Social Security Ruling, SSR 07-01p; Titles II and XVI: Evaluating Visual Field Loss Using Automated Static Threshold Perimetry, 41796-41808 [07-3708]
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Federal Register / Vol. 72, No. 146 / Tuesday, July 31, 2007 / Notices
issues that interested persons believe
the Commission should address during
the amendment cycle ending May 1,
2008. Further, with respect to items (7)
and (8), the Commission requests
specific comment regarding what circuit
conflict issues it should address and
what research topics it should consider.
To the extent practicable, public
comment should include the following:
(1) A statement of the issue, including
scope and manner of study, particular
problem areas and possible solutions,
and any other matters relevant to a
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statutes, case law, and constitutional
provisions; and (3) a direct and concise
statement of why the Commission
should make the issue a priority.
be based on determinations or decisions
made at all administrative levels of
adjudication, Federal court decisions,
Commissioner’s decisions, opinions of
the Office of the General Counsel, and
policy interpretations of the law and
regulations.
Although Social Security Rulings do
not have the same force and effect as the
statute or regulations, they are binding
on all components of the Social Security
Administration, in accordance with 20
CFR 402.35(b)(1), and are binding as
precedents in adjudicating cases.
If this Social Security Ruling is later
superseded, modified, or rescinded, we
will publish a notice in the Federal
Register to that effect.
Titles II and XVI: Evaluating Visual
Field Loss Using Automated Static
Threshold Perimetry
Purpose: To clarify how we use
automated static threshold perimetry to
evaluate visual field loss.
Citations (Authority): Sections 205(a),
216(i)(1), 221, 223(d), 1614(a), 1631(d),
and 1633 of the Social Security Act
(Act), as amended; Regulations No. 4,
subpart P, sections 404.1520, 404.1525,
404.1526, 404.1581, and 2.00A, 2.03,
102.00A, and 102.03 of appendix 1; and
Regulations No.16, subpart I, sections
416.920, 416.924, 416.925, 416.926, and
416.981.
Pertinent History: The Act provides
for a finding of blindness based on
visual field loss when the widest
diameter of the visual field in the better
eye subtends an angle no greater than 20
degrees. Even when visual field loss
does not result in blindness, it may
nevertheless be disabling. In sections
2.00A6 and 102.00A6 of the Listing of
Impairments in appendix 1 to subpart P
of part 404 (the listings) we provide that
when we need to measure the extent of
visual field loss, we will use visual field
measurements obtained with an
automated static threshold perimetry
test that satisfies our requirements.1
Automated static threshold perimetry
measures the retina’s sensitivity to light
at predetermined locations in the visual
field. While the individual focuses on a
specific point, called the point of
fixation, stimuli are presented in
random order at each of the
predetermined locations within the
visual field. The size of the stimulus
and the locations tested remain
constant, but the intensity (brightness)
of the stimulus is varied in order to
determine the level at which the
individual sees the stimulus. The
intensity level where the individual sees
the stimulus is referred to as the
threshold. The threshold for each point
tested is reported in decibels (dB).
The results of automated static
threshold perimetry are reported on
standard charts. (See Exhibits 1 and 2 at
the end of this ruling for examples of
standard charts that may be found in
case records.) These charts:
• Identify the perimeter that was used
to perform the test;
• Provide identifying information
about the test, such as the date of the
test, the type of test used, the size and
color of the stimulus, and the
background illumination;
• Provide the mean deviation (MD); 2
and
• Contain a printout that shows the
threshold, in dB, for each of the
locations tested. We refer to this
printout, examples of which are shown
below, as the dB printout.
In this Ruling we explain:
• How to use the information in the
standard charts produced as part of
automated static threshold perimetry to
determine whether the visual field test
satisfies our requirements. To illustrate
this, we refer to standard charts
produced by the Humphrey Field
Analyzer. We refer only to the
Humphrey Field Analyzer because it is
the perimeter most widely used in the
United States.
• How to use the MD to determine
whether the individual has visual field
loss.
• Our process for determining
whether the test results show statutory
blindness based on visual field loss.3
• How to evaluate cases in which
severe visual field loss has not resulted
in statutory blindness.
1 Our rules provide that in addition to automated
static threshold perimetry we can use comparable
visual field measurements obtained with kinetic
perimetry, such as Goldmann perimetry. Because
we allow for different types of testing, our listings
provide comparable criteria that can be used with
the different types of test results. Accordingly, only
one type of testing is needed to evaluate visual field
loss under our listings.
2 The MD represents the average elevation or
depression of the individual’s visual field when
compared to a normal field. This measurement is
expressed in dB.
3 We developed our process to enable us to apply
the results of automated static threshold perimetry
to the standard for statutory blindness. Health care
providers do not use our process in their clinical
practices or for treatment purposes.
Authority: 28 U.S.C. 994(a), (o); USSC
Rules of Practice and Procedure 5.2.
(Catalog of Federal Domestic Assistance,
Program Nos 96.001 Social Security—
Disability Insurance; 96.006 Supplemental
Security Income.)
Ricardo H. Hinojosa,
Chair.
[FR Doc. E7–14829 Filed 7–30–07; 8:45 am]
Dated: May 30, 2007.
Michael J. Astrue,
Commissioner of Social Security.
BILLING CODE 2211–01–P
Policy Interpretation Ruling
SOCIAL SECURITY ADMINISTRATION
[Docket No. SSA–2007–0029]
Social Security Ruling, SSR 07–01p;
Titles II and XVI: Evaluating Visual
Field Loss Using Automated Static
Threshold Perimetry
Social Security Administration.
Notice of Social Security Ruling.
AGENCY:
ACTION:
SUMMARY: In accordance with 20 CFR
402.35(b)(1), the Commissioner of Social
Security gives notice of Social Security
Ruling, SSR 07–01p. This Ruling
clarifies how we use automated static
threshold perimetry to determine
statutory blindness based on visual field
loss.
EFFECTIVE DATE: July 31, 2007.
FOR FURTHER INFORMATION CONTACT:
Michelle Hungerman, Office of
Disability Programs, Social Security
Administration, 6401 Security
Boulevard, Baltimore, MD 21235–6401,
(410) 965–2289 or TTY 1–800–325–
0778.
Although
5 U.S.C. 552(a)(1) and (a)(2) do not
require us to publish this Social
Security Ruling, we are doing so in
accordance with 20 CFR 402.35(b)(1).
Social Security Rulings make
available to the public precedential
decisions relating to the Federal old-age,
survivors, disability, supplemental
security income, special veterans
benefits, and black lung benefits
programs. Social Security Rulings may
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Policy Interpretation: We use the
following process to evaluate automated
static threshold perimetry.
Step 1—Is the automated static
threshold perimetry test acceptable?
We consider an automated static
threshold perimetry test to be acceptable
when it meets all of the following
requirements:
• The test is performed on a
perimeter that satisfies all of the
requirements in sections 2.00A6a(ii) and
102.00A6a(ii) of the listings; 4
• The test uses a white size III
Goldmann stimulus and a 31.5 apostilb
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4 As of the effective date of this ruling, all models
of the Humphrey Field Analyzer satisfy these
requirements.
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(asb) 5 (10 candela (cd)/m2) white
background; 6
• The points tested are no more than
6 degrees apart horizontally or
vertically; and
• The test measures the central 24 to
30 degrees of the visual field; that is, the
area measuring 24 to 30 degrees around
the point of fixation.
The Humphrey Field Analyzer central
30–2 threshold test (HFA 30–2) and
central 24–2 threshold test (HFA 24–2)
are tests that can meet these criteria.
apostilb is a unit of luminance.
background color is not shown on the
standard charts produced by the Humphrey Field
Analyzer. However, as of the effective date of this
ruling, the Humphrey Field Analyzer always uses
a white background if a white stimulus is used.
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5 An
6 The
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The HFA 30–2 tests 76 points in the
central 30 degrees of the visual field.
The HFA 24–2 tests 54 points in the
central 24 to 30 degrees of the visual
field. For both of these tests, the tested
points are spaced in an equidistant grid
pattern, with each point 6 degrees apart
horizontally or vertically from any
adjacent point. Therefore, we consider
the HFA 30–2 and the HFA 24–2 to be
acceptable tests when performed using
a size III white stimulus on a 31.5 asb
white background.
The following examples of dB
printouts illustrate the grid patterns
used for the HFA 30–2 and the HFA 24–
2 and provide information for
interpreting the test results.
BILLING CODE 2211–01–P
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Billing Code 2211–01–C
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We will not use automated static
threshold perimetry test results to
evaluate the visual field loss if the test
was not performed using all of our
requirements; for example, a stimulus
other than a size III stimulus was used,
or the stimulus was not white.
Step 2—Are the test results reliable?
Each perimeter manufacturer will
identify factors that are used to
determine whether the test results are
reliable.
For the Humphrey Field Analyzer, the
reliability factors are fixation losses,
false positive errors, and false negative
errors. Information about these factors is
at the top of the chart (see Exhibits 1
and 2). The test results are not reliable
for evaluating visual field loss if the
fixation losses exceed 20 percent, or if
the false positive errors or false negative
errors exceed 33 percent.
Even when the reliability factors are
within the manufacturer’s
specifications, we will not use the test
results to evaluate visual field loss if
there is other information in the case
file that suggests that the results are not
valid; for example, the test results are
inconsistent with the clinical findings
or the individual’s daily activities.
Step 3—Does the individual have
visual field loss?
For acceptable tests performed on a
Humphrey Field Analyzer, an MD equal
to or greater than ¥5 dB (for example,
¥4.39, ¥2.58, or 0) indicates that the
visual field is normal. An MD less than
¥5 dB (for example, ¥5.5, ¥8.85, or
¥11.18) indicates the individual has
visual field loss.
Step 4—Do the test results show
statutory blindness based on visual field
loss?
In automated static threshold
perimetry, the intensity of the stimulus
varies. We measure the extent of visual
field loss by determining the portion of
the visual field in which the individual
can see a white III4e stimulus. The ‘‘III’’
refers to the standard Goldmann test
stimulus size III. The ‘‘4e’’ refers to the
standard Goldmann filters used to
determine the intensity of the stimulus.
Therefore, a determination is needed as
to the dB threshold level that
corresponds to a 4e intensity for the
particular perimeter being used. Points
that are at this dB threshold level or
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above are considered seeing points
because they are the same intensity or
dimmer than a 4e stimulus. Points that
are below this dB threshold level are
considered non-seeing points because
they are brighter than a 4e stimulus.
For acceptable tests performed on a
Humphrey Field Analyzer, a 10 dB
threshold is equivalent to a 4e intensity.
Therefore, for these tests we consider
any point with a threshold of 10 dB or
higher to be a seeing point; we consider
any point with a threshold of less than
10 dB to be a non-seeing point (see
sections 2.00A6a(vii) and
102.00A6a(vii) of the listings).
After we determine the dB threshold
that is comparable to a 4e stimulus, we
use the dB printout to determine
whether the widest diameter of the field
is less than or equal to 20 degrees. The
diameter must go through the point of
fixation.
To determine whether the widest
diameter is greater than 20 degrees, we
may map the visual field on a copy of
the dB printout by drawing a line,
which we refer to as a pseudoisopter,
midway between the seeing and nonseeing points.7 For example, for
acceptable tests performed on a
Humphrey Field Analyzer, we draw the
pseudoisopter between any two adjacent
tested points when one threshold is 10
dB or greater and the other threshold is
less than 10 dB. If any number at the
outermost edge of the field is a seeing
point, we draw the pseudoisopter on the
edge of the field at that point. If more
than one number is shown for a
particular point, we use the higher
number to determine whether the point
is a seeing point. We include the map
of the visual field in the case record.
The pseudoisopter(s) differentiates
the seeing area of the visual field from
7 A pseudoisopter is similar to an isopter drawn
as part of kinetic visual field testing. Drawing a
pseudoisopter assists in determining the location of
the widest diameter of the visual field and whether
that diameter is 20 degrees or less. However, we do
not always need to draw a pseudoisopter to
determine whether the widest diameter is 20
degrees or less. For example, if the only seeing
points on the dB printout are the four locations
around the point of fixation, we can determine that
the widest diameter of the visual field is less than
20 degrees without drawing a pseudoisopter. If all
the points in an entire quadrant of the dB printout
are seeing points, we can determine that the widest
diameter is greater than 20 degrees.
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the non-seeing area. We consider the
pseudoisopter itself to be part of the
seeing area.
We determine whether the widest
diameter is greater than 20 degrees by
using the hash marks on the horizontal
(x-) and vertical (y-) axes of the
Humphrey Field Analyzer dB printout
or by calculating the distance between
the points. As shown above, for the
HFA 30–2 and the HFA 24–2, each hash
mark covers a distance of 10 degrees,
and the degrees are divided evenly
between the hash marks. Additionally,
each tested point on a dB printout from
an HFA 30–2 or an HFA 24–2 is 6
degrees apart horizontally or vertically
from any adjacent tested point. The four
tested points immediately surrounding
the point of fixation are each 3 degrees
horizontally and vertically from the
point of fixation. Any tested point
adjacent to an axis is 3 degrees from that
axis.
When we measure the widest
diameter of the visual field, we subtract
the length of any scotoma (non-seeing
area), other than the ‘‘normal’’ blind
spot,8 from the overall length of any
diameter on which it falls. (On some
Humphrey Field Analyzer dB printouts,
the normal blind spot is identified by a
small triangle, as shown in Example 1.)
As previously noted, we consider the
pseudoisopter to be a seeing area and do
not subtract it from the overall length of
the diameter.
We will determine that the individual
has statutory blindness if the widest
diameter in the better eye is less than or
equal to 20 degrees, this finding is
consistent with the other evidence in
the case record, and for title II, a
medically determinable impairment that
could result in the visual field loss has
been identified.
Examples of how we determine
whether the individual has statutory
blindness based on visual field loss.
8 The normal blind spot is usually located 15.5
degrees temporal to fixation (to the right for the
right eye, to the left for the left eye) and 1.5 degrees
below the horizontal meridian. It is approximately
5.5 degrees in width and 7.5 degrees in length.
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printout above are 10 dB or higher, we
draw the pseudoisopter delineating the
outer edge of the visual field around the
tested area.
After determining the outer edge of
the seeing area as shown on the dB
printout, we need to determine whether
there are any scotomata; that is, blind
spots. If so, we map the scotomata as we
do not consider them when we
determine whether the widest diameter
of the visual field is greater than 20
degrees. A scotoma is illustrated below.
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than 10 dB, or by drawing the
pseudoisopter on the edge of the tested
area when the thresholds at the
outermost points are 10 dB or higher. As
all of the outermost points on the dB
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To measure the widest diameter, we
create a pseudoisopter by drawing a line
midway between points with a
threshold of 10 dB and higher and
adjacent points with a threshold less
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3 degrees above the non-seeing point to
the 3 degrees below it). We subtract the
6 degrees from the 60 degrees for a total
diameter of 54 degrees.
On the x-axis, the diameter extends
from one side of the dB printout to the
other side of the dB printout, which is
60 degrees in length. However, there is
a segment of the x-axis that is in the
scotoma, the segment from 12 degrees to
18 degrees.10 This segment is 6 degrees
long. We subtract the 6 degrees from the
60 degrees for a diameter of 54 degrees.
9 We would not deduct the segments of the y-axis
from the point of fixation to 6 degrees or from ¥6
to ¥12 degrees because those segments are part of
the pseudoisopter and we consider the
pseudoisopter to be a seeing area.
10 This segment includes the ‘‘normal’’ blind spot,
which is usually not deducted from the visual field.
However, because the area around the‘‘normal’’
blind spot is part of the non-seeing area, the
‘‘normal’’ blind spot is no longer considered
‘‘normal’’ and we include it as part of the scotoma.
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not have statutory blindness based on
visual field loss.
Although we did not need to calculate
the widest diameter for this example,
the widest diameter shown on this dB
printout is 54 degrees on both axes. On
the y-axis, the diameter extends from
the top of the dB printout to the bottom
of the dB printout, which is 60 degrees
in length. However, there is a segment
of the y-axis that is in the scotoma, the
segment from 6 degrees to 12 degrees.9
This segment is 6 degrees long
(calculated on the y-axis by adding the
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As all of the thresholds in the lower
left quadrant of this dB printout are
higher than 10 dB, we consider this
entire quadrant to be a seeing area. Any
diameter that is drawn through this
quadrant will be at least 30 degrees
long. Therefore, without calculating the
actual length of the widest diameter
shown on the dB printout, we can
determine that the widest diameter of
this visual field must be greater than 20
degrees and that this individual does
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41803
adjacent points with a threshold less
than 10 dB.
individual does not have statutory
blindness based on visual field loss
because the widest diameter is greater
than 20 degrees.
To measure the widest diameter, we
create a pseudoisopter by drawing a line
midway between points with a
threshold of 10 dB or higher and
adjacent points with a threshold less
than 10 dB.
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midway between points with a
threshold of 10 dB and higher and
The widest diameter is 24 degrees on
the y-axis. We can determine that the
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To measure the widest diameter, we
create a pseudoisopter by drawing a line
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The widest diameter is shown below.
below and 6 degrees to the right of the
point of fixation. These two points are
9 degrees apart vertically and 18 degrees
apart horizontally, as shown below.
11 The formula for calculating the length of the
hypotenuse of a right triangle is a2 + b2 = c2, where
a and b represent the vertical and horizontal
distances between two points and c represents the
diagonal distance between two points.
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in the field that is 6 degrees above and
12 degrees to the left of the point of
fixation, through the point of fixation, to
the point in the field that is 3 degrees
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The widest diameter is on a diagonal;
therefore, we calculate its length as the
hypotenuse of a right triangle.11 The
widest diameter extends from the point
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To measure the widest diameter, we
apply the formula for calculating the
length of the hypotenuse of a right
triangle as follows: 92 + 182 = 81 + 324
= 405. The widest diameter is the square
root of 405, or 20.12 degrees, which we
round to 20 degrees.12 Assuming that
this is the individual’s better eye, that
the field shown is consistent with the
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12 When determining the widest diameter of the
visual field, follow the normal rules for rounding
to the nearest whole number; that is, round
decimals below 0.5 down to the lower whole
number and round decimals 0.5 and above up to the
higher whole number.
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other evidence in file, and for a title II
claim, that there is a medically
determinable impairment that could
cause this field loss, we will find that
the individual has statutory blindness.
Step 5—How do we evaluate severe
visual field loss that has not resulted in
statutory blindness?
If the individual’s visual disorder has
resulted in severe visual field loss but
has not resulted in statutory blindness,
we will consider whether the visual
disorder meets listing 2.03B or 102.03B.
A visual disorder meets listing 2.03B or
102.03B when the MD for the better eye,
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measured with an HFA 30–2, is ¥22 dB
or worse.13 If the visual disorder does
not meet a listing, we will determine
whether the visual disorder medically
equals a listing or, if not, assess the
limitations imposed by the visual
disorder.
BILLING CODE 4191–02–P
13 An HFA 24–2 cannot be used to determine if
the visual disorder meets or medically equals listing
2.03B or 102.03B because the criterion in those
listings was calculated using an HFA 30–2. An MD
calculated using an HFA 24–2 cannot be substituted
for an MD calculated using an HFA 30–2.
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Effective Date: This Ruling is effective
upon publication in the Federal
Register.
Cross-References: Program Operations
Manual System DI 34001.012 and DI
34005.102; Special Senses and Speech—
Adult, Program Policy Online
104167188, Special Senses and
Speech—Child, Program Policy Online
734761857.
[FR Doc. 07–3708 Filed 7–30–07 8:45 am]
BILLING CODE 4191–02–C
DEPARTMENT OF STATE
[Public Notice 5870]
United States-Egypt Science and
Technology Joint Board; Public
Announcement of a Science and
Technology Program for Competitive
Grants to Support International,
Collaborative Projects in Science and
Technology Between U.S. and
Egyptian Cooperators
Department of State.
Notice.
AGENCY:
ACTION:
EFFECTIVE DATE:
July 2, 2007.
FOR FURTHER INFORMATION CONTACT:
Barbara Jones, Program Administrator,
U.S.-Egypt Science and Technology
Grants Program, USAID/Cairo, Unit
64900, Box 5, APO AE 09839–4900;
phone: 011–(20–2) 2522–6887; fax: 011–
(20–2) 2522–7041; E-mail:
bljones@usaid.gov.
The 2007 Program Announcement,
including proposal guidelines, will be
available starting July 2, 2007 on the
Joint Board Web site: https://
www.usembassy.egnet.net/usegypt/
joint-st.htm.
SUPPLEMENTARY INFORMATION:
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Authority: This program is established
under 22 U.S.C. 2656d and the Agreement for
Scientific and Technological Cooperation
between the Government of the United States
of America and the Government of the Arab
Republic of Egypt.
A solicitation for this program will
begin July 2, 2007. This program will
provide modest grants for successfully
competitive proposals for binational
collaborative projects and other
activities submitted by U.S. and
Egyptian experts. Projects must help the
United States and Egypt utilize science
and apply technology by providing
opportunities to exchange ideas,
information, skills, and techniques, and
to collaborate on scientific and
technological endeavors of mutual
interest and benefit. Proposals which
fully meet the submission requirements
as outlined in the Program
Announcement will receive peer
VerDate Aug<31>2005
15:11 Jul 30, 2007
Jkt 211001
reviews. Proposals considered for
funding in fiscal year 2008 must be
postmarked by October 22, 2007. All
proposals will be considered; however,
special consideration will be given to
proposals that address priority areas
defined by the Joint Board. These
include priorities in the areas of
information technology, environmental
technologies, biotechnology, energy,
standards and metrology, manufacturing
technologies, and others. More
information and copies of the Program
Announcement and Application may be
obtained by request.
FOR FURTHER INFORMATION CONTACT:
Please contact Robert S. Senseney,
Senior Advisor for Science Partnerships,
Office of Science and Technology
Cooperation, Bureau of Oceans,
Environment and Science, U.S.
Department of State and Chair, U.S.Egypt S&T Joint Board at (202) 663–
3246 or SenseneyRS@state.gov.
Dated: July 24, 2007.
Shirley Hart,
Deputy Director, Office of Science and
Technology Cooperation, Bureau of Oceans,
Environment and Science, Department of
State.
[FR Doc. E7–14807 Filed 7–30–07; 8:45 am]
BILLING CODE 4710–09–P
DEPARTMENT OF STATE
[Public Notice 5871]
United States-Egypt Science and
Technology Joint Board; Public
Announcement of a Science and
Technology Program for Competitive
Grants To Support Junior Scientist
Development Visits by U.S. and
Egyptian Scientists
Department of State.
ACTION: Notice.
AGENCY:
EFFECTIVE DATE:
July 2, 2007.
FOR FURTHER INFORMATION, CONTACT:
Barbara Jones, Program Administrator,
U.S.-Egypt Science and Technology
Grants Program, USAID/Cairo, Unit
64900, Box 5, APO AE 09839–4900;
phone: 011–(20–2) 2522–6887; fax:
011 (20–2) 2522–7041; E-mail:
bljones@usaid.gov.
The 2007 Program guidelines for
Junior Scientist Development visits will
be available starting July 2, 2007 on the
Joint Board Web site: https://
egypt.usembassy.gov/usegypt.htm.
SUPPLEMENTARY INFORMATION:
Authority: This program is established
under 22 U.S.C. 2656d and the Agreement for
Scientific and Technological Cooperation
between the Government of the United States
PO 00000
Frm 00107
Fmt 4703
Sfmt 4703
of America and the Government of the Arab
Republic of Egypt.
A solicitation for this program will
begin July 2, 2007. This program will
provide modest grants for successfully
competitive proposals for development
visits by U.S. Junior Scientists to Egypt
and Junior Egyptian Scientists to the
United States. Applicants must be
scientists who have received their PhD
within the past ten years. U.S.
applicants only may have a Master’s
degree or be currently enrolled in a PhD
program. Applications considered for
funding must be postmarked by October
29, 2007. All proposals which fully
meet the submission requirements will
be considered. More information and
copies of the Program Announcement
and Application may be obtained upon
request.
FOR FURTHER INFORMATION CONTACT:
Please contact Robert S. Senseney,
Senior Advisor for Science Partnerships,
Office of Science and Technology
Cooperation, Bureau of Oceans,
Environment and Science, U.S.
Department of State and Chair, U.S.Egypt S&T Joint Board at (202) 663–
3246 or SenseneyRS@state.gov.
Dated: July 24, 2007.
Shirley Hart,
Deputy Director, Office of Science and
Technology Cooperation, Bureau of Oceans,
Environment and Science, Department of
State.
[FR Doc. E7–14806 Filed 7–30–07; 8:45 am]
BILLING CODE 4710–09–P
DEPARTMENT OF TRANSPORTATION
Office of the Secretary
Notice of Applications for Certificates
of Public Convenience and Necessity
and Foreign Air Carrier Permits Filed
Under Subpart B (Formerly Subpart Q)
During the Week Ending June 22, 2007
The following Applications for
Certificates of Public Convenience and
Necessity and Foreign Air Carrier
Permits were filed under Subpart B
(formerly Subpart Q) of the Department
of Transportation’s Procedural
Regulations (See 14 CFR 301.201 et
seq.).
The due date for Answers,
Conforming Applications, or Motions to
Modify Scope are set forth below for
each application. Following the Answer
period DOT may process the application
by expedited procedures. Such
procedures may consist of the adoption
of a show-cause order, a tentative order,
or in appropriate cases a final order
without further proceedings.
E:\FR\FM\31JYN1.SGM
31JYN1
]]>Agencies
[Federal Register Volume 72, Number 146 (Tuesday, July 31, 2007)]
[Notices]
[Pages 41796-41808]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 07-3708]
=======================================================================
-----------------------------------------------------------------------
SOCIAL SECURITY ADMINISTRATION
[Docket No. SSA-2007-0029]
Social Security Ruling, SSR 07-01p; Titles II and XVI: Evaluating
Visual Field Loss Using Automated Static Threshold Perimetry
AGENCY: Social Security Administration.
ACTION: Notice of Social Security Ruling.
-----------------------------------------------------------------------
SUMMARY: In accordance with 20 CFR 402.35(b)(1), the Commissioner of
Social Security gives notice of Social Security Ruling, SSR 07-01p.
This Ruling clarifies how we use automated static threshold perimetry
to determine statutory blindness based on visual field loss.
EFFECTIVE DATE: July 31, 2007.
FOR FURTHER INFORMATION CONTACT: Michelle Hungerman, Office of
Disability Programs, Social Security Administration, 6401 Security
Boulevard, Baltimore, MD 21235-6401, (410) 965-2289 or TTY 1-800-325-
0778.
SUPPLEMENTARY INFORMATION: Although 5 U.S.C. 552(a)(1) and (a)(2) do
not require us to publish this Social Security Ruling, we are doing so
in accordance with 20 CFR 402.35(b)(1).
Social Security Rulings make available to the public precedential
decisions relating to the Federal old-age, survivors, disability,
supplemental security income, special veterans benefits, and black lung
benefits programs. Social Security Rulings may be based on
determinations or decisions made at all administrative levels of
adjudication, Federal court decisions, Commissioner's decisions,
opinions of the Office of the General Counsel, and policy
interpretations of the law and regulations.
Although Social Security Rulings do not have the same force and
effect as the statute or regulations, they are binding on all
components of the Social Security Administration, in accordance with 20
CFR 402.35(b)(1), and are binding as precedents in adjudicating cases.
If this Social Security Ruling is later superseded, modified, or
rescinded, we will publish a notice in the Federal Register to that
effect.
(Catalog of Federal Domestic Assistance, Program Nos 96.001 Social
Security--Disability Insurance; 96.006 Supplemental Security
Income.)
Dated: May 30, 2007.
Michael J. Astrue,
Commissioner of Social Security.
Policy Interpretation Ruling
Titles II and XVI: Evaluating Visual Field Loss Using Automated Static
Threshold Perimetry
Purpose: To clarify how we use automated static threshold perimetry
to evaluate visual field loss.
Citations (Authority): Sections 205(a), 216(i)(1), 221, 223(d),
1614(a), 1631(d), and 1633 of the Social Security Act (Act), as
amended; Regulations No. 4, subpart P, sections 404.1520, 404.1525,
404.1526, 404.1581, and 2.00A, 2.03, 102.00A, and 102.03 of appendix 1;
and Regulations No.16, subpart I, sections 416.920, 416.924, 416.925,
416.926, and 416.981.
Pertinent History: The Act provides for a finding of blindness
based on visual field loss when the widest diameter of the visual field
in the better eye subtends an angle no greater than 20 degrees. Even
when visual field loss does not result in blindness, it may
nevertheless be disabling. In sections 2.00A6 and 102.00A6 of the
Listing of Impairments in appendix 1 to subpart P of part 404 (the
listings) we provide that when we need to measure the extent of visual
field loss, we will use visual field measurements obtained with an
automated static threshold perimetry test that satisfies our
requirements.\1\
---------------------------------------------------------------------------
\1\ Our rules provide that in addition to automated static
threshold perimetry we can use comparable visual field measurements
obtained with kinetic perimetry, such as Goldmann perimetry. Because
we allow for different types of testing, our listings provide
comparable criteria that can be used with the different types of
test results. Accordingly, only one type of testing is needed to
evaluate visual field loss under our listings.
---------------------------------------------------------------------------
Automated static threshold perimetry measures the retina's
sensitivity to light at predetermined locations in the visual field.
While the individual focuses on a specific point, called the point of
fixation, stimuli are presented in random order at each of the
predetermined locations within the visual field. The size of the
stimulus and the locations tested remain constant, but the intensity
(brightness) of the stimulus is varied in order to determine the level
at which the individual sees the stimulus. The intensity level where
the individual sees the stimulus is referred to as the threshold. The
threshold for each point tested is reported in decibels (dB).
The results of automated static threshold perimetry are reported on
standard charts. (See Exhibits 1 and 2 at the end of this ruling for
examples of standard charts that may be found in case records.) These
charts:
Identify the perimeter that was used to perform the test;
Provide identifying information about the test, such as
the date of the test, the type of test used, the size and color of the
stimulus, and the background illumination;
Provide the mean deviation (MD); \2\ and
---------------------------------------------------------------------------
\2\ The MD represents the average elevation or depression of the
individual's visual field when compared to a normal field. This
measurement is expressed in dB.
---------------------------------------------------------------------------
Contain a printout that shows the threshold, in dB, for
each of the locations tested. We refer to this printout, examples of
which are shown below, as the dB printout.
In this Ruling we explain:
How to use the information in the standard charts produced
as part of automated static threshold perimetry to determine whether
the visual field test satisfies our requirements. To illustrate this,
we refer to standard charts produced by the Humphrey Field Analyzer. We
refer only to the Humphrey Field Analyzer because it is the perimeter
most widely used in the United States.
How to use the MD to determine whether the individual has
visual field loss.
Our process for determining whether the test results show
statutory blindness based on visual field loss.\3\
---------------------------------------------------------------------------
\3\ We developed our process to enable us to apply the results
of automated static threshold perimetry to the standard for
statutory blindness. Health care providers do not use our process in
their clinical practices or for treatment purposes.
---------------------------------------------------------------------------
How to evaluate cases in which severe visual field loss
has not resulted in statutory blindness.
[[Page 41797]]
Policy Interpretation: We use the following process to evaluate
automated static threshold perimetry.
Step 1--Is the automated static threshold perimetry test
acceptable?
We consider an automated static threshold perimetry test to be
acceptable when it meets all of the following requirements:
The test is performed on a perimeter that satisfies all of
the requirements in sections 2.00A6a(ii) and 102.00A6a(ii) of the
listings; \4\
---------------------------------------------------------------------------
\4\ As of the effective date of this ruling, all models of the
Humphrey Field Analyzer satisfy these requirements.
---------------------------------------------------------------------------
The test uses a white size III Goldmann stimulus and a
31.5 apostilb (asb) \5\ (10 candela (cd)/m\2\) white background; \6\
---------------------------------------------------------------------------
\5\ An apostilb is a unit of luminance.
\6\ The background color is not shown on the standard charts
produced by the Humphrey Field Analyzer. However, as of the
effective date of this ruling, the Humphrey Field Analyzer always
uses a white background if a white stimulus is used.
---------------------------------------------------------------------------
The points tested are no more than 6 degrees apart
horizontally or vertically; and
The test measures the central 24 to 30 degrees of the
visual field; that is, the area measuring 24 to 30 degrees around the
point of fixation.
The Humphrey Field Analyzer central 30-2 threshold test (HFA 30-2)
and central 24-2 threshold test (HFA 24-2) are tests that can meet
these criteria. The HFA 30-2 tests 76 points in the central 30 degrees
of the visual field. The HFA 24-2 tests 54 points in the central 24 to
30 degrees of the visual field. For both of these tests, the tested
points are spaced in an equidistant grid pattern, with each point 6
degrees apart horizontally or vertically from any adjacent point.
Therefore, we consider the HFA 30-2 and the HFA 24-2 to be acceptable
tests when performed using a size III white stimulus on a 31.5 asb
white background.
The following examples of dB printouts illustrate the grid patterns
used for the HFA 30-2 and the HFA 24-2 and provide information for
interpreting the test results.
BILLING CODE 2211-01-P
[[Page 41798]]
[GRAPHIC] [TIFF OMITTED] TN31JY07.017
[[Page 41799]]
[GRAPHIC] [TIFF OMITTED] TN31JY07.018
Billing Code 2211-01-C
[[Page 41800]]
We will not use automated static threshold perimetry test results
to evaluate the visual field loss if the test was not performed using
all of our requirements; for example, a stimulus other than a size III
stimulus was used, or the stimulus was not white.
Step 2--Are the test results reliable?
Each perimeter manufacturer will identify factors that are used to
determine whether the test results are reliable.
For the Humphrey Field Analyzer, the reliability factors are
fixation losses, false positive errors, and false negative errors.
Information about these factors is at the top of the chart (see
Exhibits 1 and 2). The test results are not reliable for evaluating
visual field loss if the fixation losses exceed 20 percent, or if the
false positive errors or false negative errors exceed 33 percent.
Even when the reliability factors are within the manufacturer's
specifications, we will not use the test results to evaluate visual
field loss if there is other information in the case file that suggests
that the results are not valid; for example, the test results are
inconsistent with the clinical findings or the individual's daily
activities.
Step 3--Does the individual have visual field loss?
For acceptable tests performed on a Humphrey Field Analyzer, an MD
equal to or greater than -5 dB (for example, -4.39, -2.58, or 0)
indicates that the visual field is normal. An MD less than -5 dB (for
example, -5.5, -8.85, or -11.18) indicates the individual has visual
field loss.
Step 4--Do the test results show statutory blindness based on
visual field loss?
In automated static threshold perimetry, the intensity of the
stimulus varies. We measure the extent of visual field loss by
determining the portion of the visual field in which the individual can
see a white III4e stimulus. The ``III'' refers to the standard Goldmann
test stimulus size III. The ``4e'' refers to the standard Goldmann
filters used to determine the intensity of the stimulus. Therefore, a
determination is needed as to the dB threshold level that corresponds
to a 4e intensity for the particular perimeter being used. Points that
are at this dB threshold level or above are considered seeing points
because they are the same intensity or dimmer than a 4e stimulus.
Points that are below this dB threshold level are considered non-seeing
points because they are brighter than a 4e stimulus.
For acceptable tests performed on a Humphrey Field Analyzer, a 10
dB threshold is equivalent to a 4e intensity. Therefore, for these
tests we consider any point with a threshold of 10 dB or higher to be a
seeing point; we consider any point with a threshold of less than 10 dB
to be a non-seeing point (see sections 2.00A6a(vii) and 102.00A6a(vii)
of the listings).
After we determine the dB threshold that is comparable to a 4e
stimulus, we use the dB printout to determine whether the widest
diameter of the field is less than or equal to 20 degrees. The diameter
must go through the point of fixation.
To determine whether the widest diameter is greater than 20
degrees, we may map the visual field on a copy of the dB printout by
drawing a line, which we refer to as a pseudoisopter, midway between
the seeing and non-seeing points.\7\ For example, for acceptable tests
performed on a Humphrey Field Analyzer, we draw the pseudoisopter
between any two adjacent tested points when one threshold is 10 dB or
greater and the other threshold is less than 10 dB. If any number at
the outermost edge of the field is a seeing point, we draw the
pseudoisopter on the edge of the field at that point. If more than one
number is shown for a particular point, we use the higher number to
determine whether the point is a seeing point. We include the map of
the visual field in the case record.
---------------------------------------------------------------------------
\7\ A pseudoisopter is similar to an isopter drawn as part of
kinetic visual field testing. Drawing a pseudoisopter assists in
determining the location of the widest diameter of the visual field
and whether that diameter is 20 degrees or less. However, we do not
always need to draw a pseudoisopter to determine whether the widest
diameter is 20 degrees or less. For example, if the only seeing
points on the dB printout are the four locations around the point of
fixation, we can determine that the widest diameter of the visual
field is less than 20 degrees without drawing a pseudoisopter. If
all the points in an entire quadrant of the dB printout are seeing
points, we can determine that the widest diameter is greater than 20
degrees.
---------------------------------------------------------------------------
The pseudoisopter(s) differentiates the seeing area of the visual
field from the non-seeing area. We consider the pseudoisopter itself to
be part of the seeing area.
We determine whether the widest diameter is greater than 20 degrees
by using the hash marks on the horizontal (x-) and vertical (y-) axes
of the Humphrey Field Analyzer dB printout or by calculating the
distance between the points. As shown above, for the HFA 30-2 and the
HFA 24-2, each hash mark covers a distance of 10 degrees, and the
degrees are divided evenly between the hash marks. Additionally, each
tested point on a dB printout from an HFA 30-2 or an HFA 24-2 is 6
degrees apart horizontally or vertically from any adjacent tested
point. The four tested points immediately surrounding the point of
fixation are each 3 degrees horizontally and vertically from the point
of fixation. Any tested point adjacent to an axis is 3 degrees from
that axis.
When we measure the widest diameter of the visual field, we
subtract the length of any scotoma (non-seeing area), other than the
``normal'' blind spot,\8\ from the overall length of any diameter on
which it falls. (On some Humphrey Field Analyzer dB printouts, the
normal blind spot is identified by a small triangle, as shown in
Example 1.) As previously noted, we consider the pseudoisopter to be a
seeing area and do not subtract it from the overall length of the
diameter.
---------------------------------------------------------------------------
\8\ The normal blind spot is usually located 15.5 degrees
temporal to fixation (to the right for the right eye, to the left
for the left eye) and 1.5 degrees below the horizontal meridian. It
is approximately 5.5 degrees in width and 7.5 degrees in length.
---------------------------------------------------------------------------
We will determine that the individual has statutory blindness if
the widest diameter in the better eye is less than or equal to 20
degrees, this finding is consistent with the other evidence in the case
record, and for title II, a medically determinable impairment that
could result in the visual field loss has been identified.
Examples of how we determine whether the individual has statutory
blindness based on visual field loss.
[[Page 41801]]
[GRAPHIC] [TIFF OMITTED] TN31JY07.019
To measure the widest diameter, we create a pseudoisopter by
drawing a line midway between points with a threshold of 10 dB and
higher and adjacent points with a threshold less than 10 dB, or by
drawing the pseudoisopter on the edge of the tested area when the
thresholds at the outermost points are 10 dB or higher. As all of the
outermost points on the dB printout above are 10 dB or higher, we draw
the pseudoisopter delineating the outer edge of the visual field around
the tested area.
[GRAPHIC] [TIFF OMITTED] TN31JY07.020
After determining the outer edge of the seeing area as shown on the
dB printout, we need to determine whether there are any scotomata; that
is, blind spots. If so, we map the scotomata as we do not consider them
when we determine whether the widest diameter of the visual field is
greater than 20 degrees. A scotoma is illustrated below.
[[Page 41802]]
[GRAPHIC] [TIFF OMITTED] TN31JY07.021
As all of the thresholds in the lower left quadrant of this dB
printout are higher than 10 dB, we consider this entire quadrant to be
a seeing area. Any diameter that is drawn through this quadrant will be
at least 30 degrees long. Therefore, without calculating the actual
length of the widest diameter shown on the dB printout, we can
determine that the widest diameter of this visual field must be greater
than 20 degrees and that this individual does not have statutory
blindness based on visual field loss.
Although we did not need to calculate the widest diameter for this
example, the widest diameter shown on this dB printout is 54 degrees on
both axes. On the y-axis, the diameter extends from the top of the dB
printout to the bottom of the dB printout, which is 60 degrees in
length. However, there is a segment of the y-axis that is in the
scotoma, the segment from 6 degrees to 12 degrees.\9\ This segment is 6
degrees long (calculated on the y-axis by adding the 3 degrees above
the non-seeing point to the 3 degrees below it). We subtract the 6
degrees from the 60 degrees for a total diameter of 54 degrees.
---------------------------------------------------------------------------
\9\ We would not deduct the segments of the y-axis from the
point of fixation to 6 degrees or from -6 to -12 degrees because
those segments are part of the pseudoisopter and we consider the
pseudoisopter to be a seeing area.
---------------------------------------------------------------------------
On the x-axis, the diameter extends from one side of the dB
printout to the other side of the dB printout, which is 60 degrees in
length. However, there is a segment of the x-axis that is in the
scotoma, the segment from 12 degrees to 18 degrees.\10\ This segment is
6 degrees long. We subtract the 6 degrees from the 60 degrees for a
diameter of 54 degrees.
---------------------------------------------------------------------------
\10\ This segment includes the ``normal'' blind spot, which is
usually not deducted from the visual field. However, because the
area around the``normal'' blind spot is part of the non-seeing area,
the ``normal'' blind spot is no longer considered ``normal'' and we
include it as part of the scotoma.
[GRAPHIC] [TIFF OMITTED] TN31JY07.022
[[Page 41803]]
To measure the widest diameter, we create a pseudoisopter by
drawing a line midway between points with a threshold of 10 dB and
higher and adjacent points with a threshold less than 10 dB.
[GRAPHIC] [TIFF OMITTED] TN31JY07.023
The widest diameter is 24 degrees on the y-axis. We can determine
that the individual does not have statutory blindness based on visual
field loss because the widest diameter is greater than 20 degrees.
[GRAPHIC] [TIFF OMITTED] TN31JY07.024
To measure the widest diameter, we create a pseudoisopter by
drawing a line midway between points with a threshold of 10 dB or
higher and adjacent points with a threshold less than 10 dB.
[[Page 41804]]
[GRAPHIC] [TIFF OMITTED] TN31JY07.025
The widest diameter is shown below.
[GRAPHIC] [TIFF OMITTED] TN31JY07.026
The widest diameter is on a diagonal; therefore, we calculate its
length as the hypotenuse of a right triangle.\11\ The widest diameter
extends from the point in the field that is 6 degrees above and 12
degrees to the left of the point of fixation, through the point of
fixation, to the point in the field that is 3 degrees below and 6
degrees to the right of the point of fixation. These two points are 9
degrees apart vertically and 18 degrees apart horizontally, as shown
below.
---------------------------------------------------------------------------
\11\ The formula for calculating the length of the hypotenuse of
a right triangle is a\2\ + b\2\ = c\2\, where a and b represent the
vertical and horizontal distances between two points and c
represents the diagonal distance between two points.
[GRAPHIC] [TIFF OMITTED] TN31JY07.027
[[Page 41805]]
To measure the widest diameter, we apply the formula for
calculating the length of the hypotenuse of a right triangle as
follows: 9\2\ + 18\2\ = 81 + 324 = 405. The widest diameter is the
square root of 405, or 20.12 degrees, which we round to 20 degrees.\12\
Assuming that this is the individual's better eye, that the field shown
is consistent with the other evidence in file, and for a title II
claim, that there is a medically determinable impairment that could
cause this field loss, we will find that the individual has statutory
blindness.
---------------------------------------------------------------------------
\12\ When determining the widest diameter of the visual field,
follow the normal rules for rounding to the nearest whole number;
that is, round decimals below 0.5 down to the lower whole number and
round decimals 0.5 and above up to the higher whole number.
---------------------------------------------------------------------------
Step 5--How do we evaluate severe visual field loss that has not
resulted in statutory blindness?
If the individual's visual disorder has resulted in severe visual
field loss but has not resulted in statutory blindness, we will
consider whether the visual disorder meets listing 2.03B or 102.03B. A
visual disorder meets listing 2.03B or 102.03B when the MD for the
better eye, measured with an HFA 30-2, is -22 dB or worse.\13\ If the
visual disorder does not meet a listing, we will determine whether the
visual disorder medically equals a listing or, if not, assess the
limitations imposed by the visual disorder.
---------------------------------------------------------------------------
\13\ An HFA 24-2 cannot be used to determine if the visual
disorder meets or medically equals listing 2.03B or 102.03B because
the criterion in those listings was calculated using an HFA 30-2. An
MD calculated using an HFA 24-2 cannot be substituted for an MD
calculated using an HFA 30-2.
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BILLING CODE 4191-02-P
[[Page 41806]]
[GRAPHIC] [TIFF OMITTED] TN31JY07.028
[[Page 41807]]
[GRAPHIC] [TIFF OMITTED] TN31JY07.029
[[Page 41808]]
Effective Date: This Ruling is effective upon publication in the
Federal Register.
Cross-References: Program Operations Manual System DI 34001.012 and
DI 34005.102; Special Senses and Speech--Adult, Program Policy Online
104167188, Special Senses and Speech--Child, Program Policy Online
734761857.
[FR Doc. 07-3708 Filed 7-30-07 8:45 am]
BILLING CODE 4191-02-C
