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Eye Disability Rating

Eye Disability Rating

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Eye Disability Rating

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  1. Eye Disability Rating Fall Conference 2009 Steve Heye / Jim Sampson

  2. 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

  3. Objective of this Training Class • What changed? • Effective date • Specific changes

  4. What changed? • Numerous changes, technical and substantive • See handout for details

  5. 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

  6. 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)

  7. Number of diagnostic codes • There were 19 different diagnostic codes • This has been reduced to 6 • 33 codes revised • 20 removed • 2 added

  8. Measuring visual acuity • Examination requirements • Uncorrected and corrected visual acuity for distance and near must be measured and recorded

  9. 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

  10. Causes of visual impairment • Common causes: • Retinal degeneration, including macular degeneration • Retinopathy • Cataracts • Glaucoma • Muscle imbalance problems • Corneal disorders • Trauma • Infection

  11. 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

  12. 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

  13. Methods of evaluating eyes • Need specialist exams • Include uncorrected and corrected central visual acuity • Basis for rating • Best distant vision after correction by glasses

  14. 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

  15. Pyramiding 38 CFR 4.14   Avoidance of pyramiding • Don’t rate same symptoms under different diagnoses

  16. 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

  17. 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

  18. 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

  19. 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

  21. 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

  22. 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)

  23. 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%

  24. Example of evaluation of one eye See student handout

  25. 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

  26. 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.

  27. Conditions considered as refractive error • VA considers 3 conditions as refractive error: • 1. Regular astigmatism • 2. Presbyopia (hyperopia, farsightedness) • 3. Myopia (nearsightedness)

  28. Refractive errors • Effect of uncomplicated refractive error excluded • when considering visual impairment from standpoint of SC & evaluation.

  29. Congenital or developmental defects • Normally static conditions incapable of improvement or deterioration, such as conditions present at birth that affect eyes or vision

  30. 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)

  31. Incurrence or aggravation of hereditary or familial disease Manifested after entry on duty Progresses during service at a rate greater than normally expected

  32. 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

  33. 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.

  34. 6012, Angle-closure glaucoma • Title changed from “glaucoma, congestive or inflammatory” to “angle-closure glaucoma” • Because this is current medical term for this condition.

  35. 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.

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. 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

  44. Ptosis, continued • May be due to muscle or nerve impairment • May be cosmetic problem • May also result in loss of superior (looking up) vision

  45. 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

  46. 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

  47. 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

  48. 6026, Optic neuropathy • Disease or optic nerve injury • Macular degeneration • Glaucoma • Retinitis pigmentosa • Need field of vision measurements

  49. 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

  50. 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