Can you explain what a bioptic telescope is and how it helps people with low vision drive?

A bioptic telescope is a spectacle mounted telescope (the telescope is mounted at the top of a conventional spectacle lens), used for people that have mild to moderate central vision loss, but their peripheral visual field is intact. Most of the time the driver sights through the normal conventional spectacle lens, given that their residual, peripheral vision is still adequate to perform driving tasks safely. When extra detail (such as on a sign) is required, the driver drops their chin to access the magnification of the telescope momentarily. The driver then lifts the chin to resume looking through the conventional spectacle lens. The dropping of the chin is very quick, much like the action of looking through the rear-view mirror of a car.

What types of eye conditions might make someone a good candidate for bioptic driving?

Conditions that affect high contrast visual acuity only are best candidates, including macular dystrophies like Stargardts, especially in the earlier stages.

Those with non-progressive diseases have less risk of vision changing: Oculocuteaneous albinism, nystagmus. (have some glare sensitivity)

Others also benefit: achromatopsia have great success, but also have extreme glare sensitivity.

Age related macular degeneration (AMD): although aging has other comorbidities that can impact bioptic use.

What’s involved in assessing someone’s suitability, and who makes that decision?

The person needs a comprehensive low vision assessment and bioptic trial. Bioptic trialling needs to be done by an eye care practitioner with advanced skills in low vision, vision for driving understanding and expertise in bioptic telescope assessment and training. The person along with the optometrist/eye care practitioner makes the decision in an evidence-based way according to their vision condition, visual field, contrast, sensitivity, glare sensitivity and prescription.

Driving is a complex task, the eye care practitioner makes a decision regarding whether vision meets the vision requirements for driving, but other considerations such as processing, general health and age might need to be considered by other professionals. The eye care practitioner considers the results of (including but not limited to) contrast sensitivity, high contrast visual acuity, visual field, diplopia, colour vision, glare, diagnosis and prognosis, the driving task, driving experience and driving record.

Regarding driving: The eye care practitioner makes the decision about whether to support a recommendation for a private conditional driver’s licence, but the driving licensing authority ultimately makes the driving licensing decision. Both these decisions are based on the assessing fitness to drive guidelines.

If someone is eligible, what kind of training do they need before they can drive with a bioptic system?

Established bioptic driving programs overseas describe progression from in office, to on foot (walking), to passenger in the car, to hours and hours of driving practice. Functional vision is tested by requiring bioptic driving candidates to give an auditory commentary of all signs, hazards and traffic lights along the route, as a method of assessing that the driver can identify these, and this is done first while walking, then as a passenger in the car, and finally as the driver. Drivers use their carrier lens vision for most tasks, only aligning the telescope for a magnified view of a sign or hazard when required, and to identify detail in the sign or hazard from farther away, and are trained to do this only when it is safe to do so. As with novice driving, the task of bioptic driving requires hours and hours of driving practice.

Are there restrictions or limitations like only driving in daylight or needing to re-sit a driving test?

Yes, established bioptic driving programs overseas generally establish day driving first for two to four years, and then drivers undergo further training and testing for night driving when required and if appropriate for their diagnosis and condition. A bioptic driving program is still to be established in Australia, however all drivers with central vision impairment will have a conditional licence. Conditions include no night driving, spectacle wear, periodic review and/or restricted kilometres from home. These restrictions are dependent on the diagnosis, person, driving tasks and are thus case by case.

Currently in NSW all drivers over the age of 85 (even those without vision impairment) can elect to restrict their driving to a 15km radius from home rather than undergo an on road driving assessment. See this link.

How is the telescope used in real-world driving? Is it for everything or just certain tasks like reading signs?

The telescope is not for everything. The driver has to be able to see to drive safely with their normal vision. This is why other vision measurements like visual field and contrast sensitivity are so important. The driver is aware of all tasks like signs, hazards, or traffic lights with their normal vision. The telescope is ONLY aligned for one to two seconds to identify the detail in that task from farther away (for example: they might be aware of a stop sign from its shape through the carrier or normal spectacle lens, and align the telescope momentarily to make sure). The driver is taught to align the telescope for specific tasks only, and only when within the driving task it is safe to do so.

What are some of the biggest challenges people face when adapting to driving with bioptics?

Licencing: people with mild vision impairment often feel discriminated against as they are not given the opportunity to learn to drive and be tested on road.

Many people with mild central vision loss have been told they cannot drive, and thus lack confidence to advocate for themselves.

Drivers with vision loss, once they are given the opportunity, are made aware that driving is a privilege not a right (American Ophthalmology Society), so they need extra care to abide by all road rules and licensing restrictions.

What impact does it tend to have on someone’s confidence and lifestyle when they obtain or regain the ability to drive this way?

Driving is an instrumental activity of daily living. Loss of driving licensure has been shown to have a major impact on quality of life. In Australia, especially in areas where there is less access to public transport, like in rural or remote locations this has even a larger impact, the person might have to move. This becomes more complex for parents caring for children and limits their independence, or makes them more reliant on others, and on government schemes like the NDIS. Thus where it is safe for someone to drive, it can have a major impact on their confidence and lifestyle, and economically for government planning schemes as well.

Is this option widely available in Australia, and is it affordable or are there barriers to access?

There are many barriers to access. Bioptic telescopes are mentioned in the driving guidelines, but not stipulated in the standards, more evidence and research is needed. There are limited low vision centres in Australia, and even less that have bioptic telescope trial sets and expertise to assess people with vision impairment for driving. The UNSW Optometry Clinic (part of the School of Optometry and Vision Science at UNSW) has the trial sets, equipment, research infrastructure and expertise to do these assessments. As awareness of bioptic telescope use grows (note: only those with mild to moderate central vision loss can use), centres that can assess bioptic telescope use across Australia are growing. However, the next phase in the bioptic driving program, (which overseas is done by certified driving rehabilitation specialist, occupational therapist, orientation and mobility instructors and/or orthoptists, and trains the driving candidate to use the device in the car) is still lacking in Australia. Research has shown that driving rehabilitation specialists in Australia have the skills to adapt to teach drivers with vision loss, this process still requires awareness, input and interest from these professions.

What about costs and funding?

Bioptic telescopes can be expensive, as is purchasing and running a motor vehicle. Some funding can be accessed eg through the NDIS, where a person has NDIS registration. Regarding NDIS funding, if the bioptic telescope device and driving training is funded, this is capacity building, and might be better economically for the scheme than providing personalised on going transport funding, apart from the increased quality of life and independence for the person.

Finally, what would you most want someone with low vision to know if they’re unsure whether driving could be possible for them again?

I would strongly encourage them to advocate for themselves and to be assessed by an eye care practitioner that assesses low vision and has expertise in assessing functional vision for a conditional driver’s licence - even if that means exploring several opinions. I would encourage someone to understand their vision numbers themselves, educate themselves (the internet and now sites like Seeway) make this easier.