[Blindvet-talk] Revised rule on visual disorders of the eye
Kirk Harmon
kvh54 at cfl.rr.com
Tue Nov 11 00:31:19 UTC 2008
Thanks for the informmation good Man!Kirk
----- Original Message -----
From: <NABlindVets at aol.com>
To: <blindvet-talk at nfbnet.org>
Sent: Monday, November 10, 2008 6:50 PM
Subject: [Blindvet-talk] Revised rule on visual disorders of the eye
> All Vets,
> Notice from Jim McCarthy in Baltimore.
> Read on Please.
> Dwight
>
>
>
> ____________________________________
> From: JMcCarthy at nfb.org
> To: MisterAdvocate at aol.com
> Sent: 11/10/2008 2:36:19 P.M. Eastern Standard Time
> Subj: Revised rule on visual disorders of the eye
>
>
> Dwight,
> This is the veteran's revised rule on disabilities of the eye. It has
> been under consideration from 1998 and perhaps some here were aware of
> that, but because there was no discussion of the rule, I was not. The
> rule becomes final after December 10 and here it is as published in the
> federal Register.
> Jim McCarthy
>
> FR Doc E8-26304[Federal Register: November 10, 2008 (Volume 73, Number
> 218)]
> [Rules and Regulations]
> [Page 66543-66554]
>>From the Federal Register Online via GPO Access [wais.access.gpo.gov]
> [DOCID:fr10no08-17]
>
> =======================================================================
> -----------------------------------------------------------------------
>
> DEPARTMENT OF VETERANS AFFAIRS
>
> 38 CFR Part 4
>
> RIN 2900-AH43
>
>
> Schedule for Rating Disabilities; Eye
>
> AGENCY: Department of Veterans Affairs.
>
> ACTION: Final rule.
>
> -----------------------------------------------------------------------
>
> SUMMARY: This document amends the Department of Veterans Affairs (VA)
> Schedule for Rating Disabilities (Rating Schedule) by updating the
> portion of the schedule that addresses disabilities of the eye. These
> amendments ensure that the schedule uses current medical terminology,
> provides unambiguous criteria for evaluating disabilities, and
>
> [[Page 66544]]
>
> incorporates pertinent medical advances.
>
> DATES: Effective Date: This amendment is effective December 10, 2008.
> Applicability Date: These amendments shall apply to all
> applications for benefits received by VA on or after December 10, 2008.
>
> FOR FURTHER INFORMATION CONTACT: Maya Ferrandino, Consultant, Policy
> and Regulations Staff (211D), Compensation and Pension Service,
> Veterans Benefits Administration, Department of Veterans Affairs, 810
> Vermont Ave., NW., Washington, DC, 20420, (727) 319-5847. (This is not
> a toll-free number.)
>
> SUPPLEMENTARY INFORMATION: As part of its review of the Schedule for
> Rating Disabilities (38 CFR part 4), VA published a proposal to amend
> the portion of the schedule pertaining to the eye in the Federal
> Register of May 11, 1999 (64 FR 25246-25258). Interested persons were
> invited to submit written comments on or before July 12, 1999. We
> received comments from the Disabled American Veterans, the Blinded
> Veterans Association, and one other interested party.
>
> Section 4.75 General Considerations for Evaluating Visual Impairment
>
> We proposed to add paragraph (c) to Sec. 4.75 to codify the
> longstanding VA practice that when visual impairment of only one eye is
> service-connected, either directly or by aggravation, the visual acuity
> of the nonservice-connected eye must be considered to be 20/40, subject
> to the provisions of 38 CFR 3.383(a). Section 3.383(a) directs that
> when there is blindness in one eye as a result of service-connected
> disability and blindness in the other eye as a result of nonservice-
> connected disability, VA will pay compensation as if both were service-
> connected.
> We also proposed to remove current Sec. 4.78, which provides a
> method of determining the level of disability when the visual
> impairment is aggravated during military service. As stated in the
> proposed rule, Sec. 4.78 is not consistent with VA's method of
> evaluating visual impairment incurred in service in one eye only, nor
> is it consistent with VA's statutory scheme governing VA benefits. Its
> application may, in some cases, result in a higher evaluation for a
> condition that is aggravated by service than for an identical condition
> incurred in service, which is not equitable. Section 4.78 is also
> inconsistent with the method of evaluating other paired organs, such as
> the hands, where only the service-connected hand is evaluated,
> regardless of the status of the nonservice-connected hand, subject to
> the provisions of Sec. 3.383(a).
> One commenter challenges the rule proposed in Sec. 4.75(c) as
> contrary to legal authority and long-standing VA practice. According to
> the commenter, the proper rating of visual disability always considers:
> (1) The vision of each eye, regardless of whether the origin of the
> service-connected disability is one or both eyes and (2) the entire
> disability, regardless of whether service connection is based on
> incurrence or aggravation. The commenter stated that ``service
> connection is always bilateral in the legal sense.'' The commenter
> stated that VA used the term ``service connected'' in current Sec.
> 4.78 in its literal sense and that the nonservice-connected visual
> impairment to which Sec. 4.78 refers ``denotes the origin of the
> disability, not its legal status.'' The commenter further asserted that
> ``service connection attaches to the impairment of function or
> disability and not to the organ or body part per se'' and that
> ``service connection is accordingly established for visual impairment
> that is incurred in or aggravated by service and is not limited to the
> eye with the service-related disability.'' The commenter cited VA's
> Office of the General Counsel opinion VAOPGC 25-60 (9-13-60) and 38
> U.S.C. 1160 in support of these assertions.
> To an extent, the commenter is correct that the proper rating of
> visual disability always considers the vision of each eye, regardless
> of whether the origin of the service-connected disability is one or
> both eyes. However, if visual impairment of only one eye is service-
> connected, the vision in the other eye is considered to be normal,
> i.e., 20/40. To do otherwise would violate 38 CFR 4.14, which provides
> that ``the use of manifestations not resulting from service-connected
> disease or injury in establishing the service-connected evaluation * *
> * [is] to be avoided.'' Proposed Sec. 4.75(c) merely states long-
> standing VA practice in this regard.
> The commenter is mistaken about the entire disability being
> considered, regardless of whether service connection is based on
> incurrence or aggravation. As 38 CFR 4.22 plainly states: ``In cases
> involving aggravation by active service, the rating will reflect only
> the degree of disability over and above the degree existing at the time
> of entrance into the active service * * *. It is necessary therefore,
> in all cases of this character[,] to deduct from the present degree of
> disability the degree, if ascertainable, of the disability existing at
> the time of entrance into active service. * * *''
> Although there are certain specified exceptions (such as 38 U.S.C.
> 1151 and 1160), generally the statutes governing VA benefits authorize
> compensation for service-connected disability only. 38 U.S.C. 101(13),
> 1110, 1131. Only disabilities that result from injury or disease
> incurred or aggravated in service may be service connected. 38 U.S.C.
> 1110, 1131; 38 CFR 3.310(a). VAOPGC 25-60 addressed whether VA had
> authority to award a 100-percent disability rating for visual
> impairment where there is service-connected loss or loss of use of one
> eye and nonservice-connected loss or loss of use of the other eye
> arising after service. The opinion held that VA did not have statutory
> authority to compensate veterans for nonservice-connected visual
> disability arising after service. However, Congress later provided an
> exception in 38 U.S.C. 1160. If a veteran has visual impairment in one
> eye as a result of service-connected disability and visual impairment
> in the other eye as a result of nonservice-connected disability not the
> result of the veteran's own willful misconduct and either (1) the
> impairment of visual acuity in each eye is rated at a visual acuity of
> 20/200 or less or (2) the peripheral field of vision for each eye is 20
> degrees or less, VA must pay compensation to the veteran as if the
> combination of both disabilities were the result of service-connected
> disability. 38 U.S.C. 1160(a). Thus, VA's authority to consider
> nonservice-connected visual disability for compensation purposes is
> limited to the circumstances described in section 1160(a). Absent the
> degree of visual impairment in both eyes prescribed in section 1160(a),
> nonservice-connected visual disability is not compensable and therefore
> not to be considered when rating service-connected disability. Where a
> claimant has a service-connected disability of only one eye and a
> nonservice-connected visual impairment but not of the degree prescribed
> by section 1160(a) in the other eye, deeming the nonservice-connected
> eye as having a visual acuity of 20/40 results in accurate evaluations
> that are based solely upon service-connected visual impairment. Our
> proposal to deem the nonservice-connected eye as having a visual acuity
> of 20/40 is consistent with current law. We make no change based upon
> this comment.
> This commenter also asserted that VA should consider hearing loss
> less than total deafness and visual impairment less than blindness when
> evaluating impairment of the nonservice-connected ear and eye,
> respectively. The
>
> [[Page 66545]]
>
> commenter disagreed with VA's Office of the General Counsel opinion
> VAOPGCPREC 32-97, which interpreted the statutes governing compensation
> for service-connected disabilities and concluded that where a claimant
> has service-connected hearing loss in one ear and nonservice-connected
> hearing loss in the other ear, for purposes of evaluating the service-
> connected disability, the hearing in the ear with nonservice-connected
> hearing loss should be considered normal, unless the claimant is
> totally deaf in both ears. The issue raised by the commenter was mooted
> by the Veterans Benefits Act of 2002, Public Law 107-330, which
> authorized VA, when a veteran has compensable service-connected hearing
> loss in one ear and nonservice-connected deafness in the other ear, to
> assign an evaluation and pay compensation as though both ears were
> service-connected, and the Dr. James Allen Veteran Vision Equity Act of
> 2007, Public Law 110-157, which authorized VA, when a veteran has
> service-connected visual impairment in one eye and nonservice-connected
> visual impairment in the other eye of the degree described above, to
> assign an evaluation and pay compensation as though both eye
> disabilities were service connected. See 38 U.S.C. 1160(a)(1) and (3).
> Further, while Sec. 4.78 addressed aggravation, it is unnecessary
> to include this in this regulation as it is covered in 38 CFR 4.22.
> Section 4.78's discussion of aggravation was duplicative of Sec. 4.22.
> Proposed Sec. 4.75(d) stated that the evaluation for visual
> impairment of one eye may be combined with evaluations for other
> disabilities that are not based on visual impairment and included
> disfigurement as an example. One commenter suggested that we evaluate
> phthisis bulbi (shrunken eyeball) or other serious cosmetic defect of
> the eyeball at 40 percent instead of referring the rater to diagnostic
> code 7800 (``Scars, disfiguring, head, face, or neck'') under the skin
> portion of the Rating Schedule. The commenter felt this would provide a
> standard evaluation for this problem.
> The portion of the Rating Schedule that addresses the skin has been
> revised (67 FR 49590, July 31, 2002) since the comment was written.
> Diagnostic code 7800 is no longer limited to evaluation of scarring of
> the skin. The revised evaluation criteria include a 30-percent
> evaluation for gross distortion or asymmetry of a paired set of
> features with visible or palpable tissue loss. Since by definition,
> phthisis bulbi is a shrunken or atrophic eyeball, there would be
> visible or palpable tissue loss, and this level of evaluation under
> diagnostic code 7800 would apply. Any other cosmetic defect of the
> eyeball that meets the criteria for disfigurement could also be
> evaluated under diagnostic code 7800, with the level of evaluation
> based on application of the criteria for disfigurement. Therefore, we
> make no change based on this comment.
> Proposed Sec. 4.75(e) instructed adjudicators to increase
> evaluations by 10 percent in situations where a claimant has anatomical
> loss of one eye with inability to wear a prosthesis. One commenter
> suggested that 10 percent be added in the absence of anatomical loss
> but with deformity and inability to wear a prosthesis. The evaluation
> criteria of diagnostic code 7800 would apply in this situation. The
> level of evaluation for deformity and inability to wear a prosthesis
> could be more or less than 10 percent, depending on the extent of
> disfigurement. However, to avoid pyramiding under 38 CFR 4.14 (``the
> evaluation of the same manifestation under different diagnoses [is] to
> be avoided''), an evaluation under diagnostic code 7800 would preclude
> an additional 10 percent for the same deformity under Sec. 4.75. We
> have decided to also specify in Sec. 4.75(e) that the 10-percent
> increase in evaluation under that provision for anatomical loss of one
> eye with inability to wear a prosthesis precludes an evaluation under
> diagnostic code 7800 based on gross distortion or asymmetry of the eye.
> We made nonsubstantive revisions to proposed Sec. 4.75(b), (c),
> (d), (e), and (f) to improve clarity.
>
> Section 4.76 Visual Acuity
>
> We proposed to delete Sec. 4.83, which stated that a person not
> able to read at any one of the scheduled steps or distances, but able
> to read at the ``next scheduled step or distance,'' is to be rated as
> reading at this latter step or distance. A commenter noted that this
> rule is vital for determining whether to select the higher or lower
> evaluation and recommended that we retain Sec. 4.83. In our view, an
> adjudicator could simply refer to 38 CFR 4.7 to determine the correct
> evaluation. However, we will retain this instruction to promote
> consistency of evaluations. We have included the following language in
> Sec. 4.76(b) at Sec. 4.76(b)(4): ``To evaluate the impairment of
> visual acuity where a claimant has a reported visual acuity that is
> between two sequentially listed visual acuities, use the visual acuity
> which permits the higher evaluation.''
> We proposed that visual acuity would generally be evaluated on the
> basis of corrected distance vision. One commenter suggested that
> because VA policy is to rate on central acuity, not eccentric viewing,
> we should revise the proposed language of Sec. 4.76(b)(1) to clarify
> that even when a central scotoma is present, central visual acuity is
> evaluated based upon best corrected distance vision with central
> fixation. We agree that central visual acuity should be emphasized. To
> assure consistency of evaluation and eliminate the variability that
> could result if eccentric vision were tested, we have revised the
> language of proposed Sec. 4.76(b)(1) according to the commenter's
> suggestion. For the sake of consistency, we have also added ``central''
> to Sec. 4.76(a) before ``uncorrected and corrected visual acuity''.
> Another commenter asked how visual acuity is determined if central
> fixation is not possible. Visual acuity can be determined in these
> cases by optometrists and ophthalmologists, because they are routinely
> trained in special methods and techniques that allow them to assess
> visual acuity and/or function when there is loss of central fixation.
> Thus, central visual acuity can still be used to rate visual
> impairment, even if central fixation is impossible.
> In Sec. 4.76(b)(1), we proposed to amend how we evaluate visual
> acuity where there is a significant difference in the lens required to
> correct distance vision in the poorer eye compared to the lens required
> to correct distance vision in the better eye. We proposed to evaluate
> the visual acuity of the poorer eye using either its uncorrected visual
> acuity or its visual acuity as corrected by a lens that does not differ
> by more than three diopters from the lens needed for correction of the
> other eye, whichever results in better combined visual acuity. This
> provision reduced the diopter difference required for application of
> this provision from the current requirement of more than four diopters
> to a requirement of more than three diopters. We proposed to reduce the
> diopter difference because at more than three diopters there is a
> significant possibility that a claimant will have visual difficulties.
> However, we have learned that even reducing the diopter difference
> required for application of this provision from more than four diopters
> to more than three diopters may still not assure that the individual's
> brain will be able to ``fuse'' the two differently sized images. The
> inability to do so results in an intolerable optical correction from
> clinically significant aniseikonia (where the ocular image of an object
> as seen by one eye differs in size and shape from that seen by the
> other).
> Therefore, we have decided to remove the language ``by a lens that
> does not
>
> [[Page 66546]]
>
> differ by more than three diopters from the lens needed for correction
> of the other eye.'' By permitting evaluation based on either
> uncorrected vision or corrected vision without specifying the
> refractive power of the lens, we can accommodate both individuals who
> do experience visual difficulty when wearing such different lenses and
> individuals who do not experience visual difficulty.
> Further, we have added to Sec. 4.76(b)(1) language stating, ``and
> either the poorer eye or both eyes are service connected'' to emphasize
> VA's authority to service connect unilateral visual impairment. This
> additional language clarifies that VA evaluators must apply this
> provision whether disability of either only one eye (the poorer eye) or
> both eyes is service-connected.
> We made nonsubstantive revisions to proposed Sec. 4.76(a), (b)(1),
> (b)(2) and (b)(3) to improve clarity.
>
> Section 4.76a Computation of Average Concentric Contraction of Visual
> Fields
>
> We proposed to remove Sec. 4.76a because directions for evaluating
> visual fields were revised and moved to Sec. 4.77. The proposed rule
> did not make it clear whether or not Table III and Figure 1, which are
> part of Sec. 4.76a, were to be retained. Table III lists the normal
> degrees of the visual field at the eight principal meridians and also
> gives an example of computing concentric contraction of abnormal visual
> fields. One commenter suggested that we retain the example of computing
> visual fields because it is useful for understanding the material on
> average concentric contraction. We agree, and although we have deleted
> from Sec. 4.76a the text preceding Table III, we have retained Table
> III (including the example) and Figure 1 in the final rule.
>
> Section 4.77 Visual Fields
>
> Proposed Sec. 4.77(a) stated that to be adequate for VA purposes,
> examinations of visual fields must be conducted using a Goldmann
> kinetic perimeter or equivalent kinetic method, using a standard target
> size and luminance (Goldmann's equivalent (III/4e)). It required that
> at least 16 meridians 221/2 degrees apart be charted for each eye.
> Table III listed the normal extent of the visual fields (in degrees) at
> the 8 principal meridians (45 degrees apart). It also stated that the
> examination must be supplemented by the use of a tangent screen when
> the examiner indicates it is necessary.
> The preamble to the proposed rule also stated that until there are
> reliable standards for comparing the results from static and kinetic
> perimetry, we propose to retain the requirement for the use of Goldmann
> kinetic perimetry, which is more reliable than the alternatives. One
> commenter suggested that VA's disability examination worksheet for the
> eye also specify the use of a Goldmann kinetic perimeter or equivalent
> kinetic examination method.
> After the proposed rule was published, software programs for
> automated perimetry were developed that completely simulate results
> from Goldmann perimetry and can be charted on standard Goldmann charts.
> The Compensation and Pension Service, after consultation with the
> Veterans Health Administration's Chiefs of Ophthalmology and Optometry,
> sent a letter (FL06-21) on November 8, 2006, to the Veterans Benefits
> Administration regional offices stating that Humphrey Model 750,
> Octopus Model 101, and later versions of these perimetric devices with
> simulated kinetic Goldmann testing capability are acceptable devices
> for determining the extent of visual field loss for compensation and
> pension eye rating examinations.
> Therefore, we have changed proposed Sec. 4.77(a) to indicate that
> examiners must assess visual fields using either Goldmann kinetic
> perimetry or automated perimetry using Humphrey Model 750, Octopus
> Model 101, or later versions of these perimetric devices with simulated
> kinetic Goldmann testing capability. We also clarified the directions
> about the Goldmann equivalent that must be used for phakic (normal),
> aphakic, and pseudophakic individuals. The content of the disability
> examination worksheets is beyond the scope of this rulemaking, and we
> make no change based on the comment about the worksheet.
> We proposed to evaluate visual fields by using a Goldmann kinetic
> perimeter or equivalent kinetic method, using a standard target size
> and luminance (Goldmann's equivalent (III/4e)). That Goldmann
> equivalent is useful for evaluating visual fields except in certain
> cases where a larger equivalent size is needed. We have therefore
> clarified the use of Goldmann equivalents in the final rule by revising
> proposed Sec. 4.77(a) to state that, for phakic (normal) individuals,
> as well as for pseudophakic or aphakic individuals who are well adapted
> to intraocular lens implant or contact lens correction, visual field
> examinations must be conducted using a standard target size and
> luminance, which is Goldmann's equivalent III/4e. For aphakic
> individuals not well adapted to contact lens correction or pseudophakic
> individuals not well adapted to intraocular lens implant, visual field
> examinations must be conducted using Goldmann's equivalent IV/4e.
> Proposed Sec. 4.77(a) stated that ``[a]t least two recordings of
> visual fields must be made'' for purposes of VA's disability
> evaluations. We have learned from vision specialists that this is not
> necessary and is not standard procedure, since the visual field outline
> is determined by testing multiple objects along each meridian.
> Therefore, we have removed the language requiring ``two recordings'' as
> unnecessary. In conjunction with this change, we have also removed the
> proposed statement that the confirmed visual fields must be made a part
> of the examination report. Instead, we have stated in Sec. 4.77(a)
> that in all cases, the results of visual field examinations must be
> recorded on a standard Goldmann chart. We additionally require that the
> Goldmann chart be included with the examination report.
> Proposed Sec. 4.77(a) also said that the examination must be
> supplemented by the use of a tangent screen when the examiner indicates
> it is necessary. We have determined that a 30-degree threshold visual
> field with the Goldmann III stimulus size could be used in lieu of a
> tangent screen. This test provides information similar to the tangent
> screen. For this reason, the final rule provides that adjudicators must
> consider either of these two tests when additional testing of visual
> fields becomes necessary, and requires that the examination report
> include either the tracing of the tangent screen or the tracing of the
> 30-degree threshold visual field.
> We made further nonsubstantive revisions to proposed Sec. 4.77(a),
> (b), and (c) to improve clarity.
>
> Section 4.78 Muscle Function
>
> In proposed Sec. 4.78(b)(1), we provided guidance concerning the
> evaluation of diplopia, and proposed that adjudicators assign an
> evaluation for diplopia for only one eye. Further, we proposed that
> where a claimant has both diplopia and decreased visual acuity or a
> visual field defect, the corrected visual acuity for the poorer eye (or
> the affected eye, if only one eye is service-connected) is deemed to
> be, depending on the severity of the diplopia, between one and three
> steps poorer, provided that the adjusted level of corrected visual
> acuity does not exceed 5/200. Using the adjusted visual acuity for the
> poorer eye (or the affected eye) and the corrected visual acuity for
> the better eye, we proposed that the claimant's visual impairment be
> evaluated under diagnostic codes 6064 through 6066.
>
> [[Page 66547]]
>
> Proposed diagnostic code 6064 refers to light perception only (LPO),
> which exceeds a visual acuity level of 5/200. Hence, an evaluation
> under diagnostic code 6064 is not permitted under Sec. 4.78(b).
> Therefore, in Sec. 4.78(b)(1) we have omitted reference to diagnostic
> code 6064.
> We proposed not to retain in Sec. 4.78(b)(1) the rule from former
> Sec. 4.77 (Examination of muscle function) which stated that
> ``[d]iplopia which is only occasional or correctable is not considered
> a disability,'' since it pertains to the issue of service connection
> rather than evaluation. Section 4.78(b)(1) addresses evaluation of
> muscle function rather than service connection. One commenter stated
> that this rule provides useful guidance to adjudicators considering
> claims for service connection for diplopia. In response to this
> comment, and because disease of or injury to one or more extraocular
> eye muscles may cause diplopia which is occasional or correctable,
> rather than including this language in Sec. 4.78(b)(1), we have added
> a note under diagnostic code 6090 (diplopia) stating that in accordance
> with 38 CFR 4.31, diplopia that is occasional or that is correctable
> with spectacles is evaluated at 0 percent. This would clarify how to
> evaluate diplopia with these characteristics.
> In order to remove any doubt about the difference between Sec.
> 4.78(b)(2), which explains how to evaluate diplopia that is present in
> more than one quadrant or range of degrees, and Sec. 4.78(b)(3), which
> explains how to evaluate diplopia that exists in two separate areas of
> the same eye, we have changed the language of Sec. 4.78(b)(2) from
> ``[w]hen diplopia is present in more than one quadrant,'' as proposed,
> to ``[w]hen diplopia extends beyond more than one quadrant''. This is
> similar to the language in the current rating schedule and will ensure
> a clear distinction between these provisions.
> We made nonsubstantive revisions to proposed Sec. 4.78 (a) and (b)
> to improve clarity.
>
> Section 4.79 Schedule of Ratings--Eye
>
> We proposed to evaluate angle-closure glaucoma (diagnostic code
> 6012), which often presents as a red, painful eye, sometimes
> accompanied by nausea and vomiting, either on the basis of visual
> impairment or on the basis of incapacitating episodes, whichever
> results in a higher evaluation. We proposed to evaluate open-angle
> glaucoma (diagnostic code 6013), which generally presents as painless,
> chronic, progressive loss of vision, solely on the basis of visual
> impairment because open-angle glaucoma is unlikely to result in
> incapacitating episodes.
> One commenter questioned why angle-closure glaucoma based on
> incapacitating episodes does not include a 10-percent evaluation for
> incapacitating episodes of at least 1 week, but less than 2 weeks total
> duration per year, when diagnostic codes 6000 through 6009 provide for
> such an evaluation. Under the proposed rule, a minimum evaluation of 10
> percent would be assigned for angle-closure glaucoma if continuous
> medication is required. In our view, virtually all claimants with
> symptomatic angle-closure glaucoma would require continuous medication,
> which would entitle them to a minimum 10-percent evaluation. Therefore,
> we did not propose a 10-percent evaluation based on incapacitating
> episodes. We make no change based upon this comment.
> One commenter suggested that we evaluate both angle-closure and
> open-angle glaucoma on the basis of visual field loss or central visual
> acuity impairment, whichever results in a higher evaluation. Section
> 4.75(a) states that the evaluation of visual impairment is based on
> impairment of visual acuity (excluding developmental errors of
> refraction), visual field, and muscle function. All three elements of
> visual impairment may be present in glaucoma, although visual field
> loss is most common. Not only would the commenter's suggestion limit
> the rating possibilities to two of the three elements of visual
> impairment, it also would not allow for evaluation of angle-closure
> glaucoma based on incapacitating episodes. Section 4.75(b) states that
> eye examinations must be conducted by a licensed optometrist or
> ophthalmologist, and such specialists are unlikely to overlook a visual
> field defect or any other type of visual impairment in an individual
> with glaucoma. In our judgment, allowing evaluation to be based on any
> of the three elements of visual impairment or on incapacitating
> episodes is a fair way to assess glaucoma and to assure that the
> veteran is evaluated based on the disabling effects that provide the
> higher benefit. We have therefore not adopted the commenter's
> suggestion.
> We proposed that certain eye disabilities be evaluated either on
> visual impairment or on incapacitating episodes, whichever results in a
> higher evaluation. We proposed to define an incapacitating episode as a
> period of acute symptoms severe enough to require bed rest and
> treatment by a physician or other healthcare provider.
> One commenter suggested that the rating formula based on
> incapacitating episodes--60 percent if there are incapacitating
> episodes of at least 6 weeks total duration per year, 40 percent if
> there are incapacitating episodes of at least 4 weeks, but less than 6
> weeks, total duration per year, etc.--is miserly because a veteran will
> be compensated only for visual impairment or periods of incapacitation,
> but not both, and with less than bedrest, the veteran receives nothing.
> In most eye diseases, visual impairment will be the major problem
> and therefore the more common basis of evaluation. With modern medical
> and surgical treatment, few patients require bedrest of any duration
> for eye disease. However, an evaluation based on incapacitating
> episodes might be higher in those few cases in which bedrest might be
> required, e.g., angle-closure glaucoma with severe pain, nausea, and
> vomiting. If bedrest is not required, evaluation is based on visual
> impairment. The evaluations based on visual impairment and those based
> on incapacitating episodes are both meant to account for the average
> occupational impairment. Providing alternative criteria allows the
> rater to evaluate using the set of criteria more favorable to the
> veteran.
> The same commenter asked why there is a maximum evaluation of 60
> percent for incapacitating episodes.
> As stated above, with modern medical and surgical treatment, very
> few, if any, veterans will experience incapacitating episodes of more
> than 6 weeks total duration per year due to eye disease. However, for
> any who do, 38 CFR 4.16(a), which provides for a total evaluation based
> on individual unemployability, and 38 CFR 3.321(b)(1), which provides
> for extra-schedular evaluations in cases where an evaluation is
> inadequate because the condition presents such an unusual disability
> picture that applying the regular schedular standards would be
> impractical, provide reasonable alternatives for assigning an
> evaluation greater than 60 percent. In our judgment, the range of
> evaluations we have provided based on incapacitating episodes of eye
> disease will adequately compensate veterans, and a 100-percent
> evaluation level based on incapacitating episodes is not warranted.
> Conditions evaluated on the basis of incapacitating episodes are
> entitled to a 60-percent evaluation when the claimant has experienced
> at least 6 weeks of incapacitating episodes over the preceding 12
> months. One commenter suggested that, in some cases, an adjudicator
> would not be able
>
> [[Page 66548]]
>
> to assign the maximum 60-percent evaluation until after the passage of
> an entire year, and felt that evaluations based upon incapacitating
> episodes should be retroactive to the date of the first incapacitating
> episode, regardless of when it occurred.
> By statute (38 U.S.C. 5110(a)), except as otherwise provided, the
> effective date of an award of compensation will be fixed in accordance
> with the facts but not before the date of receipt of the claim.
> Furthermore, an award of increased compensation will be effective the
> earliest date it is ascertainable that an increase in disability
> occurred if application is received within 1 year of that date. 38
> U.S.C. 5110(b)(2). Otherwise, the effective date is the date the claim
> was received. 38 CFR 3.400(o)(2). We are aware of no special provisions
> that would apply to the evaluation of incapacitating episodes of the
> eye. Under governing law, entitlement to a 60-percent rating would not
> arise until 6 weeks of incapacitating episodes have taken place, and
> the effective date could not be established before then. Once the
> claimant has experienced 6 weeks of incapacitating episodes, the 60-
> percent evaluation will be assigned, even if the evaluation occurs
> within several months of the initial incapacitating episode. In cases
> where it takes the entire 12-month period for a claimant to experience
> 6 weeks of incapacitating episodes, the 60-percent evaluation will be
> assigned at that time. However, during the interim, a rating
> corresponding to the total duration of incapacitating episodes already
> experienced may be assigned. That is to say, once 1 week of
> incapacitating episodes is experienced, a 10-percent rating may be
> assigned; once 2 weeks of incapacitating episodes are experienced, a
> 20-percent rating may be assigned; etc. We make no change based on this
> comment.
> The proposed criteria based on incapacitating episodes referred to
> the total duration of incapacitating episodes ``per year''. To clarify
> that we mean during the preceding 12-month period, and not the calendar
> year, we have changed this language to refer to incapacitating episodes
> ``during the past 12 months''. This language is consistent with other
> provisions in the rating schedule that evaluate incapacitating episodes
> (e.g., diagnostic code 5243, intervertebral disc syndrome, and
> diagnostic code 7354, hepatitis C). We are also adding language to
> indicate that bed rest must be prescribed by a physician to the notes
> following diagnostic codes 6000 through 6009 and diagnostic code 6012
> of the rating schedule. This clarifies VA's intent in the proposed rule
> and makes a nonsubstantive change for clarification purposes.
> One commenter asked for clarification as to whether the absence of
> light perception is to be evaluated as anatomical loss of one eye
> (diagnostic code 6063) or light perception only (diagnostic code 6064).
> Section 4.75(d) states that the evaluation for visual impairment of
> one eye must not exceed 30-percent unless there is anatomical loss of
> the eye. This is clear and straightforward and names no exceptions.
> Therefore, in evaluating visual acuity of one eye, no light perception
> is evaluated the same as light perception only. To avoid confusion, we
> have revised the titles of diagnostic codes 6062 to ``No more than
> light perception in both eyes'' and 6064 to ``No more than light
> perception in one eye.''
> As previously discussed under one of the comments about diplopia,
> we have added a note to diagnostic code 6090 stating that occasional or
> correctable diplopia will be evaluated as 0-percent disabling.
> One commenter asked that we clarify whether the use of an eye patch
> for diplopia warrants special monthly compensation (SMC) (see 38 CFR
> 3.350) for loss or loss of use of an eye. Since the eye is present when
> an eye patch is used for diplopia, SMC for loss of an eye is not
> warranted. Visual impairment due to diplopia is determined without the
> eye patch, and it could be at any level of severity, so SMC for loss of
> use of an eye is also not warranted. The fact that the eye is not being
> used when it is patched does not necessarily mean it cannot be used,
> which would be required for loss of use.
> We use the word ``alternatively'' instead of the proposed
> ``otherwise'' in diagnostic code 6011 for clarity and add ``if this
> would result in a higher evaluation'' for further guidance. We use
> similar language in diagnostic code 6081 for the same purpose. We
> additionally edited the proposed criteria for evaluating malignant
> neoplasms of the eyeball (diagnostic code 6014) for the sake of
> clarity.
> VA appreciates the comments submitted in response to the proposed
> rule. Based on the rationale stated in the proposed rule and in this
> document, the proposed rule is adopted as final with the changes noted.
>
> Unfunded Mandates
>
> The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C.
> 1532, that agencies prepare an assessment of anticipated costs and
> benefits before issuing any rule that may result in the expenditure by
> State, local, and tribal governments, in the aggregate, or by the
> private sector, of $100 million or more (adjusted annually for
> inflation) in any year. This final rule would have no such effect on
> State, local, and tribal governments, or on the private sector.
>
> Paperwork Reduction Act
>
> This document contains no provisions constituting a collection of
> information under the Paperwork Reduction Act (44 U.S.C. 3501-3521).
>
> Executive Order 12866
>
> Executive Order 12866 directs agencies to assess all costs and
> benefits of available regulatory alternatives and, when regulation is
> necessary, to select regulatory approaches that maximize net benefits
> (including potential economic, environmental, public health and safety,
> and other advantages; distributive impacts; and equity). The Executive
> Order classifies a ``significant regulatory action,'' requiring review
> by the Office of Management and Budget (OMB) unless OMB waives such
> review, as any regulatory action that is likely to result in a rule
> that may: (1) Have an annual effect on the economy of $100 million or
> more or adversely affect in a material way the economy, a sector of the
> economy, productivity, competition, jobs, the environment, public
> health or safety, or State, local, or tribal governments or
> communities; (2) create a serious inconsistency or otherwise interfere
> with an action taken or planned by another agency; (3) materially alter
> the budgetary impact of entitlements, grants, user fees, or loan
> programs or the rights and obligations of recipients thereof; or (4)
> raise novel legal or policy issues arising out of legal mandates, the
> President's priorities, or the principles set forth in the Executive
> Order.
> The economic, interagency, budgetary, legal, and policy
> implications of this final rule has been examined, and it has been
> determined to be a significant regulatory action under the Executive
> Order because it is likely to result in a rule that may raise novel
> legal or policy issues arising out of legal mandates, the President's
> priorities, or the principles set forth in the Executive Order.
>
> Regulatory Flexibility Act
>
> The Secretary hereby certifies that this final rule will not have a
> significant economic impact on a substantial number of small entities
> as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-
> 612. This final rule would not affect any small entities. Only VA
> beneficiaries could be directly
>
> [[Page 66549]]
>
> affected. Therefore, pursuant to 5 U.S.C. 605(b), this final rule is
> exempt from the initial and final regulatory flexibility analysis
> requirements of sections 603 and 604.
>
> Catalog of Federal Domestic Assistance Numbers and Titles
>
> The Catalog of Federal Domestic Assistance program numbers and
> titles are 64.104, Pension for Non-Service-Connected Disability for
> Veterans, and 64.109, Veterans Compensation for Service-Connected
> Disability.
>
> List of Subjects in 38 CFR Part 4
>
> Disability benefits, Pensions, Veterans.
>
> Approved: August 6, 2008.
> Gordon H. Mansfield,
> Deputy Secretary of Veterans Affairs.
>
> 0
> For the reasons set out in the preamble, 38 CFR part 4, subpart B, is
> amended as set forth below:
>
> PART 4--SCHEDULE FOR RATING DISABILITIES
>
> 0
> 1. The authority citation for part 4 continues to read as follows:
>
> Authority: 38 U.S.C. 1155, unless otherwise noted.
>
> Subpart B--Disability Ratings
>
> 0
> 2. Section 4.75 is revised to read as follows:
>
>
> Sec. 4.75 General considerations for evaluating visual impairment.
>
> (a) Visual impairment. The evaluation of visual impairment is based
> on impairment of visual acuity (excluding developmental errors of
> refraction), visual field, and muscle function.
> (b) Examination for visual impairment. The examination must be
> conducted by a licensed optometrist or by a licensed ophthalmologist.
> The examiner must identify the disease, injury, or other pathologic
> process responsible for any visual impairment found. Examinations of
> visual fields or muscle function will be conducted only when there is a
> medical indication of disease or injury that may be associated with
> visual field defect or impaired muscle function. Unless medically
> contraindicated, the fundus must be examined with the claimant's pupils
> dilated.
> (c) Service-connected visual impairment of only one eye. Subject to
> the provisions of 38 CFR 3.383(a), if visual impairment of only one eye
> is service-connected, the visual acuity of the other eye will be
> considered to be 20/40 for purposes of evaluating the service-connected
> visual impairment.
> (d) Maximum evaluation for visual impairment of one eye. The
> evaluation for visual impairment of one eye must not exceed 30 percent
> unless there is anatomical loss of the eye. Combine the evaluation for
> visual impairment of one eye with evaluations for other disabilities of
> the same eye that are not based on visual impairment (e.g.,
> disfigurement under diagnostic code 7800).
> (e) Anatomical loss of one eye with inability to wear a prosthesis.
> When the claimant has anatomical loss of one eye and is unable to wear
> a prosthesis, increase the evaluation for visual acuity under
> diagnostic code 6063 by 10 percent, but the maximum evaluation for
> visual impairment of both eyes must not exceed 100 percent. A 10-
> percent increase under this paragraph precludes an evaluation under
> diagnostic code 7800 based on gross distortion or asymmetry of the eye
> but not an evaluation under diagnostic code 7800 based on other
> characteristics of disfigurement.
> (f) Special monthly compensation. When evaluating visual
> impairment, refer to 38 CFR 3.350 to determine whether the claimant may
> be entitled to special monthly compensation. Footnotes in the schedule
> indicate levels of visual impairment that potentially establish
> entitlement to special monthly compensation; however, other levels of
> visual impairment combined with disabilities of other body systems may
> also establish entitlement.
>
> (Authority: 38 U.S.C. 1114 and 1155)
>
>
>
> 0
> 3. Section 4.76 is revised to read as follows:
>
>
> Sec. 4.76 Visual acuity.
>
> (a) Examination of visual acuity. Examination of visual acuity must
> include the central uncorrected and corrected visual acuity for
> distance and near vision using Snellen's test type or its equivalent.
> (b) Evaluation of visual acuity. (1) Evaluate central visual acuity
> on the basis of corrected distance vision with central fixation, even
> if a central scotoma is present. However, when the lens required to
> correct distance vision in the poorer eye differs by more than three
> diopters from the lens required to correct distance vision in the
> better eye (and the difference is not due to congenital or
> developmental refractive error), and either the poorer eye or both eyes
> are service connected, evaluate the visual acuity of the poorer eye
> using either its uncorrected or corrected visual acuity, whichever
> results in better combined visual acuity.
> (2) Provided that he or she customarily wears contact lenses,
> evaluate the visual acuity of any individual affected by a corneal
> disorder that results in severe irregular astigmatism that can be
> improved more by contact lenses than by eyeglass lenses, as corrected
> by contact lenses.
> (3) In any case where the examiner reports that there is a
> difference equal to two or more scheduled steps between near and
> distance corrected vision, with the near vision being worse, the
> examination report must include at least two recordings of near and
> distance corrected vision and an explanation of the reason for the
> difference. In these cases, evaluate based on corrected distance vision
> adjusted to one step poorer than measured.
> (4) To evaluate the impairment of visual acuity where a claimant
> has a reported visual acuity that is between two sequentially listed
> visual acuities, use the visual acuity which permits the higher
> evaluation.
>
> (Authority: 38 U.S.C. 1155)
>
>
>
> 0
> 4. In Sec. 4.76a, remove the introductory text, retain Table III--
> Normal Visual Field Extent at 8 Principal Meridians, retain Figure 1.
> Chart of visual field showing normal field right eye and abnormal
> contraction visual field left eye and the text and table following
> Figure 1, and add an authority citation at the end of the section to
> read as follows.
>
>
> Sec. 4.76a Computation of average concentric contraction of visual
> fields.
>
> * * * * *
>
> (Authority: 38 U.S.C. 1155)
>
>
>
> 0
> 5. Section 4.77 is amended by:
> 0
> a. Revising the section heading.
> 0
> b. Removing the introductory text and adding, in its place, paragraphs
> (a), (b), and (c).
> 0
> c. Retaining Figure 2. Goldmann Perimeter Chart.
> 0
> d. Adding an authority citation at the end of the section.
> The additions read as follows:
>
>
> Sec. 4.77 Visual fields.
>
> (a) Examination of visual fields. Examiners must use either
> Goldmann kinetic perimetry or automated perimetry using Humphrey Model
> 750, Octopus Model 101, or later versions of these perimetric devices
> with simulated kinetic Goldmann testing capability. For phakic (normal)
> individuals, as well as for pseudophakic or aphakic individuals who are
> well adapted to intraocular lens implant or contact lens correction,
> visual field examinations must be conducted using a standard target
> size
>
> [[Page 66550]]
>
> and luminance, which is Goldmann's equivalent III/4e. For aphakic
> individuals not well adapted to contact lens correction or pseudophakic
> individuals not well adapted to intraocular lens implant, visual field
> examinations must be conducted using Goldmann's equivalent IV/4e. In
> all cases, the results must be recorded on a standard Goldmann chart
> (see Figure 1), and the Goldmann chart must be included with the
> examination report. The examiner must chart at least 16 meridians 22\1/
> 2\ degrees apart for each eye and indicate the Goldmann equivalent
> used. See Table III for the normal extent (in degrees) of the visual
> fields at the 8 principal meridians (45 degrees apart). When the
> examiner indicates that additional testing is necessary to evaluate
> visual fields, the additional testing must be conducted using either a
> tangent screen or a 30-degree threshold visual field with the Goldmann
> III stimulus size. The examination report must then include the tracing
> of either the tangent screen or of the 30-degree threshold visual field
> with the Goldmann III stimulus size.
> (b) Evaluation of visual fields. Determine the average concentric
> contraction of the visual field of each eye by measuring the remaining
> visual field (in degrees) at each of eight principal meridians 45
> degrees apart, adding them, and dividing the sum by eight.
> (c) Combination of visual field defect and decreased visual acuity.
> To determine the evaluation for visual impairment when both decreased
> visual acuity and visual field defect are present in one or both eyes
> and are service connected, separately evaluate the visual acuity and
> visual field defect (expressed as a level of visual acuity), and
> combine them under the provisions of Sec. 4.25.
> * * * * *
>
> (Authority: 38 U.S.C. 1155)
>
>
>
> 0
> 6. Section 4.78 is revised to read as follows:
>
>
> Sec. 4.78 Muscle function.
>
> (a) Examination of muscle function. The examiner must use a
> Goldmann perimeter chart that identifies the four major quadrants
> (upward, downward, left and right lateral) and the central field (20
> degrees or less) (see Figure 2). The examiner must chart the areas of
> diplopia and include the plotted chart with the examination report.
> (b) Evaluation of muscle function. (1) An evaluation for diplopia
> will be assigned to only one eye. When a claimant has both diplopia and
> decreased visual acuity or visual field defect, assign a level of
> corrected visual acuity for the poorer eye (or the affected eye, if
> disability of only one eye is service-connected) that is: one step
> poorer than it would otherwise warrant if the evaluation for diplopia
> under diagnostic code 6090 is 20/70 or 20/100; two steps poorer if the
> evaluation under diagnostic code 6090 is 20/200 or 15/200; or three
> steps poorer if the evaluation under diagnostic code 6090 is 5/200.
> This adjusted level of corrected visual acuity, however, must not
> exceed a level of 5/200. Use the adjusted visual acuity for the poorer
> eye (or the affected eye, if disability of only one eye is service-
> connected), and the corrected visual acuity for the better eye (or
> visual acuity of 20/40 for the other eye, if only one eye is service-
> connected) to determine the percentage evaluation for visual impairment
> under diagnostic codes 6065 through 6066.
> (2) When diplopia extends beyond more than one quadrant or range of
> degrees, evaluate diplopia based on the quadrant and degree range that
> provides the highest evaluation.
> (3) When diplopia exists in two separate areas of the same eye,
> increase the equivalent visual acuity under diagnostic code 6090 to the
> next poorer level of visual acuity, not to exceed 5/200.
>
> (Authority: 38 U.S.C. 1155)
>
>
>
> 0
> 7. Section 4.79 is revised to read as follows:
>
>
> Sec. 4.79 Schedule of ratings--eye.
>
> Diseases of the Eye
> ------------------------------------------------------------------------
> Rating
> ------------------------------------------------------------------------
> 6000 Choroidopathy, including uveitis, iritis, cyclitis, and
> choroiditis.
> 6001 Keratopathy.
> 6002 Scleritis.
> 6006 Retinopathy or maculopathy.
> 6007 Intraocular hemorrhage.
> 6008 Detachment of retina.
> 6009 Unhealed eye injury.
> ------------------------------------------------------------------------
> General Rating Formula for Diagnostic Codes 6000 through 6009
> ------------------------------------------------------------------------
> Evaluate on the basis of either visual impairment due to
> the particular condition or on incapacitating episodes,
> whichever results in a higher evaluation.
> With incapacitating episodes having a total duration of 60
> at least 6 weeks during the past 12 months..............
> With incapacitating episodes having a total duration of 40
> at least 4 weeks, but less than 6 weeks, during the past
> 12 months...............................................
> With incapacitating episodes having a total duration of 20
> at least 2 weeks, but less than 4 weeks, during the past
> 12 months...............................................
> With incapacitating episodes having a total duration of 10
> at least 1 week, but less than 2 weeks, during the past
> 12 months...............................................
> Note: For VA purposes, an incapacitating episode is a period
> of acute symptoms severe enough to require prescribed bed
> rest and treatment by a physician or other healthcare
> provider.
> 6010 Tuberculosis of eye:
> Active................................................... 100
> Inactive: Evaluate under Sec. 4.88c or Sec. 4.89 of
> this part, whichever is appropriate.
> 6011 Retinal scars, atrophy, or irregularities:
> Localized scars, atrophy, or irregularities of the 10
> retina, unilateral or bilateral, that are centrally
> located and that result in an irregular, duplicated,
> enlarged, or diminished image...........................
> Alternatively, evaluate based on visual impairment due to
> retinal scars, atrophy, or irregularities, if this would
> result in a higher evaluation.
> 6012 Angle-closure glaucoma:
> Evaluate on the basis of either visual impairment due to
> angle-closure glaucoma or incapacitating episodes,
> whichever results in a higher evaluation.
> With incapacitating episodes having a total duration of 60
> at least 6 weeks during the past 12 months..............
>
> [[Page 66551]]
>
>
> With incapacitating episodes having a total duration of 40
> at least 4 weeks, but less than 6 weeks, during the past
> 12 months...............................................
> With incapacitating episodes having a total duration of 20
> at least 2 weeks, but less than 4 weeks, during the past
> 12 months...............................................
> Minimum evaluation if continuous medication is required.. 10
> Note: For VA purposes, an incapacitating episode is a period
> of acute symptoms severe enough to require prescribed bed
> rest and treatment by a physician or other healthcare
> provider.
> 6013 Open-angle glaucoma:
> Evaluate based on visual impairment due to open-angle
> glaucoma.
> Minimum evaluation if continuous medication is required.. 10
> 6014 Malignant neoplasms (eyeball only):
> Malignant neoplasm of the eyeball that requires therapy 100
> that is comparable to that used for systemic
> malignancies, i.e., systemic chemotherapy, X-ray therapy
> more extensive than to the area of the eye, or surgery
> more extensive than enucleation.........................
> Note: Continue the 100-percent rating beyond the cessation of
> any surgical, X-ray, antineoplastic chemotherapy or other
> therapeutic procedure. Six months after discontinuance of
> such treatment, the appropriate disability rating will be
> determined by mandatory VA examination. Any change in
> evaluation based upon that or any subsequent examination
> will be subject to the provisions of Sec. 3.105(e) of this
> chapter. If there has been no local recurrence or
> metastasis, evaluate based on residuals.
> Malignant neoplasm of the eyeball that does not require
> therapy comparable to that for systemic malignancies:
> Separately evaluate visual impairment and nonvisual
> impairment, e.g., disfigurement (diagnostic code 7800),
> and combine the evaluations.
> 6015 Benign neoplasms (of eyeball and adnexa):
> Separately evaluate visual impairment and nonvisual
> impairment, e.g., disfigurement (diagnostic code 7800),
> and combine the evaluations.
> 6016 Nystagmus, central...................................... 10
> 6017 Trachomatous conjunctivitis:
> Active: Evaluate based on visual impairment, minimum..... 30
> Inactive: Evaluate based on residuals, such as visual
> impairment and disfigurement (diagnostic code 7800).
> 6018 Chronic conjunctivitis (nontrachomatous):
> Active (with objective findings, such as red, thick 10
> conjunctivae, mucous secretion, etc.)...................
> Inactive: Evaluate based on residuals, such as visual
> impairment and disfigurement (diagnostic code 7800).
> 6019 Ptosis, unilateral or bilateral:
> Evaluate based on visual impairment or, in the absence of
> visual impairment, on disfigurement (diagnostic code
> 7800).
> 6020 Ectropion:
> Bilateral................................................ 20
> Unilateral............................................... 10
> 6021 Entropion:
> Bilateral................................................ 20
> Unilateral............................................... 10
> 6022 Lagophthalmos:
> Bilateral................................................ 20
> Unilateral............................................... 10
> 6023 Loss of eyebrows, complete, unilateral or bilateral..... 10
> 6024 Loss of eyelashes, complete, unilateral or bilateral.... 10
> 6025 Disorders of the lacrimal apparatus (epiphora,
> dacryocystitis, etc.):
> Bilateral................................................ 20
> Unilateral............................................... 10
> 6026 Optic neuropathy:
> Evaluate based on visual impairment.
> 6027 Cataract of any type:
> Preoperative:
> Evaluate based on visual impairment.
> Postoperative:
> If a replacement lens is present (pseudophakia), evaluate
> based on visual impairment. If there is no replacement
> lens, evaluate based on aphakia.
> 6029 Aphakia or dislocation of crystalline lens:
> Evaluate based on visual impairment, and elevate the
> resulting level of visual impairment one step.
> Minimum (unilateral or bilateral)........................ 30
> 6030 Paralysis of accommodation (due to neuropathy of the 20
> Oculomotor Nerve (cranial nerve III)).
> 6032 Loss of eyelids, partial or complete:
> Separately evaluate both visual impairment due to eyelid
> loss and nonvisual impairment, e.g., disfigurement
> (diagnostic code 7800), and combine the evaluations.
> 6034 Pterygium:
> Evaluate based on visual impairment, disfigurement
> (diagnostic code 7800), conjunctivitis (diagnostic code
> 6018), etc., depending on the particular findings.
> 6035 Keratoconus:
> Evaluate based on impairment of visual acuity.
> 6036 Status post corneal transplant:
> Evaluate based on visual impairment.
> Minimum, if there is pain, photophobia, and glare 10
> sensitivity.............................................
> 6037 Pinguecula:
> Evaluate based on disfigurement (diagnostic code 7800).
> ------------------------------------------------------------------------
>
> [[Page 66552]]
>
>
> Impairment of Central Visual Acuity
> ------------------------------------------------------------------------
> 6061 Anatomical loss of both eyes \1\........................ 100
> 6062 No more than light perception in both eyes \1\.......... 100
> 6063 Anatomical loss of one eye: \1\
> In the other eye 5/200 (1.5/60).......................... 100
> In the other eye 10/200 (3/60)........................... 90
> In the other eye 15/200 (4.5/60)......................... 80
> In the other eye 20/200 (6/60)........................... 70
> In the other eye 20/100 (6/30)........................... 60
> In the other eye 20/70 (6/21)............................ 60
> In the other eye 20/50 (6/15)............................ 50
> In the other eye 20/40 (6/12)............................ 40
> 6064 No more than light perception in one eye: \1\
> In the other eye 5/200 (1.5/60).......................... 100
> In the other eye 10/200 (3/60)........................... 90
> In the other eye 15/200 (4.5/60)......................... 80
> In the other eye 20/200 (6/60)........................... 70
> In the other eye 20/100 (6/30)........................... 60
> In the other eye 20/70 (6/21)............................ 50
> In the other eye 20/50 (6/15)............................ 40
> In the other eye 20/40 (6/12)............................ 30
> 6065 Vision in one eye 5/200 (1.5/60):
> In the other eye 5/200 (1.5/60).......................... \1\100
> In the other eye 10/200 (3/60)........................... 90
> In the other eye 15/200 (4.5/60)......................... 80
> In the other eye 20/200 (6/60)........................... 70
> In the other eye 20/100 (6/30)........................... 60
> In the other eye 20/70 (6/21)............................ 50
> In the other eye 20/50 (6/15)............................ 40
> In the other eye 20/40 (6/12)............................ 30
> 6066 Visual acuity in one eye 10/200 (3/60) or better:
> Vision in one eye 10/200 (3/60):
> In the other eye 10/200 (3/60)........................... 90
> In the other eye 15/200 (4.5/60)......................... 80
> In the other eye 20/200 (6/60)........................... 70
> In the other eye 20/100 (6/30)........................... 60
> In the other eye 20/70 (6/21)............................ 50
> In the other eye 20/50 (6/15)............................ 40
> In the other eye 20/40 (6/12)............................ 30
> Vision in one eye 15/200 (4.5/60):
> In the other eye 15/200 (4.5/60)......................... 80
> In the other eye 20/200 (6/60)........................... 70
> In the other eye 20/100 (6/30)........................... 60
> In the other eye 20/70 (6/21)............................ 40
> In the other eye 20/50 (6/15)............................ 30
> In the other eye 20/40 (6/12)............................ 20
> Vision in one eye 20/200 (6/60):
> In the other eye 20/200 (6/60)........................... 70
> In the other eye 20/100 (6/30)........................... 60
> In the other eye 20/70 (6/21)............................ 40
> In the other eye 20/50 (6/15)............................ 30
> In the other eye 20/40 (6/12)............................ 20
> Vision in one eye 20/100 (6/30):
> In the other eye 20/100 (6/30)........................... 50
> In the other eye 20/70 (6/21)............................ 30
> In the other eye 20/50 (6/15)............................ 20
> In the other eye 20/40 (6/12)............................ 10
> Vision in one eye 20/70 (6/21):
> In the other eye 20/70 (6/21)............................ 30
> In the other eye 20/50 (6/15)............................ 20
> In the other eye 20/40 (6/12)............................ 10
> Vision in one eye 20/50 (6/15):
> In the other eye 20/50 (6/15)............................ 10
> In the other eye 20/40 (6/12)............................ 10
> Vision in one eye 20/40 (6/12):
> In the other eye 20/40 (6/12)............................ 0
> ------------------------------------------------------------------------
> \1\ Review for entitlement to special monthly compensation under 38 CFR
> 3.350.
>
>
> [[Page 66553]]
>
>
> Ratings for Impairment of Visual Fields
> ------------------------------------------------------------------------
> Rating
> ------------------------------------------------------------------------
> 6080 Visual field defects:
> Homonymous hemianopsia................................... 30
> Loss of temporal half of visual field:
> Bilateral................................................ 30
> Unilateral............................................... 10
> Or evaluate each affected eye as 20/70 (6/21)............
> Loss of nasal half of visual field:
> Bilateral................................................ 10
> Unilateral............................................... 10
> Or evaluate each affected eye as 20/50 (6/15)............
> Loss of inferior half of visual field:
> Bilateral................................................ 30
> Unilateral............................................... 10
> Or evaluate each affected eye as 20/70 (6/21)............
> Loss of superior half of visual field:
> Bilateral................................................ 10
> Unilateral............................................... 10
> Or evaluate each affected eye as 20/50 (6/15)............
> Concentric contraction of visual field:
> With remaining field of 5 degrees: \1\
> Bilateral................................................ 100
> Unilateral............................................... 30
> Or evaluate each affected eye as 5/200 (1.5/60)..........
> With remaining field of 6 to 15 degrees:
> Bilateral................................................ 70
> Unilateral............................................... 20
> Or evaluate each affected eye as 20/200 (6/60)...........
> With remaining field of 16 to 30 degrees:
> Bilateral................................................ 50
> Unilateral............................................... 10
> Or evaluate each affected eye as 20/100 (6/30)...........
> With remaining field of 31 to 45 degrees:
> Bilateral................................................ 30
> Unilateral............................................... 10
> Or evaluate each affected eye as 20/70 (6/21)............
> With remaining field of 46 to 60 degrees:
> Bilateral................................................ 10
> Unilateral............................................... 10
> Or evaluate each affected eye as 20/50 (6/15)............
> 6081 Scotoma, unilateral:
> Minimum, with scotoma affecting at least one-quarter of 10
> the visual field (quadrantanopsia) or with centrally
> located scotoma of any size.............................
> Alternatively, evaluate based on visual impairment due to
> scotoma, if that would result in a higher evaluation....
> ------------------------------------------------------------------------
> \1\ Review for entitlement to special monthly compensation under 38 CFR
> 3.350.
>
>
> Ratings for Impairment of Muscle Function
> ------------------------------------------------------------------------
> Equivalent
> Degree of diplopia visual acuity
> ------------------------------------------------------------------------
> 6090 Diplopia (double vision):
> (a) Central 20 degrees........................... 5/200 (1.5/60)
> (b) 21 degrees to 30 degrees
> (1) Down..................................... 15/200 (4.5/60)
> (2) Lateral.................................. 20/100 (6/30)
> (3) Up....................................... 20/70 (6/21)
> (c) 31 degrees to 40 degrees
> (1) Down..................................... 20/200 (6/60)
> (2) Lateral.................................. 20/70 (6/21)
> (3) Up....................................... 20/40 (6/12)
> Note: In accordance with 38 CFR 4.31, diplopia that
> is occasional or that is correctable with spectacles
> is evaluated at 0 percent.
> 6091 Symblepharon:
> Evaluate based on visual impairment,
> lagophthalmos (diagnostic code 6022),
> disfigurement (diagnostic code 7800), etc.,
> depending on the particular findings.
> ------------------------------------------------------------------------
>
>
> [[Page 66554]]
>
>
> (Authority: 38 U.S.C. 1155)
>
>
> Sec. Sec. 4.80, 4.83, and 4.84 [Removed and Reserved]
>
> 0
> 8. Sections 4.80, 4.83, and 4.84 are removed and reserved.
>
>
> Sec. Sec. 4.83a and 4.84a [Removed]
>
> 0
> 9. Sections 4.83a and 4.84a are removed.
>
> [FR Doc. E8-26304 Filed 11-7-08; 8:45 am]
>
> BILLING CODE 8320-01-P
>
>
>
>
>
>
>
> ____________________________________
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