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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

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eye disability rating

Eye Disability Rating

Fall Conference 2009

Steve Heye / Jim Sampson

what is important for me as a cso to know
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
objective of this training class
Objective of this Training Class
  • What changed?
  • Effective date
  • Specific changes
what changed
What changed?
  • Numerous changes, technical and substantive
  • See handout for details
effective date
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
specific changes
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)
number of diagnostic codes
Number of diagnostic codes
  • There were 19 different diagnostic codes
  • This has been reduced to 6
    • 33 codes revised
    • 20 removed
    • 2 added
measuring visual acuity
Measuring visual acuity
  • Examination requirements
    • Uncorrected and corrected visual acuity for distance and near must be measured and recorded
what is visual impairment
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
causes of visual impairment
Causes of visual impairment
  • Common causes:
    • Retinal degeneration, including macular degeneration
    • Retinopathy
    • Cataracts
    • Glaucoma
    • Muscle imbalance problems
    • Corneal disorders
    • Trauma
    • Infection
distance visual acuity
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
near visual acuity
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
methods of evaluating eyes
Methods of evaluating eyes
  • Need specialist exams
  • Include uncorrected and corrected central visual acuity
  • Basis for rating
    • Best distant vision after correction by glasses
additional considerations
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

pyramiding
Pyramiding

38 CFR 4.14   Avoidance of pyramiding

  • Don’t rate same symptoms under different diagnoses
higher of two evaluations
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
summary of new narrative for 38 cfr 4 75
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

summary of new narrative for 38 cfr 4 76
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
summary of new narrative for 38 cfr 4 77
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
summary of new narrative for 38 cfr 4 78
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

summary of new narrative for 38 cfr 4 79
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
smc for bilateral blindness
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)

evaluation when only one eye is sc
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%
38 cfr 3 383 paired organs
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
no light perception
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.

conditions considered as refractive error
Conditions considered as refractive error
  • VA considers 3 conditions as refractive error:
    • 1. Regular astigmatism
    • 2. Presbyopia (hyperopia, farsightedness)
    • 3. Myopia (nearsightedness)
refractive errors
Refractive errors
  • Effect of uncomplicated refractive error excluded
    • when considering visual impairment from standpoint of SC & evaluation.
congenital or developmental defects
Congenital or developmental defects
  • Normally static conditions incapable of improvement or deterioration, such as conditions present at birth that affect eyes or vision
establishing sc for congenital or developmental diseases
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)
incurrence or aggravation of hereditary or familial disease
Incurrence or aggravation of hereditary or familial disease

Manifested after entry on duty

Progresses during service at a rate greater than normally expected

reconciling inconsistent findings with refractive error
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
diagnostic codes 6000 6009
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.
6012 angle closure glaucoma
6012, Angle-closure glaucoma
  • Title changed from “glaucoma, congestive or inflammatory” to “angle-closure glaucoma”
    • Because this is current medical term for this condition.
6013 open angle glaucoma
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.
6014 malignant neoplasms eyeball only
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
6014 first method of evaluation
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
6014 second method of evaluation
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
38 cfr 3 105 e
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
6015 benign neoplasms of eyeball and adnexa
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
6017 trachomatous conjunctivitis
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
6018 chronic conjunctivitis non trachomatous
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
6019 ptosis
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

ptosis continued
Ptosis, continued
  • May be due to muscle or nerve impairment
  • May be cosmetic problem
  • May also result in loss of superior

(looking up) vision

rating ptosis
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
6025 disorders of the lacrimal apparatus epiphora
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
rating epiphora
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
6026 optic neuropathy
6026, Optic neuropathy
  • Disease or optic nerve injury
    • Macular degeneration
    • Glaucoma
    • Retinitis pigmentosa
  • Need field of vision measurements
6027 cataract of any type
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
6029 aphakia or dislocation of crystalline lens
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

6034 pterygium
6034, Pterygium

Fleshy tissue that grows over

Formerly evaluated on loss of vision, if any

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

6035 keratoconus
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
6036 status post corneal transplant
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

6037 pinguecula
6037, Pinguecula

Yellowish, thickened lesion on the conjunctiva near cornea

Added diagnostic code for this sometimes disfiguring condition

Evaluated based on disfigurement

6081 scotoma unilateral
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

6090 diplopia
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
6091 symblepharon
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
retinitis pigmentosa
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

presumption of soundness
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

vaopgcprec 11 99
VAOPGCPREC 11-99

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

vaopgprec 82 90
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.”
quirin v shinseki
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.
ancillary benefits
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
auto allowance
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)
specially adapted housing
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).
special home adaptation grant
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)

summary of what we have learned today
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