[Federal Register Volume 77, Number 29 (Monday, February 13, 2012)]
[Proposed Rules]
[Pages 7549-7558]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2012-3226]


=======================================================================
-----------------------------------------------------------------------

SOCIAL SECURITY ADMINISTRATION

20 CFR Part 404

[Docket No. SSA-2010-0078]
RIN 0960-AH28


Revised Medical Criteria for Evaluating Visual Disorders

AGENCY: Social Security Administration.

ACTION: Notice of proposed rulemaking.

-----------------------------------------------------------------------

SUMMARY: We propose to revise and reorganize the criteria in the 
Listing of Impairments (listings) that we use to evaluate cases 
involving visual disorders in adults and children under titles II and 
XVI of the Social Security Act (Act). The proposed revisions reflect 
our program experience and address adjudicator questions we have 
received since we last revised these criteria in 2006. These proposed 
revisions reflect guidance we have issued in response to adjudicator 
questions and will ensure more timely adjudication of claims in which 
we evaluate visual impairments that involve a loss of visual acuity or 
loss of visual fields.

DATES: To ensure that your comments are considered, we must receive 
them by no later than April 13, 2012.

ADDRESSES: You may submit comments by any one of three methods--
Internet, fax, or mail. Do not submit the same comments multiple times 
or by more than one method. Regardless of which method you choose, 
please state that your comments refer to Docket No. SSA-2010-0078 so 
that we may

[[Page 7550]]

associate your comments with the correct regulation.
    Caution: You should be careful to include in your comments only 
information that you wish to make publicly available. We strongly urge 
you not to include in your comments any personal information, such as 
Social Security numbers or medical information.
    1. Internet: We strongly recommend that you submit your comments 
via the Internet. Visit the Federal eRulemaking portal at http://www.regulations.gov. Use the Search function to find docket number SSA-
2010-0078. The system will issue you a tracking number to confirm your 
submission. You will not be able to view your comment immediately 
because we must post each comment manually. It may take up to a week 
for your comment to be viewable.
    2. Fax: Fax comments to (410) 966-2830.
    3. Mail: Address your comments to the Office of Regulations, Social 
Security Administration, 107 Altmeyer Building, 6401 Security 
Boulevard, Baltimore, Maryland 21235-6401.
    Comments are available for public viewing on the Federal 
eRulemaking portal at http://www.regulations.gov or in person, during 
regular business hours, by arranging with the contact person identified 
below.

FOR FURTHER INFORMATION CONTACT: Cheryl Williams, Office of Medical 
Listings Improvement, Social Security Administration, 6401 Security 
Boulevard, Baltimore, Maryland 21235-6401, (410) 965-1020. 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 site, Social Security Online, at http://www.socialsecurity.gov.

SUPPLEMENTARY INFORMATION: 

Why are we proposing to revise the listings for evaluating visual 
disorders?

    We last published final rules revising the criteria that we use to 
evaluate visual disorders in the Federal Register on November 20, 
2006.\1\ Although these listings do not expire until February 20, 2015, 
we are proposing to revise them now to reflect our program experience 
and to address adjudicator questions that we have received since 2006. 
We intend to publish revisions that would update the criteria for 
evaluating hearing disorders and speech and language disorders 
separately.
---------------------------------------------------------------------------

    \1\ 71 FR 67037.
---------------------------------------------------------------------------

What changes are we proposing to the introductory text of the adult 
listings for evaluating visual disorders?

    Most of the proposed introductory text is substantively the same as 
the current introductory text. We propose to clarify, simplify, and 
reorganize the introductory text. We also propose to expand some 
sections to clarify the existing guidance and to include additional 
acceptable testing for evaluating a person's visual field loss. In the 
following paragraphs, we describe the significant changes we propose to 
make to the introductory text of the adult listings for evaluating 
visual disorders in part A of appendix 1 to subpart P of part 404, 
using the titles of the proposed sections.

Section 2.00A2, How do we define statutory blindness?

    In proposed 2.00A2a, we would add the word ``central'' before 
``visual acuity'' to correct the definition of statutory blindness in 
current 2.00A2. We would also add a reference to proposed 2.00A5, which 
explains visual acuity testing requirements. In proposed 2.00A2b, we 
would add a reference to proposed 2.00A6, which explains our visual 
field testing requirements. In proposed 2.00A2c, we would add proposed 
listings 2.04A and 2.04B to our guidance in current 2.00A2, which 
explains that if your visual disorder medically equals the criteria of 
2.02 or 2.03A, or meets or medically equals 2.03B, 2.03C, or 2.04, we 
will find that you have a disability if your visual disorder also meets 
the duration requirement.

Section 2.00A4, What evidence do we need to evaluate visual disorders, 
including those that result in statutory blindness under title II?

    In proposed 2.00A4, we would remove current 2.00A4b, which 
describes cortical visual disorders, because it does not provide useful 
guidance to adjudicators on how to evaluate vision loss due to cortical 
visual disorders. While we added current 2.00A4b when we last published 
final rules making comprehensive revisions to section 2.00 on November 
20, 2006,\2\ it is not our intention to list in these rules every 
visual disorder that may result in vision loss. We propose to include 
cortical visual disorders as an example of a disorder that may result 
in abnormalities that do not appear on a standard eye examination. We 
also intend to provide guidance for evaluating a person's vision loss 
due to cortical visual disorders and any other disorders that may 
result in vision loss or a loss in visual functioning (for example, 
blepharospasm) in our internal operating instructions and training.
---------------------------------------------------------------------------

    \2\ 71 FR 67040, 67045, 67046, and 67049.
---------------------------------------------------------------------------

Section 2.00A5, How do we measure your best-corrected central visual 
acuity?

    We propose to make the following changes to current 2.00A5:
     Provide guidance in proposed 2.00A5a(ii) that explains how 
we use visual acuity measurements not recorded in Snellen notation, 
such as counts fingers (CF) or no light perception (NLP), to evaluate 
your vision loss. This guidance is in response to questions from our 
adjudicators.
     Add the guidance in current 2.00A8a, which explains how we 
use test charts that measure visual acuity between 20/100 and 20/200, 
to proposed 2.00A5b.
     Provide guidance in proposed 2.00A5d, which we currently 
provide in our internal operating instructions, that explains how we 
use the results of cycloplegic refraction.

Section 2.00A6, How do we measure your visual fields?

    We propose to make the following changes to current 2.00A6:
     Combine the guidance in current 2.00A6a(i) and 2.00A6a(ii) 
in proposed 2.00A6a, with one exception. As we explain below, we would 
move the guidance that explains our requirements for acceptable 
perimeters in current 2.00A6a(ii) to proposed section 2.00A8.
     Move the guidance on visual field testing requirements in 
current 2.00A6a(iii), (vi), and (vii), to proposed 2.00A6b(i), (ii), 
and (iii), respectively.
     Revise our guidance on automated static threshold 
perimeters to remove specific references to perimeter manufacturers. In 
the preamble to our final rules published in the Federal Register on 
November 20, 2006, we explained that while the National Research 
Council (NRC) 2002 report, Visual Impairments: Determining Eligibility 
for Social Security Benefits, cited both the Humphrey Field Analyzer 
and the Octopus perimeter as acceptable perimeters, we were not 
including the Octopus perimeter as an example of an acceptable 
perimeter. We decided not to include the Octopus perimeter at that time 
because we did not intend to list every acceptable perimeter in our 
rules. However, since the publication of those rules, we have received 
numerous questions from adjudicators on the acceptability of the tests 
performed on Octopus and other perimeters. We have determined that 
other tests (including the Octopus 32) and perimeters

[[Page 7551]]

(including the Octopus 300 Series), meet our requirements for 
acceptable testing and acceptable perimeters.
     Move the guidance in current 2.00A6a(iv), which explains 
how we evaluate vision loss under 2.03A, to proposed 2.00A6c, and add 
the Octopus 32 test as an acceptable test.
     Move the guidance in current 2.00A6a(v), which explains 
how we evaluate vision loss under 2.03B, to proposed 2.00A6d. We would 
add the definition of the term mean deviation (or defect), abbreviated 
as MD, which we use in current and proposed 2.03B but do not define. We 
would explain that Humphrey Field Analyzer (HFA) tests report the MD as 
a negative number and, therefore, we use the absolute value of the MD 
when determining whether the person's visual field loss meets the 
listing.
     Move the guidance in current 2.00A6a(viii), which explains 
when we can use visual field measurements obtained using kinetic 
perimetry to evaluate vision loss, to proposed 2.00A6e.
     Move the guidance on visual field screening tests in 
current 2.00A6a(ix) to proposed 2.00A6f.
     Move the guidance on the use of corrective lenses in 
visual field testing in current 2.00A6b to proposed 2.00A6g.
     Move the guidance on scotomas in current 2.00A8c to 
proposed 2.00A6h.

2.00A7, How do we determine your visual acuity efficiency, visual field 
efficiency, and visual efficiency?

    We propose to make the following changes to current 2.00A7:
     Introduce ``value'' as a term to express visual 
efficiency, in addition to the term ``percentage,'' in proposed 
2.00A7a, which we explain in the paragraphs below.
     Add current Table 1 (Percentage of Visual Acuity 
Efficiency Corresponding to Best-Corrected Visual Acuity), which is 
located at the end of the current special senses and speech listings, 
to proposed 2.00A7b because it is more useful to our adjudicators to 
place this table in the introductory text immediately after the 
explanation of visual acuity efficiency. Our current rules describe 
overall visual efficiency as a percentage and we provide the equivalent 
visual acuity efficiency percentages corresponding to Snellen best-
corrected central visual acuities for distance in Table 1. In the 
proposed table, we would include a column for visual acuity efficiency 
values that correspond to Snellen best-corrected central visual 
acuities for distance.
     Expand current 2.00A7b and redesignate as proposed 
2.00A7c. A person's visual field efficiency can be expressed as a 
percentage (using the visual field determined by kinetic perimetry) or 
as a value (using the MD determined by automated static threshold 
perimetry). We would explain that a visual field efficiency percentage 
of 20 is comparable to an MD of 22, which we currently explain in 
training.
     Add guidance in proposed 2.00A7c(i) on how to calculate 
visual field efficiency value using the MD determined by automated 
static threshold perimetry, which we currently provide in our internal 
operating instructions.
     Redesignate current 2.00A7b as proposed 2.00A7c(ii).
     Add current Table 2 (Chart of Visual Fields), which is 
located at the end of the current special senses and speech listings, 
to proposed 2.00A7c(ii), and redesignate it as Figure 1, because it is 
more useful to our adjudicators to place this figure in the 
introductory text immediately after the explanation of visual field 
efficiency. We would also add, and make minor changes to, the example 
for calculating visual field efficiency percentage under the current 
table to proposed 2.00A7c(ii)A and B.
     Expand current 2.00A7c and redesignate as proposed 
2.00A7d. We would add an example for calculating visual efficiency 
value in proposed 2.00A7d(i). In proposed 2.00A7d(ii), we would revise 
the example for calculating visual efficiency percentage, which is in 
current 2.00A7c, to simply state more clearly how we convert a decimal 
value to a percentage.

Section 2.00A8, What are our requirements for an acceptable perimeter?

    We propose to move the guidance on acceptable perimeters in current 
2.00A6a(ii)A-F to proposed section 2.00A8 because perimeter 
manufacturers must provide us with the evidence that their automated 
static threshold perimeter(s) meet these requirements before we can use 
any results of visual field testing performed on their perimeters to 
evaluate visual field loss. Although we are not proposing to change 
these requirements, we believe placing them at the end of the 
introductory text will allow adjudicators to more quickly access the 
guidance on visual field testing requirements that are applicable to 
testing performed on all acceptable perimeters. We would also remove 
the reference to the HFA because acceptable perimeters may change over 
time and we do not want to appear to be giving preference in our rules 
to one manufacturer over another.

Other Changes

    We propose to remove 2.00A8b, which describes blepharospasm, 
because it does not provide useful guidance to adjudicators on how to 
evaluate vision loss due to blepharospasm and has led to repeated 
questions from our adjudicators. As we explained earlier with cortical 
visual disorders, we intend to provide guidance for evaluating a 
person's vision loss due to blepharospasm and any other visual 
disorders that may result in vision loss or a loss in visual 
functioning in our internal operating instructions and training.

What changes are we proposing to the listings for evaluating visual 
disorders in adults?

    In the following paragraphs, we describe the substantive changes to 
the adult listings for evaluating visual disorders in part A of 
appendix 1 to subpart P of part 404. We propose to:
     Add 2.04A to evaluate visual efficiency determined using 
the MD from acceptable automated static threshold perimetry.
     Redesignate current 2.04, which we use to evaluate visual 
efficiency determined by kinetic perimetry, as proposed 2.04B.

What changes are we proposing to the introductory text and listings for 
evaluating visual disorders in children?

    We propose to clarify, simplify, and reorganize the introductory 
text in the childhood rules as in the adult rules. Since these are 
conforming changes, we do not summarize them here. We also propose to 
move the examples in current 102.00A5b(iii) to proposed 102.02B. We 
believe it is more helpful to adjudicators to include these examples 
directly in the listing to which they apply.

What is our authority to make rules and set procedures for determining 
whether a person is disabled under the statutory definition?

    The Act authorizes us to make rules and regulations and to 
establish necessary and appropriate procedures to implement them. 
Sections 205(a), 702(a)(5), and 1631(d)(1).

How long would these proposed rules be effective?

    If we publish these proposed rules as final rules, they will remain 
in effect for 5 years after the date they become effective, unless we 
extend them, or revise and issue them again.

[[Page 7552]]

Clarity of These Proposed Rules

    Executive Order 12866, as supplemented by Executive Order 13563, 
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 them easier to understand.
    For example:
     Would more, but shorter sections be better?
     Are the requirements in the rules clearly stated?
     Have we organized the material to suit your needs?
     Could we improve clarity by adding more tables, lists, or 
diagrams?
     What else could we do to make the rules easier to 
understand?
     Do the rules contain technical language or jargon that is 
not clear?
     Would a different format make the rules easier to 
understand, e.g., grouping and order of sections, use of headings, 
paragraphing?

When will we start to use these rules?

    We will not use these rules until we evaluate public comments and 
publish final rules in the Federal Register. All final rules we issue 
include an effective date. We will continue to use our current rules 
until that date. If we publish final rules, we will include a summary 
of those relevant comments we received along with responses and an 
explanation of how we will apply the new rules.

Regulatory Procedures

Executive Order 12866, as Supplemented by Executive Order 13563

    We have consulted with the Office of Management and Budget (OMB) 
and determined that this NPRM meets the criteria for a significant 
regulatory action under Executive Order 12866, as supplemented by 
Executive Order 13563. Therefore, OMB reviewed it.

Regulatory Flexibility Act

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

Paperwork Reduction Act

    These proposed rules do not create any new or affect any existing 
collections and, therefore, do not require OMB approval under the 
Paperwork Reduction Act.

(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.

Michael J. Astrue,
Commissioner of Social Security.
    For the reasons set out in the preamble, we propose to amend 20 CFR 
chapter III, part 404, subpart P as set forth below:

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

Subpart P--[Amended]

    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), 
(i), and (j), 222(c), 223, 225, and 702(a)(5) of the Social Security 
Act (42 U.S.C. 402, 405(a)-(b) and (d)-(h), 416(i), 421(a), (i), and 
(j), 422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-193, 
110 Stat. 2105, 2189; sec. 202, Pub. L. 108-203, 118 Stat. 509 (42 
U.S.C. 902 note).

    2. Amend appendix 1 to subpart P of part 404 by:
    a. Revising item 3 of the introductory text before part A;
    b. Revising section 2.00A and sections 2.01 through 2.04 in part A; 
and
    c. Revising section 102.00A and sections 102.01 through 102.04 in 
part B.
    The revisions read 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 5 
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. How do we define statutory blindness? Statutory blindness is 
blindness as defined in sections 216(i)(1) and 1614(a)(2) of the 
Social Security Act (Act).
    a. The Act defines blindness as central visual acuity of 20/200 
or less in the better eye with the use of a correcting lens. We use 
your best-corrected central visual acuity for distance in the better 
eye when we determine if this definition is met. (For visual acuity 
testing requirements, see 2.00A5.)
    b. 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 
a central visual acuity of 20/200 or less. (For visual field testing 
requirements, see 2.00A6.)
    c. You have statutory blindness only if your visual disorder 
meets the criteria of 2.02 or 2.03A. In order to find that you have 
statutory blindness under the law for a period of disability and for 
payment of disability insurance benefits, your blindness under 2.02 
or 2.03A must also meet the duration requirement (see Sec. Sec.  
404.1509 and 404.1581). You do not have statutory blindness if your 
visual disorder medically equals the criteria of 2.02 or 2.03A or 
meets or medically equals the criteria of 2.03B, 2.03C, 2.04A, or 
2.04B because your disability is based on criteria other than those 
in the statutory definition of blindness. If your visual disorder 
medically equals the criteria of 2.02 or 2.03A or meets or medically 
equals the criteria of 2.03B, 2.03C, 2.04A, or 2.04B, we will find 
that you are under a disability if your visual disorder also meets 
the duration requirement (see Sec. Sec.  404.1509 and 416.909 of 
this chapter).
    3. What evidence do we need to establish statutory blindness 
under title XVI? To establish that you have statutory blindness 
under title XVI, we need evidence showing only that your central 
visual acuity in your better eye or your visual field in your better 
eye meets the criteria in 2.00A2, provided that those measurements 
are consistent with the other evidence in your case record. We do 
not need documentation of 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 of this chapter).
    4. What evidence do we need to evaluate visual disorders, 
including those that result in statutory blindness under title II? 
To evaluate your visual disorder, we usually need a report of an eye 
examination that includes measurements of your best-corrected 
central visual acuity (see 2.00A5) or the extent of your visual 
fields (see 2.00A6), as appropriate. If you have visual acuity or 
visual field loss, we need documentation of the cause of the loss. A 
standard eye examination will usually indicate the cause of any 
visual acuity loss. An eye examination can also indicate the cause 
of some types of visual field deficits. Some disorders, such as 
cortical visual disorders, may result in abnormalities that do not 
appear on a standard eye examination. If the eye examination does 
not indicate the cause of your vision loss, we will request the 
information the physician or optometrist used to establish the 
presence of your visual disorder. If your visual disorder does not 
satisfy the criteria in 2.02, 2.03, or 2.04, we will request a 
description of how your visual disorder affects your ability to 
function.
    5. How do we measure your best-corrected central visual acuity?

[[Page 7553]]

    a. Visual acuity testing. When we need to measure your best-
corrected central visual acuity, which is your optimal visual acuity 
attainable with the use of a corrective lens, we use visual acuity 
testing for distance that was carried out using Snellen methodology 
or any other testing methodology that is comparable to Snellen 
methodology.
    (i) Your best-corrected central visual acuity for distance is 
usually measured by determining what you can see from 20 feet. If 
your visual acuity is measured for a distance other than 20 feet, we 
will convert it to a 20-foot measurement. For example, if your 
visual acuity is measured at 10 feet and is reported as 10/40, we 
will convert this measurement to 20/80.
    (ii) A visual acuity recorded as CF (counts fingers), HM (hand 
motion only), LP or LPO (light perception or light perception only), 
or NLP (no light perception) indicates that no optical correction 
will improve your visual acuity. If your central visual acuity in an 
eye is recorded as CF, HM, LP or LPO, or NLP, we will determine that 
your best-corrected central visual acuity is 20/200 or less in that 
eye.
    (iii) We will not use the results of pinhole testing or 
automated refraction acuity to determine your best-corrected central 
visual acuity. These tests provide an estimate of potential visual 
acuity but not an actual measurement of your best-corrected central 
visual acuity.
    b. Other test charts. Most test charts that use Snellen 
methodology do not have lines that measure visual acuity between 20/
100 and 20/200. Some test charts, such as the Bailey-Lovie or the 
Early Treatment Diabetic Retinopathy Study (ETDRS) used mostly in 
research settings, have such lines. If your visual acuity is 
measured with one of these 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. For 
example, if your best-corrected central visual acuity for distance 
in the better eye is 20/160 using an ETDRS chart, we will find that 
you have statutory blindness. 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. For example, if your best-corrected 
central visual acuity for distance in the better eye is 20/125+1 
using an ETDRS chart, we will find that you do not have statutory 
blindness because you are able to read one letter on the 20/100 
line.
    c. Testing using a specialized lens. In some instances, you may 
perform visual acuity testing 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. We will not use 
visual acuity measurements obtained with telescopic lenses because 
they significantly reduce the visual field.
    d. Cycloplegic refraction. Cycloplegic refraction, which 
measures your visual acuity in the absence of accommodation 
(focusing ability) after the eye has been dilated, is not part of a 
routine eye examination because it is not needed to determine your 
best-corrected central visual acuity. If your case record contains 
the results of cycloplegic refraction, we may use the results to 
determine your best-corrected central visual acuity. We will not 
purchase cycloplegic refraction.
    e. Visual evoked response (VER) testing. VER testing measures 
your response to visual events and can often detect dysfunction that 
is undetectable through other types of examinations. If you have an 
absent response to VER testing in your better eye, we will determine 
that your best-corrected central visual acuity is 20/200 or less in 
that eye and that your visual acuity loss satisfies the criterion in 
2.02, when these test results are consistent with the other evidence 
in your case record. If you have a positive response to VER testing 
in an eye, we will not use that result to determine your best-
corrected central visual acuity in that eye.
    6. How do we measure your visual fields?
    a. General. 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. When we need to 
measure the extent of your visual field loss, we use visual field 
testing (also referred to as perimetry) carried out using automated 
static threshold perimetry performed on an acceptable perimeter (for 
perimeter requirements, see 2.00A8).
    b. Automated static threshold perimetry requirements.
    (i) The test must use a white size III Goldmann stimulus and a 
31.5 apostilb (asb) white background (or a 10 candela per square 
meter (cd/m\2\) white background). The stimuli test 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.
    (ii) We measure the extent of your visual field loss by 
determining the portion of the visual field in which you can see a 
white III4e stimulus. The ``III'' refers to the standard Goldmann 
test stimulus size III (4 mm\2\), and the ``4e'' refers to the 
standard Goldmann intensity filter (0 dB attenuation, which allows 
presentation of the maximum luminance) used to determine the 
intensity of the stimulus.
    (iii) In automated static threshold perimetry, the intensity of 
the stimulus varies. The intensity of the stimulus is expressed in 
decibels (dB). A perimeter's maximum stimulus luminance is usually 
assigned the value 0 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 you 
see at a 4e intensity level (a ``seeing point''). For example:
    A. When the maximum stimulus luminance (0 dB stimulus) on an 
acceptable perimeter is 10,000 asb, a 10 dB stimulus is equivalent 
to a 4e stimulus. Any point you see at 10 dB or greater is a seeing 
point.
    B. When the maximum stimulus luminance (0 dB stimulus) on an 
acceptable perimeter is 4,000 asb, a 6 dB stimulus is equivalent to 
a 4e stimulus. Any point you see at 6 dB or greater is a seeing 
point.
    c. Evaluation under 2.03A. To determine statutory blindness 
based on visual field loss in your better eye (2.03A), we need the 
results of a visual field test that measures the central 24 to 30 
degrees of your visual field; that is, the area measuring 24 to 30 
degrees from the point of fixation. Acceptable tests include the 
Humphrey Field Analyzer (HFA) 30-2, HFA 24-2, and Octopus 32.
    d. Evaluation under 2.03B. To determine whether your visual 
field loss meets listing 2.03B, we use the mean deviation or defect 
(MD) from acceptable automated static threshold perimetry that 
measures the central 30 degrees of the visual field. MD is the 
average sensitivity deviation from normal values for all measured 
visual field locations within the central 30 degrees of the field. 
When using results from HFA tests, which report the MD as a negative 
number, we use the absolute value of the MD to determine whether 
your visual field loss meets listing 2.03B. We cannot use tests that 
do not measure the central 30 degrees of the visual field, such as 
the HFA 24-2, to determine if your impairment meets or medically 
equals 2.03B.
    e. Other types of perimetry. If your case record contains visual 
field measurements obtained using manual or automated kinetic 
perimetry, such as Goldmann perimetry or the HFA ``SSA Test 
Kinetic,'' we can generally use these results if the kinetic test 
was performed using a white III4e stimulus projected on a white 31.5 
asb (10 cd/m\2\) background. Automated kinetic perimetry, such as 
the HFA ``SSA Test Kinetic,'' does not detect limitations in the 
central visual field because testing along a meridian stops when you 
see the stimulus. If your visual disorder has progressed to the 
point at which it is likely to result in a significant limitation in 
the central visual field, such as a scotoma (see 2.00A6h), we will 
not use automated kinetic perimetry to determine the extent of your 
visual field loss. Instead, we will determine the extent of your 
visual field loss using automated static threshold perimetry or 
manual kinetic perimetry.
    f. Screening tests. 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 can consider normal results from 
visual field screening tests to determine whether your visual 
disorder is severe when these test results are consistent with the 
other evidence in your case record. (See Sec. Sec.  404.1520(c), 
404.1521, 416.920(c), and 416.921 of this chapter.) We will not 
consider normal test results to be consistent with the other 
evidence if the clinical findings indicate that your visual disorder 
has progressed to the point that it is likely to cause visual field 
loss, or you have a history of an operative procedure for retinal 
detachment.
    g. Use of corrective lenses. You must not wear eyeglasses during 
visual field testing because they limit your field of vision. You 
may wear contact lenses or perimetric lenses to correct your visual 
acuity during the visual field test to obtain the most accurate 
visual field measurements. For this single purpose,

[[Page 7554]]

you do not need to demonstrate that you have the ability to use the 
contact or perimetric lenses on a sustained basis.
    h. Scotoma. A scotoma is a non-seeing area (also referred to as 
a blind spot) in the visual field surrounded by a seeing area. When 
we measure your 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.
    7. How do we determine your visual acuity efficiency, visual 
field efficiency, and visual efficiency?
    a. General. Visual efficiency is the combination of your visual 
acuity efficiency and your visual field efficiency expressed as a 
value or as a percentage.
    b. Visual acuity efficiency. Visual acuity efficiency is a value 
or a percentage that corresponds to the best-corrected central 
visual acuity for distance in your better eye. See Table 1.

                                                     Table 1
----------------------------------------------------------------------------------------------------------------
   Snellen best-corrected central visual acuity for distance                                      Visual acuity
---------------------------------------------------------------  Visual acuity efficiency value     efficiency
                                                                            (2.04A)                 percentage
                   English                         Metric                                            (2.04B)
----------------------------------------------------------------------------------------------------------------
20/16.......................................              6/5   0.00...........................              100
20/20.......................................              6/6   0.00...........................              100
20/25.......................................            6/7.5   0.10...........................               95
20/30.......................................              6/9   0.18...........................               90
20/40.......................................             6/12   0.30...........................               85
20/50.......................................             6/15   0.40...........................               75
20/60.......................................             6/18   0.48...........................               70
20/70.......................................             6/21   0.54...........................               65
20/80.......................................             6/24   0.60...........................               60
20/100......................................             6/30   0.70...........................               50
----------------------------------------------------------------------------------------------------------------

    c. Visual field efficiency. Visual field efficiency is a value 
or a percentage that corresponds to the visual field in your better 
eye. Under 2.03C, we require kinetic perimetry to determine your 
visual field efficiency percentage. (A visual field efficiency 
percentage of 20, determined using kinetic perimetry, is comparable 
to an MD of 22, determined using automated static threshold 
perimetry.)
    (i) Value determined by automated static threshold perimetry. 
Using the MD from acceptable automated static threshold perimetry, 
we calculate the visual field efficiency value by dividing the 
absolute value of the MD by 22. For example, if your MD on an HFA 
30-2 is -16, your visual field efficiency value is: [mid]-16[mid] / 
22 = 0.73.
    (ii) Percentage determined by kinetic perimetry. Using kinetic 
perimetry, we calculate the visual field efficiency percentage by 
adding the number of degrees you see along the eight principal 
meridians found on a visual field chart (0, 45, 90, 135, 180, 225, 
270, and 315) in your better eye and dividing by 5. For example, in 
Figure 1:
    A. The diagram of the left eye illustrates a visual field, as 
measured with a III4e stimulus, contracted to 30 degrees in two 
meridians (180 and 225) and to 20 degrees in the remaining six 
meridians. The visual efficiency percentage of this field is: ((2 x 
30) + (6 x 20)) / 5 = 36 percent.
    B. 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. The 
visual efficiency percentage of this field is 500 / 5 = 100 percent.
[GRAPHIC] [TIFF OMITTED] TP13FE12.004

    d. Visual efficiency.
    (i) Determined by automated static threshold perimetry (2.04A). 
Under 2.04A, we calculate the visual efficiency value by adding your 
visual acuity efficiency value

[[Page 7555]]

(see 2.00A7b) and your visual field efficiency value (see 
2.00A7c(i)). For example, if your visual acuity efficiency value is 
0.48 and your visual field efficiency value is 0.73, your visual 
efficiency value is: 0.48 + 0.73 = 1.21.
    (ii) Determined by kinetic perimetry (2.04B). Under 2.04B, we 
calculate the visual efficiency percentage by multiplying your 
visual acuity efficiency percentage (see 2.00A7b) by your visual 
field efficiency percentage (see 2.00A7c(ii)) and dividing by 100. 
For example, if your visual acuity efficiency percentage is 75 and 
your visual field efficiency percentage is 36, your visual 
efficiency percentage is: (75 x 36) / 100 = 27 percent.
    8. What are our requirements for an acceptable perimeter? We 
will use results from automated static threshold perimetry performed 
on a perimeter that:
    a. Uses optical projection to generate the test stimuli.
    b. Has an internal normative database for automatically 
comparing your performance with that of the general population.
    c. Has a statistical analysis package that is able to calculate 
visual field indices, particularly mean deviation or mean defect.
    d. Demonstrates the ability to correctly detect visual field 
loss and correctly identify normal visual fields.
    e. Demonstrates good test-retest reliability.
    f. Has undergone clinical validation studies by three or more 
independent laboratories with results published in peer-reviewed 
ophthalmic journals.
* * * * *

2.01 Category of Impairments, Special Senses and Speech

    2.02 Loss of central 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 around the point of 
fixation no greater than 20 degrees.

OR

    B. An MD of 22 decibels or greater, determined by automated 
static threshold perimetry that measures the central 30 degrees of 
the visual field (see 2.00A6d).

OR

    C. A visual field efficiency of 20 percent or less, determined 
by kinetic perimetry (see 2.00A7c).
    2.04 Loss of visual efficiency in the better eye, with:
    A. A visual efficiency value of 1.00 or greater after best 
correction (see 2.00A7d(i)).

OR

    B. A visual efficiency percentage of 20 or less after best 
correction (see 2.00A7d(ii)).
* * * * *

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. How do we define statutory blindness? Statutory blindness is 
blindness as defined in sections 216(i)(1) and 1614(a)(2) of the 
Social Security Act (Act).
    a. The Act defines blindness as central visual acuity of 20/200 
or less in the better eye with the use of a correcting lens. We use 
your best-corrected central visual acuity for distance in the better 
eye when we determine if this definition is met. (For visual acuity 
testing requirements, see 102.00A5.)
    b. 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 
a central visual acuity of 20/200 or less. (For visual field testing 
requirements, see 102.00A6.)
    c. You have statutory blindness only if your visual disorder 
meets the criteria of 102.02A, 102.02B, or 102.03A. You do not have 
statutory blindness if your visual disorder medically equals the 
criteria of 102.02A, 102.02B, or 102.03A or meets or medically 
equals the criteria of 102.03B, 102.03C, 102.04A, or 102.04B because 
your disability is based on criteria other than those in the 
statutory definition of blindness. If your visual disorder medically 
equals the criteria of 102.02A, 102.02B, or 102.03A or meets or 
medically equals the criteria of 102.03B, 102.03C, 102.04A, or 
102.04B, we will find that you are under a disability if your visual 
disorder also meets the duration requirement (see Sec.  416.909 of 
this chapter).
    3. What evidence do we need to establish statutory blindness 
under title XVI? To establish that you have statutory blindness 
under title XVI, we need evidence showing only that your central 
visual acuity in your better eye or your visual field in your better 
eye meets the criteria in 102.00A2, provided that those measurements 
are consistent with the other evidence in your case record. We do 
not need documentation of 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 of this chapter).
    4. What evidence do we need to evaluate visual disorders, 
including those that result in statutory blindness under title II? 
To evaluate your visual disorder, we usually need a report of an eye 
examination that includes measurements of your best-corrected 
central visual acuity (see 102.00A5) or the extent of your visual 
fields (see 102.00A6), as appropriate. If you have visual acuity or 
visual field loss, we need documentation of the cause of the loss. A 
standard eye examination will usually indicate the cause of any 
visual acuity loss. An eye examination can also indicate the cause 
of some types of visual field deficits. Some disorders, such as 
cortical visual disorders, may result in abnormalities that do not 
appear on a standard eye examination. If the eye examination does 
not indicate the cause of your vision loss, we will request the 
information the physician or optometrist used to establish the 
presence of your visual disorder. If your visual disorder does not 
satisfy the criteria in 102.02, 102.03, or 102.04, we will request a 
description of how your visual disorder affects your ability to 
function.
    5. How do we measure your best-corrected central visual acuity?
    a. Visual acuity testing. When we need to measure your best-
corrected central visual acuity, which is your optimal visual acuity 
attainable with the use of a corrective lens, we use visual acuity 
testing for distance that was carried out using Snellen methodology 
or any other testing methodology that is comparable to Snellen 
methodology.
    (i) Your best-corrected central visual acuity for distance is 
usually measured by determining what you can see from 20 feet. If 
your visual acuity is measured for a distance other than 20 feet, we 
will convert it to a 20-foot measurement. For example, if your 
visual acuity is measured at 10 feet and is reported as 10/40, we 
will convert this measurement to 20/80.
    (ii) A visual acuity recorded as CF (counts fingers), HM (hand 
motion only), LP or LPO (light perception or light perception only), 
or NLP (no light perception) indicates that no optical correction 
will improve your visual acuity. If your central visual acuity in an 
eye is recorded as CF, HM, LP or LPO, or NLP, we will determine that 
your best-corrected central visual acuity is 20/200 or less in that 
eye.
    (iii) We will not use the results of pinhole testing or 
automated refraction acuity to determine your best-corrected central 
visual acuity. These tests provide an estimate of potential visual 
acuity but not an actual measurement of your best-corrected central 
visual acuity.
    (iv) Very young children, such as infants and toddlers, cannot 
participate in testing using Snellen methodology or other comparable 
testing. If you are unable to participate in testing using Snellen 
methodology or other comparable testing, we will consider clinical 
findings of your fixation and visual-following behavior. If both 
these behaviors are absent, we will consider the anatomical findings 
or the results of neuroimaging, electroretinogram, or visual evoked 
response (VER) testing when this testing has been performed.
    b. Other test charts.
    (i) Children between the ages of 3 and 5 often cannot identify 
the letters on a Snellen or other letter test chart. Specialists 
with expertise in assessment of childhood vision use alternate 
methods for measuring visual acuity in young children. We consider 
alternate methods, for example, 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.
    (ii) Most test charts that use Snellen methodology do not have 
lines that measure visual acuity between 20/100 and 20/200. Some 
test charts, such as the Bailey-Lovie or the Early Treatment 
Diabetic Retinopathy Study (ETDRS) used mostly in research settings, 
have such lines. If your visual acuity

[[Page 7556]]

is measured with one of these 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. For 
example, if your best-corrected central visual acuity for distance 
in the better eye is 20/160 using an ETDRS chart, we will find that 
you have statutory blindness. 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. For example, if your best-corrected 
central visual acuity for distance in the better eye is 20/125+1 
using an ETDRS chart, we will find that you do not have statutory 
blindness because you are able to read one letter on the 20/100 
line.
    c. Testing using a specialized lens. In some instances, you may 
perform visual acuity testing 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. We will not use 
visual acuity measurements obtained with telescopic lenses because 
they significantly reduce the visual field.
    d. Cycloplegic refraction. Cycloplegic refraction, which 
measures your visual acuity in the absence of accommodation 
(focusing ability) after the eye has been dilated, is not part of a 
routine eye examination because it is not needed to determine your 
best-corrected central visual acuity. It can be useful for 
determining refractive error and visual acuity in some children. If 
your case record contains the results of cycloplegic refraction, we 
may use the results to determine your best-corrected central visual 
acuity. We will not purchase cycloplegic refraction.
    e. VER testing. VER testing measures your response to visual 
events and can often detect dysfunction that is undetectable through 
other types of examinations. If you have an absent response to VER 
testing in your better eye, we will determine that your best-
corrected central visual acuity is 20/200 or less in that eye and 
that your visual acuity loss satisfies the criterion in 102.02A or 
102.02B4, as appropriate, when these test results are consistent 
with the other evidence in your case record. If you have a positive 
response to VER testing in an eye, we will not use that result to 
determine your best-corrected central visual acuity in that eye.
    6. How do we measure your visual fields?
    a. General. 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. When we need to 
measure the extent of your visual field loss, we use visual field 
testing (also referred to as perimetry) carried out using automated 
static threshold perimetry performed on an acceptable perimeter (for 
perimeter requirements, see 102.00A8).
    b. Automated static threshold perimetry requirements.
    (i) The test must use a white size III Goldmann stimulus and a 
31.5 apostilb (asb) white background (or a 10 candela per square 
meter (cd/m\2\) white background). The stimuli test 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.
    (ii) We measure the extent of your visual field loss by 
determining the portion of the visual field in which you can see a 
white III4e stimulus. The ``III'' refers to the standard Goldmann 
test stimulus size III (4 mm\2\), and the ``4e'' refers to the 
standard Goldmann intensity filter (0 dB attenuation, which allows 
presentation of the maximum luminance) used to determine the 
intensity of the stimulus.
    (iii) In automated static threshold perimetry, the intensity of 
the stimulus varies. The intensity of the stimulus is expressed in 
decibels (dB). A perimeter's maximum stimulus luminance is usually 
assigned the value 0 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 you 
see at a 4e intensity level (a ``seeing point''). For example:
    A. When the maximum stimulus luminance (0 dB stimulus) on an 
acceptable perimeter is 10,000 asb, a 10 dB stimulus is equivalent 
to a 4e stimulus. Any point you see at 10 dB or greater is a seeing 
point.
    B. When the maximum stimulus luminance (0 dB stimulus) on an 
acceptable perimeter is 4,000 asb, a 6 dB stimulus is equivalent to 
a 4e stimulus. Any point you see at 6 dB or greater is a seeing 
point.
    c. Evaluation under 102.03A. To determine statutory blindness 
based on visual field loss in your better eye (102.03A), we need the 
results of a visual field test that measures the central 24 to 30 
degrees of your visual field; that is, the area measuring 24 to 30 
degrees from the point of fixation. Acceptable tests include the 
Humphrey Field Analyzer (HFA) 30-2, HFA 24-2, and Octopus 32.
    d. Evaluation under 102.03B. To determine whether your visual 
field loss meets listing 102.03B, we use the mean deviation or 
defect (MD) from acceptable automated static threshold perimetry 
that measures the central 30 degrees of the visual field. MD is the 
average sensitivity deviation from normal values for all measured 
visual field locations within the central 30 degrees of the field. 
When using results from HFA tests, which report the MD as a negative 
number, we use the absolute value of the MD to determine whether 
your visual field loss meets listing 102.03B. We cannot use tests 
that do not measure the central 30 degrees of the visual field, such 
as the HFA 24-2, to determine if your impairment meets or medically 
equals 102.03B.
    e. Other types of perimetry. If your case record contains visual 
field measurements obtained using manual or automated kinetic 
perimetry, such as Goldmann perimetry or the HFA ``SSA Test 
Kinetic,'' we can generally use these results if the kinetic test 
was performed using a white III4e stimulus projected on a white 31.5 
asb (10 cd/m\2\) background. Automated kinetic perimetry, such as 
the HFA ``SSA Test Kinetic,'' does not detect limitations in the 
central visual field because testing along a meridian stops when you 
see the stimulus. If your visual disorder has progressed to the 
point at which it is likely to result in a significant limitation in 
the central visual field, such as a scotoma (see 102.00A6h), we will 
not use automated kinetic perimetry to determine the extent of your 
visual field loss. Instead, we will determine the extent of your 
visual field loss using automated static threshold perimetry or 
manual kinetic perimetry.
    f. Screening tests. 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 can consider normal results from visual 
field screening tests to determine whether your visual disorder is 
severe when these test results are consistent with the other 
evidence in your case record. (See Sec.  416.924(c) of this 
chapter.) We will not consider normal test results to be consistent 
with the other evidence if the clinical findings indicate that your 
visual disorder has progressed to the point that it is likely to 
cause visual field loss, or you have a history of an operative 
procedure for retinal detachment.
    g. Use of corrective lenses. You must not wear eyeglasses during 
visual field testing because they limit your field of vision. You 
may wear contact lenses or perimetric lenses to correct your visual 
acuity during the visual field test 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.
    h. Scotoma. A scotoma is a non-seeing area (also referred to as 
a blind spot) in the visual field surrounded by a seeing area. When 
we measure your 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.
    7. How do we determine your visual acuity efficiency, visual 
field efficiency, and visual efficiency?
    a. General. Visual efficiency is the combination of your visual 
acuity efficiency and your visual field efficiency expressed as a 
value or as a percentage.
    b. Visual acuity efficiency. Visual acuity efficiency is a value 
or a percentage that corresponds to the best-corrected central 
visual acuity for distance in your better eye. See Table 1.

[[Page 7557]]



                                                     Table 1
----------------------------------------------------------------------------------------------------------------
   Snellen best-corrected central visual acuity for distance                                      Visual acuity
---------------------------------------------------------------  Visual acuity efficiency value     efficiency
                                                                           (102.04A)                percentage
                   English                         Metric                                           (102.04B)
----------------------------------------------------------------------------------------------------------------
20/16.......................................              6/5   0.00...........................              100
20/20.......................................              6/6   0.00...........................              100
20/25.......................................            6/7.5   0.10...........................               95
20/30.......................................              6/9   0.18...........................               90
20/40.......................................             6/12   0.30...........................               85
20/50.......................................             6/15   0.40...........................               75
20/60.......................................             6/18   0.48...........................               70
20/70.......................................             6/21   0.54...........................               65
20/80.......................................             6/24   0.60...........................               60
20/100......................................             6/30   0.70...........................               50
----------------------------------------------------------------------------------------------------------------

    c. Visual field efficiency. Visual field efficiency is a value 
or a percentage that corresponds to the visual field in your better 
eye. Under 102.03C, we require kinetic perimetry to determine your 
visual field efficiency percentage. (A visual field efficiency 
percentage of 20, determined using kinetic perimetry, is comparable 
to an MD of 22, determined using automated static threshold 
perimetry.)
    (i) Value determined by automated static threshold perimetry. 
Using the MD from acceptable automated static threshold perimetry, 
we calculate the visual field efficiency value by dividing the 
absolute value of the MD by 22. For example, if your MD on an HFA 
30-2 is -16, your visual field efficiency value is: [bond]-16[bond] 
/ 22 = 0.73.
    (ii) Percentage determined by kinetic perimetry. Using kinetic 
perimetry, we calculate the visual field efficiency percentage by 
adding the number of degrees you see along the eight principal 
meridians found on a visual field chart (0, 45, 90, 135, 180, 225, 
270, and 315) in your better eye and dividing by 5. For example, in 
Figure 1:
    A. The diagram of the left eye illustrates a visual field, as 
measured with a III4e stimulus, contracted to 30 degrees in two 
meridians (180 and 225) and to 20 degrees in the remaining six 
meridians. The visual efficiency percentage of this field is: ((2 x 
30) + (6 x 20)) / 5 = 36 percent.
    B. 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. The 
visual efficiency percentage of this field is 500 / 5 = 100 percent.
[GRAPHIC] [TIFF OMITTED] TP13FE12.005

    d. Visual efficiency.
    (i) Determined by automated static threshold perimetry 
(102.04A). Under 102.04A, we calculate the visual efficiency value 
by adding your visual acuity efficiency value (see 102.00A7b) and 
your visual field efficiency value (see 102.00A7c(i)). For example, 
if your visual acuity efficiency value is 0.48 and your visual field 
efficiency value is 0.73, your visual efficiency value is: 0.48 + 
0.73 = 1.21.
    (ii) Determined by kinetic perimetry (102.04B). Under 102.04B, 
we calculate the visual efficiency percentage by multiplying your 
visual acuity efficiency percentage (see 102.00A7b) by your visual 
field efficiency percentage (see 102.00A7c(ii)) and dividing by 100. 
For example, if your visual acuity efficiency percentage is 75 and 
your visual field efficiency percentage is 36, your visual 
efficiency percentage is: (75 x 36) / 100 = 27 percent.
    8. What are our requirements for an acceptable perimeter? We 
will use results from automated static threshold perimetry performed 
on a perimeter that:
    a. Uses optical projection to generate the test stimuli.

[[Page 7558]]

    b. Has an internal normative database for automatically 
comparing your performance with that of the general population.
    c. Has a statistical analysis package that is able to calculate 
visual field indices, particularly mean deviation or mean defect.
    d. Demonstrates the ability to correctly detect visual field 
loss and correctly identify normal visual fields.
    e. Demonstrates good test-retest reliability.
    f. Has undergone clinical validation studies by three or more 
independent laboratories with results published in peer-reviewed 
ophthalmic journals.
* * * * *

102.01 Category of Impairments, Special Senses and Speech

    102.02 Loss of central visual acuity.
    A. Remaining vision in the better eye after best correction is 
20/200 or less.

OR

    B. An inability to participate in visual acuity testing using 
Snellen methodology or other comparable testing, clinical findings 
that fixation and visual-following behavior are absent in the better 
eye, and one of the following:
    1. Abnormal anatomical findings indicating a visual acuity of 
20/200 or less in the better eye (such as the presence of Stage III 
or worse retinopathy of prematurity despite surgery, hypoplasia of 
the optic nerve, albinism with macular aplasia, or bilateral optic 
atrophy); or
    2. Abnormal neuroimaging documenting damage to the cerebral 
cortex which would be expected to prevent the development of a 
visual acuity better than 20/200 in the better eye (such as 
neuroimaging showing bilateral encephalomyelitis or bilateral 
encephalomalacia); or
    3. Abnormal electroretinogram documenting the presence of 
Leber's congenital amaurosis or achromatopsia in the better eye; or
    4. An absent response to VER testing in the better eye.
    102.03 Contraction of the visual field in the better eye, with:
    A. The widest diameter subtending an angle around the point of 
fixation no greater than 20 degrees.

OR

    B. An MD of 22 decibels or greater, determined by automated 
static threshold perimetry that measures the central 30 degrees of 
the visual field (see 102.00A6d).

OR

    C. A visual field efficiency of 20 percent or less, determined 
by kinetic perimetry (see 102.00A7c).
    102.04 Loss of visual efficiency in the better eye, with:
    A. A visual efficiency value of 1.00 or greater after best 
correction (see 102.00A7d(i)).

OR

    B. A visual efficiency percentage of 20 or less after best 
correction (see 102.00A7d(ii)).
* * * * *
[FR Doc. 2012-3226 Filed 2-10-12; 8:45 am]
BILLING CODE 4191-02-P