[Federal Register: November 20, 2006 (Volume 71, Number 223)]
[Rules and Regulations]
[Page 67037-67055]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr20no06-4]
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SOCIAL SECURITY ADMINISTRATION
20 CFR Part 404
[Docket No. SSA-2006-0098]
RIN 0960-AF34
Revised Medical Criteria for Evaluating Visual Disorders
AGENCY: Social Security Administration.
ACTION: Final rules.
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SUMMARY: We are revising the criteria in the Listing of Impairments
(the listings) that we use to evaluate claims involving visual
disorders. We apply these criteria when you claim benefits based on
disability under title II and title XVI of the Social Security Act (the
Act). The revisions reflect our program experience and advances in
medical knowledge, treatment, and methods of evaluating visual
disorders.
DATES: These rules are effective February 20, 2007.
FOR FURTHER INFORMATION CONTACT: Michelle Hungerman, Social Insurance
Specialist, Office of Disability and Income Security Programs, Social
Security Administration, 100 Altmeyer Building, 6401 Security
Boulevard, Baltimore, MD 21235-6401, (410) 965-2289 or TTY (410) 966-
5609 for information about these rules. For information on eligibility
or filing for benefits, call our national toll-free number, 1-800-772-
1213 or TTY 1-800-325-0778, or visit our Internet Web site, Social
Security Online at http://www.socialsecurity.gov.
[[Page 67038]]
SUPPLEMENTARY INFORMATION:
Electronic Version
The electronic file of this document is available on the date of
publication in the Federal Register at http://www.gpoaccess.gov/fr/index.html
.
We are revising and making final the rules we proposed for
evaluating visual disorders in the notice of proposed rulemaking (NPRM)
published in the Federal Register on August 17, 2005 (70 FR 48342). We
provide a summary of the provisions of the final rules below, with an
explanation of the changes we have made from the text in the NPRM. We
then provide summaries of the public comments and our reasons for
adopting or not adopting the recommendations in those comments in the
section ``Public Comments.'' The final rule language follows the Public
Comments section.
What programs do these final regulations affect?
These final regulations affect disability and blindness
determinations and decisions that we make under title II and title XVI
of the Act. In addition, to the extent that Medicare entitlement and
Medicaid eligibility are based on whether you qualify for disability or
blindness benefits under title II or title XVI, these final regulations
also affect the Medicare and Medicaid programs.
Who can get disability or blindness benefits?
Under title II of the Act, we provide for the payment of disability
benefits, including disability benefits based on blindness if you are
disabled and belong to one of the following three groups:
Workers insured under the Act;
Children of insured workers; and
Widows, widowers, and surviving divorced spouses (see
Sec. 404.336) of insured workers.
Under title XVI of the Act, we provide for Supplemental Security
Income (SSI) payments on the basis of disability or blindness if you
are disabled or blind and have limited income and resources.
Is blindness treated differently under title II and title XVI?
Under title II, impairments that result in ``blindness'' are
evaluated in the same way as other impairments. However, under title
XVI, ``blindness'' is considered separately from other impairments
under different eligibility requirements. In other words, under title
XVI, you may qualify for benefits on the basis of ``blindness'' or on
the basis of ``disability.''
How do we define blindness?
For both the title II and title XVI programs, the Act defines
blindness as ``central visual acuity of 20/200 or less in the better
eye with the use of a correcting lens. An eye which is accompanied by a
limitation in the fields of vision such that the widest diameter of the
visual field subtends an angle no greater than 20 degrees shall be
considered * * * as having a central visual acuity of 20/200 or less.''
(Sections 216(i)(1) and 1614(a)(2) of the Act.) We refer to the Act's
definition of blindness as ``statutory blindness.''
If you are seeking benefits under title II, your blindness
generally must meet the 12-month statutory duration requirement.
However, if you are seeking payments under title XVI of the Act based
on blindness (rather than disability, as discussed below), your
blindness need not meet the 12-month statutory duration requirement.
Also, if you are seeking payments under title XVI of the Act based on
blindness, there is no requirement that you be unable to do any
substantial gainful activity (SGA). However, if you are working, we
will consider your earnings to determine if you are eligible for SSI
payments.
How do we define disability?
If your visual disorder does not meet our definition of blindness,
you may still be eligible for disability benefits. Under both the title
II and title XVI programs, disability must be the result of any
medically determinable physical or mental impairment or combination of
impairments that is expected to result in death or which has lasted or
is expected to last for a continuous period of at least 12 months. Our
definitions of disability are shown in the following table:
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Disability means you have a medically determinable impairment(s) as
If you file a claim under * * * And you are * * * described above that results in * * *
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title II................................ an adult or a child................ the inability to do any SGA.
title XVI............................... a person age 18 or older........... the inability to do any SGA.
title XVI............................... a person under age 18.............. marked and severe functional limitations.
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There is also an additional definition of disability if you are
seeking benefits under title II of the Act, have attained age 55, and
have blindness as defined in section 216(i)(1) of the Act: Disability
means that the blindness has resulted in the inability to engage in SGA
requiring skills or abilities comparable to those of any gainful
activity in which you previously engaged with some regularity and over
a substantial period of time. (See section 223(d)(1)(B) of the Act.)
How do we decide whether you are disabled?
If you are seeking benefits under title II of the Act, or if you
are an adult seeking payments under title XVI of the Act, we use a
five-step ``sequential evaluation process'' to decide whether you are
disabled. We describe this five-step process in our regulations at
Sec. Sec. 404.1520 and 416.920. We follow the five steps in order and
stop as soon as we can make a determination or decision. The steps are:
1. Are you working, and if so, is the work you are doing
substantial gainful activity? If you are working and the work you are
doing is substantial gainful activity, we will find that you are not
disabled, regardless of your medical condition or your age, education,
and work experience. If you are not, we will go on to step 2.
2. Do you have a ``severe'' impairment? If you do not have an
impairment or combination of impairments that significantly limits your
physical or mental ability to do basic work activities, we will find
that you are not disabled. If you do, we will go on to step 3.
3. Do you have an impairment(s) that meets or medically equals the
severity of an impairment in the listings? If you do, and the
impairment(s) meets the duration requirement, we will find that you are
disabled. If you do not, we will go on to step 4.
4. Do you have the residual functional capacity to do your past
relevant work? If you do, we will find that you are not disabled. If
you do not, we will go on to step 5.
5. Does your impairment(s) prevent you from doing any other work
that exists in significant numbers in the national economy, considering
your residual functional capacity, age,
[[Page 67039]]
education, and work experience? If it does, and it meets the duration
requirement, we will find that you are disabled. If it does not, we
will find that you are not disabled.
We use a different sequential evaluation process for children who
apply for payments based on disability under title XVI of the Act. We
describe that sequential evaluation process in Sec. 416.924 of our
regulations. If you are already receiving benefits, we also use a
different sequential evaluation process when we decide whether your
disability continues. See Sec. Sec. 404.1594, 416.994, and 416.994a of
our regulations. However, all of the processes include steps at which
we consider whether your impairment(s) meets or medically equals one of
our listings.
What are the listings?
The listings are examples of impairments that we consider severe
enough to prevent you as an adult from doing any gainful activity. If
you are a child seeking SSI payments based on disability, the listings
describe impairments that we consider severe enough to result in marked
and severe functional limitations. Although the listings are contained
only in appendix 1 to subpart P of part 404 of our regulations, we
incorporate them by reference in the SSI program in Sec. 416.925 of
our regulations, and apply them to claims under both title II and title
XVI of the Act.
How do we use the listings?
The listings are in two parts. There are listings for adults (part
A) and for children (part B). If you are an individual age 18 or over,
we apply the listings in part A when we assess your claim, and we do
not use the listings in part B.
If you are an individual under age 18, we first use the criteria in
part B of the listings. If the listings in part B do not apply, and
your specific disease process(es) has a similar effect on adults and
children, we then use the criteria in part A. (See Sec. Sec. 404.1525
and 416.925.)
If your impairment(s) does not meet any listing, we will also
consider whether it medically equals any listing; that is, whether it
is as medically severe as an impairment in the listings. (See
Sec. Sec. 404.1526 and 416.926.)
What if you do not have an impairment(s) that meets or medically equals
a listing?
We use the listings only to decide that you are disabled or that
you are still disabled. We will not deny your claim because your
impairment(s) does not meet or medically equal a listing. If you are
not doing work that is substantial gainful activity, and you have a
severe impairment(s) that does not meet or medically equal any listing,
we may still find you disabled based on other rules in the ``sequential
evaluation process'' described above. Likewise, we will not decide that
your disability has ended only because your impairment(s) does not meet
or medically equal a listing.
Also, when we conduct reviews to determine whether your disability
continues, we will not find that your disability has ended because we
have changed a listing. Our regulations explain that, when we change
our listings, we continue to use our prior listings when we review your
case, if you had qualified for disability benefits or SSI payments
based on our determination or decision that your impairment(s) met or
medically equaled the listings. In these cases, we determine whether
you have experienced medical improvement, and if so, whether the
medical improvement is related to the ability to work. If your
condition(s) has medically improved so that you no longer meet or
medically equal the prior listing, we evaluate your case further to
determine whether you are currently disabled. We may find that you are
currently disabled depending on the full circumstances of your case.
(See Sec. Sec. 404.1594(c)(3)(i) and 416.994(b)(2)(iv)(A).) If you are
a child who is eligible for SSI payments, we follow a similar rule
after we decide that you have experienced medical improvement in your
condition(s). See Sec. 416.994a(b)(2).
Why are we revising the listings for visual disorders?
We are making these revisions to update the medical criteria in the
listings for visual disorders and to provide more information about how
we evaluate visual disorders.
The listings for visual disorders, disturbances of labyrinthine-
vestibular function, hearing impairments, and loss of speech are
contained in listings for Special Senses and Speech. In these final
rules, we are making changes only to the listings for visual disorders.
On April 24, 2002, we published final rules in the Federal Register
(67 FR 20018) that included technical revisions to the listings for
special senses and speech disorders. Prior to this, we published final
rules that included revisions to the special senses and speech listings
in the Federal Register on December 6, 1985 (50 FR 50068). We last
published final rules making comprehensive revisions to the part A
special senses and speech listings in the Federal Register on March 27,
1979 (44 FR 18170), and final rules making comprehensive revisions to
the part B special senses and speech listings on March 16, 1977 (42 FR
14705). We intend to publish separately proposed rules that would
update the criteria for the other disorders included in the Special
Senses and Speech listings.
What do we mean by ``final rules'' and ``prior rules''?
Even though these rules will not go into effect until 90 days after
publication of this notice, for clarity, we refer to the changes we are
making here as the ``final rules'' and to the rules that will be
changed by these final rules as the ``prior rules.''
When will we start to use these final rules?
We will start to use these final rules on their effective date. We
will continue to use our prior rules until the effective date of these
final rules. When the final rules become effective, we will apply them
to new applications filed on or after the effective date of these rules
and to claims pending before us, as we describe below.
As is our usual practice when we make changes to our regulations,
we will apply these final rules on or after their effective date
whenever we make a determination or decision, including in those claims
in which we make a determination or decision after remand to us from a
Federal court. With respect to claims in which we have made a final
decision and that are pending judicial review in Federal court, we
expect that the court's review of the Commissioner's final decision
would be made in accordance with the rules in effect at the time the
final decision of the Commissioner was issued. If a court reverses the
Commissioner's final decision and remands the case for further
administrative proceedings after the effective date of these final
rules, we will apply the provisions of these final rules to the entire
period at issue in the claim in our new decision issued pursuant to the
court's remand.
How long will these final rules be effective?
These final rules will no longer be effective 8 years after the
date on which they become effective, unless we extend them, or revise
and issue them again.
How are we changing the introductory text to the special senses and
speech listings for adults?
2.00 Special Senses and Speech
We are removing the following sections of prior 2.00:
[[Page 67040]]
The last paragraph of 2.00A3, ``Field of vision.''
Paragraph 2.00A4, ``Muscle function.''
The first paragraph of 2.00A6, ``Special situations.''
The last paragraph of prior 2.00A3, ``Field of vision,'' explained
that when the visual field loss was predominantly in the lower visual
fields, a system such as the weighted grid scale for perimetric fields
as described by B. Esterman in 1968 could be used for determining
whether the visual field loss was comparable to that described in table
2 in section 2.00 of the listings. As this kind of scale is rarely
used, we no longer need this guidance in the introductory text.
Prior 2.00A4, ``Muscle function,'' described the type of impairment
evaluated under prior listing 2.06, ``Total bilateral
ophthalmoplegia.'' (Ophthalmoplegia is paralysis of the eye muscles.)
As the causes of this disorder are now more readily detectable and
treatable, this disorder has become extremely rare. Therefore, we are
removing both the prior listing and the guidance in the introductory
text that addressed this disorder. Instead, we will evaluate total
bilateral ophthalmoplegia and other eye muscle disorders by assessing
the impact of such disorders on your visual efficiency under final
listing 2.04, or based on your visual functioning.
The first paragraph of prior 2.00A6, ``Special situations,''
explained how we calculated visual acuity efficiency for individuals
with aphakia (the absence of the anatomical lens of the eye). Advances
in technology have led to the development of effective synthetic
intraocular lenses. Also, contact lenses have been technically refined
and may be used in those instances in which the anatomical lens is not
replaced with a synthetic lens. Because the synthetic intraocular lens
or the contact lens corrects both the visual acuity and the visual
field, we compute the visual acuity efficiency or visual field
efficiency as though your eye has an anatomical lens.
We are reorganizing and expanding the rest of the introductory text
for visual disorders to provide additional guidance. The following is a
detailed explanation of the final introductory text.
2.00A--How do we evaluate visual disorders?
This section corresponds to prior 2.00A, ``Disorders of Vision.''
We are clarifying the information in the prior section by reorganizing
the material into eight subsections and by providing additional
guidance as explained below.
2.00A1--What are visual disorders?
This section corresponds to prior 2.00A1, ``Causes of impairment.''
We are making nonsubstantive editorial changes for clarity.
2.00A2--How do we define statutory blindness?
This section revises prior 2.00A7, ``Statutory blindness,'' to
include the statutory definition. In response to a public comment, we
have added an explanation that we use your best-corrected visual acuity
for distance in the better eye when we determine if you have statutory
blindness based on visual acuity loss. We also clarify that you have
statutory blindness only if your visual disorder meets the criteria of
2.02 or 2.03A. We further clarify that you do not have statutory
blindness if your visual disorder medically equals the criteria of 2.02
or 2.03A, or if it meets or medically equals 2.03B, 2.03C, or 2.04. If
your visual disorder medically equals the criteria of 2.02 or 2.03A, or
if it 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.
In the NPRM, this section was headed ``What is statutory
blindness?'' We are changing the heading to be consistent with other
headings in this section.
2.00A3--What evidence do we need to establish statutory blindness under
title XVI?
In this new section, we explain that when we make a determination
or decision that you have statutory blindness under title XVI, we
require evidence showing only that the statutory criteria are
satisfied; we do not need evidence to document the visual disorder that
causes the blindness. We also explain that there is no duration
requirement for statutory blindness under title XVI.
We are adding this section because blindness is treated differently
under title II and title XVI of the Act. Under title II, blindness is
generally evaluated in the same way as other medical impairments. Under
title XVI, blindness and disability are separate categories, and the
requirements for eligibility based on blindness are different from the
requirements for eligibility based on disability.
2.00A4--What evidence do we need to evaluate visual disorders,
including those that result in statutory blindness under title II?
We are revising the last sentence of prior 2.00A1 to explain what
evidence we need to evaluate a visual disorder. In response to public
comments, we have revised proposed 2.00A4b to refer to a ``cortical
visual disorder'' instead of ``cortical blindness'' and provided
additional guidance on cortical visual disorders and how to document
them.
2.00A5--How do we measure best-corrected visual acuity?
We are revising the guidance in the second sentence of prior
2.00A2, ``Visual acuity,'' by providing that, in addition to testing
that uses Snellen methodology, we may also use visual acuity
measurements obtained using another testing methodology that is
comparable to Snellen methodology. We also clarify what constitutes
best-corrected visual acuity.
In the NPRM, we proposed, in 2.00A5b(i), that we would not use the
results of visual evoked response (VER) testing to determine best-
corrected visual acuity. This guidance was questioned by several
commenters who indicated that no response to VER testing demonstrates
that an individual cannot see in that eye. We agree with these
commenters, and have revised proposed 2.00A5b(i) to indicate that if
you have an absent response to VER testing in an eye, we can use that
result to determine that your visual acuity is 20/200 or less in that
eye. However, we will not use a positive response to VER testing to
determine best-corrected visual acuity. VER testing evaluates the
function of the visual pathways from the retina, along the optic nerve
and optic tract, to the vision cortex in the occipital lobe of the
brain. While this testing can provide an estimate of visual acuity, it
is not a direct measure of visual acuity.
We also provide that we will not use pinhole testing to determine
best-corrected visual acuity. Pinhole testing is used to determine
whether your visual acuity can be improved with a corrective lens.
However, you may not achieve the same degree of correction with
corrective lenses that you have with pinholes. Additionally, even when
pinhole testing fails to show an improvement in your acuity, your
acuity may improve with corrective lenses. Because pinhole testing may
underestimate or overestimate your visual acuity, we will not use it to
determine your best-corrected visual acuity.
[[Page 67041]]
In response to a public comment, we have also added guidance in
final 2.00A5b(i) explaining that we will not use automated refraction
acuity to determine your best-corrected visual acuity. An automated
refractor is a machine that measures how light is changed as it enters
the eye. It is used to provide an estimate of refractive error and the
prescription for glasses. This estimate gives the clinician a place to
start in determining the best-corrected visual acuity; it is not a
direct measure of visual acuity.
In response to another public comment, we have added guidance in
final 2.00A5b(ii) to explain that best-corrected visual acuity for
distance is your best acuity at 20 feet, and to explain how we use
visual acuity measurements obtained for other distances.
2.00A6--How do we measure visual fields?
This section replaces prior 2.00A3, ``Field of vision.'' Prior
2.00A3 indicated that we would use ``usual perimetric methods'' or
other ``comparable perimetric devices'' to measure the size of the
visual field. The Goldmann perimeter was cited as a comparable
perimetric device.
The National Research Council (NRC), in its 2002 report, Visual
Impairments: Determining Eligibility for Social Security Benefits
(hereinafter, the ``NRC report''), recommended that ``the current SSA
standard [for assessing visual field loss] should be revised so that
disability determinations are based on the results of automated static
projection perimetry rather than Goldmann (kinetic, nonautomated)
visual fields.'' (Citations for the NRC report and other sources cited
in this preamble are available in the NPRM (70 FR at 48348).) These
final rules partially adopt this recommendation by providing that we
will use visual field measurements obtained with an automated static
threshold perimetry test performed on a perimeter that meets our
requirements. However, we have decided that we will also continue to
use visual field measurements obtained with Goldmann or other kinetic
perimetry as these measurements are comparable to those obtained with
automated static threshold perimetry.
In final 2.00A6a(i), we explain when we need visual field testing.
In response to a public comment, we have deleted macular edema as an
example of a visual disorder that could cause visual field loss.
In final 2.00A6a(ii), we explain that, when we need to measure the
extent of your visual field loss, we will use visual field measurements
obtained with an automated static threshold perimetry test performed on
a perimeter that meets our requirements. We adopted as our requirements
the criteria recommended in the NRC report. We cite the Humphrey Field
Analyzer as an example of an acceptable perimeter because the NRC
report cited it, and the Humphrey Field Analyzer is the most widely
used automated perimeter in the United States to perform this type of
test.
The NRC report also cited the Octopus perimeter as another example
of an automated perimeter that meets the criteria set out in its
recommendations. We have not included the Octopus perimeter as an
example of an acceptable perimeter in final 2.00A6a(ii), because it is
not our intention to list in these rules every acceptable automated
perimeter and the Octopus perimeter is not widely used in the United
States. However, we will accept findings from the Octopus perimeter or
any other automated perimeter that satisfies the requirements of final
2.00A6a(ii).
In final 2.00A6a(iii), we describe the requirements of an
acceptable automated static threshold perimetry test.
In final 2.00A6a(iv), we explain that we need a test that measures
the central 24 to 30 degrees of the visual field to determine statutory
blindness. We also provide examples of acceptable tests. In response to
a public comment, we have added a reference to final listing 2.03A in
this section.
In proposed 2.00A6a(v), we indicated that to determine if the
criterion in listing 2.03B is met, we need a test performed on a
Humphrey Field Analyzer that measures the central 30 degrees of the
visual field. We also indicated that we could use comparable results
from other acceptable perimeters. In response to a comment that these
two statements were inconsistent with each other, we have clarified
this section to explain that while the criterion in final listing 2.03B
is based on using a test performed on a Humphrey Field Analyzer that
measures the central 30 degrees of the visual field, we can also use
comparable results from other acceptable perimeters. We also provide an
example of a comparable result. Additionally, we explain that we cannot
use tests that do not measure the central 30 degrees of the visual
field, such as the Humphrey 24-2 test, to determine if your impairment
meets or medically equals final listing 2.03B. The criterion we use in
final listing 2.03B adopts the recommendation in the NRC report for
determining that your visual field loss is disabling. That
recommendation was based on the use of a test measuring the central 30
degrees of the visual field.
In final 2.00A6a(vi), we explain that we measure the extent of
visual field loss by determining the portion of the visual field in
which you can see a white III4e stimulus. This stimulus specification
is the same as the specification in the second paragraph of prior
2.00A3.
In final 2.00A6a(vii), we explain that we need to determine the
decibel (dB) level that corresponds to a 4e intensity for the
particular perimeter being used. We further explain that we will then
use the dB printout to determine which points would be seen at the 4e
intensity level. We also give an example that explains that, for tests
performed on Humphrey Field Analyzers, any point seen at 10 dB or
higher is a point that would be seen with a 4e stimulus.
In final 2.00A6a(viii), we explain that we can also use visual
field measurements obtained using kinetic perimetry, such as the
Humphrey ``SSA Test Kinetic'' (a kind of automated kinetic perimetry)
or Goldmann perimetry (a kind of manual kinetic perimetry). In response
to a public comment, we have clarified this section to make it clear
that this type of testing may be used instead of automated static
threshold perimetry.
We contracted with West Virginia University to conduct research to
determine whether the Humphrey ``SSA Test Kinetic'' is comparable to
Goldmann perimetry. This research, which was completed in April 2000,
showed that the Humphrey ``SSA Test Kinetic'' is comparable to Goldmann
perimetry, except that the Humphrey ``SSA Test Kinetic'' does not
identify scotomata, that is, non-seeing areas in the visual field
surrounded by seeing areas. Therefore, in the NPRM, we proposed that if
we needed additional information because your visual disorder had
progressed to the point where it was likely to result in a significant
limitation in the central visual field, such as a scotoma, we would
supplement the automated kinetic perimetry with the results of a
Humphrey 30-2 or comparable test. There were public comments
questioning this guidance. In response to those comments, we have
clarified this section to state that we will not use the results of
automated kinetic testing to assess your visual field loss in this
situation. Instead, we will assess your visual field loss with
automated static threshold perimetry or with manual kinetic perimetry.
[[Page 67042]]
In final 2.00A6a(ix), we explain that we will not use the results
of visual field screening tests, such as confrontation tests, tangent
screen tests, or automated static screening tests, to determine that
your impairment meets or medically equals a listing or to evaluate your
residual functional capacity. We also explain that we can consider
normal results from visual field screening tests to determine whether
your visual disorder is severe when these results are consistent with
the other evidence in your case record. We also list some circumstances
under which we will not consider normal test results to be consistent
with the other evidence in the file.
Consistent with our removal of the guidance on aphakia, we are
removing the stimulus specifications used to test individuals with
aphakia contained in the first two paragraphs of prior 2.00A3.
In final 2.00A6b, we revise the guidance in the first paragraph of
prior 2.00A3 on the use of corrective lenses during visual field
testing. We explain that eyeglasses must not be worn during the visual
field examination because they limit your field of vision, but contact
lenses or perimetric lenses may be used in order to obtain the most
accurate visual field measurements. We also provide that, for this
single purpose, you do not need to demonstrate that you have the
ability to use the contact or perimetric lenses on a sustained basis.
2.00A7--How do we calculate visual efficiency?
In this section, we expand the guidance in prior 2.00A5, ``Visual
efficiency,'' by explaining how we calculate visual acuity efficiency,
visual field efficiency, and visual efficiency. The guidance in 2.00A7b
is based on the first sentence of paragraph 2 of the explanatory text
following Table 2 in the prior rules. We are deleting that sentence
from the explanation of Table 2 because we are moving it here. The
guidance in 2.00A7c is based on prior 2.00A5 and the parenthetical
statement at the end of prior listing 2.04, which we are deleting
because it is redundant. In response to a public comment, we are also
adding an example to 2.00A7c to illustrate how visual efficiency is
calculated.
2.00A8--How do we evaluate specific visual problems?
This section replaces prior 2.00A6, ``Special situations.'' In this
section, we are adding guidance for evaluating specific visual
problems. The following is a discussion of the section.
2.00A8a--Statutory blindness
In this section, we codify a longstanding procedure. The most
commonly used visual acuity test charts are charts based on Snellen
methodology. These charts usually do not have lines that measure visual
acuity between 20/100 and 20/200. Therefore, if you are unable to read
any of the letters on the 20/100 line on a test chart based on Snellen
methodology, your visual acuity will be assessed as 20/200 or less.
There are newer test charts (not yet widely used, but comparable to
charts based on Snellen methodology) that do have lines to measure
visual acuity between 20/100 and 20/200. Based on medical literature,
we know that if your visual acuity is between 20/100 and 20/200 as
measured on those newer test charts, it would be 20/200 if it were
measured using the more common chart based on Snellen methodology. We
explain in this section that if your visual acuity is measured using
one of these newer charts and you cannot read any of the letters on the
20/100 line, we will determine that you have statutory blindness based
on a visual acuity of 20/200 or less. We also provide that, regardless
of the type of test chart used, you do not have statutory blindness if
you can read at least one letter on the 20/100 line. In response to a
public comment, we have added examples of how we evaluate visual acuity
measurements between 20/100 and 20/200.
2.00A8b--Blepharospasm
In the NPRM, we described the disorder and explained that we must
consider how the involuntary blinking that characterizes it can affect
your ability to maintain the measured visual acuities and visual fields
over time. In response to a public comment, we have revised this
section to refer to your ability to maintain visual functioning over
time instead of your ability to maintain the measured visual acuities
and visual fields over time. Also, as we reviewed this section to
respond to the public comment, we realized that ``closure of the
eyelids'' is a better descriptor of how the disease manifests than
``eye blinking,'' and have made this nonsubstantive change to more
clearly describe the disorder. We have also made other nonsubstantive
editorial changes for clarity.
2.00A8c--Scotoma
We define the term ``scotoma'' as a non-seeing area in the visual
field surrounded by a seeing area. We also explain that when we measure
your visual field, we will subtract the length of any scotoma, other
than the normal blind spot, from the overall length of any diameter on
which it falls.
2.00C--How do we evaluate impairments that do not meet one of the
special senses and speech listings?
We are revising the guidance in the second paragraph of prior
2.00A6 by stating our basic adjudicative principle that if the
impairment(s) does not meet or medically equal the criteria of a
listing in this body system, we must consider whether it meets or
medically equals the criteria of a listing in another body system. If
not, we must continue the sequential evaluation process (see Sec. Sec.
404.1520 and 416.920) to determine whether you are disabled or continue
to be disabled (see Sec. Sec. 404.1594, 416.994 and 416.994a). This
new section applies to all the impairments in this body system, not
just visual disorders.
How are we changing the criteria in the special senses and speech
listings for adults?
2.01 Category of Impairments, Special Senses and Speech
We are removing the reservation for listing 2.05 because it is no
longer needed. We are also removing prior listing 2.06, ``Total
bilateral ophthalmoplegia,'' for the reasons cited in ``2.00 Special
Senses and Speech'' above.
Listing 2.02--Loss of visual acuity
This final listing corresponds to prior listing 2.02, ``Impairment
of visual acuity.'' We are changing the heading to be consistent with
other language in these final rules.
Listing 2.03--Contraction of the visual field in the better eye
This final listing corresponds to prior listing 2.03, ``Contraction
of peripheral visual fields in the better eye.'' We are removing prior
listing 2.03A, which provided that an individual's visual field loss
was of listing-level severity when the field was contracted to 10
degrees or less from the point of fixation. Prior listing 2.03B
provided that an individual's visual field loss was of listing-level
severity if that loss resulted in the widest diameter of the field
subtending an angle no greater than 20 degrees. Any visual field loss
that satisfied the criterion in prior listing 2.03A also satisfied the
criterion in prior listing 2.03B. Therefore, prior listing 2.03A was
unnecessary.
We are redesignating prior listing 2.03B as final listing 2.03A. In
response to a public comment, we have added the phrase ``around the
point of fixation'' to
[[Page 67043]]
make it clear that when we measure the widest diameter, the diameter
must go through the point of fixation.
The NRC report contained a recommendation that a mean deviation
(MD) of -22 or worse on an automated static threshold perimetry test
measuring the central 30 degrees of the visual field ``would serve as a
reasonable criterion for disability determination.'' We agree with the
NRC and are adding this criterion as final listing 2.03B.
Final listing 2.03C corresponds to prior listing 2.03C. We are
clarifying the criterion by indicating that a determination of visual
field efficiency must be based on kinetic perimetry.
Listing 2.04--Loss of visual efficiency
This final listing corresponds to prior listing 2.04, ``Loss of
visual efficiency.'' As already explained, we are removing the
parenthetical statement at the end of the prior listing because it was
redundant of information in proposed 2.00A7c. However, we are adding a
reference to that section of the final introductory text as a reminder
of where this guidance is contained.
Table 1--Percentage of Visual Acuity Efficiency Corresponding to the
Best-Corrected Visual Acuity Measurement for Distance in the Better Eye
To be consistent with our removal of the introductory text on
aphakia, we are removing the columns and guidance addressing aphakia
from prior Table 1. We are also removing the entries for visual
acuities worse than 20/100 for the reasons we gave under the
explanation of final 2.00A8a. In response to a public comment, we are
removing the entries for visual acuities of 20/32 and 20/64 and adding
entries for visual acuities of 20/30, 20/60, and 20/70.
Table 2--Charts of Visual Fields
We are removing the first sentence of prior paragraph 2 in the
explanation of how to use Table 2. That sentence provided instructions
for calculating the percent of visual field efficiency, and we moved it
to final 2.00A7b. We are also making nonsubstantive editorial changes
for clarity.
How are we changing the introductory text to the special senses and
speech listings for children?
102.00 Special Senses and Speech
Except for minor editorial changes, we have repeated much of the
introductory text of final 2.00A in the introductory text to final
102.00A. This is because the same basic rules for establishing and
evaluating the existence and severity of visual disorders in adults
also apply to children. Because we have already described these
provisions under the explanation of final 2.00A, the following
discussions describe only those provisions that are unique to the
childhood rules or that require further explanation specific to
evaluating disability in children.
We are removing the second paragraph of prior 102.00A, ``Visual
impairments in children.'' This paragraph indicated that the
accommodative reflex is generally not present in children under 6
months of age (or, for a premature child, until 6 months of age plus
the number of months the child is premature). It also provided that the
absence of this reflex should be considered indicative of a visual
impairment only in children above this age. We included this guidance
in the prior rules to explain that it was not appropriate to use the
criterion in prior listing 102.02B1 until the child reached the
required age. However, in these final listings, we incorporated prior
listing 102.02B1 into the more general category of abnormal anatomical
findings evaluated under final listing 102.02B2. As the lack of the
accommodative reflex is not considered an abnormal anatomical finding
in very young children, its absence would not satisfy the final listing
criterion. Therefore, we no longer need this explanation.
102.00A1--What are visual disorders?
In this section, we expand the guidance provided for adults in
final 2.00A1 to indicate that in addition to limiting your ability to
distinguish detail, read, and do fine work, a loss of visual acuity may
affect your ability to perform other age-appropriate activities. We
added this supplemental guidance to reflect the way we evaluate
disability claims of children.
102.00A2--How do we define statutory blindness?
In this section, we repeat the guidance in final 2.00A2, but refer
to the childhood listings that show statutory blindness.
102.00A4--What evidence do we need to evaluate visual disorders,
including those that result in statutory blindness under title II?
In this section, which is the same as final 2.00A4, we replace and
expand the third paragraph of prior 102.00A.
102.00A5--How do we measure best-corrected visual acuity?
In this section, we revise the guidance in the first paragraph of
prior 102.00A. In final 102.00A5a, we discuss comparable visual acuity
testing for children who are unable to participate in testing using
Snellen methodology, for example, because they are too young, and add
guidance for how we evaluate children who are unable to participate in
testing using Snellen methodology or other comparable testing. In
response to a public comment, we have revised proposed 102.00A5b by
adding examples of abnormal anatomical findings and abnormal
neuroimaging of the cerebral cortex that would indicate a visual acuity
of 20/200 or less.
102.00A6--How do we measure visual fields?
In this final section, we repeat the guidance in final 2.00A6 but
in 102.00A6a(ix) refer to the way we evaluate disability in children.
102.00C--How do we evaluate impairments that do not meet one of the
special senses and speech listings?
In this section, we repeat the guidance in final 2.00C, but include
the definition of disability for children who are filing for or are
receiving SSI payments.
How are we proposing to change the criteria in the special senses and
speech listings for children?
102.01 Category of Impairments, Special Senses and Speech
We are adding new listings 102.03, ``Contraction of the visual
field in the better eye,'' and 102.04, ``Loss of visual efficiency,''
because they apply to children as well as adults. Due to the addition
of these listings, we are also adding Table 1, ``Percentage of Visual
Acuity Efficiency Corresponding to the Best-Corrected Visual Acuity
Measurements for Distance in the Better Eye,'' and Table 2, ``Charts of
Visual Fields.''
These new listings and tables are identical to the corresponding
adult listings and tables. Previously, we used prior listings 2.03 and
2.04 (and their corresponding tables) to evaluate children with visual
field and visual efficiency impairments. With final listings 102.03 and
102.04 we will no longer need to refer to the listings in part A when
we evaluate these impairments in children.
We are also making nonsubstantive editorial changes to the heading
of this section to be consistent with the heading of 2.01.
Listing 102.02--Loss of visual acuity
This final listing corresponds to prior listing 102.02,
``Impairments of visual acuity.'' We are not making any changes to
prior listing 102.02A.
[[Page 67044]]
We used prior listing 102.02B to evaluate loss of visual acuity in
children below 3 years of age at the time of adjudication. We are
removing the age criterion and instead will use final listing 102.02B
to evaluate loss of visual acuity in any child who is unable to
participate in testing using Snellen methodology or other comparable
visual acuity testing and who has clinical findings that fixation and
visual-following behavior are absent in the better eye.
The criteria in prior listing 102.02B were all examples of abnormal
anatomical findings observable during a clinical eye examination. When
present in the better eye, these abnormal anatomical findings would be
expected to result in the absence of fixation and visual-following
behavior, and would indicate a visual acuity of 20/200 or less. Rather
than list each type of abnormal anatomical finding, we combined the
prior criteria into a general category of abnormal anatomical findings
in final listing 102.02B1. We used the phrase ``a visual acuity of 20/
200 or worse'' in proposed listing 102.02B1. We have revised this
phrase in final listing 102.02B1 to read ``a visual acuity of 20/200 or
less'' to be consistent with the statutory language that defines
blindness.
Final listings 102.02B2, 102.02B3, and 102.02B4 add criteria for
impairments that generally are not observable during a clinical eye
examination, but are diagnosed based on abnormal neuroimaging, an
abnormal electroretinogram, or an absent response to VER testing. We
did not propose the criterion in final listing 102.02B4, an absent
response to VER testing in the better eye, in the NPRM. This criterion
was added in response to a public comment.
Public Comments
In the NPRM we published in the Federal Register on August 17, 2005
(70 FR 48342), we provided the public with a 60-day comment period that
ended on October 17, 2005. In addition to our notice to the public, we
invited comments from national medical organizations and professionals
who have expertise in the evaluation of visual disorders. As part of
our outreach efforts, we also invited comments from advocacy groups and
legal services organizations.
We received comments from 13 commenters. The commenters included
advocacy groups, legal services organizations, State agencies that make
disability determinations for us, medical organizations,
ophthalmologists, and other individuals. We carefully considered all of
the comments. Because some of the comments were long, we have
condensed, summarized, and paraphrased them. We believe we have
presented the commenters' views accurately, and have responded to all
of the significant issues raised by the commenters that were within the
scope of these rules.
Statutory Blindness
Comment: Two commenters suggested that we use the term
``blindness'' in the listings only to describe total vision loss or
near-total vision loss; that is, situations in which the individual
must rely primarily on vision substitution skills. They indicated that
it is more appropriate to use the ranges of ``mild,'' ``moderate,''
``severe,'' and ``profound'' vision loss as defined in the American
Medical Association's Guides to the Evaluation of Permanent Impairment,
Fifth Edition (hereinafter, the ``AMA Guides'') for those individuals
who have residual vision; that is, those that can still benefit from
vision enhancement aids. As defined in the AMA Guides, the term
``severe vision loss'' reflects the statutory standard.
Response: We were not able to adopt this comment because we must
follow the language of the Act. The definition of ``blindness'' in
sections 216(i)(1) and 1614(a)(2) of the Act is:
[C]entral visual acuity of 20/200 or less in the better eye with the
use of a correcting lens. An eye which is accompanied by a
limitation in the fields of vision such that the widest diameter of
the visual field subtends an angle no greater than 20 degrees shall
be considered * * * as having a central visual acuity of 20/200 or
less.
Comment: One commenter noted that the definition of blindness in
proposed 2.00A2 and 102.00A2 contained the phrase ``with the use of a
correcting lens.'' The commenter believed that this language can be
taken to mean that any corrective lens will fulfill the requirement and
recommended that the language be changed to read ``visual acuity of 20/
200 or less in the better eye with the use of best possible corrective
lens.''
Response: We partially adopted this comment. We have not deleted
the phrase ``with the use of a correcting lens'' from the definition of
blindness in final 2.00A2 and 102.00A2 as those sections reflect the
statutory definition of blindness and the phrase is part of the
statutory language. However, we have added a reference to sections
216(i)(1) and 1614(a)(2) of the Act in final sections 2.00A2 and
102.00A2 of the rules to make it clearer that we are providing the
statutory definition. We also added guidance indicating that when we
determine whether the statutory definition of blindness based on visual
acuity is met, we use the best-corrected visual acuity for distance in
the better eye.
Comment: One commenter suggested that we expand the definition of
statutory blindness to include the criteria in proposed listings 2.03B
and C and proposed listing 2.04. The commenter indicated that we can
interpret the statute, and that the suggestion would be a reasonable
interpretation.
Response: We did not adopt this comment. Although we agree that we
have the authority to interpret the statute when necessary, the
definition of blindness in the Act is clear and explicit, and there is
nothing in the legislative history to suggest that Congress intended us
to apply any standard other than the definitions in the statute, which
are reflected in final listings 2.02 and 2.03A. (S. Rep. No. 90-744, at
7, 46-47 (1967), as reprinted in 1967 U.S.C.C.A.N. 2834, 2842, 2886-
2887.)
Comment: We received several comments on our method for evaluating
visual acuity measurements between 20/100 and 20/200 (proposed 2.00A8a
and 102.00A8a). One commenter said that finding statutory blindness
based on a visual acuity of 20/200 is a more liberal standard than that
used in any other country, and that our proposal to treat visual acuity
measurements between 20/100 and 20/200 as visual acuity of 20/200 would
move us even further out of the global mainstream. This commenter
stated we should instead use visual acuity that is worse than 20/160 as
our standard, and indicated that when the clinician does not use a
chart containing visual acuity measurements between 20/100 and 20/200,
the clinician should measure best-corrected visual acuity from a
distance of 10 feet instead of the usual 20 feet. Other commenters,
including the American Optometric Association, indicated that our
approach to interpreting visual acuity measurements between 20/100 and
20/200 is sensible because it does not adversely affect people who had
previously been classified as disabled. Another commenter wondered
whether an individual who can see only one letter on the 20/100 line of
a visual acuity chart has functionally better vision than someone with
best-corrected visual acuity of 20/200. However, this commenter did
acknowledge that a line must be drawn somewhere.
Response: We did not adopt the recommendations to change our policy
on evaluating visual acuity measurements between 20/100 and 20/
[[Page 67045]]
200. As we indicated in our explanation of proposed 2.00A8a in the NPRM
(70 FR at 48346) and in our explanation of final 2.00A8a earlier in
this preamble, the most commonly used visual acuity test charts are
based on Snellen methodology and usually do not have lines that measure
visual acuity between 20/100 and 20/200. While there are newer test
charts that do provide such measurements, such as the Early Treatment
Diabetic Retinopathy Study (ETDRS) chart, these charts are not widely
used in clinical practice. Also, we know that if an individual's visual
acuity is between 20/100 and 20/200 as measured on those newer charts,
it would be 20/200 if measured using the most commonly used charts.
Rather than evaluating the severity of a visual disorder based on the
different types of charts used to test an individual's visual acuity,
we have determined that it is more appropriate to assess visual acuity
for all individuals using the same methodology--the one incorporated in
the most commonly used test charts and the one contemplated in the
statutory definition of blindness.
Moreover, we do not agree that requiring testing at 10 feet,
instead of 20 feet, is a feasible alternative. The testing of visual
acuity requires a specific optics setup in the clinician's office, and
in most offices the optics setup is designed to obtain visual acuity
measurements at a 20-foot working distance; that is, even when the
testing lane is not 20 feet long, the optics setup is designed to give
results comparable to those obtained at 20 feet. We believe that
requiring best-corrected visual acuity measurements at a 10-foot
working distance would greatly restrict our ability to use evidence
provided by the individual's treating source(s) because we do not
believe that clinicians would reconfigure the optics in their offices
to obtain measurements that are not widely used in the medical
community.
Also, we do not believe we should expand the standards for
statutory blindness to encompass individuals who can read some, but not
all, of the letters on the 20/100 line of the visual acuity chart. Such
a standard would be more lenient than the 20/200 definition for
blindness contained in the Act, even when measured on more commonly
used visual acuity test charts. As we indicated above, there is nothing
in the language of the statute or the legislative history to suggest
that Congress intended that we apply any standard other than the strict
definitions in the statute.
Comment: One commenter, who believed that we were expanding our
definition of statutory blindness by providing that individuals who
have visual acuity between 20/100 and 20/200 would meet the definition
of statutory blindness, indicated that it was not obvious that the
changes we proposed would have no cost. The commenter recommended that
we do a field study to ascertain the fiscal impact of the proposed
rules.
Response: As we indicated in our explanation of proposed 2.00A8a in
the NPRM (70 FR at 48346) and in our explanation of final 2.00A8a
earlier in this preamble, we are codifying in our regulations our
longstanding procedure for evaluating visual acuity measurements
between 20/100 and 20/200. We have used this procedure since 1991.
Therefore, the proposed rules did not, and these final rules do not,
change how we evaluate such clinical findings. We do not expect there
will be any impact on program or administrative costs, and we do not
agree that a field study is needed.
Comment: One commenter indicated that our policy on evaluating
visual acuity measurements between 20/100 and 20/200 needed to be more
clearly discussed and suggested that we add examples.
Response: We partially adopted this comment by adding examples in
final 2.00A8a and 102.00A8a to illustrate how we use visual acuity
measurements between 20/100 and 20/200 to determine whether an
individual has statutory blindness.
Comment: Several commenters questioned the differences between the
eligibility requirements for benefits based on blindness under title
XVI and benefits based on disability under title II and title XVI. One
commenter noted that individuals age 18 or older have to show an
inability to do substantial gainful activity (SGA) to receive
disability benefits, but that the inability to do SGA is not required
for benefits based on blindness under title XVI. Three commenters noted
that it is not necessary to establish the cause of the blindness in
order to receive benefits based on blindness under title XVI, but it is
necessary to establish the cause of any visual loss in order to receive
disability benefits under either title XVI or title II, including
disability benefits based on blindness under title II. One of these
commenters indicated that these differences, as well as the fact that
there is no duration requirement for benefits based on blindness under
title XVI while there is such a requirement under title II, penalize
individuals who receive title II disability benefits based on
blindness. This commenter also recommended that if the title XVI
eligibility requirements are statutory and cannot be changed, we should
apply them when we determine whether individuals are disabled based on
blindness under title II. Another commenter indicated that having
different eligibility criteria could be confusing to our adjudicators.
Response: As we indicated in our explanation of proposed 2.00A3 in
the NPRM (70 FR at 48345) and in our explanation of final 2.00A3
earlier in this preamble, these rules are required by the Act.
``Blindness'' and ``disability'' are separate categories under title
XVI, whereas under title II blindness is considered a type of
``disability.'' The statutory requirements for eligibility based on
blindness under title XVI are different from the statutory requirements
for eligibility based on disability under title II and title XVI. As a
matter of law, we cannot apply the title XVI eligibility requirements
for statutory blindness to title II claims for disability.
We do not believe that our adjudicators will be confused by the
different eligibility criteria in these final rules because we have
been following these different rules for adjudicating blindness under
title II and title XVI since the SSI program began in 1974. Therefore,
our adjudicators have long been aware of these differences.
Visual Acuity
Comment: One commenter noted that there are some visual acuity
tests used in low vision clinics that use a testing distance of 10
feet. The commenter suggested that the regulation explain how to
interpret these results.
Response: In response to this comment, we expanded our guidance in
proposed 2.00A5b(ii) and 102.00A5b(ii) to address this issue.
Comment: One commenter suggested that we revise proposed 2.00A5b(i)
and 102.00A5b(i) to add ``automated refraction acuity'' as an example
of a type of visual acuity testing that cannot be used to determine
best-corrected visual acuity.
Response: We adopted this comment.
Comment: Two commenters noted that while proposed 2.00A5b(i) and
102.00A5b(i) clarified that VER testing cannot be used to measure best-
corrected visual acuity, the proposed rules did not describe how VER
testing should be used. The commenters indicated that VER testing can
be useful in many situations, such as ascertaining whether a non-verbal
individual is able to see, diagnosing cortical visual disorders, and
evaluating cases in which malingering is suspected. One commenter asked
how we evaluate
[[Page 67046]]
cases of young children in which neuroimaging results are not
obtainable, but in which the treating source has diagnosed a cortical
visual disorder, there is an absent response to VER testing, and
fixation and following behavior are absent.
Response: We agree with the commenters that when there is an absent
response to VER testing in an eye, we can use that result to determine
that the visual acuity is 20/200 or less in that eye, and we are adding
this guidance to proposed 2.00A5b and 102.00A5b. We are also revising
proposed 2.00A4b and 102.00A4b to indicate that we will request a copy
of VER testing results if this testing was performed to help diagnose a
cortical visual disorder. Lastly, we are adding an absent response to
VER testing as a criterion in final listing 102.02B.
We also agree that VER testing has other uses in clinical practice.
However, VER testing is one tool among many that clinicians use to
assess the degree of visual loss, and it is beyond the scope of these
listings to explain how tools such as VER testing are used by
clinicians in making their assessments.
Comment: One commenter noted that proposed 2.05A and 102.05A
provided that we will use visual acuity testing that was carried out
using Snellen methodology or any other testing methodology that is
comparable to Snellen methodology. The commenter indicated that there
is no generally agreed on definition of Snellen methodology, and
suggested we use ``letter chart testing'' instead of ``Snellen
methodology.''
Response: We did not adopt the comment. The term ``Snellen
methodology'' is well recognized by the medical community as meaning a
chart on which there is one large letter for 20/200 and below it rows
of letters in progressively smaller sizes that reflect the distance at
which a normal eye would be able to see the letters in that row.
Measuring Visual Acuity in Children
Comment: One commenter noted that proposed listing 102.02A requires
best-corrected visual acuity at distance. The commenter also noted that
paragraph 102.00A5a(iii) provides that if a child is unable to
participate in visual acuity testing, fixation and following behavior
will be considered. The commenter indicated that some children retain
the ability to fix and follow at short distances, such as three feet,
but not at far distances. The commenter asked how we assess visual
acuity for these individuals if neuroimaging is not available.
Response: A child has statutory blindness based on visual acuity
loss if his or her visual acuity is 20/200 or less in the better eye
with the use of a correcting lens. For children who can participate in
visual acuity testing, we determine whether the child has statutory
blindness by assessing the child's best-corrected visual acuity for
distance in the better eye.
However, not all children can participate in visual acuity testing.
For these children, we developed alternative criteria in final listing
102.02B for determining if their visual acuity loss has resulted in
statutory blindness. One of the requirements of that listing is that
the visual disorder results in the absence of fixation and visual-
following behavior. The listing contemplates that this behavior will be
assessed at short distances; that is, within a few feet, because that
is how this behavior is assessed in clinical practice. If a child can
use the better eye to fixate and visually follow at short distances,
his or her impairment does not meet the listing. We will then evaluate
the visual disorder to determine if it medically equals a listing or
functionally equals the listings.
Comment: One commenter noted that proposed listing 102.02B required
clinical findings that fixation and visual-following behavior be absent
in the better eye and indicated that the phrase ``in the better eye''
is unnecessary. The commenter remarked that if the better eye cannot
fix and follow, the lesser eye certainly cannot.
Response: We did not delete the phrase ``in the better eye'' from
final listing 102.02B because we believe it is necessary to the meaning
of the rule. If we did not have it, the listing could be met if a child
could not fixate and visually follow in the lesser eye but could in the
better eye.
Comment: One commenter noted that proposed 102.00A5b(i) provided
that visual acuity measurements obtained with a specialized lens can be
used only if the child has demonstrated the ability to use the lens on
a sustained basis. It also provided that telescopic lenses cannot be
used because they significantly reduce the visual fields. The commenter
wanted to know how visual acuity is assessed if the child is too young
to wear specialized lenses on a sustained basis and telescopic lenses
cannot be used.
Response: If the child can participate in visual acuity testing,
his or her visual acuity will be assessed through refraction, and we
will use the best-corrected visual acuity for distance that the child
will have with regular glasses. If the child cannot participate in
visual acuity testing, we will assess his or her ability with the
better eye to fixate and visually follow. If fixation and visual
following are absent, we will look at anatomical findings, or the
results of neuroimaging, electroretinography, or VER testing, if any of
these have been done, to determine if they are consistent with a
finding of visual acuity of 20/200 or less. If they are not consistent
with such a finding, we will evaluate the visual disorder to determine
whether there is medical or functional equivalence.
Comment: Two commenters indicated we should expand the introductory
text to provide examples of abnormal anatomical findings that would
indicate a visual acuity of 20/200 or worse in the better eye. One
commenter indicated the examples could include bilateral optic atrophy,
bilateral optic pallor with specific cup-to-disc size detailed,
findings of bilateral congenital cataracts, or presence of Stage III or
worse retinopathy of prematurity despite surgical intervention. One of
the commenters also asked for examples of abnormal neuroimaging of the
cerebral cortex that would indicate a visual acuity of 20/200 or worse
in the better eye.
Response: In response to these comments we added final
102.00A5b(iii) to provide examples of abnormal anatomical findings and
abnormal neuroimaging documenting damage to the cerebral cortex that
would indicate best-corrected visual acuity of 20/200 or less. We did
not include bilateral optic pallor with specific cup-to-disc size
detailed or findings of bilateral congenital cataracts as examples of
abnormal anatomical findings that would indicate a visual acuity of 20/
200 or less in the better eye because we do not believe that these
findings are always indicative of that level of visual acuity loss.
Visual Fields
Comment: One commenter objected to several of our requirements for
acceptable perimeters in proposed 2.00A6a(ii) and 102.00A6a(ii) which
can be used to perform automated static threshold testing. The
commenter believed that the requirements seemed to be dictated more by
a desire to promote the Humphrey Field Analyzer than by the
requirements of disability evaluation. The commenter stated that our
requirements that the perimeter have an internal normative database, a
statistical analysis package, and demonstrate the ability to correctly
detect visual field loss and correctly identify normal visual fields
were unnecessary. The commenter also
[[Page 67047]]
indicated that these requirements would not permit the use of Goldmann
perimeters.
Response: As we indicated in our explanation of proposed 2.00A6a in
the NPRM (70 FR at 48345) and in our explanation of final 2.00A6a
earlier in this preamble, we adopted the criteria recommended in the
NRC report as our requirements for perimeters used to perform automated
static threshold perimetry. We agree with the NRC that all the criteria
should be satisfied.
In final 2.00A6a(ii) and 102.00A6a(ii) we cite the Humphrey Field
Analyzer as an example of an acceptable perimeter. We cite only the
Humphrey Field Analyzer because it is not our intention to list in
these rules every acceptable automated perimeter, and the Humphrey
Field Analyzer is the most widely used automated perimeter in the
United States.
Goldmann perimeters are manual kinetic perimeters. The requirements
listed in final 2.00A6a(ii) and 102.00A6a(ii) are for perimeters used
to perform automated static threshold testing; therefore, they are not
applicable to Goldmann perimeters. However, as we indicated in our
explanation of 2.00A6a in the NPRM (70 FR at 48345) and in our
explanation of final 2.00A6a earlier in this preamble, we will continue
to use visual field measurements obtained with kinetic perimetry such
as Goldmann perimetry.
Comment: Several commenters noted that proposed 2.00A6a(iv) and
102.00A6a(iv) appeared to conflict with proposed 2.00A6a(v) and
102.00A6a(v) and requested that we clarify this guidance. One commenter
indicated that we should require a 30-degree test for all situations.
Another suggested that we add a reference to listing 2.03A in proposed
2.00A6a(iv).
Response: We clarified the rules in response to the comments.
Proposed 2.00A6a(iv) and 102.00A6a(iv) described the automated static
threshold testing needed to determine if an individual's visual field
loss resulted in statutory blindness; that is, whether the widest
diameter of the visual field subtended an angle no greater than 20
degrees and thus satisfied the criterion in proposed listing 2.03A or
102.03A. Proposed 2.00A6a(v) and 102.00A6a(v) described the automated
static threshold testing needed to determine if an individual's visual
field loss satisfied the criterion in proposed listing 2.03B or
102.03B. The criterion in proposed listing 2.03B or 102.03B did not
represent statutory blindness. Therefore, the fact that there were
different documentation requirements was not a conflict. However, in
response to these comments, we added a reference to final listing 2.03A
in final 2.00A6a(iv) and a reference to final listing 102.03A in final
102.00A6a(iv).
We did not adopt the comment to require a 30-degree test to
determine if an individual has statutory blindness based on visual
field loss. If a 24-degree test shows this degree of limitation, we
believe it is not necessary to obtain a 30-degree test.
Comment: One commenter questioned the NRC's recommendations for
visual field testing. The commenter believed that, while visual field
tests that measure the central 30 degrees of the visual field are
valuable for diagnostic purposes, the NRC report failed to provide
evidence that they would also be appropriate for disability evaluation;
that is, for determining the consequences of a visual disorder. The
commenter indicated that evaluation of reading and mobility would be
better measures of visual disability. The commenter also suggested that
instead of adopting the NRC recommendation, we should evaluate visual
field loss using the method described in the AMA Guides, Fifth Edition.
Response: We did not adopt the comment. The NRC report recommended
that we use a mean deviation of -22, determined by an automated static
threshold perimetry test of the central 30 degrees of the visual field,
as an indicator of disability. The NRC explained that this mean
deviation corresponds to an individual having normal vision within the
central 10-degree radius of the visual field and no vision outside this
radius. The NRC indicated, and we agree, that this mean deviation
represents extensive visual field loss, and we believe that this degree
of visual field loss is of listing-level severity.
The NRC also looked at using reading and mobility as indicators of
visual disability and found that use of these measures was not viable.
Additionally, the NRC recommended we not use ``the visual field scoring
procedures recently published by the American Medical Association
(1993). The AMA guidelines are not based on empirical data, the
procedures have not been validated, and their properties are largely
unknown.''
Comment: One commenter noted that proposed 2.00A6a(v) and
102.00A6a(v) indicated that we need results from a Humphrey Field
Analyzer but also provided that we could use comparable results from
other acceptable perimeters. The commenter believed this language was
inconsistent.
Response: In response to this comment, we revised proposed
2.00A6a(v) and 102.00A6a(v) to indicate that, while the criterion in
final listings 2.03B and102.03B is based on the use of a test performed
on a Humphrey Field Analyzer, we can also use comparable results from
other acceptable perimeters.
Comment: One commenter noted that our explanation of proposed
2.00A6 indicated that the NRC report recommended that disability
determinations be based on visual fields obtained by automated static
threshold perimeters rather than by kinetic perimeters. The commenter
noted that while automated static threshold perimetry can be used to
determine if the visual disorder meets listing 2.03B, it cannot be used
to determine the percentage of residual field efficiency. Two
commenters believed that the fact that determinations under proposed
listing 2.03C required kinetic testing contradicted the statement that
either automated static threshold testing or kinetic testing could be
used. One of these commenters believed that the regulations could be
interpreted as requiring both automated static threshold testing and
kinetic testing, and that such a requirement would increase costs for
SSA.
Response: As we indicated in our explanation of proposed 2.00A6 in
the NPRM (70 FR at 48345) and in our explanation of final 2.00A6
earlier in this preamble, we partially adopted the NRC recommendation.
We will use results of automated static threshold perimetry to
determine the degree of visual field loss, but we will also continue to
use comparable visual field measurements obtained with kinetic
perimetry. Because we allow for different types of testing, final
listings 2.03 and 102.03 provide criteria that can be used with the
different types of test results. As the results of these tests are
comparable, only one type of testing is needed. Therefore, in response
to the second comment, we clarified proposed 2.00A6a(viii) and
102.00A6a(viii) to state that kinetic perimetry may be used instead of
automated static threshold perimetry.
Comment: One commenter noted that proposed 2.00A6a(viii) and
102.00A6a(viii) indicated that automated kinetic testing may need to be
supplemented with a Humphrey 30-2 or comparable test if the visual
disorder has progressed to the point where it is likely to result in a
significant scotoma. The commenter asked if this meant that we should
merge the test result obtained from the SSA test kinetic with the
results of the automated static threshold testing when there is a
significant scotoma present
[[Page 67048]]
and if there is a methodology that we want our adjudicators to follow
for combining these tests. Another commenter suggested we revise
proposed 2.00A6(viii) and 102.00A6a(viii) to indicate that automated
kinetic testing needs to be supplemented when there is the likelihood
of a significant limitation in the central or mid-peripheral visual
field. The commenter believed we should add a reference to the mid-
peripheral field as this is important in conditions such as retinitis
pigmentosa, but also noted that such a limitation might be missed by a
Humphrey 30-2 or comparable test.
Response: In response to these comments, we revised the guidance in
proposed 2.00A6a(viii) and 102.00A6a(viii) to indicate that we will not
use automated kinetic perimetry to assess visual field loss if the
visual disorder has progressed to the point where it is likely to
result in a significant limitation in the central visual field. In
these situations, we will use automated static threshold testing or
manual kinetic perimetry to evaluate the visual field loss.
We did not adopt the comment that asked us to add a reference to
the mid-peripheral field. As we indicate below, we believe that
measuring the central 30 degrees of the visual field will provide
sufficient information to determine disability or blindness.
Comment: One commenter noted that the Goldmann and Humphrey kinetic
tests, which measure to the periphery, used in conjunction with the 30-
2 would give a better picture of the visual field than the 30-2 alone.
Response: While we agree with the commenter, we believe that a
visual field test that measures the central 30 degrees of the visual
field will provide sufficient information to determine blindness or
disability.
Comment: One commenter suggested that we revise the language in
proposed 2.00A6a(ix) and 102.00A6a(ix) to state that we can use normal
test results to determine that the visual field loss is not severe.
Response: In response to this comment, we have clarified proposed
2.00A6a(ix) and 102.00A6a(ix) to state that we can consider normal
results from visual field screening tests to determine whether the
visual disorder is severe.
Comment: One commenter suggested we add the words ``around
fixation'' to proposed listing 2.03A, the listing for contraction of
the visual field in the better eye, with the widest diameter subtending
an angle no greater than 20 degrees.
Response: We have adopted this comment by adding the phrase
``around the point of fixation'' in final listings 2.03A and 102.03A.
This will clarify that, when we measure the widest diameter, the
diameter must go through the point of fixation.
Comment: One commenter suggested we add a chart showing how the
length of a scotoma is subtracted from the overall length of any
diameter in which it falls.
Response: We did not adopt this comment. However, we plan to issue
a Social Security Ruling to explain the procedural aspects of measuring
the visual field, and we will explain how to deduct the length of a
scotoma in that ruling.
Comment: Two commenters noted that proposed 2.00A6a(i) cited
macular edema as an example of a disorder that could result in visual
field loss in adults but this disorder was not cited in proposed
102.00A6a(i). One of these commenters suggested that macular edema not
be included as an example of a disorder that could result in visual
field loss as it does not result in more than minimal field loss. The
other commenter indicated that macular edema should be added to
proposed 102.00A6a(i) as the condition does occur in children.
Response: We agree that macular edema generally does not result in
significant visual field loss; therefore, we removed the example in
response to the comment that asked us to do that. Final 2.00A6a(i) and
102.00A6a(i) are now the same in this regard.
Visual Efficiency
Comment: Two commenters recommended that we change the way we
calculate visual efficiency to use the functional vision score (FVS) as
described in the AMA Guides.
Response: We did not adopt this comment. The FVS is based on an
assessment of visual acuity and visual fields. The visual acuity
assessment requires the use of an ETDRS-type chart which is the
preferred visual acuity chart for research purposes, but is not
commonly used in clinical practice. Additionally, this visual acuity
assessment requires a measurement of binocular visual acuity, and this
measurement usually is not performed as part of a routine eye
examination.
Also, as we indicated above, the NRC report recommended that we not
use the visual field scoring procedures published by the AMA.
Comment: Three commenters asked that we add an example to proposed
2.00A7 and 102.00A7 to clarify how we compute visual efficiency. One of
these commenters also suggested that we add the phrase ``and expressing
the product in decimals converted to a percentage'' to the end of
proposed 2.00A7c and 102.00A7c.
Response: In response to this comment, we added an example of a
visual efficiency calculation and the phrase ``and converting the
decimal to a percentage'' to proposed 2.00A7c and 102.00A7c.
Comment: Two commenters recommended that we revise proposed Table 1
to show visual acuity efficiency ratings for the visual acuities of 20/
30, 20/60, and 20/70 instead of the visual acuities of 20/32 and 20/64.
One of these commenters also suggested we add ``aphakic with a contact
lens'' to the heading of the last column in Table 1.
Response: In response to this comment we revised proposed Table 1
to show visual acuity efficiency for the visual acuities of 20/30, 20/
60, and 20/70 (and their metric equivalents) instead of the visual
acuities of 20/32 and 20/64. We did not adopt the second comment
because we removed the heading in the last column of proposed Table 1
as these rules do not differentiate between an eye that is phakic,
pseudophakic, or aphakic.
Binocular Vision
Comment: One commenter suggested we use binocular vision instead of
vision in the better eye when we evaluate blindness or disability.
Response: We did not adopt this comment. The Act specifies that we
use the vision in the better eye, that is, monocular vision, to
determine blindness. Additionally, binocular visual acuity is often not
measured during a routine eye examination. Lastly, there are no
commonly used procedures to measure binocular visual fields directly or
to derive a binocular visual field from monocular visual fields.
Specific Visual Disorders
Comment: One commenter questioned the removal of the guidance in
prior 2.00A4, ``Muscle function.'' The commenter indicated that,
although total bilateral ophthalmoplegia is very rare, paralysis of
individual eye muscles or groups of eye muscles may cause a totally
debilitating condition. The commenter noted that this type of
impairment was not addressed in the proposed rules. Another commenter
suggested that we add guidance on how to evaluate nystagmus.
Response: We did not adopt these comments as eye muscle disorders
usually do not result in a listing-level loss of visual acuity or
visual fields. As
[[Page 67049]]
we indicated in our explanation of the proposed changes to 2.00 in the
NPRM (70 FR at 48344) and in our explanation of the final changes to
2.00 earlier in this preamble, we will evaluate ophthalmoplegia and
other eye muscle disorders (such as nystagmus) by assessing the impact
of the disorder on visual efficiency or on the individual's visual
functioning.
Comment: Two commenters asked that we provide additional guidance
on how to evaluate the effect of the involuntary blinking involved in
blepharospasm on the ability to maintain measured visual acuity and
visual fields over time. One of these commenters also suggested that we
change the phrase ``maintain measured visual acuities and visual fields
over time'' in the last sentence of section 2.00A8b to ``maintain
function over time'' as blepharospasm does not cause a decrease in
measured acuities or fields.
Response: In response to this comment, we revised proposed 2.00A8b
and 102.00A8b to refer to visual functioning instead of visual acuities
and visual fields. Additionally, as we reviewed this section to respond
to this comment, we realized that we should have referred to ``closure
of your eyelids'' instead of ``eye blinking,'' and have made this and
other nonsubstantive editorial changes for clarity. We have not
provided additional guidance on how to evaluate the effect of the
involuntary eyelid closure. This assessment requires medical judgment
and must be made on a case-by-case basis.
Comment: Two commenters expressed concern that deleting our prior
guidance for evaluating aphakia will disadvantage those few individuals
who are unable to obtain or use synthetic intraocular lenses or contact
lenses.
Response: As we discussed in our explanation of the proposed
changes to 2.00 in the NPRM (70 FR at 48344) and in our explanation of
the final changes to 2.00 earlier in this preamble, we deleted the
guidance on aphakia as this condition is effectively treated with
synthetic intraocular lenses or contact lenses. We do not agree that
the very few individuals who are unable to obtain or use these
treatments will be adversely affected. If an individual with aphakia
does not have an impairment that meets a listing, we can consider the
effects of aphakia when we determine whether the impairment medically
equals a listing or when determining residual functional capacity or,
in children, functional equivalence.
Comment: One commenter suggested we add guidance about pseudophakia
to proposed 2.00A8 and 102.00A8.
Response: We did not adopt this comment as these final rules do not
differentiate between an eye that is phakic, pseudophakic, or aphakic.
Comment: One commenter suggested that we change the phrase
``cortical blindness'' used in proposed 2.00A4b and 102.00A4b to
``cortical visual impairment.'' The commenter also provided language
that describes a cortical visual impairment and suggested we add the
language to proposed 2.00A8 and 102.00A8. Another commenter noted that
proposed 2.00A4b cited stroke as an example of a catastrophic event
that can cause cortical blindness in adults. The commenter recommended
that we include the same example in proposed 102.00A4b for children.
Response: In response to these comments, we changed the phrase
``cortical blindness'' to ``cortical visual disorder'' and expanded the
discussion of cortical visual disorders in proposed 2.00A4b and
102.00A4b. Our expanded discussions include stroke as an example of a
cause of cortical visual disorders in children.
Comment: One commenter requested clarification of what is needed to
document a catastrophic event that causes blindness. The commenter
asked if mention of the specific event as part of the medical history
would be sufficient, or whether copies of the actual hospitalization,
operative report, or pertinent lab studies would be required.
Response: The mention of a specific event as part of a medical
history would be an allegation that the event took place; it would not
be documentation of the event. To document the catastrophic event, we
need medical records showing the treatment for the event.
Other Comments
Comment: One commenter noted that our reference to the American
Medical Association's Guides to the Evaluation of Permanent Impairment,
Fifth Edition, cited pages 252 and 287-295. The commenter indicated
that he believed we never consulted the fifth edition as the page
numbers are wrong and the content is not used.
Response: We did reference the fifth edition of the AMA Guides. The
reference to page 252 was an editing error. The section of the AMA
Guides on impairment of visual field is on pages 287-295. Although we
consulted this reference, we decided not to adopt the AMA's procedures
for evaluating visual field loss for reasons we have already given.
Comment: A number of commenters suggested minor editorial changes
and additions. For example, one commenter suggested we add the word
``impairments'' to the heading of this body system. Another commenter
suggested we add the acronym ``VTAP'' after the word ``Humphrey'' in
the last sentence of proposed 2.00A6a(iv) and 102.00A6a(iv). Another
commenter suggested we change the heading of proposed 2.08 and 102.08.
Response: We did not adopt these suggestions. In some cases, we did
not think they were necessary. In others, we did not think that they
clarified the issues.
Comment: One commenter asked us to clarify the reporting
requirements under the Paperwork Reduction Act.
Response: The Paperwork Reduction Act (PRA) of 1995, Public Law
104-13, requires Federal Government agencies that intend to collect
information from 10 or more members of the public to seek comment on
such information collections prior to obtaining Office of Management
and Budget approval. The purpose in seeking public comment is to reduce
to the extent practicable and appropriate the burden imposed on the
public. Sections 2.00A and 102.00A discuss evidentiary reports, such as
reports of eye examinations that we obtain from providers of medical
evidence. The evidentiary reporting requirements are covered by the
PRA; therefore; we provide an opportunity for the public to comment via
the PRA notice shown in the preamble to the proposed rules.
Regulatory Procedures
Executive Order 12866
We have consulted with the Office of Management and Budget (OMB)
and determined that these final rules meet the requirements for a
significant regulatory action under Executive Order 12866, as amended
by Executive Order 13258. Thus, they were subject to OMB review.
Regulatory Flexibility Act
We certify that these final rules do not have a significant
economic impact on a substantial number of small entities because they
affect only individuals. Thus, a regulatory flexibility analysis as
provided in the Regulatory Flexibility Act, as amended, is not
required.
Paperwork Reduction Act
The Paperwork Reduction Act (PRA) of 1995 says that no persons are
required to respond to a collection of
[[Page 67050]]
information unless it displays a valid OMB control number. In
accordance with the PRA, SSA is providing notice that OMB has approved
the information collection requirements contained in Part A, 2.00 and
Part B, 102.00 of these final rules. The OMB Control Number for this
collection is 0960-0642, expiring March 31, 2008.
(Catalog of Federal Domestic Assistance Program Nos. 96.001, Social
Security--Disability Insurance; 96.002, Social Security--Retirement
Insurance; 96.004, Social Security--Survivors Insurance; and 96.006,
Supplemental Security Income)
List of Subjects in 20 CFR Part 404
Administrative practice and procedure, Blind, Disability benefits,
Old-Age, Survivors, and Disability Insurance, Reporting and
recordkeeping requirements, Social Security.
Dated: August 2, 2006.
Jo Anne B. Barnhart,
Commissioner of Social Security.
0
For the reasons set forth in the preamble, we are amending subpart P of
part 404 of chapter III of title 20 of the Code of Federal Regulations
as set forth below:
PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE
(1950- )
0
1. The authority citation for subpart P of part 404 continues to read
as follows:
Authority: Secs. 202, 205(a), (b), and (d)-(h), 216(i), 221(a)
and (i), 222(c), 223, 225, and 702(a)(5) of the Social Security Act
(42 U.S.C. 402, 405(a), (b), and (d)-(h), 416(i), 421(a) and (i),
422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-193, 110
Stat. 2105, 2189.
Appendix 1 to Subpart P of Part 404--[Amended]
0
2. Appendix 1 to subpart P of part 404 is amended as follows:
0
a. Item 3 of the introductory text before part A of appendix 1 is
amended by revising the expiration date.
0
b. Section 2.00A of part A of appendix 1 is revised.
0
c. Section 2.00C is added to part A of appendix 1.
0
d. Listing 2.02 of part A of appendix 1 is revised.
0
e. Listing 2.03 of part A of appendix 1 is revised.
0
f. Listing 2.04 of part A of appendix 1 is revised.
0
g. The reservation for listing 2.05 is removed.
0
h. Listing 2.06 of part A of appendix 1 is removed.
0
i. Tables 1 and 2 of section 2.00 of part A of appendix 1 are revised.
0
j. Section 102.00A of part B of appendix 1 is revised.
0
k. Section 102.00C is added to part B of appendix 1.
0
l. Listing 102.01 of part B of appendix 1 is revised.
0
m. Listing 102.02 of part B of appendix 1 is revised.
0
n. Listing 102.03 is added to part B of appendix 1.
0
o. Listing 102.04 is added to part B of appendix 1.
0
p. Tables 1 and 2 are added to section 102.00 of part B of appendix 1.
The revised text is set forth as follows:
Appendix 1 to Subpart P of Part 404--Listing of Impairments
* * * * *
3. Special Senses and Speech (2.00 and 102.00): February 20,
2015.
* * * * *
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 (the Act). The Act defines blindness as visual
acuity of 20/200 or less in the better eye with the use of a
correcting lens. We use your best-corrected visual acuity for
distance in the better eye when we determine if this definition is
met. The Act also provides that an eye that has a visual field
limitation such that the widest diameter of the visual field
subtends an angle no greater than 20 degrees is considered as having
visual acuity of 20/200 or less. You have statutory blindness only
if your visual disorder meets the criteria of 2.02 or 2.03A. You do
not have statutory blindness if your visual disorder medically
equals the criteria of 2.02 or 2.03A, or if it meets or medically
equals 2.03B, 2.03C, or 2.04. If your visual disorder medically
equals the criteria of 2.02 or 2.03A, or if it 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.
3. What evidence do we need to establish statutory blindness
under title XVI? For title XVI, the only evidence we need to
establish statutory blindness is evidence showing that your visual
acuity 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 to document the cause of your blindness. Also, there is no
duration requirement for statutory blindness under title XVI (see
Sec. Sec. 416.981 and 416.983).
4. What evidence do we need to evaluate visual disorders,
including those that result in statutory blindness under title II?
a. To evaluate your visual disorder, we usually need a report of
an eye examination that includes measurements of the best-corrected
visual acuity or the extent of the visual fields, as appropriate. If
there is a loss of visual acuity or visual fields, the cause of the
loss must be documented. A standard eye examination will usually
reveal the cause of any visual acuity loss. An eye examination can
also reveal the cause of some types of visual field deficits. If the
eye examination does not reveal the cause of the visual loss, we
will request the information that was used to establish the presence
of the visual disorder.
b. A cortical visual disorder is a disturbance of the posterior
visual pathways or occipital lobes of the brain in which the visual
system does not interpret what the eyes are seeing. It may result
from such causes as traumatic brain injury, stroke, cardiac arrest,
near drowning, a central nervous system infection such as meningitis
or encephalitis, a tumor, or surgery. It can be temporary or
permanent, and the amount of visual loss can vary. It is possible to
have a cortical visual disorder and not have any abnormalities
observed in a standard eye examination. Therefore, a diagnosis of a
cortical visual disorder must be confirmed by documentation of the
cause of the brain lesion. If neuroimaging or visual evoked response
(VER) testing was performed, we will request a copy of the report or
other medical evidence that describes the findings in the report.
c. If your visual disorder does not satisfy the criteria in
2.02, 2.03, or 2.04, we will also request a description of how your
visual disorder impacts your ability to function.
5. How do we measure best-corrected visual acuity?
a. Testing for visual acuity. When we need to measure your best-
corrected visual acuity, we will use visual acuity testing that was
carried out using Snellen methodology or any other testing
methodology that is comparable to Snellen methodology.
b. Determining best-corrected visual acuity. (i) Best-corrected
visual acuity is the optimal visual acuity attainable with the use
of a corrective lens. In some instances, this assessment may be
performed using a specialized lens; for example, a contact lens. We
will use the visual acuity measurements obtained with a specialized
lens only if you have demonstrated the ability to use the
specialized lens on a sustained basis. However, we will not use
visual acuity measurements obtained with telescopic lenses because
they significantly reduce the visual field. If you have an absent
response to VER testing in an eye, we can determine that your best-
corrected visual acuity is 20/200 or less in that eye. However, if
you have a positive response to VER testing in an eye, we will not
use that result to determine your best-corrected visual acuity in
that eye. Additionally, we will not use the results of pinhole
testing or automated refraction acuity to determine your best-
corrected visual acuity.
[[Page 67051]]
(ii) We will use the best-corrected visual acuity for distance
in your better eye when we determine whether your loss of visual
acuity satisfies the criteria in 2.02. The best-corrected 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 to 20/80.
6. How do we measure visual fields?
a. Testing for visual fields.
(i) We generally need visual field testing when you have a
visual disorder that could result in visual field loss, such as
glaucoma, retinitis pigmentosa, or optic neuropathy, or when you
display behaviors that suggest a visual field loss.
(ii) When we need to measure the extent of your visual field
loss, we will use visual field measurements obtained with an
automated static threshold perimetry test performed on a perimeter,
like the Humphrey Field Analyzer, that satisfies all of the
following requirements:
A. The perimeter must use optical projection to generate the
test stimuli.
B. The perimeter must have an internal normative database for
automatically comparing your performance with that of the general
population.
C. The perimeter must have a statistical analysis package that
is able to calculate visual field indices, particularly mean
deviation.
D. The perimeter must demonstrate the ability to correctly
detect visual field loss and correctly identify normal visual
fields.
E. The perimeter must demonstrate good test-retest reliability.
F. The perimeter must have undergone clinical validation studies
by three or more independent laboratories with results published in
peer-reviewed ophthalmic journals.
(iii) The test must use a white size III Goldmann stimulus and a
31.5 apostilb (10 cd/m\2\) white background. The stimuli locations
must be no more than 6 degrees apart horizontally or vertically.
Measurements must be reported on standard charts and include a
description of the size and intensity of the test stimulus.
(iv) To determine statutory blindness based on visual field loss
(2.03A), we need a test that measures the central 24 to 30 degrees
of the visual field; that is, the area measuring 24 to 30 degrees
from the point of fixation. Acceptable tests include the Humphrey
30-2 or 24-2 tests.
(v) The criterion in 2.03B is based on the use of a test
performed on a Humphrey Field Analyzer that measures the central 30
degrees of the visual field. We can also use comparable results from
other acceptable perimeters, for example, a mean defect of 22 on an
acceptable Octopus test, to determine that the criterion in 2.03B is
met. We cannot use tests that do not measure the central 30 degrees
of the visual field, such as the Humphrey 24-2 test, to determine if
your impairment meets or medically equals 2.03B.
(vi) We measure the extent of visual field loss by determining
the portion of the visual field in which you can see a white III4e
stimulus. The ``III'' refers to the standard Goldmann test stimulus
size III, and the ``4e'' refers to the standard Goldmann intensity
filters used to determine the intensity of the stimulus.
(vii) In automated static threshold perimetry, the intensity of
the stimulus varies. The intensity of the stimulus is expressed in
decibels (dB). We need to determine the dB level that corresponds to
a 4e intensity for the particular perimeter being used. We will then
use the dB printout to determine which points would be seen at a 4e
intensity level. For example, in Humphrey Field Analyzers, a 10 dB
stimulus is equivalent to a 4e stimulus. A dB level that is higher
than 10 represents a dimmer stimulus, while a dB level that is lower
than 10 represents a brighter stimulus. Therefore, for tests
performed on Humphrey Field Analyzers, any point seen at 10 dB or
higher is a point that would be seen with a 4e stimulus.
(viii) We can also use visual field measurements obtained using
kinetic perimetry, such as the Humphrey ``SSA Test Kinetic'' or
Goldmann perimetry, instead of automated static threshold perimetry.
The kinetic test must use a white III4e stimulus projected on a
white 31.5 apostilb (10 cd/m\2\) background. In automated kinetic
tests, such as the Humphrey ``SSA Test Kinetic,'' testing along a
meridian stops when you see the stimulus. Because of this, automated
kinetic testing does not detect limitations in the central visual
field. 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 2.00A8c), we will not use
automated kinetic perimetry to evaluate your visual field loss.
Instead, we will assess your visual field loss using automated
static threshold perimetry or manual kinetic perimetry.
(ix) We will not use the results of visual field screening
tests, such as confrontation tests, tangent screen tests, or
automated static screening tests, to determine that your impairment
meets or medically equals a listing or to evaluate your residual
functional capacity. However, 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.) We will not consider normal test
results to be consistent with the other evidence if either of the
following applies:
A. The clinical findings indicate that your visual disorder has
progressed to the point that it is likely to cause visual field
loss, or
B. You have a history of an operative procedure for retinal
detachment.
b. Use of corrective lenses. You must not wear eyeglasses during
the visual field examination because they limit your field of
vision. Contact lenses or perimetric lenses may be used to correct
visual acuity during the visual field examination in order to obtain
the most accurate visual field measurements. For this single
purpose, you do not need to demonstrate that you have the ability to
use the contact or perimetric lenses on a sustained basis.
7. How do we calculate visual efficiency?
a. Visual acuity efficiency. We use the percentage shown in
Table 1 that corresponds to the best-corrected visual acuity for
distance in your better eye.
b. Visual field efficiency. We use kinetic perimetry to
calculate visual field efficiency by adding the number of degrees
seen along the eight principal meridians in your better eye and
dividing by 500. (See Table 2.)
c. Visual efficiency. We calculate the percent of visual
efficiency by multiplying the visual acuity efficiency by the visual
field efficiency and converting the decimal to a percentage. For
example, if your visual acuity efficiency is 75 percent and your
visual field efficiency is 64 percent, we will multiply 0.75 x 0.64
to determine that your visual efficiency is 0.48, or 48 percent.
8. How do we evaluate specific visual problems?
a. Statutory blindness. Most test charts that use Snellen
methodology do not have lines that measure visual acuity between 20/
100 and 20/200. Newer test charts, such as the Bailey-Lovie or the
Early Treatment Diabetic Retinopathy Study (ETDRS), do have lines
that measure visual acuity between 20/100 and 20/200. If your visual
acuity is measured with one of these newer charts, and you cannot
read any of the letters on the 20/100 line, we will determine that
you have statutory blindness based on a visual acuity of 20/200 or
less. For example, if your best-corrected visual acuity for distance
in the better eye was determined to be 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 visual acuity for distance in the better eye was
determined to be 20/125+1 using an ETDRS chart, we will find that
you do not have statutory blindness as you are able to read one
letter on the 20/100 line.
b. Blepharospasm. This movement disorder is characterized by
repetitive, bilateral, involuntary closure of the eyelids. If you
have this disorder, you may have measurable visual acuities and
visual fields that do not satisfy the criteria of 2.02 or 2.03.
Blepharospasm generally responds to therapy. However, if therapy is
not effective, we will consider how the involuntary closure of your
eyelids affects your ability to maintain visual functioning over
time.
c. Scotoma. A scotoma is a non-seeing area in the visual field
surrounded by a seeing area. When we measure the visual field, we
subtract the length of any scotoma, other than the normal blind
spot, from the overall length of any diameter on which it falls.
* * * * *
C. How do we evaluate impairments that do not meet one of the
special senses and speech listings?
1. These listings are only examples of common special senses and
speech disorders that we consider severe enough to prevent an
individual from doing any gainful activity. If your impairment(s)
does not meet the criteria of any of these listings, we must also
consider whether you have an impairment(s) that satisfies the
criteria of a listing in another body system.
[[Page 67052]]
2. If you have a medically determinable impairment(s) that does
not meet a listing, we will determine whether the impairment(s)
medically equals a listing. (See Sec. Sec. 404.1526 and 416.926.)
If you have an impairment(s) that does not meet or medically equal a
listing, you may or may not have the residual functional capacity to
engage in substantial gainful activity. Therefore, we proceed to the
fourth, and if necessary, the fifth steps of the sequential
evaluation process in Sec. Sec. 404.1520 and 416.920. When we
decide whether you continue to be disabled, we use the rules in
Sec. Sec. 404.1594, 416.994, or 416.994a, as appropriate.
2.01 Category of Impairments, Special Senses and Speech
2.02 Loss of visual acuity. Remaining vision in the better eye
after best correction is 20/200 or less.
2.03 Contraction of the visual field in the better eye, with:
A. The widest diameter subtending an angle around the point of
fixation no greater than 20 degrees;
OR
B. A mean deviation of -22 or worse, determined by automated
static threshold perimetry as described in 2.00A6a(v);
OR
C. A visual field efficiency of 20 percent or less as determined
by kinetic perimetry (see 2.00A7b).
2.04 Loss of visual efficiency. Visual efficiency of the better
eye of 20 percent or less after best correction (see 2.00A7c).
* * * * *
Table 1.--Percentage of Visual Acuity Efficiency Corresponding to the
Best-Corrected Visual Acuity Measurement for Distance in the Better Eye
------------------------------------------------------------------------
Snellen Percent
--------------------------------------------------------- visual acuity
English Metric efficiency
------------------------------------------------------------------------
20/16........................................ 6/5 100
20/20........................................ 6/6 100
20/25........................................ 6/7.5 95
20/30........................................ 6/9 90
20/40........................................ 6/12 85
20/50........................................ 6/15 75
20/60........................................ 6/18 70
20/70........................................ 6/21 65
20/80........................................ 6/24 60
20/100....................................... 6/30 50
------------------------------------------------------------------------
Table 2.--Chart of Visual Fields
[GRAPHIC] [TIFF OMITTED] TR20NO06.000
1. The diagram of the right eye illustrates the extent of a
normal visual field as measured with a III4e stimulus. The sum of
the eight principal meridians of this field is 500 degrees.
2. The diagram of the left eye illustrates a visual field
contracted to 30 degrees in two meridians and to 20 degrees in the
remaining six meridians. The percent of visual field efficiency of
this field is: (2 x 30) + (6 x 20) = 180/500 = 0.36 or 36 percent
visual field efficiency.
* * * * *
Part B
* * * * *
102.00 SPECIAL SENSES AND SPEECH
A. How do we evaluate visual disorders?
1. What are visual disorders? Visual disorders are abnormalities
of the eye, the optic nerve, the optic tracts, or the brain that may
cause a loss of visual acuity or visual fields. A loss of visual
acuity limits your ability to distinguish detail, read, do fine
work, or perform other age-appropriate activities. A loss of visual
fields limits your ability to perceive visual stimuli in the
peripheral extent of vision.
2. 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 (the Act). The Act defines blindness as visual
acuity of 20/200 or less in the better eye with the use of a
correcting lens. We use your best-corrected visual acuity for
distance in the better eye when we determine if this definition is
met. 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
[[Page 67053]]
greater than 20 degrees is considered as having visual acuity of 20/
200 or less. You have statutory blindness only if your visual
disorder meets the criteria of 102.02 or 102.03A. You do not have
statutory blindness if your visual disorder medically equals the
criteria of 102.02 or 102.03A, or if it meets or medically equals
102.03B, 102.03C, or 102.04. If your visual disorder medically
equals the criteria of 102.02 or 102.03A, or if it meets or
medically equals 102.03B, 102.03C, or 102.04, we will find that you
have a disability if your visual disorder also meets the duration
requirement.
3. What evidence do we need to establish statutory blindness
under title XVI? For title XVI, the only evidence we need to
establish statutory blindness is evidence showing that your visual
acuity 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 to document the cause of your blindness. Also, there is no
duration requirement for statutory blindness under title XVI (see
Sec. Sec. 416.981 and 416.983).
4. What evidence do we need to evaluate visual disorders,
including those that result in statutory blindness under title II?
a. To evaluate your visual disorder, we usually need a report of
an eye examination that includes measurements of the best-corrected
visual acuity or the extent of the visual fields, as appropriate. If
there is a loss of visual acuity or visual fields, the cause of the
loss must be documented. A standard eye examination will usually
reveal the cause of any visual acuity loss. An eye examination can
also reveal the cause of some types of visual field deficits. If the
eye examination does not reveal the cause of the visual loss, we
will request the information that was used to establish the presence
of the visual disorder.
b. A cortical visual disorder is a disturbance of the posterior
visual pathways or occipital lobes of the brain in which the visual
system does not interpret what the eyes are seeing. It may result
from such causes as traumatic brain injury, stroke, cardiac arrest,
near drowning, a central nervous system infection such as meningitis
or encephalitis, a tumor, or surgery. It can be temporary or
permanent, and the amount of visual loss can vary. It is possible to
have a cortical visual disorder and not have any abnormalities
observed in a standard eye examination. Therefore, a diagnosis of a
cortical visual disorder must be confirmed by documentation of the
cause of the brain lesion. If neuroimaging or visual evoked response
(VER) testing was performed, we will request a copy of the report or
other medical evidence that describes the findings in the report.
c. If your visual disorder does not satisfy the criteria in
102.02, 102.03, or 102.04, we will also request a description of how
your visual disorder impacts your ability to function.
5. How do we measure best-corrected visual acuity?
a. Testing for visual acuity.
(i) When we need to measure your best-corrected visual acuity,
we will use visual acuity testing that was carried out using Snellen
methodology or any other testing methodology that is comparable to
Snellen methodology.
(ii) We consider tests such as the Landolt C test or the
tumbling-E test, which are used to evaluate young children who are
unable to participate in testing using Snellen methodology, to be
comparable to testing using Snellen methodology. These alternate
methods for measuring visual acuity should be performed by
specialists with expertise in assessment of childhood vision.
(iii) If you are unable to participate in testing using Snellen
methodology or other comparable testing, we will consider your
fixation and visual-following behavior. If both these behaviors are
absent, we will consider the anatomical findings or the results of
neuroimaging, electroretinogram, or VER testing when this testing
has been performed.
b. Determining best-corrected visual acuity. (i) Best-corrected
visual acuity is the optimal visual acuity attainable with the use
of a corrective lens. In some instances, this assessment may be
performed using a specialized lens; for example, a contact lens. We
will use the visual acuity measurements obtained with a specialized
lens only if you have demonstrated the ability to use the
specialized lens on a sustained basis. However, we will not use
visual acuity measurements obtained with telescopic lenses because
they significantly reduce the visual field. If you have an absent
response to VER testing in an eye, we can determine that your best-
corrected visual acuity is 20/200 or less in that eye. However, if
you have a positive response to VER testing in an eye, we will not
use that result to determine your best-corrected visual acuity in
that eye. Additionally, we will not use the results of pinhole
testing or automated refraction acuity to determine your best-
corrected visual acuity.
(ii) We will use the best-corrected visual acuity for distance
in your better eye when we determine whether your loss of visual
acuity satisfies the criteria in 102.02A. The best-corrected 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 to 20/80.
(iii) If you cannot participate in visual acuity testing, we
will determine that your best-corrected visual acuity is 20/200 or
less in your better eye if your visual disorder meets the criteria
in 102.02B. To meet 102.02B1, your impairment must result in the
absence of fixation and visual-following behavior and abnormal
anatomical findings indicating a visual acuity of 20/200 or less in
your better eye. Such abnormal anatomical findings include, but are
not limited to, the presence of Stage III or worse retinopathy of
prematurity despite surgery, hypoplasia of the optic nerve, albinism
with macular aplasia, and bilateral optic atrophy. To meet 102.02B2,
your impairment must result in the absence of fixation and visual-
following behavior and 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 your better
eye. Such abnormal neuroimaging includes, but is not limited to,
neuroimaging showing bilateral encephalomyelitis or bilateral
encephalomalacia.
6. How do we measure visual fields?
a. Testing for visual fields.
(i) We generally need visual field testing when you have a
visual disorder that could result in visual field loss, such as
glaucoma, retinitis pigmentosa, or optic neuropathy, or when you
display behaviors that suggest a visual field loss.
(ii) When we need to measure the extent of your visual field
loss, we will use visual field measurements obtained with an
automated static threshold perimetry test performed on a perimeter,
like the Humphrey Field Analyzer, that satisfies all of the
following requirements:
A. The perimeter must use optical projection to generate the
test stimuli.
B. The perimeter must have an internal normative database for
automatically comparing your performance with that of the general
population.
C. The perimeter must have a statistical analysis package that
is able to calculate visual field indices, particularly mean
deviation.
D. The perimeter must demonstrate the ability to correctly
detect visual field loss and correctly identify normal visual
fields.
E. The perimeter must demonstrate good test-retest reliability.
F. The perimeter must have undergone clinical validation studies
by three or more independent laboratories with results published in
peer-reviewed ophthalmic journals.
(iii) The test must use a white size III Goldmann stimulus and a
31.5 apostilb (10 cd/m2) white background. The stimuli
locations must be no more than 6 degrees apart horizontally or
vertically. Measurements must be reported on standard charts and
include a description of the size and intensity of the test
stimulus.
(iv) To determine statutory blindness based on visual field loss
(102.03A), we need a test that measures the central 24 to 30 degrees
of the visual field; that is, the area measuring 24 to 30 degrees
from the point of fixation. Acceptable tests include the Humphrey
30-2 or 24-2 tests.
(v) The criterion in 102.03B is based on the use of a test
performed on a Humphrey Field Analyzer that measures the central 30
degrees of the visual field. We can also use comparable results from
other acceptable perimeters; for example, a mean defect of 22 on an
acceptable Octopus test, to determine that the criterion in 102.03B
is met. We cannot use tests that do not measure the central 30
degrees of the visual field, such as the Humphrey 24-2 test, to
determine if your impairment meets or medically equals 102.03B.
(vi) We measure the extent of visual field loss by determining
the portion of the visual field in which you can see a white III4e
stimulus. The ``III'' refers to the standard Goldmann test stimulus
size III, and the
[[Page 67054]]
``4e''efers to the standard Goldmann intensity filters used to
determine the intensity of the stimulus.
(vii) In automated static threshold perimetry, the intensity of
the stimulus varies. The intensity of the stimulus is expressed in
decibels (dB). We need to determine the dB level that corresponds to
a 4e intensity for the particular perimeter being used. We will then
use the dB printout to determine which points would be seen at a 4e
intensity level. For example, in Humphrey Field Analyzers, a 10 dB
stimulus is equivalent to a 4e stimulus. A dB level that is higher
than 10 represents a dimmer stimulus, while a dB level that is lower
than 10 represents a brighter stimulus. Therefore, for tests
performed on Humphrey Field Analyzers, any point seen at 10 dB or
higher is a point that would be seen with a 4e stimulus.
(viii) We can also use visual field measurements obtained using
kinetic perimetry, such as the Humphrey ``SSA Test Kinetic'' or
Goldmann perimetry, instead of automated static threshold perimetry.
The kinetic test must use a white III4e stimulus projected on a
white 31.5 apostilb (10 cd/m2) background. In automated
kinetic tests, such as the Humphrey ``SSA Test Kinetic,'' testing
along a meridian stops when you see the stimulus. Because of this,
automated kinetic testing does not detect limitations in the central
visual field. 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 102.00A8c), we will not
use automated kinetic perimetry to evaluate your visual field loss.
Instead, we will assess your visual field loss using automated
static threshold perimetry or manual kinetic perimetry.
(ix) We will not use the results of visual field screening
tests, such as confrontation tests, tangent screen tests, or
automated static screening tests, to determine that your impairment
meets or medically equals a listing, or functionally equals the
listings. However, 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).) We will not consider
normal test results to be consistent with the other evidence if
either of the following applies:
A. The clinical findings indicate that your visual disorder has
progressed to the point that it is likely to cause visual field
loss; or
B. You have a history of an operative procedure for retinal
detachment.
b. Use of corrective lenses. You must not wear eyeglasses during
the visual field examination because they limit your field of
vision. Contact lenses or perimetric lenses may be used to correct
visual acuity during the visual field examination in order to obtain
the most accurate visual field measurements. For this single
purpose, you do not need to demonstrate that you have the ability to
use the contact or perimetric lenses on a sustained basis.
7. How do we calculate visual efficiency?
a. Visual acuity efficiency. We use the percentage shown in
Table 1 that corresponds to the best-corrected visual acuity for
distance in your better eye.
b. Visual field efficiency. We use kinetic perimetry to
calculate visual field efficiency by adding the number of degrees
seen along the eight principal meridians in your better eye and
dividing by 500. (See Table 2.)
c. Visual efficiency. We calculate the percent of visual
efficiency by multiplying the visual acuity efficiency by the visual
field efficiency and converting the decimal to a percentage. For
example, if your visual acuity efficiency is 75 percent and your
visual field efficiency is 64 percent, we will multiply 0.75 x 0.64
to determine that your visual efficiency is 0.48, or 48 percent.
8. How do we evaluate specific visual problems?
a. Statutory blindness. Most test charts that use Snellen
methodology do not have lines that measure visual acuity between 20/
100 and 20/200. Newer test charts, such as the Bailey-Lovie or the
Early Treatment Diabetic Retinopathy Study (ETDRS), do have lines
that measure visual acuity between 20/100 and 20/200. If your visual
acuity is measured with one of these newer charts, and you cannot
read any of the letters on the 20/100 line, we will determine that
you have statutory blindness based on a visual acuity of 20/200 or
less. For example, if your best-corrected visual acuity for distance
in the better eye was determined to be 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 visual acuity for distance in the better eye was
determined to be 20/125+1 using an ETDRS chart, we will find that
you do not have statutory blindness as you are able to read one
letter on the 20/100 line.
b. Blepharospasm. This movement disorder is characterized by
repetitive, bilateral, involuntary closure of the eyelids. If you
have this disorder, you may have measurable visual acuities and
visual fields that do not satisfy the criteria of 102.02 or 102.03.
Blepharospasm generally responds to therapy. However, if therapy is
not effective, we will consider how the involuntary closure of your
eyelids affects your ability to maintain visual functioning over
time.
c. Scotoma. A scotoma is a non-seeing area in the visual field
surrounded by a seeing area. When we measure the visual field, we
subtract the length of any scotoma, other than the normal blind
spot, from the overall length of any diameter on which it falls.
* * * * *
C. How do we evaluate impairments that do not meet one of the
special senses and speech listings?
1. These listings are only examples of common special senses and
speech disorders that we consider severe enough to result in marked
and severe functional limitations. If your impairment(s) does not
meet the criteria of any of these listings, we must also consider
whether you have an impairment(s) that satisfies the criteria of a
listing in another body system.
2. If you have a medically determinable impairment(s) that does
not meet a listing, we will determine whether the impairment(s)
medically equals a listing or functionally equals the listings. (See
Sec. Sec. 416.926 and 416.92