter)Confrontation visual fields are not an acceptable substitute for formal visual field testing for the purpose of qualifying for a bioptic telescope driver's license in this setting.

Color Vision
The following testing strategies are suggested:
1. Ishihara color plates (may need closer working distance based upon acuity)
2. Farnsworth D 15
3. HRR Pseudoisochromatic plates
4. Holmgren's Worsted Test for Color Blindness

Contrast Sensitivity
According to several studies and driving experts, contrast sensitivity plays a critical role in patients' success for safely operating a motor vehicle.
The following testing strategies are suggested:
1. Eschenbach flip chart (continuous text, single number/symbol)
2. Pelli Robson Chart 
3. Sloan Letter Logarithmic (ETDRS) Chart
4. MARS contrast sensitivity test

Glare Assessment
Glare often contributes to an individual's ability to drive safely. Tinted lenses may need to be considered if glare is an issue for the patient.
Brightness Acuity Testing (BAT) can be used to determine the impact of glare on vision that the patient may experience with driving.

Prescription of Bioptic Telescope
The clinician should have access to 2X 3X, 4X, Galilean and Keplerian designs as well as a 6X Keplerian system
The telescope must ultimately be mounted in a bioptic position (superior aspect of the carrier lens and angled up). 
The carrier lens must contain the lens Rx that achieved 20/200 acuity in the best corrected eye. It must also be determined if a correction is to be incorporated into the telescope to obtain best clarity and acuity.
When prescribing the telescope, the following should be considered.
-ease of use
-optimum visual field possible
-overall stability of the patient's ocular diagnosis

Guided discussion should take place with patients regarding the selection of an appropriate telescope system.  
Patients should be advised that:
1. Lower powered telescopic options will provide a larger field of view and facilitate ease of use, however reduced visual acuities will be obtained.
2.  The patient may sacrifice the ability to drive at night (based upon visual acuity measurements) if opting for a larger field of view.

To help in the determination of an appropriate telescope, a patient should be taken to a location outside the exam room, ideally outdoors, to compare magnification and field of view of the different options in a natural setting. It is also recommended that initial instruction in the use of the appropriate telescope should take place in the same natural setting, remembering that the carrier is used for general viewing and maximum field-of-view; dipping into the telescope to see detail of the target is the technique of spotting. 

Bioptic spotting
During a spotting activity, the patient must be made aware that the telescope is ideally only used for 1 to 2 seconds to spot details, then returning to the carrier lens (spectacle lens) which is used for the majority of viewing time. To get into the telescope, a vertical technique is as follows:
1. The patient should be viewing through the carrier lens to locate the target that is of interest.
2. Patient should dip his/her head down moving the eyes upward to spot the target through the telescope, thereby enhancing the detail of the target being viewed.
3. While spotting through the bioptic, the patient should still be aware of objects in the periphery.

Training with the telescope (can begin with a handheld telescope if necessary) can be done as follows:
Localize under the telescope
Spot through the telescope
Focus the telescope as needed

Next level of training is as follows:
(For all of these activities take note of spatial (or environmental) awareness and adjustments to lighting conditions.)

1. Spot a stationary object with the carrier then dip into the bioptic to identify the target while patient is stationary.
2. Spot a moving target with the carrier then then dip into the bioptic to identify the target while patient is stationary.
3. Spot stationary objects with the carrier then then dip into the bioptic to identify the target while patient is moving.
4. Spot a moving target with the carrier then then dip into the bioptic to identify the target while patient is moving. 

Instruct the patient to practice at home while stationary, while walking, and while on a stationary bike. These activities can also be done concurrently when the patient is being instructed in front seat passenger in car.