Eye Disability Rating

Fall Conference 2009

Steve Heye / Jim Sampson

What is important for me as a CSO to know

• VA updated portion of Rating Schedule that deals with eyes

• Visual acuity will generally be rated on basis of best corrected distance vision

• Certain eye disabilities will be rated either on – Visual impairment or– Incapacitating episodes

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Objective of this Training Class

• What changed?

• Effective date

• Specific changes

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What changed?– Numerous changes, technical and substantive

– See handout for details

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Effective date • Effective date of new criteria: 12-10-08

• Claims received on or after 12-10-08– Rating under new criteria

• Claim pending on 12-10-08– Examination and rating under old criteria

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Specific changes• Reorganized instructions for rating visual

impairment

• Now four sections:– 1. Visual impairment (38 CFR 4.75)– 2. Visual acuity (38 CFR 4.76)– 3. Visual fields (38 CFR 4.77)– 4. Muscle function (38 CFR 4.78)

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Number of diagnostic codes• There were 19 different diagnostic codes

• This has been reduced to 6– 33 codes revised – 20 removed – 2 added

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Measuring visual acuity• Examination requirements

– Uncorrected and corrected visual acuity for distance and near must be measured and recorded

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What is visual impairment?• 1. Impairment of visual acuity, and/or

– excluding development errors of refraction

• 2. Impairment of visual field, and/or

• 3. Impairment of muscle function

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Causes of visual impairment

• Common causes:– Retinal degeneration, including macular degeneration– Retinopathy– Cataracts– Glaucoma– Muscle imbalance problems– Corneal disorders– Trauma– Infection

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Distance visual acuity• Distance visual acuity

– Visual acuity of 20/20 means a person can see on an eye chart at 20 feet the smallest symbol that a person with normal visual acuity can see at that distance

– Visual acuity of 20/40 means a person can see on an eye chart at 20 feet that which a person with normal visual acuity can see at 40 feet

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Near visual acuity

– Measured by reading print samples of different sizes

• From a card at distance of 14 inches from person’s eye.

– Near visual acuity of 14/14 means a person can read at 14 inches what someone with normal vision can read at 14 inches

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Methods of evaluating eyes

– Need specialist exams– Include uncorrected and corrected central

visual acuity– Basis for rating

• Best distant vision after correction by glasses

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Additional considerations• Other conditions such as multiple sclerosis

(MS), diabetes mellitus, pituitary tumors or CVA (strokes) can cause visual disturbances

• MS can cause partial blindness, pain, diplopia, or optic neuritis

• CVA and pituitary tumors can cause disturbances in visual fields

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Pyramiding

38 CFR 4.14   Avoidance of pyramiding• Don’t rate same symptoms under different

diagnoses

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Higher of two evaluations• 38 CFR 4.83

– Unable to read at a particular scheduled step or distance,

– But able to read at the next scheduled step or distance,

• Rate using visual acuity that permits the higher evaluation

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Summary of new narrative for 38 CFR 4.75

• Licensed optometrist or ophthalmologist must conduct examination

• Identify disease or injury responsible for visual impairment

• Examinations of visual field or muscle function only when necessary

• Eyes examined with pupils dilated

• Refer to 38 CFR 3.350 if potential entitlement to SMC

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Summary of new narrative for 38 CFR 4.76

• Record uncorrected and corrected visual acuity– for distant and near

• Central visual acuity based on best corrected distance vision even when central scotoma (blind spot) detected

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Summary of new narrative for 38 CFR 4.77

• Determining extent of concentric visual field defect

• When both visual acuity and visual field impaired in one or both eyes– Combine under 38 CFR 4.25

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Summary of new narrative for 38 CFR 4.78

• Revises method of evaluating muscle function when another type of visual impairment also present

• A test is used to measure muscle function and to chart areas of diplopia

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Summary of new narrative for 38 CFR 4.79

• Loss of use of one eye is SMC “k.”

• Requires 2 findings:– Inability to recognize largest letters on Eye

Chart at 1 foot, and– Perception of objects, hand movement, or

counting fingers cannot be done far away as 3 feet

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SMC for Bilateral Blindness

• Best corrected vision in better eye 5/200 or less; or

• Visual field restriction to 5º or less = 5/200

• SMC “l”

• 38 CFR 3.350(b)(2)

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Evaluation when only one eye is SC• If only one eye SC,

– Only visual acuity of that eye is evaluated

– Consider visual acuity of the other (NSC) eye to be 20/40, subject to

• 38 CFR 3.383(a)(1), paired organ rule.

• For loss of visual acuity alone, maximum for single eye 30%

• With anatomic loss, maximum 40%• If anatomic loss and can’t wear prosthesis , maximum 50%

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Example of evaluation of one eye

• See student handout

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38 CFR 3.383: Paired organs• If a veteran has SC loss or LOU in one eye only and

impairment of vision in NSC eye (not due to misconduct) – Then VA compensates the veteran “as if” both eyes are

SC

• For VA purposes, impairment of vision in the NSC eye means – Best corrected vision is 20/200 or less, or– Peripheral field of vision for each eye is 20 degrees or

less

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No light perception• VA removed term :”blindness” from titles

of diagnostic codes 6062 and 6064.

• In evaluating the visual acuity of one eye, no light perception is now evaluated the same as light perception only.

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Conditions considered as refractive error

• VA considers 3 conditions as refractive error:– 1. Regular astigmatism

– 2. Presbyopia (hyperopia, farsightedness)

– 3. Myopia (nearsightedness)

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Refractive errors

– Effect of uncomplicated refractive error excluded

• when considering visual impairment from standpoint of SC & evaluation.

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Congenital or developmental defects

– Normally static conditions incapable of improvement or deterioration, such as conditions present at birth that affect eyes or vision

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Establishing SC for congenital or developmental diseases

• SC may be established for diseases of congenital, developmental, or familial, hereditary origin that– First manifest themselves during service, OR– Pre-exist service and progress at abnormally high

rate during service, and– Hereditary or familial disease that first became

manifest to compensable degree within presumptive period following discharge from service (38 CFR 3.309(a)

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Incurrence or aggravation of hereditary or familial disease

• Manifested after entry on duty

• Progresses during service at a rate greater than normally expected

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Reconciling inconsistent findings with refractive error

• When dealing with refractive error only, – If best corrected vision on any examination by

VA is better than on prior examinations, – VA assumes the prior determinations to be

erroneous or at least as not representing the best correction

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Diagnostic codes 6000-6009

• Formerly evaluated 10 to 100 percent – based on impairment of visual acuity or field loss, pain,

rest-requirements, or episodic incapacity, – combining additional rating of 10 percent during

continuance of active pathology.

• Revised set of evaluation criteria in form of general rating formula following diagnostic code 6009– based either on visual impairment

– or incapacitating episodes, whichever results in higher evaluation.

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6012, Angle-closure glaucoma• Title changed from “glaucoma, congestive

or inflammatory” to “angle-closure glaucoma”– Because this is current medical term for this

condition.

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6013, Open-angle glaucoma• VA changed the title of diagnostic code

6013 from “glaucoma, simple, primary, noncongestive” to “open-angle glaucoma” – Because this is current medical term for this

condition.

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6014, Malignant neoplasms (eyeball only)

• Updated title from “new growth” to “neoplasm.” – Since not all malignant neoplasms of the eye are

• totally disabling or require treatment that is totally disabling for a period of time

• and often require no treatment other than observation,

– There are now two methods of evaluation:• For treatment confined to the eye• For treatment not confined to the eye

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6014, first method of evaluation

• If malignant neoplasm requires treatment more extensive than to the eye

• For example, – Systemic chemotherapy– Radiation therapy more extensive than to the eye, or– Surgery more extensive than enucleation

• Then, a 100 percent evaluation will be assigned

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6014, second method of evaluation

• If treatment is confined to the eye – then provisions of 38 CFR 3.105(e) do not

apply.

• The evaluation is based on • Visual impairment and non visual impairment,

such as disfigurement (DC 7800)

• The evaluations are combined under 38 CFR 4.25

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38 CFR 3.105(e)• Reduction in evaluation—compensation

• Rating proposing reduction

• 60 days for presentation of additional evidence

• If additional evidence is not received within 60 days or a request for a pre determination hearing within 30 days after the notice proposing reduction, – Then final rating action will be taken and the award

reduced

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6015, Benign neoplasms of eyeball and adnexa

• VA edited the title

• Removed 10 percent minimum evaluation as not warranted in all cases

• Evaluation based on visual impairment– to be combined with evaluation for any non-

visual impairment, • for example, disfigurement

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6017, Trachomatous conjunctivitis

• A chronic infection of the conjunctiva due to Chlamydia trachomatis

• Formerly evaluated based on impairment of visual acuity– with a minimum evaluation of 30 percent for active

pathology• The 30 percent evaluation for active trachoma has

been retained, but • Inactive trachoma is now evaluated based on residuals

– such as visual impairment and disfigurement

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6018, Chronic conjunctivitis, non trachomatous

• Other forms of conjunctivitis (pink eye) • An inflammation of the conjunctiva (the outermost layer of

the eye and the inner surface of the eyelids), most commonly due to an allergic reaction or an infection(usually viral, but sometimes bacterial

• Formerly, – It was evaluated at 10 percent for “objective symptoms”

• “Objective symptoms” changed to “objective findings” • “Healed” changed to “inactive”

– because conjunctivitis may be active intermittently without actually being healed

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6019, Ptosis

• Means droopy eyelid (blepharoptosis)Can affect vision if covers part or all of pupil

• May be congenital or acquired

• May be cosmetic problem

• May also result in loss of superior

(looking up) vision

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Ptosis, continued• May be due to muscle or nerve impairment

• May be cosmetic problem

• May also result in loss of superior

(looking up) vision

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Rating ptosis• Formerly, (DC 6019) rated

– equivalent to visual acuity of • 5/200 whenever the pupil was completely obscured, or • 20/100 if pupil ½ or more obscured• on disfigurement if less than ½ of pupil obscured

– Now, because extent to which pupil is obscured can be difficult to determine reliably,

• Evaluated based on visual impairment, or • In absence of visual impairment, on disfigurement

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6025, Disorders of the lacrimal apparatus (epiphora)

• Epiphora is excessive tearing

• Acute type often results from – corneal foreign bodies or allergic

conjunctivitis, and often resolves

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Rating epiphora

• Rated under diagnostic code 6025 at 10 percent if unilateral and 20 percent if bilateral

• Example:– Unilateral epiphora due to acquired

nasolacrimal duct (tear duct)obstruction– Would be rated at 10 percent

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6026, Optic neuropathy

• Disease or optic nerve injury– Macular degeneration– Glaucoma– Retinitis pigmentosa

• Need field of vision measurements

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6027, Cataract of any type• Preoperative

– Evaluate based on visual impairment• Postoperative

– If replacement lens is present (pseudophakia), evaluate based on visual impairment

– If is no replacement lens, evaluate based on aphakia(absence of the lens of the eye)

• Important change because, under the old criteria– if veteran underwent cataract surgery with lens implantation,

• received a minimum 30 percent rating regardless of any visual impairment following surgery

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6029, Aphakia or dislocation of crystalline lens

• Definition: Absence of lens of the eye• Evaluate based on visual impairment• And elevate resulting level of visual

impairment one step• Minimum rating (unilateral or bilateral) 30 percent

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6034, Pterygium• Fleshy tissue that grows over

• Formerly evaluated on loss of vision, if any

• Now evaluated on visual impairment, disfigurement, conjunctivitis, etc.

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6035, Keratoconus

• Progressive eye disease – Cornea thins and begins to bulge into cone-like

shape– Cone shape deflects light as enters eye on way to

light-sensitive retina

• Formerly minimum 30 percent evaluation when contact lenses “medically required”

• Minimum evaluation now deleted • Evaluation now based on corrected visual acuity

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6036, Status post corneal transplant

• New diagnosis for common condition

• Evaluation based on visual impairment

• Minimum evaluation of 10 percent if pain, photophobia, and glare sensitivity after transplant

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6037, Pinguecula

• Yellowish, thickened lesion on the conjunctiva near cornea

• Added diagnostic code for this sometimes disfiguring condition

• Evaluated based on disfigurement

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6081, Scotoma, unilateral

• A scotoma is a loss of vision in a defined area in one or both eyes, often called a blind spot

• Formerly minimum 10 percent evaluation for large or centrally located scotoma

• Changed “large” to “affecting at least ¼ of visual field”

• Evaluation otherwise based on visual impairment

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6090,Diplopia

• Diplopia: double vision

• If disease or injury involves– Extrinsic muscles of the eye, or– Motor nerve supplying these muscles, then– Exam should include measurement of muscle

function

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6091, Symblepharon

• Adhesion of one or both eyelids to the eyeball• Formerly rated under diagnostic code 6090

(diplopia)• Is evaluated based on

– visual impairment– lagophthalmos (DC 6022), inability to close or poor

closure, of upper eyelid– disfigurement, etc.

• May also result in other types of impairments

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Retinitis pigmentosa

• Retinitis pigmentosa– Not changed, but is a very important topic

– Hereditary or congenital

– May grant SC under certain circumstances (see next few slides)

– No diagnostic code for retinitis pigmentosa

– Evaluation based on visual impairment

– Often loss of peripheral visual fields, but may also be loss of central visual acuity and widespread

field loss

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Presumption of soundness

• Veteran will be considered to have been in sound condition when examined, accepted and enrolled for service

• Except as to defects, infirmities, or disorders noted at entrance into service, or

• Evidence clearly shows that condition existed before and was not aggravated by service

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VAOPGCPREC 11-99

 Service connection may be granted for retinitis pigmentosa even though it existed prior to service if there was in-service aggravation

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VAOPGPREC 82-90• A defect differs from a disease

– A defect is “more or less stationary in nature” and

– A disease is “capable of improving or deteriorating.”

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Quirin v. Shinseki• BVA must properly apply VAOPG 82-90 in

determining whether or not a condition is a disease or defect

• Worsening – any change at all – might demonstrate condition is a disease

•  Presumption of soundness does not apply to congenital defects, – but must be applied if condition determined to be a

congenital disease.

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Ancillary benefits

• 1. Auto allowance

• 2. Specially Adapted Housing

• 3. Special Home Adaptation Grant

• A specific claim is required, however, – It becomes an inferred issue when the veteran

meets the schedular requirements and VA can grant the benefit

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Auto allowance

• A certificate of eligibility for financial assistance in the purchase of one automobile or other conveyance in an amount not exceeding the amount specified in 38 U.S.C. 3902 (including all State, local, and other taxes where such are applicable and included in the purchase price) and of basic entitlement to necessary adaptive equipment

• Payable where best corrected central visual acuity no better than 20/200 in better eye (at least 70 percent evaluation using DC 6066), or

• Visual field no better than 20 degrees in better eye (at least 50 percent evaluation under DC 6080)• 38 CFR 3.808(b)(1)(iii)

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Specially adapted housing

• A certificate of eligibility for assistance in acquiring specially adapted housing under 38 U.S.C. 2101

• Not payable for blindness alone, but is payable for – Blindness in both eyes no better than light perception

(LPO)

– Plus anatomical loss or loss of use of one lower extremity

– 38 CFR 3.809   Specially adapted housing under 38 U.S.C. 2101(a).

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Special home adaptation grant

• A certificate of eligibility for assistance in acquiring necessary special home adaptations, or, on or after October 28, 1986, for assistance in acquiring a residence already adapted with necessary special features, under 38 U.S.C. 2101(b)

• Blindness of both eyes with visual acuity of 5/200 or less, or

• Bilateral concentric contraction of visual field to 5 degrees or less under DC 6080 (visual field defects)

• 38 CFR 3.809(a)

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Summary of what we have learned today

• The VA Rating Schedule for the Eyes changed effective 12-10-08

• Reorganized into 4 sections– 1. Visual impairment (38 CFR 4.75)– 2. Visual acuity (38 CFR 4.76)– 3. Visual fields (38 CFR 4.77)– 4. Muscle function (38 CFR 4.78)

• Certain eye disabilities will be rated either on – Visual impairment or– Incapacitating episodes

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Questions?