[Federal Register Volume 70, Number 158 (Wednesday, August 17, 2005)]
[Proposed Rules]
[Pages 48342-48354]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-16218]


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SOCIAL SECURITY ADMINISTRATION

20 CFR Part 404

[Regulation No. 4]
RIN 0960-AF34


Revised Medical Criteria for Evaluating Visual Disorders

AGENCY: Social Security Administration.

ACTION: Proposed rules.

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SUMMARY: We propose to revise the criteria in the Listing of 
Impairments (the listings) that we use to evaluate

[[Page 48343]]

claims involving visual disorders. We apply these criteria when you 
claim benefits based on disability under title II and title XVI of the 
Social Security Act (the Act). The proposed revisions reflect our 
program experience and advances in medical knowledge, treatment, and 
methods of evaluating visual disorders.

DATES: To be sure your comments are considered, we must receive them by 
October 17, 2005.

ADDRESSES: You may give us your comments by: using our Internet site 
facility (i.e., Social Security Online) at http://policy.ssa.gov/pnpublic.nsf/LawsRegs or the Federal eRulemaking Portal at http://www.regulations.gov; e-mail to [email protected]; telefax to (410) 
966-2830; or by letter to the Commissioner of Social Security, P.O. Box 
17703, Baltimore, Maryland 21235-7703. You may also deliver them to the 
Office of Regulations, Social Security Administration, 100 Altmeyer 
Building, 6401 Security Boulevard, Baltimore, Maryland 21235-6401, 
between 8 a.m. and 4:30 p.m. on regular business days. Comments are 
posted on our Internet site at http://policy.ssa.gov/pnpublic.nsf/LawsRegs or you may inspect them on regular business days by making 
arrangements with the contact person shown in this preamble.
    Electronic Version: The electronic file of this document is 
available on the date of publication in the Federal Register at http://www.gpoaccess.gov/fr/index.html. It is also available on the Internet 
site for SSA (i.e., Social Security Online) at http://policy.ssa.gov/pnpublic.nsf/LawsRegs.

FOR FURTHER INFORMATION CONTACT: Robert Augustine, Social Insurance 
Specialist, Office of Disability and Income Security Programs, Social 
Security Administration, 100 Altmeyer, 6401 Security Boulevard, 
Baltimore, Maryland 21235-6401, (410) 965-0020 or TTY (410) 966-5609. 
For information on eligibility or filing for benefits, call our 
national toll-free number, 1-800-772-1213 or TTY 1-800-325-0778, or 
visit our Internet Web site, Social Security Online, at http://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION:

What Programs Would These Proposed Regulations Affect?

    These proposed regulations would affect disability and blindness 
determinations and decisions that we make under title II and title XVI 
of the Act. In addition, to the extent that Medicare entitlement and 
Medicaid eligibility are based on whether you qualify for disability or 
blindness benefits under title II or title XVI, these proposed 
regulations also would affect the Medicare and Medicaid programs.

Who Can Get Disability or Blindness Benefits?

    Under title II of the Act, we provide for the payment of disability 
benefits, including disability benefits based on blindness, if you are 
disabled and belong to one of the following three groups:
     Workers insured under the Act;
     Children of insured workers; and
     Widows, widowers, and surviving divorced spouses (see 20 
CFR 404.336) of insured workers.
    Under title XVI of the Act, we provide for Supplemental Security 
Income (SSI) payments on the basis of disability or blindness if you 
are disabled or blind and have limited income and resources.

How Do We Define Blindness?

    For both the title II and title XVI programs, the Act defines 
blindness as ``central visual acuity of 20/200 or less in the better 
eye with the use of a correcting lens. An eye which is accompanied by a 
limitation in the fields of vision such that the widest diameter of the 
visual field subtends an angle no greater than 20 degrees shall be 
considered * * * as having a central visual acuity of 20/200 or less.'' 
(Sections 216(i)(1) and 1614(a)(2) of the Act.)
    If you are seeking benefits under title II, your blindness 
generally must meet the 12-month statutory duration requirement. 
However, if you are seeking payments under title XVI of the Act, your 
blindness need not meet the 12-month statutory duration requirement. 
Also, if you are seeking payments under title XVI of the Act, there is 
no requirement that you be unable to do any substantial gainful 
activity (SGA). However, if you are working, we will consider your 
earnings to determine if you are eligible for SSI payments.

How Do We Define Disability?

    Under both the title II and title XVI programs, disability must be 
the result of any medically determinable physical or mental impairment 
or combination of impairments that is expected to result in death or 
which has lasted or is expected to last for a continuous period of at 
least 12 months. Our definitions of disability are shown in the 
following table:

------------------------------------------------------------------------
                                                    Disability means you
                                                      have a medically
 If you file a claim under * *                          determinable
               *                And you are * * *     impairment(s) as
                                                    described above and
                                                   that results in * * *
------------------------------------------------------------------------
title II......................  an adult or a      the inability to do
                                 child.             any SGA.
title XVI.....................  a person age 18    the inability to do
                                 or older.          any SGA.
title XVI.....................  a person under     marked and severe
                                 age 18.            functional
                                                    limitations.
------------------------------------------------------------------------

    There is also an additional definition of disability if you are 
seeking benefits under title II of the Act, have attained age 55, and 
have blindness as defined in section 216(i)(1) of the Act: Disability 
means that the blindness has resulted in the inability to engage in SGA 
requiring skills or abilities comparable to those of any gainful 
activity in which you previously engaged with some regularity and over 
a substantial period of time.

What are the Listings?

    The listings are examples of impairments that we consider severe 
enough to prevent an individual from doing any gainful activity without 
considering vocational factors, or that result in ``marked and severe 
functional limitations'' in children seeking SSI payments based on 
disability under title XVI of the Act. Although we publish the listings 
only in appendix 1 to subpart P of part 404 of our rules, we 
incorporate them by reference in the SSI program in Sec.  416.925 of 
our regulations, and apply them to claims under both title II and title 
XVI of the Act.

How Do We Use the Listings?

    We generally use the medical criteria in the listings only to make 
determinations or decisions of disability. The listings are in two 
parts. There are listings for adults (part A) and for children (part 
B). If you are a person age 18 or over, we apply the listings in part A 
when we assess your claim, and we never use the listings in part B.
    If you are an individual under age 18, we first use the criteria in 
part B of the listings. If the listings in part B do not apply, and the 
specific disease process(es) has a similar effect on adults and 
children, we then use the criteria in part A. (See Sec. Sec.  404.1525 
and 416.925.)
    If your impairment(s) does not meet the criteria in any listing, we 
will also

[[Page 48344]]

consider whether it medically equals any listing; that is, whether it 
is as medically severe as the criteria in the listed impairment. (See 
Sec. Sec.  404.1526 and 416.926.)
    We will never deny your claim or decide that you no longer qualify 
for benefits because your impairment(s) does not meet or medically 
equal a listing. If you have a severe impairment(s) that does not meet 
or medically equal any listing, we may still find you disabled based on 
other rules in the ``sequential evaluation process'' that we use to 
evaluate all disability claims. (See Sec. Sec.  404.1520, 416.920, and 
416.924.)
    Also, when we conduct reviews to determine whether your disability 
continues, we will not find that your disability has ended based only 
on any changes in the listings. Our regulations explain that, when we 
change our listings, we continue to use our prior listings when we 
review your case, if you qualified for disability benefits or SSI 
payments based on our determination or decision that your impairment(s) 
met or medically equaled the listings. In these cases, we determine 
whether you have experienced medical improvement, and if so, whether 
the medical improvement is related to the ability to work. If your 
condition(s) has medically improved so that you no longer meet or 
medically equal the prior listing, we evaluate your case further to 
determine whether you are currently disabled. We may find that you are 
currently disabled, depending on the full circumstances of your case. 
(See Sec. Sec.  404.1594(c)(3)(i) and 416.994(b)(2)(iv)(A)). If you are 
a child who is eligible for SSI payments, we follow a similar rule 
after we decide that you have experienced medical improvement in your 
condition(s). See Sec.  416.994a(b)(2).

Why Are We Proposing To Revise the Listings for Visual Disorders?

    We are proposing these revisions to update the medical criteria in 
the listings for visual disorders and to provide more information about 
how we evaluate visual disorders. We are not proposing any changes here 
to the listings for disturbances of labyrinthine-vestibular function 
(listing 2.07), hearing impairments (listings 2.08 and 102.08), and 
loss of speech (listing 2.09). However, we intend to publish separately 
proposed rules that would update the criteria for those disorders.
    On April 24, 2002, we published final rules in the Federal Register 
(67 FR 20018) that included technical revisions to the listings for 
special senses and speech disorders. Prior to this, we published final 
rules that included revisions to the special senses and speech listings 
in the Federal Register on December 6, 1985 (50 FR 50068). We last 
published final rules making comprehensive revisions to the part A 
special senses and speech listings in the Federal Register on March 27, 
1979 (44 FR 18170), and final rules making comprehensive revisions to 
the part B special senses and speech listings on March 16, 1977 (42 FR 
14705). The current special senses and speech listings will no longer 
be effective on July 2, 2005, unless we extend them, or revise and 
issue them again.

When Will We Start To Use These Proposed Rules?

    We will not use these proposed rules until we evaluate the public 
comments we receive on them, determine whether to issue them as final 
rules, and issue final rules in the Federal Register. If we publish 
final rules, we will explain in the preamble how we will apply them, 
and we will summarize and respond to the major public comments. Until 
the effective date of any final rules, we will continue to use our 
current rules.

How Long Would These Proposed Rules Be Effective?

    If we publish these proposed rules as final rules, they will remain 
in effect for 8 years after the date they become effective, unless we 
extend them, or revise and issue them again.

How Are We Proposing To Change the Introductory Text to the Special 
Senses and Speech Listings for Adults?

2.00 Special Senses and Speech

    We propose to remove the following sections of current 2.00:
     The last paragraph of 2.00A3, ``Field of vision.''
     Paragraph 2.00A4, ``Muscle function.''
     The first paragraph of 2.00A6, ``Special situations.''
    The last paragraph of current 2.00A3, ``Field of vision,'' explains 
that when the visual field loss is predominantly in the lower visual 
fields, a system such as the weighted grid scale for perimetric fields 
as described by B. Esterman in 1968 may be used for determining whether 
the visual field loss is comparable to that described in table 2 in 
section 2.00 of the listings. As this kind of scale is rarely used, we 
believe that we no longer need this guidance in the introductory text.
    Current 2.00A4, ``Muscle function,'' describes the type of 
impairment evaluated under current listing 2.06, ``Total bilateral 
ophthalmoplegia.'' (Ophthalmoplegia is paralysis of the eye muscles.) 
As the causes of this disorder are now more readily detectable and 
treatable, this disorder has become extremely rare. Therefore, we 
propose to remove both the current listing and the guidance in the 
introductory text that addresses this disorder. Instead, we would 
evaluate total bilateral ophthalmoplegia and other eye muscle disorders 
by assessing the impact of such disorders on your visual efficiency 
under proposed listing 2.04, or based on your actual visual 
functioning.
    The first paragraph of current 2.00A6, ``Special situations,'' 
explains how we calculate visual acuity efficiency for individuals with 
aphakia (the absence of the anatomical lens of the eye). Advances in 
technology have led to the development of effective synthetic 
intraocular lenses. Also, contact lenses have been technically refined 
and may be used in those instances in which the anatomical lens is not 
replaced with a synthetic lens. Because the synthetic intraocular lens 
or the contact lens corrects both the visual acuity and the visual 
field, we would compute the visual acuity efficiency or visual field 
efficiency as though the eye had an anatomical lens. Therefore, we no 
longer need this guidance.
    We propose to reorganize and expand the rest of the current 
introductory text for visual disorders to provide additional guidance. 
The following is a detailed explanation of the proposed introductory 
text.

Proposed 2.00A--How Do We Evaluate Visual Disorders?

    This section corresponds to current 2.00A, ``Disorders of Vision.'' 
We propose to clarify the information in the current section by 
reorganizing the material into eight subsections and by providing 
additional guidance as explained below.

Proposed 2.00A1--What Are Visual Disorders?

    This proposed section corresponds to current 2.00A1, ``Causes of 
impairment.'' We propose to make nonsubstantive editorial changes for 
clarity.

Proposed 2.00A2--What Is Statutory Blindness?

    This proposed section would revise current 2.00A7, ``Statutory 
blindness,'' to include the statutory definition. We also propose to 
update the references to the listings that show statutory blindness to 
reflect the revised listing criteria.

[[Page 48345]]

Proposed 2.00A3--What Evidence Do We Need To Establish Statutory 
Blindness Under Title XVI?

    In this new section, we propose to explain that when we make a 
determination or decision that you have statutory blindness under title 
XVI, we require evidence showing only that the statutory criteria are 
satisfied; we do not need evidence to document the visual disorder that 
causes the blindness. We also propose to explain that there is no 
duration requirement for statutory blindness under title XVI.
    We propose to add this section because blindness is treated 
differently under title II and title XVI of the Act. Under title II, 
blindness is generally evaluated in the same way as other medical 
impairments. Under title XVI, blindness and disability are separate 
categories, and the requirements for eligibility based on blindness are 
different from the requirements for eligibility based on disability.

Proposed 2.00A4--What Evidence Do We Need to Evaluate Visual Disorders, 
Including Those That Result in Statutory Blindness Under Title II?

    We propose to revise the last sentence of current 2.00A1 to explain 
what evidence we need to evaluate a visual disorder.

Proposed 2.00A5--How Do We Measure Best-Corrected Visual Acuity?

    We propose to revise the guidance in the second sentence of current 
2.00A2, ``Visual acuity,'' by providing that, in addition to testing 
that uses Snellen methodology, we may also use visual acuity 
measurements obtained using another testing methodology that is 
comparable to Snellen methodology. We also propose to clarify what 
constitutes best-corrected visual acuity and to add guidance indicating 
that we will not use the results of visual evoked response testing or 
pinhole testing to determine best-corrected visual acuity.
    Visual evoked response testing evaluates the function of the visual 
pathways from the retina, along the optic nerve and optic tract, to the 
vision cortex in the occipital lobe of the brain. While this testing 
can provide an estimate of visual acuity, it is not a direct measure of 
visual acuity.
    Pinhole testing is used to determine whether your visual acuity can 
be improved with a corrective lens. However, you may not have the same 
degree of correction with corrective lenses that you have with 
pinholes. Additionally, even though pinhole testing fails to show an 
improvement in your acuity, your acuity may improve with corrective 
lenses. Because pinhole testing may underestimate or overestimate your 
visual acuity, we will not use it to determine your best-corrected 
visual acuity.

Proposed 2.00A6--How Do We Measure Visual Fields?

    This section would replace current 2.00A3, ``Field of vision.'' 
Current 2.00A3 indicates that we will use ``usual perimetric methods'' 
or other ``comparable perimetric devices'' to measure the size of the 
visual field. The Goldmann perimeter is specifically cited as a 
comparable perimetric device.
    In its 2002 report, Visual Impairments: Determining Eligibility for 
Social Security Benefits, the National Research Council's (NRC's) 
Committee on Disability Determination for Individuals with Visual 
Impairments stated, as part of its recommendations for improvements to 
assessing visual field loss, ``the current SSA standard should be 
revised so that disability determinations are based on the results of 
automated static projection perimetry rather than Goldmann (kinetic, 
nonautomated) visual fields.'' (See the full citation at the end of 
this preamble.) These proposed rules would partially adopt this 
recommendation and provide that we will use visual field measurements 
obtained with an automated static threshold perimetry test performed on 
a perimeter that meets our requirements. However, we will also continue 
to use comparable visual field measurements obtained with Goldmann or 
other kinetic perimetry.
    In proposed 2.00A6a(i), we explain when we need visual field 
testing.
    In proposed 2.00A6a(ii), we explain that when we need to measure 
the extent of your visual field loss, we will use visual field 
measurements obtained with an automated static threshold perimetry test 
performed on a perimeter that meets our requirements. We adopted as our 
requirements the criteria recommended in the NRC report referred to 
above. We propose to cite the Humphrey Field Analyzer as an example of 
an acceptable perimeter because the NRC report cited it, and the 
Humphrey Field Analyzer is the most widely used automated perimeter in 
the United States that is used to perform this type of test.
    The NRC report also cited the Octopus perimeter as another example 
of an automated perimeter that meets the criteria set out in its 
recommendations. We have not included the Octopus perimeter as an 
example of an acceptable perimeter in proposed 2.00A6a(ii), because it 
is not our intention to list in these rules every acceptable automated 
perimeter and the Octopus perimeter is not widely used in the United 
States.
    In proposed 2.00A6a(iii), we describe the requirements of an 
acceptable automated static threshold perimetry test.
    In proposed 2.00A6a(iv), we explain that to determine statutory 
blindness, we need a test that measures the central 24 to 30 degrees of 
the visual field. We also provide examples of acceptable tests.
    In proposed 2.00A6a(v), we explain that to determine if the 
criterion in 2.03B is met, we need a test, performed on a Humphrey 
field analyzer, that measures the central 30 degrees of the visual 
field. We explain that we can use comparable results from other 
acceptable perimeters, and we provide an example of a comparable 
result. We also explain that we cannot use tests that do not measure 
the central 30 degrees of the visual field, such as the Humphrey 24-2 
test, to determine if your impairment meets or medically equals listing 
2.03B. This criterion, which we are proposing in listing 2.03B, adopts 
the NRC's recommendation in its 2002 report that we require a test 
measuring the central 30 degrees of the visual field.
    In proposed 2.00A6a(vi), we explain that we measure the extent of 
visual field loss by determining the portion of the visual field in 
which you can see a white III4e stimulus. This stimulus specification 
is the same as the specification in the second paragraph of current 
2.00A3.
    In proposed 2.00A6a(vii), we explain that we need to determine the 
decibel (dB) level that corresponds to a 4e intensity for the 
particular perimeter being used. We further explain that we will then 
use the dB printout to determine which points would be seen at the 4e 
intensity level. We also give an example which explains that, for tests 
performed on Humphrey perimeters, any point seen at 10 dB or higher is 
a point that would be seen with a 4e stimulus.
    In proposed 2.00A6a(viii), we explain that we can also use visual 
field measurements obtained using kinetic perimetry, such as the 
Humphrey ``SSA Test Kinetic'' or Goldmann perimetry. We contracted with 
West Virginia University to conduct research to determine whether the 
Humphrey ``SSA Test Kinetic'' is comparable to Goldmann perimetry. This 
research, which was completed in April 2000, showed that the Humphrey 
``SSA Test Kinetic'' is comparable to Goldmann perimetry, except that 
the Humphrey ``SSA Test Kinetic'' does not identify

[[Page 48346]]

scotomata, that is, non-seeing areas in the visual field surrounded by 
seeing areas. Therefore, we propose to provide that if we need 
additional information because your visual disorder has progressed to 
the point where it is likely to result in a significant limitation in 
the central visual field, such as a scotoma, we will supplement the 
automated kinetic perimetry with the results of a Humphrey 30-2 or 
comparable test.
    In proposed 2.00A6a(ix), we explain that we will not use the 
results of visual field screening tests, such as confrontation tests, 
tangent screen tests, or automated static screening tests, to determine 
that your impairment meets or medically equals a listing or to evaluate 
your residual functional capacity. We also explain that we can use 
normal results from visual field screening tests to determine whether 
the impact of your visual disorder on your visual field is severe when 
these results are consistent with the other evidence in your case 
record. We would also list some circumstances under which we will not 
consider normal test results to be consistent with the other evidence 
in the file.
    Consistent with our proposed removal of the guidance on aphakia, we 
propose to remove the stimulus specifications used to test individuals 
with aphakia contained in the first two paragraphs of current 2.00A3.
    In proposed 2.00A6b, we would revise the guidance in the first 
paragraph of current 2.00A3 on the use of corrective lenses during 
visual field testing. We propose to explain that eyeglasses must not be 
worn during the visual field examination because they limit your field 
of vision, but contact lenses or perimetric lenses may be used in order 
to obtain the most accurate visual field measurements. We also provide 
that, for this single purpose, you do not need to demonstrate that you 
have the ability to use the contact or perimetric lenses on a sustained 
basis.

Proposed 2.00A7--How Do We Calculate Visual Efficiency?

    In this proposed section, we would expand the guidance in current 
2.00A5, ``Visual efficiency,'' by explaining how we calculate visual 
acuity efficiency, visual field efficiency, and visual efficiency. The 
provisions in proposed 2.00A7b are based on the first sentence of 
paragraph 2 of the explanatory text following Table 2 in the current 
rules. As we explain below, we are proposing to delete that sentence 
because we are moving it here. The provisions in proposed 2.00A7c are 
based on the current language of 2.00A5 as well as the parenthetical 
statement at the end of current listing 2.04, which we are proposing to 
delete because it is redundant.

Proposed 2.00A8--How Do We Evaluate Specific Visual Problems?

    This section would replace current 2.00A6, ``Special situations.'' 
In this section, we propose to add guidance for evaluating specific 
visual problems. The following is a discussion of the proposed section.

Proposed 2.00A8a--Statutory Blindness

    In this proposed section, we would codify in our regulations a 
longstanding procedure. The most commonly used visual acuity test 
charts are charts based on Snellen methodology. These charts usually do 
not measure visual acuity between 20/100 and 20/200. Therefore, if you 
are unable to read any of the letters on the 20/100 line on a test 
chart based on Snellen methodology, your visual acuity will be assessed 
as 20/200 or less.
    There are newer test charts (not yet widely used, but comparable to 
charts based on Snellen methodology) that provide measurements of 
visual acuity between 20/100 and 20/200. Based on medical literature, 
we know that if your visual acuity is between 20/100 and 20/200 as 
measured on those newer test charts, it would be 20/200 if it were 
measured using the more common chart based on Snellen methodology. We 
explain in the proposed section that if your visual acuity is measured 
using one of these newer charts, and you cannot read any of the letters 
on the 20/100 line, we will determine that you have statutory blindness 
based on a visual acuity of 20/200 or less. We also provide that, 
regardless of the type of test chart used, you do not have statutory 
blindness if you can read at least one letter on the 20/100 line.

Proposed 2.00A8b--Blepharospasm

    We propose to describe the disorder and explain that we must 
consider how the involuntary blinking that characterizes it can affect 
your ability to maintain the measured visual acuities and visual fields 
over time.

Proposed 2.00A8c--Scotoma

    We propose to define the term scotoma as a non-seeing area in the 
visual field surrounded by a seeing area. We also explain that when we 
measure your visual field, we will subtract the length of any scotoma, 
other than the normal blind spot, from the overall length of any 
diameter on which it falls.

Proposed 2.00C--How Do We Evaluate Impairments That Do Not Meet One of 
the Special Senses and Speech Listings?

    We propose to revise the guidance in the second paragraph of 
current 2.00A6 by stating our basic adjudicative principle that if the 
impairment(s) does not meet or medically equal the criteria of a 
listing in this body system, we must consider whether it meets or 
medically equals the criteria of a listing in another body system. If 
not, we must continue the sequential evaluation process (see Sec. Sec.  
404.1520 and 416.920) to determine whether you are disabled or continue 
to be disabled (see Sec. Sec.  404.1594, 416.994 and 416.994a). This 
new section would apply to all the impairments in this body system, not 
just visual disorders.

How Are We Proposing To Change the Criteria in the Special Senses and 
Speech Listings for Adults?

2.01 Category of Impairments, Special Senses and Speech

    We propose to remove the reservation for listing 2.05 because it is 
no longer needed. We also propose to remove current listing 2.06, 
``Total bilateral ophthalmoplegia,'' for the reasons cited above in the 
explanation of the proposed removal of current 2.00A4, ``Muscle 
function.''

Proposed Listing 2.02--Loss of Visual Acuity

    This proposed listing corresponds to current listing 2.02, 
``Impairment of visual acuity.'' We propose to change the heading to be 
consistent with other language in these proposed rules.

Proposed Listing 2.03--Contraction of the Visual Field in the Better 
Eye

    This proposed listing corresponds to current listing 2.03, 
``Contraction of peripheral visual fields in the better eye.'' We 
propose to remove current listing 2.03A, which provides that an 
individual's visual field loss is of listing-level severity when the 
field is contracted to 10 degrees or less from the point of fixation. 
Current listing 2.03B provides that an individual's visual field loss 
is of listing-level severity if that loss results in the widest 
diameter of the field subtending an angle no greater than 20 degrees. 
Any visual field loss that satisfies the criterion in current listing 
2.03A will also satisfy the criterion in current listing 2.03B. 
Therefore, current listing 2.03A is unnecessary. We also propose to 
redesignate current listing 2.03B as listing 2.03A, and to make 
nonsubstantive editorial changes.
    In its 2002 report, the NRC suggested that a mean deviation (MD) of 
-22 or

[[Page 48347]]

worse on an automated static threshold perimetry test measuring the 
central 30 degrees of the visual field ``would serve as a reasonable 
criterion for disability determination.'' (See the full citation at the 
end of this preamble.) We agree with the NRC and would add this 
criterion as proposed listing 2.03B.
    Proposed listing 2.03C corresponds to current listing 2.03C. We 
propose to clarify the criterion by indicating that a determination of 
visual field efficiency must be based on kinetic visual field testing.

Proposed Listing 2.04--Loss of Visual Efficiency

    This proposed listing corresponds to current listing 2.04, ``Loss 
of visual efficiency.'' As already explained, we propose to remove the 
parenthetical statement at the end of the current listing because it is 
redundant. However, we propose to add a reference to that section of 
the proposed preface as a reminder of where this guidance is contained.
Proposed Table 1--Percentage of Visual Acuity Efficiency Corresponding 
to the Best-Corrected Visual Acuity Measurement for Distance in the 
Better Eye
    To be consistent with our proposed removal of the introductory text 
on aphakia, we propose to remove the columns and guidance addressing 
aphakia from current Table 1. We also propose to remove the entries for 
visual acuities worse than 20/100 for the reasons we gave under the 
explanation of proposed 2.00A8a.
Proposed Table 2--Charts of Visual Fields
    We propose to remove the first sentence of current paragraph 2 in 
the explanation of how to use Table 2, which provides instructions for 
calculating the percent of visual field efficiency, since this 
provision has been moved to proposed 2.00A7b. We also propose to make 
nonsubstantive editorial changes for clarity.

How Are We Proposing To Change the Introductory Text to the Special 
Senses Listings for Children?

102.00 Special Senses and Speech

    Except for minor editorial changes, we have repeated much of the 
introductory text of proposed 2.00A in the introductory text to 
proposed 102.00A. This is because the same basic rules for establishing 
and evaluating the existence and severity of visual disorders in adults 
also apply to children. Because we have already described these 
provisions under the explanation of proposed 2.00A, the following 
discussions describe only those provisions that are unique to the 
childhood rules or that require further explanation specific to 
evaluating disability in children.
    We propose to remove the second paragraph of current 102.00A, 
``Visual impairments in children.'' This paragraph indicates that the 
accommodative reflex is generally not present in children under 6 
months of age (or, for a premature child, until 6 months of age plus 
the number of months the child is premature). It also provides that the 
absence of this reflex should be considered indicative of a visual 
impairment only in children above this age. We include this guidance in 
the current rules to explain that it is not appropriate to use the 
criterion in current listing 102.02B1 until the child has reached the 
required age. However, in these proposed listings, current listing 
102.02B1 would be incorporated into the more general category of 
abnormal anatomical findings evaluated under proposed listing 102.02B2. 
As the lack of the accommodative reflex would not be considered an 
abnormal anatomical finding in very young children, its absence would 
not satisfy the proposed listing criterion. Therefore, we no longer 
need this explanation.

Proposed 102.00A1--What Are Visual Disorders?

    In this section, we would expand the guidance in proposed 2.00A1 to 
indicate that a loss of visual acuity may affect other age-appropriate 
activities. We added this example to reflect the way we evaluate 
disability claims of children who are filing for or are receiving SSI 
payments.

Proposed 102.00A2--What Is Statutory Blindness?

    In this section, we repeat the guidance in proposed 2.00A2, but 
refer to the childhood listings that show statutory blindness.

Proposed 102.00A4--What Evidence Do We Need To Evaluate Visual 
Disorders, Including Those That Result in Statutory Blindness Under 
Title II?

    In this section, we propose to include more detailed guidance than 
we now have in the third paragraph of current 102.00A. In proposed 
102.00A4a, we repeat the guidance in proposed section 2.00A4a. Proposed 
102.00A4b is also the same as proposed 2.00A4b, except that we include 
``near drowning'' rather than ``stroke'' as an example of a 
catastrophic event that could result in cortical blindness in children. 
We have included a different example because stroke is not likely to 
occur in children. Proposed 102.00A4c is the same as proposed 2.00A4c.

Proposed 102.00A5--How Do We Measure Best-Corrected Visual Acuity?

    In this section, we propose to revise the guidance in the first 
paragraph of current 102.00A. In proposed 102.00A5, we would repeat the 
guidance in proposed 2.00A5. We also discuss, in proposed 102.00A5a, 
comparable visual acuity testing for children who are unable to 
participate in testing using Snellen methodology, for example, because 
they are too young, and add guidance for how we propose to evaluate 
children who are unable to participate in testing using Snellen 
methodology or other comparable testing.

Proposed 102.00A6--How Do We Measure Visual Fields?

    In this section, we propose to repeat the guidance in 2.00A6 with 
the following exceptions:
     We would not include macular edema as an example of a 
visual disorder that could result in visual field loss because this 
disorder is not likely to occur in children.
     We would revise the guidance in the first paragraph of 
proposed 2.00A6a(ix) to include an additional way we evaluate 
disability claims of children who are filing for or are receiving SSI 
payments.

Proposed 102.00C--How Do We Evaluate Impairments That Do Not Meet One 
of the Special Senses and Speech Listings?

    In this section, we repeat the guidance in proposed 2.00C, but 
include the definition of disability for children who are filing for or 
are receiving SSI payments.

How Are We Proposing To Change the Criteria in the Special Senses and 
Speech Listings for Children?

102.01 Category of Impairments, Special Sense Organs

    We propose to add new listings 102.03, ``Contraction of the visual 
field in the better eye,'' and 102.04, ``Loss of visual efficiency,'' 
because they apply to children as well as adults. Due to the addition 
of these listings, we also propose to add Table 1, ``Percentage of 
Visual Acuity Efficiency Corresponding to the Best-Corrected Visual 
Acuity Measurements for Distance in the Better Eye,'' and Table 2, 
``Charts of Visual Fields.''
    These proposed new listings and tables are identical to the 
corresponding

[[Page 48348]]

adult listings and tables. Currently, we use listings 2.03 and 2.04 
(and their corresponding tables) to evaluate children with visual field 
and visual efficiency impairments. With proposed listings 102.03 and 
102.04 we would no longer need to refer to the listings in part A when 
we evaluate these impairments in children.

Proposed Listing 102.02--Loss of Visual Acuity

    This proposed listing corresponds to current listing 102.02, 
``Impairments of visual acuity.'' We are not proposing any changes to 
current listing 102.02A.
    We use current listing 102.02B to evaluate visual acuity 
impairments in children below 3 years of age at the time of 
adjudication. We propose to remove the age criterion and instead to 
provide that the listing will be used to evaluate a visual acuity 
disorder in any child who is unable to participate in testing using 
Snellen methodology or other comparable visual acuity testing, and who 
has specified abnormal anatomical findings.
    The criteria in current listing 102.02B are all examples of 
abnormal anatomical findings observable during a clinical eye 
examination. When present in the better eye, these abnormal anatomical 
findings would be expected to result in the absence of fixation and 
visual following behavior, and would indicate a visual acuity of 20/200 
or worse. Rather than list each type of abnormal anatomical finding, we 
propose to combine the current criteria into a general category of 
abnormal physical findings in proposed listing 102.02B1. Proposed 
listings 102.02B2 and 102.02B3 would add criteria for impairments that 
generally are not observable during a clinical eye examination, but are 
diagnosed based on abnormal neuroimaging or an abnormal 
electroretinogram.

Clarity of These Proposed Rules

    Executive Order 12866, as amended by Executive Order 13258, 
requires each agency to write all rules in plain language. In addition 
to your substantive comments on these proposed rules, we invite your 
comments on how to make these proposed rules easier to understand. For 
example:
     Have we organized the material to suit your needs?
     Are the requirements in the rules clearly stated?
     Do the rules contain technical language or jargon that is 
not clear?
     Would a different format (grouping and order of sections, 
use of headings, paragraphing) make the rules easier to understand?
     Would more (but shorter) sections be better?
     Could we improve clarity by adding tables, lists, or 
diagrams?
     What else could we do to make the rules easier to 
understand?

Regulatory Procedures

Executive Order 12866

    We have consulted with the Office of Management and Budget (OMB) 
and determined that these proposed rules meet the requirements for a 
significant regulatory action under Executive Order 12866, as amended 
by Executive Order 13258. Thus, they were subject to OMB review.

Regulatory Flexibility Act

    We certify that these proposed rules would not have a significant 
economic impact on a substantial number of small entities because they 
would affect only individuals. Thus, a regulatory flexibility analysis 
as provided in the Regulatory Flexibility Act, as amended, is not 
required.

Paperwork Reduction Act

    These proposed rules contain reporting requirements at 2.00A and 
102.00A. The public reporting burden is accounted for in the 
Information Collection Requests for the various forms that the public 
uses to submit information to SSA. Consequently, a 1-hour placeholder 
burden is being assigned to the specific reporting requirement(s) 
contained in these rules. We are seeking clearance of the burden 
referenced in these rules because they were not considered during the 
clearance of the forms. An Information Collection Request has been 
submitted to OMB. We are soliciting comments on the burden estimate; 
the need for the information; its practical utility; ways to enhance 
its quality, utility and clarity; and on ways to minimize the burden on 
respondents, including the use of automated collection techniques or 
other forms of information technology. Comments should be submitted or 
faxed to the Office of Management and Budget and to the Social Security 
Administration at the following addresses/numbers: Office of Management 
and Budget, Attn: Desk Officer for SSA, Fax Number: 202-395-6974. 
Social Security Administration, Attn: SSA Reports Clearance Officer, 
Rm. 1338 Annex Building, 6401 Security Boulevard, Baltimore, MD 21235-
6401, Fax Number: 410-965-6400.
    Comments can be received for up to 60 days after publication of 
this notice and will be most useful if received within 30 days of 
publication. To receive a copy of the OMB clearance package, you may 
call the SSA Reports Clearance Officer on 410-965-0454.

References

    We consulted the following sources when developing these proposed 
rules:
    Judie Charlton, MD, et al. ``A Comparison of Manual and Automated 
Kinetic Perimetry.'' Final Report: SSA-RFP-98-3537, n.d.
    National Research Council, Committee on Vision, Commission on 
Behavioral and Social Sciences and Education. Measurement of Visual 
Field and Visual Acuity for Disability Determination. Washington, DC: 
National Academy Press, 1994.
    National Research Council, Committee on Disability Determination 
for Individuals With Visual Impairments. Visual Impairments: 
Determining Eligibility for Social Security Benefits. Washington, DC: 
National Academy Press, 2002 (available at http://www.nap.edu/catalog/10320.html?se_side).
    American Medical Association. Guides to the Evaluation of Permanent 
Impairment. Fifth edition, AMA Press, 2001:252, 287-295.
    These references are included in the rulemaking record for these 
proposed rules and are available for inspection by interested 
individuals by making arrangements with the contact person shown in 
this preamble.

(Catalog of Federal Domestic Assistance Program Nos. 96.001, Social 
Security-Disability Insurance; 96.002, Social Security-Retirement 
Insurance; 96.004, Social Security-Survivors Insurance; and 96.006, 
Supplemental Security Income)

List of Subjects in 20 CFR Part 404

    Administrative practice and procedure, Blind, Disability benefits, 
Old-Age, Survivors, and Disability Insurance, Reporting and 
recordkeeping requirements, Social Security.

    Dated: May 11, 2005.
Jo Anne B. Barnhart,
Commissioner of Social Security.
    For the reasons set forth in the preamble, we propose to amend 
subpart P of part 404 of chapter III of title 20 of the Code of Federal 
Regulations as set forth below:

PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE 
(1950-)

    1. The authority citation for subpart P of part 404 continues to 
read as follows:

    Authority: Secs. 202, 205(a), (b), and (d)-(h), 216(i), 221(a) 
and (i), 222(c), 223, 225,

[[Page 48349]]

and 702(a)(5) of the Social Security Act (42 U.S.C. 402, 405(a), 
(b), and (d)-(h), 416(i), 421(a) and (i), 422(c), 423, 425, and 
902(a)(5)); sec. 211(b), Pub. L. 104-193, 110 Stat. 2105, 2189.

Appendix 1 to Subpart P of Part 404--[Amended]

    2. Appendix 1 to subpart P of part 404 is amended as follows:
    a. Item 3 of the introductory text before part A of appendix 1 is 
amended by revising the expiration date.
    b. Section 2.00A of part A of appendix 1 is revised.
    c. Section 2.00C is added to part A of appendix 1.
    d. Listing 2.02 of part A of appendix 1 is amended by revising the 
heading.
    e. Listing 2.03 of part A of appendix 1 is revised.
    f. Listing 2.04 of part A of appendix 1 is revised.
    g. The reservation for listing 2.05 is removed.
    h. Listing 2.06 of part A of appendix 1 is removed
    i. Tables 1 and 2 of section 2.01 of part A of appendix 1 are 
revised.
    j. Section 102.00A of part B of appendix 1 is revised.
    k. Section 102.00C is added to part B of appendix.
    l. Listing 102.02 of part B of appendix 1 is revised.
    m. Listing 102.03 is added to part B of appendix 1.
    n. Listing 102.04 is added to part B of appendix 1.
    o. Tables 1 and 2 are added to section 102.01 of part B of appendix 
1.
    The revised text is set forth as follows:

Appendix 1 to Subpart P of Part 404--Listing of Impairments

* * * * *
    3. Special Senses and Speech (2.00 and 102.00): (Insert date 8 
years from the effective date of the final rules).
* * * * *

Part A

* * * * *

2.00 SPECIAL SENSES AND SPEECH

A. How do we evaluate visual disorders?

    1. What are visual disorders? Visual disorders are abnormalities 
of the eye, the optic nerve, the optic tracts, or the brain that may 
cause a loss of visual acuity or visual fields. A loss of visual 
acuity limits your ability to distinguish detail, read, or do fine 
work. A loss of visual fields limits your ability to perceive visual 
stimuli in the peripheral extent of vision.
    2. What is statutory blindness? Statutory blindness is blindness 
as defined in the Social Security Act (the Act). The Act defines 
blindness as visual acuity of 20/200 or less in the better eye with 
the use of a correcting lens. The Act also provides that an eye that 
has a visual field limitation such that the widest diameter of the 
visual field subtends an angle no greater than 20 degrees is 
considered as having visual acuity of 20/200 or less. You have 
statutory blindness if your visual disorder meets the criteria of 
2.02 or 2.03A.

3. What Evidence Do We Need To Establish Statutory Blindness Under 
Title XVI?

    For title XVI, the only evidence we need to establish statutory 
blindness is evidence showing that your visual acuity or visual 
field, in the better eye, meets the criteria in A2 above, provided 
that those measurements are consistent with the other evidence in 
your case record. We do not need to document the cause of your 
blindness. Also, there is no duration requirement for statutory 
blindness under title XVI (see Sec. Sec.  416.981 and 416.983).

4. What Evidence Do We Need To Evaluate Visual Disorders, Including 
Those That Result in Statutory Blindness Under Title II?

    a. To evaluate your visual disorder, we usually need a report of 
an eye examination that includes measurements of the best-corrected 
visual acuity or the extent of the visual fields, as appropriate. If 
there is a loss of visual acuity or visual fields, the cause of the 
loss must be documented. A standard eye examination will usually 
reveal the cause of any visual acuity loss. An eye examination can 
also reveal the cause of some types of visual field deficits. If the 
eye examination does not reveal the cause of the visual loss, we 
will request the information that was used to establish the presence 
of the visual disorder.
    b. A diagnosis of cortical blindness (blindness due to a brain 
lesion) must be confirmed by documentation of the catastrophic 
event, such as a cardiac arrest or stroke, that caused the brain 
lesion. If neuroimaging was performed, we will request a copy of the 
report or other medical evidence that describes the findings in the 
report.
    c. If your visual disorder does not satisfy the criteria in 
2.02, 2.03, or 2.04, we will also request a description of how your 
visual disorder impacts your ability to function.

5. How Do We Measure Best-Corrected Visual Acuity?

    a. Testing for visual acuity. When we need to measure your best-
corrected visual acuity, we will use visual acuity testing that was 
carried out using Snellen methodology or any other testing 
methodology that is comparable to Snellen methodology.
    b. Determining best-corrected visual acuity.
    i. Best-corrected visual acuity is the optimal visual acuity 
attainable with the use of a corrective lens. In some instances, 
this assessment may be performed using a specialized lens; for 
example, a contact lens. We will use the visual acuity measurements 
obtained with a specialized lens only if you have demonstrated the 
ability to use the specialized lens on a sustained basis. However, 
we will not use visual acuity measurements obtained with telescopic 
lenses because they significantly reduce the visual field. 
Additionally, we will not use the results of visual evoked response 
testing or pinhole testing to determine best-corrected visual 
acuity.
    ii. We will use the best-corrected visual acuity for distance in 
the better eye when we determine whether your loss of visual acuity 
satisfies the criteria in 2.02.

6. How Do We Measure Visual Fields?

    a. Testing for visual fields.
    i. We generally need visual field testing when you have a visual 
disorder that could result in visual field loss, such as glaucoma, 
retinitis pigmentosa, macular edema, or optic neuropathy, or when 
you display behaviors that suggest a visual field loss.
    ii. When we need to measure the extent of your visual field 
loss, we will use visual field measurements obtained with an 
automated static threshold perimetry test performed on a perimeter, 
like the Humphrey Field Analyzer, that satisfies all of the 
following requirements:
    A. The perimeter must use optical projection to generate the 
test stimuli.
    B. The perimeter must have an internal normative database for 
automatically comparing your performance with that of the general 
population.
    C. The perimeter must have a statistical analysis package that 
is able to calculate visual field indices, particularly mean 
deviation.
    D. The perimeter must demonstrate the ability to correctly 
detect visual field loss and correctly identify normal visual 
fields.
    E. The perimeter must demonstrate good test-retest reliability.
    F. The perimeter must have undergone clinical validation studies 
by three or more independent laboratories with results published in 
peer-reviewed ophthalmic journals.
    iii. The test must use a white size III Goldmann stimulus and a 
31.5 apostilb (10 cd/m2) white background. The stimuli 
locations must be no more than 6 degrees apart horizontally or 
vertically. Measurements must be reported on standard charts and 
include a description of the size and intensity of the test 
stimulus.
    iv. To determine statutory blindness, we need a test that 
measures the central 24 to 30 degrees of the visual field; that is, 
the area measuring 24 to 30 degrees from the point of fixation. 
Acceptable tests include the Humphrey 30-2 or 24-2 tests.
    v. To determine if the criterion in 2.03B is met, we need a test 
performed on a Humphrey field analyzer that measures the central 30 
degrees of the visual field. (We can also use comparable results 
from other acceptable perimeters, for example, a mean defect of 22 
on an acceptable Octopus test, to determine that the criterion in 
2.03B is met.) We cannot use tests that do not measure the central 
30 degrees of the visual field, such as the Humphrey 24-2 test, to 
determine if your impairment meets or medically equals 2.03B.
    vi. We measure the extent of visual field loss by determining 
the portion of the visual field in which you can see a white III4e 
stimulus. As indicated above, the ``III'' refers to the standard 
Goldmann test stimulus size III. The ``4e'' refers to the standard 
Goldmann intensity filters used to determine the intensity of the 
stimulus.
    vii. In automated static threshold perimetry, the intensity of 
the stimulus

[[Page 48350]]

varies. The intensity of the stimulus is expressed in decibels (dB). 
We need to determine the dB level that corresponds to a 4e intensity 
for the particular perimeter being used. We will then use the dB 
printout to determine which points would be seen at a 4e intensity 
level. For example, in Humphrey perimeters, a 10 dB stimulus is 
equivalent to a 4e stimulus. A dB level that is higher than 10 
represents a dimmer stimulus, while a dB level that is lower than 10 
represents a brighter stimulus. Therefore, for tests performed on 
Humphrey perimeters, any point seen at 10 dB or higher is a point 
that would be seen with a 4e stimulus.
    viii. We can also use visual field measurements obtained using 
kinetic perimetry, such as the Humphrey ``SSA Test Kinetic'' or 
Goldmann perimetry. The test must use a white III4e stimulus 
projected on a white 31.5 apostilb (10 cd/m\2\) background. In 
automated kinetic tests, such as the Humphrey ``SSA Test Kinetic,'' 
testing along a meridian stops when you see the stimulus. If we need 
additional information because your visual disorder has progressed 
to the point where it is likely to result in a significant 
limitation in the central visual field, such as a scotoma, we will 
supplement the automated kinetic perimetry with the results of a 
Humphrey 30-2 or comparable test.
    ix. We will not use the results of visual field screening tests, 
such as confrontation tests, tangent screen tests, or automated 
static screening tests, to determine that your impairment meets or 
medically equals a listing or to evaluate your residual functional 
capacity. We will use normal results from visual field screening 
tests to determine whether the impact of your visual disorder on 
your visual field is severe when these test results are consistent 
with the other evidence in your case record. We will not consider 
normal test results to be consistent with the other evidence if 
either of the following applies:
    A. The clinical findings indicate that your visual disorder has 
progressed to the point that it is likely to cause visual field 
loss.
    B. You have a history of an operative procedure for retinal 
detachment.
    b. Use of corrective lenses. You must not wear eyeglasses during 
the visual field examination because they limit your field of 
vision. Contact lenses or perimetric lenses may be used to correct 
visual acuity during the visual field examination in order to obtain 
the most accurate visual field measurements. For this single 
purpose, you do not need to demonstrate that you have the ability to 
use the contact or perimetric lenses on a sustained basis.

7. How Do We Calculate Visual Efficiency?

    a. Visual acuity efficiency. We use the percentage shown in 
Table 1 that corresponds to the best-corrected visual acuity for 
distance in the better eye.
    b. Visual field efficiency. We use kinetic perimetry to 
calculate visual field efficiency by adding the number of degrees 
seen along the eight principal meridians in the better eye and 
dividing by 500. (See Table 2.)
    c. Visual efficiency. We calculate the percent of visual 
efficiency by multiplying the visual acuity efficiency by the visual 
field efficiency.

8. How Do We Evaluate Specific Visual Problems?

    a. Statutory blindness. Most test charts that use Snellen 
methodology do not measure visual acuity between 20/100 and 20/200. 
Newer test charts, such as the Bailey-Lovie or the Early Treatment 
Diabetic Retinopathy Study (ETDRS), do measure visual acuity between 
20/100 and 20/200. If your visual acuity is measured with one of 
these newer charts, and you cannot read any of the letters on the 
20/100 line, we will determine that you have statutory blindness 
based on a visual acuity of 20/200 or less. Regardless of the type 
of test chart used, you do not have statutory blindness if you can 
read at least one letter on the 20/100 line.
    b. Blepharospasm. This movement disorder is characterized by 
repetitive, involuntary, bilateral eye blinking. It generally 
responds to therapy. When therapy is not effective, we will evaluate 
this disorder on the basis of clinical observations or visual 
behaviors. If you have this disorder, you may have measurable visual 
acuities and visual fields that do not satisfy the criteria of 2.02 
or 2.03. However, we must consider how the involuntary blinking 
affects your ability to maintain the measured visual acuities and 
visual fields over time.
    c. Scotoma. A scotoma is a non-seeing area in the visual field 
surrounded by a seeing area. When we measure the visual field, we 
subtract the length of any scotoma, other than the normal blind 
spot, from the overall length of any diameter on which it falls.
* * * * *

C. How Do We Evaluate Impairments That Do Not Meet One of the 
Special Senses and Speech Listings?

    1. These listings are only examples of common special senses and 
speech disorders that we consider severe enough to prevent an 
individual from doing any gainful activity. If your impairment(s) 
does not meet the criteria of any of these listings, we must also 
consider whether you have an impairment(s) that satisfies the 
criteria of a listing in another body system.
    2. If you have a medically determinable impairment(s) that does 
not meet a listing, we will determine whether the impairment(s) 
medically equals a listing. (See Sec. Sec.  404.1526 and 416.926.) 
If you have an impairment(s) that does not meet or medically equal a 
listing, you may or may not have the residual functional capacity to 
engage in substantial gainful activity. Therefore, we proceed to the 
fourth, and if necessary, the fifth steps of the sequential 
evaluation process in Sec. Sec.  404.1520 and 416.920. When we 
decide whether you continue to be disabled, we use the rules in 
Sec. Sec.  404.1594, 416.994, or 416.994a as appropriate.
    2.01 Category of Impairments, Special Senses and Speech
    2.02 Loss of visual acuity. Remaining vision in the better eye 
after best correction is 20/200 or less.
    2.03 Contraction of the visual field in the better eye, with:
    A. The widest diameter subtending an angle no greater than 20 
degrees;

OR

    B. A mean deviation of -22 or worse, determined by automated 
static threshold perimetry as described in 2.00A6a(v);

OR

    C. A visual field efficiency of 20 percent or less as determined 
by kinetic perimetry (see 2.00A7b).
    2.04 Loss of visual efficiency. Visual efficiency of the better 
eye of 20 percent or less after best correction (see 2.00A7c).
* * * * *

  Table 1.--Percentage of Visual Acuity Efficiency Corresponding to the
 Best-Corrected Visual Acuity Measurement for Distance in the Better Eye
------------------------------------------------------------------------
                     Snellen                       Percent visual acuity
-------------------------------------------------       efficiency
                                                 -----------------------
        English                   Metric          Phakic or Pseudophakic
------------------------------------------------------------------------
              20/16                    6/5                       100
              20/20                    6/6                       100
              20/25                    6/7.5                      95
              20/32                   6/10                        90
              20/40                   6/12                        85
              20/50                   6/15                        75
              20/64                   6/20                        65
              20/80                   6/24                        60
             20/100                   6/30                        50
------------------------------------------------------------------------


[[Page 48351]]

Table 2.--Chart of Visual Fields
[GRAPHIC] [TIFF OMITTED] TP17AU05.000

    1. The diagram of the right eye illustrates the extent of a 
normal visual field as measured with a III4e stimulus. The sum of 
the eight principal meridians of this field is 500 degrees.
    2. The diagram of the left eye illustrates a visual field 
contracted to 30 degrees in two meridians and to 20 degrees in the 
remaining six meridians. The percent of visual field efficiency of 
this field is: (2 x 30) + (6 x 20) = 180 / 500 = 0.36 or 36 percent 
visual field efficiency.
* * * * *

Part B

* * * * *

102.00 SPECIAL SENSES AND SPEECH

A. How Do We Evaluate Visual Disorders?

1. What Are Visual Disorders?

    Visual disorders are abnormalities of the eye, the optic nerve, 
the optic tracts, or the brain that may cause a loss of visual 
acuity or visual fields. A loss of visual acuity limits your ability 
to distinguish detail, read, do fine work, or perform other age-
appropriate activities. A loss of visual fields limits your ability 
to perceive visual stimuli in the peripheral extent of vision.

2. What Is Statutory Blindness?

    Statutory blindness is blindness as defined in the Social 
Security Act (the Act). The Act defines blindness as visual acuity 
of 20/200 or less in the better eye with the use of a correcting 
lens. The Act also provides that an eye that has a visual field 
limitation such that the widest diameter of the visual field 
subtends an angle no greater than 20 degrees is considered as having 
visual acuity of 20/200 or less. You have statutory blindness if 
your visual disorder meets the criteria of 102.02A, 102.02B, or 
102.03A.

3. What Evidence Do We Need To Establish Statutory Blindness Under 
Title XVI?

    For title XVI, the only evidence we need to establish statutory 
blindness is evidence showing that your visual acuity or visual 
field, in the better eye, meets the criteria in A2 above, provided 
that those measurements are consistent with the other evidence in 
your case record. We do not need to document the cause of your 
blindness. Also, there is no duration requirement for statutory 
blindness under title XVI (see Sec. Sec.  416.981 and 416.983).

4. What Evidence Do We Need To Evaluate Visual Disorders, Including 
Those That Result in Statutory Blindness Under Title II?

    a. To evaluate your visual disorder, we usually need a report of 
an eye examination that includes measurements of the best-corrected 
visual acuity or the extent of the visual fields, as appropriate. If 
there is a loss of visual acuity or visual fields, the cause of the 
loss must be documented. A standard eye examination will usually 
reveal the cause of any visual acuity loss. An eye examination can 
also reveal the cause of some types of visual field deficits. If the 
eye examination does not reveal the cause of the visual loss, we 
will request the information that was used to establish the presence 
of the visual disorder.
    b. A diagnosis of cortical blindness (blindness due to a brain 
lesion) must be confirmed by documentation of the catastrophic 
event, such as a cardiac arrest or near drowning, that caused the 
brain lesion. If neuroimaging was performed, we will request a copy 
of the report or other medical evidence that describes the findings 
in the report.
    c. If your visual disorder does not satisfy the criteria in 
102.02, 102.03, or 102.04, we will also request a description of how 
your visual disorder impacts your ability to function.

5. How Do We Measure Best-Corrected Visual Acuity?

    a. Testing for visual acuity.
    i. When we need to measure your best-corrected visual acuity, we 
will use visual acuity testing that was carried out using Snellen 
methodology or any other testing methodology that is comparable to 
Snellen methodology.
    ii. We consider tests such as the Landolt C test or the 
tumbling-E test, which are used to evaluate young children who are 
unable to participate in testing using Snellen methodology, to be 
comparable to testing using Snellen methodology. These alternate 
methods for measuring visual acuity should

[[Page 48352]]

be performed by specialists with expertise in assessment of 
childhood vision.
    iii. If you are unable to participate in testing using Snellen 
methodology or other comparable testing, we will consider your 
fixation and visual following behavior. If both these behaviors are 
absent, we will consider the anatomical findings or the results of 
neuroimaging when this testing has been performed.
    b. Determining best-corrected visual acuity.
    i. Best-corrected visual acuity is the optimal visual acuity 
attainable with the use of a corrective lens. In some instances, 
this assessment may be performed using a specialized lens; for 
example, a contact lens. We will use the visual acuity measurements 
obtained with a specialized lens only if you have demonstrated the 
ability to use the specialized lens on a sustained basis. However, 
we will not use visual acuity measurements obtained with telescopic 
lenses because they significantly reduce the visual field. 
Additionally, we will not use the results of visual evoked response 
testing or pinhole testing to determine best-corrected visual 
acuity.
    ii. We will use the best-corrected visual acuity for distance in 
the better eye when we determine whether your loss of visual acuity 
satisfies the criteria in 102.02A.

6. How Do We Measure Visual Fields?

    a. Testing for visual fields.
    i. We generally need visual field testing when you have a visual 
disorder that could result in visual field loss, such as glaucoma, 
retinitis pigmentosa, or optic neuropathy, or when you display 
behaviors that suggest a visual field loss.
    ii. When we need to measure the extent of your visual field 
loss, we will use visual field measurements obtained with an 
automated static threshold perimetry test performed on a perimeter, 
like the Humphrey Field Analyzer, that satisfies all of the 
following requirements:
    A. The perimeter must use optical projection to generate the 
test stimuli.
    B. The perimeter must have an internal normative database for 
automatically comparing your performance with that of the general 
population.
    C. The perimeter must have a statistical analysis package that 
is able to calculate visual field indices, particularly mean 
deviation.
    D. The perimeter must demonstrate the ability to correctly 
detect visual field loss and correctly identify normal visual 
fields.
    E. The perimeter must demonstrate good test-retest reliability.
    F. The perimeter must have undergone clinical validation studies 
by three or more independent laboratories with results published in 
peer-reviewed ophthalmic journals.
    iii. The test must use a white size III Goldmann stimulus and a 
31.5 apostilb (10 cd/m2) white background. The stimuli locations 
must be no more than 6 degrees apart horizontally or vertically. 
Measurements must be reported on standard charts and include a 
description of the size and intensity of the test stimulus.
    iv. To determine statutory blindness, we need a test that 
measures the central 24 to 30 degrees of the visual field; that is, 
the area measuring 24 to 30 degrees from the point of fixation. 
Acceptable tests include the Humphrey 30-2 or 24-2 tests.
    v. To determine if the criterion in 102.03B is met, we need a 
test performed on a Humphrey field analyzer that measures the 
central 30 degrees of the visual field. (We can also use comparable 
results from other acceptable perimeters, for example, a mean defect 
of 22 on an acceptable Octopus test, to determine that the criterion 
in 102.03B is met.) We cannot use tests that do not measure the 
central 30 degrees of the visual field, such as the Humphrey 24-2 
test, to determine if your impairment meets or medically equals 
102.03B.
    vi. We measure the extent of visual field loss by determining 
the portion of the visual field in which you can see a white III4e 
stimulus. As indicated above, the ``III'' refers to the standard 
Goldmann test stimulus size III. The ``4e'' refers to the standard 
Goldmann intensity filters used to determine the intensity of the 
stimulus.
    vii. In automated static threshold perimetry, the intensity of 
the stimulus varies. The intensity of the stimulus is expressed in 
decibels (dB). We need to determine the dB level that corresponds to 
a 4e intensity for the particular perimeter being used. We will then 
use the dB printout to determine which points would be seen at a 4e 
intensity level. For example, in Humphrey perimeters, a 10 dB 
stimulus is equivalent to a 4e stimulus. A dB level that is higher 
than 10 represents a dimmer stimulus, while a dB level that is lower 
than 10 represents a brighter stimulus. Therefore, for tests 
performed on Humphrey perimeters, any point seen at 10 dB or higher 
is a point that would be seen with a 4e stimulus.
    viii. We can also use visual field measurements obtained using 
kinetic perimetry, such as the Humphrey ``SSA Test Kinetic'' or 
Goldmann perimetry. The test must use a white III4e stimulus 
projected on a white 31.5 apostilb (10 cd/m2) background. In 
automated kinetic tests, such as the Humphrey ``SSA Test Kinetic,'' 
testing along a meridian stops when you see the stimulus. If we need 
additional information because your visual disorder has progressed 
to the point where it is likely to result in a significant 
limitation in the central visual field, such as a scotoma, we will 
supplement the automated kinetic perimetry with the results of a 
Humphrey 30-2 or comparable test.
    ix. We will not use the results of visual field screening tests, 
such as confrontation tests, tangent screen tests, or automated 
static screening tests, to determine that your impairment meets or 
medically equals a listing, or functionally equals the listings. We 
will use normal results from visual field screening tests to 
determine whether the impact of your visual disorder on your visual 
field is severe when these test results are consistent with the 
other evidence in your case record. We will not consider normal test 
results to be consistent with the other evidence if either of the 
following applies:
    A. The clinical findings indicate that your visual disorder has 
progressed to the point that it is likely to cause visual field 
loss.
    B. You have a history of an operative procedure for retinal 
detachment.
    b. Use of corrective lenses. You must not wear eyeglasses during 
the visual field examination because they limit your field of 
vision. Contact lenses or perimetric lenses may be used to correct 
visual acuity during the visual field examination in order to obtain 
the most accurate visual field measurements. For this single 
purpose, you do not need to demonstrate that you have the ability to 
use the contact or perimetric lenses on a sustained basis.

7. How Do We Calculate Visual Efficiency?

    a. Visual acuity efficiency. We use the percentage shown in 
Table 1 that corresponds to the best-corrected visual acuity for 
distance in the better eye.
    b. Visual field efficiency. We use kinetic perimetry to 
calculate visual field efficiency by adding the number of degrees 
seen along the eight principal meridians in the better eye and 
dividing by 500. (See Table 2.)
    c. Visual efficiency. We calculate the percent of visual 
efficiency by multiplying the visual acuity efficiency by the visual 
field efficiency.

8. How Do We Evaluate Specific Visual Problems?

    a. Statutory blindness. Most test charts that use Snellen 
methodology do not measure visual acuity between 20/100 and 20/200. 
Newer test charts, such as the Bailey-Lovie or the Early Treatment 
Diabetic Retinopathy Study (ETDRS), do measure visual acuity between 
20/100 and 20/200. If your visual acuity is measured with one of 
these newer charts, and you cannot read any of the letters on the 
20/100 line, we will determine that you have statutory blindness 
based on a visual acuity of 20/200 or less. Regardless of the type 
of test used, you do not have statutory blindness if you can read at 
least one letter on the 20/100 line.
    b. Blepharospasm. This movement disorder is characterized by 
repetitive, involuntary, bilateral eye blinking. It generally 
responds to therapy. When therapy is not effective, we will evaluate 
this disorder on the basis of clinical observations or visual 
behaviors. If you have this disorder, you may have measurable visual 
acuities and visual fields that do not satisfy the criteria of 
102.02 or 102.03. However, we must consider how the involuntary 
blinking affects your ability to maintain the measured visual 
acuities and visual fields over time.
    c. Scotoma. A scotoma is a non-seeing area in the visual field 
surrounded by a seeing area. When we measure the visual field, we 
subtract the length of any scotoma, other than the normal blind 
spot, from the overall length of any diameter on which it falls.
* * * * *

C. How Do We Evaluate Impairments That Do Not Meet One of the 
Special Senses and Speech Listings?

    1. These listings are only examples of common special senses and 
speech disorders that we consider severe enough to result in marked 
and severe functional limitations. If your impairment(s) does not 
meet the criteria of any of these listings, we must also

[[Page 48353]]

consider whether you have an impairment(s) that satisfies the 
criteria of a listing in another body system.
    2. If you have a medically determinable impairment(s) that does 
not meet a listing, we will determine whether the impairment(s) 
medically equals a listing or functionally equals the listings. (See 
Sec. Sec.  404.1526, 416.926, and 416.926a.) If you are receiving 
title XVI payments, we use the rules in Sec.  416.994a when we 
decide whether you continue to be disabled.
* * * * *
    102.02 Loss of visual acuity.
    A. Remaining vision in the better eye after best correction is 
20/200 or less;

OR

    B. An inability to participate in testing using Snellen 
methodology or other comparable visual acuity testing and clinical 
findings that fixation and visual following behavior are absent in 
the better eye, and:
    1. Abnormal anatomical findings indicating a visual acuity of 
20/200 or worse in the better eye; or
    2. Abnormal neuroimaging documenting damage to the cerebral 
cortex which would be expected to prevent the development, in the 
better eye, of a visual acuity better than 20/200; or
    3. Abnormal electroretinogram documenting the presence of 
Leber's congenital amaurosis or achromatopsia.
    102.03 Contraction of the visual field in the better eye, with:
    A. The widest diameter subtending an angle no greater than 20 
degrees;

OR

    B. A mean deviation of -22 or worse, determined by automated 
static threshold perimetry as described in 102.00A6a(v);

OR

    C. A visual field efficiency of 20 percent or less as determined 
by kinetic perimetry (see 102.00A7b).
    102.04 Loss of visual efficiency. Visual efficiency of the 
better eye of 20 percent or less after best correction (see 
102.00A7c).
* * * * *

  Table 1.--Percentage of Visual Acuity Efficiency Corresponding to the
Best-Corrected Visual Acuity Measurement for Distance in the Better Eye.
------------------------------------------------------------------------
                     Snellen                       Percent visual acuity
-------------------------------------------------       efficiency
                                                 -----------------------
        English                   Metric          Phakic or Pseudophakic
------------------------------------------------------------------------
              20/16                    6/5                       100
              20/20                    6/6                       100
              20/25                    6/7.5                      95
              20/32                   6/10                        90
              20/40                   6/12                        85
              20/50                   6/15                        75
              20/64                   6/20                        65
              20/80                   6/24                        60
             20/100                   6/30                        50
------------------------------------------------------------------------

Table 2.--Chart of Visual Fields
[GRAPHIC] [TIFF OMITTED] TP17AU05.001


[[Page 48354]]


    1. The diagram of the right eye illustrates the extent of a 
normal visual field as measured with a III4e stimulus. The sum of 
the eight principal meridians of this field is 500 degrees.
    2. The diagram of the left eye illustrates a visual field 
contracted to 30 degrees in two meridians and to 20 degrees in the 
remaining six meridians. The percent of visual field efficiency of 
this field is: (2x30) + (6x20) = 180 / 500 = 0.36 or 36 percent 
visual field efficiency.
* * * * *
[FR Doc. 05-16218 Filed 8-16-05; 8:45 am]
BILLING CODE 4191-02-P