[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