Vision and Driving What is Vision Seeing Your Way to Better Client Outcomes The primary sense that we use to acquire information about our environment. Includes Beth Rolland, OTR, CDRS Eye movement Acuity Perception

Vision Facts Vision Facts

90% of the information we gather Eye is the only organ in the body comes from the . innervated by both the central and Vision allows us to be anticipatory autonomic nervous systems  Central – voluntary movements The visual system is the fastest and (pursuits, saccades, lid opening/closing) most complicated of all sensory systems. Autonomic – involuntary control ( constriction and dilation) 50% of all neurologic insults cause visual deficits.

Vision Facts

 The visual system provides the highest level of sensory information processing in the human body and is the most highly integrated of all systems. Anatomy of the  It is estimated that 65% of all nerve fiber interactions with the brain have Eye something to do with the visual An Overview information processing system.

1 Anatomy of the Eye Eye Structure & Function

Eye parts resemble a camera  - white outer protective coat; the "white of the eye".  - transparent, curved structure in front  - colored part seen through the cornea.  Pupil - black part in the middle of the iris. Constricts or dilates according to the amount of light passing through.  - transparent disc (with both sides being convex) immediately behind the iris and pupil.

Eye Structure & Function Eye Structure & Function

 Rods - more numerous, mostly at outer edge  Aqueous humour - transparent fluid respond to low levels of light, peripheral (water consistency) circulates behind cornea and in front of the lens. movement.  Vitreous humour – fills the eyeball  Cones - far fewer, concentrated in center between lens and (like transparent  respond to color and details. jelly).  Macula - small center of the retina  Retina - light-sensitive layer of millions of nerve cells lining back of the eyeball. responsible for central vision—ie: reading. Rod cells – tall, thin  Retinal pigment epithelium – dark layer of cells at Cone cells - rounder back of retina Provide oxygen & nutrients to rods/cones.

Eye Structure & Function Eye Structure & Function

- large network of blood vessels (behind  Retina – the retina) located at the back of the eye and connected transport oxygen & nutrients to retinal pigment to the brain. cells. made up of many millions of light-sensitive cells  - small yellow oval structure in retina known as photoreceptor cells which transmit nerve cell connections travel from all the rods electrical impulses to the brain to enable sight. and cones.  and beyond - "cord" of nerve cell connections that passes from eyeball to destinations throughout brain.

2 Cranial Nerves Cranial Nerve II (cont.)

Cranial Nerve II (Optic Nerve)  The optic nerve has only a special sensory component Originates at the Retina  Visual information enters the eye in the Connected to the specialized receptors form of photons of light in the retina—the rods and cones.  Light is converted to electrical signals in the photoreceptors (rods and cones) Exits the back of the eye in the located in the retina Where the optic nerve tract begins.  Signals travel optic nerves, chiasm, and tract  lateral geniculate nucleus (thalamus)  occipital lobe (visual centers)

Cranial Nerves Cranial Nerve III (cont.)

Cranial Nerve III (Oculamotor Medial Rectus: Nerve)  the ocular muscle whose contraction turns the eyeball medially Raises and controls These muscles are an integral part  Drooping eyelid = Controls several key eye muscles. of how well and how smoothly your These muscles include the following: eyes move.  Superior Rectus: the ocular muscle whose contraction turns the eyeball upward and medially  Inferior Rectus: the ocular muscle whose contraction turns the eyeball down and medially

Cranial Nerves Cranial Nerves

 Cranial Nerve IV (Trochlear Nerve)  Purely motor nerve supplying one muscle:  Cranial Nerve VI (Abducens Nerve) Superior oblique: Intorsion- inward rotation of upper part of Lateral Rectus: eye about an axis or a fixed point. Pulls the eye away from the nose Secondary movement-moves eye out and down.  Damage to this nerve will result in the Damage results in eye slightly affected eye turning inward (cross elevated in primary gaze position eye) (straight ahead gaze) Intermittent double vision in lateral gaze Effect of is greater at distance Reading ok, driving a problem

3 Cranial Nerve Summary

Nerve Nerve supplies Function Clinical observations

CNIII- oculomotor Upper eyelid Eyelid movement Ptosis SR, IR, MR, IO Eyeball movement-up, (down&out) Ciliary Muscle down, and medially at near Sphincter of Iris Pupil constriction No pupil accomodation CNIV-trochlear Superior obique Eyeball movement- down /phoria and out Vertical diplopia Lateral tilt of head

CNVI- abducens Lateral rectus Eyeball movement Esotropia/phoria outwards Diplopia at distance

Eye Anatomy Videos

 Dr. Tim Root https://timroot.com/anatomy-of-the-eye- video/ Anatomy video  Neuro-anatomy Functional Vision

Hierarchy of Visual Oculamotor Control Adaptation

 Oculamotor Control (pursuits,  Visual Fixation - ability to find target and saccades) hold eyes on it  Visual Attention  Pursuits – ability to follow a moving target (without head movement)  Visual Scanning  Saccades – rapid eye movements in any  Pattern Recognition direction (without head movement)  Visual Memory  Visuo-Cognition (perception) Implication for driving: if you can’t see it, you can’t respond to it!; objects are moving in driving  Adaptation (thought, reasoning) environment – pedestrians, bicycles, cars

4 Visual Attention Visual Scanning

 Cognitive component  Ability to pick out relevant information in an environment and suppress irrelevant  Visual Scanning – ability to find things in information the environment Sustained attention – maintain over time  Peripheral Vision – what can be seen on Shifting attention – change focus from one thing to the side without head or eye movement another rapidly  Not clear, but brain fills in and seems clear Divided attention – attend to multiple factors at  Alerts to movement – prompts saccade or head once (ie: hazards on both right and left side) turn to use central vision for more information

Implication for driving: if you are not paying attention, Implication for driving: hazards come from all you will miss things fields; inadequate scan will miss things

Visual Fields – Peripheral Pattern Recognition Vision Norms: . Cognitive process that matches information  65 degrees upward from a stimulus with information retrieved  70 degrees downward from memory  60 degrees nasally  90-110 degrees temporally . Allows anticipatory awareness

Implication for driving: if you don’t anticipate, you will respond late

Visual Memory Visuo-Cognition (perception)

 Ability to process and interpret meaning from Recollected information about what visual information gained through eye sight one has seen.  visual discrimination Mental storage of information  visual figure ground – distinguishing object from background  Ability to retrieve stored information visual closure – “seeing” the whole from a part  visual memory – recalling what you saw  visual form constancy – recognizing objects when they are Implication for driving: deficit may lead to turned around difficulty finding your way, finding your  visual spatial relationships – where one thing is in relation to car in a lot, remembering what was on the another left when you scan right  visual-motor integration – eye/hand coordination

5

Implication for driving: . Poor lane position . Unsure where they are relative to parked cars, lanes . Unable to coordinate steering movements quickly enough to maintain straight path Other Crucial . Improperly placed turns . Unsure where to start turn – especially lefts Vision Skills . Unsure where curve starts for rights . Poor sign recognition (ie: branch over stop sign) . Difficulty driving at night (poor contrast)

Visual Acuity Visual Acuity

Ability to focus either near or far Includes Contrast Sensitivity Expressed as a fraction  Ability to see objects of decreasing contrast rather than size  High contrast: black on white, etc.  Numerator: testing distance at which stimulus is recognized  Low Contrast: grey on white; white on white, etc.  Denominator: distance at which letter being viewed could be recognized by a person with normal visual acuity (20/20)  Contrast Sensitivity has been linked to crash risk Implication for driving: difficulty driving at night, Implication for driving: state laws for minimum; dusk or dawn; difficulty seeing items against same inability to read signs or see road details color background (green car with green bushes)

Contrast Sensitivity

Combining images from each eye into single image.  Images must fall precisely on corresponding positions on each retina or double vision will occur.  Muscles work together to position eyes properly to focus light on center of each eye, providing clear vision.

6 Binocular and Stereoscopic Binocular Vision Vision Focusing near - eyes move closer together (convergence) Focusing far - the eyes move further apart (divergence) Misalignment of eyes – double vision Double vision usually either near OR far Muscle weakness pulls eye opposite  May be in one gaze (ie: far left gaze)  May be constant

Implication for driving: blurry vision, motion sickness, inability to accurately judge space

Stereoscopic Vision Binocular and Stereoscopic Vision Depth Perception  Slight difference in angles of images received in each eye gives  People think and learn best in three images depth  Loss or suppression of one eye affects depth dimensions. Do use other cues When scanning text quickly, we can absorb 100 Light, shade, shadows, color and relative letters per second - the computer equivalent of 100 sizes of objects contribute to depth bits per second. Cognitive component - learn the signs When glancing at a three-dimensional object, we can that enable them to perceive depth. see the equivalent of 1 billion bits per second.

Implication for driving: difficulty judging space and speed Implication for driving: good binocular vision lets you see faster and react faster on the road

Visual History

Patient complaints (diplopia, blurred vision, dizziness, headaches, eye fatigue, balance difficulties) Optical History (, , diabetes, macular Vision Screen degeneration, surgery)

7 Evaluating Far Acuity Evaluating Far Acuity

*Must pass state standard for vision in state they hold license Test each eye separately and then  Options: together (Optec tests separately with both eyes working) Optec Vision Tester – quick and easy; also tests contrast sensitivity, alignment, depth, Many states have requirements that color, road sign recognition both eyes pass the standard Snellen or Lea Chart – cheap and easy Testing separately lets you know which eye has an issue

Visual Acuity Evaluating Far Acuity

Optec Procedure Equipment Client wears corrective lenses for distance  Select appropriate assessment tool (Optec, Snellen chart/ Lea symbols) Begin at 20/40 line Left eye sees left column; right eye sees right column; both eyes see middle column If client does not start with left column, turn off right eye and have them try again If client does not read right column, turn off left eye

Evaluating Far Acuity Evaluating Far Acuity

Snellen Chart (or Lea Chart) Procedure Optec Stand 10 or 20 feet away (based on chart) Instruct client to read down to last line Client wears corrective lenses for distance they can make out Test monocularly then binocularly Far acuity is last line where 3 out of 4 letters in the column are identified Begin at 20/40 line (or line required by state of correctly license) If the client has aphasia, try giving If patient has difficulty, isolate lines them a piece of paper and pencil to write the letters

8 Evaluating Far Acuity Evaluating Far Acuity

. A large discrepancy between eyes can lead to Snellen Chart suppression and will affect depth Use Lea symbols if client has aphasia . Two line discrepancy – refer to a vision specialist . Far acuity is last line where 75% or Older patients often have cataracts, which affect more of letters are identified acuity correctly . May not meet state standard for vision

Evaluating Far Acuity Evaluating Contrast Sensitivity . Some folks have trouble with Optec . If not meeting standard in Optec, try Snellen  Optec 5000 – contrast slides . **In most cases, it is not legal to take a client on  the road if vision does not meet state minimum Day and night testing . If below state standard, refer to eye doctor Can also test glare . May have to wait for surgery prior to BTW Contrast Sensitivity Chart

Contrast Sensitivity-Optec Contrast Sensitivity Charts

Pelli Robson Chart

Hamilton-Veale Chart

9 Evaluating Pursuits Evaluating Pursuits

Equipment – colored target, eye patch  Look for: choppy movement, inability to move the eye through entire range of motion, Procedure: (slow beating motion), excessive head movement Patch one eye  Refer to eye doctor if deficits are significant Test without glasses  Nystagmus – often in extreme side gaze; can be in Have client hold head still and follow target as primary gaze you move it.  Will blur image on that side Hold target 16” from patient and move in the  Can appear like double vision form of “H”, “X” and “O”  Client will have to be taught to turn head to that side rather than relying only on saccades

Evaluating Saccades Evaluating Saccades

Equipment: two different colored targets;  Look for: choppy movement, overshooting, eye patch undershooting, nystagmus, searching for target, inability to disassociate head and eye movements Procedure: Searching for target may mean field cut or Patch one eye inattention on that side Test without glasses May benefit from visual exercise program Have patient hold head still and look back and Refer to eye doctor with overshooting, forth between the targets on your command undershooting, significant deficit, searching for Hold targets 16” from patient, 12” apart target on return (suspect neglect) Test in upward, horizontal and downward gaze

Evaluating Visual Fields Evaluating Visual Fields

Optec has test Will only test horizontal field Double simultaneous stimuli Will not test superior or inferior field cuts Will detect field cuts in planes other If you suspect a field cut, don’t rely only on Optec than horizontal Easy for client to cheat! Obvious when cheating! They will move eyes to search for targets Use with known or suspected field cut Clients don’t always understand directions Use with clients who have difficulty Mix up right, left and both with Optec

10 Evaluating Visual Fields Evaluating Visual Fields

Optec procedure: Double simultaneous stimuli procedure: Test without glasses (ear piece often obscures Patch one eye, sit opposite client and instruct target) them to look at your nose at all times Instruct client to look straight ahead Start with arms in horizontal plane and Emphasize that targets will not be in the picture, but determine end ranges of fields will be well to the side Instruct client to identify right left or both Randomly choose targets right, left or both fingers moving Check each target several times Start with single stimulus then move to simultaneous stimulus Repeat procedure for vertical and diagonal  Look for targets missed repeatedly, targets seen planes when singular but missed when double (suspect inattention/neglect), delay in responding Repeat binocular (inattention more obvious)

Evaluating Visual Fields Clinical Correlations

1. Macula Norms: 2. Optic Nerve  60-65 degrees upward 3. Optic Chiasm  70-75 degrees downward 4. Optic Tract  60 degrees nasally 5. Lateral Geniculate  90-100 degrees temporally 6. Optic Radiation 7. Visual Association 8. Primary Visual Area

Visual Field Loss Visual Field Loss

 Homonymous field loss – both eyes  – half of field; severe loss Many states will not allow driving with HH Quadranopsia – one quarter of field Temporal lobe – usually upper field Parietal love – usually lower field Easier to compensate for upper field loss  Location of infarct will dictate field loss  Infarcts further back will cause greater loss and be more permanent  More likely to be in one eye if further forward • Right Homonomous Hemianopsia

11 Visual Field Loss Visual Field Loss

• Binasal Hemianopsia •

Visual Field Loss Visual Field Inattention/Neglect

 Can be with field loss or without  Three types (may have one or all) Personal space – dressing, shaving, washing face Peripersonal space – arm’s reach, desk activities Will show up with cancellation tests, field testing, clock drawing, Rey Osterreith figure copy Extrapersonal space – beyond arm’s reach • Quadrantopsia Difficult to test in office More dangerous for driving May veer to one side when walking; miss doorway to office,

Evaluating Evaluating Inattention/Neglect Inattention/Neglect Look for patterns:  Clock drawing  Poor saccade to one side (searching on return)  Ask client to draw a clock with all the numbers on it, and the time reading “10 minutes past 11”  Difficulty with field testing (maybe just unpredictable)  Look for:  Odd clock drawing spacing – even, or more on one side? (inattention)  Leaving out details on one side of Rey Osterreith copy Hand placement (abstract skills)  Taking longer to find targets on one side of Trails A or B  Rey Osterreith copy  Ignoring small peripheral shapes on Visual Form  Discrimination Test Have client copy the picture  Look for missing details on one side

12 Clock Drawing Test Rey Osterreith Figure Copy

Rey Osterrieth Errors Evaluating Convergence

Procedure Client wears reading glasses if applicable Hold a pencil 16” in front of client’s nose Slowly move pencil toward client’s nose Client tells you when pencil doubles OR – note when one eye stops coming in toward the nose Normal is 2”-4” from nose

Evaluating Alignment Evaluating Alignment

. Optec – simple, quick . Corneal Reflex Procedure . Use slide with musical notes and arrow Hold pen light 16” from bridge of nose . Ask client if they see both notes and an arrow Client looks at light pointing down from the top of the slide Observe reflection in both pupils . Have them identify to which number note the Look for symmetry of reflection arrow is pointing  Medial reflection indicates  Lateral reflection indicates . Normal range – between 4 and 12 **Do not perform if seizure precautions!**

13 Evaluating Alignment Evaluating Visual Scanning

. Maddox Rod Procedure . Paper & Pencil Scan sheets Test each eye separately . C & E Cancellation Sheet Hold rod so lines on rod are oriented horizontally . Trails A Stand 10 feet from client Hold penlight behind card and direct light through . Mesclun Scans the hole in the center . Star Cancellations Client indicates which number the vertical line passes through. This represents horizontal . Disadvantage: small space – mostly focal vision alignment Repeat with lines on rod oriented vertically for vertical alignment **Inability to see line may be a suppression**

Evaluating Visual Scanning Dynavision

. Dynavision or Wayne Sacadic Fixator . Advantage: bigger space; uses periphery . Disadvantage: cost, size . If your clinic has one, great test to add . Norms . Grossly looking for one target per second (60 targets/minute)

Neuro-optometrists

 Specialize in functional vision What do I do if I Evaluate more than acuity and eye health Use interventions such as prism lenses find a vision Refer clients for therapy (or treat in their offices) deficit??  Find one and get to know them! Source of referrals as well as help for your clients

14 Neuro-optometrists Neuro-optometrists

NORA  Put off Behind the Wheel evaluation if deficits are significant and have not Neuro-optometric Rehab Assoc. been addressed https://nora.cc Both neurological and congenital diagnoses Search feature to find a provider may make it to you before a good functional evaluation Courses in evaluation and treating vision dysfunction  If training in the car and noticing poor tracking, trouble with curves/turns, take a step back and send for vision therapy

Vision Therapy Vision Exercise Program

 OT clinic with a vision rehab program  Deficits in Pursuits/Saccades  Neurological Outpatient Rehab site Thumb Rotations - pursuits  Often covered by insurance Hart Charts - saccades Eyecanlearn.com  Neuro-optometrist with in-office program Tracking – Pursuits/Saccades  Often out of pocket expense Program for kids, but good for adults also Brock String – eye pointing, accomodation

Skills that Decline as we Age Vision Deficits Common in Older Drivers Acuity Contrast sensitivity Spatial skills Peripheral fields Awareness – particularly of the periphery, and of multiple targets Visual processing speed Anticipatory decision making Visual/Physical reaction – “reflexes”

15 Vision Deficits Useful field of view

 Visual area over which information can be extracted at a brief glance without eye or  Visual Acuity head movements.  Static – ability to focus on a target  State standards differ  Correlated to crash risk in older drivers  Road signs designed for 20/40  UFOV decreases with age  NJ does not retest after initial licensing (!) decreases in visual processing speed  Dynamic – distinguishing details of objects in motion reduced attentional resources less ability to ignore distracting information.  40% of 90 year olds have a UFOV of less than 20 degrees (tunnel vision)

Visual Diseases/Disorders Visual Diseases/Disorders (cont.)  Cataracts Loss of central vision; periphery intact Clouding of the lens--loss of acuity/hazy vision Very dangerous for driving as it worsens  Poor night vision Loss of a spot of vision (macular degeneration, optic Diabetic neuritis, surgery, etc.) Can sometimes learn to move head and adjust spot Leakage and other damage to blood vessels of to a place it does not interfere the retina  Glaucoma Retinal scars; blind spots from laser treatments Increased fluid pressure-damages optic nerve Loss of peripheral vision Poor night vision

Visual Diseases/Disorders Macular Degeneration (cont.)

 Low Vision  Significantly decreased acuity  Bioptic Lenses—some states allow  Require significant training

 Outside the car

 Inside the car

16 Scotoma 20/200 Acuity

Glaucoma

Vision Deficits Common after Stroke/TBI

Ocular-motor deficits Cranial Nerve III Damage

 Pursuits, saccades Cranial nerve damage III  drooping eyelid; may impair peripheral vision  Eye postures down and out  IV –  Difficulty with downgaze  Head tilt to opposite side VI  eye won’t move out (“cross eye”)  **big effect on driving Decreased ability to scan for hazards Nystagmus—abnormal oscillations of eye(s)

17 Cranial Nerve VI Damage Poor Alignment

. (tropia) – unable to voluntarily align eyes to look at an object; constant . “Cross Eyed” – one eye deviates medially . “Wall Eyed” – one eye deviates laterally . Corrected surgically . Phoria – misalignment that fluctuates; more apparent with fatigue . May be alternating – either eye different times

Alignment Deficits

Suppression Brain ignores image from one eye Common when there is double vision Loss of depth perception New? Or longstanding? Fusion deficits Not using both eyes together as a team Loss of depth perception New? Or longstanding?

Visual Field Loss Visual Field Loss

 Homonymous field loss – both eyes Hemianopsia – half of field; severe loss Many states will not allow driving with HH Quadranopsia – one quarter of field Temporal lobe – usually upper field Parietal love – usually lower field Easier to compensate for upper field loss  Location of infarct will dictate field loss  Infarcts further back will cause greater loss and be more permanent  More likely to be in one eye if further forward • Right Homonomous Hemianopsia

18 Visual Field Loss Visual Field Loss

• Binasal Hemianopsia • Bitemporal Hemianopsia

Visual Field Loss Vision Deficits (cont.)

 Peripheral Deficits Visual Field Cuts One eye only – easier to compensate Homonymous – most states won’t allow driving (NJ & NY do, PA does not) Normal binocular field=180 deg. side to side Effect of vehicle speed on Visual Field 200 deg field at 20 mph=104 degrees 200 deg field at 40 mph=70 degrees • Quadrantopsia Normal VF at 60 mph=40 degrees Field deficit will worsen as speed increases Peripheral vision is not clear—alerts to motion

Visual Attention Deficits Impaired Visual Processing

 Inattention/Neglect (neurological dx) Combines visual and cognitive systems  Field is either normal or decreased Slow Processing common in:  Unfit for driving if extrapersonal—needs to resolve first Neurological dx – CVA, PD, MS, TBI  Unable to compensate  Decreased divided attention General aging population  Field can be either normal or decreased Compounded by:  Work in clinic first Low illumination  Common in neurological dx, but also prevalent in the well elderly Stress Illness Fatigue Sensory overload

19 Spatial Skills Deficits Spatial Skills Deficits (cont.)  Figure Ground

 Differentiating foreground from background  Topographical Disorientation  Form Constancy  Relationships of places to one another  Attending to subtle variations in form  Finding your way in space  Perceiving the whole object when you only see a piece of it  Spatial Relations  Position in Space  Position of objects in relation to each other  Up/down, front/behind, left/right  Interpreting speeds of movement

Spatial Skills Deficits (cont.) Implications for Driving Time and space management (stopping too late or too soon at intersections) Parking difficulties (esp. backing) Not seeing signs, confusing arrows Vision Deficits Common Interpretation of the unexpected with Congenital Diagnoses (construction, car breakdowns) Maneuvering difficulties—position on road Getting lost in familiar surroundings Lane selection

Vision Deficits Cerebral Palsy

Congenital Diagnoses that often present Common Deficits with vision deficits Strabismus or Phoria Cerebral Palsy Poor Binocular vision Spina Bifida Absent depth perception Learning Disabilities Poor visual/spatial skills ADHD/Asperger’s Slow scanning  Pigmentosa Difficulty multi-tasking Albinism  Often have difficulty with lane position, turns and curves  Often see detail at expense of big picture

20 Spina Bifida ADHD/Asperger’s

Common deficits Common deficits Weak eye muscles – strabismus Difficulty with visual multi-tasking Poor scanning skills Difficulty disassociating head & eye movements Inefficient visual scanning – or looking for the wrong things  Often see detail at expense of big picture Watch Rey Osterreith drawing

Retinitis Pigmentosa Ocular Albinism

Common deficits Common deficits Unable to see the color red Reduced pigment in eye – crucial for vision Very poor contrast sensitivity (see brake lights Low vision better in the dark) Poor depth perception  Low vision – often referred with bioptic lenses Nystagmus Decreased peripheral vision Strabismus Poor night vision  Abnormalities in optic nerve – affects connection to the brain

Bioptic Lenses

 For drivers whose acuity cannot be corrected to the state minimum Carrier lens plus telescopic lens Driver uses carrier lens 95% of time Uses telescopic lens to read signs Legal in 37 states, including NY, NJ, PA Driving with Low Vision  Requires significant training OUTSIDE the car prior to any driving  Requires a driving specialist with special training

21 Driving with Vision Deficits

Driving with Homonymous Hemianopia Driving with HH (HH)  Homonymous hemianopias (HH)  Approx. 40% of post-chiasmal lesions HH Research  22 states and many countries do not allow driving (2009)  No study has looked at actual crash rates  Disqualified by arc of vision requirement  Prognosis may be better with macular sparing  Some allow after special evaluation  Monocular Sector Prisms  Lower accuracy in seeing pedestrians in simulator and  Can increase arc of vision enough to qualify traffic/pedestrians in on-road study (Bowers I)  No research yet to determine if they increase safety (Elgin)  Widely differing abilities to compensate (miss rates  Recommend training prior to evaluation on-road from 0-100% )  Greater incidence of positioning errors (over lane line Bowers II)  Age is the best predictor of blind-side miss rates

Driving with HH Evaluation – Field Cuts

 HH research (cont.)  Tips for Evaluators

. Most detection errors occurred at intersections (Bowers pilot)  Know the law in your state for peripheral fields

. Scan magnitude was not large enough (especially to right side Bowers IV)  Clients with significant field loss may be able to drive safely . No peripheral vision cue how far to scan  Question client about navigation in crowded places – malls, . Missing pedestrians, etc. on sidewalk supermarkets, etc. Do they run into things?

. Judgment on fitness to drive cannot be based solely on visual field size (Gera)  Send to an OT vision specialist to learn scanning strategies and improve speed and accuracy outside the car first . Longer time not driving adversely affects outcome (Gera)  less expensive (often covered by insurance) . Better prognosis with good contrast sensitivity and faster processing speed (Elgin)  safer . Research shows that many people with HH are driving AMA

22 Evaluation – Field Cuts Training Techniques-Field Cuts  Tips for Evaluators  Look closely at the following maneuvers during BTW:  Teach compensation techniques  lane position – middle line, shoulder line, lane choice  Look as far down the road as possible  intersection hazard detection – are they scanning far enough to see the sidewalk on both sides?  Turn head when approaching targets identified  steering stability – do they hold a straight line?  Children playing, cars at intersections, people getting into cars in driveways, bicycles, pedestrians  One drive is not enough to make decision   Routes should include a variety of traffic scenarios Keep eyes moving constantly  Choose routes that challenge client from the blind side  Turn head and be especially vigilant at  Choose areas with pedestrians intersections  Insist on 8-10 drives with different traffic and times of day  Be sure to scan far enough – all the way to sidewalk to look for pedestrians  Familiar roads will be safer – but there can be changes, detours, surprises

Training Techniques-Field Training Techniques-Field Cuts Cuts

 Teach compensation techniques  Teach compensation techniques Use mirrors more frequently Choose lane wisely Scan for aggressive drivers coming from Driving in lane corresponding with field cut behind, tailgaters, traffic in lane on vision loss will eliminate cars cutting you off from that side lane Vigilently check the side mirror on side of loss Staying in the right lane will avoid difficulty of lane change to the left and vise versa – but Beware of parking lots!! eventually left lane drivers may have to lane Uncontrolled air space – look for backup change right to exit lights, pedestrians, doors opening, cars cutting Plan lane changes far in advance – don’t try to across spaces, cars at ends of rows cut over at the last second

Training Techniques-Field Training Techniques-Field Cuts Cuts

Teach compensation techniques  Suggest technology  If client can purchase a new vehicle, suggest the With right side loss, beware of parking following options: lot entrances/exits, driveways, kids  Blindspot detection playing in yards  Lane position detection  Back-up camera – looking over shoulder will be harder With left side loss, be wary of car in with field cut left lane directly next to you  Intelligent cruise control  Address position of side mirrors to reduce blindspot  Suggest spot mirrors on both sides  Suggest panel rearview mirror

23 Training Techniques-Field Training Techniques- Cuts Turns/curves/lane position Teach client to look ahead, as far around Teach compensation techniques the curve/turn as possible With right side loss, beware of parking Look for yellow line ahead lot entrances/exits, driveways, kids playing in yards Try to keep same distance from yellow line With left side loss, be wary of car in Use landmarks left lane directly next to you There is almost always a manhole where you need to start a left turn Use a magnet on the hood of the car to line up with the yellow line

Training Techniques- Training Techniques- New Drivers New Drivers

Teach hierarchy of scanning Teach eyes up and out Most important to least important (ie: Look far down the road brake lights ahead vs. car in its lane Use saccadic eye movements approaching from ahead constantly  Teach first as passenger – parent/you. Emphasize hazards Identify one thing, then two, etc. Bicycles, motorcycles, pedestrians, Commentary driving runners, car approaching over center line

Techniques-Driving at Night Techniques-Driving in Bad Weather More difficult with: glaucoma, More difficult with: glaucoma, cataracts, photosensivity, poor cataracts, poor contrast sensitivity contrast sensitivity Techniques Techniques Keep windshield clean Don’t look at headlights – look to Windshield wipers fully functioning side of road Slow speed Drive new routes first in daylight Leave greater following distance Use yellow lenses to cut glare

24 Techniques-Lane Techniques-Vision/Vestibular Position Difficulty Dysfunction Common after Concussion Teach client to use center (yellow line) as guide Dizziness with head turns Uncomfortable with motion in the Right side of road expands and periphery contracts May feel movement that is not Use a magnet to line up with center there line Difficulty judging space May need vision therapy Convergence and Accomodation Visual midline off deficits

Techniques-Vision/Vestibular Vision Resources Dysfunction  Strategies NORA – www.nora.cc Move eyes first, then head to scan Neuro-optometric Rehab Move more slowly Association – locate a neuro- Expanded rearview mirrors, spot optometrist mirrors Bernell – www.bernell.com Vision therapy Source for vision testing and Very effective for convergence training products Slower roads, familiar routes at first

Questions References

 Alberti CF, Peli E, Bowers AR. Driving with hemianopia: II. Detection of stationary and approaching pedestrians in a simulator. Invest Ophthalmol Vis Sci. 2013;55:369-374  Bowers AR, Ananyev E, Mandel AJ, Goldstein RB, Peli E. Driving with hemianopia: IV. Head Scanning and Detection at Intersections in a simulator. Invest Ophthalmol Vis Sci. 2014;55:1540-1548  Bowers AR, Mandel AJ, Goldstein RB, Peli E. Driving with hemianopia: III. Detection performance in a simulator. Invest Ophthalmol Vis Sci. 2009;50:5137-5147  Bowers AR, Mandel AJ, Goldstein RB, Peli E. Driving with hemianopia: I. Detection performance in a simulator. Invest Ophthalmol Vis Sci. 2009;50:5137-5147  Bowers AR, Tant M, Peli E. A pilot evaluation of on-road detection performance by drivers with hemianopia using oblique peripheral prisms. Stroke Res Treat. 2012; 2012:176806  de Haan GA, Melis-Dankers BJM, Brouwer WH, Bredwoud RA, Tucha O, Heutink, J. Car driving performance in hemianopia: in On-Road Driving Study. Assoc. for Research in Vision and Ophth. 2014:14-14042

25 References References

 Dickerson, AE. Screening and Assessment Tools for Determining Fitness to  Glass TA, de Leon CM, Marottoli RA, Berkman LF. Population based study of Drive: A Review of the Literature for the Pathways Project. Occupational social and productive activities as predictors of survival among elderly Therapy in Healthcare. 2014; 28(2):82-121 Americans. BMJ 1999;319:478-83  Dickerson, AD, Bedard, M. Decision Tool for Clients with Medical Issues: A  Korner-Bitensky NA, Mazer BL, Sofer S, Gelina I, Meyer MB, Morrison C, et Framework for Identifying Driving Risk and Potential to Return to Driving. al. Visual testing for readiness to drive after stroke: A multicenter study. Occupational Therapy in Healthcare. 2014; 28(2):194-202 Amer Jour of Physical Med & Rehab 2000;79:254-259  Elgin J, McGwin G, Wood J, Vaphiades MS, Braswell R, DeCarlo D, Kline L, Owsley  Legh-Smith J, Wade DR, Hewer RL. Driving after a stroke. J R Soc Med C. Evaluation of on-road driving in people with hemianopia and . 1986; 79:200-3 Amer Journ of OT 2010; 64:268-278  Liddle J, McKenna K. Older drivers and driving cessation. Br J Occup Ther  Fisk GD, Owsley C, Mennemeier M. Vision, attention and self-reported driving 2003; 66:125-32 behaviors in community-dwelling stroke survivors. Arch Phys Med Rehabil. 2002; 83(4):469-477  Lundquist A, Gerdle B, Ronnberg J. Neuropsychological aspects of driving after a stroke – the simulator and on the road. Applied Cog Psych, 2000;14,  Fist GD, Owsley C, Pulley LV. Driving after stroke: driving exposure, advice and 135-150 evaluations. Arch Phys Med Rehabil. 1997;78(12):1338-1345   Glass TA, de Leon CM, Marottoli RA, Berkman LF. Population based study of Marrottoli RA, de Leon CF, Glass TA, Williams CS, Cooney LM, Berkman LF. social and productive activities as predictors of survival among elderly Consequences of driving cessation: decreased out-of-home activity levels. J Americans. BMJ 1999;319:478-83 Gerontol B Psychol Sci Soc Sci 2000; 55:S334-40  Mazer Bl, Korner-Bitensky NA, & Sofer S. Predicting ability to drive after stroke. Archives of Phys. Med and Rehab. 1998;79:743-750

References References

. Michon, J.A. Explanatory pitfalls and rule-based driver models. Accident Analysis and Prevention 21. 1989, 341-353.  Szlyk JP, Brigell M, Seiple W. Effects of age and hemianopic  Michon, JA. A critical view of driver behavior models: What do we know, visual field loss on driving. Optom Vis Sci. 1993;70:1031-1037 what should we do? L Evans & RC Schwing (Eds.) Human behavior and traffic safety, (pp. 485-520). New York: Plenum Press  Tamietto, Marco, Torrini, Gaia, Mauro, Adenzato, Pietrapiana, Paolo, Rago, Roberto, Perino, Claudio. To Drive or not to drive  Moss AM, Harrison AR, Lee MS. Patients with homonymous hemianopia (after TBI)? A review of the literature and its implications for become visually qualified to drive using novel monocular sector prisms. J rehabilitation and future research. NeuroRehabilitation 21 Neuro-Ophthalmol 2014; 34:53-56 Owsley C, Ball K, McGwin G, et al. Visual (2006) 81-92 processing impairment and risk of motor vehicle crash among older adults. JAMA 1998;279:1083-8  Pierce S, Blackburn, C. Building Blocks for Developing a Driving Program. 1999; p. 50  Schanke AK, Sundet K. Comprehensive driving assessment: Neuropsychological testing and on-road evaluation of brain injured patients. Scandinavian Jour of Psych. 2000;41:113-121  Soderstrom, Staffan T, Petterson, Richard P., Leppert, Jerzy. Prediction of driving ability after stroke and the effect of behind-the-wheel training. Scandinavian Journal of Psychology, 2006;47:419-429

Traffic Safety References Traffic Safety References (cont.)  Traffic Safety Facts 2002: Older Population. US Department of Transportation, National Highway Traffic Safety Administration. Available at: http://www-fars.nhtsa.dot.gov/pubs/7.pdf. Accessed January 17, 2003.  Traffic Safety Facts 2000: A Compilation of Motor Vehicle  10 Leading Causes of Injury Deaths, United States, 1999, All Races, Both Crash Data from the Fatality Analysis Reporting System and Sexes. Office of Statistics and Programming, National Center for Injury the General Estimates System. Washington, DC: US Prevention and Control, Center for Disease Control. Data source: National Department of Transportation, National Highway Traffic Center for Health Statistics Vital Statistics System. Safety Administration; 2001.  Eberhard J. Safe mobility for senior citizens. International Association for  Calculated from reference 7. Traffic and Safety Services Research. 1996;20(1):29-37.  Li G, Braver ER, Chen LH. Fragility versus excessive crash involvement as  Eberhard J. Older Drivers Up Close: They Aren’t Dangerous. determinants of high death rates per vehicle-mile of travel among older Insurance Institute for Highway Safety Status Report (Special drivers. Accident Analysis and Prevention. 2003;35(2): 227-235. Issue: Older Drivers). 2001;36(8):1-2.  Preusser DF, Williams AF, Ferguson SA, Ullmer RG, Weinstein HB. Fatal  Eberhard J. Safe mobility for senior citizens. International crash risk for older drivers at intersections. Accident Analysis and Association for Traffic and Safety Services Research. Prevention. 1998;30(2):151-159. 1996;20(1):29-37.

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