[Federal Register Volume 64, Number 90 (Tuesday, May 11, 1999)]
[Proposed Rules]
[Pages 25246-25258]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-11771]


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DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AH43


Schedule for Rating Disabilities; Eye

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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SUMMARY: The Department of Veterans Affairs (VA) is proposing to amend 
that portion of its rating schedule that addresses the eye. The 
intended effect of this action is to ensure that this section of the 
Schedule for Rating Disabilities uses current medical terminology and 
provides unambiguous criteria for evaluating disabilities of the eye.

DATES: Comments must be received on or before July 12, 1999.

ADDRESSES: Mail or hand-deliver written comments to: Director, Office 
of Regulations Management (02D), Department of Veterans Affairs, 810 
Vermont Ave., NW, Room 1154, Washington, DC 20420. Comments should 
indicate that they are in response to ``RIN 2900-AH43.'' All written 
comments received will be available for public inspection at the above 
address in the Office of Regulations Management, Room 1158, between the 
hours of 8:00 a.m. and 4:30 p.m., Monday through Friday (except 
holidays).

FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant, 
Regulations Staff (211B), Compensation and Pension Service, Veterans 
Benefits Administration, Department of Veterans Affairs, 810 Vermont 
Ave., NW, Washington, DC, 20420, (202) 273-7230.

SUPPLEMENTARY INFORMATION: As part of a comprehensive review of its 
rating schedule, VA published an advance notice of proposed rulemaking 
regarding impairments of the eye, ear and other sense organs in the 
Federal Register on May 2, 1991 (56 FR 20170). In response, we received 
a number of comments from private and VA physicians and from other VA 
employees. For the reasons discussed below, this document proposes to 
amend the portion of the rating schedule that addresses disabilities of 
the eye.
    The comments received included suggestions that we delete several 
diagnostic codes, provide diagnostic codes for additional conditions, 
and change evaluation criteria for a number of conditions. We have 
considered these comments as explained below.
    In addition to publishing an advance notice of proposed rulemaking, 
we also contracted with an outside consultant to recommend changes to 
ensure that the schedule uses current medical terminology and 
unambiguous criteria, and that it reflects medical advances that have 
occurred since the last review. The consultant convened a panel of non-
VA specialists to review the portion of the rating schedule that 
addresses eye conditions in order to formulate recommendations. We are 
proposing to adopt many of the recommendations the contract consultants 
submitted. However, we do not propose to adopt recommendations that 
address areas, such as frequency of examinations, that are clearly 
beyond the scope of the contract or that deal with issues that affect 
the internal consistency of the rating schedule, such as percentage 
evaluations. Assignments of disability

[[Page 25247]]

ratings are supposed to reflect relative levels of economic impairment, 
and the consultants did not consider eye disabilities in relation to 
the other parts of the rating schedule in making their recommendations. 
Relevant recommendations from these individuals are discussed below.
    We determined that a number of grammatical changes would be helpful 
in eliminating ambiguity and ensuring that the schedule presents the 
rating criteria for listed disabilities as precisely as possible. We 
are thus proposing editorial changes, primarily in syntax and 
punctuation, throughout this portion of the schedule. These changes, 
which will not be addressed individually, are intended to clarify the 
rating criteria and represent no substantive amendment.
    For VA purposes, the evaluation of visual impairment is based on 
impairment of visual acuity, visual field, and muscle function. General 
instructions for rating these disabilities are currently contained in 
Secs. 4.75 through 4.84a of 38 CFR, and in notes appended to various 
diagnostic codes. The material is randomly organized, however, and we 
propose to reorganize it so that all material related to a single issue 
is grouped together. We propose to reorganize these instructions under 
four topics: (1) General considerations for evaluating visual 
impairment; (2) Visual acuity; (3) Visual fields; and (4) Muscle 
function.
    We propose that Sec. 4.75, ``General considerations for evaluating 
visual impairment,'' be composed of six paragraphs: (a) Visual 
impairment, (b) Examination for visual impairment, (c) Service-
connected visual impairment of only one eye, (d) Maximum evaluation for 
visual impairment of one eye, (e) Anatomical loss of one eye without 
prosthesis, and (f) Special monthly compensation.
    For the sake of clarity, we propose that paragraph (a), ``Visual 
impairment,'' state that the evaluation of visual impairment is based 
on impairment of visual acuity (excluding developmental errors of 
refraction), visual field, and muscle function.
    Proposed paragraph (b) of Sec. 4.75, ``Examination for visual 
impairment,'' is derived from current Secs. 4.75 and 4.77 and the notes 
following diagnostic code 6080 and would require that a licensed 
optometrist or ophthalmologist conduct the examination and that the 
examiner identify the disease, injury, or other pathologic process 
responsible for any visual impairment found. It also states that 
examinations for the evaluation 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. It also states that the fundus must be examined with 
the veteran's pupils dilated (unless medically contraindicated).
    The method of evaluation when visual impairment of only one eye is 
service-connected is not specifically addressed in current regulations. 
We propose to add paragraph (c), ``Service-connected visual impairment 
of only one eye,'' to direct that when visual impairment of only one 
eye is service-connected, either directly or by aggravation, the visual 
acuity of the non-service-connected eye shall be considered to be 20/
40, subject to the provisions of 38 CFR 3.383(a) (which 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 non-service-
connected disability, compensation is payable as if both were service-
connected). This method is consistent with current VA practice in 
determining the level of disability when only one eye is service-
connected. The approach is also consistent with VAOPGCPREC 32-97, in 
which the General Counsel held that, if a claimant has service-
connected hearing loss in one ear and nonservice-connected hearing loss 
in the other ear, the hearing in the ear having nonservice-connected 
loss should be considered normal for purposes of computing the service-
connected disability rating, unless the claimant is totally deaf in 
both ears. In VAOPGCPREC 32-97, the General Counsel noted that the 
statutory scheme governing VA benefits generally authorizes 
compensation for service-connected disabilities only, see 38 U.S.C. 101 
(13), 1110, and 1131, and does not permit combination of ratings for 
service-connected and nonservice-connected disabilities for 
compensation purposes. See 38 U.S.C. 1523 (authorizing, for nonservice-
connected pension purposes, combination of ratings for service-
connected and nonservice-connected disabilities) and 1157 (authorizing 
compensation based on the combination of ratings for service-connected 
disabilities). See also 38 CFR 3.323; 38 CFR 4.14 (``the use of 
manifestations not resulting from service-connected disease or injury 
in establishing the service-connected evaluation * * * [is] to be 
avoided.''). Therefore, we propose to consider the visual acuity of the 
nonservice-connected eye to be 20/40, the level of visual acuity that 
warrants a zero-percent evaluation, so that any loss of visual acuity 
in the non-service-connected eye will not affect the determination of 
the level of disability for the service-connected eye. Adding the 
provisions of paragraph (c) will remove any doubt about the correct 
method of evaluation, and will assure that evaluations will be 
consistent, in cases where visual impairment of only one eye is 
service-connected.
    In conjunction with the addition of paragraph (c) of Sec. 4.75, we 
propose to remove current Sec. 4.78, ``Computing aggravation,'' which 
states that aggravation of preexisting visual disability will be 
determined based upon the evaluation of vision in both eyes before and 
after suffering the aggravation, even if the impairment of vision in 
only one eye is service-connected, and that with subsequent increase in 
the disability of either eye due to intercurrent injury or disease not 
associated with service, the basis of compensation will be the 
condition of the eyes before suffering the subsequent increase. This 
section is not consistent with VA's method of evaluating visual 
impairment incurred in service in one eye only nor is it consistent 
with the statutory scheme, as discussed above. Furthermore, 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, and this is simply not equitable. This method 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 non-service-connected hand, again 
subject to the provisions of 38 CFR 3.383(a), and where the same method 
is used for incurrence as for aggravation. For these reasons, we 
propose to remove the material in Sec. 4.78 in favor of the clear and 
consistent method of evaluation described in paragraph (c).
    Proposed paragraph (d) of Sec. 4.75, ``Maximum evaluation for 
visual impairment of one eye,'' is derived from current Sec. 4.80, 
``Rating of one eye,'' which states that the combined ratings for 
disabilities of the same eye should not exceed the amount for total 
loss of vision of that eye unless there is enucleation or a serious 
cosmetic defect added to the total loss of vision. Some of this 
language--``disabilities of the same eye,'' ``total loss of vision,'' 
and ``serious cosmetic defect''--is subjective or ambiguous. Since some 
disabilities (e.g., malignant neoplasm) that may affect only one eye 
can be evaluated up to 100 percent, we propose to change the reference 
to ``disabilities'' of one eye to ``visual impairment'' of one eye to 
clarify that it is only an evaluation for

[[Page 25248]]

visual impairment that is limited to 30 percent. In place of ``shall 
not exceed the maximum,'' we propose to use the more direct language 
``shall not exceed 30 percent,'' in order to remove any ambiguity. Only 
anatomical loss of an eye can result in a higher evaluation (under 
diagnostic code 6063). We further propose to change ``serious cosmetic 
defect'' to ``disfigurement,'' because a proposed diagnostic code 
(7800) and evaluation criteria for disfigurement of the head, face, or 
neck were published in the Federal Register of January 19, 1993 (See 58 
FR 4969) as part of the revision of the portion of the rating schedule 
that addresses the skin, but there is no diagnostic code that addresses 
``serious cosmetic defect.'' Section 4.75(d) is therefore proposed to 
read ``The evaluation for visual impairment of one eye shall not exceed 
30 percent unless there is anatomical loss of the eye. The evaluation 
for visual impairment of one eye may, however, be combined with 
evaluations for other disabilities, e.g., disfigurement, that are not 
based on visual impairment.''
    We propose that paragraph (e) of Sec. 4.75, ``Anatomical loss of 
one eye with inability to wear a prosthesis,'' require that evaluations 
be increased by 10 percent when there is anatomical loss of one eye, 
and a prosthesis cannot be worn. This is derived from material in a 
footnote to diagnostic codes 6064, 6065, and 6066 concerning the 
evaluation for anatomical loss of one eye, and we therefore propose to 
delete that portion of the footnote as redundant. We further propose to 
add for clarity a statement that the maximum evaluation shall not 
exceed 100 percent.
    We propose that paragraph (f) of Sec. 4.75, ``Special monthly 
compensation,'' direct the rating agency to refer to 38 CFR 3.350 to 
determine whether the veteran may be entitled to special monthly 
compensation (SMC). This is similar to instructions we have placed in 
other revised portions of the rating schedule where there is potential 
entitlement to special monthly compensation, e.g., in the portion that 
addresses gynecological conditions and disorders of the breasts. This 
is intended as an additional reminder to the rating agency to assure 
that SMC is assigned when warranted.
    We propose that Secs. 4.76, 4.77, and 4.78 address impairment of 
visual acuity, visual fields, and muscle function, respectively, with 
each section containing subsections that address examinations and 
evaluations of the impairments, as discussed in more detail below.
    We propose that Sec. 4.76, ``Visual acuity,'' derived from material 
currently found in Secs. 4.75 and 4.84, plus M21-1, Part VI, consist of 
two paragraphs: (a) Examination of visual acuity and (b) Evaluation of 
visual acuity.
    We propose that paragraph (a) of Sec. 4.76, which is based on 
current Sec. 4.75, require that, to be adequate for VA purposes, 
uncorrected and corrected visual acuity for distance and near be 
recorded, as determined using Snellen's test type or its equivalent.
    We propose two subparagraphs under proposed paragraph (b) of 
Sec. 4.76, ``Evaluation of visual acuity.'' Subparagraph (1) would 
require that visual acuity be generally evaluated on the basis of 
corrected distance vision. 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 a congenital/developmental refractive 
error, the visual acuity of the poorer eye for evaluation purposes 
shall be 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 the better combined visual acuity. The current schedule has similar 
provisions but uses a four-diopter, rather than a three-diopter, 
difference, and refers only to spherical correction. We propose to use 
three diopters of difference instead of four because our contract 
consultants suggested that, since three diopters of difference would 
cause a patient to be symptomatic, requiring a four-diopter difference 
is too stringent. The consultants further pointed out that the 
astigmatism that underlies this disorder may require cylindrical, as 
well as spherical, correction, and we therefore propose to delete the 
language referring to spherical correction.
    Paragraph (b)(2) of Sec. 4.76 would direct that, as long as the 
individual customarily wears contact lenses, VA evaluate visual acuity 
for eyes 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. The current 
Sec. 4.75 states that the best distant vision obtainable after best 
correction by glasses shall be the basis of rating except in cases of 
keratoconus in which contact lenses are medically required. However, on 
the recommendation of our contract consultants, we propose to include 
corneal disorders other than keratoconus, if they also result in 
astigmatism where contact lenses are more useful for correction than 
eyeglasses. We propose to remove the requirement that contact lenses be 
``medically required'' in order to use this method of evaluation, in 
favor of a requirement that it be used only if contact lenses improve 
visual acuity better than eyeglass lenses, and if the individual 
customarily wears contact lenses (because some patients cannot wear 
contact lenses even though they would improve their vision). This 
provision assures an accurate assessment of corrected vision for those 
with a cornea that is scarred or irregularly shaped, and in whom 
individually fitted contact lenses provide the best visual acuity.
    Paragraph (b)(3) of Sec. 4.76 would require that in cases where the 
examiner reports a difference equal to two or more scheduled steps 
between near and distance corrected vision, with the near vision being 
worse, the examination must include at least two recordings of near and 
distance corrected vision and an explanation of the reason for the 
difference. We propose to require two recordings of visual acuity and 
an explanation of the cause of the difference between near and distance 
vision to assure that the presence of such a difference, which is very 
unusual, is confirmed and that any pathologic condition responsible for 
the difference is diagnosed. Current Sec. 4.84 states that when there 
is a substantial difference between the near and distant corrected 
vision, the case should be referred to the Director, Compensation and 
Pension Service. We propose to specify a difference of two or more 
scheduled steps because our medical consultants stated that amount 
would be considered a ``substantial'' difference, and this more 
objective standard will assure consistency in determining which cases 
require application of this special provision. Evaluations of visual 
acuity are ordinarily based on distance vision, and distance vision is 
normally very similar, if not identical, to near vision. Since that is 
not true of these cases, and because near vision is so important for 
many tasks, we propose to adjust the evaluation for distance vision in 
these cases. In order to assure consistent and fair evaluations in 
these cases without the need to refer them to the Director of the 
Compensation and Pension Service, we propose, after consultation with 
licensed optometrists and ophthalmologists, that evaluation be made as 
if distance vision were one step poorer than measured, which, while 
recognizing that distance vision is the principal basis of the 
evaluation of visual acuity, will approximately

[[Page 25249]]

compensate for the additional loss of near vision in these cases.
    We propose that Sec. 4.77, ``Visual Fields,'' be composed of three 
paragraphs: (a) Examination of visual fields, (b) Evaluation of visual 
fields, and (c) Combination of visual field defect and decreased visual 
acuity.
    Paragraph (a) of Sec. 4.77, ``Examination of visual fields,'' 
derived from current Sec. 4.76, Examination of field vision, would 
require use of a Goldmann kinetic perimeter or equivalent kinetic 
method to measure visual fields. We propose to revise the language, for 
the sake of accuracy, by changing the requirement for using a 3mm. 
white test object to one for using a standard target size and luminance 
(Goldmann equivalent (III/4e). This equivalent is a test object with an 
area of 4mm\2\, average diameter of 0.43 degrees visual angle, and zero 
decibels of attenuation of luminance (maximum brightness for the 
Goldmann perimeter). Although the static (automated, computerized) 
perimeter is now in common use, the visual fields measured by the 
static and kinetic methods are not always comparable, and standards 
remain uncertain, despite ongoing research on this subject. 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.
    Paragraph (b) of Sec. 4.77, ``Evaluation of visual fields,'' 
derived from current Sec. 4.76a, ``Computation of average concentric 
contraction of visual fields,'' would establish the method for 
determining the extent of concentric visual field defect by measuring 
the remaining visual field in the eight principal meridians 
(horizontal, vertical, and main diagonals) and averaging them. We 
propose to remove the example in current Sec. 4.76a since, in our 
judgment, it is unnecessary. We propose to delete the statement from 
Sec. 4.76 that concentric contraction to five degrees or less is the 
equivalent of 5/200 visual acuity because this information is included 
under diagnostic code 6080 (visual field defects) and there is no need, 
nor would it serve any useful purpose, to repeat it in Sec. 4.76.
    We propose that paragraph (c) of Sec. 4.77, ``Combination of visual 
field defect and decreased visual acuity,'' direct how to determine the 
evaluation when both visual acuity and visual field are impaired in one 
or both eyes. VA's Adjudication Manual, M21-1, Part VI, currently 
directs that such cases be referred to the Director of the Compensation 
and Pension Service for evaluation. We propose that the percentage 
evaluation for visual acuity and for visual field loss each be 
determined and then combined under 38 CFR 4.25 (Combined ratings 
table). This change is consistent with the method of combining 
disabilities elsewhere in the body, which is allowed as long as the 
same disability is not evaluated twice, and would eliminate the need to 
refer these cases to the Director of the Compensation and Pension 
Service. It would provide a fair and consistent method of evaluation 
that takes into account both facets of visual impairment.
    We propose that Sec. 4.78, ``Muscle function,'' be composed of two 
paragraphs: (a) Examination of muscle function, and (b) Evaluation of 
muscle function.
    Paragraph (a) of Sec. 4.78, ``Examination of muscle function,'' 
derived from current Sec. 4.77, would require that the Goldmann 
perimeter be used to measure muscle function and that the areas of 
diplopia be charted. We propose to delete as unnecessary the statement 
that impairment of muscle function is to be supported by record of 
actual appropriate pathology because Sec. 4.75(b) includes a 
requirement that the disease, injury, or other pathologic process 
responsible for any visual impairment found must be identified and that 
examinations for the evaluation 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. Section 4.75(b) is sufficient, in our judgment, to 
assure that the underlying pathology is identified.
    Paragraph (b) of Sec. 4.78, ``Evaluation of muscle function,'' 
would establish a revised method of evaluating muscle function when 
another type of visual impairment is also present. Current note (2) 
following diagnostic code 6090 states that an evaluation for diplopia 
will be applied to only one eye and may not be combined with an 
evaluation for decreased visual acuity or visual field loss in the same 
eye. It further states that when both diplopia and decreased visual 
acuity or visual field loss are present in both eyes, the evaluation 
for diplopia shall be assigned to the poorer eye, and the evaluation 
for either corrected visual acuity or contraction of visual field to 
the better eye. It does not address the situation where diplopia is 
present, and another type of visual impairment is present in only one 
eye. Under the current method, lower evaluations may result when the 
diplopia is taken into account in the evaluation than when it is not, 
unless the diplopia is very severe. VA's manual for adjudication 
procedures, M21-1, states that this method is to be used only if it 
would be advantageous to the veteran.
    For the sake of equitable and fair evaluations, we propose, after 
consultation with licensed optometrists and ophthalmologists, that 
subparagraph (1) establish the following method of evaluating diplopia, 
whether associated with unilateral or bilateral impaired visual acuity 
or visual field. We propose that, for the poorer eye (or the affected 
eye, if only one eye is service-connected), the rating agency assign a 
level of visual acuity (for decreased visual acuity or visual field 
defect expressed as a level of visual acuity) one step poorer than it 
would be otherwise, if the evaluation for diplopia under diagnostic 
code 6090 is 20/70 or 20/100; a level two steps poorer if the 
evaluation for diplopia is 20/200 or 15/200; and a level three steps 
poorer if the evaluation for diplopia is 5/200. The adjusted level, 
however, could not exceed 5/200. The percentage evaluation would then 
be determined under diagnostic codes 6064 through 6066, using the 
adjusted visual acuity for the poorer eye (or the affected eye), and 
the corrected visual acuity for the better eye. Under this method, the 
severity of diplopia would correlate with the evaluation level, with 
the higher evaluation assigned when the diplopia is worse, and the 
adjusted evaluation could never be lower than one that doesn't take 
diplopia into account, as can happen under the current method. An 
evaluation for diplopia of 20/40, assigned when diplopia affects only 
vision at 31 to 40 degrees on upward gaze, would have no effect on the 
overall evaluation. This method allows a full range of evaluation for 
visual impairment of a single eye, but does not exceed it. Unlike the 
current schedule provision, it also provides a method of evaluating 
visual impairment when both diplopia and loss of visual acuity are 
present in only one eye, or when they are present in both eyes, but 
only one eye is service-connected.
    The current schedule contains a statement that diplopia which is 
occasional or correctable is not considered a disability. Since this 
fact is pertinent to the issue of service connection for diplopia, but 
has no bearing on evaluation, including it in the rating schedule is 
unnecessary and inappropriate.
    Paragraph (b)(2) of Sec. 4.78, derived from Sec. 4.77 and the third 
note following diagnostic code 6090, would define impairment of muscle 
function and establish the procedure for evaluating

[[Page 25250]]

diplopia when the affected field extends beyond more than one quadrant 
or range of degrees.
    Paragraph (b)(3) of Sec. 4.78, derived from note (4) following 
diagnostic code 6090, would require that the evaluation for diplopia 
under diagnostic code 6090 be increased to the next higher evaluation 
provided in the rating schedule whenever diplopia exists in separate 
areas of the same eye.
    Current Sec. 4.79, ``Loss of use of one eye, having only light 
perception,'' duplicates 38 CFR 3.350(a)(4), (b)(2) and (b)(3), which 
reflect statutory criteria for entitlement to special monthly 
compensation. Because it is redundant, we propose to delete Sec. 4.79 
in favor of a footnote following diagnostic codes 6066 and 6080 
referring the rating agency to Sec. 3.350.
    We propose to delete current Secs. 4.80 and 4.84 and the notes 
following the diagnostic codes in these sections because the material 
will be moved to proposed Secs. 4.75 through 4.78.
    Current Table IV, ``Table for Rating Bilateral Blindness or 
Blindness Combined with Hearing Loss with Dictator's Code and 38 CFR 
Citations,'' is a chart displaying SMC codes to be used by the rating 
agency when dictating rating decisions for transcription. The 
dictator's rating codes have been changed since they were first 
published in Table IV, and they appear in their current form in 
Appendix A of Part I of M21-1, VA's Adjudication Procedures Manual. 
This chart's only purpose is to simplify the process of dictating 
ratings to a transcription unit. Since it has no bearing on the 
evaluation of disabilities, and contains no policy guidelines which 
rating agencies must follow, we propose to delete Table IV from the 
rating schedule.
    Current Table V, ``Ratings for Central Visual Acuity Impairment,'' 
repeats the evaluations and diagnostic codes for impaired visual acuity 
in chart form. Since diagnostic codes 6061 through 6066 establish 
evaluation criteria in a format which is consistent with the rest of 
the rating schedule, we propose to delete Table V as redundant and 
unnecessary for any regulatory purpose. Since current Sec. 4.83a 
explains how to use Table V, we also propose to remove Sec. 4.83a. 
Current Sec. 4.83 explains how to record ratings for impairment of 
central visual acuity, and it is therefore directed more at examiners 
than at rating agencies. Since the method described is standard, we 
propose to delete that section as unnecessary.
    Uveitis, keratitis, scleritis, iritis, cyclitis, choroiditis, 
retinitis, recent intra-ocular hemorrhage, detachment of retina, and 
unhealed eye injury (diagnostic codes 6000 through 6009) are currently 
evaluated at levels of 10 to 100 percent based on impairment of visual 
acuity or field loss, pain, rest-requirements, or episodic incapacity, 
combining an additional rating of 10 percent during continuance of 
active pathology. We propose a revised set of evaluation criteria in 
the form of a general rating formula following diagnostic code 6009. We 
propose that evaluation be based either on visual impairment or on 
incapacitating episodes, whichever results in a higher evaluation. We 
propose to define an incapacitating episode, for VA purposes, as one 
requiring bedrest and treatment by a physician or other healthcare 
provider. We propose to establish evaluation levels of 10, 20, 40, and 
60 percent based on incapacitating episodes, in order to accommodate 
this broad group of conditions with the potential for a wide range of 
length of periods of incapacitation. We propose an evaluation of 60 
percent with incapacitating episodes of at least six weeks total 
duration per year; of 40 percent with incapacitating episodes of at 
least four weeks, but less than six weeks, total duration per year; of 
20 percent with incapacitating episodes of at least two weeks, but less 
than four weeks, total duration per year; and of 10 percent with 
incapacitating episodes total of at least one week, but less than two 
weeks, total duration per year. These criteria are clearer and more 
objective than current criteria, and will allow the extent of 
incapacitating episodes to be consistently taken into account.
    We propose to change the terminology in several diagnostic codes to 
reflect current medical usage, in accord with suggestions by our 
consultants. We propose to change the title of diagnostic code 6000, 
``uveitis,'' to ``choroidopathy,'' because the term ``choroidopathy'' 
includes pathological conditions of the choroid other than 
inflammation, and also encompasses the subcategories of uveitis, 
iritis, cyclitis, and choroiditis. We therefore propose to delete 
diagnostic codes 6003 (iritis), 6004 (cyclitis), and 6005 
(choroiditis), since they are included in diagnostic code 6000. 
Similarly, we propose to change the title of diagnostic code 6001, 
``keratitis,'' to ``keratopathy,'' a broader category that includes 
corneal conditions other than inflammation, and the title of diagnostic 
code 6006, ``retinitis,'' to ``retinopathy or maculopathy,'' broader 
terms that encompass not only retinitis but other retinal and macular 
diseases and degenerations, for the same reason. We propose to revise 
the title of diagnostic code 6007 (hemorrhage, intra-ocular, recent) to 
``intra-ocular hemorrhage'' because both recent (or acute) and chronic 
intra-ocular hemorrhage may be disabling. We propose to edit the title 
of diagnostic code 6010 (tuberculosis of eye) and to correct an 
erroneous reference to codes under which inactive tuberculosis of the 
eye is evaluated. The current schedule refers to Secs. 4.88b and 4.89, 
but Sec. 4.88b was redesignated Sec. 4.88c in a separate rulemaking, 
and the correct section references are now 4.88c and 4.89. We propose 
to simplify the title of diagnostic code 6011 from ``retina, localized 
scars, atrophy, or irregularities of, centrally located, with 
irregular, duplicated, enlarged or diminished image'' to ``retinal 
scars, atrophy, or irregularities.'' We propose to retain a ten-percent 
evaluation under diagnostic code 6011 for localized scars, atrophy, or 
irregularities that are centrally located and that result in an 
irregular, duplicated, enlarged, or diminished image. Evaluation of 
these conditions would otherwise be based on visual impairment, as 
defined in proposed Sec. 4.75(a).
    We propose to revise the title of diagnostic code 6012, ``glaucoma, 
congestive or inflammatory,'' to ``angle-closure glaucoma,'' the 
current medical term for the condition. For the same reason, we propose 
to change the title of diagnostic code 6013, ``glaucoma, simple, 
primary, noncongestive,'' to ``open-angle glaucoma.''
    Diagnostic code 6012, angle-closure glaucoma, is currently 
evaluated either as iritis (diagnostic code 6003) or by rating at 100 
percent if there are ``frequent attacks of considerable duration; 
during continuance of actual total disability.'' ``Frequent'' and 
``considerable'' are subjective terms that are susceptible to different 
interpretations. In addition, these criteria are difficult to apply 
because acute attacks are usually of short duration, and it is unlikely 
that an examination for disability could be scheduled and conducted 
during such an attack. Therefore, we propose to evaluate this condition 
similarly to diagnostic codes 6000 through 6009, based either on visual 
impairment or on incapacitating episodes, whichever results in a higher 
evaluation. Because in some cases this condition is characterized 
primarily by frequent and sometimes prolonged intermittent episodes of 
incapacitation, we propose to provide a wide range of evaluations--from 
20 to 60 percent--based on incapacitating episodes. We also propose to 
establish a ten-percent

[[Page 25251]]

minimum evaluation if continuous medication is required. A minimum 
evaluation is not warranted if there is no visual impairment and no 
treatment is needed other than frequent observation. We propose these 
more objective criteria in order to provide clearer guidance on 
evaluation and to assure more consistent evaluations. With these 
criteria, the direction to rate as iritis is not needed, and we propose 
to delete it.
    Diagnostic code 6013, open-angle glaucoma, is currently evaluated 
on impairment of visual acuity or field loss, with a minimum evaluation 
of ten percent. We propose that it be evaluated on visual impairment, 
which will allow consideration of impairment of visual acuity, visual 
field, or muscle function, with a ten-percent minimum evaluation if 
continuous medication is required. A minimum evaluation is not 
warranted if there is no visual impairment and no treatment is needed 
other than frequent observation.
    We propose to update the term ``new growth'' to ``neoplasm'' in the 
titles of diagnostic codes 6014 and 6015, which address malignant and 
benign eye tumors, respectively.
    Malignant neoplasms (diagnostic code 6014) are now evaluated at 100 
percent pending completion of surgery or other indicated treatment, 
and, when healed, are rated on residuals. However, not all malignant 
neoplasms of the eye are totally disabling or require treatment that is 
totally disabling for a period of time. For example, eye malignancies 
such as iris melanoma and choroid melanoma often require no treatment 
other than observation, even though they are malignant on pathology 
examination. We therefore propose to evaluate malignancies of the 
eyeball similar to the way we proposed to evaluate skin malignancies 
(published in the Federal Register of January 19, 1993 (See 58 FR 
4969)). If a malignant neoplasm of the eyeball requires therapy that is 
comparable to that used for internal malignancies, i.e., systemic 
chemotherapy, X-ray therapy more extensive than to the eye, or surgery 
more extensive than enucleation, a 100 percent evaluation would be 
assigned from the date of onset of treatment, and would continue, with 
a mandatory VA examination six months following the completion of such 
antineoplastic treatment, and any change in evaluation based upon that 
or any subsequent examination would be subject to the effective date 
provisions of Sec. 3.105(e). If there has been no local recurrence or 
metastasis, evaluation would then be made on residuals. These revisions 
are similar to those now in effect for malignant neoplasms in several 
revised sections of the rating schedule (e.g., gynecological conditions 
and disorders of the breast, respiratory system, endocrine system). If 
treatment is confined to the eye, the provisions for a 100 percent 
evaluation would not apply. If no treatment other than observation is 
required, we propose that evaluation be made by separately evaluating 
visual impairment and nonvisual impairment, e.g., disfigurement 
(diagnostic code 7800), and combining the evaluations under Sec. 4.25. 
In our judgment, neoplasms that require only periodic observation, 
without surgical or other medical intervention, are not totally 
disabling and therefore do not warrant the total evaluation ordinarily 
provided for malignant neoplasms. If treatment comparable to that for 
internal malignancies is needed, eye malignancies would be evaluated in 
the same manner as internal malignancies requiring treatment.
    Benign neoplasms (diagnostic code 6015) are currently evaluated on 
impaired vision, with a minimum evaluation of 10 percent, and healed 
benign neoplasms are rated on residuals. A standard ophthalmology text, 
(Frank W. Newell, M.D., Ophthalmology Principles and Concepts, p. 207, 
7th ed. 1992), indicates no specific impairment due to benign 
neoplasms, and no need for continuing medication. A minimum evaluation 
for all cases is therefore not warranted, and we propose to remove it. 
We propose that evaluation be based on visual impairment, with that 
evaluation to be combined with an evaluation for any nonvisual 
impairment, e.g., disfigurement. These criteria better encompass the 
impairments that may result from benign neoplasms. We propose to revise 
the title of diagnostic code 6015 from ``new growths, benign (eyeball 
and adnexa, other than superficial)'' to ``benign neoplasms (of eyeball 
and adnexa)'' because without the requirement for a minimum evaluation, 
the distinction between superficial and other types of benign neoplasm 
is not relevant.
    We propose to edit the title of diagnostic code 6017, 
``conjunctivitis, trachomatous, chronic'' to ``trachomatous 
conjunctivitis'' and the title of diagnostic code 6018, 
``conjunctivitis, other, chronic'' to ``chronic conjunctivitis 
(nontrachomatous).'' Evaluations of healed trachomatous and 
nontrachomatous conjunctivitis are currently based on residuals, with a 
zero-percent evaluation if there are no residuals. We propose to remove 
the zero-percent evaluation level. 38 CFR 4.31 provides for a zero-
percent evaluation in all cases when the criteria for a compensable 
evaluation is not met, which obviates the need to include zero-percent 
evaluation criteria in this case. Active trachomatous conjunctivitis is 
currently evaluated on impairment of visual acuity, with a minimum 
evaluation of 30 percent while there is active pathology; other forms 
of active conjunctivitis are evaluated at 10 percent when there are 
``objective symptoms.'' We propose to change ``objective symptoms'' to 
``objective findings, such as red, thick conjunctivae, mucous 
secretion, etc.'' under diagnostic code 6018, since symptoms are, by 
definition, subjective, and to change ``healed'' to ``inactive'' 
because conjunctivitis may be active intermittently. We propose that 
inactive trachomatous conjunctivitis and inactive chronic 
conjunctivitis be evaluated on residuals, such as visual impairment, 
disfigurement (diagnostic code 7800), etc. Our contract consultants 
suggested that these categories of conjunctivitis be combined because 
of the rarity of trachoma. Because trachoma is much more severe than 
most other types of chronic conjunctivitis and often leads to 
blindness, it warrants a 30-percent minimum evaluation, when active, an 
evaluation level that cannot be justified for other types of 
conjunctivitis. Since we must assure appropriate evaluations for these 
disparate conditions, we do not propose to adopt the consultants' 
suggestion.
    Ptosis (diagnostic code 6019) is currently evaluated equivalent to 
visual acuity of 5/200 whenever the pupil is wholly obscured, 
equivalent to 20/100 if the pupil is one-half or more obscured, and on 
disfigurement if less than one-half of the pupil is obscured. The 
extent to which a pupil is obscured can be difficult to determine 
reliably, and an evaluation for ptosis based directly on visual 
impairment was recommended by our contract consultants. We propose to 
adopt their suggestion and, in the absence of visual impairment, base 
evaluation on disfigurement (diagnostic code 7800).
    Our contract consultants recommended that we add a note providing 
an alternative evaluation as disfigurement (diagnostic code 7800) for 
ectropion (diagnostic code 6020), entropion (diagnostic code 6121), 
lagophthalmos (diagnostic code 6022), eyebrows, loss of complete, 
unilateral or bilateral (diagnostic code 6023), eyelashes, loss of, 
complete, unilateral or bilateral (diagnostic code 6024), and epiphora 
(diagnostic code 6025). The diagnosis of one of these conditions is

[[Page 25252]]

sufficient to assign the current percentage evaluations because the 
diagnosis itself implies the presence of some degree of disfigurement, 
which is the primary basis of these evaluations. Since an evaluation 
for disfigurement is encompassed in the percentages provided, the 
suggested note would be redundant, and we do not propose to adopt the 
consultants' suggestion.
    We propose to change the title of diagnostic code 6025 from 
``epiphora'' to ``disorders of the lacrimal apparatus (epiphora, 
dacryocystitis, etc.)'' because all disorders of the lacrimal apparatus 
are evaluated in the same way, and they commonly occur together. In 
conjunction with this change, we propose to delete dacryocystitis 
(diagnostic code 6031), as our consultants suggested, because it will 
be included under diagnostic code 6025.
    We propose to change the title of diagnostic code 6026 from 
``neuritis, optic'', to ``optic neuropathy'', a broader term that 
includes conditions other than inflammation of the optic nerve. It is 
likely that optic nerve conditions other than neuritis are currently 
being evaluated under this code, because there is no other diagnostic 
code that specifically addresses diseases of the optic nerve, but this 
change will assure consistency by including all optic nerve disorders 
under diagnostic code 6026.
    Current diagnostic codes 6027, ``cataract, traumatic,'' and 6028, 
``cataract, senile, and others,'' are evaluated under the same 
criteria--impairment of vision preoperatively, and impairment of vision 
and aphakia postoperatively--because they result in identical 
impairment. We therefore propose to delete diagnostic code 6028 and to 
establish a single diagnostic code, 6027, ``cataract of any type,'' for 
all types of cataracts. We propose that evaluation preoperatively be 
based on visual impairment and postoperatively on visual impairment if 
a replacement lens is present, and on aphakia if there is no 
replacement lens. Our contract consultants suggested we add a 
diagnostic code for pseudophakia to the rating schedule. The term 
``pseudophakia'' has two meanings--one, a condition where the lens has 
been replaced status post-cataract removal and the other, a condition 
in which a degenerated lens is spontaneously replaced by some other 
type of tissue. Dorland's Illustrated Medical Dictionary (27th ed. 
1988) does not include the former definition. Therefore, to avoid 
confusion, instead of adding a code for pseudophakia, we propose to use 
clear and unambiguous language in diagnostic code 6027 concerning the 
post-operative evaluation of cataracts and to include pseudophakia as a 
parenthetical expression after ``if a replacement lens is present.''
    Current diagnostic codes 6029, ``aphakia,'' and 6033, ``lens, 
crystalline, dislocation of,'' are evaluated under the same criteria 
because they result in identical impairments. We propose to combine the 
conditions under diagnostic code 6029, retitle it ``aphakia or 
dislocation of crystalline lens,'' and delete diagnostic code 6033, 
since there is no need to retain two separate diagnostic codes for 
these conditions for statistical or other purposes. There is currently 
a minimum evaluation of 30 percent under diagnostic code 6029, whether 
unilateral or bilateral, and there are a number of additional rules for 
evaluation that are applied depending on whether one or both eyes are 
aphakic. In order to simplify the current method of evaluation, which 
has sometimes caused confusion, we propose to instruct the rating 
agency to evaluate on the basis of visual impairment, elevated by one 
step. We propose to retain the minimum 30-percent evaluation for 
unilateral or bilateral aphakia. These minimum evaluations are 
warranted because the severe hyperopia that results from aphakia cannot 
be adequately corrected. In addition, there is substantial 
magnification of the image in an aphakic eye, peripheral vision is 
reduced, and with aphakia of a single eye, image fusion may be 
difficult because of the great difference in refraction between the 
eyes. Glare and photophobia are common additional problems, and 
eyeglasses cause a ring scotoma so that objects appear to jump in and 
out of view. The proposed criteria are consistent with other methods of 
evaluating conditions manifested primarily by visual impairment, take 
into account visual problems other than loss of visual acuity that are 
not precisely measurable, and are clearer, which should assure 
consistent evaluations.
    We propose to revise the title of diagnostic code 6030 from 
``accommodation, paralysis of'' to ``paralysis of accommodation (due to 
neuropathy of the Oculomotor Nerve)'' because pathology of that cranial 
nerve is the usual etiology.
    We propose to change the title of diagnostic code 6032 from 
``eyelids, loss of portion of'' to ``loss of eyelids, partial or 
complete,'' because complete loss of eyelids may also require 
evaluation and can be evaluated under the same criteria. Diagnostic 
code 6032 is currently rated as disfigurement (diagnostic code 7800). 
Our contract consultants suggested we combine an evaluation for the 
underlying disease (none of which they named) with an evaluation for 
visual impairment. Instead, we propose to direct that an evaluation for 
visual impairment be combined with an evaluation for disfigurement 
(diagnostic code 7800). An underlying disease producing other 
impairments would be evaluated under the appropriate body system, but 
it is not necessary to provide this instruction here because it is not 
unique to this condition.
    Pterygium, diagnostic code 6034, is currently evaluated on loss of 
vision, if any, and we propose that it be evaluated on visual 
impairment, disfigurement (diagnostic code 7800), conjunctivitis 
(diagnostic code 6018), etc. This proposed change better encompasses 
the possible range of impairments from pterygium.
    A note currently following diagnostic code 6035, keratoconus, 
requires a 30-percent minimum evaluation when ``contact lenses are 
medically required.'' We propose to delete the minimum evaluation and 
base evaluation on corrected visual acuity (using contact lenses rather 
than eyeglass lenses for that determination if they provide the best 
corrected visual acuity and are customarily worn by the individual) 
because decreased visual acuity is the only disabling effect of 
keratoconus. If contact lenses best correct the visual impairment, and 
can be worn by the individual, there would be no significant additional 
disability to warrant a minimum evaluation, and the corrected visual 
acuity using contact lenses would be a reasonable basis of evaluation. 
If eyeglass lenses can correct the visual acuity, the usual method of 
determining corrected visual acuity would be the basis of evaluation.
    We propose to add diagnostic code 6036 for ``status post corneal 
transplant,'' a common condition, with evaluation based on visual 
impairment. Either loss of visual acuity or visual field loss or both 
may occur in corneal transplant, and this direction allows any visual 
impairment to be evaluated. Since pain, photophobia, and glare 
sensitivity may be disabling following corneal transplant, we propose a 
minimum of evaluation of ten percent if those symptoms are present.
    The current schedule uses 19 different diagnostic codes to 
designate impairment of central visual acuity, and some designate more 
than one level of visual acuity, e.g., diagnostic code 6078 designates 
six different levels. No useful purpose is served by this large number 
of codes, and we propose to decrease the number to six for more ease of 
use.

[[Page 25253]]

We propose to retain separate codes for anatomical loss of both eyes 
(diagnostic code 6061); for light perception only, both eyes 
(diagnostic code 6062); for anatomical loss of one eye (diagnostic code 
6063); for light perception only, one eye, (diagnostic code 6064); for 
vision in one eye 5/200 (1.5/60) (diagnostic code 6065); and for 
impairment of visual acuity 10/200 (3/60) or better (diagnostic code 
6066). In addition, we propose to remove the term ``blindness'' from 
the titles of diagnostic codes 6062 and 6064 in favor of the terms 
``light perception only, both eyes'' and ``light perception only, one 
eye,'' respectively because the term ``blindness,'' as used in 38 
U.S.C. 1114, ``Rates of wartime disability compensation,'' has more 
than one meaning, and using it in the rating schedule to refer to only 
one level of visual impairment promotes confusion.
    In the current rating schedule, footnote number five, attached to 
diagnostic codes 6061-63 and 6067-71, refers to entitlement to SMC, and 
footnote number six, attached to diagnostic codes 6064-66, refers both 
to entitlement to SMC and to evaluation when there is inability to wear 
a prosthesis following anatomical loss of an eye. (Footnotes number 
five and six are currently the only footnotes in this section.) We have 
discussed above our proposal to remove the part of the footnote that 
addresses the inability to wear a prosthesis. We propose to place the 
material concerning SMC in footnote number one, following diagnostic 
code 6066 and also following diagnostic code 6080. We propose to remove 
footnotes five and six and to attach footnote number one to diagnostic 
codes 6061 through 6064, under diagnostic code 6065 at the 100 percent 
evaluation for ``vision in one eye 5/200, in the other eye 5/200,'' and 
under diagnostic code 6080 at ``visual field, concentric contraction 
of, to 5 degrees'' (because concentric contraction of the visual field 
to five degrees is the equivalent of 5/200, and must also be considered 
for SMC (see 38 CFR 3.350)). This combination of footnotes and 
paragraph (f) of Sec. 4.75 referring to SMC is, in our opinion, the 
best way to ensure complete review for SMC.
    We propose to update the subpart title ``Ratings for Impairment of 
Field of Vision'' to ``Ratings for Impairment of Visual Fields'' and 
the title of diagnostic code 6080 from ``Field vision, impairment of'' 
to ``Visual field defects,'' in accordance with current usage. In order 
to make the evaluations for visual field defects under diagnostic code 
6080 more comprehensive, as suggested by our consultants, we propose to 
add evaluations for loss of superior and inferior altitudinal fields. 
Inferior field loss will be evaluated at 10 percent for the unilateral 
and 30 percent for the bilateral condition (or impaired visual acuity 
of 20/70 (6/21) for each affected eye), and superior field loss will be 
evaluated at 10 percent for both the unilateral and bilateral 
conditions (or impaired visual acuity of 20/50 (6/15) for each affected 
eye). For the sake of accuracy, we propose, under diagnostic code 6080, 
to make 10 percent (or impaired visual acuity of 20/50 (6/15) for each 
affected eye), instead of 20 percent, the evaluation for unilateral or 
bilateral condition for both concentric contraction to 46 to 60 degrees 
and for loss of the nasal half of the visual field. This will correct 
the bilateral percentage evaluation, currently indicated to be 20 
percent for these conditions, because both bilateral and unilateral 
visual acuity of 20/50 warrant a 10-percent, not a 20-percent, 
evaluation. Notes one and two, currently following diagnostic code 
6080, discuss the requirements for correct diagnosis, demonstrable 
pathology, and contraction within the stated degrees for concentric 
contraction ratings. We propose to delete these notes because similar 
information is contained in Sec. 4.1, proposed Sec. 4.77(a), and under 
diagnostic code 6080, and they are therefore redundant.
    We propose to revise the evaluation criteria for diagnostic code 
6081, ``scotoma, unilateral,'' which currently provide a minimum 10-
percent evaluation for a large or centrally located scotoma, by 
changing ``large'' to ``affecting at least one-quarter of the visual 
field (quadrantanopsia).'' This language is clearer, and the term 
``quadrantanopsia,'' is widely accepted. We propose that evaluation 
otherwise be based on visual impairment, which is not a substantive 
change from the current direction to ``rate on loss of central visual 
acuity or impairment of field vision.''
    Symblepharon (diagnostic code 6091) is currently rated under the 
criteria for diagnostic code 6090 (diplopia). However, it may also 
result in other types of impairments, and we therefore propose to 
direct that it be evaluated on visual impairment, lagophthalmos 
(diagnostic code 6022), disfigurement (diagnostic code 7800), etc.
    Diplopia is currently evaluated under diagnostic code 6090 and also 
under diagnostic code 6092, which is described as ``diplopia, due to 
limited muscle function'' and evaluated according to the criteria under 
diagnostic code 6090. We propose to eliminate diagnostic code 6092 
because diplopia due to limited muscle function is not functionally 
distinct from diplopia (double vision) and does not warrant a separate 
code. As stated above, we propose to delete the note following 
diagnostic code 6090 regarding a citing of the correct diagnosis as 
redundant.
    For purposes of clarity, we propose to make numerous additional 
nonsubstantive changes in this document.
    The Secretary hereby certifies that this regulatory amendment 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. The reason for this certification is that this 
amendment would not directly affect any small entities. Only VA 
beneficiaries could be directly affected. Therefore, pursuant to 5 
U.S.C. 605(b), this amendment is exempt from the initial and final 
regulatory flexibility analysis requirements of sections 603 and 604. 
This regulation has been reviewed by the Office of Management and 
Budget under Executive Order 12866.
    The Catalog of Federal Domestic Assistance numbers are 64.104 and 
64.109.

List of Subjects in 38 CFR Part 4

    Disability benefits, Individuals with disabilities, Pensions, 
Veterans.

    Approved: December 14, 1998.
Togo D. West, Jr.,
Secretary of Veterans Affairs.
    For the reasons set out in the preamble, 38 CFR part 4, subpart B, 
is proposed to be amended as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

    1. The authority citation for part 4 continues to read as follows:

    Authority: 38 U.S.C. 1155.

Subpart B--Disability Ratings

    2. Sections 4.75 and 4.76 are 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. To be adequate for VA 
purposes, an examination to evaluate visual impairment must be 
conducted by a licensed optometrist or

[[Page 25254]]

ophthalmologist. The examiner must identify the disease, injury, or 
other pathologic process responsible for any visual impairment found. 
Examinations for the evaluation 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. The fundus must be examined with the veteran's pupils 
dilated (unless medically contraindicated).
    (c) Service-connected visual impairment of only one eye. If visual 
impairment of only one eye is service-connected, either directly or by 
aggravation, the visual acuity of the non-service-connected eye shall 
be considered to be 20/40 for evaluation purposes, subject to the 
provisions of Sec. 3.383(a) of this chapter.
    (d) Maximum evaluation for visual impairment of one eye. The 
evaluation for visual impairment of one eye shall not exceed 30 percent 
unless there is anatomical loss of the eye. The evaluation for visual 
impairment of one eye may, however, be combined with evaluations for 
other disabilities, e.g., disfigurement, that are not based on visual 
impairment.
    (e) Anatomical loss of one eye with inability to wear a prosthesis. 
When there is anatomical loss of one eye, the evaluation for visual 
acuity under diagnostic code 6063 shall be increased by 10 percent if 
the veteran is unable to wear a prosthesis, but the maximum evaluation 
shall not exceed 100 percent.
    (f) Special monthly compensation. When evaluating any claim 
involving visual impairment, the rating agency shall refer to 
Sec. 3.350 of this chapter to determine whether the veteran 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. 1155 and 1114)


Sec. 4.76  Visual acuity.

    (a) Examination of visual acuity. To be adequate for VA purposes, 
an examination to evaluate visual acuity must record uncorrected and 
corrected visual acuity for distance and near, as determined using 
Snellen's test type or its equivalent.
    (b) Evaluation of visual acuity. (1) For VA purposes, visual acuity 
shall generally be evaluated on the basis of corrected distance vision. 
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, the visual acuity 
of the poorer eye for evaluation purposes shall be 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.
    (2) Provided that he or she customarily wears contact lenses, VA 
shall 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 explain the reason for the difference. 
Evaluation in those cases will be based on distance vision adjusted to 
one step poorer than measured.


Sec. 4.76a  [Removed]

    3. Section 4.76a is removed.
    4. Sections 4.77, 4.78 and 4.79 are revised to read as follows:


Sec. 4.77  Visual fields.

    (a) Examination of visual fields. 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/4-e)). At least two 
recordings of visual fields must be made, and the examination must be 
supplemented by the use of a tangent screen when the examiner indicates 
it is necessary. At least 16 meridians 22\1/2\ degrees apart must be 
charted for each eye (see Figure 1). See Table III for the normal 
extent of the visual fields (in degrees) at the 8 principal meridians 
(45 degrees apart). The confirmed visual fields shall be made a part of 
the examination report.
    (b) Evaluation of visual fields. The average concentric contraction 
of the visual field of each eye is determined 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, 
the rating agency shall combine the evaluations for visual acuity and 
visual field defect (expressed as a level of visual acuity) (see 
Sec. 4.25).

(Authority: 38 U.S.C. 1155)


Sec. 4.78  Muscle function.

    (a) Examination of muscle function. To be adequate for VA purposes, 
measurement of muscle function must be performed using a Goldmann 
Perimeter Chart which identifies the four major quadrants, (upward, 
downward, left and right lateral) and the central field (20 degrees or 
less) (see Figure 2). The examiner will chart the areas in which 
diplopia exists and include the plotted chart in the examination 
report.
    (b) Evaluation of muscle function. (1) An evaluation for diplopia 
shall be assigned to only one eye. When both diplopia and decreased 
visual acuity or visual field defect are present in an individual, the 
rating agency shall assign a level of corrected visual acuity for the 
poorer eye (or the affected eye, if 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; and three steps poorer if the evaluation under diagnostic 
code 6090 is 5/200. These adjusted levels of corrected visual acuity, 
however, shall not exceed a level of 5/200. The percentage evaluation 
for visual impairment shall then be determined under diagnostic codes 
6064 through 6066, using the adjusted visual acuity for the poorer eye 
(or the affected eye), and the corrected visual acuity for the better 
eye.
    (2) When diplopia is present in more than one quadrant or range of 
degrees, the rating agency shall evaluate diplopia on the quadrant and 
degree range that provides the highest evaluation.
    (3) When diplopia exists in two separate areas of the same eye, the 
equivalent visual acuity under diagnostic code 6090 shall be increased 
to the next poorer level of visual acuity, but not to exceed 5/200.

(Authority: 38 U.S.C. 1155)


Sec. 4.79  Schedule of ratings--eye.

[[Page 25255]]



                           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
------------------------------------------------------------------------
                                                                  Rating
------------------------------------------------------------------------
    Evaluate on the basis of either visual impairment or
     incapacitating episodes, whichever results in a higher
     evaluation.
    With incapacitating episodes of at least six weeks total          60
     duration per year.........................................
    With incapacitating episodes of at least four weeks, but          40
     less than six weeks, total duration per year..............
    With incapacitating episodes of at least two weeks, but           20
     less than four weeks, total duration per year.............
    With incapacitating episodes of at least one week, but less       10
     than two weeks, total duration per year...................
Note: For VA purposes, an incapacitating episode is a period of
 acute symptoms severe enough to require bed rest and treatment
 by a physician or other healthcare provider.
6010  Tuberculosis of eye:
    Active:....................................................      100
    Inactive: Rate under Secs.  4.88c or 4.89 of this part,
     whichever is appropriate.
6011  Retinal scars, atrophy, or irregularities:
    Localized scars, atrophy, or irregularities of the retina,        10
     unilateral or bilateral, that are centrally located and
     that result in an irregular, duplicated, enlarged, or
     diminished image..........................................
    Otherwise, evaluate on visual impairment.
6012  Angle-closure glaucoma:
    Evaluate on the basis of either visual impairment or
     incapacitating episodes, whichever results in a higher
     evaluation.
    Minimum evaluation if continuous medication is required....       10
    With incapacitating episodes of at least six weeks total          60
     duration per year.........................................
    With incapacitating episodes of at least four weeks, but          40
     less than six weeks, total duration per year..............
    With incapacitating episodes of at least two weeks, but           20
     less than four weeks, total duration per year.............
Note: For VA purposes, an incapacitating episode is a period of
 acute symptoms severe enough to require bed rest and treatment
 by a physician or other healthcare provider.
6013  Open-angle:
    Evaluate on visual impairment.
    Minimum evaluation if continuous medication is required....       10
6014  Malignant neoplasms (eyeball only):
Note (1): If a malignant neoplasm of the eyeball requires
 therapy 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, a rating of 100 percent shall be
 assigned that shall continue 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 shall be
 determined by mandatory VA examination. Any change in
 evaluation based upon that or any subsequent examination shall
 be subject to the provisions of Sec.  3.105(e) of this
 chapter. If there has been no local recurrence or metastasis,
 rate on residuals.
Note (2): To evaluate residuals, or malignant neoplasms that do
 not require therapy comparable to that for systemic
 malignancies, evaluate visual impairment and nonvisual
 impairment, e.g., disfigurement (diagnostic code 7800),
 separately and combine the evaluations.
6015  Benign neoplasms (of eyeball and adnexa):
    Evaluate visual impairment and nonvisual impairment, e.g.,
     disfigurement (diagnostic code 7800), separately and
     combine the evaluations.
6016  Nystagmus, central.......................................       10
6017  Trachomatous conjunctivitis:
    Active: Evaluate on visual impairment, minimum.............       30
    Inactive: Evaluate 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 on residuals, such as visual impairment
     and disfigurement (diagnostic code 7800).
6019  Ptosis, unilateral or bilateral:
    Evaluate on visual impairment, or; in the absence of visual
     impairment, evaluate 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.):

[[Page 25256]]

 
    Bilateral..................................................       20
    Unilateral.................................................       10
6026  Optic neuropathy:
    Evaluate on visual impairment.
6027  Cataract of any type:
    Preoperative:
    Evaluate on visual impairment.
    Postoperative:
    If a replacement lens is present (pseudophakia), evaluate
     on visual impairment. If there is no replacement lens,
     evaluate on aphakia.
6029  Aphakia or dislocation of crystalline lens:
    Evaluate 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).............................................
6032  Loss of eyelids, partial or complete:
    Evaluate both visual impairment and nonvisual impairment,
     e.g., disfigurement (diagnostic code 7800), separately and
     combine the evaluations.
6034  Pterygium:
    Evaluate on visual impairment, disfigurement (diagnostic
     code 7800), conjunctivitis (diagnostic code 6018), etc.
6035  Keratoconus:
    Evaluate loss of visual acuity.
6036  Status post corneal transplant
    Evaluate visual impairment.
    Minimum, if there is pain, photophobia, and glare                 10
     sensitivity...............................................
6037  Pinguecula:
    Evaluate on disfigurement (diagnostic code 7800).
    Impairment of Central Visual Acuity:
6061  Anatomical loss both eyes \1\                                  100
6062  Light perception only, 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  Light perception only, 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

[[Page 25257]]

 
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 Sec.
  3.350 of this chapter.


                 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 rate each affected eye as 20/70 (6/21).
Loss of nasal half of visual field:
    Bilateral..................................................       10
    Unilateral.................................................       10
    Or rate each affected eye as 20/50 (6/15).
Loss of inferior half of visual field:
    Bilateral..................................................       30
    Unilateral.................................................       10
    Or rate each affected eye as 20/70 (6/21).
Loss of superior half of visual field:
    Bilateral..................................................       10
    Unilateral.................................................       10
    Or rate 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 rate each affected eye as 5/200 (1.5/60).
With remaining field of 6 to 15 degrees:
    Bilateral..................................................       70
    Unilateral.................................................       20
    Or rate each affected eye as 20/200 (6/60).
With remaining field of 16 to 30 degrees:
    Bilateral..................................................       50
    Unilateral.................................................       10
    Or rate each affected eye as 20/100 (6/30).
With remaining field of 31 to 45 degrees:
    Bilateral..................................................       30
    Unilateral.................................................       10
    Or rate each affected eye as 20/70 (6/21).
With remaining field of 46 to 60 degrees:
    Bilateral..................................................       10
    Unilateral.................................................       10
    Or rate each affected eye as 20/50 (6/15).
6081  Scotoma, unilateral:
    Minimum, with scotoma affecting at least one-quarter of the       10
     visual field (quadrantanopsia) or with centrally located
     scotoma of any size.......................................
    Otherwise, evaluate on visual impairment.
------------------------------------------------------------------------
\1\ Review for entitlement to special monthly compensation under Sec.
  3.350 of this chapter.


[[Page 25258]]


                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)
6091  Symblepharon:
    Evaluate on visual impairment, lagophthalmos
     (diagnostic code 6022), disfigurement (diagnostic
     code 7800), etc., depending on particular findings
     in individual case.
------------------------------------------------------------------------

(Authority: 38 U.S.C 1155)


Secs. 4.80, 4.83 and 4.84  [Removed and Reserved]

    5. Sections 4.80, 4.83 and 4.84 are removed and reserved.


Secs. 4.83a and 4.84a  [Removed]

    6. Sections 4.83a and 4.84a are removed.
[FR Doc 99-11771 Filed 5-10-99; 8:45 am]
BILLING CODE 8320-01-P