Schedule for Rating Disabilities; Eye

DEPARTMENT OF VETERANS AFFAIRS

38 CFR Part 4

RIN 2900-AH43

Schedule for Rating Disabilities; Eye

AGENCY: Department of Veterans Affairs.

ACTION: Proposed rule.

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

SUMMARY: The Department of Veterans Affairs (VA) is proposing to amend

that portion of its rating schedule that addresses the eye. The

intended effect of this action is to ensure that this section of the

Schedule for Rating Disabilities uses current medical terminology and

provides unambiguous criteria for evaluating disabilities of the eye.

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

ADDRESSES: Mail or hand-deliver written comments to: Director, Office

of Regulations Management (02D), Department of Veterans Affairs, 810

Vermont Ave., NW, Room 1154, Washington, DC 20420. Comments should

indicate that they are in response to ``RIN 2900-AH43.'' All written

comments received will be available for public inspection at the above

address in the Office of Regulations Management, Room 1158, between the

hours of 8:00 a.m. and 4:30 p.m., Monday through Friday (except

holidays).

FOR FURTHER INFORMATION CONTACT: Caroll McBrine, M.D., Consultant,

Regulations Staff (211B), Compensation and Pension Service, Veterans

Benefits Administration, Department of Veterans Affairs, 810 Vermont

Ave., NW, Washington, DC, 20420, (202) 273-7230.

SUPPLEMENTARY INFORMATION: As part of a comprehensive review of its

rating schedule, VA published an advance notice of proposed rulemaking

regarding impairments of the eye, ear and other sense organs in the

Federal Register on May 2, 1991 (56 FR 20170). In response, we received

a number of comments from private and VA physicians and from other VA

employees. For the reasons discussed below, this document proposes to

amend the portion of the rating schedule that addresses disabilities of

the eye.

The comments received included suggestions that we delete several

diagnostic codes, provide diagnostic codes for additional conditions,

and change evaluation criteria for a number of conditions. We have

considered these comments as explained below.

In addition to publishing an advance notice of proposed rulemaking,

we also contracted with an outside consultant to recommend changes to

ensure that the schedule uses current medical terminology and

unambiguous criteria, and that it reflects medical advances that have

occurred since the last review. The consultant convened a panel of non-

VA specialists to review the portion of the rating schedule that

addresses eye conditions in order to formulate recommendations. We are

proposing to adopt many of the recommendations the contract consultants

submitted. However, we do not propose to adopt recommendations that

address areas, such as frequency of examinations, that are clearly

beyond the scope of the contract or that deal with issues that affect

the internal consistency of the rating schedule, such as percentage

evaluations. Assignments of disability

[[Page 25247]]

ratings are supposed to reflect relative levels of economic impairment,

and the consultants did not consider eye disabilities in relation to

the other parts of the rating schedule in making their recommendations.

Relevant recommendations from these individuals are discussed below.

We determined that a number of grammatical changes would be helpful

in eliminating ambiguity and ensuring that the schedule presents the

rating criteria for listed disabilities as precisely as possible. We

are thus proposing editorial changes, primarily in syntax and

punctuation, throughout this portion of the schedule. These changes,

which will not be addressed individually, are intended to clarify the

rating criteria and represent no substantive amendment.

For VA purposes, the evaluation of visual impairment is based on

impairment of visual acuity, visual field, and muscle function. General

instructions for rating these disabilities are currently contained in

Secs. 4.75 through 4.84a of 38 CFR, and in notes appended to various

diagnostic codes. The material is randomly organized, however, and we

propose to reorganize it so that all material related to a single issue

is grouped together. We propose to reorganize these instructions under

four topics: (1) General considerations for evaluating visual

impairment; (2) Visual acuity; (3) Visual fields; and (4) Muscle

function.

We propose that Sec. 4.75, ``General considerations for evaluating

visual impairment,'' be composed of six paragraphs: (a) Visual

impairment, (b) Examination for visual impairment, (c) Service-

connected visual impairment of only one eye, (d) Maximum evaluation for

visual impairment of one eye, (e) Anatomical loss of one eye without

prosthesis, and (f) Special monthly compensation.

For the sake of clarity, we propose that paragraph (a), ``Visual

impairment,'' state that the evaluation of visual impairment is based

on impairment of visual acuity (excluding developmental errors of

refraction), visual field, and muscle function.

Proposed paragraph (b) of Sec. 4.75, ``Examination for visual

impairment,'' is derived from current Secs. 4.75 and 4.77 and the notes

following diagnostic code 6080 and would require that a licensed

optometrist or ophthalmologist conduct the examination and that the

examiner identify the disease, injury, or other pathologic process

responsible for any visual impairment found. It also states that

examinations for the evaluation of visual fields or muscle function

will be conducted only when there is a medical indication of disease or

injury that may be associated with visual field defect or impaired

muscle function. It also states that the fundus must be examined with

the veteran's pupils dilated (unless medically contraindicated).

The method of evaluation when visual impairment of only one eye is

service-connected is not specifically addressed in current regulations.

We propose to add paragraph (c), ``Service-connected visual impairment

of only one eye,'' to direct that when visual impairment of only one

eye is service-connected, either directly or by aggravation, the visual

acuity of the non-service-connected eye shall be considered to be 20/

40, subject to the provisions of 38 CFR 3.383(a) (which directs that

when there is blindness in one eye as a result of service-connected

disability and blindness in the other eye as a result of non-service-

connected disability, compensation is payable as if both were service-

connected). This method is consistent with current VA practice in

determining the level of disability when only one eye is service-

connected. The approach is also consistent with VAOPGCPREC 32-97, in

which the General Counsel held that, if a claimant has service-

connected hearing loss in one ear and nonservice-connected hearing loss

in the other ear, the hearing in the ear having nonservice-connected

loss should be considered normal for purposes of computing the service-

connected disability rating, unless the claimant is totally deaf in

both ears. In VAOPGCPREC 32-97, the General Counsel noted that the

statutory scheme governing VA benefits generally authorizes

compensation for service-connected disabilities only, see 38 U.S.C. 101

(13), 1110, and 1131, and does not permit combination of ratings for

service-connected and nonservice-connected disabilities for

compensation purposes. See 38 U.S.C. 1523 (authorizing, for nonservice-

connected pension purposes, combination of ratings for service-

connected and nonservice-connected disabilities) and 1157 (authorizing

compensation based on the combination of ratings for service-connected

disabilities). See also 38 CFR 3.323; 38 CFR 4.14 (``the use of

manifestations not resulting from service-connected disease or injury

in establishing the service-connected evaluation * * * [is] to be

avoided.''). Therefore, we propose to consider the visual acuity of the

nonservice-connected eye to be 20/40, the level of visual acuity that

warrants a zero-percent evaluation, so that any loss of visual acuity

in the non-service-connected eye will not affect the determination of

the level of disability for the service-connected eye. Adding the

provisions of paragraph (c) will remove any doubt about the correct

method of evaluation, and will assure that evaluations will be

consistent, in cases where visual impairment of only one eye is

service-connected.

In conjunction with the addition of paragraph (c) of Sec. 4.75, we

propose to remove current Sec. 4.78, ``Computing aggravation,'' which

states that aggravation of preexisting visual disability will be

determined based upon the evaluation of vision in both eyes before and

after suffering the aggravation, even if the impairment of vision in

only one eye is service-connected, and that with subsequent increase in

the disability of either eye due to intercurrent injury or disease not

associated with service, the basis of compensation will be the

condition of the eyes before suffering the subsequent increase. This

section is not consistent with VA's method of evaluating visual

impairment incurred in service in one eye only nor is it consistent

with the statutory scheme, as discussed above. Furthermore, its

application may, in some cases, result in a higher evaluation for a

condition that is aggravated by service than for an identical condition

incurred in service, and this is simply not equitable. This method is

also inconsistent with the method of evaluating other paired organs,

such as the hands, where only the service-connected hand is evaluated,

regardless of the status of the non-service-connected hand, again

subject to the provisions of 38 CFR 3.383(a), and where the same method

is used for incurrence as for aggravation. For these reasons, we

propose to remove the material in Sec. 4.78 in favor of the clear and

consistent method of evaluation described in paragraph (c).

Proposed paragraph (d) of Sec. 4.75, ``Maximum evaluation for

visual impairment of one eye,'' is derived from current Sec. 4.80,

``Rating of one eye,'' which states that the combined ratings for

disabilities of the same eye should not exceed the amount for total

loss of vision of that eye unless there is enucleation or a serious

cosmetic defect added to the total loss of vision. Some of this

language--``disabilities of the same eye,'' ``total loss of vision,''

and ``serious cosmetic defect''--is subjective or ambiguous. Since some

disabilities (e.g., malignant neoplasm) that may affect only one eye

can be evaluated up to 100 percent, we propose to change the reference

to ``disabilities'' of one eye to ``visual impairment'' of one eye to

clarify that it is only an evaluation for

[[Page 25248]]

visual impairment that is limited to 30 percent. In place of ``shall

not exceed the maximum,'' we propose to use the more direct language

``shall not exceed 30 percent,'' in order to remove any ambiguity. Only

anatomical loss of an eye can result in a higher evaluation (under

diagnostic code 6063). We further propose to change ``serious cosmetic

defect'' to ``disfigurement,'' because a proposed diagnostic code

(7800) and evaluation criteria for disfigurement of the head, face, or

neck were published in the Federal Register of January 19, 1993 (See 58

FR 4969) as part of the revision of the portion of the rating schedule

that addresses the skin, but there is no diagnostic code that addresses

``serious cosmetic defect.'' Section 4.75(d) is therefore proposed to

read ``The evaluation for visual impairment of one eye shall not exceed

30 percent unless there is anatomical loss of the eye. The evaluation

for visual impairment of one eye may, however, be combined with

evaluations for other disabilities, e.g., disfigurement, that are not

based on visual impairment.''

We propose that paragraph (e) of Sec. 4.75, ``Anatomical loss of

one eye with inability to wear a prosthesis,'' require that evaluations

be increased by 10 percent when there is anatomical loss of one eye,

and a prosthesis cannot be worn. This is derived from material in a

footnote to diagnostic codes 6064, 6065, and 6066 concerning the

evaluation for anatomical loss of one eye, and we therefore propose to

delete that portion of the footnote as redundant. We further propose to

add for clarity a statement that the maximum evaluation shall not

exceed 100 percent.

We propose that paragraph (f) of Sec. 4.75, ``Special monthly

compensation,'' direct the rating agency to refer to 38 CFR 3.350 to

determine whether the veteran may be entitled to special monthly

compensation (SMC). This is similar to instructions we have placed in

other revised portions of the rating schedule where there is potential

entitlement to special monthly compensation, e.g., in the portion that

addresses gynecological conditions and disorders of the breasts. This

is intended as an additional reminder to the rating agency to assure

that SMC is assigned when warranted.

We propose that Secs. 4.76, 4.77, and 4.78 address impairment of

visual acuity, visual fields, and muscle function, respectively, with

each section containing subsections that address examinations and

evaluations of the impairments, as discussed in more detail below.

We propose that Sec. 4.76, ``Visual acuity,'' derived from material

currently found in Secs. 4.75 and 4.84, plus M21-1, Part VI, consist of

two paragraphs: (a) Examination of visual acuity and (b) Evaluation of

visual acuity.

We propose that paragraph (a) of Sec. 4.76, which is based on

current Sec. 4.75, require that, to be adequate for VA purposes,

uncorrected and corrected visual acuity for distance and near be

recorded, as determined using Snellen's test type or its equivalent.

We propose two subparagraphs under proposed paragraph (b) of

Sec. 4.76, ``Evaluation of visual acuity.'' Subparagraph (1) would

require that visual acuity be generally evaluated on the basis of

corrected distance vision. However, when the lens required to correct

distance vision in the poorer eye differs by more than three diopters

from the lens required to correct distance vision in the better eye,

and the difference is not due to a congenital/developmental refractive

error, the visual acuity of the poorer eye for evaluation purposes

shall be either its uncorrected visual acuity or its visual acuity as

corrected by a lens that does not differ by more than three diopters

from the lens needed for correction of the other eye, whichever results

in the better combined visual acuity. The current schedule has similar

provisions but uses a four-diopter, rather than a three-diopter,

difference, and refers only to spherical correction. We propose to use

three diopters of difference instead of four because our contract

consultants suggested that, since three diopters of difference would

cause a patient to be symptomatic, requiring a four-diopter difference

is too stringent. The consultants further pointed out that the

astigmatism that underlies this disorder may require cylindrical, as

well as spherical, correction, and we therefore propose to delete the

language referring to spherical correction.

Paragraph (b)(2) of Sec. 4.76 would direct that, as long as the

individual customarily wears contact lenses, VA evaluate visual acuity

for eyes affected by a corneal disorder that results in severe

irregular astigmatism that can be improved more by contact lenses than

by eyeglass lenses, as corrected by contact lenses. The current

Sec. 4.75 states that the best distant vision obtainable after best

correction by glasses shall be the basis of rating except in cases of

keratoconus in which contact lenses are medically required. However, on

the recommendation of our contract consultants, we propose to include

corneal disorders other than keratoconus, if they also result in

astigmatism where contact lenses are more useful for correction than

eyeglasses. We propose to remove the requirement that contact lenses be

``medically required'' in order to use this method of evaluation, in

favor of a requirement that it be used only if contact lenses improve

visual acuity better than eyeglass lenses, and if the individual

customarily wears contact lenses (because some patients cannot wear

contact lenses even though they would improve their vision). This

provision assures an accurate assessment of corrected vision for those

with a cornea that is scarred or irregularly shaped, and in whom

individually fitted contact lenses provide the best visual acuity.

Paragraph (b)(3) of Sec. 4.76 would require that in cases where the

examiner reports a difference equal to two or more scheduled steps

between near and distance corrected vision, with the near vision being

worse, the examination must include at least two recordings of near and

distance corrected vision and an explanation of the reason for the

difference. We propose to require two recordings of visual acuity and

an explanation of the cause of the difference between near and distance

vision to assure that the presence of such a difference, which is very

unusual, is confirmed and that any pathologic condition responsible for

the difference is diagnosed. Current Sec. 4.84 states that when there

is a substantial difference between the near and distant corrected

vision, the case should be referred to the Director, Compensation and

Pension Service. We propose to specify a difference of two or more

scheduled steps because our medical consultants stated that amount

would be considered a ``substantial'' difference, and this more

objective standard will assure consistency in determining which cases

require application of this special provision. Evaluations of visual

acuity are ordinarily based on distance vision, and distance vision is

normally very similar, if not identical, to near vision. Since that is

not true of these cases, and because near vision is so important for

many tasks, we propose to adjust the evaluation for distance vision in

these cases. In order to assure consistent and fair evaluations in

these cases without the need to refer them to the Director of the

Compensation and Pension Service, we propose, after consultation with

licensed optometrists and ophthalmologists, that evaluation be made as

if distance vision were one step poorer than measured, which, while

recognizing that distance vision is the principal basis of the

evaluation of visual acuity, will approximately

[[Page 25249]]

compensate for the additional loss of near vision in these cases.

We propose that Sec. 4.77, ``Visual Fields,'' be composed of three

paragraphs: (a) Examination of visual fields, (b) Evaluation of visual

fields, and (c) Combination of visual field defect and decreased visual

acuity.

Paragraph (a) of Sec. 4.77, ``Examination of visual fields,''

derived from current Sec. 4.76, Examination of field vision, would

require use of a Goldmann kinetic perimeter or equivalent kinetic

method to measure visual fields. We propose to revise the language, for

the sake of accuracy, by changing the requirement for using a 3mm.

white test object to one for using a standard target size and luminance

(Goldmann equivalent (III/4e). This equivalent is a test object with an

area of 4mm\2\, average diameter of 0.43 degrees visual angle, and zero

decibels of attenuation of luminance (maximum brightness for the

Goldmann perimeter). Although the static (automated, computerized)

perimeter is now in common use, the visual fields measured by the

static and kinetic methods are not always comparable, and standards

remain uncertain, despite ongoing research on this subject. Until there

are reliable standards for comparing the results from static and

kinetic perimetry, we propose to retain the requirement for the use of

Goldmann kinetic perimetry, which is more reliable than the

alternatives.

Paragraph (b) of Sec. 4.77, ``Evaluation of visual fields,''

derived from current Sec. 4.76a, ``Computation of average concentric

contraction of visual fields,'' would establish the method for

determining the extent of concentric visual field defect by measuring

the remaining visual field in the eight principal meridians

(horizontal, vertical, and main diagonals) and averaging them. We

propose to remove the example in current Sec. 4.76a since, in our

judgment, it is unnecessary. We propose to delete the statement from

Sec. 4.76 that concentric contraction to five degrees or less is the

equivalent of 5/200 visual acuity because this information is included

under diagnostic code 6080 (visual field defects) and there is no need,

nor would it serve any useful purpose, to repeat it in Sec. 4.76.

We propose that paragraph (c) of Sec. 4.77, ``Combination of visual

field defect and decreased visual acuity,'' direct how to determine the

evaluation when both visual acuity and visual field are impaired in one

or both eyes. VA's Adjudication Manual, M21-1, Part VI, currently

directs that such cases be referred to the Director of the Compensation

and Pension Service for evaluation. We propose that the percentage

evaluation for visual acuity and for visual field loss each be

determined and then combined under 38 CFR 4.25 (Combined ratings

table). This change is consistent with the method of combining

disabilities elsewhere in the body, which is allowed as long as the

same disability is not evaluated twice, and would eliminate the need to

refer these cases to the Director of the Compensation and Pension

Service. It would provide a fair and consistent method of evaluation

that takes into account both facets of visual impairment.

We propose that Sec. 4.78, ``Muscle function,'' be composed of two

paragraphs: (a) Examination of muscle function, and (b) Evaluation of

muscle function.

Paragraph (a) of Sec. 4.78, ``Examination of muscle function,''

derived from current Sec. 4.77, would require that the Goldmann

perimeter be used to measure muscle function and that the areas of

diplopia be charted. We propose to delete as unnecessary the statement

that impairment of muscle function is to be supported by record of

actual appropriate pathology because Sec. 4.75(b) includes a

requirement that the disease, injury, or other pathologic process

responsible for any visual impairment found must be identified and that

examinations for the evaluation of visual fields or muscle function

will be conducted only when there is a medical indication of disease or

injury that may be associated with visual field defect or impaired

muscle function. Section 4.75(b) is sufficient, in our judgment, to

assure that the underlying pathology is identified.

Paragraph (b) of Sec. 4.78, ``Evaluation of muscle function,''

would establish a revised method of evaluating muscle function when

another type of visual impairment is also present. Current note (2)

following diagnostic code 6090 states that an evaluation for diplopia

will be applied to only one eye and may not be combined with an

evaluation for decreased visual acuity or visual field loss in the same

eye. It further states that when both diplopia and decreased visual

acuity or visual field loss are present in both eyes, the evaluation

for diplopia shall be assigned to the poorer eye, and the evaluation

for either corrected visual acuity or contraction of visual field to

the better eye. It does not address the situation where diplopia is

present, and another type of visual impairment is present in only one

eye. Under the current method, lower evaluations may result when the

diplopia is taken into account in the evaluation than when it is not,

unless the diplopia is very severe. VA's manual for adjudication

procedures, M21-1, states that this method is to be used only if it

would be advantageous to the veteran.

For the sake of equitable and fair evaluations, we propose, after

consultation with licensed optometrists and ophthalmologists, that

subparagraph (1) establish the following method of evaluating diplopia,

whether associated with unilateral or bilateral impaired visual acuity

or visual field. We propose that, for the poorer eye (or the affected

eye, if only one eye is service-connected), the rating agency assign a

level of visual acuity (for decreased visual acuity or visual field

defect expressed as a level of visual acuity) one step poorer than it

would be otherwise, if the evaluation for diplopia under diagnostic

code 6090 is 20/70 or 20/100; a level two steps poorer if the

evaluation for diplopia is 20/200 or 15/200; and a level three steps

poorer if the evaluation for diplopia is 5/200. The adjusted level,

however, could not exceed 5/200. The percentage evaluation would then

be determined under diagnostic codes 6064 through 6066, using the

adjusted visual acuity for the poorer eye (or the affected eye), and

the corrected visual acuity for the better eye. Under this method, the

severity of diplopia would correlate with the evaluation level, with

the higher evaluation assigned when the diplopia is worse, and the

adjusted evaluation could never be lower than one that doesn't take

diplopia into account, as can happen under the current method. An

evaluation for diplopia of 20/40, assigned when diplopia affects only

vision at 31 to 40 degrees on upward gaze, would have no effect on the

overall evaluation. This method allows a full range of evaluation for

visual impairment of a single eye, but does not exceed it. Unlike the

current schedule provision, it also provides a method of evaluating

visual impairment when both diplopia and loss of visual acuity are

present in only one eye, or when they are present in both eyes, but

only one eye is service-connected.

The current schedule contains a statement that diplopia which is

occasional or correctable is not considered a disability. Since this

fact is pertinent to the issue of service connection for diplopia, but

has no bearing on evaluation, including it in the rating schedule is

unnecessary and inappropriate.

Paragraph (b)(2) of Sec. 4.78, derived from Sec. 4.77 and the third

note following diagnostic code 6090, would define impairment of muscle

function and establish the procedure for evaluating

[[Page 25250]]

diplopia when the affected field extends beyond more than one quadrant

or range of degrees.

Paragraph (b)(3) of Sec. 4.78, derived from note (4) following

diagnostic code 6090, would require that the evaluation for diplopia

under diagnostic code 6090 be increased to the next higher evaluation

provided in the rating schedule whenever diplopia exists in separate

areas of the same eye.

Current Sec. 4.79, ``Loss of use of one eye, having only light

perception,'' duplicates 38 CFR 3.350(a)(4), (b)(2) and (b)(3), which

reflect statutory criteria for entitlement to special monthly

compensation. Because it is redundant, we propose to delete Sec. 4.79

in favor of a footnote following diagnostic codes 6066 and 6080

referring the rating agency to Sec. 3.350.

We propose to delete current Secs. 4.80 and 4.84 and the notes

following the diagnostic codes in these sections because the material

will be moved to proposed Secs. 4.75 through 4.78.

Current Table IV, ``Table for Rating Bilateral Blindness or

Blindness Combined with Hearing Loss with Dictator's Code and 38 CFR

Citations,'' is a chart displaying SMC codes to be used by the rating

agency when dictating rating decisions for transcription. The

dictator's rating codes have been changed since they were first

published in Table IV, and they appear in their current form in

Appendix A of Part I of M21-1, VA's Adjudication Procedures Manual.

This chart's only purpose is to simplify the process of dictating

ratings to a transcription unit. Since it has no bearing on the

evaluation of disabilities, and contains no policy guidelines which

rating agencies must follow, we propose to delete Table IV from the

rating schedule.

Current Table V, ``Ratings for Central Visual Acuity Impairment,''

repeats the evaluations and diagnostic codes for impaired visual acuity

in chart form. Since diagnostic codes 6061 through 6066 establish

evaluation criteria in a format which is consistent with the rest of

the rating schedule, we propose to delete Table V as redundant and

unnecessary for any regulatory purpose. Since current Sec. 4.83a

explains how to use Table V, we also propose to remove Sec. 4.83a.

Current Sec. 4.83 explains how to record ratings for impairment of

central visual acuity, and it is therefore directed more at examiners

than at rating agencies. Since the method described is standard, we

propose to delete that section as unnecessary.

Uveitis, keratitis, scleritis, iritis, cyclitis, choroiditis,

retinitis, recent intra-ocular hemorrhage, detachment of retina, and

unhealed eye injury (diagnostic codes 6000 through 6009) are currently

evaluated at levels of 10 to 100 percent based on impairment of visual

acuity or field loss, pain, rest-requirements, or episodic incapacity,

combining an additional rating of 10 percent during continuance of

active pathology. We propose a revised set of evaluation criteria in

the form of a general rating formula following diagnostic code 6009. We

propose that evaluation be based either on visual impairment or on

incapacitating episodes, whichever results in a higher evaluation. We

propose to define an incapacitating episode, for VA purposes, as one

requiring bedrest and treatment by a physician or other healthcare

provider. We propose to establish evaluation levels of 10, 20, 40, and

60 percent based on incapacitating episodes, in order to accommodate

this broad group of conditions with the potential for a wide range of

length of periods of incapacitation. We propose an evaluation of 60

percent with incapacitating episodes of at least six weeks total

duration per year; of 40 percent with incapacitating episodes of at

least four weeks, but less than six weeks, total duration per year; of

20 percent with incapacitating episodes of at least two weeks, but less

than four weeks, total duration per year; and of 10 percent with

incapacitating episodes total of at least one week, but less than two

weeks, total duration per year. These criteria are clearer and more

objective than current criteria, and will allow the extent of

incapacitating episodes to be consistently taken into account.

We propose to change the terminology in several diagnostic codes to

reflect current medical usage, in accord with suggestions by our

consultants. We propose to change the title of diagnostic code 6000,

``uveitis,'' to ``choroidopathy,'' because the term ``choroidopathy''

includes pathological conditions of the choroid other than

inflammation, and also encompasses the subcategories of uveitis,

iritis, cyclitis, and choroiditis. We therefore propose to delete

diagnostic codes 6003 (iritis), 6004 (cyclitis), and 6005

(choroiditis), since they are included in diagnostic code 6000.

Similarly, we propose to change the title of diagnostic code 6001,

``keratitis,'' to ``keratopathy,'' a broader category that includes

corneal conditions other than inflammation, and the title of diagnostic

code 6006, ``retinitis,'' to ``retinopathy or maculopathy,'' broader

terms that encompass not only retinitis but other retinal and macular

diseases and degenerations, for the same reason. We propose to revise

the title of diagnostic code 6007 (hemorrhage, intra-ocular, recent) to

``intra-ocular hemorrhage'' because both recent (or acute) and chronic

intra-ocular hemorrhage may be disabling. We propose to edit the title

of diagnostic code 6010 (tuberculosis of eye) and to correct an

erroneous reference to codes under which inactive tuberculosis of the

eye is evaluated. The current schedule refers to Secs. 4.88b and 4.89,

but Sec. 4.88b was redesignated Sec. 4.88c in a separate rulemaking,

and the correct section references are now 4.88c and 4.89. We propose

to simplify the title of diagnostic code 6011 from ``retina, localized

scars, atrophy, or irregularities of, centrally located, with

irregular, duplicated, enlarged or diminished image'' to ``retinal

scars, atrophy, or irregularities.'' We propose to retain a ten-percent

evaluation under diagnostic code 6011 for localized scars, atrophy, or

irregularities that are centrally located and that result in an

irregular, duplicated, enlarged, or diminished image. Evaluation of

these conditions would otherwise be based on visual impairment, as

defined in proposed Sec. 4.75(a).

We propose to revise the title of diagnostic code 6012, ``glaucoma,

congestive or inflammatory,'' to ``angle-closure glaucoma,'' the

current medical term for the condition. For the same reason, we propose

to change the title of diagnostic code 6013, ``glaucoma, simple,

primary, noncongestive,'' to ``open-angle glaucoma.''

Diagnostic code 6012, angle-closure glaucoma, is currently

evaluated either as iritis (diagnostic code 6003) or by rating at 100

percent if there are ``frequent attacks of considerable duration;

during continuance of actual total disability.'' ``Frequent'' and

``considerable'' are subjective terms that are susceptible to different

interpretations. In addition, these criteria are difficult to apply

because acute attacks are usually of short duration, and it is unlikely

that an examination for disability could be scheduled and conducted

during such an attack. Therefore, we propose to evaluate this condition

similarly to diagnostic codes 6000 through 6009, based either on visual

impairment or on incapacitating episodes, whichever results in a higher

evaluation. Because in some cases this condition is characterized

primarily by frequent and sometimes prolonged intermittent episodes of

incapacitation, we propose to provide a wide range of evaluations--from

20 to 60 percent--based on incapacitating episodes. We also propose to

establish a ten-percent

[[Page 25251]]

minimum evaluation if continuous medication is required. A minimum

evaluation is not warranted if there is no visual impairment and no

treatment is needed other than frequent observation. We propose these

more objective criteria in order to provide clearer guidance on

evaluation and to assure more consistent evaluations. With these

criteria, the direction to rate as iritis is not needed, and we propose

to delete it.

Diagnostic code 6013, open-angle glaucoma, is currently evaluated

on impairment of visual acuity or field loss, with a minimum evaluation

of ten percent. We propose that it be evaluated on visual impairment,

which will allow consideration of impairment of visual acuity, visual

field, or muscle function, with a ten-percent minimum evaluation if

continuous medication is required. A minimum evaluation is not

warranted if there is no visual impairment and no treatment is needed

other than frequent observation.

We propose to update the term ``new growth'' to ``neoplasm'' in the

titles of diagnostic codes 6014 and 6015, which address malignant and

benign eye tumors, respectively.

Malignant neoplasms (diagnostic code 6014) are now evaluated at 100

percent pending completion of surgery or other indicated treatment,

and, when healed, are rated on residuals. However, not all malignant

neoplasms of the eye are totally disabling or require treatment that is

totally disabling for a period of time. For example, eye malignancies

such as iris melanoma and choroid melanoma often require no treatment

other than observation, even though they are malignant on pathology

examination. We therefore propose to evaluate malignancies of the

eyeball similar to the way we proposed to evaluate skin malignancies

(published in the Federal Register of January 19, 1993 (See 58 FR

4969)). If a malignant neoplasm of the eyeball requires therapy that is

comparable to that used for internal malignancies, i.e., systemic

chemotherapy, X-ray therapy more extensive than to the eye, or surgery

more extensive than enucleation, a 100 percent evaluation would be

assigned from the date of onset of treatment, and would continue, with

a mandatory VA examination six months following the completion of such

antineoplastic treatment, and any change in evaluation based upon that

or any subsequent examination would be subject to the effective date

provisions of Sec. 3.105(e). If there has been no local recurrence or

metastasis, evaluation would then be made on residuals. These revisions

are similar to those now in effect for malignant neoplasms in several

revised sections of the rating schedule (e.g., gynecological conditions

and disorders of the breast, respiratory system, endocrine system). If

treatment is confined to the eye, the provisions for a 100 percent

evaluation would not apply. If no treatment other than observation is

required, we propose that evaluation be made by separately evaluating

visual impairment and nonvisual impairment, e.g., disfigurement

(diagnostic code 7800), and combining the evaluations under Sec. 4.25.

In our judgment, neoplasms that require only periodic observation,

without surgical or other medical intervention, are not totally

disabling and therefore do not warrant the total evaluation ordinarily

provided for malignant neoplasms. If treatment comparable to that for

internal malignancies is needed, eye malignancies would be evaluated in

the same manner as internal malignancies requiring treatment.

Benign neoplasms (diagnostic code 6015) are currently evaluated on

impaired vision, with a minimum evaluation of 10 percent, and healed

benign neoplasms are rated on residuals. A standard ophthalmology text,

(Frank W. Newell, M.D., Ophthalmology Principles and Concepts, p. 207,

7th ed. 1992), indicates no specific impairment due to benign

neoplasms, and no need for continuing medication. A minimum evaluation

for all cases is therefore not warranted, and we propose to remove it.

We propose that evaluation be based on visual impairment, with that

evaluation to be combined with an evaluation for any nonvisual

impairment, e.g., disfigurement. These criteria better encompass the

impairments that may result from benign neoplasms. We propose to revise

the title of diagnostic code 6015 from ``new growths, benign (eyeball

and adnexa, other than superficial)'' to ``benign neoplasms (of eyeball

and adnexa)'' because without the requirement for a minimum evaluation,

the distinction between superficial and other types of benign neoplasm

is not relevant.

We propose to edit the title of diagnostic code 6017,

``conjunctivitis, trachomatous, chronic'' to ``trachomatous

conjunctivitis'' and the title of diagnostic code 6018,

``conjunctivitis, other, chronic'' to ``chronic conjunctivitis

(nontrachomatous).'' Evaluations of healed trachomatous and

nontrachomatous conjunctivitis are currently based on residuals, with a

zero-percent evaluation if there are no residuals. We propose to remove

the zero-percent evaluation level. 38 CFR 4.31 provides for a zero-

percent evaluation in all cases when the criteria for a compensable

evaluation is not met, which obviates the need to include zero-percent

evaluation criteria in this case. Active trachomatous conjunctivitis is

currently evaluated on impairment of visual acuity, with a minimum

evaluation of 30 percent while there is active pathology; other forms

of active conjunctivitis are evaluated at 10 percent when there are

``objective symptoms.'' We propose to change ``objective symptoms'' to

``objective findings, such as red, thick conjunctivae, mucous

secretion, etc.'' under diagnostic code 6018, since symptoms are, by

definition, subjective, and to change ``healed'' to ``inactive''

because conjunctivitis may be active intermittently. We propose that

inactive trachomatous conjunctivitis and inactive chronic

conjunctivitis be evaluated on residuals, such as visual impairment,

disfigurement (diagnostic code 7800), etc. Our contract consultants

suggested that these categories of conjunctivitis be combined because

of the rarity of trachoma. Because trachoma is much more severe than

most other types of chronic conjunctivitis and often leads to

blindness, it warrants a 30-percent minimum evaluation, when active, an

evaluation level that cannot be justified for other types of

conjunctivitis. Since we must assure appropriate evaluations for these

disparate conditions, we do not propose to adopt the consultants'

suggestion.

Ptosis (diagnostic code 6019) is currently evaluated equivalent to

visual acuity of 5/200 whenever the pupil is wholly obscured,

equivalent to 20/100 if the pupil is one-half or more obscured, and on

disfigurement if less than one-half of the pupil is obscured. The

extent to which a pupil is obscured can be difficult to determine

reliably, and an evaluation for ptosis based directly on visual

impairment was recommended by our contract consultants. We propose to

adopt their suggestion and, in the absence of visual impairment, base

evaluation on disfigurement (diagnostic code 7800).

Our contract consultants recommended that we add a note providing

an alternative evaluation as disfigurement (diagnostic code 7800) for

ectropion (diagnostic code 6020), entropion (diagnostic code 6121),

lagophthalmos (diagnostic code 6022), eyebrows, loss of complete,

unilateral or bilateral (diagnostic code 6023), eyelashes, loss of,

complete, unilateral or bilateral (diagnostic code 6024), and epiphora

(diagnostic code 6025). The diagnosis of one of these conditions is

[[Page 25252]]

sufficient to assign the current percentage evaluations because the

diagnosis itself implies the presence of some degree of disfigurement,

which is the primary basis of these evaluations. Since an evaluation

for disfigurement is encompassed in the percentages provided, the

suggested note would be redundant, and we do not propose to adopt the

consultants' suggestion.

We propose to change the title of diagnostic code 6025 from

``epiphora'' to ``disorders of the lacrimal apparatus (epiphora,

dacryocystitis, etc.)'' because all disorders of the lacrimal apparatus

are evaluated in the same way, and they commonly occur together. In

conjunction with this change, we propose to delete dacryocystitis

(diagnostic code 6031), as our consultants suggested, because it will

be included under diagnostic code 6025.

We propose to change the title of diagnostic code 6026 from

``neuritis, optic'', to ``optic neuropathy'', a broader term that

includes conditions other than inflammation of the optic nerve. It is

likely that optic nerve conditions other than neuritis are currently

being evaluated under this code, because there is no other diagnostic

code that specifically addresses diseases of the optic nerve, but this

change will assure consistency by including all optic nerve disorders

under diagnostic code 6026.

Current diagnostic codes 6027, ``cataract, traumatic,'' and 6028,

``cataract, senile, and others,'' are evaluated under the same

criteria--impairment of vision preoperatively, and impairment of vision

and aphakia postoperatively--because they result in identical

impairment. We therefore propose to delete diagnostic code 6028 and to

establish a single diagnostic code, 6027, ``cataract of any type,'' for

all types of cataracts. We propose that evaluation preoperatively be

based on visual impairment and postoperatively on visual impairment if

a replacement lens is present, and on aphakia if there is no

replacement lens. Our contract consultants suggested we add a

diagnostic code for pseudophakia to the rating schedule. The term

``pseudophakia'' has two meanings--one, a condition where the lens has

been replaced status post-cataract removal and the other, a condition

in which a degenerated lens is spontaneously replaced by some other

type of tissue. Dorland's Illustrated Medical Dictionary (27th ed.

1988) does not include the former definition. Therefore, to avoid

confusion, instead of adding a code for pseudophakia, we propose to use

clear and unambiguous language in diagnostic code 6027 concerning the

post-operative evaluation of cataracts and to include pseudophakia as a

parenthetical expression after ``if a replacement lens is present.''

Current diagnostic codes 6029, ``aphakia,'' and 6033, ``lens,

crystalline, dislocation of,'' are evaluated under the same criteria

because they result in identical impairments. We propose to combine the

conditions under diagnostic code 6029, retitle it ``aphakia or

dislocation of crystalline lens,'' and delete diagnostic code 6033,

since there is no need to retain two separate diagnostic codes for

these conditions for statistical or other purposes. There is currently

a minimum evaluation of 30 percent under diagnostic code 6029, whether

unilateral or bilateral, and there are a number of additional rules for

evaluation that are applied depending on whether one or both eyes are

aphakic. In order to simplify the current method of evaluation, which

has sometimes caused confusion, we propose to instruct the rating

agency to evaluate on the basis of visual impairment, elevated by one

step. We propose to retain the minimum 30-percent evaluation for

unilateral or bilateral aphakia. These minimum evaluations are

warranted because the severe hyperopia that results from aphakia cannot

be adequately corrected. In addition, there is substantial

magnification of the image in an aphakic eye, peripheral vision is

reduced, and with aphakia of a single eye, image fusion may be

difficult because of the great difference in refraction between the

eyes. Glare and photophobia are common additional problems, and

eyeglasses cause a ring scotoma so that objects appear to jump in and

out of view. The proposed criteria are consistent with other methods of

evaluating conditions manifested primarily by visual impairment, take

into account visual problems other than loss of visual acuity that are

not precisely measurable, and are clearer, which should assure

consistent evaluations.

We propose to revise the title of diagnostic code 6030 from

``accommodation, paralysis of'' to ``paralysis of accommodation (due to

neuropathy of the Oculomotor Nerve)'' because pathology of that cranial

nerve is the usual etiology.

We propose to change the title of diagnostic code 6032 from

``eyelids, loss of portion of'' to ``loss of eyelids, partial or

complete,'' because complete loss of eyelids may also require

evaluation and can be evaluated under the same criteria. Diagnostic

code 6032 is currently rated as disfigurement (diagnostic code 7800).

Our contract consultants suggested we combine an evaluation for the

underlying disease (none of which they named) with an evaluation for

visual impairment. Instead, we propose to direct that an evaluation for

visual impairment be combined with an evaluation for disfigurement

(diagnostic code 7800). An underlying disease producing other

impairments would be evaluated under the appropriate body system, but

it is not necessary to provide this instruction here because it is not

unique to this condition.

Pterygium, diagnostic code 6034, is currently evaluated on loss of

vision, if any, and we propose that it be evaluated on visual

impairment, disfigurement (diagnostic code 7800), conjunctivitis

(diagnostic code 6018), etc. This proposed change better encompasses

the possible range of impairments from pterygium.

A note currently following diagnostic code 6035, keratoconus,

requires a 30-percent minimum evaluation when ``contact lenses are

medically required.'' We propose to delete the minimum evaluation and

base evaluation on corrected visual acuity (using contact lenses rather

than eyeglass lenses for that determination if they provide the best

corrected visual acuity and are customarily worn by the individual)

because decreased visual acuity is the only disabling effect of

keratoconus. If contact lenses best correct the visual impairment, and

can be worn by the individual, there would be no significant additional

disability to warrant a minimum evaluation, and the corrected visual

acuity using contact lenses would be a reasonable basis of evaluation.

If eyeglass lenses can correct the visual acuity, the usual method of

determining corrected visual acuity would be the basis of evaluation.

We propose to add diagnostic code 6036 for ``status post corneal

transplant,'' a common condition, with evaluation based on visual

impairment. Either loss of visual acuity or visual field loss or both

may occur in corneal transplant, and this direction allows any visual

impairment to be evaluated. Since pain, photophobia, and glare

sensitivity may be disabling following corneal transplant, we propose a

minimum of evaluation of ten percent if those symptoms are present.

The current schedule uses 19 different diagnostic codes to

designate impairment of central visual acuity, and some designate more

than one level of visual acuity, e.g., diagnostic code 6078 designates

six different levels. No useful purpose is served by this large number

of codes, and we propose to decrease the number to six for more ease of

use.

[[Page 25253]]

We propose to retain separate codes for anatomical loss of both eyes

(diagnostic code 6061); for light perception only, both eyes

(diagnostic code 6062); for anatomical loss of one eye (diagnostic code

6063); for light perception only, one eye, (diagnostic code 6064); for

vision in one eye 5/200 (1.5/60) (diagnostic code 6065); and for

impairment of visual acuity 10/200 (3/60) or better (diagnostic code

6066). In addition, we propose to remove the term ``blindness'' from

the titles of diagnostic codes 6062 and 6064 in favor of the terms

``light perception only, both eyes'' and ``light perception only, one

eye,'' respectively because the term ``blindness,'' as used in 38

U.S.C. 1114, ``Rates of wartime disability compensation,'' has more

than one meaning, and using it in the rating schedule to refer to only

one level of visual impairment promotes confusion.

In the current rating schedule, footnote number five, attached to

diagnostic codes 6061-63 and 6067-71, refers to entitlement to SMC, and

footnote number six, attached to diagnostic codes 6064-66, refers both

to entitlement to SMC and to evaluation when there is inability to wear

a prosthesis following anatomical loss of an eye. (Footnotes number

five and six are currently the only footnotes in this section.) We have

discussed above our proposal to remove the part of the footnote that

addresses the inability to wear a prosthesis. We propose to place the

material concerning SMC in footnote number one, following diagnostic

code 6066 and also following diagnostic code 6080. We propose to remove

footnotes five and six and to attach footnote number one to diagnostic

codes 6061 through 6064, under diagnostic code 6065 at the 100 percent

evaluation for ``vision in one eye 5/200, in the other eye 5/200,'' and

under diagnostic code 6080 at ``visual field, concentric contraction

of, to 5 degrees'' (because concentric contraction of the visual field

to five degrees is the equivalent of 5/200, and must also be considered

for SMC (see 38 CFR 3.350)). This combination of footnotes and

paragraph (f) of Sec. 4.75 referring to SMC is, in our opinion, the

best way to ensure complete review for SMC.

We propose to update the subpart title ``Ratings for Impairment of

Field of Vision'' to ``Ratings for Impairment of Visual Fields'' and

the title of diagnostic code 6080 from ``Field vision, impairment of''

to ``Visual field defects,'' in accordance with current usage. In order

to make the evaluations for visual field defects under diagnostic code

6080 more comprehensive, as suggested by our consultants, we propose to

add evaluations for loss of superior and inferior altitudinal fields.

Inferior field loss will be evaluated at 10 percent for the unilateral

and 30 percent for the bilateral condition (or impaired visual acuity

of 20/70 (6/21) for each affected eye), and superior field loss will be

evaluated at 10 percent for both the unilateral and bilateral

conditions (or impaired visual acuity of 20/50 (6/15) for each affected

eye). For the sake of accuracy, we propose, under diagnostic code 6080,

to make 10 percent (or impaired visual acuity of 20/50 (6/15) for each

affected eye), instead of 20 percent, the evaluation for unilateral or

bilateral condition for both concentric contraction to 46 to 60 degrees

and for loss of the nasal half of the visual field. This will correct

the bilateral percentage evaluation, currently indicated to be 20

percent for these conditions, because both bilateral and unilateral

visual acuity of 20/50 warrant a 10-percent, not a 20-percent,

evaluation. Notes one and two, currently following diagnostic code

6080, discuss the requirements for correct diagnosis, demonstrable

pathology, and contraction within the stated degrees for concentric

contraction ratings. We propose to delete these notes because similar

information is contained in Sec. 4.1, proposed Sec. 4.77(a), and under

diagnostic code 6080, and they are therefore redundant.

We propose to revise the evaluation criteria for diagnostic code

6081, ``scotoma, unilateral,'' which currently provide a minimum 10-

percent evaluation for a large or centrally located scotoma, by

changing ``large'' to ``affecting at least one-quarter of the visual

field (quadrantanopsia).'' This language is clearer, and the term

``quadrantanopsia,'' is widely accepted. We propose that evaluation

otherwise be based on visual impairment, which is not a substantive

change from the current direction to ``rate on loss of central visual

acuity or impairment of field vision.''

Symblepharon (diagnostic code 6091) is currently rated under the

criteria for diagnostic code 6090 (diplopia). However, it may also

result in other types of impairments, and we therefore propose to

direct that it be evaluated on visual impairment, lagophthalmos

(diagnostic code 6022), disfigurement (diagnostic code 7800), etc.

Diplopia is currently evaluated under diagnostic code 6090 and also

under diagnostic code 6092, which is described as ``diplopia, due to

limited muscle function'' and evaluated according to the criteria under

diagnostic code 6090. We propose to eliminate diagnostic code 6092

because diplopia due to limited muscle function is not functionally

distinct from diplopia (double vision) and does not warrant a separate

code. As stated above, we propose to delete the note following

diagnostic code 6090 regarding a citing of the correct diagnosis as

redundant.

For purposes of clarity, we propose to make numerous additional

nonsubstantive changes in this document.

The Secretary hereby certifies that this regulatory amendment will

not have a significant economic impact on a substantial number of small

entities as they are defined in the Regulatory Flexibility Act, 5

U.S.C. 601-612. The reason for this certification is that this

amendment would not directly affect any small entities. Only VA

beneficiaries could be directly affected. Therefore, pursuant to 5

U.S.C. 605(b), this amendment is exempt from the initial and final

regulatory flexibility analysis requirements of sections 603 and 604.

This regulation has been reviewed by the Office of Management and

Budget under Executive Order 12866.

The Catalog of Federal Domestic Assistance numbers are 64.104 and

64.109.

List of Subjects in 38 CFR Part 4

Disability benefits, Individuals with disabilities, Pensions,

Veterans.

Approved: December 14, 1998.

Togo D. West, Jr.,

Secretary of Veterans Affairs.

For the reasons set out in the preamble, 38 CFR part 4, subpart B,

is proposed to be amended as set forth below:

PART 4--SCHEDULE FOR RATING DISABILITIES

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

Authority: 38 U.S.C. 1155.

Subpart B--Disability Ratings

2. Sections 4.75 and 4.76 are revised to read as follows:

Sec. 4.75 General considerations for evaluating visual impairment.

(a) Visual impairment. The evaluation of visual impairment is based

on impairment of visual acuity (excluding developmental errors of

refraction), visual field, and muscle function.

(b) Examination for visual impairment. To be adequate for VA

purposes, an examination to evaluate visual impairment must be

conducted by a licensed optometrist or

[[Page 25254]]

ophthalmologist. The examiner must identify the disease, injury, or

other pathologic process responsible for any visual impairment found.

Examinations for the evaluation of visual fields or muscle function

will be conducted only when there is a medical indication of disease or

injury that may be associated with visual field defect or impaired

muscle function. The fundus must be examined with the veteran's pupils

dilated (unless medically contraindicated).

(c) Service-connected visual impairment of only one eye. If visual

impairment of only one eye is service-connected, either directly or by

aggravation, the visual acuity of the non-service-connected eye shall

be considered to be 20/40 for evaluation purposes, subject to the

provisions of Sec. 3.383(a) of this chapter.

(d) Maximum evaluation for visual impairment of one eye. The

evaluation for visual impairment of one eye shall not exceed 30 percent

unless there is anatomical loss of the eye. The evaluation for visual

impairment of one eye may, however, be combined with evaluations for

other disabilities, e.g., disfigurement, that are not based on visual

impairment.

(e) Anatomical loss of one eye with inability to wear a prosthesis.

When there is anatomical loss of one eye, the evaluation for visual

acuity under diagnostic code 6063 shall be increased by 10 percent if

the veteran is unable to wear a prosthesis, but the maximum evaluation

shall not exceed 100 percent.

(f) Special monthly compensation. When evaluating any claim

involving visual impairment, the rating agency shall refer to

Sec. 3.350 of this chapter to determine whether the veteran may be

entitled to special monthly compensation. Footnotes in the schedule

indicate levels of visual impairment that potentially establish

entitlement to special monthly compensation; however, other levels of

visual impairment combined with disabilities of other body systems may

also establish entitlement.

(Authority: 38 U.S.C. 1155 and 1114)

Sec. 4.76 Visual acuity.

(a) Examination of visual acuity. To be adequate for VA purposes,

an examination to evaluate visual acuity must record uncorrected and

corrected visual acuity for distance and near, as determined using

Snellen's test type or its equivalent.

(b) Evaluation of visual acuity. (1) For VA purposes, visual acuity

shall generally be evaluated on the basis of corrected distance vision.

However, when the lens required to correct distance vision in the

poorer eye differs by more than three diopters from the lens required

to correct distance vision in the better eye, and the difference is not

due to congenital or developmental refractive error, the visual acuity

of the poorer eye for evaluation purposes shall be either its

uncorrected visual acuity or its visual acuity as corrected by a lens

that does not differ by more than three diopters from the lens needed

for correction of the other eye, whichever results in better combined

visual acuity.

(2) Provided that he or she customarily wears contact lenses, VA

shall evaluate the visual acuity of any individual affected by a

corneal disorder that results in severe irregular astigmatism that can

be improved more by contact lenses than by eyeglass lenses, as

corrected by contact lenses.

(3) In any case where the examiner reports that there is a

difference equal to two or more scheduled steps between near and

distance corrected vision, with the near vision being worse, the

examination report must include at least two recordings of near and

distance corrected vision and explain the reason for the difference.

Evaluation in those cases will be based on distance vision adjusted to

one step poorer than measured.

Sec. 4.76a [Removed]

3. Section 4.76a is removed.

4. Sections 4.77, 4.78 and 4.79 are revised to read as follows:

Sec. 4.77 Visual fields.

(a) Examination of visual fields. To be adequate for VA purposes,

examinations of visual fields must be conducted using a Goldmann

kinetic perimeter or equivalent kinetic method, using a standard target

size and luminance (Goldmann's equivalent (III/4-e)). At least two

recordings of visual fields must be made, and the examination must be

supplemented by the use of a tangent screen when the examiner indicates

it is necessary. At least 16 meridians 22\1/2\ degrees apart must be

charted for each eye (see Figure 1). See Table III for the normal

extent of the visual fields (in degrees) at the 8 principal meridians

(45 degrees apart). The confirmed visual fields shall be made a part of

the examination report.

(b) Evaluation of visual fields. The average concentric contraction

of the visual field of each eye is determined by measuring the

remaining visual field (in degrees) at each of eight principal

meridians 45 degrees apart, adding them, and dividing the sum by eight.

(c) Combination of visual field defect and decreased visual acuity.

To determine the evaluation for visual impairment when both decreased

visual acuity and visual field defect are present in one or both eyes,

the rating agency shall combine the evaluations for visual acuity and

visual field defect (expressed as a level of visual acuity) (see

Sec. 4.25).

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

Sec. 4.78 Muscle function.

(a) Examination of muscle function. To be adequate for VA purposes,

measurement of muscle function must be performed using a Goldmann

Perimeter Chart which identifies the four major quadrants, (upward,

downward, left and right lateral) and the central field (20 degrees or

less) (see Figure 2). The examiner will chart the areas in which

diplopia exists and include the plotted chart in the examination

report.

(b) Evaluation of muscle function. (1) An evaluation for diplopia

shall be assigned to only one eye. When both diplopia and decreased

visual acuity or visual field defect are present in an individual, the

rating agency shall assign a level of corrected visual acuity for the

poorer eye (or the affected eye, if only one eye is service-connected),

that is: one step poorer than it would otherwise warrant if the

evaluation for diplopia under diagnostic code 6090 is 20/70 or 20/100;

two steps poorer if the evaluation under diagnostic code 6090 is 20/200

or 15/200; and three steps poorer if the evaluation under diagnostic

code 6090 is 5/200. These adjusted levels of corrected visual acuity,

however, shall not exceed a level of 5/200. The percentage evaluation

for visual impairment shall then be determined under diagnostic codes

6064 through 6066, using the adjusted visual acuity for the poorer eye

(or the affected eye), and the corrected visual acuity for the better

eye.

(2) When diplopia is present in more than one quadrant or range of

degrees, the rating agency shall evaluate diplopia on the quadrant and

degree range that provides the highest evaluation.

(3) When diplopia exists in two separate areas of the same eye, the

equivalent visual acuity under diagnostic code 6090 shall be increased

to the next poorer level of visual acuity, but not to exceed 5/200.

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

Sec. 4.79 Schedule of ratings--eye.

[[Page 25255]]

Diseases of the Eye

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

Rating

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

6000 Choroidopathy, including uveitis, iritis, cyclitis, and

choroiditis

6001 Keratopathy

6002 Scleritis

6006 Retinopathy or maculopathy

6007 Intraocular hemorrhage

6008 Detachment of retina

6009 Unhealed eye injury

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

GENERAL RATING FORMULA FOR DIAGNOSTIC CODES 6000 THROUGH 6009

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

Rating

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

Evaluate on the basis of either visual impairment or

incapacitating episodes, whichever results in a higher

evaluation.

With incapacitating episodes of at least six weeks total 60

duration per year.........................................

With incapacitating episodes of at least four weeks, but 40

less than six weeks, total duration per year..............

With incapacitating episodes of at least two weeks, but 20

less than four weeks, total duration per year.............

With incapacitating episodes of at least one week, but less 10

than two weeks, total duration per year...................

Note: For VA purposes, an incapacitating episode is a period of

acute symptoms severe enough to require bed rest and treatment

by a physician or other healthcare provider.

6010 Tuberculosis of eye:

Active:.................................................... 100

Inactive: Rate under Secs. 4.88c or 4.89 of this part,

whichever is appropriate.

6011 Retinal scars, atrophy, or irregularities:

Localized scars, atrophy, or irregularities of the retina, 10

unilateral or bilateral, that are centrally located and

that result in an irregular, duplicated, enlarged, or

diminished image..........................................

Otherwise, evaluate on visual impairment.

6012 Angle-closure glaucoma:

Evaluate on the basis of either visual impairment or

incapacitating episodes, whichever results in a higher

evaluation.

Minimum evaluation if continuous medication is required.... 10

With incapacitating episodes of at least six weeks total 60

duration per year.........................................

With incapacitating episodes of at least four weeks, but 40

less than six weeks, total duration per year..............

With incapacitating episodes of at least two weeks, but 20

less than four weeks, total duration per year.............

Note: For VA purposes, an incapacitating episode is a period of

acute symptoms severe enough to require bed rest and treatment

by a physician or other healthcare provider.

6013 Open-angle:

Evaluate on visual impairment.

Minimum evaluation if continuous medication is required.... 10

6014 Malignant neoplasms (eyeball only):

Note (1): If a malignant neoplasm of the eyeball requires

therapy that is comparable to that used for systemic

malignancies, i.e., systemic chemotherapy, X-ray therapy more

extensive than to the area of the eye, or surgery more

extensive than enucleation, a rating of 100 percent shall be

assigned that shall continue beyond the cessation of any

surgical, X-ray, antineoplastic chemotherapy or other

therapeutic procedure. Six months after discontinuance of such

treatment, the appropriate disability rating shall be

determined by mandatory VA examination. Any change in

evaluation based upon that or any subsequent examination shall

be subject to the provisions of Sec. 3.105(e) of this

chapter. If there has been no local recurrence or metastasis,

rate on residuals.

Note (2): To evaluate residuals, or malignant neoplasms that do

not require therapy comparable to that for systemic

malignancies, evaluate visual impairment and nonvisual

impairment, e.g., disfigurement (diagnostic code 7800),

separately and combine the evaluations.

6015 Benign neoplasms (of eyeball and adnexa):

Evaluate visual impairment and nonvisual impairment, e.g.,

disfigurement (diagnostic code 7800), separately and

combine the evaluations.

6016 Nystagmus, central....................................... 10

6017 Trachomatous conjunctivitis:

Active: Evaluate on visual impairment, minimum............. 30

Inactive: Evaluate on residuals, such as visual impairment

and disfigurement (diagnostic code 7800).

6018 Chronic conjunctivitis (nontrachomatous):

Active (with objective findings, such as red, thick 10

conjunctivae, Mucous secretion, etc.).....................

Inactive: Evaluate on residuals, such as visual impairment

and disfigurement (diagnostic code 7800).

6019 Ptosis, unilateral or bilateral:

Evaluate on visual impairment, or; in the absence of visual

impairment, evaluate on disfigurement (diagnostic code

7800).

6020 Ectropion:

Bilateral.................................................. 20

Unilateral................................................. 10

6021 Entropion:

Bilateral.................................................. 20

Unilateral................................................. 10

6022 Lagophthalmos:

Bilateral...................................................... 20

Unilateral..................................................... 10

6023 Loss of eyebrows, complete, unilateral or bilateral 10

6024 Loss of eyelashes, complete, unilateral or bilateral 10

6025 Disorders of the lacrimal apparatus (epiphora,

dacryocystitis, etc.):

[[Page 25256]]

Bilateral.................................................. 20

Unilateral................................................. 10

6026 Optic neuropathy:

Evaluate on visual impairment.

6027 Cataract of any type:

Preoperative:

Evaluate on visual impairment.

Postoperative:

If a replacement lens is present (pseudophakia), evaluate

on visual impairment. If there is no replacement lens,

evaluate on aphakia.

6029 Aphakia or dislocation of crystalline lens:

Evaluate on visual impairment, and elevate the resulting

level of visual impairment one step.

Minimum (unilateral or bilateral).......................... 30

6030 Paralysis of accommodation (due to neuropathy of the 20

Oculomotor Nerve).............................................

6032 Loss of eyelids, partial or complete:

Evaluate both visual impairment and nonvisual impairment,

e.g., disfigurement (diagnostic code 7800), separately and

combine the evaluations.

6034 Pterygium:

Evaluate on visual impairment, disfigurement (diagnostic

code 7800), conjunctivitis (diagnostic code 6018), etc.

6035 Keratoconus:

Evaluate loss of visual acuity.

6036 Status post corneal transplant

Evaluate visual impairment.

Minimum, if there is pain, photophobia, and glare 10

sensitivity...............................................

6037 Pinguecula:

Evaluate on disfigurement (diagnostic code 7800).

Impairment of Central Visual Acuity:

6061 Anatomical loss both eyes \1\ 100

6062 Light perception only, in both eyes \1\ 100

6063 Anatomical loss of one eye: \1\

In the other eye 5/200 (1.5/60)............................ 100

In the other eye 10/200 (3/60)............................. 90

In the other eye 15/200 (4.5/60)........................... 80

In the other eye 20/200 (6/60)............................. 70

In the other eye 20/100 (6/30)............................. 60

In the other eye 20/70 (6/21).............................. 60

In the other eye 20/50 (6/15).............................. 50

In the other eye 20/40 (6/12).............................. 40

6064 Light perception only, in one eye: \1\

In the other eye 5/200 (1.5/60)............................ 100

In the other eye 10/200 (3/60)............................. 90

In the other eye 15/200 (4.5/60)........................... 80

In the other eye 20/200 (6/60)............................. 70

In the other eye 20/100 (6/30)............................. 60

In the other eye 20/70 (6/21).............................. 50

In the other eye 20/50 (6/15).............................. 40

In the other eye 20/40 (6/12).............................. 30

6065 Vision in one eye 5/200 (1.5/60):

In the other eye 5/200 (1.5/60)............................ \1\ 100

In the other eye 10/200 (3/60)............................. 90

In the other eye 15/200 (4.5/60)........................... 80

In the other eye 20/200 (6/60)............................. 70

In the other eye 20/100 (6/30)............................. 60

In the other eye 20/70 (6/21).............................. 50

In the other eye 20/50 (6/15).............................. 40

In the other eye 20/40 (6/12).............................. 30

6066 Visual acuity in one eye 10/200 (3/60) or better

Vision in one eye 10/200 (3/60):

In the other eye 10/200 (3/60)............................. 90

In the other eye 15/200 (4.5/60)........................... 80

In the other eye 20/200 (6/60)............................. 70

In the other eye 20/100 (6/30)............................. 60

In the other eye 20/70 (6/21).............................. 50

In the other eye 20/50 (6/15).............................. 40

In the other eye 20/40 (6/12).............................. 30

Vision in one eye 15/200 (4.5/60):

In the other eye 15/200 (4.5/60)........................... 80

In the other eye 20/200 (6/60)............................. 70

In the other eye 20/100 (6/30)............................. 60

In the other eye 20/70 (6/21).............................. 40

In the other eye 20/50 (6/15).............................. 30

In the other eye 20/40 (6/12).............................. 20

[[Page 25257]]

Vision in one eye 20/200 (6/60):

In the other eye 20/200 (6/60)............................. 70

In the other eye 20/100 (6/30)............................. 60

In the other eye 20/70 (6/21).............................. 40

In the other eye 20/50 (6/15).............................. 30

In the other eye 20/40 (6/12).............................. 20

Vision in one eye 20/100 (6/30):

In the other eye 20/100 (6/30)............................. 50

In the other eye 20/70 (6/21).............................. 30

In the other eye 20/50 (6/15).............................. 20

In the other eye 20/40 (6/12).............................. 10

Vision in one eye 20/70 (6/21):

In the other eye 20/70 (6/21).............................. 30

In the other eye 20/50 (6/15).............................. 20

In the other eye 20/40 (6/12).............................. 10

Vision in one eye 20/50 (6/15):

In the other eye 20/50 (6/15).............................. 10

In the other eye 20/40 (6/12).............................. 10

Vision in one eye 20/40 (6/12):

In the other eye 20/40 (6/12).............................. 0

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

\1\ Review for entitlement to special monthly compensation under Sec.

3.350 of this chapter.

Ratings for Impairment of Visual Fields

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

Rating

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

6080 Visual field defects:

Homonymous hemianopsia..................................... 30

Loss of temporal half of visual field:

Bilateral.................................................. 30

Unilateral................................................. 10

Or rate each affected eye as 20/70 (6/21).

Loss of nasal half of visual field:

Bilateral.................................................. 10

Unilateral................................................. 10

Or rate each affected eye as 20/50 (6/15).

Loss of inferior half of visual field:

Bilateral.................................................. 30

Unilateral................................................. 10

Or rate each affected eye as 20/70 (6/21).

Loss of superior half of visual field:

Bilateral.................................................. 10

Unilateral................................................. 10

Or rate each affected eye as 20/50 (6/15).

Concentric contraction of visual field:

With remaining field of 5 degrees\1\

Bilateral.................................................. 100

Unilateral................................................. 30

Or rate each affected eye as 5/200 (1.5/60).

With remaining field of 6 to 15 degrees:

Bilateral.................................................. 70

Unilateral................................................. 20

Or rate each affected eye as 20/200 (6/60).

With remaining field of 16 to 30 degrees:

Bilateral.................................................. 50

Unilateral................................................. 10

Or rate each affected eye as 20/100 (6/30).

With remaining field of 31 to 45 degrees:

Bilateral.................................................. 30

Unilateral................................................. 10

Or rate each affected eye as 20/70 (6/21).

With remaining field of 46 to 60 degrees:

Bilateral.................................................. 10

Unilateral................................................. 10

Or rate each affected eye as 20/50 (6/15).

6081 Scotoma, unilateral:

Minimum, with scotoma affecting at least one-quarter of the 10

visual field (quadrantanopsia) or with centrally located

scotoma of any size.......................................

Otherwise, evaluate on visual impairment.

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

\1\ Review for entitlement to special monthly compensation under Sec.

3.350 of this chapter.

[[Page 25258]]

Ratings for Impairment of Muscle Function

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

Equivalent

Degree of diplopia visual acuity

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

6090 Diplopia (double vision):

(a) Central 20 degrees.............................. 5/200 (1.5/60)

(b) 21 degrees to 30 degrees:

(1) Down........................................ 15/200 (4.5/

60)

(2) Lateral..................................... 20/100 (6/30)

(3) Up.......................................... 20/70 (6/21)

(c) 31 degrees to 40 degrees:

(1) Down........................................ 20/200 (6/60)

(2) Lateral..................................... 20/70 (6/21)

(3) Up.......................................... 20/40 (6/12)

6091 Symblepharon:

Evaluate on visual impairment, lagophthalmos

(diagnostic code 6022), disfigurement (diagnostic

code 7800), etc., depending on particular findings

in individual case.

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

(Authority: 38 U.S.C 1155)

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

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

Secs. 4.83a and 4.84a [Removed]

6. Sections 4.83a and 4.84a are removed.

[FR Doc 99-11771 Filed 5-10-99; 8:45 am]

BILLING CODE 8320-01-P