Revised Medical Criteria for Evaluating Visual Disorders, 7549-7558 [2012-3226]
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Federal Register / Vol. 77, No. 29 / Monday, February 13, 2012 / Proposed Rules
freezer—automatic defrost with topmounted freezer without through-thedoor ice service (product class 3) and
refrigerator-freezer—automatic defrost
with side-mounted freezer with
through-the-door ice service (product
class 7)) and because DOE expected that
results for these product classes would
be representative for all of the product
classes. DOE had this expectation
because these two product classes
represent a large majority of refrigeratorfreezers, which in turn represent the
majority of energy use of refrigeration
products. (See pages 5–9 and 2–1 of the
2005 report). The technical report and
the associated data sheets helped direct
the priorities for DOE’s rulemaking
activities. As a result, other products
were given a higher priority, and limited
rulemaking work on refrigerators and
freezers was carried out in the following
years prior to the enactment of the
Energy Independence and Security Act
of 2007, Public Law 110–140 (Dec. 19,
2007) (EISA).
EISA required DOE to publish a final
rule to determine whether to amend the
standards in effect for residential
refrigeration products manufactured
starting in 2014. Consistent with this
requirement, DOE issued a notice of
proposed rulemaking on September 27,
2010. 75 FR 59470. Subsequently, on
September 15, 2011, DOE issued a final
rule that established energy
conservation standards for over 40
classes of residential refrigeration
products. See 76 FR 57516 and 76 FR
70865 (November 16, 2011) (date
correction notice). The standards
adopted in that final rule were largely
based on a consensus agreement that a
coalition of energy efficiency advocates
and industry representatives submitted
to DOE in July 2010, see DOE Docket
No. EERE–2008–BT–STD–0012,
Comment 49,3 and provided
manufacturers with the requisite threeyear lead time contemplated by EPCA.
See 42 U.S.C. 6295(m).
In the preamble to the final rule, DOE
discussed the issue of wine chiller
coverage. See, e.g. 76 FR at 57534. The
test procedure final rule and interim
final rule distinguished between those
products designed to safely store fresh
food and those that were not. See 75 FR
78810, 78817 (Dec. 16, 2010). Wine
chillers are not treated as refrigerators
because they are not designed to be
capable of achieving compartment
temperatures below the 39 °F limit
specified in the definition for ‘‘electric
3 Note: In the regulations.gov Web site, this is
listed as comment 52, although it was originally
comment 49, and its header identifies it as
comment 49.
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14:45 Feb 10, 2012
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refrigerator.’’ See 10 CFR 430.2. DOE
indicated that it would consider the
coverage of wine chillers as part of a
separate future rulemaking. Today’s
notice begins that process of examining
the coverage of those residential
refrigeration products, including wine
chillers, that are not yet addressed by
any Federal energy conservation
standards. Under EPCA, refrigerators,
refrigerator-freezers, and freezers are
limited to those products that can be
operated by alternating current
electricity, but excluding (A) any type
designed to be used without doors; and
(B) any type which does not include a
compressor and condenser unit as an
integral part of the cabinet assembly.
See 42 U.S.C. 6292(a)(1).
The framework document explains
the issues, analyses, and process that
DOE is considering for the development
of energy efficiency standards for wine
chillers and miscellaneous refrigeration
products. An accompanying public
meeting will be held that will focus on
the analyses and issues contained in
various sections of the framework
document. DOE plans to present and
solicit discussion regarding these issues.
DOE will also make a brief presentation
on the process that it plans to follow
when evaluating potential standards for
these products.
DOE encourages anyone who wishes
to participate in the public meeting to
obtain and review the framework
document and to be prepared to discuss
its contents. A copy of the draft
framework document is available at
https://www1.eere.energy.gov/buildings/
appliance_standards/residential/
refrigerators_freezers.html.
However, public meeting participants
need not limit their comments to the
topics identified in the framework
document. DOE is also interested in
receiving views on other relevant issues
that participants believe would affect
energy conservation standards for these
products. DOE invites all interested
parties, whether or not they participate
in the public meeting, to submit in
writing by March 14, 2012, comments
and information on matters addressed in
the framework document and on other
matters relevant to consideration of
standards for wine chillers and
miscellaneous refrigeration products.
DOE will conduct the public meeting
in an informal, facilitated, conference
style. There shall be no discussion of
proprietary information, costs or prices,
market shares, or other commercial
matters regulated by U.S. antitrust laws.
A court reporter will record the minutes
of the meeting, after which a transcript
will be available for purchase from the
court reporter and placed on the DOE
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7549
Web site at www1.eere.energy.gov/
buildings/appliance_standards/
residential/refrigerators_freezers.htm.
After the public meeting and the close
of the comment period for the
framework document, DOE will begin
collecting data, conducting the analyses
as discussed at the public meeting, and
reviewing public comments.
Anyone who wishes to participate in
the public meeting, receive meeting
materials, or be added to the DOE
mailing list to receive future notices and
information about wine chillers and
miscellaneous refrigeration products
should contact Ms. Brenda Edwards at
(202) 586–2945.
Issued in Washington, DC, on February 6,
2012.
Kathleen B. Hogan,
Deputy Assistant Secretary for Energy
Efficiency, Energy Efficiency and Renewable
Energy.
[FR Doc. 2012–3261 Filed 2–10–12; 8:45 am]
BILLING CODE 6450–01–P
SOCIAL SECURITY ADMINISTRATION
20 CFR Part 404
[Docket No. SSA–2010–0078]
RIN 0960–AH28
Revised Medical Criteria for Evaluating
Visual Disorders
Social Security Administration.
Notice of proposed rulemaking.
AGENCY:
ACTION:
We propose to revise and
reorganize the criteria in the Listing of
Impairments (listings) that we use to
evaluate cases involving visual
disorders in adults and children under
titles II and XVI of the Social Security
Act (Act). The proposed revisions reflect
our program experience and address
adjudicator questions we have received
since we last revised these criteria in
2006. These proposed revisions reflect
guidance we have issued in response to
adjudicator questions and will ensure
more timely adjudication of claims in
which we evaluate visual impairments
that involve a loss of visual acuity or
loss of visual fields.
DATES: To ensure that your comments
are considered, we must receive them
by no later than April 13, 2012.
ADDRESSES: You may submit comments
by any one of three methods—Internet,
fax, or mail. Do not submit the same
comments multiple times or by more
than one method. Regardless of which
method you choose, please state that
your comments refer to Docket No.
SSA–2010–0078 so that we may
SUMMARY:
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associate your comments with the
correct regulation.
Caution: You should be careful to
include in your comments only
information that you wish to make
publicly available. We strongly urge you
not to include in your comments any
personal information, such as Social
Security numbers or medical
information.
1. Internet: We strongly recommend
that you submit your comments via the
Internet. Visit the Federal eRulemaking
portal at https://www.regulations.gov.
Use the Search function to find docket
number SSA–2010–0078. The system
will issue you a tracking number to
confirm your submission. You will not
be able to view your comment
immediately because we must post each
comment manually. It may take up to a
week for your comment to be viewable.
2. Fax: Fax comments to (410) 966–
2830.
3. Mail: Address your comments to
the Office of Regulations, Social
Security Administration, 107 Altmeyer
Building, 6401 Security Boulevard,
Baltimore, Maryland 21235–6401.
Comments are available for public
viewing on the Federal eRulemaking
portal at https://www.regulations.gov or
in person, during regular business
hours, by arranging with the contact
person identified below.
FOR FURTHER INFORMATION CONTACT:
Cheryl Williams, Office of Medical
Listings Improvement, Social Security
Administration, 6401 Security
Boulevard, Baltimore, Maryland 21235–
6401, (410) 965–1020. For information
on eligibility or filing for benefits, call
our national toll-free number, 1–800–
772–1213 or TTY 1–800–325–0778, or
visit our Internet site, Social Security
Online, at https://
www.socialsecurity.gov.
SUPPLEMENTARY INFORMATION:
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Why are we proposing to revise the
listings for evaluating visual disorders?
We last published final rules revising
the criteria that we use to evaluate
visual disorders in the Federal Register
on November 20, 2006.1 Although these
listings do not expire until February 20,
2015, we are proposing to revise them
now to reflect our program experience
and to address adjudicator questions
that we have received since 2006. We
intend to publish revisions that would
update the criteria for evaluating
hearing disorders and speech and
language disorders separately.
1 71
FR 67037.
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What changes are we proposing to the
introductory text of the adult listings
for evaluating visual disorders?
Most of the proposed introductory
text is substantively the same as the
current introductory text. We propose to
clarify, simplify, and reorganize the
introductory text. We also propose to
expand some sections to clarify the
existing guidance and to include
additional acceptable testing for
evaluating a person’s visual field loss. In
the following paragraphs, we describe
the significant changes we propose to
make to the introductory text of the
adult listings for evaluating visual
disorders in part A of appendix 1 to
subpart P of part 404, using the titles of
the proposed sections.
Section 2.00A2, How do we define
statutory blindness?
In proposed 2.00A2a, we would add
the word ‘‘central’’ before ‘‘visual
acuity’’ to correct the definition of
statutory blindness in current 2.00A2.
We would also add a reference to
proposed 2.00A5, which explains visual
acuity testing requirements. In proposed
2.00A2b, we would add a reference to
proposed 2.00A6, which explains our
visual field testing requirements. In
proposed 2.00A2c, we would add
proposed listings 2.04A and 2.04B to
our guidance in current 2.00A2, which
explains that if your visual disorder
medically equals the criteria of 2.02 or
2.03A, or meets or medically equals
2.03B, 2.03C, or 2.04, we will find that
you have a disability if your visual
disorder also meets the duration
requirement.
Section 2.00A4, What evidence do we
need to evaluate visual disorders,
including those that result in statutory
blindness under title II?
In proposed 2.00A4, we would
remove current 2.00A4b, which
describes cortical visual disorders,
because it does not provide useful
guidance to adjudicators on how to
evaluate vision loss due to cortical
visual disorders. While we added
current 2.00A4b when we last published
final rules making comprehensive
revisions to section 2.00 on November
20, 2006,2 it is not our intention to list
in these rules every visual disorder that
may result in vision loss. We propose to
include cortical visual disorders as an
example of a disorder that may result in
abnormalities that do not appear on a
standard eye examination. We also
intend to provide guidance for
evaluating a person’s vision loss due to
cortical visual disorders and any other
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FR 67040, 67045, 67046, and 67049.
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disorders that may result in vision loss
or a loss in visual functioning (for
example, blepharospasm) in our internal
operating instructions and training.
Section 2.00A5, How do we measure
your best-corrected central visual
acuity?
We propose to make the following
changes to current 2.00A5:
• Provide guidance in proposed
2.00A5a(ii) that explains how we use
visual acuity measurements not
recorded in Snellen notation, such as
counts fingers (CF) or no light
perception (NLP), to evaluate your
vision loss. This guidance is in response
to questions from our adjudicators.
• Add the guidance in current
2.00A8a, which explains how we use
test charts that measure visual acuity
between 20/100 and 20/200, to
proposed 2.00A5b.
• Provide guidance in proposed
2.00A5d, which we currently provide in
our internal operating instructions, that
explains how we use the results of
cycloplegic refraction.
Section 2.00A6, How do we measure
your visual fields?
We propose to make the following
changes to current 2.00A6:
• Combine the guidance in current
2.00A6a(i) and 2.00A6a(ii) in proposed
2.00A6a, with one exception. As we
explain below, we would move the
guidance that explains our requirements
for acceptable perimeters in current
2.00A6a(ii) to proposed section 2.00A8.
• Move the guidance on visual field
testing requirements in current
2.00A6a(iii), (vi), and (vii), to proposed
2.00A6b(i), (ii), and (iii), respectively.
• Revise our guidance on automated
static threshold perimeters to remove
specific references to perimeter
manufacturers. In the preamble to our
final rules published in the Federal
Register on November 20, 2006, we
explained that while the National
Research Council (NRC) 2002 report,
Visual Impairments: Determining
Eligibility for Social Security Benefits,
cited both the Humphrey Field Analyzer
and the Octopus perimeter as acceptable
perimeters, we were not including the
Octopus perimeter as an example of an
acceptable perimeter. We decided not to
include the Octopus perimeter at that
time because we did not intend to list
every acceptable perimeter in our rules.
However, since the publication of those
rules, we have received numerous
questions from adjudicators on the
acceptability of the tests performed on
Octopus and other perimeters. We have
determined that other tests (including
the Octopus 32) and perimeters
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(including the Octopus 300 Series),
meet our requirements for acceptable
testing and acceptable perimeters.
• Move the guidance in current
2.00A6a(iv), which explains how we
evaluate vision loss under 2.03A, to
proposed 2.00A6c, and add the Octopus
32 test as an acceptable test.
• Move the guidance in current
2.00A6a(v), which explains how we
evaluate vision loss under 2.03B, to
proposed 2.00A6d. We would add the
definition of the term mean deviation
(or defect), abbreviated as MD, which
we use in current and proposed 2.03B
but do not define. We would explain
that Humphrey Field Analyzer (HFA)
tests report the MD as a negative
number and, therefore, we use the
absolute value of the MD when
determining whether the person’s visual
field loss meets the listing.
• Move the guidance in current
2.00A6a(viii), which explains when we
can use visual field measurements
obtained using kinetic perimetry to
evaluate vision loss, to proposed
2.00A6e.
• Move the guidance on visual field
screening tests in current 2.00A6a(ix) to
proposed 2.00A6f.
• Move the guidance on the use of
corrective lenses in visual field testing
in current 2.00A6b to proposed
2.00A6g.
• Move the guidance on scotomas in
current 2.00A8c to proposed 2.00A6h.
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2.00A7, How do we determine your
visual acuity efficiency, visual field
efficiency, and visual efficiency?
We propose to make the following
changes to current 2.00A7:
• Introduce ‘‘value’’ as a term to
express visual efficiency, in addition to
the term ‘‘percentage,’’ in proposed
2.00A7a, which we explain in the
paragraphs below.
• Add current Table 1 (Percentage of
Visual Acuity Efficiency Corresponding
to Best-Corrected Visual Acuity), which
is located at the end of the current
special senses and speech listings, to
proposed 2.00A7b because it is more
useful to our adjudicators to place this
table in the introductory text
immediately after the explanation of
visual acuity efficiency. Our current
rules describe overall visual efficiency
as a percentage and we provide the
equivalent visual acuity efficiency
percentages corresponding to Snellen
best-corrected central visual acuities for
distance in Table 1. In the proposed
table, we would include a column for
visual acuity efficiency values that
correspond to Snellen best-corrected
central visual acuities for distance.
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• Expand current 2.00A7b and
redesignate as proposed 2.00A7c. A
person’s visual field efficiency can be
expressed as a percentage (using the
visual field determined by kinetic
perimetry) or as a value (using the MD
determined by automated static
threshold perimetry). We would explain
that a visual field efficiency percentage
of 20 is comparable to an MD of 22,
which we currently explain in training.
• Add guidance in proposed
2.00A7c(i) on how to calculate visual
field efficiency value using the MD
determined by automated static
threshold perimetry, which we
currently provide in our internal
operating instructions.
• Redesignate current 2.00A7b as
proposed 2.00A7c(ii).
• Add current Table 2 (Chart of
Visual Fields), which is located at the
end of the current special senses and
speech listings, to proposed 2.00A7c(ii),
and redesignate it as Figure 1, because
it is more useful to our adjudicators to
place this figure in the introductory text
immediately after the explanation of
visual field efficiency. We would also
add, and make minor changes to, the
example for calculating visual field
efficiency percentage under the current
table to proposed 2.00A7c(ii)A and B.
• Expand current 2.00A7c and
redesignate as proposed 2.00A7d. We
would add an example for calculating
visual efficiency value in proposed
2.00A7d(i). In proposed 2.00A7d(ii), we
would revise the example for
calculating visual efficiency percentage,
which is in current 2.00A7c, to simply
state more clearly how we convert a
decimal value to a percentage.
Section 2.00A8, What are our
requirements for an acceptable
perimeter?
We propose to move the guidance on
acceptable perimeters in current
2.00A6a(ii)A–F to proposed section
2.00A8 because perimeter
manufacturers must provide us with the
evidence that their automated static
threshold perimeter(s) meet these
requirements before we can use any
results of visual field testing performed
on their perimeters to evaluate visual
field loss. Although we are not
proposing to change these requirements,
we believe placing them at the end of
the introductory text will allow
adjudicators to more quickly access the
guidance on visual field testing
requirements that are applicable to
testing performed on all acceptable
perimeters. We would also remove the
reference to the HFA because acceptable
perimeters may change over time and
we do not want to appear to be giving
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7551
preference in our rules to one
manufacturer over another.
Other Changes
We propose to remove 2.00A8b,
which describes blepharospasm,
because it does not provide useful
guidance to adjudicators on how to
evaluate vision loss due to
blepharospasm and has led to repeated
questions from our adjudicators. As we
explained earlier with cortical visual
disorders, we intend to provide
guidance for evaluating a person’s
vision loss due to blepharospasm and
any other visual disorders that may
result in vision loss or a loss in visual
functioning in our internal operating
instructions and training.
What changes are we proposing to the
listings for evaluating visual disorders
in adults?
In the following paragraphs, we
describe the substantive changes to the
adult listings for evaluating visual
disorders in part A of appendix 1 to
subpart P of part 404. We propose to:
• Add 2.04A to evaluate visual
efficiency determined using the MD
from acceptable automated static
threshold perimetry.
• Redesignate current 2.04, which we
use to evaluate visual efficiency
determined by kinetic perimetry, as
proposed 2.04B.
What changes are we proposing to the
introductory text and listings for
evaluating visual disorders in children?
We propose to clarify, simplify, and
reorganize the introductory text in the
childhood rules as in the adult rules.
Since these are conforming changes, we
do not summarize them here. We also
propose to move the examples in
current 102.00A5b(iii) to proposed
102.02B. We believe it is more helpful
to adjudicators to include these
examples directly in the listing to which
they apply.
What is our authority to make rules
and set procedures for determining
whether a person is disabled under the
statutory definition?
The Act authorizes us to make rules
and regulations and to establish
necessary and appropriate procedures to
implement them. Sections 205(a),
702(a)(5), and 1631(d)(1).
How long would these proposed rules
be effective?
If we publish these proposed rules as
final rules, they will remain in effect for
5 years after the date they become
effective, unless we extend them, or
revise and issue them again.
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Clarity of These Proposed Rules
Executive Order 12866, as
supplemented by Executive Order
13563, requires each agency to write all
rules in plain language. In addition to
your substantive comments on these
proposed rules, we invite your
comments on how to make them easier
to understand.
For example:
• Would more, but shorter sections be
better?
• Are the requirements in the rules
clearly stated?
• Have we organized the material to
suit your needs?
• Could we improve clarity by adding
more tables, lists, or diagrams?
• What else could we do to make the
rules easier to understand?
• Do the rules contain technical
language or jargon that is not clear?
• Would a different format make the
rules easier to understand, e.g., grouping
and order of sections, use of headings,
paragraphing?
When will we start to use these rules?
We will not use these rules until we
evaluate public comments and publish
final rules in the Federal Register. All
final rules we issue include an effective
date. We will continue to use our
current rules until that date. If we
publish final rules, we will include a
summary of those relevant comments
we received along with responses and
an explanation of how we will apply the
new rules.
Regulatory Procedures
Executive Order 12866, as
Supplemented by Executive Order
13563
We have consulted with the Office of
Management and Budget (OMB) and
determined that this NPRM meets the
criteria for a significant regulatory
action under Executive Order 12866, as
supplemented by Executive Order
13563. Therefore, OMB reviewed it.
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Regulatory Flexibility Act
We certify that these proposed rules
will not have a significant economic
impact on a substantial number of small
entities because they affect individuals
only. Therefore, a regulatory flexibility
analysis is not required under the
Regulatory Flexibility Act, as amended.
Paperwork Reduction Act
These proposed rules do not create
any new or affect any existing
collections and, therefore, do not
require OMB approval under the
Paperwork Reduction Act.
(Catalog of Federal Domestic Assistance
Program Nos. 96.001, Social Security—
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14:45 Feb 10, 2012
Jkt 226001
Disability Insurance; 96.002, Social
Security—Retirement Insurance; 96.004,
Social Security—Survivors Insurance; and
96.006, Supplemental Security Income)
List of Subjects in 20 CFR Part 404
Administrative practice and
procedure; Blind, Disability benefits;
Old-age, survivors, and disability
insurance; Reporting and recordkeeping
requirements; Social Security.
Michael J. Astrue,
Commissioner of Social Security.
For the reasons set out in the
preamble, we propose to amend 20 CFR
chapter III, part 404, subpart P as set
forth below:
PART 404—FEDERAL OLD-AGE,
SURVIVORS AND DISABILITY
INSURANCE (1950–)
Subpart P—[Amended]
1. The authority citation for subpart P
of part 404 continues to read as follows:
Authority: Secs. 202, 205(a)–(b) and (d)–
(h), 216(i), 221(a), (i), and (j), 222(c), 223,
225, and 702(a)(5) of the Social Security Act
(42 U.S.C. 402, 405(a)–(b) and (d)–(h), 416(i),
421(a), (i), and (j), 422(c), 423, 425, and
902(a)(5)); sec. 211(b), Pub. L. 104–193, 110
Stat. 2105, 2189; sec. 202, Pub. L. 108–203,
118 Stat. 509 (42 U.S.C. 902 note).
2. Amend appendix 1 to subpart P of
part 404 by:
a. Revising item 3 of the introductory
text before part A;
b. Revising section 2.00A and sections
2.01 through 2.04 in part A; and
c. Revising section 102.00A and
sections 102.01 through 102.04 in part
B.
The revisions read as follows:
APPENDIX 1 TO SUBPART P OF PART
404—LISTING OF IMPAIRMENTS
*
*
*
*
*
3. Special Senses and Speech (2.00 and
102.00): [Insert date 5 years from the effective
date of the final rules].
*
*
*
*
*
*
*
*
Part A
*
*
2.00 Special Senses and Speech
A. How do we evaluate visual disorders?
1. What are visual disorders? Visual
disorders are abnormalities of the eye, the
optic nerve, the optic tracts, or the brain that
may cause a loss of visual acuity or visual
fields. A loss of visual acuity limits your
ability to distinguish detail, read, or do fine
work. A loss of visual fields limits your
ability to perceive visual stimuli in the
peripheral extent of vision.
2. How do we define statutory blindness?
Statutory blindness is blindness as defined in
sections 216(i)(1) and 1614(a)(2) of the Social
Security Act (Act).
a. The Act defines blindness as central
visual acuity of 20/200 or less in the better
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eye with the use of a correcting lens. We use
your best-corrected central visual acuity for
distance in the better eye when we determine
if this definition is met. (For visual acuity
testing requirements, see 2.00A5.)
b. The Act also provides that an eye that
has a visual field limitation such that the
widest diameter of the visual field subtends
an angle no greater than 20 degrees is
considered as having a central visual acuity
of 20/200 or less. (For visual field testing
requirements, see 2.00A6.)
c. You have statutory blindness only if
your visual disorder meets the criteria of 2.02
or 2.03A. In order to find that you have
statutory blindness under the law for a
period of disability and for payment of
disability insurance benefits, your blindness
under 2.02 or 2.03A must also meet the
duration requirement (see §§ 404.1509 and
404.1581). You do not have statutory
blindness if your visual disorder medically
equals the criteria of 2.02 or 2.03A or meets
or medically equals the criteria of 2.03B,
2.03C, 2.04A, or 2.04B because your
disability is based on criteria other than those
in the statutory definition of blindness. If
your visual disorder medically equals the
criteria of 2.02 or 2.03A or meets or
medically equals the criteria of 2.03B, 2.03C,
2.04A, or 2.04B, we will find that you are
under a disability if your visual disorder also
meets the duration requirement (see
§§ 404.1509 and 416.909 of this chapter).
3. What evidence do we need to establish
statutory blindness under title XVI? To
establish that you have statutory blindness
under title XVI, we need evidence showing
only that your central visual acuity in your
better eye or your visual field in your better
eye meets the criteria in 2.00A2, provided
that those measurements are consistent with
the other evidence in your case record. We
do not need documentation of the cause of
your blindness. Also, there is no duration
requirement for statutory blindness under
title XVI (see §§ 416.981 and 416.983 of this
chapter).
4. What evidence do we need to evaluate
visual disorders, including those that result
in statutory blindness under title II? To
evaluate your visual disorder, we usually
need a report of an eye examination that
includes measurements of your bestcorrected central visual acuity (see 2.00A5)
or the extent of your visual fields (see
2.00A6), as appropriate. If you have visual
acuity or visual field loss, we need
documentation of the cause of the loss. A
standard eye examination will usually
indicate the cause of any visual acuity loss.
An eye examination can also indicate the
cause of some types of visual field deficits.
Some disorders, such as cortical visual
disorders, may result in abnormalities that do
not appear on a standard eye examination. If
the eye examination does not indicate the
cause of your vision loss, we will request the
information the physician or optometrist
used to establish the presence of your visual
disorder. If your visual disorder does not
satisfy the criteria in 2.02, 2.03, or 2.04, we
will request a description of how your visual
disorder affects your ability to function.
5. How do we measure your best-corrected
central visual acuity?
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a. Visual acuity testing. When we need to
measure your best-corrected central visual
acuity, which is your optimal visual acuity
attainable with the use of a corrective lens,
we use visual acuity testing for distance that
was carried out using Snellen methodology
or any other testing methodology that is
comparable to Snellen methodology.
(i) Your best-corrected central visual acuity
for distance is usually measured by
determining what you can see from 20 feet.
If your visual acuity is measured for a
distance other than 20 feet, we will convert
it to a 20-foot measurement. For example, if
your visual acuity is measured at 10 feet and
is reported as 10/40, we will convert this
measurement to 20/80.
(ii) A visual acuity recorded as CF (counts
fingers), HM (hand motion only), LP or LPO
(light perception or light perception only), or
NLP (no light perception) indicates that no
optical correction will improve your visual
acuity. If your central visual acuity in an eye
is recorded as CF, HM, LP or LPO, or NLP,
we will determine that your best-corrected
central visual acuity is 20/200 or less in that
eye.
(iii) We will not use the results of pinhole
testing or automated refraction acuity to
determine your best-corrected central visual
acuity. These tests provide an estimate of
potential visual acuity but not an actual
measurement of your best-corrected central
visual acuity.
b. Other test charts. Most test charts that
use Snellen methodology do not have lines
that measure visual acuity between 20/100
and 20/200. Some test charts, such as the
Bailey-Lovie or the Early Treatment Diabetic
Retinopathy Study (ETDRS) used mostly in
research settings, have such lines. If your
visual acuity is measured with one of these
charts, and you cannot read any of the letters
on the 20/100 line, we will determine that
you have statutory blindness based on a
visual acuity of 20/200 or less. For example,
if your best-corrected central visual acuity for
distance in the better eye is 20/160 using an
ETDRS chart, we will find that you have
statutory blindness. Regardless of the type of
test chart used, you do not have statutory
blindness if you can read at least one letter
on the 20/100 line. For example, if your bestcorrected central visual acuity for distance in
the better eye is 20/125+1 using an ETDRS
chart, we will find that you do not have
statutory blindness because you are able to
read one letter on the 20/100 line.
c. Testing using a specialized lens. In some
instances, you may perform visual acuity
testing using a specialized lens; for example,
a contact lens. We will use the visual acuity
measurements obtained with a specialized
lens only if you have demonstrated the
ability to use the specialized lens on a
sustained basis. We will not use visual acuity
measurements obtained with telescopic
lenses because they significantly reduce the
visual field.
d. Cycloplegic refraction. Cycloplegic
refraction, which measures your visual acuity
in the absence of accommodation (focusing
ability) after the eye has been dilated, is not
part of a routine eye examination because it
is not needed to determine your bestcorrected central visual acuity. If your case
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record contains the results of cycloplegic
refraction, we may use the results to
determine your best-corrected central visual
acuity. We will not purchase cycloplegic
refraction.
e. Visual evoked response (VER) testing.
VER testing measures your response to visual
events and can often detect dysfunction that
is undetectable through other types of
examinations. If you have an absent response
to VER testing in your better eye, we will
determine that your best-corrected central
visual acuity is 20/200 or less in that eye and
that your visual acuity loss satisfies the
criterion in 2.02, when these test results are
consistent with the other evidence in your
case record. If you have a positive response
to VER testing in an eye, we will not use that
result to determine your best-corrected
central visual acuity in that eye.
6. How do we measure your visual fields?
a. General. We generally need visual field
testing when you have a visual disorder that
could result in visual field loss, such as
glaucoma, retinitis pigmentosa, or optic
neuropathy, or when you display behaviors
that suggest a visual field loss. When we
need to measure the extent of your visual
field loss, we use visual field testing (also
referred to as perimetry) carried out using
automated static threshold perimetry
performed on an acceptable perimeter (for
perimeter requirements, see 2.00A8).
b. Automated static threshold perimetry
requirements.
(i) The test must use a white size III
Goldmann stimulus and a 31.5 apostilb (asb)
white background (or a 10 candela per square
meter (cd/m2) white background). The
stimuli test locations must be no more than
6 degrees apart horizontally or vertically.
Measurements must be reported on standard
charts and include a description of the size
and intensity of the test stimulus.
(ii) We measure the extent of your visual
field loss by determining the portion of the
visual field in which you can see a white
III4e stimulus. The ‘‘III’’ refers to the
standard Goldmann test stimulus size III (4
mm2), and the ‘‘4e’’ refers to the standard
Goldmann intensity filter (0 dB attenuation,
which allows presentation of the maximum
luminance) used to determine the intensity of
the stimulus.
(iii) In automated static threshold
perimetry, the intensity of the stimulus
varies. The intensity of the stimulus is
expressed in decibels (dB). A perimeter’s
maximum stimulus luminance is usually
assigned the value 0 dB. We need to
determine the dB level that corresponds to a
4e intensity for the particular perimeter being
used. We will then use the dB printout to
determine which points you see at a 4e
intensity level (a ‘‘seeing point’’). For
example:
A. When the maximum stimulus
luminance (0 dB stimulus) on an acceptable
perimeter is 10,000 asb, a 10 dB stimulus is
equivalent to a 4e stimulus. Any point you
see at 10 dB or greater is a seeing point.
B. When the maximum stimulus
luminance (0 dB stimulus) on an acceptable
perimeter is 4,000 asb, a 6 dB stimulus is
equivalent to a 4e stimulus. Any point you
see at 6 dB or greater is a seeing point.
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c. Evaluation under 2.03A. To determine
statutory blindness based on visual field loss
in your better eye (2.03A), we need the
results of a visual field test that measures the
central 24 to 30 degrees of your visual field;
that is, the area measuring 24 to 30 degrees
from the point of fixation. Acceptable tests
include the Humphrey Field Analyzer (HFA)
30–2, HFA 24–2, and Octopus 32.
d. Evaluation under 2.03B. To determine
whether your visual field loss meets listing
2.03B, we use the mean deviation or defect
(MD) from acceptable automated static
threshold perimetry that measures the central
30 degrees of the visual field. MD is the
average sensitivity deviation from normal
values for all measured visual field locations
within the central 30 degrees of the field.
When using results from HFA tests, which
report the MD as a negative number, we use
the absolute value of the MD to determine
whether your visual field loss meets listing
2.03B. We cannot use tests that do not
measure the central 30 degrees of the visual
field, such as the HFA 24–2, to determine if
your impairment meets or medically equals
2.03B.
e. Other types of perimetry. If your case
record contains visual field measurements
obtained using manual or automated kinetic
perimetry, such as Goldmann perimetry or
the HFA ‘‘SSA Test Kinetic,’’ we can
generally use these results if the kinetic test
was performed using a white III4e stimulus
projected on a white 31.5 asb (10 cd/m2)
background. Automated kinetic perimetry,
such as the HFA ‘‘SSA Test Kinetic,’’ does
not detect limitations in the central visual
field because testing along a meridian stops
when you see the stimulus. If your visual
disorder has progressed to the point at which
it is likely to result in a significant limitation
in the central visual field, such as a scotoma
(see 2.00A6h), we will not use automated
kinetic perimetry to determine the extent of
your visual field loss. Instead, we will
determine the extent of your visual field loss
using automated static threshold perimetry or
manual kinetic perimetry.
f. Screening tests. We will not use the
results of visual field screening tests, such as
confrontation tests, tangent screen tests, or
automated static screening tests, to determine
that your impairment meets or medically
equals a listing or to evaluate your residual
functional capacity. We can consider normal
results from visual field screening tests to
determine whether your visual disorder is
severe when these test results are consistent
with the other evidence in your case record.
(See §§ 404.1520(c), 404.1521, 416.920(c),
and 416.921 of this chapter.) We will not
consider normal test results to be consistent
with the other evidence if the clinical
findings indicate that your visual disorder
has progressed to the point that it is likely
to cause visual field loss, or you have a
history of an operative procedure for retinal
detachment.
g. Use of corrective lenses. You must not
wear eyeglasses during visual field testing
because they limit your field of vision. You
may wear contact lenses or perimetric lenses
to correct your visual acuity during the visual
field test to obtain the most accurate visual
field measurements. For this single purpose,
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you do not need to demonstrate that you
have the ability to use the contact or
perimetric lenses on a sustained basis.
h. Scotoma. A scotoma is a non-seeing area
(also referred to as a blind spot) in the visual
field surrounded by a seeing area. When we
measure your visual field, we subtract the
length of any scotoma, other than the normal
blind spot, from the overall length of any
diameter on which it falls.
7. How do we determine your visual acuity
efficiency, visual field efficiency, and visual
efficiency?
a. General. Visual efficiency is the
combination of your visual acuity efficiency
and your visual field efficiency expressed as
a value or as a percentage.
b. Visual acuity efficiency. Visual acuity
efficiency is a value or a percentage that
corresponds to the best-corrected central
visual acuity for distance in your better eye.
See Table 1.
TABLE 1
Snellen best-corrected central
visual acuity for distance
English
Metric
20/16 ...........................................................................
20/20 ...........................................................................
20/25 ...........................................................................
20/30 ...........................................................................
20/40 ...........................................................................
20/50 ...........................................................................
20/60 ...........................................................................
20/70 ...........................................................................
20/80 ...........................................................................
20/100 .........................................................................
0.00
0.00
0.10
0.18
0.30
0.40
0.48
0.54
0.60
0.70
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
100
100
95
90
85
75
70
65
60
50
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perimetry, we calculate the visual field
efficiency value by dividing the absolute
value of the MD by 22. For example, if your
MD on an HFA 30–2 is ¥16, your visual field
efficiency value is: |¥16| ÷ 22 = 0.73.
(ii) Percentage determined by kinetic
perimetry. Using kinetic perimetry, we
calculate the visual field efficiency
percentage by adding the number of degrees
you see along the eight principal meridians
found on a visual field chart (0, 45, 90, 135,
180, 225, 270, and 315) in your better eye and
dividing by 5. For example, in Figure 1:
A. The diagram of the left eye illustrates a
visual field, as measured with a III4e
stimulus, contracted to 30 degrees in two
meridians (180 and 225) and to 20 degrees in
the remaining six meridians. The visual
efficiency percentage of this field is: ((2 × 30)
+ (6 × 20)) ÷ 5 = 36 percent.
B. The diagram of the right eye illustrates
the extent of a normal visual field as
measured with a III4e stimulus. The sum of
the eight principal meridians of this field is
500 degrees. The visual efficiency percentage
of this field is 500 ÷ 5 = 100 percent.
(i) Determined by automated static
threshold perimetry (2.04A). Under 2.04A,
d. Visual efficiency.
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6/5
6/6
6/7.5
6/9
6/12
6/15
6/18
6/21
6/24
6/30
Visual acuity
efficiency
percentage
(2.04B)
we calculate the visual efficiency value by
adding your visual acuity efficiency value
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c. Visual field efficiency. Visual field
efficiency is a value or a percentage that
corresponds to the visual field in your better
eye. Under 2.03C, we require kinetic
perimetry to determine your visual field
efficiency percentage. (A visual field
efficiency percentage of 20, determined using
kinetic perimetry, is comparable to an MD of
22, determined using automated static
threshold perimetry.)
(i) Value determined by automated static
threshold perimetry. Using the MD from
acceptable automated static threshold
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Visual acuity
efficiency
value
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(see 2.00A7b) and your visual field efficiency
value (see 2.00A7c(i)). For example, if your
visual acuity efficiency value is 0.48 and
your visual field efficiency value is 0.73,
your visual efficiency value is: 0.48 + 0.73 =
1.21.
(ii) Determined by kinetic perimetry
(2.04B). Under 2.04B, we calculate the visual
efficiency percentage by multiplying your
visual acuity efficiency percentage (see
2.00A7b) by your visual field efficiency
percentage (see 2.00A7c(ii)) and dividing by
100. For example, if your visual acuity
efficiency percentage is 75 and your visual
field efficiency percentage is 36, your visual
efficiency percentage is: (75 × 36) ÷ 100 = 27
percent.
8. What are our requirements for an
acceptable perimeter? We will use results
from automated static threshold perimetry
performed on a perimeter that:
a. Uses optical projection to generate the
test stimuli.
b. Has an internal normative database for
automatically comparing your performance
with that of the general population.
c. Has a statistical analysis package that is
able to calculate visual field indices,
particularly mean deviation or mean defect.
d. Demonstrates the ability to correctly
detect visual field loss and correctly identify
normal visual fields.
e. Demonstrates good test-retest reliability.
f. Has undergone clinical validation studies
by three or more independent laboratories
with results published in peer-reviewed
ophthalmic journals.
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2.01 Category of Impairments, Special
Senses and Speech
2.02 Loss of central visual acuity.
Remaining vision in the better eye after best
correction is 20/200 or less.
2.03 Contraction of the visual field in the
better eye, with:
A. The widest diameter subtending an
angle around the point of fixation no greater
than 20 degrees.
OR
B. An MD of 22 decibels or greater,
determined by automated static threshold
perimetry that measures the central 30
degrees of the visual field (see 2.00A6d).
OR
C. A visual field efficiency of 20 percent
or less, determined by kinetic perimetry (see
2.00A7c).
2.04 Loss of visual efficiency in the better
eye, with:
A. A visual efficiency value of 1.00 or
greater after best correction (see 2.00A7d(i)).
OR
B. A visual efficiency percentage of 20 or
less after best correction (see 2.00A7d(ii)).
*
*
*
*
*
*
*
*
*
Part B
*
102.00 Special Senses and Speech
A. How do we evaluate visual disorders?
1. What are visual disorders? Visual
disorders are abnormalities of the eye, the
optic nerve, the optic tracts, or the brain that
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may cause a loss of visual acuity or visual
fields. A loss of visual acuity limits your
ability to distinguish detail, read, do fine
work, or perform other age-appropriate
activities. A loss of visual fields limits your
ability to perceive visual stimuli in the
peripheral extent of vision.
2. How do we define statutory blindness?
Statutory blindness is blindness as defined in
sections 216(i)(1) and 1614(a)(2) of the Social
Security Act (Act).
a. The Act defines blindness as central
visual acuity of 20/200 or less in the better
eye with the use of a correcting lens. We use
your best-corrected central visual acuity for
distance in the better eye when we determine
if this definition is met. (For visual acuity
testing requirements, see 102.00A5.)
b. The Act also provides that an eye that
has a visual field limitation such that the
widest diameter of the visual field subtends
an angle no greater than 20 degrees is
considered as having a central visual acuity
of 20/200 or less. (For visual field testing
requirements, see 102.00A6.)
c. You have statutory blindness only if
your visual disorder meets the criteria of
102.02A, 102.02B, or 102.03A. You do not
have statutory blindness if your visual
disorder medically equals the criteria of
102.02A, 102.02B, or 102.03A or meets or
medically equals the criteria of 102.03B,
102.03C, 102.04A, or 102.04B because your
disability is based on criteria other than those
in the statutory definition of blindness. If
your visual disorder medically equals the
criteria of 102.02A, 102.02B, or 102.03A or
meets or medically equals the criteria of
102.03B, 102.03C, 102.04A, or 102.04B, we
will find that you are under a disability if
your visual disorder also meets the duration
requirement (see § 416.909 of this chapter).
3. What evidence do we need to establish
statutory blindness under title XVI? To
establish that you have statutory blindness
under title XVI, we need evidence showing
only that your central visual acuity in your
better eye or your visual field in your better
eye meets the criteria in 102.00A2, provided
that those measurements are consistent with
the other evidence in your case record. We
do not need documentation of the cause of
your blindness. Also, there is no duration
requirement for statutory blindness under
title XVI (see §§ 416.981 and 416.983 of this
chapter).
4. What evidence do we need to evaluate
visual disorders, including those that result
in statutory blindness under title II? To
evaluate your visual disorder, we usually
need a report of an eye examination that
includes measurements of your bestcorrected central visual acuity (see 102.00A5)
or the extent of your visual fields (see
102.00A6), as appropriate. If you have visual
acuity or visual field loss, we need
documentation of the cause of the loss. A
standard eye examination will usually
indicate the cause of any visual acuity loss.
An eye examination can also indicate the
cause of some types of visual field deficits.
Some disorders, such as cortical visual
disorders, may result in abnormalities that do
not appear on a standard eye examination. If
the eye examination does not indicate the
cause of your vision loss, we will request the
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information the physician or optometrist
used to establish the presence of your visual
disorder. If your visual disorder does not
satisfy the criteria in 102.02, 102.03, or
102.04, we will request a description of how
your visual disorder affects your ability to
function.
5. How do we measure your best-corrected
central visual acuity?
a. Visual acuity testing. When we need to
measure your best-corrected central visual
acuity, which is your optimal visual acuity
attainable with the use of a corrective lens,
we use visual acuity testing for distance that
was carried out using Snellen methodology
or any other testing methodology that is
comparable to Snellen methodology.
(i) Your best-corrected central visual acuity
for distance is usually measured by
determining what you can see from 20 feet.
If your visual acuity is measured for a
distance other than 20 feet, we will convert
it to a 20-foot measurement. For example, if
your visual acuity is measured at 10 feet and
is reported as 10/40, we will convert this
measurement to 20/80.
(ii) A visual acuity recorded as CF (counts
fingers), HM (hand motion only), LP or LPO
(light perception or light perception only), or
NLP (no light perception) indicates that no
optical correction will improve your visual
acuity. If your central visual acuity in an eye
is recorded as CF, HM, LP or LPO, or NLP,
we will determine that your best-corrected
central visual acuity is 20/200 or less in that
eye.
(iii) We will not use the results of pinhole
testing or automated refraction acuity to
determine your best-corrected central visual
acuity. These tests provide an estimate of
potential visual acuity but not an actual
measurement of your best-corrected central
visual acuity.
(iv) Very young children, such as infants
and toddlers, cannot participate in testing
using Snellen methodology or other
comparable testing. If you are unable to
participate in testing using Snellen
methodology or other comparable testing, we
will consider clinical findings of your
fixation and visual-following behavior. If
both these behaviors are absent, we will
consider the anatomical findings or the
results of neuroimaging, electroretinogram, or
visual evoked response (VER) testing when
this testing has been performed.
b. Other test charts.
(i) Children between the ages of 3 and 5
often cannot identify the letters on a Snellen
or other letter test chart. Specialists with
expertise in assessment of childhood vision
use alternate methods for measuring visual
acuity in young children. We consider
alternate methods, for example, the Landolt
C test or the tumbling-E test, which are used
to evaluate young children who are unable to
participate in testing using Snellen
methodology, to be comparable to testing
using Snellen methodology.
(ii) Most test charts that use Snellen
methodology do not have lines that measure
visual acuity between 20/100 and 20/200.
Some test charts, such as the Bailey-Lovie or
the Early Treatment Diabetic Retinopathy
Study (ETDRS) used mostly in research
settings, have such lines. If your visual acuity
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is measured with one of these charts, and you
cannot read any of the letters on the 20/100
line, we will determine that you have
statutory blindness based on a visual acuity
of 20/200 or less. For example, if your bestcorrected central visual acuity for distance in
the better eye is 20/160 using an ETDRS
chart, we will find that you have statutory
blindness. Regardless of the type of test chart
used, you do not have statutory blindness if
you can read at least one letter on the 20/100
line. For example, if your best-corrected
central visual acuity for distance in the better
eye is 20/125+1 using an ETDRS chart, we
will find that you do not have statutory
blindness because you are able to read one
letter on the 20/100 line.
c. Testing using a specialized lens. In some
instances, you may perform visual acuity
testing using a specialized lens; for example,
a contact lens. We will use the visual acuity
measurements obtained with a specialized
lens only if you have demonstrated the
ability to use the specialized lens on a
sustained basis. We will not use visual acuity
measurements obtained with telescopic
lenses because they significantly reduce the
visual field.
d. Cycloplegic refraction. Cycloplegic
refraction, which measures your visual acuity
in the absence of accommodation (focusing
ability) after the eye has been dilated, is not
part of a routine eye examination because it
is not needed to determine your bestcorrected central visual acuity. It can be
useful for determining refractive error and
visual acuity in some children. If your case
record contains the results of cycloplegic
refraction, we may use the results to
determine your best-corrected central visual
acuity. We will not purchase cycloplegic
refraction.
e. VER testing. VER testing measures your
response to visual events and can often
detect dysfunction that is undetectable
through other types of examinations. If you
have an absent response to VER testing in
your better eye, we will determine that your
best-corrected central visual acuity is 20/200
or less in that eye and that your visual acuity
loss satisfies the criterion in 102.02A or
102.02B4, as appropriate, when these test
results are consistent with the other evidence
in your case record. If you have a positive
response to VER testing in an eye, we will
not use that result to determine your bestcorrected central visual acuity in that eye.
6. How do we measure your visual fields?
a. General. We generally need visual field
testing when you have a visual disorder that
could result in visual field loss, such as
glaucoma, retinitis pigmentosa, or optic
neuropathy, or when you display behaviors
that suggest a visual field loss. When we
need to measure the extent of your visual
field loss, we use visual field testing (also
referred to as perimetry) carried out using
automated static threshold perimetry
performed on an acceptable perimeter (for
perimeter requirements, see 102.00A8).
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b. Automated static threshold perimetry
requirements.
(i) The test must use a white size III
Goldmann stimulus and a 31.5 apostilb (asb)
white background (or a 10 candela per square
meter (cd/m2) white background). The
stimuli test locations must be no more than
6 degrees apart horizontally or vertically.
Measurements must be reported on standard
charts and include a description of the size
and intensity of the test stimulus.
(ii) We measure the extent of your visual
field loss by determining the portion of the
visual field in which you can see a white
III4e stimulus. The ‘‘III’’ refers to the
standard Goldmann test stimulus size III (4
mm2), and the ‘‘4e’’ refers to the standard
Goldmann intensity filter (0 dB attenuation,
which allows presentation of the maximum
luminance) used to determine the intensity of
the stimulus.
(iii) In automated static threshold
perimetry, the intensity of the stimulus
varies. The intensity of the stimulus is
expressed in decibels (dB). A perimeter’s
maximum stimulus luminance is usually
assigned the value 0 dB. We need to
determine the dB level that corresponds to a
4e intensity for the particular perimeter being
used. We will then use the dB printout to
determine which points you see at a 4e
intensity level (a ‘‘seeing point’’). For
example:
A. When the maximum stimulus
luminance (0 dB stimulus) on an acceptable
perimeter is 10,000 asb, a 10 dB stimulus is
equivalent to a 4e stimulus. Any point you
see at 10 dB or greater is a seeing point.
B. When the maximum stimulus
luminance (0 dB stimulus) on an acceptable
perimeter is 4,000 asb, a 6 dB stimulus is
equivalent to a 4e stimulus. Any point you
see at 6 dB or greater is a seeing point.
c. Evaluation under 102.03A. To determine
statutory blindness based on visual field loss
in your better eye (102.03A), we need the
results of a visual field test that measures the
central 24 to 30 degrees of your visual field;
that is, the area measuring 24 to 30 degrees
from the point of fixation. Acceptable tests
include the Humphrey Field Analyzer (HFA)
30–2, HFA 24–2, and Octopus 32.
d. Evaluation under 102.03B. To determine
whether your visual field loss meets listing
102.03B, we use the mean deviation or defect
(MD) from acceptable automated static
threshold perimetry that measures the central
30 degrees of the visual field. MD is the
average sensitivity deviation from normal
values for all measured visual field locations
within the central 30 degrees of the field.
When using results from HFA tests, which
report the MD as a negative number, we use
the absolute value of the MD to determine
whether your visual field loss meets listing
102.03B. We cannot use tests that do not
measure the central 30 degrees of the visual
field, such as the HFA 24–2, to determine if
your impairment meets or medically equals
102.03B.
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e. Other types of perimetry. If your case
record contains visual field measurements
obtained using manual or automated kinetic
perimetry, such as Goldmann perimetry or
the HFA ‘‘SSA Test Kinetic,’’ we can
generally use these results if the kinetic test
was performed using a white III4e stimulus
projected on a white 31.5 asb (10 cd/m2)
background. Automated kinetic perimetry,
such as the HFA ‘‘SSA Test Kinetic,’’ does
not detect limitations in the central visual
field because testing along a meridian stops
when you see the stimulus. If your visual
disorder has progressed to the point at which
it is likely to result in a significant limitation
in the central visual field, such as a scotoma
(see 102.00A6h), we will not use automated
kinetic perimetry to determine the extent of
your visual field loss. Instead, we will
determine the extent of your visual field loss
using automated static threshold perimetry or
manual kinetic perimetry.
f. Screening tests. We will not use the
results of visual field screening tests, such as
confrontation tests, tangent screen tests, or
automated static screening tests, to determine
that your impairment meets or medically
equals a listing, or functionally equals the
listings. We can consider normal results from
visual field screening tests to determine
whether your visual disorder is severe when
these test results are consistent with the other
evidence in your case record. (See
§ 416.924(c) of this chapter.) We will not
consider normal test results to be consistent
with the other evidence if the clinical
findings indicate that your visual disorder
has progressed to the point that it is likely
to cause visual field loss, or you have a
history of an operative procedure for retinal
detachment.
g. Use of corrective lenses. You must not
wear eyeglasses during visual field testing
because they limit your field of vision. You
may wear contact lenses or perimetric lenses
to correct your visual acuity during the visual
field test to obtain the most accurate visual
field measurements. For this single purpose,
you do not need to demonstrate that you
have the ability to use the contact or
perimetric lenses on a sustained basis.
h. Scotoma. A scotoma is a non-seeing area
(also referred to as a blind spot) in the visual
field surrounded by a seeing area. When we
measure your visual field, we subtract the
length of any scotoma, other than the normal
blind spot, from the overall length of any
diameter on which it falls.
7. How do we determine your visual acuity
efficiency, visual field efficiency, and visual
efficiency?
a. General. Visual efficiency is the
combination of your visual acuity efficiency
and your visual field efficiency expressed as
a value or as a percentage.
b. Visual acuity efficiency. Visual acuity
efficiency is a value or a percentage that
corresponds to the best-corrected central
visual acuity for distance in your better eye.
See Table 1.
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7557
TABLE 1
Snellen best-corrected central
visual acuity for distance
English
Visual acuity
efficiency
value
(102.04A)
Metric
20/16 ...........................................................................
20/20 ...........................................................................
20/25 ...........................................................................
20/30 ...........................................................................
20/40 ...........................................................................
20/50 ...........................................................................
20/60 ...........................................................................
20/70 ...........................................................................
20/80 ...........................................................................
20/100 .........................................................................
6/5
6/6
6/7.5
6/9
6/12
6/15
6/18
6/21
6/24
6/30
0.00
0.00
0.10
0.18
0.30
0.40
0.48
0.54
0.60
0.70
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
............................................................................
Visual acuity
efficiency
percentage
(102.04B)
100
100
95
90
85
75
70
65
60
50
perimetry, we calculate the visual field
efficiency value by dividing the absolute
value of the MD by 22. For example, if your
MD on an HFA 30–2 is ¥16, your visual field
efficiency value is: |¥16| ÷ 22 = 0.73.
(ii) Percentage determined by kinetic
perimetry. Using kinetic perimetry, we
calculate the visual field efficiency
percentage by adding the number of degrees
you see along the eight principal meridians
found on a visual field chart (0, 45, 90, 135,
180, 225, 270, and 315) in your better eye and
dividing by 5. For example, in Figure 1:
A. The diagram of the left eye illustrates a
visual field, as measured with a III4e
stimulus, contracted to 30 degrees in two
meridians (180 and 225) and to 20 degrees in
the remaining six meridians. The visual
efficiency percentage of this field is: ((2 × 30)
+ (6 × 20)) ÷ 5 = 36 percent.
B. The diagram of the right eye illustrates
the extent of a normal visual field as
measured with a III4e stimulus. The sum of
the eight principal meridians of this field is
500 degrees. The visual efficiency percentage
of this field is 500 ÷ 5 = 100 percent.
d. Visual efficiency.
(i) Determined by automated static
threshold perimetry (102.04A). Under
102.04A, we calculate the visual efficiency
value by adding your visual acuity efficiency
value (see 102.00A7b) and your visual field
efficiency value (see 102.00A7c(i)). For
example, if your visual acuity efficiency
value is 0.48 and your visual field efficiency
value is 0.73, your visual efficiency value is:
0.48 + 0.73 = 1.21.
(ii) Determined by kinetic perimetry
(102.04B). Under 102.04B, we calculate the
visual efficiency percentage by multiplying
your visual acuity efficiency percentage (see
102.00A7b) by your visual field efficiency
percentage (see 102.00A7c(ii)) and dividing
by 100. For example, if your visual acuity
efficiency percentage is 75 and your visual
field efficiency percentage is 36, your visual
efficiency percentage is: (75 × 36) ÷ 100 = 27
percent.
8. What are our requirements for an
acceptable perimeter? We will use results
from automated static threshold perimetry
performed on a perimeter that:
a. Uses optical projection to generate the
test stimuli.
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c. Visual field efficiency. Visual field
efficiency is a value or a percentage that
corresponds to the visual field in your better
eye. Under 102.03C, we require kinetic
perimetry to determine your visual field
efficiency percentage. (A visual field
efficiency percentage of 20, determined using
kinetic perimetry, is comparable to an MD of
22, determined using automated static
threshold perimetry.)
(i) Value determined by automated static
threshold perimetry. Using the MD from
acceptable automated static threshold
7558
Federal Register / Vol. 77, No. 29 / Monday, February 13, 2012 / Proposed Rules
b. Has an internal normative database for
automatically comparing your performance
with that of the general population.
c. Has a statistical analysis package that is
able to calculate visual field indices,
particularly mean deviation or mean defect.
d. Demonstrates the ability to correctly
detect visual field loss and correctly identify
normal visual fields.
e. Demonstrates good test-retest reliability.
f. Has undergone clinical validation studies
by three or more independent laboratories
with results published in peer-reviewed
ophthalmic journals.
DEPARTMENT OF HOUSING AND
URBAN DEVELOPMENT
*
AGENCY:
*
*
*
*
erowe on DSK2VPTVN1PROD with PROPOSALS-1
102.01 Category of Impairments, Special
Senses and Speech
102.02 Loss of central visual acuity.
A. Remaining vision in the better eye after
best correction is 20/200 or less.
OR
B. An inability to participate in visual
acuity testing using Snellen methodology or
other comparable testing, clinical findings
that fixation and visual-following behavior
are absent in the better eye, and one of the
following:
1. Abnormal anatomical findings
indicating a visual acuity of 20/200 or less in
the better eye (such as the presence of Stage
III or worse retinopathy of prematurity
despite surgery, hypoplasia of the optic
nerve, albinism with macular aplasia, or
bilateral optic atrophy); or
2. Abnormal neuroimaging documenting
damage to the cerebral cortex which would
be expected to prevent the development of a
visual acuity better than 20/200 in the better
eye (such as neuroimaging showing bilateral
encephalomyelitis or bilateral
encephalomalacia); or
3. Abnormal electroretinogram
documenting the presence of Leber’s
congenital amaurosis or achromatopsia in the
better eye; or
4. An absent response to VER testing in the
better eye.
102.03 Contraction of the visual field in
the better eye, with:
A. The widest diameter subtending an
angle around the point of fixation no greater
than 20 degrees.
OR
B. An MD of 22 decibels or greater,
determined by automated static threshold
perimetry that measures the central 30
degrees of the visual field (see 102.00A6d).
OR
C. A visual field efficiency of 20 percent
or less, determined by kinetic perimetry (see
102.00A7c).
102.04 Loss of visual efficiency in the
better eye, with:
A. A visual efficiency value of 1.00 or
greater after best correction (see
102.00A7d(i)).
OR
B. A visual efficiency percentage of 20 or
less after best correction (see 102.00A7d(ii)).
*
*
*
*
*
[FR Doc. 2012–3226 Filed 2–10–12; 8:45 am]
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24 CFR Part 202
[Docket No. FR–5416–N–02]
RIN 2502–AI91
Withdrawal of Proposed Rule on
Approval of Farm Credit System
Lending Institutions in Federal
Housing Administration (FHA)
Mortgage Insurance Programs
Office of the Assistant
Secretary for Housing—Federal Housing
Commissioner, HUD.
ACTION: Withdrawal of proposed rule.
This notice withdraws HUD’s
August 2011 rule that proposed to
amend HUD’s regulations to enable the
direct lending institutions of the Farm
Credit System to seek approval to
participate in the FHA mortgage
insurance programs as approved
mortgagees and lenders.
DATES: The proposed rule is withdrawn
February 13, 2012.
FOR FURTHER INFORMATION CONTACT:
Office of Lender Activities and Program
Compliance, Department of Housing
and Urban Development, 451 7th Street
SW., Washington, DC 20410–8000;
telephone number 202–708–1515 (this
is not a toll-free number). Persons with
hearing or speech impairments may
access this number through TTY by
calling the toll-free Federal Information
Relay Service at 800–877–8339.
SUPPLEMENTARY INFORMATION:
SUMMARY:
I. Background
On August 26, 2011, at 76 FR 53362,
HUD published a proposed rule that
would enable the direct lending
institutions of the Farm Credit System
to seek approval to participate in the
FHA mortgage insurance programs as
FHA-approved mortgagees and lenders.
In the proposed rule, HUD noted that
recent difficulties in mortgage finance
markets indicated reduced availability
of housing credit in rural areas. HUD
therefore proposed to extend FHA
mortgagee and lender eligibility to the
lending institutions of the Farm Credit
System to provide an additional avenue
for mortgage financing in rural areas.
The Farm Credit System is a federally
chartered network of borrower-owned
lending institutions composed of
cooperatives and related service
organizations. The public comment
period for the proposed rule closed on
October 25, 2011. HUD received
approximately 27 substantive public
comments in response to the August 26,
2011, proposed rule. Certain comments
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were identical in substance, having been
submitted as part of mailing campaigns.
The public comments on this rule can
be found at https://www.regulations.gov/
#!searchResults;rpp=10;po=0;s=FR5416-P-01.
The commenters were almost evenly
divided in their support of and
opposition to the rule. Those
commenters that supported the rule
stated that there was indeed a need for
available housing credit in rural areas
and that allowing Farm Credit lending
institutions to be FHA-approved lenders
would aid in the necessary extension of
credit. The commenters stated that the
Farm Credit System has been a source
of consistent and reliable credit for rural
homeowners and that the ability to
provide the option of FHA programs to
families in rural areas will help ensure
that the borrowing needs of rural
families are met. Those commenters that
opposed the rule stated that there was
no need to expand FHA mortgage
availability to Farm Credit member
institutions; that the banking
community was satisfactorily meeting
the need for credit in rural areas. The
commenters opposing the rule also
stated that it was their view that
approval of Farm Credit lending
institutions to originate FHA insured
loans runs afoul of the Administration’s
proposal to reduce government
involvement in the housing finance
market.
Upon consideration of the issues
raised by public comments, HUD is
withdrawing the August 26, 2011,
proposed rule. While HUD seeks to
ensure the availability of mortgage
financing for qualified borrowers
nationwide—and particularly in
underserved areas—HUD and the
Administration remain committed to
reducing FHA’s market share and
facilitating the return of private capital
to the housing finance market.
Therefore, in concert with its network of
FHA-approved lending partners, FHA
will continue to monitor the adequacy
of mortgage credit in rural areas to
ensure that rural residents have access
to homeownership.
Accordingly, the proposed rule to
amend 24 CFR 202.10, published on
August 26, 2011, at 76 FR 53362,
entitled ‘‘Approval of Farm Credit
System Lending Institutions in FHA
Mortgage Insurance Programs,’’ is
hereby withdrawn.
Dated: February 7, 2012.
Carol J. Galante,
Acting Assistant Secretary for Housing—
Federal Housing Commissioner.
[FR Doc. 2012–3289 Filed 2–10–12; 8:45 am]
BILLING CODE 4210–67–P
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]]>Agencies
[Federal Register Volume 77, Number 29 (Monday, February 13, 2012)]
[Proposed Rules]
[Pages 7549-7558]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2012-3226]
=======================================================================
-----------------------------------------------------------------------
SOCIAL SECURITY ADMINISTRATION
20 CFR Part 404
[Docket No. SSA-2010-0078]
RIN 0960-AH28
Revised Medical Criteria for Evaluating Visual Disorders
AGENCY: Social Security Administration.
ACTION: Notice of proposed rulemaking.
-----------------------------------------------------------------------
SUMMARY: We propose to revise and reorganize the criteria in the
Listing of Impairments (listings) that we use to evaluate cases
involving visual disorders in adults and children under titles II and
XVI of the Social Security Act (Act). The proposed revisions reflect
our program experience and address adjudicator questions we have
received since we last revised these criteria in 2006. These proposed
revisions reflect guidance we have issued in response to adjudicator
questions and will ensure more timely adjudication of claims in which
we evaluate visual impairments that involve a loss of visual acuity or
loss of visual fields.
DATES: To ensure that your comments are considered, we must receive
them by no later than April 13, 2012.
ADDRESSES: You may submit comments by any one of three methods--
Internet, fax, or mail. Do not submit the same comments multiple times
or by more than one method. Regardless of which method you choose,
please state that your comments refer to Docket No. SSA-2010-0078 so
that we may
[[Page 7550]]
associate your comments with the correct regulation.
Caution: You should be careful to include in your comments only
information that you wish to make publicly available. We strongly urge
you not to include in your comments any personal information, such as
Social Security numbers or medical information.
1. Internet: We strongly recommend that you submit your comments
via the Internet. Visit the Federal eRulemaking portal at https://www.regulations.gov. Use the Search function to find docket number SSA-
2010-0078. The system will issue you a tracking number to confirm your
submission. You will not be able to view your comment immediately
because we must post each comment manually. It may take up to a week
for your comment to be viewable.
2. Fax: Fax comments to (410) 966-2830.
3. Mail: Address your comments to the Office of Regulations, Social
Security Administration, 107 Altmeyer Building, 6401 Security
Boulevard, Baltimore, Maryland 21235-6401.
Comments are available for public viewing on the Federal
eRulemaking portal at https://www.regulations.gov or in person, during
regular business hours, by arranging with the contact person identified
below.
FOR FURTHER INFORMATION CONTACT: Cheryl Williams, Office of Medical
Listings Improvement, Social Security Administration, 6401 Security
Boulevard, Baltimore, Maryland 21235-6401, (410) 965-1020. For
information on eligibility or filing for benefits, call our national
toll-free number, 1-800-772-1213 or TTY 1-800-325-0778, or visit our
Internet site, Social Security Online, at https://www.socialsecurity.gov.
SUPPLEMENTARY INFORMATION:
Why are we proposing to revise the listings for evaluating visual
disorders?
We last published final rules revising the criteria that we use to
evaluate visual disorders in the Federal Register on November 20,
2006.\1\ Although these listings do not expire until February 20, 2015,
we are proposing to revise them now to reflect our program experience
and to address adjudicator questions that we have received since 2006.
We intend to publish revisions that would update the criteria for
evaluating hearing disorders and speech and language disorders
separately.
---------------------------------------------------------------------------
\1\ 71 FR 67037.
---------------------------------------------------------------------------
What changes are we proposing to the introductory text of the adult
listings for evaluating visual disorders?
Most of the proposed introductory text is substantively the same as
the current introductory text. We propose to clarify, simplify, and
reorganize the introductory text. We also propose to expand some
sections to clarify the existing guidance and to include additional
acceptable testing for evaluating a person's visual field loss. In the
following paragraphs, we describe the significant changes we propose to
make to the introductory text of the adult listings for evaluating
visual disorders in part A of appendix 1 to subpart P of part 404,
using the titles of the proposed sections.
Section 2.00A2, How do we define statutory blindness?
In proposed 2.00A2a, we would add the word ``central'' before
``visual acuity'' to correct the definition of statutory blindness in
current 2.00A2. We would also add a reference to proposed 2.00A5, which
explains visual acuity testing requirements. In proposed 2.00A2b, we
would add a reference to proposed 2.00A6, which explains our visual
field testing requirements. In proposed 2.00A2c, we would add proposed
listings 2.04A and 2.04B to our guidance in current 2.00A2, which
explains that if your visual disorder medically equals the criteria of
2.02 or 2.03A, or meets or medically equals 2.03B, 2.03C, or 2.04, we
will find that you have a disability if your visual disorder also meets
the duration requirement.
Section 2.00A4, What evidence do we need to evaluate visual disorders,
including those that result in statutory blindness under title II?
In proposed 2.00A4, we would remove current 2.00A4b, which
describes cortical visual disorders, because it does not provide useful
guidance to adjudicators on how to evaluate vision loss due to cortical
visual disorders. While we added current 2.00A4b when we last published
final rules making comprehensive revisions to section 2.00 on November
20, 2006,\2\ it is not our intention to list in these rules every
visual disorder that may result in vision loss. We propose to include
cortical visual disorders as an example of a disorder that may result
in abnormalities that do not appear on a standard eye examination. We
also intend to provide guidance for evaluating a person's vision loss
due to cortical visual disorders and any other disorders that may
result in vision loss or a loss in visual functioning (for example,
blepharospasm) in our internal operating instructions and training.
---------------------------------------------------------------------------
\2\ 71 FR 67040, 67045, 67046, and 67049.
---------------------------------------------------------------------------
Section 2.00A5, How do we measure your best-corrected central visual
acuity?
We propose to make the following changes to current 2.00A5:
Provide guidance in proposed 2.00A5a(ii) that explains how
we use visual acuity measurements not recorded in Snellen notation,
such as counts fingers (CF) or no light perception (NLP), to evaluate
your vision loss. This guidance is in response to questions from our
adjudicators.
Add the guidance in current 2.00A8a, which explains how we
use test charts that measure visual acuity between 20/100 and 20/200,
to proposed 2.00A5b.
Provide guidance in proposed 2.00A5d, which we currently
provide in our internal operating instructions, that explains how we
use the results of cycloplegic refraction.
Section 2.00A6, How do we measure your visual fields?
We propose to make the following changes to current 2.00A6:
Combine the guidance in current 2.00A6a(i) and 2.00A6a(ii)
in proposed 2.00A6a, with one exception. As we explain below, we would
move the guidance that explains our requirements for acceptable
perimeters in current 2.00A6a(ii) to proposed section 2.00A8.
Move the guidance on visual field testing requirements in
current 2.00A6a(iii), (vi), and (vii), to proposed 2.00A6b(i), (ii),
and (iii), respectively.
Revise our guidance on automated static threshold
perimeters to remove specific references to perimeter manufacturers. In
the preamble to our final rules published in the Federal Register on
November 20, 2006, we explained that while the National Research
Council (NRC) 2002 report, Visual Impairments: Determining Eligibility
for Social Security Benefits, cited both the Humphrey Field Analyzer
and the Octopus perimeter as acceptable perimeters, we were not
including the Octopus perimeter as an example of an acceptable
perimeter. We decided not to include the Octopus perimeter at that time
because we did not intend to list every acceptable perimeter in our
rules. However, since the publication of those rules, we have received
numerous questions from adjudicators on the acceptability of the tests
performed on Octopus and other perimeters. We have determined that
other tests (including the Octopus 32) and perimeters
[[Page 7551]]
(including the Octopus 300 Series), meet our requirements for
acceptable testing and acceptable perimeters.
Move the guidance in current 2.00A6a(iv), which explains
how we evaluate vision loss under 2.03A, to proposed 2.00A6c, and add
the Octopus 32 test as an acceptable test.
Move the guidance in current 2.00A6a(v), which explains
how we evaluate vision loss under 2.03B, to proposed 2.00A6d. We would
add the definition of the term mean deviation (or defect), abbreviated
as MD, which we use in current and proposed 2.03B but do not define. We
would explain that Humphrey Field Analyzer (HFA) tests report the MD as
a negative number and, therefore, we use the absolute value of the MD
when determining whether the person's visual field loss meets the
listing.
Move the guidance in current 2.00A6a(viii), which explains
when we can use visual field measurements obtained using kinetic
perimetry to evaluate vision loss, to proposed 2.00A6e.
Move the guidance on visual field screening tests in
current 2.00A6a(ix) to proposed 2.00A6f.
Move the guidance on the use of corrective lenses in
visual field testing in current 2.00A6b to proposed 2.00A6g.
Move the guidance on scotomas in current 2.00A8c to
proposed 2.00A6h.
2.00A7, How do we determine your visual acuity efficiency, visual field
efficiency, and visual efficiency?
We propose to make the following changes to current 2.00A7:
Introduce ``value'' as a term to express visual
efficiency, in addition to the term ``percentage,'' in proposed
2.00A7a, which we explain in the paragraphs below.
Add current Table 1 (Percentage of Visual Acuity
Efficiency Corresponding to Best-Corrected Visual Acuity), which is
located at the end of the current special senses and speech listings,
to proposed 2.00A7b because it is more useful to our adjudicators to
place this table in the introductory text immediately after the
explanation of visual acuity efficiency. Our current rules describe
overall visual efficiency as a percentage and we provide the equivalent
visual acuity efficiency percentages corresponding to Snellen best-
corrected central visual acuities for distance in Table 1. In the
proposed table, we would include a column for visual acuity efficiency
values that correspond to Snellen best-corrected central visual
acuities for distance.
Expand current 2.00A7b and redesignate as proposed
2.00A7c. A person's visual field efficiency can be expressed as a
percentage (using the visual field determined by kinetic perimetry) or
as a value (using the MD determined by automated static threshold
perimetry). We would explain that a visual field efficiency percentage
of 20 is comparable to an MD of 22, which we currently explain in
training.
Add guidance in proposed 2.00A7c(i) on how to calculate
visual field efficiency value using the MD determined by automated
static threshold perimetry, which we currently provide in our internal
operating instructions.
Redesignate current 2.00A7b as proposed 2.00A7c(ii).
Add current Table 2 (Chart of Visual Fields), which is
located at the end of the current special senses and speech listings,
to proposed 2.00A7c(ii), and redesignate it as Figure 1, because it is
more useful to our adjudicators to place this figure in the
introductory text immediately after the explanation of visual field
efficiency. We would also add, and make minor changes to, the example
for calculating visual field efficiency percentage under the current
table to proposed 2.00A7c(ii)A and B.
Expand current 2.00A7c and redesignate as proposed
2.00A7d. We would add an example for calculating visual efficiency
value in proposed 2.00A7d(i). In proposed 2.00A7d(ii), we would revise
the example for calculating visual efficiency percentage, which is in
current 2.00A7c, to simply state more clearly how we convert a decimal
value to a percentage.
Section 2.00A8, What are our requirements for an acceptable perimeter?
We propose to move the guidance on acceptable perimeters in current
2.00A6a(ii)A-F to proposed section 2.00A8 because perimeter
manufacturers must provide us with the evidence that their automated
static threshold perimeter(s) meet these requirements before we can use
any results of visual field testing performed on their perimeters to
evaluate visual field loss. Although we are not proposing to change
these requirements, we believe placing them at the end of the
introductory text will allow adjudicators to more quickly access the
guidance on visual field testing requirements that are applicable to
testing performed on all acceptable perimeters. We would also remove
the reference to the HFA because acceptable perimeters may change over
time and we do not want to appear to be giving preference in our rules
to one manufacturer over another.
Other Changes
We propose to remove 2.00A8b, which describes blepharospasm,
because it does not provide useful guidance to adjudicators on how to
evaluate vision loss due to blepharospasm and has led to repeated
questions from our adjudicators. As we explained earlier with cortical
visual disorders, we intend to provide guidance for evaluating a
person's vision loss due to blepharospasm and any other visual
disorders that may result in vision loss or a loss in visual
functioning in our internal operating instructions and training.
What changes are we proposing to the listings for evaluating visual
disorders in adults?
In the following paragraphs, we describe the substantive changes to
the adult listings for evaluating visual disorders in part A of
appendix 1 to subpart P of part 404. We propose to:
Add 2.04A to evaluate visual efficiency determined using
the MD from acceptable automated static threshold perimetry.
Redesignate current 2.04, which we use to evaluate visual
efficiency determined by kinetic perimetry, as proposed 2.04B.
What changes are we proposing to the introductory text and listings for
evaluating visual disorders in children?
We propose to clarify, simplify, and reorganize the introductory
text in the childhood rules as in the adult rules. Since these are
conforming changes, we do not summarize them here. We also propose to
move the examples in current 102.00A5b(iii) to proposed 102.02B. We
believe it is more helpful to adjudicators to include these examples
directly in the listing to which they apply.
What is our authority to make rules and set procedures for determining
whether a person is disabled under the statutory definition?
The Act authorizes us to make rules and regulations and to
establish necessary and appropriate procedures to implement them.
Sections 205(a), 702(a)(5), and 1631(d)(1).
How long would these proposed rules be effective?
If we publish these proposed rules as final rules, they will remain
in effect for 5 years after the date they become effective, unless we
extend them, or revise and issue them again.
[[Page 7552]]
Clarity of These Proposed Rules
Executive Order 12866, as supplemented by Executive Order 13563,
requires each agency to write all rules in plain language. In addition
to your substantive comments on these proposed rules, we invite your
comments on how to make them easier to understand.
For example:
Would more, but shorter sections be better?
Are the requirements in the rules clearly stated?
Have we organized the material to suit your needs?
Could we improve clarity by adding more tables, lists, or
diagrams?
What else could we do to make the rules easier to
understand?
Do the rules contain technical language or jargon that is
not clear?
Would a different format make the rules easier to
understand, e.g., grouping and order of sections, use of headings,
paragraphing?
When will we start to use these rules?
We will not use these rules until we evaluate public comments and
publish final rules in the Federal Register. All final rules we issue
include an effective date. We will continue to use our current rules
until that date. If we publish final rules, we will include a summary
of those relevant comments we received along with responses and an
explanation of how we will apply the new rules.
Regulatory Procedures
Executive Order 12866, as Supplemented by Executive Order 13563
We have consulted with the Office of Management and Budget (OMB)
and determined that this NPRM meets the criteria for a significant
regulatory action under Executive Order 12866, as supplemented by
Executive Order 13563. Therefore, OMB reviewed it.
Regulatory Flexibility Act
We certify that these proposed rules will not have a significant
economic impact on a substantial number of small entities because they
affect individuals only. Therefore, a regulatory flexibility analysis
is not required under the Regulatory Flexibility Act, as amended.
Paperwork Reduction Act
These proposed rules do not create any new or affect any existing
collections and, therefore, do not require OMB approval under the
Paperwork Reduction Act.
(Catalog of Federal Domestic Assistance Program Nos. 96.001, Social
Security--Disability Insurance; 96.002, Social Security--Retirement
Insurance; 96.004, Social Security--Survivors Insurance; and 96.006,
Supplemental Security Income)
List of Subjects in 20 CFR Part 404
Administrative practice and procedure; Blind, Disability benefits;
Old-age, survivors, and disability insurance; Reporting and
recordkeeping requirements; Social Security.
Michael J. Astrue,
Commissioner of Social Security.
For the reasons set out in the preamble, we propose to amend 20 CFR
chapter III, part 404, subpart P as set forth below:
PART 404--FEDERAL OLD-AGE, SURVIVORS AND DISABILITY INSURANCE
(1950-)
Subpart P--[Amended]
1. The authority citation for subpart P of part 404 continues to
read as follows:
Authority: Secs. 202, 205(a)-(b) and (d)-(h), 216(i), 221(a),
(i), and (j), 222(c), 223, 225, and 702(a)(5) of the Social Security
Act (42 U.S.C. 402, 405(a)-(b) and (d)-(h), 416(i), 421(a), (i), and
(j), 422(c), 423, 425, and 902(a)(5)); sec. 211(b), Pub. L. 104-193,
110 Stat. 2105, 2189; sec. 202, Pub. L. 108-203, 118 Stat. 509 (42
U.S.C. 902 note).
2. Amend appendix 1 to subpart P of part 404 by:
a. Revising item 3 of the introductory text before part A;
b. Revising section 2.00A and sections 2.01 through 2.04 in part A;
and
c. Revising section 102.00A and sections 102.01 through 102.04 in
part B.
The revisions read as follows:
APPENDIX 1 TO SUBPART P OF PART 404--LISTING OF IMPAIRMENTS
* * * * *
3. Special Senses and Speech (2.00 and 102.00): [Insert date 5
years from the effective date of the final rules].
* * * * *
Part A
* * * * *
2.00 Special Senses and Speech
A. How do we evaluate visual disorders?
1. What are visual disorders? Visual disorders are abnormalities
of the eye, the optic nerve, the optic tracts, or the brain that may
cause a loss of visual acuity or visual fields. A loss of visual
acuity limits your ability to distinguish detail, read, or do fine
work. A loss of visual fields limits your ability to perceive visual
stimuli in the peripheral extent of vision.
2. How do we define statutory blindness? Statutory blindness is
blindness as defined in sections 216(i)(1) and 1614(a)(2) of the
Social Security Act (Act).
a. The Act defines blindness as central visual acuity of 20/200
or less in the better eye with the use of a correcting lens. We use
your best-corrected central visual acuity for distance in the better
eye when we determine if this definition is met. (For visual acuity
testing requirements, see 2.00A5.)
b. The Act also provides that an eye that has a visual field
limitation such that the widest diameter of the visual field
subtends an angle no greater than 20 degrees is considered as having
a central visual acuity of 20/200 or less. (For visual field testing
requirements, see 2.00A6.)
c. You have statutory blindness only if your visual disorder
meets the criteria of 2.02 or 2.03A. In order to find that you have
statutory blindness under the law for a period of disability and for
payment of disability insurance benefits, your blindness under 2.02
or 2.03A must also meet the duration requirement (see Sec. Sec.
404.1509 and 404.1581). You do not have statutory blindness if your
visual disorder medically equals the criteria of 2.02 or 2.03A or
meets or medically equals the criteria of 2.03B, 2.03C, 2.04A, or
2.04B because your disability is based on criteria other than those
in the statutory definition of blindness. If your visual disorder
medically equals the criteria of 2.02 or 2.03A or meets or medically
equals the criteria of 2.03B, 2.03C, 2.04A, or 2.04B, we will find
that you are under a disability if your visual disorder also meets
the duration requirement (see Sec. Sec. 404.1509 and 416.909 of
this chapter).
3. What evidence do we need to establish statutory blindness
under title XVI? To establish that you have statutory blindness
under title XVI, we need evidence showing only that your central
visual acuity in your better eye or your visual field in your better
eye meets the criteria in 2.00A2, provided that those measurements
are consistent with the other evidence in your case record. We do
not need documentation of the cause of your blindness. Also, there
is no duration requirement for statutory blindness under title XVI
(see Sec. Sec. 416.981 and 416.983 of this chapter).
4. What evidence do we need to evaluate visual disorders,
including those that result in statutory blindness under title II?
To evaluate your visual disorder, we usually need a report of an eye
examination that includes measurements of your best-corrected
central visual acuity (see 2.00A5) or the extent of your visual
fields (see 2.00A6), as appropriate. If you have visual acuity or
visual field loss, we need documentation of the cause of the loss. A
standard eye examination will usually indicate the cause of any
visual acuity loss. An eye examination can also indicate the cause
of some types of visual field deficits. Some disorders, such as
cortical visual disorders, may result in abnormalities that do not
appear on a standard eye examination. If the eye examination does
not indicate the cause of your vision loss, we will request the
information the physician or optometrist used to establish the
presence of your visual disorder. If your visual disorder does not
satisfy the criteria in 2.02, 2.03, or 2.04, we will request a
description of how your visual disorder affects your ability to
function.
5. How do we measure your best-corrected central visual acuity?
[[Page 7553]]
a. Visual acuity testing. When we need to measure your best-
corrected central visual acuity, which is your optimal visual acuity
attainable with the use of a corrective lens, we use visual acuity
testing for distance that was carried out using Snellen methodology
or any other testing methodology that is comparable to Snellen
methodology.
(i) Your best-corrected central visual acuity for distance is
usually measured by determining what you can see from 20 feet. If
your visual acuity is measured for a distance other than 20 feet, we
will convert it to a 20-foot measurement. For example, if your
visual acuity is measured at 10 feet and is reported as 10/40, we
will convert this measurement to 20/80.
(ii) A visual acuity recorded as CF (counts fingers), HM (hand
motion only), LP or LPO (light perception or light perception only),
or NLP (no light perception) indicates that no optical correction
will improve your visual acuity. If your central visual acuity in an
eye is recorded as CF, HM, LP or LPO, or NLP, we will determine that
your best-corrected central visual acuity is 20/200 or less in that
eye.
(iii) We will not use the results of pinhole testing or
automated refraction acuity to determine your best-corrected central
visual acuity. These tests provide an estimate of potential visual
acuity but not an actual measurement of your best-corrected central
visual acuity.
b. Other test charts. Most test charts that use Snellen
methodology do not have lines that measure visual acuity between 20/
100 and 20/200. Some test charts, such as the Bailey-Lovie or the
Early Treatment Diabetic Retinopathy Study (ETDRS) used mostly in
research settings, have such lines. If your visual acuity is
measured with one of these charts, and you cannot read any of the
letters on the 20/100 line, we will determine that you have
statutory blindness based on a visual acuity of 20/200 or less. For
example, if your best-corrected central visual acuity for distance
in the better eye is 20/160 using an ETDRS chart, we will find that
you have statutory blindness. Regardless of the type of test chart
used, you do not have statutory blindness if you can read at least
one letter on the 20/100 line. For example, if your best-corrected
central visual acuity for distance in the better eye is 20/125+1
using an ETDRS chart, we will find that you do not have statutory
blindness because you are able to read one letter on the 20/100
line.
c. Testing using a specialized lens. In some instances, you may
perform visual acuity testing using a specialized lens; for example,
a contact lens. We will use the visual acuity measurements obtained
with a specialized lens only if you have demonstrated the ability to
use the specialized lens on a sustained basis. We will not use
visual acuity measurements obtained with telescopic lenses because
they significantly reduce the visual field.
d. Cycloplegic refraction. Cycloplegic refraction, which
measures your visual acuity in the absence of accommodation
(focusing ability) after the eye has been dilated, is not part of a
routine eye examination because it is not needed to determine your
best-corrected central visual acuity. If your case record contains
the results of cycloplegic refraction, we may use the results to
determine your best-corrected central visual acuity. We will not
purchase cycloplegic refraction.
e. Visual evoked response (VER) testing. VER testing measures
your response to visual events and can often detect dysfunction that
is undetectable through other types of examinations. If you have an
absent response to VER testing in your better eye, we will determine
that your best-corrected central visual acuity is 20/200 or less in
that eye and that your visual acuity loss satisfies the criterion in
2.02, when these test results are consistent with the other evidence
in your case record. If you have a positive response to VER testing
in an eye, we will not use that result to determine your best-
corrected central visual acuity in that eye.
6. How do we measure your visual fields?
a. General. We generally need visual field testing when you have
a visual disorder that could result in visual field loss, such as
glaucoma, retinitis pigmentosa, or optic neuropathy, or when you
display behaviors that suggest a visual field loss. When we need to
measure the extent of your visual field loss, we use visual field
testing (also referred to as perimetry) carried out using automated
static threshold perimetry performed on an acceptable perimeter (for
perimeter requirements, see 2.00A8).
b. Automated static threshold perimetry requirements.
(i) The test must use a white size III Goldmann stimulus and a
31.5 apostilb (asb) white background (or a 10 candela per square
meter (cd/m\2\) white background). The stimuli test locations must
be no more than 6 degrees apart horizontally or vertically.
Measurements must be reported on standard charts and include a
description of the size and intensity of the test stimulus.
(ii) We measure the extent of your visual field loss by
determining the portion of the visual field in which you can see a
white III4e stimulus. The ``III'' refers to the standard Goldmann
test stimulus size III (4 mm\2\), and the ``4e'' refers to the
standard Goldmann intensity filter (0 dB attenuation, which allows
presentation of the maximum luminance) used to determine the
intensity of the stimulus.
(iii) In automated static threshold perimetry, the intensity of
the stimulus varies. The intensity of the stimulus is expressed in
decibels (dB). A perimeter's maximum stimulus luminance is usually
assigned the value 0 dB. We need to determine the dB level that
corresponds to a 4e intensity for the particular perimeter being
used. We will then use the dB printout to determine which points you
see at a 4e intensity level (a ``seeing point''). For example:
A. When the maximum stimulus luminance (0 dB stimulus) on an
acceptable perimeter is 10,000 asb, a 10 dB stimulus is equivalent
to a 4e stimulus. Any point you see at 10 dB or greater is a seeing
point.
B. When the maximum stimulus luminance (0 dB stimulus) on an
acceptable perimeter is 4,000 asb, a 6 dB stimulus is equivalent to
a 4e stimulus. Any point you see at 6 dB or greater is a seeing
point.
c. Evaluation under 2.03A. To determine statutory blindness
based on visual field loss in your better eye (2.03A), we need the
results of a visual field test that measures the central 24 to 30
degrees of your visual field; that is, the area measuring 24 to 30
degrees from the point of fixation. Acceptable tests include the
Humphrey Field Analyzer (HFA) 30-2, HFA 24-2, and Octopus 32.
d. Evaluation under 2.03B. To determine whether your visual
field loss meets listing 2.03B, we use the mean deviation or defect
(MD) from acceptable automated static threshold perimetry that
measures the central 30 degrees of the visual field. MD is the
average sensitivity deviation from normal values for all measured
visual field locations within the central 30 degrees of the field.
When using results from HFA tests, which report the MD as a negative
number, we use the absolute value of the MD to determine whether
your visual field loss meets listing 2.03B. We cannot use tests that
do not measure the central 30 degrees of the visual field, such as
the HFA 24-2, to determine if your impairment meets or medically
equals 2.03B.
e. Other types of perimetry. If your case record contains visual
field measurements obtained using manual or automated kinetic
perimetry, such as Goldmann perimetry or the HFA ``SSA Test
Kinetic,'' we can generally use these results if the kinetic test
was performed using a white III4e stimulus projected on a white 31.5
asb (10 cd/m\2\) background. Automated kinetic perimetry, such as
the HFA ``SSA Test Kinetic,'' does not detect limitations in the
central visual field because testing along a meridian stops when you
see the stimulus. If your visual disorder has progressed to the
point at which it is likely to result in a significant limitation in
the central visual field, such as a scotoma (see 2.00A6h), we will
not use automated kinetic perimetry to determine the extent of your
visual field loss. Instead, we will determine the extent of your
visual field loss using automated static threshold perimetry or
manual kinetic perimetry.
f. Screening tests. We will not use the results of visual field
screening tests, such as confrontation tests, tangent screen tests,
or automated static screening tests, to determine that your
impairment meets or medically equals a listing or to evaluate your
residual functional capacity. We can consider normal results from
visual field screening tests to determine whether your visual
disorder is severe when these test results are consistent with the
other evidence in your case record. (See Sec. Sec. 404.1520(c),
404.1521, 416.920(c), and 416.921 of this chapter.) We will not
consider normal test results to be consistent with the other
evidence if the clinical findings indicate that your visual disorder
has progressed to the point that it is likely to cause visual field
loss, or you have a history of an operative procedure for retinal
detachment.
g. Use of corrective lenses. You must not wear eyeglasses during
visual field testing because they limit your field of vision. You
may wear contact lenses or perimetric lenses to correct your visual
acuity during the visual field test to obtain the most accurate
visual field measurements. For this single purpose,
[[Page 7554]]
you do not need to demonstrate that you have the ability to use the
contact or perimetric lenses on a sustained basis.
h. Scotoma. A scotoma is a non-seeing area (also referred to as
a blind spot) in the visual field surrounded by a seeing area. When
we measure your visual field, we subtract the length of any scotoma,
other than the normal blind spot, from the overall length of any
diameter on which it falls.
7. How do we determine your visual acuity efficiency, visual
field efficiency, and visual efficiency?
a. General. Visual efficiency is the combination of your visual
acuity efficiency and your visual field efficiency expressed as a
value or as a percentage.
b. Visual acuity efficiency. Visual acuity efficiency is a value
or a percentage that corresponds to the best-corrected central
visual acuity for distance in your better eye. See Table 1.
Table 1
----------------------------------------------------------------------------------------------------------------
Snellen best-corrected central visual acuity for distance Visual acuity
--------------------------------------------------------------- Visual acuity efficiency value efficiency
(2.04A) percentage
English Metric (2.04B)
----------------------------------------------------------------------------------------------------------------
20/16....................................... 6/5 0.00........................... 100
20/20....................................... 6/6 0.00........................... 100
20/25....................................... 6/7.5 0.10........................... 95
20/30....................................... 6/9 0.18........................... 90
20/40....................................... 6/12 0.30........................... 85
20/50....................................... 6/15 0.40........................... 75
20/60....................................... 6/18 0.48........................... 70
20/70....................................... 6/21 0.54........................... 65
20/80....................................... 6/24 0.60........................... 60
20/100...................................... 6/30 0.70........................... 50
----------------------------------------------------------------------------------------------------------------
c. Visual field efficiency. Visual field efficiency is a value
or a percentage that corresponds to the visual field in your better
eye. Under 2.03C, we require kinetic perimetry to determine your
visual field efficiency percentage. (A visual field efficiency
percentage of 20, determined using kinetic perimetry, is comparable
to an MD of 22, determined using automated static threshold
perimetry.)
(i) Value determined by automated static threshold perimetry.
Using the MD from acceptable automated static threshold perimetry,
we calculate the visual field efficiency value by dividing the
absolute value of the MD by 22. For example, if your MD on an HFA
30-2 is -16, your visual field efficiency value is: [mid]-16[mid] /
22 = 0.73.
(ii) Percentage determined by kinetic perimetry. Using kinetic
perimetry, we calculate the visual field efficiency percentage by
adding the number of degrees you see along the eight principal
meridians found on a visual field chart (0, 45, 90, 135, 180, 225,
270, and 315) in your better eye and dividing by 5. For example, in
Figure 1:
A. The diagram of the left eye illustrates a visual field, as
measured with a III4e stimulus, contracted to 30 degrees in two
meridians (180 and 225) and to 20 degrees in the remaining six
meridians. The visual efficiency percentage of this field is: ((2 x
30) + (6 x 20)) / 5 = 36 percent.
B. The diagram of the right eye illustrates the extent of a
normal visual field as measured with a III4e stimulus. The sum of
the eight principal meridians of this field is 500 degrees. The
visual efficiency percentage of this field is 500 / 5 = 100 percent.
[GRAPHIC] [TIFF OMITTED] TP13FE12.004
d. Visual efficiency.
(i) Determined by automated static threshold perimetry (2.04A).
Under 2.04A, we calculate the visual efficiency value by adding your
visual acuity efficiency value
[[Page 7555]]
(see 2.00A7b) and your visual field efficiency value (see
2.00A7c(i)). For example, if your visual acuity efficiency value is
0.48 and your visual field efficiency value is 0.73, your visual
efficiency value is: 0.48 + 0.73 = 1.21.
(ii) Determined by kinetic perimetry (2.04B). Under 2.04B, we
calculate the visual efficiency percentage by multiplying your
visual acuity efficiency percentage (see 2.00A7b) by your visual
field efficiency percentage (see 2.00A7c(ii)) and dividing by 100.
For example, if your visual acuity efficiency percentage is 75 and
your visual field efficiency percentage is 36, your visual
efficiency percentage is: (75 x 36) / 100 = 27 percent.
8. What are our requirements for an acceptable perimeter? We
will use results from automated static threshold perimetry performed
on a perimeter that:
a. Uses optical projection to generate the test stimuli.
b. Has an internal normative database for automatically
comparing your performance with that of the general population.
c. Has a statistical analysis package that is able to calculate
visual field indices, particularly mean deviation or mean defect.
d. Demonstrates the ability to correctly detect visual field
loss and correctly identify normal visual fields.
e. Demonstrates good test-retest reliability.
f. Has undergone clinical validation studies by three or more
independent laboratories with results published in peer-reviewed
ophthalmic journals.
* * * * *
2.01 Category of Impairments, Special Senses and Speech
2.02 Loss of central visual acuity. Remaining vision in the
better eye after best correction is 20/200 or less.
2.03 Contraction of the visual field in the better eye, with:
A. The widest diameter subtending an angle around the point of
fixation no greater than 20 degrees.
OR
B. An MD of 22 decibels or greater, determined by automated
static threshold perimetry that measures the central 30 degrees of
the visual field (see 2.00A6d).
OR
C. A visual field efficiency of 20 percent or less, determined
by kinetic perimetry (see 2.00A7c).
2.04 Loss of visual efficiency in the better eye, with:
A. A visual efficiency value of 1.00 or greater after best
correction (see 2.00A7d(i)).
OR
B. A visual efficiency percentage of 20 or less after best
correction (see 2.00A7d(ii)).
* * * * *
Part B
* * * * *
102.00 Special Senses and Speech
A. How do we evaluate visual disorders?
1. What are visual disorders? Visual disorders are abnormalities
of the eye, the optic nerve, the optic tracts, or the brain that may
cause a loss of visual acuity or visual fields. A loss of visual
acuity limits your ability to distinguish detail, read, do fine
work, or perform other age-appropriate activities. A loss of visual
fields limits your ability to perceive visual stimuli in the
peripheral extent of vision.
2. How do we define statutory blindness? Statutory blindness is
blindness as defined in sections 216(i)(1) and 1614(a)(2) of the
Social Security Act (Act).
a. The Act defines blindness as central visual acuity of 20/200
or less in the better eye with the use of a correcting lens. We use
your best-corrected central visual acuity for distance in the better
eye when we determine if this definition is met. (For visual acuity
testing requirements, see 102.00A5.)
b. The Act also provides that an eye that has a visual field
limitation such that the widest diameter of the visual field
subtends an angle no greater than 20 degrees is considered as having
a central visual acuity of 20/200 or less. (For visual field testing
requirements, see 102.00A6.)
c. You have statutory blindness only if your visual disorder
meets the criteria of 102.02A, 102.02B, or 102.03A. You do not have
statutory blindness if your visual disorder medically equals the
criteria of 102.02A, 102.02B, or 102.03A or meets or medically
equals the criteria of 102.03B, 102.03C, 102.04A, or 102.04B because
your disability is based on criteria other than those in the
statutory definition of blindness. If your visual disorder medically
equals the criteria of 102.02A, 102.02B, or 102.03A or meets or
medically equals the criteria of 102.03B, 102.03C, 102.04A, or
102.04B, we will find that you are under a disability if your visual
disorder also meets the duration requirement (see Sec. 416.909 of
this chapter).
3. What evidence do we need to establish statutory blindness
under title XVI? To establish that you have statutory blindness
under title XVI, we need evidence showing only that your central
visual acuity in your better eye or your visual field in your better
eye meets the criteria in 102.00A2, provided that those measurements
are consistent with the other evidence in your case record. We do
not need documentation of the cause of your blindness. Also, there
is no duration requirement for statutory blindness under title XVI
(see Sec. Sec. 416.981 and 416.983 of this chapter).
4. What evidence do we need to evaluate visual disorders,
including those that result in statutory blindness under title II?
To evaluate your visual disorder, we usually need a report of an eye
examination that includes measurements of your best-corrected
central visual acuity (see 102.00A5) or the extent of your visual
fields (see 102.00A6), as appropriate. If you have visual acuity or
visual field loss, we need documentation of the cause of the loss. A
standard eye examination will usually indicate the cause of any
visual acuity loss. An eye examination can also indicate the cause
of some types of visual field deficits. Some disorders, such as
cortical visual disorders, may result in abnormalities that do not
appear on a standard eye examination. If the eye examination does
not indicate the cause of your vision loss, we will request the
information the physician or optometrist used to establish the
presence of your visual disorder. If your visual disorder does not
satisfy the criteria in 102.02, 102.03, or 102.04, we will request a
description of how your visual disorder affects your ability to
function.
5. How do we measure your best-corrected central visual acuity?
a. Visual acuity testing. When we need to measure your best-
corrected central visual acuity, which is your optimal visual acuity
attainable with the use of a corrective lens, we use visual acuity
testing for distance that was carried out using Snellen methodology
or any other testing methodology that is comparable to Snellen
methodology.
(i) Your best-corrected central visual acuity for distance is
usually measured by determining what you can see from 20 feet. If
your visual acuity is measured for a distance other than 20 feet, we
will convert it to a 20-foot measurement. For example, if your
visual acuity is measured at 10 feet and is reported as 10/40, we
will convert this measurement to 20/80.
(ii) A visual acuity recorded as CF (counts fingers), HM (hand
motion only), LP or LPO (light perception or light perception only),
or NLP (no light perception) indicates that no optical correction
will improve your visual acuity. If your central visual acuity in an
eye is recorded as CF, HM, LP or LPO, or NLP, we will determine that
your best-corrected central visual acuity is 20/200 or less in that
eye.
(iii) We will not use the results of pinhole testing or
automated refraction acuity to determine your best-corrected central
visual acuity. These tests provide an estimate of potential visual
acuity but not an actual measurement of your best-corrected central
visual acuity.
(iv) Very young children, such as infants and toddlers, cannot
participate in testing using Snellen methodology or other comparable
testing. If you are unable to participate in testing using Snellen
methodology or other comparable testing, we will consider clinical
findings of your fixation and visual-following behavior. If both
these behaviors are absent, we will consider the anatomical findings
or the results of neuroimaging, electroretinogram, or visual evoked
response (VER) testing when this testing has been performed.
b. Other test charts.
(i) Children between the ages of 3 and 5 often cannot identify
the letters on a Snellen or other letter test chart. Specialists
with expertise in assessment of childhood vision use alternate
methods for measuring visual acuity in young children. We consider
alternate methods, for example, the Landolt C test or the tumbling-E
test, which are used to evaluate young children who are unable to
participate in testing using Snellen methodology, to be comparable
to testing using Snellen methodology.
(ii) Most test charts that use Snellen methodology do not have
lines that measure visual acuity between 20/100 and 20/200. Some
test charts, such as the Bailey-Lovie or the Early Treatment
Diabetic Retinopathy Study (ETDRS) used mostly in research settings,
have such lines. If your visual acuity
[[Page 7556]]
is measured with one of these charts, and you cannot read any of the
letters on the 20/100 line, we will determine that you have
statutory blindness based on a visual acuity of 20/200 or less. For
example, if your best-corrected central visual acuity for distance
in the better eye is 20/160 using an ETDRS chart, we will find that
you have statutory blindness. Regardless of the type of test chart
used, you do not have statutory blindness if you can read at least
one letter on the 20/100 line. For example, if your best-corrected
central visual acuity for distance in the better eye is 20/125+1
using an ETDRS chart, we will find that you do not have statutory
blindness because you are able to read one letter on the 20/100
line.
c. Testing using a specialized lens. In some instances, you may
perform visual acuity testing using a specialized lens; for example,
a contact lens. We will use the visual acuity measurements obtained
with a specialized lens only if you have demonstrated the ability to
use the specialized lens on a sustained basis. We will not use
visual acuity measurements obtained with telescopic lenses because
they significantly reduce the visual field.
d. Cycloplegic refraction. Cycloplegic refraction, which
measures your visual acuity in the absence of accommodation
(focusing ability) after the eye has been dilated, is not part of a
routine eye examination because it is not needed to determine your
best-corrected central visual acuity. It can be useful for
determining refractive error and visual acuity in some children. If
your case record contains the results of cycloplegic refraction, we
may use the results to determine your best-corrected central visual
acuity. We will not purchase cycloplegic refraction.
e. VER testing. VER testing measures your response to visual
events and can often detect dysfunction that is undetectable through
other types of examinations. If you have an absent response to VER
testing in your better eye, we will determine that your best-
corrected central visual acuity is 20/200 or less in that eye and
that your visual acuity loss satisfies the criterion in 102.02A or
102.02B4, as appropriate, when these test results are consistent
with the other evidence in your case record. If you have a positive
response to VER testing in an eye, we will not use that result to
determine your best-corrected central visual acuity in that eye.
6. How do we measure your visual fields?
a. General. We generally need visual field testing when you have
a visual disorder that could result in visual field loss, such as
glaucoma, retinitis pigmentosa, or optic neuropathy, or when you
display behaviors that suggest a visual field loss. When we need to
measure the extent of your visual field loss, we use visual field
testing (also referred to as perimetry) carried out using automated
static threshold perimetry performed on an acceptable perimeter (for
perimeter requirements, see 102.00A8).
b. Automated static threshold perimetry requirements.
(i) The test must use a white size III Goldmann stimulus and a
31.5 apostilb (asb) white background (or a 10 candela per square
meter (cd/m\2\) white background). The stimuli test locations must
be no more than 6 degrees apart horizontally or vertically.
Measurements must be reported on standard charts and include a
description of the size and intensity of the test stimulus.
(ii) We measure the extent of your visual field loss by
determining the portion of the visual field in which you can see a
white III4e stimulus. The ``III'' refers to the standard Goldmann
test stimulus size III (4 mm\2\), and the ``4e'' refers to the
standard Goldmann intensity filter (0 dB attenuation, which allows
presentation of the maximum luminance) used to determine the
intensity of the stimulus.
(iii) In automated static threshold perimetry, the intensity of
the stimulus varies. The intensity of the stimulus is expressed in
decibels (dB). A perimeter's maximum stimulus luminance is usually
assigned the value 0 dB. We need to determine the dB level that
corresponds to a 4e intensity for the particular perimeter being
used. We will then use the dB printout to determine which points you
see at a 4e intensity level (a ``seeing point''). For example:
A. When the maximum stimulus luminance (0 dB stimulus) on an
acceptable perimeter is 10,000 asb, a 10 dB stimulus is equivalent
to a 4e stimulus. Any point you see at 10 dB or greater is a seeing
point.
B. When the maximum stimulus luminance (0 dB stimulus) on an
acceptable perimeter is 4,000 asb, a 6 dB stimulus is equivalent to
a 4e stimulus. Any point you see at 6 dB or greater is a seeing
point.
c. Evaluation under 102.03A. To determine statutory blindness
based on visual field loss in your better eye (102.03A), we need the
results of a visual field test that measures the central 24 to 30
degrees of your visual field; that is, the area measuring 24 to 30
degrees from the point of fixation. Acceptable tests include the
Humphrey Field Analyzer (HFA) 30-2, HFA 24-2, and Octopus 32.
d. Evaluation under 102.03B. To determine whether your visual
field loss meets listing 102.03B, we use the mean deviation or
defect (MD) from acceptable automated static threshold perimetry
that measures the central 30 degrees of the visual field. MD is the
average sensitivity deviation from normal values for all measured
visual field locations within the central 30 degrees of the field.
When using results from HFA tests, which report the MD as a negative
number, we use the absolute value of the MD to determine whether
your visual field loss meets listing 102.03B. We cannot use tests
that do not measure the central 30 degrees of the visual field, such
as the HFA 24-2, to determine if your impairment meets or medically
equals 102.03B.
e. Other types of perimetry. If your case record contains visual
field measurements obtained using manual or automated kinetic
perimetry, such as Goldmann perimetry or the HFA ``SSA Test
Kinetic,'' we can generally use these results if the kinetic test
was performed using a white III4e stimulus projected on a white 31.5
asb (10 cd/m\2\) background. Automated kinetic perimetry, such as
the HFA ``SSA Test Kinetic,'' does not detect limitations in the
central visual field because testing along a meridian stops when you
see the stimulus. If your visual disorder has progressed to the
point at which it is likely to result in a significant limitation in
the central visual field, such as a scotoma (see 102.00A6h), we will
not use automated kinetic perimetry to determine the extent of your
visual field loss. Instead, we will determine the extent of your
visual field loss using automated static threshold perimetry or
manual kinetic perimetry.
f. Screening tests. We will not use the results of visual field
screening tests, such as confrontation tests, tangent screen tests,
or automated static screening tests, to determine that your
impairment meets or medically equals a listing, or functionally
equals the listings. We can consider normal results from visual
field screening tests to determine whether your visual disorder is
severe when these test results are consistent with the other
evidence in your case record. (See Sec. 416.924(c) of this
chapter.) We will not consider normal test results to be consistent
with the other evidence if the clinical findings indicate that your
visual disorder has progressed to the point that it is likely to
cause visual field loss, or you have a history of an operative
procedure for retinal detachment.
g. Use of corrective lenses. You must not wear eyeglasses during
visual field testing because they limit your field of vision. You
may wear contact lenses or perimetric lenses to correct your visual
acuity during the visual field test to obtain the most accurate
visual field measurements. For this single purpose, you do not need
to demonstrate that you have the ability to use the contact or
perimetric lenses on a sustained basis.
h. Scotoma. A scotoma is a non-seeing area (also referred to as
a blind spot) in the visual field surrounded by a seeing area. When
we measure your visual field, we subtract the length of any scotoma,
other than the normal blind spot, from the overall length of any
diameter on which it falls.
7. How do we determine your visual acuity efficiency, visual
field efficiency, and visual efficiency?
a. General. Visual efficiency is the combination of your visual
acuity efficiency and your visual field efficiency expressed as a
value or as a percentage.
b. Visual acuity efficiency. Visual acuity efficiency is a value
or a percentage that corresponds to the best-corrected central
visual acuity for distance in your better eye. See Table 1.
[[Page 7557]]
Table 1
----------------------------------------------------------------------------------------------------------------
Snellen best-corrected central visual acuity for distance Visual acuity
--------------------------------------------------------------- Visual acuity efficiency value efficiency
(102.04A) percentage
English Metric (102.04B)
----------------------------------------------------------------------------------------------------------------
20/16....................................... 6/5 0.00........................... 100
20/20....................................... 6/6 0.00........................... 100
20/25....................................... 6/7.5 0.10........................... 95
20/30....................................... 6/9 0.18........................... 90
20/40....................................... 6/12 0.30........................... 85
20/50....................................... 6/15 0.40........................... 75
20/60....................................... 6/18 0.48........................... 70
20/70....................................... 6/21 0.54........................... 65
20/80....................................... 6/24 0.60........................... 60
20/100...................................... 6/30 0.70........................... 50
----------------------------------------------------------------------------------------------------------------
c. Visual field efficiency. Visual field efficiency is a value
or a percentage that corresponds to the visual field in your better
eye. Under 102.03C, we require kinetic perimetry to determine your
visual field efficiency percentage. (A visual field efficiency
percentage of 20, determined using kinetic perimetry, is comparable
to an MD of 22, determined using automated static threshold
perimetry.)
(i) Value determined by automated static threshold perimetry.
Using the MD from acceptable automated static threshold perimetry,
we calculate the visual field efficiency value by dividing the
absolute value of the MD by 22. For example, if your MD on an HFA
30-2 is -16, your visual field efficiency value is: [bond]-16[bond]
/ 22 = 0.73.
(ii) Percentage determined by kinetic perimetry. Using kinetic
perimetry, we calculate the visual field efficiency percentage by
adding the number of degrees you see along the eight principal
meridians found on a visual field chart (0, 45, 90, 135, 180, 225,
270, and 315) in your better eye and dividing by 5. For example, in
Figure 1:
A. The diagram of the left eye illustrates a visual field, as
measured with a III4e stimulus, contracted to 30 degrees in two
meridians (180 and 225) and to 20 degrees in the remaining six
meridians. The visual efficiency percentage of this field is: ((2 x
30) + (6 x 20)) / 5 = 36 percent.
B. The diagram of the right eye illustrates the extent of a
normal visual field as measured with a III4e stimulus. The sum of
the eight principal meridians of this field is 500 degrees. The
visual efficiency percentage of this field is 500 / 5 = 100 percent.
[GRAPHIC] [TIFF OMITTED] TP13FE12.005
d. Visual efficiency.
(i) Determined by automated static threshold perimetry
(102.04A). Under 102.04A, we calculate the visual efficiency value
by adding your visual acuity efficiency value (see 102.00A7b) and
your visual field efficiency value (see 102.00A7c(i)). For example,
if your visual acuity efficiency value is 0.48 and your visual field
efficiency value is 0.73, your visual efficiency value is: 0.48 +
0.73 = 1.21.
(ii) Determined by kinetic perimetry (102.04B). Under 102.04B,
we calculate the visual efficiency percentage by multiplying your
visual acuity efficiency percentage (see 102.00A7b) by your visual
field efficiency percentage (see 102.00A7c(ii)) and dividing by 100.
For example, if your visual acuity efficiency percentage is 75 and
your visual field efficiency percentage is 36, your visual
efficiency percentage is: (75 x 36) / 100 = 27 percent.
8. What are our requirements for an acceptable perimeter? We
will use results from automated static threshold perimetry performed
on a perimeter that:
a. Uses optical projection to generate the test stimuli.
[[Page 7558]]
b. Has an internal normative database for automatically
comparing your performance with that of the general population.
c. Has a statistical analysis package that is able to calculate
visual field indices, particularly mean deviation or mean defect.
d. Demonstrates the ability to correctly detect visual field
loss and correctly identify normal visual fields.
e. Demonstrates good test-retest reliability.
f. Has undergone clinical validation studies by three or more
independent laboratories with results published in peer-reviewed
ophthalmic journals.
* * * * *
102.01 Category of Impairments, Special Senses and Speech
102.02 Loss of central visual acuity.
A. Remaining vision in the better eye after best correction is
20/200 or less.
OR
B. An inability to participate in visual acuity testing using
Snellen methodology or other comparable testing, clinical findings
that fixation and visual-following behavior are absent in the better
eye, and one of the following:
1. Abnormal anatomical findings indicating a visual acuity of
20/200 or less in the better eye (such as the presence of Stage III
or worse retinopathy of prematurity despite surgery, hypoplasia of
the optic nerve, albinism with macular aplasia, or bilateral optic
atrophy); or
2. Abnormal neuroimaging documenting damage to the cerebral
cortex which would be expected to prevent the development of a
visual acuity better than 20/200 in the better eye (such as
neuroimaging showing bilateral encephalomyelitis or bilateral
encephalomalacia); or
3. Abnormal electroretinogram documenting the presence of
Leber's congenital amaurosis or achromatopsia in the better eye; or
4. An absent response to VER testing in the better eye.
102.03 Contraction of the visual field in the better eye, with:
A. The widest diameter subtending an angle around the point of
fixation no greater than 20 degrees.
OR
B. An MD of 22 decibels or greater, determined by automated
static threshold perimetry that measures the central 30 degrees of
the visual field (see 102.00A6d).
OR
C. A visual field efficiency of 20 percent or less, determined
by kinetic perimetry (see 102.00A7c).
102.04 Loss of visual efficiency in the better eye, with:
A. A visual efficiency value of 1.00 or greater after best
correction (see 102.00A7d(i)).
OR
B. A visual efficiency percentage of 20 or less after best
correction (see 102.00A7d(ii)).
* * * * *
[FR Doc. 2012-3226 Filed 2-10-12; 8:45 am]
BILLING CODE 4191-02-P
