Eye Disability Rating

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Eye Disability Rating

• Fall Conference 2009
• Steve Heye / Jim Sampson

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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
  persons 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
• Dont 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

20
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 cant 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 evaluationcompensation
• 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?