Download Janet Szlyk - BiOptic Driving Network

A Controlled Study Of The Use Of
BiOptic Telescopes By Patients With
Macular Degeneration
For Driving - With Follow-Up
Janet Szlyk, PhD
VA Chicago Health Care System/
University of Illinois at Chicago
Colleagues
William Seiple, PhD
Denice Laderman, MS
Roger Kelsch, RKT
Joan Stelmack, OD
Timothy McMahon, OD
 Kenneth Alexander, PhD
Gerald Fishman, MD
Visual Criteria for Driving in
Most US States
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Visual acuity of 20/40 or better
Worse than 20/40 to 20/70 Daytime only
Binocular visual field of 140 degrees
Monocular visual field of 105 degrees
Research Focus: Disease-based
performance profiles
• Central Vision Loss
- Age-Related Macular Degeneration
- Juvenile-Onset Macular Dystrophies
• Peripheral Vision Loss
- Retinitis Pigmentosa
- Hemianopsia due to Stroke
• Both Central & Peripheral
- Glaucoma
- Diabetic Retinopathy
Measurement of Driving
Performance
• Simulator Methods
Comparison to Norms
Road Course Performance
• Recognition – Speed, Following Distance
• Mobility – Pulling-Out Behavior,
Navigating Complex Environments
• Peripheral Detection – Lane Position,
Locating Signs/Landmarks
• Scanning – Spotting through Lenses
Disease-Based Risk Profiles: Central
Vision Loss
• Age-Related Macular Degeneration
Visual Acuity Limitations
• 20/30 to 20/100
• Significantly more control subjects than
patients were involved in accidents
• The AMD group had poorer performance on
the driving simulator and the road course
• Evidence of compensation in 4 areas
Compensation
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Not driving in unfamiliar areas
Traveling at slow speeds
Self-restricting their nighttime driving
Taking fewer risks while driving
Juvenile Macular Dystrophies
• Central visual field scotomas
• Reduced visual acuity
• Color vision abnormalities
Visual Fields - JMD
Visual Acuity Limitations
• 20/40 to 20/70
• The proportion of individuals involved in
accidents in the central vision group was
comparable to that of the control group
• Those who drove at night had a higher
likelihood of accident involvement
Retinitis Pigmentosa
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Group of inherited retinal degenerations
Progressive loss of visual field
Poor vision in dim light
Central vision may remain intact until later
stages of the disease
Visual Fields - RP
Visual Field Limitations
20/40 or better visual acuity
88% of patients with constricted visual
fields less than or equal to 100° diameter
had one or more accidents in the prior five
years; whereas, only 25% of the patients
with greater than 100° diameter had one or
more accidents in this time period.
Model for Accident Risk in RP
• Visual field extent + Braking pressure +
Braking response time to a stop sign = Realworld accidents
• Binocular visual field area + Lane position
+ Speed = Real-world accidents
Proposed Model for
Accident Risk
• Simulator variables (Abruptness of braking,
Speed, Response time, Lane boundary crossings,
Brake pressure, Simulator accidents)
• On-road variables (Stop sign responses, lane
observance, overall score)
• Risk-taking
• Binocular visual acuity
• Visual field extent
Summary of Disease-Based
Research:
• 20/40 -20/70 Daylight Restriction – JMD
• Monocular visual field of 105 degrees – RP
and Glaucoma
• Bioptic Telescope with 20/100 vision –
AMD; JMD
Goals
• To Develop a Rehabilitation and Training
Program for Use with Optical Enhancement
Devices
• To Develop and Validate an Assessment
Battery That Will Allow Objective
Evaluation of the Training Program
Three phases of our research:
• Phase 1- Bilateral Peripheral Visual Field
Loss Using Amorphic Lenses
Phase 2 - Central Vision Loss Using Bioptic
Telescopes
• Phase 3 - Hemifield Loss Using Prism
Lenses and Gottlieb Visual Field Awareness
Systems
Central Visual Loss
With Bioptic Telescope
BiOptic Study
• Inclusion Criteria
Central Vision Loss Due to Macular
Degeneration (N=7), Stargardt disease (7),
Cone-Rod Dystrophy (3), Retinopathy of
Prematurity (2), Albinism (1), Best’s disease
(1), Cone-Dystrophy (1), Diabetic (1),
Macular Hole (1), Pattern Dystrophy (1)
• Bioptic Telescopic Lens Prescription: 3X
or 4X power
Patient Profiles
Central Loss
Age (Yrs)
46.6 (16-78)
Visual Acuity
(Log Mar)
0.73 (20/100)
Contrast Sensitivity
1.20
Visual Field
(III-4-e)
-3.8  5
Study Design
• Patients Divided into 3 Experimental Groups
Matched on Age, Gender, and Clinical Variables
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Day 1
Day 2
Day 3
Group A W/O lenses Training
W/ lenses
No training W/ lenses
Group B W/O lenses No training W/O lenses Training
No lenses
• Group C W/O lenses No Training W/ lenses
lenses
W/ lenses
Data Analysis
• Test-Retest Reliability
(Group B (Delayed): Day 1 to Day 2)
• Training Effects
(Group A (Immediate): Day 1 to Day 2)
(Group B: Day 2 to Day 3)
(Group C: Day 1 to Day 2/No Training)
• Sustained Effects of Training
(Group A: Day 1 to Day 3)
Laboratory and
Real-World Training
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5 sessions
Locating Objects with The Lenses
Tracking Stimuli and Visual Memory Skills
Using Scanning Skills to Gather Visual
Information
• Navigating Complex Environments
On-Road Training
• 8 Sessions
• Vehicle Instrument Orientation and Spotting
Techniques
• Pulling-Out Techniques, Proper Following
Distance, Maintaining Proper Lane Position
• Locating Building Numbers, and
Landmarks
• Awareness of Critical Peripheral
Information
On-Road Training (continued)
• Visual Memory Skills
• Utilizing Side and Rear-View Mirrors
• Navigating Complex Environments as a
Passenger
Indoor Functional Assessment
• 39 Items
• Recognition, Mobility, Peripheral Detection,
Scanning, Tracking, and Visual Memory
Tasks
Outdoor Functional Assessment
• 53 Items
• Recognition, Mobility, Peripheral Detection,
Scanning, Tracking, and Visual Memory
Tasks
Driving Simulator Assessment
• Recognition - Speed
• Mobility - Accidents, Braking Response
Times to Traffic Lights and Stop Signs,
Braking Pressure, Deceleration Ratio
• Peripheral Detection - Lane Boundary
Crossings
• Scanning - Horizontal and Vertical Eye
Movements
On-Road Driving Assessment
• Recognition - Speed, Following Distance
• Mobility - Pulling-Out Behavior, Navigating
Complex Traffic Environments
• Peripheral Detection - Lane Position, Locating
Signs/Landmarks, Side Mirror Use, Noticing
Critical Peripheral Information
• Scanning - Spotting Through Lenses, Visual
Memory, Remembering Critical Information in
Traffic
Psychophysical Tests
• Attentional Visual Acuity - Letter Optotype
Sizes Ranging from 20/50 to 20/700 Tested
at 7°, 14°, 23° eccentricity
• Attentional Motion Sensitivity - Drift Rates
of Sinusoidal Grating from 0.6 to 30
Cycles/Second
• Peripheral Detection - Detect and Identify
Targets Presented Randomly at 4 Peripheral
Locations
Visual Skills Categories
• The Individual Tasks within The
Assessment Battery Were Coded
Independently by Three Investigators
According to The Primary Visual Skill
Involved in Each Task: Recognition,
Mobility, Peripheral Detection, Scanning,
Tracking, and Visual Memory
Visual Skills Categories
• Recognition - Tasks Requiring Central Vision
• Mobility - General Orientation and Navigation
• Peripheral Detection - Tasks Requiring Peripheral
Vision
• Scanning - Locating Objects
• Tracking - Visual Following
• Visual Memory - Recalling Objects
Data Analysis
• Calculated the Change for each Patient for each
Task for Group B (Day 2 - Day 1)
• Averaged Change for each Task across Patients
• Effects of Training - Individual Patient’s Scores
Coded As Improvement If They Exceeded The
Average For The Control Condition For That Task
• We Calculated The Percentage Of Tasks Showing
Improvement Within Each Visual Skills Category
Results
Bioptic – Group A (Immediate)
Results
Bioptic – Group B (Delayed)
Results
Sustained Effect (6 mo.)/Group A
EFFECTS OF TRAINING
SERIES 1 - LENSES + TRAINING
SERIES 2 - LENSES - NO TRAINING
100
PERCENT OF TASKS IMPROVED
90
80
70
60
50
40
30
20
10
0
RECOGNITION
MOBILITY
PERIPHERAL
SCANNING
TRACKING
VISUAL
MEMORY
Trained vs. Untrained Groups
Greater Improvement in:
Recognition (p < 0.05); Peripheral
Identification (0.02); Scanning (0.03)
 Not Statistically Different in:
Mobility (0.06), Tracking (1.5), Visual
Memory (0.07)
Analyzing Driving-Related Skills
 Percentage of DR Skills showing
improvement for each group
 Group A (Immediate Training) – 62%
 Group B (Delayed Training) – 66%
 Group C (No Training) – 55%
How Do You Like The Bioptic
Telescopic Lenses?
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Extremely Satisfied - 82%
Very Satisfied - 0%
Satisfied - 18%
Somewhat Satisfied - 0%
Unsatisfied - 0%
How Will You Use The Bioptic
Telescopic Lenses?
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Grocery Shopping
Viewing Movies at the Theater
Reading Signs
Recognizing Faces
Results
Across Systems
Effect of Training
90
80
70
60
Amorphi c
50
Bi opti c
40
Pri sm
30
20
10
0
Recogni t i on
Mobi l i t y
Peri pheral
Scanni ng
Tracki ng
Vi s Mem
Two-Year Follow-Up
• Able to contact 23 out of the 25 patients
Two-Year Follow-Up
• 11 (47.8%) of the patients reported that their
vision had changed in the 2 years since the
study
Two-Year Follow-Up
• 10 patients were driving
4 used the BiOptics
Two-Year Follow-Up
Reported Frequency of Use
• 4 (17.4%)
• 12 (52.2%)
• 7 (30.4%)
Use Frequently
Occasionally
Never
Two-Year Follow-Up
Stated BiOptic Uses
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Reading chalkboard
Shopping
Seeing things as car passenger
TV or movie viewing
Address locating
Sporting events
Bird watching
Conclusions
• Optical enhancement devices are useful to
patients with compromised vision when
combined with O&M and driving training
• Improve Quality of Life for persons with
reduced central vision
Conclusions
• Training with BiOptics Improves
Performance on Visual Skills Tasks
• Research on the effectiveness of individual
training techniques and the time course of
skill acquisition could lead to a
standardization of BiOptic Training
Methods
Acknowledgements
U.S. Department of Veterans Affairs
Rehabilitation Research & Development
Service; AAA Foundation for Traffic
Safety; Illinois Eye Fund; Foundation
Fighting Blindness; Research to Prevent
Blindness, Inc., NEI Core Grant EY01792