Revised Medical Criteria for Evaluating Visual Disorders, 18837-18846 [2013-06975]

Agencies

• Social Security Administration

[Federal Register Volume 78, Number 60 (Thursday, March 28, 2013)]
[Rules and Regulations]
[Pages 18837-18846]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2013-06975]


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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: Final rules.

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SUMMARY: We are revising and reorganizing 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 revisions reflect our program experience 
and guidance we have issued in response to adjudicator questions we 
have received since we last revised these criteria in 2006. These 
revisions will provide clarification about how we evaluate visual 
disorders and ensure more timely adjudication of claims in which we 
evaluate visual disorders that result in a loss of visual acuity or 
field.

DATES: These rules are effective April 29, 2013.

FOR FURTHER INFORMATION CONTACT: Cheryl A. 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: 

Background

    We are making final the rules for evaluating visual disorders we 
proposed in a notice of proposed rulemaking (NPRM) published in the 
Federal Register on February 13, 2012 (77 FR 7549). The preamble to the 
NPRM provides a full explanation of the background of these revisions. 
You can view the preamble by visiting www.regulations.gov and searching 
for document ``SSA-2010-0078-0001.'' We are making a number of changes 
because of public comments to the NPRM. We explain those changes in our 
summary of the public comments and our responses later in this 
preamble. We are also making a number of minor editorial changes 
throughout these final rules.

Why are we revising the listings for evaluating visual disorders?

    We are revising the listings for evaluating visual disorders to 
update the medical criteria, clarify how we evaluate visual disorders, 
and address adjudicator questions.

When will we begin to use these final rules?

    We will begin to use these final rules on their effective date. We 
will continue to use the current rules until the date these final rules 
become effective. We will apply the final rules to new applications 
filed on or after the effective date of these final rules and to claims 
that are pending on or after the effective date.\1\ These final rules 
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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    \1\ This means that we will use these final rules on and after 
their effective date in any case in which we make a determination or 
decision. We expect that Federal courts will review our final 
decisions using the rules that were in effect at the time we issued 
the decisions. If a court reverses the Commissioner's final decision 
and remands a case for further administrative proceedings after the 
effective date of these final rules, we will apply these final rules 
to the entire period at issue in the decision we make after the 
court's remand.
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Public Comments

    In the NPRM, we provided the public with a 60-day comment period, 
which ended on April 13, 2012. We received 12 public comment letters. 
The comments came from members of the public, national medical 
organizations, disability examiners, and a national association 
representing disability examiners in the State agencies that make 
disability determinations for us. We have summarized the comments below 
because some of them were long. We summarized only those comments with 
concerns or suggestions and responded to the significant issues that 
were relevant to this rulemaking. Some commenters supported the 
proposed changes and noted the provisions with which they agreed. While 
we appreciate those comments, we have not summarized or responded to 
them

[[Page 18838]]

below because they do not require a response.

Evidence

    Comment: One commenter suggested that we replace the reference to 
``physician or optometrist'' with ``optometrist or ophthalmologist'' in 
2.00A4 and 102.00A4 where we explain what evidence we need to evaluate 
visual disorders, including those that result in statutory blindness 
under title II.
    Response: We did not adopt this comment because we removed the 
reference to ``physician or optometrist'' from those sections. When we 
were considering this comment, we determined we did not need to include 
the reference because our rules that explain the sources who can 
provide evidence to establish an impairment are in 20 CFR 404.1513 and 
416.913, and, therefore, we do not need to restate those sources in the 
introductory text.

Vision Testing

    Comment: One commenter suggested that we maintain the specific 
references to the Humphrey Field Analyzer (HFA) and Octopus perimeters 
that were provided in the introductory text. The commenter believed 
that the specific references were essential for making accurate 
determinations and decisions.
    Response: We did not adopt this comment because we believe that 
providing the requirements for acceptable perimeters and perimetry is 
sufficient for accurate decisionmaking. We provide the requirements for 
acceptable perimeters in 2.00A9 and 102.00A9. We also provide the 
requirements for acceptable perimetry in 2.00A6 and 102.00A6 and 
include examples of acceptable automated static threshold tests (HFA 
30-2, HFA 24-2, and Octopus 32) that can be used to evaluate visual 
field loss.
    Comment: One commenter suggested that we develop a formula for 
determining the intensity of the stimulus based on the maximum stimulus 
luminance of the instrument rather than include two examples in 
2.00A6b(iii) and 102.00A6b(iii).
    Response: We did not adopt the commenter's suggestion that we 
develop a formula to determine the intensity of the stimulus, but we 
did make a change in the final rules to address the commenter's 
concern. We added a third example (2.00Ab(iii)C and 102.00Ab(iii)C), so 
the listings now include the most common maximum stimulus luminances on 
automated static threshold perimeters.
    Comment: One commenter said that the mean deviation in 2.03B and 
102.03B varies by age and suggested that we reconsider using mean 
deviation as a listing criterion.
    Response: We did not adopt this comment. As we said when we 
published the final rule in 2006 (71 FR 67013), the National Research 
Council recommended that a mean deviation of 22 or worse on an 
automated static threshold test measuring the central 30 degrees of the 
visual field would serve as a reasonable criterion for disability 
determination. We continue to agree with that recommendation.\2\
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    \2\ National Research Council, Committee on Disability 
Determination for Individuals with Visual Impairments. (2002). 
Visual Impairments: Determining Eligibility for Social Security 
Benefits. Washington, DC: National Academy Press. Retrieved from 
https://www.nap.edu/catalog/10320.html?se_side.
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    Comment: One commenter requested that we provide guidance on how to 
interpret and assess medical findings included in the case file that 
are outside of the specified testing requirements.
    Response: We did not adopt this comment. We cannot provide guidance 
on how to use all vision tests. We believe that it is sufficient to 
provide specific guidance on the testing that is required to meet the 
listings. All other testing found in the medical evidence can be 
evaluated with the totality of the evidence when making a determination 
or decision at other steps in the sequential evaluation.
    Commenter: One commenter said that our use of the term 
``cycloplegic refraction'' in proposed listing sections 2.00A5d and 
102.00A5d is incorrect and suggested that we revise the definition for 
clarity and accuracy. The commenter also noted that cycloplegic 
refraction is a part of a comprehensive eye examination and may be used 
to provide a more precise measurement of refractive error.
    Response: We partially adopted this comment. We revised the 
definition of ``cycloplegic refraction'' in 2.00A5d and 102.00A5d, but 
we did not adopt the commenter's suggestion to note that cycloplegic 
refraction is a part of a comprehensive eye examination. Rather, we 
deleted the statement in the proposed rules that said cycloplegic 
refraction testing is not part of a routine examination.

Evaluating Vision Loss in Young Children

    Comment: One commenter suggested that we modify the behavioral 
criteria in 102.02B for evaluating visual acuity in pre-verbal children 
by stating that the inability to fixate and pursue a one-inch toy at 
one foot with the better eye qualifies as legal blindness in children 
over one year of age. Another commenter suggested that we provide 
additional guidance in 102.00A for evaluating vision loss in young 
children.
    Response: We did not adopt these comments. We believe that the 
guidance we provide in 102.00A5a(iv) sufficiently addresses the fact 
that very young children test differently from older children. We 
believe the requirements of 102.02B adequately address the possible 
issues that may arise when testing very young children. There is no 
need to modify the behavioral criteria. We did, however, clarify in 
final 102.00A5a(iv) that the inability to participate in testing using 
Snellen methodology or other comparable testing must be ``due to your 
young age.''

Scotomas

    Comment: One commenter suggested that we expand our guidance on 
scotomas in 2.00A6h by including information about how scotomas affect 
visual fields. The commenter also suggested that we provide guidance on 
the test instruments that would be best for measuring and evaluating 
the limitations caused by the scotoma.
    Response: We did not adopt this comment. We clarify the definition 
of scotoma by including ``field defect'' in addition to a ``non-seeing 
area.'' We believe that the guidance we provide in 2.00A6h (and 
102.00A6h) for how we consider scotomas when evaluating vision loss, in 
addition to the guidance in 2.00A6a, 2.00A6b, and 2.00A6e (and 
102.00A6a, 102.00A6b, and 102.00A6e) on acceptable perimeters, explains 
sufficiently how scotomas affect visual fields, how we consider 
scotomas, and which instruments are best for measuring visual field 
loss.

Social Security Act

    Comment: Several commenters recommended that we amend the language 
used in the Act regarding blindness.
    Response: We did not adopt these comments. We use the language in 
the Act in our regulations because we do not have the authority to 
revise the language Congress used in the Act without Congressional 
legislation.

Visual Efficiency

    Comment: One commenter noted that the sum of the eight principal 
meridians we identify in the right eye in Figure 1 in 2.00A7 is 
incorrect. The commenter noted that the correct sum of the principal 
meridians should be 530 instead of 500.

[[Page 18839]]

    Response: We partially adopted this comment. We revised Figure 1 in 
2.00A7 and 102.00A7 to show the points on the principal meridians 
clearly. However, because we are using the figure to explain a visual 
efficiency percentage of 100 percent, the sum of the meridians remains 
500.
    Comment: One commenter believed that we should clarify our guidance 
on visual efficiency values and percentages to make it easier to 
differentiate between the two. The commenter said that the term 
``efficiency value'' is inappropriate because it indicates impairment 
rather than severity, and the commenter suggested that we use the term 
``impairment value.'' The commenter also believed that Table 1 in 
2.00A7 is confusing because it contains both values and percentages.
    Response: We adopted these comments. We have revised 2.00A7 and 
102.00A7, and added 2.00A8 and 102.00A8 to include language that 
clarifies the differences between visual acuity efficiency values and 
visual acuity efficiency percentages. We also revised the listing 
criteria for 2.04 and 102.04 to reflect the clarification.

Lenses

    Comment: One commenter suggested that we remove the phrase 
``because they significantly reduce the visual field'' from our 
guidance on telescopic lenses in 2.00A5c because reduced field is only 
one of many reasons why telescopic lenses should not be used to test 
visual acuity.
    Response: We adopted this comment. We agree that there are several 
reasons that the telescopic lens should not be used to test visual 
acuity. It is unnecessary to provide an explanation for why each reason 
is unacceptable for our purposes. We believe that it is sufficient to 
simply state that visual acuity measurements obtained with telescopic 
lenses are unacceptable.
    Comment: One commenter stated that our use of ``perimetric lenses'' 
in proposed 2.00A6g and 102.00A6g is outdated because these types of 
lenses are rarely used in modern medical practice. The commenter 
believed that it would be more logical to measure visual fields using 
the person's usual mode of corrective lenses.
    Response: We partially adopted this comment. One of the goals of 
updating our regulations is to address advances in medical technology 
and terminology. We have removed the term ``perimetric lenses'' from 
2.00A6g. We did not adopt the comment about using the person's usual 
mode of corrective lenses for testing. We continue to provide our 
guidance that eyeglasses should not be worn during visual field 
testing. Visual field testing accommodates the need for eyeglasses or 
other corrective lenses, allowing for accurate measurement of visual 
fields.

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).

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 these final rules meet the criteria for a 
significant regulatory action under Executive Order 12866, as 
supplemented by Executive Order 13563. Therefore, OMB reviewed them.

Regulatory Flexibility Act

    We certify that these final rules will not have a significant 
economic impact on a substantial number of small entities because they 
affect individuals only. Therefore, the Regulatory Flexibility Act, as 
amended, does not require us to prepare a regulatory flexibility 
analysis.

Paperwork Reduction Act

    These rules do not create any new or affect any existing 
collections and, therefore, do not require Office of Management and 
Budget 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.

Carolyn W. Colvin,
Acting Commissioner of Social Security.

    For the reasons set out in the preamble, we are amending 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]

0
1. The authority citation for subpart P of part 404 continues to read 
as follows:

    Authority:  Secs. 202, 205(a)-(b) and (d)-(h), 216(i), 221(a), 
(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).


0
2. Amend appendix 1 to subpart P of part 404 by:
0
a. Revising item 3 of the introductory text before part A.
0
b. Revising section 2.00A in part A.
0
c. Revising sections 2.01 through 2.04 in part A.
0
d. Revising section 102.00A in part B.
0
e. Revising sections 102.101 through 102.104 in part B.
    The revisions read as follows:

Appendix 1 to Subpart P of Part 404--Listing of Impairments

* * * * *
0
3. Special Senses and Speech (2.00 and 102.00): April 29, 2018.
* * * * *
    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

[[Page 18840]]

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. 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.
    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. A standard 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 standard eye examination does not indicate the cause of your vision 
loss, we will request the information 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?
    a. Visual acuity testing. When we need to measure your best-
corrected central visual acuity (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 
have visual acuity testing performed using specialized lens, such as 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.
    d. Cycloplegic refraction is an examination of the eye performed 
after administering cycloplegic eye drops capable of relaxing the 
ability of the pupil to become smaller and temporarily paralyzing the 
focusing muscles. 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 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 2.00A9.)
    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 decibel (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

[[Page 18841]]

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. When the maximum stimulus luminance (0 dB stimulus) on an 
acceptable perimeter is 1,000 asb, a 0 dB stimulus is equivalent to a 
4e stimulus. Any point you see at 0 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. 
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 the evidence in your case 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 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 lenses on a sustained basis.
    h. Scotoma. A scotoma is a field defect or non-seeing area (also 
referred to as a ``blind spot'') in the visual field surrounded by a 
normal field or 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, a calculated value of your remaining 
visual function, is the combination of your visual acuity efficiency 
and your visual field efficiency expressed as a percentage.
    b. Visual acuity efficiency. Visual acuity efficiency is a 
percentage that corresponds to the best-corrected central visual acuity 
for distance in your better eye. See Table 1.

                    Table 1--Visual Acuity Efficiency
------------------------------------------------------------------------
Snellen best-corrected central visual acuity for
                    distance                           Visual acuity
------------------------------------------------- efficiency (%) (2.04A)
        English                   Metric
------------------------------------------------------------------------
           20/16                      6/5                      100
           20/20                      6/6                      100
           20/25                    6/7.5                       95
           20/30                      6/9                       90
           20/40                     6/12                       85
           20/50                     6/15                       75
           20/60                     6/18                       70
           20/70                     6/21                       65
           20/80                     6/24                       60
          20/100                     6/30                       50
------------------------------------------------------------------------

    c. Visual field efficiency. Visual field efficiency is 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. 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.

[[Page 18842]]

[GRAPHIC] [TIFF OMITTED] TR28MR13.002

    d. Visual efficiency. Under 2.04A, 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) 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. How do we determine your visual acuity impairment value, visual 
field impairment value, and visual impairment value?
    a. General. Visual impairment value, a calculated value of your 
loss of visual function, is the combination of your visual acuity 
impairment value and your visual field impairment value.
    b. Visual acuity impairment value. Your visual acuity impairment 
value corresponds to the best-corrected central visual acuity for 
distance in your better eye. See Table 2.

                 Table 2--Visual Acuity Impairment Value
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Snellen best-corrected central visual acuity for       Visual acuity
 distance                                               impairment
                                                     value (2.04B)
------------------------------------------------------------------------
        English                   Metric
------------------------------------------------------------------------
           20/16                      6/5                     0.00
           20/20                      6/6                     0.00
           20/25                    6/7.5                     0.10
           20/30                      6/9                     0.18
           20/40                     6/12                     0.30
           20/50                     6/15                     0.40
           20/60                     6/18                     0.48
           20/70                     6/21                     0.54
           20/80                     6/24                     0.60
          20/100                     6/30                     0.70
------------------------------------------------------------------------

    c. Visual field impairment value. Your visual field impairment 
value corresponds to the visual field in your better eye. Using the MD 
from acceptable automated static threshold perimetry, we calculate the 
visual field impairment 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 
impairment value is: -16 / 22 = 0.73.
    d. Visual impairment value. Under 2.04B, we calculate the visual 
impairment value by adding your visual acuity impairment value (see 
2.00A8b) and your visual field impairment value (see 2.00A8c). For 
example, if your visual acuity impairment value is 0.48 and your visual 
field impairment value is 0.73, your visual impairment value is: 0.48 + 
0.73 = 1.21.
    9. 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 MD.
    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


[[Page 18843]]


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

OR

    B. A visual impairment value of 1.00 or greater after best 
correction (see 2.00A8d).
* * * * *
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.
    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. A standard 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 standard eye examination does not indicate the cause of your vision 
loss, we will request the information 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 due to your young age, 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 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.

[[Page 18844]]

    c. Testing using a specialized lens. In some instances, you may 
have visual acuity testing performed using a specialized lens, such as 
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.
    d. Cycloplegic refraction is an examination of the eye performed 
after administering cycloplegic eye drops capable of relaxing the 
ability of the pupil to become smaller and temporarily paralyzing the 
focusing muscles. 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 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 102.00A9.)
    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 decibel (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. When the maximum stimulus luminance (0 dB stimulus) on an 
acceptable perimeter is 1,000 asb, a 0 dB stimulus is equivalent to a 
4e stimulus. Any point you see at 0 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. 
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 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 lenses on a sustained basis.
    h. Scotoma. A scotoma is a field defect or non-seeing area (also 
referred to as a ``blind spot'') in the visual field surrounded by a 
normal field or 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.

[[Page 18845]]

    7. How do we determine your visual acuity efficiency, visual field 
efficiency, and visual efficiency?
    a. General. Visual efficiency, a calculated value of your remaining 
visual function, is the combination of your visual acuity efficiency 
and your visual field efficiency expressed as a percentage.
    b. Visual acuity efficiency. Visual acuity efficiency is a 
percentage that corresponds to the best-corrected central visual acuity 
for distance in your better eye. See Table 1.

                    Table 1--Visual Acuity Efficiency
------------------------------------------------------------------------
Snellen best-corrected central visual acuity for
                    distance                           Visual acuity
-------------------------------------------------     efficiency (%)
        English                   Metric                 (102.04A)
------------------------------------------------------------------------
           20/16                      6/5                      100
           20/20                      6/6                      100
           20/25                    6/7.5                       95
           20/30                      6/9                       90
           20/40                     6/12                       85
           20/50                     6/15                       75
           20/60                     6/18                       70
           20/70                     6/21                       65
           20/80                     6/24                       60
          20/100                     6/30                       50
------------------------------------------------------------------------

    c. Visual field efficiency. Visual field efficiency is 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. 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] TR28MR13.003

    d. Visual efficiency. Under 102.04A, 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) 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. How do we determine your visual acuity impairment value, visual 
field impairment value, and visual impairment value?
    a. General. Visual impairment value, a calculated value of your 
loss of visual function, is the combination of your visual acuity 
impairment value and your visual field impairment value.
    b. Visual acuity impairment value. Your visual acuity impairment 
value corresponds to the best-corrected central visual acuity for 
distance in your better eye. See Table 2.

                 Table 2--Visual Acuity Impairment Value
------------------------------------------------------------------------
Snellen best-corrected central visual acuity for
                    distance                           Visual acuity
-------------------------------------------------    impairment value
        English                   Metric                 (102.04B)
------------------------------------------------------------------------
           20/16                      6/5                     0.00
           20/20                      6/6                     0.00
           20/25                    6/7.5                     0.10
           20/30                      6/9                     0.18
           20/40                     6/12                     0.30
           20/50                     6/15                     0.40
           20/60                     6/18                     0.48
           20/70                     6/21                     0.54

[[Page 18846]]

 
           20/80                     6/24                     0.60
          20/100                     6/30                     0.70
------------------------------------------------------------------------

    c. Visual field impairment value. Your visual field impairment 
value corresponds to the visual field in your better eye. Using the MD 
from acceptable automated static threshold perimetry, we calculate the 
visual field impairment 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 
impairment value is: [bond]-16[bond] / 22 = 0.73.
    d. Visual impairment value. Under 102.04B, we calculate the visual 
impairment value by adding your visual acuity impairment value (see 
102.00A8b) and your visual field impairment value (see 102.00A8c). For 
example, if your visual acuity impairment value is 0.48 and your visual 
field impairment value is 0.73, your visual impairment value is: 0.48 + 
0.73 = 1.21.
    9. 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.
* * * * *
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, or visual impairment, in the 
better eye:
    A. A visual efficiency percentage of 20 or less after best 
correction (see 102.00A7d.).

OR

    B. A visual impairment value of 1.00 or greater after best 
correction (see 102.00A8d).
* * * * *
[FR Doc. 2013-06975 Filed 3-27-13; 8:45 am]
BILLING CODE 4191-02-P