2015-13788. Schedule for Rating Disabilities; The Organs of Special Sense and Schedule of Ratings-Eye

AGENCY:

Department of Veterans Affairs.

ACTION:

Proposed rule.

SUMMARY:

The Department of Veterans Affairs (VA) proposes to amend the portion of the VA Schedule for Rating Disabilities (VASRD or rating schedule) that addresses the organs of special sense and schedule of ratings—eye. The purpose of these changes is to incorporate medical advances that have occurred since the last review, update current medical terminology, and provide clear evaluation criteria. The proposed rule reflects advances in medical knowledge, recommendations from the National Academy of Sciences (NAS), and comments from subject matter experts and the public garnered as part of a public forum. The public forum, focusing on revisions to the organs of special sense and schedule of ratings for eye disabilities, was held on January 19-20, 2012.

DATES:

Comments must be received on or before August 10, 2015.

ADDRESSES:

Written comments may be submitted through www.Regulations.gov;​; by mail or hand-delivery to Director, Office of Regulation Policy and Management (02REG), Department of Veterans Affairs, 810 Vermont Avenue NW., Room 1068, Washington, DC 20420; or by fax to [phone]. Comments should indicate that they are submitted in response to “RIN 2900-AP14-Schedule for Rating Disabilities; The Organs of Special Sense and Schedule of Ratings—Eye.” Copies of comments received will be available for public inspection in the Office of Regulation Policy and Management, Room 1068, between the hours of 8:00 a.m. and 4:30 p.m., Monday through Friday (except holidays). Please call [phone] for an appointment. (This is not a toll-free number.) In addition, during the comment period, comments may be viewed online through the Federal Docket Management System (FDMS) at www.Regulations.gov.

FOR FURTHER INFORMATION CONTACT:

Nick Olmos-Lau, M.D., Medical Officer, Part 4 VASRD Staff (211C), Compensation Service, Veterans Benefits Administration, Department of Veterans Affairs, 810 Vermont Avenue NW., Washington, DC 20420, [phone]. (This is not a toll-free telephone number.)

SUPPLEMENTARY INFORMATION:

As part of VA's ongoing revision of the VA Schedule for Rating Disabilities (VASRD or rating schedule), VA proposes changes to 38 CFR 4.77-4.79, which pertain to the organs of special sense and disabilities and disease of the eye. The proposed changes will: (1) Update the medical terminology of certain eye conditions; (2) add medical conditions frequently encountered but not currently found in the rating schedule; and (3) refine evaluation criteria based on medical advances that have occurred since the last revision and current understanding of functional changes associated with or resulting from disease or injury (pathophysiology).

I. § 4.77 Visual Fields

Current § 4.77(a) requires examiners to record the results of visual field testing on a standard Goldmann chart and include the Goldmann chart with the examination report. In order to improve the efficiency and timeliness of claims processing, VA proposes to eliminate the requirement that examiners provide VA with the Goldmann chart and instead only require the visual field measurements necessary for rating purposes.

An examination of visual fields requires an examiner to indicate the Veteran's maximum visual field at 16 prescribed points of measurement. Under the current regulation, if the results of an examination do not include the Goldmann chart used for visual field testing, it must be returned to the examiner for inclusion of the completed chart prior to evaluating the disability. This results in unnecessary delays in claims where all relevant information to evaluate visual field impairment is present, but is not in the prescribed format. In addition to reducing delays in processing time, eliminating the chart requirement expands the ability to evaluate disabilities on the basis of private treatment records, provided they contain sufficient evidence to evaluate the disability. Under the proposed change, an examination of a visual field impairment is sufficient for rating purposes if it provides, at a minimum, visual field measurements of at least 16 meridians 221/2 degrees apart for each eye and it indicates the Goldmann equivalent used during testing. As this information need not be provided in a chart format, VA proposes to amend in current paragraph (a) the phrase “The examiner must chart at least 16 meridians . . .” to read “The examiner must document the results for at least 16 meridians . . .”.

Similarly, VA proposes to amend the language in current paragraph (a) which directs an examiner to “include the tracing of either the tangent screen or of the 30-degree threshold visual field . . .” when additional testing is required. As above, VA proposes that the examiner need only “document the results” of the additional testing rather than provide the actual tracing itself.

No other changes to § 4.77 are proposed.

II. § 4.78 Muscle Function

Section 4.78(a) currently requires muscle function to be examined and measured using Goldmann perimeters. However, due to the increasing difficulty encountered by evaluation facilities in acquiring and repairing Goldmann perimeters, the Tangent Screen has been developed as an alternative method for documenting alteration of eye muscle function. David F. Chang, Chapter 2. Ophthalmologic Examination, Vaughan & Asbury's General Ophthalmology, http://accessmedicine.mhmedical.com/​content.aspx?​bookid=​387&​Sectionid=​40229319 (last visited Apr. 29, 2014). The Tangent Screen is an inexpensive device, commonly found in many eye clinics, and is used to test for diplopia due to eye muscle dysfunction. Like the Goldmann perimeter, the results of the Tangent Screen method are documented on a Goldmann chart recording sheet, which plots areas of diplopia across the major visual fields. Furthermore, the results of both tests are relatively similar. See Agnes M.F. Wong, MD, and James A. Sharpe, MD, A Comparison of Tangent Screen, Goldmann, and Humphrey Perimetry in the Detection and Localization of Occipital Lesions, Ophthalmology 1107:527-544 (2000). In order to accommodate more modern and readily available methods, VA proposes to amend § 4.78(a) to allow for measurement of muscle function using either Goldmann perimeters or Tangent Screen method.

Current § 4.78(a) requires examiners to plot the results of muscle function testing on a standard Goldmann chart and include the chart with the examination report. VA proposes to remove these requirements for the same reasons indicated in the section above discussing proposed changes to § 4.77. Under the proposed change, an examination of muscle function is sufficient for rating purposes if it identifies the quadrant(s) and range(s) of degrees in which diplopia exists.

No other changes to § 4.78 are proposed.

III. § 4.79 Schedule of Ratings—Eye

Current § 4.79 contains a General Rating Formula for Diagnostic Codes 6000 through 6009. This formula evaluates disease of the eye on the basis of incapacitating episodes or visual impairment (impairment of visual acuity, visual field, and/or muscle function), whichever provides the highest evaluation. Currently, “incapacitating episodes” is defined as a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. This definition provides limited applicability of the rating formula as bed rest is no longer a uniformly valid method of treatment, nor is it a pertinent domain in the field of disability criteria. R.I. Cho & E. Savitsky, Ocular Trauma, Combat Casualty Care: Lessons Learned from OEF and OIF, 299 (M. Lenhart ed. 2012). Limiting the definition to bed rest categorically excludes periods of incapacitation due to eye disease requiring intensive treatment and medical management other than bed rest, as well as the potential for development of medical complications. Therefore, VA proposes to update the definition of an incapacitating episode to mean an episode that requires clinic visits for treatment for an active eye disease.

Through its definition, VA intends to require that these visits be documented in the medical record by a physician or other health care provider and that such visits must relate to the monitoring of progress, administration of treatment(s), and the development of complications related to the underlying active eye disability. Incorporating documented treatment allows for consideration of intensive interventional care, the use of complex drugs, and the placement of devices when evaluating the severity of a given eye disability. By providing evaluations based on the duration of treatment for an active eye disease, the proposed criteria more accurately reflect occupational disruption and impairment due to eye diseases that do not necessarily involve measurable visual impairment. This updated definition of incapacitating episodes aligns with modern medical practice and the treatment of eye diseases, providing an alternative basis for evaluation of eye disabilities in the absence of visual impairment. VA also proposes to add a non-exhaustive list of examples of treatment to the definition of incapacitating episodes. This list would clarify the evaluation criteria to claims processors and ease application of the rating schedule by indicating possible treatment options for the various eye diseases.

VA proposes a 60 percent evaluation for documented incapacitating episodes requiring 10 or more medical visits for monitoring or treatment of an active eye disease or complications per year. A 40 percent evaluation is proposed for documented incapacitating episodes requiring at least 7 but no more than 9 medical visits for monitoring or treatment of an active eye disease or complications per year. A 20 percent evaluation is proposed for documented incapacitating episodes requiring at least 4 but no more than 6 medical visits for monitoring or treatment of an active eye disease or complications per year. VA proposes a 10 percent evaluation for documented incapacitating episodes requiring 3 medical visits for monitoring or treatment of an active eye disease or complications per year.

VA would add a note to § 4.79 that would refer raters, when evaluating visual impairment due to the particular condition, to 38 CFR 4.75-4.78 and to § 4.79, diagnostic codes 6061-6090.

A. Diseases of the Eye—Organizational Headings

The current schedule of ratings for the eye contains one general category for Diseases of the Eye with a limited listing of diagnoses and/or disabilities. This category does not organize the listed disabilities in a manner that represents the current scientific understanding of the specific anatomy of the eye, etiology of the disease, or the disabling effect of the disease itself. When presented with a diagnosis that is not listed in the rating schedule, claims processors must rate by analogy to a listed diagnosis.

Section 4.27 directs claims processors to analogize these disabilities on the basis of disease similarity and residual disability to allow for easy identification of the source of each rating. However, it is specifically noted that “the diagnostic terminology will be that of the medical examiner, with no attempt to translate the terms into schedule nomenclature.” Id. In other words, the determination of disease type and residual disability is to be made by a medical professional; the claims processor should not partake in any type of medical determination when deciding how to rate analogously.

In order to ease the use of analogous codes when evaluating eye diseases, VA proposes to organize the Diseases of the Eye into nine categories. These diagnostic categories organize the listed disabilities into medically logical sets on the basis of diagnostic criteria, anatomical location, and disease etiology. By grouping disabilities according to medical criteria, the categories would ease the use of analogous coding by claims processors. Additionally, the categories would allow VA to track the use of analogous codes with more specificity, providing data on the need for inclusion of new disabilities in future revisions to the VASRD.

All disabilities contained in § 4.79 would be evaluated under the General Rating Formula for Diseases of the Eye unless otherwise directed. The organizational categories and specific diagnostic codes within each category are as follows:

B. Diseases of the Uveal Tract

The uveal tract consists of three eye structures: the iris, the ciliary body, and the choroid. This category of conditions includes infections, inflammations including Tuberculosis of the eye (DC 6010) and other diseases involving these three structures of the eye. This category would include the following diagnostic codes (DCs): DC 6000, choroidopathy, including uveitis, iritis, cyclitis, and choroiditis; and DC 6002, scleritis. VA proposes to continue evaluating both conditions under the General Rating Formula for Diseases of the Eye, as amended above.

C. Diseases of the Retina, Macula, and Vitreous

The retina is the inner layer of the eye, containing blood vessels and nerve structures that connect the eye with the optic nerve and brain. The retina participates in light, motion, and color perception and image formation. The macula is the visual center of the eye and contains receptors that perceive light and color. Vitreous is the thick, transparent substance that fills the eye, providing it with volume and shape. This category includes the following diagnostic codes:

1. Diagnostic Code 6006

Current DC 6006 addresses retinopathy or maculopathy. VA proposes to clarify this code as “not otherwise specified,” as new DCs are proposed to capture other specified types of retinopathy. If the retinopathy diagnosed is not one of the other specified diagnoses, it will be evaluated as DC 6006. This condition would continue to be evaluated under the General Rating Formula for Diseases of the Eye.

2. Diagnostic Code 6008

VA proposes to continue evaluating this condition, detachment of the retina, under the General Rating Formula for Diseases of the Eye. VA proposes no other changes to this diagnostic code.

3. Diagnostic Code 6011

Current DC 6011 instructs claims processors to evaluate retinal scars, atrophy, or irregularities as 10 percent disabling if such scars, etc., are centrally located and result in an irregular, duplicated, enlarged, or diminished image. Alternatively, claims processors may evaluate based on visual impairment. VA proposes to further expand this alternate rating criteria by directing claims processors to evaluate this condition under the General Rating Formula for Diseases of the Eye if this would result in a higher evaluation. In other words, the only change to the diagnostic code is to allow this condition to be evaluated on the basis of “incapacitating episodes,” in addition to visual impairment or the nature of the scar, atrophy, or irregularity itself.

4. New Diagnostic Code 6040

VA proposes to add a new DC 6040, titled “Diabetic retinopathy,” in order to account for retinal impairment specifically caused by diabetes in the Veteran population. Visual impairment is a common complication of diabetes mellitus. Diabetes is the most significant cause of visual impairment and blindness in the United States in working age adults. James Orcutt et al., Eye Disease in Veterans with Diabetes, 27 Diabetes Care B50 (2004). Epidemiologic studies of diabetic retinopathy show that 15 years after the onset of diabetes, retinopathy appears in 97 percent of patients with type 1 diabetes, 80 percent of type 2 diabetes treated with insulin, and 55 percent of type 2 diabetes treated without insulin. Id. The most severe form of retinopathy (proliferative) was evident 15 years after the initial diagnosis of diabetes in 30 percent of cases with type 1 diabetes, in 15 percent of those with type 2 diabetes treated with insulin, and in 5 percent of those not treated with insulin. Id. Of 429,918 patients treated at the VA hospital with diabetes in 1998, 9.5 percent developed proliferative retinopathy related to diabetes. In addition, the study noted that diabetic veterans with lower-extremity amputations have an increased risk for developing diabetic retinopathy. Id. at 52.

Currently, this condition is evaluated under DC 6006 (retinopathy or maculopathy) without any method of identifying those cases caused by diabetes. Given the significance of diabetes in the Veteran population and the likelihood of developing this related eye disease, VA proposes to add a separate diagnostic code to properly track and evaluate the Veteran population with diabetic retinopathy. VA proposes to continue evaluating this condition under the General Rating Formula for Diseases of the Eye.

5. New Diagnostic Code 6042

VA proposes to add a new DC 6042, titled “Retinal dystrophy (including retinitis pigmentosa),” in order to account for impairment due to this condition in the Veteran population. Retinal dystrophy is an important and growing group of disorders that cause blindness. Included within the larger group of retinal dystrophy is retinitis pigmentosa, perhaps the best known and most commonly recognized condition. While retinitis pigmentosa is hereditary, the onset of symptoms may be delayed until early adult years, meaning impairment may not manifest until well after an individual has begun his or her military service. In certain situations, disability compensation can be provided to Veterans with this condition when the symptoms first manifest themselves during active duty military service. To reinforce the potential for service-connection for these disabilities, VA proposes to add a specific diagnostic code for these conditions.

In retinitis pigmentosa there is a gradual loss of the eye photoreceptors (rods and cones) with a deposition of pigment caused by involutional changes of the cells of the retinal pigment epithelium layer. Retinitis pigmentosa, A.D.A.M. Medical Encyclopedia, PubMed Health, U.S. National Library of Medicine, http://www.ncbi.nlm.nih.gov/​pubmedhealth/​PMH0002024/​ (last visited Apr. 29, 2014). This leads to the gradual onset of night blindness, tripping over objects in the visual periphery due to constricion of the peripheral visual field, tunnel vision, and eventually total blindness. Id. There is currently no known effective treatment for this condition. Id. Given the functional effects of this disability, VA proposes to evaluate this condition under the General Rating Formula for Diseases of the Eye, which would allow for rating based on either visual impairment or on incapacitating episodes.

D. Glaucoma

Glaucoma is a group of diseases that can damage the eye's optic nerve and can result in loss of vision. Glaucoma, MayoClinic, http://www.mayoclinic.org/​diseases-conditions/​glaucoma/​basics/​symptoms/​con-20024042 (last visited Apr. 29, 2014). The most common types of glaucoma are open-angle glaucoma and angle-closure glaucoma. Id.

Angle closure glaucoma is due to a blockage of the fluid (aqueous humor) drainage canals, causing a rapid and dangerous increase in eye pressure. This is an acute emergency that can lead to permanent visual loss. These conditions can be primary or secondary to an injury, medication, inflammation, tumor, or other medical condition. Id. This category includes the following diagnostic codes:

1. Diagnostic Code 6012

Current DC 6012, angle-closure glaucoma, lists evaluation criteria based on either visual impairment or on incapacitating episodes, whichever results in a higher evaluation. In addition, a minimum 10 percent evaluation is provided for the requirement of continuous medication. For clarity and uniformity with the remainder of § 4.79, VA proposes to include the general instruction to evaluate this disability under the General Rating Formula for Diseases of the Eye with a minimum evaluation of 10 percent when continuous medication is required.

2. Diagnostic Code 6013

Current DC 6013, open-angle glaucoma, states to evaluate on the basis of visual impairment due to this condition. VA proposes to direct evaluation under the General Rating Formula for Diseases of the Eye, which includes evaluation on the basis of visual impairment or incapacitating episodes, whichever provides a higher evaluation. This proposal expands the evaluation criteria to provide an alternative measure of disability outside the realm of visual impairment for this disability, allowing VA to more accurately and adequately capture the disabling effects.

Current DC 6013 also provides a minimum 10 percent evaluation if continuous medication is required for treatment. VA proposes no change to this minimum evaluation.

E. Ocular Neoplasms and Trauma

This category includes current diagnostic codes for neoplasms of the eye (both malingnant and benign) as well as eye traumas. This category includes the following diagnostic codes:

1. Diagnostic Code 6007

VA proposes to continue evaluating DC 6007, intraocular hemorrhage, under the General Rating Formula for Diseases of the Eye. VA proposes no other changes to this diagnostic code.

2. Diagnostic Code 6009

Current DC 6009, unhealed eye injury, includes orbital trauma, as well as penetrating and non-penetrating eye injury. VA proposes to continue evaluating this condition under the General Rating Formula for Diseases of the Eye. VA also proposes to add a note stating that this code includes orbital trauma, as well as penetrating and non-penetrating eye injury. This note would facilitate the identification and recording of significant eye injuries in one DC.

3. Diagnostic Code 6014

Current DC 6014 evaluates malignant neoplasm of the eyeball only. VA proposes to replace the word “eyeball” with “eye” to conform with modern medical terminology. The preferred nomenclature in medicine for the organ of vision is the eye. While eyeball and eye are used interchangeably, it is customary to use the word eye when referring to diseases or anatomy. American Academy of Ophthalmology, Introducing Ophthalmology: A Primer for Office Staff, 8 (3d ed. 2013). Additionally, VA proposes to clarify that this diagnostic code includes malignant neoplasms of the orbit and adnexa. The most prevalent intraocular malignant neoplasms include uveal melanoma, intraocular lymphoma, and intraocular metastasis. These malignancies affect not only the eyeball, but often involve the orbit and adnexa. To ensure these malignancies are adequately evaluated under the VASRD, VA proposes to clarify that DC 6014 is not limited to neoplasms of the eyeball only. Malignant neoplasms of the skin are still excluded as these are evaluated under current DC 7818 within a different body system. VA proposes no changes to the evaluation criteria for DC 6014.

4. Diagnostic Code 6015

Current DC 6015 evaluates benign neoplasm of the eyeball and adnexa only. VA proposes to replace the word “eyeball” with “eye” to conform with modern medical terminology. Id. Additionally, VA proposes to expand the applicability of this diagnostic code to include benign neoplasms of the orbit, this includes lid tumors in adults, cavernous hemangioma, dermoid, epidermal cysts and other conditions. By expanding the applicability, the VASRD would provide a specific diagnostic code for the evaluation of benign growths of the orbit and adnexa. Benign neoplasms of the skin are still excluded as these are evaluated under current DC 7819 within a different body system. VA proposes no changes to the evaluation criteria for DC 6015.

F. Conditions of the Lacrimal System

The lacrimal system consists of the lacrimal glands and the nasolacrimal duct. This system is responsible for the secretion and drainage of tears and, when properly functioning, serves to moisten, lubricate, and protect the surface of the eye. Cat N. Burkat MD, and Mark J. Lucarelli MD, Anatomy of the Lacrimal System, The Lacrimal System: Diagnosis, Management, and Surgery, http://link.springer.com/​book/​10.1007%2F978-0-387-35267-1. This category includes DC 6025, which pertains to disorders of the lacrimal apparatus (epiphora, dacrocystitis, etc.). VA proposes no changes to this diagnostic code.

G. Corneal Diseases

The cornea is the eye's outermost layer. It is a clear, dome-shaped surface, overlying the pupil, that covers the front of the eye. Facts About the Cornea and Corneal Disease, National Eye Institute, http://www.nei.nih.gov/​health/​cornealdisease/​ (last visited Apr. 29, 2014). The cornea functions as a lens which focuses light on the retina. Id. An injury to the cornea generally produces redness, itching, tearing, and, depending on the severity of the injury, pain and blurring of vision. Id. This category includes the following diagnostic codes:

1. Diagnostic Code 6001

VA proposes to continue evaluating DC 6001, keratopathy, under the General Rating Formula for Diseases of the Eye. VA proposes no other changes to this diagnostic code.

2. Diagnostic Codes 6017 and 6018

Current DC 6017 states to evaluate trachomatous conjunctivitis on the basis of visual impairment when this condition is active, with a minimum evaluation of 30 percent. Current DC 6018 states to evaluate chronic conjunctivitis (nontrachomatous) on the basis of visual impairment when this condition is active, with a minimum evaluation of 10 percent.

VA proposes to direct evaluation of active trachomatous and nontrachomatous conjunctivitis under the General Rating Formula for Diseases of the Eye, which includes evaluation on the basis of visual impairment or incapacitating episodes, whichever provides a higher evaluation. This proposal expands the evaluation criteria to provide an alternative measure of disability outside the realm of visual impairment for these disabilities, allowing VA to more accurately and adequately capture the disabling effects. VA proposes to retain the respective minimum evaluations for cases of active conjunctivitis.

Once conjunctivitis (trachomatous or nontrachomatous) is found to be inactive, current DCs 6017 and 6018 state to evaluate based on residuals, including visual impairment or disfigurement under DC 7800. VA proposes no change to these evaluation criteria.

3. Diagnostic Code 6035

Current DC 6035 states to evaluate keratoconus on the basis of visual impairment due to this condition. VA proposes to direct evaluation under the General Rating Formula for Diseases of the Eye, which includes evaluation on the basis of visual impairment or incapacitating episodes, whichever provides a higher evaluation. This proposal expands the evaluation criteria to provide an alternative measure of disability outside the realm of visual impairment for this disability, allowing VA to more accurately and adequately capture the disabling effects.

4. Diagnostic Code 6036

Current DC 6036 states to evaluate status post corneal transplant on the basis of visual impairment due to this condition, with a minimum evaluation of 10 percent in the presence of pain, photophobia, and glare sensitivity. VA proposes to direct evaluation under the General Rating Formula for Diseases of the Eye, which includes evaluation on the basis of visual impairment or incapacitating episodes, whichever provides a higher evaluation. This proposal expands the evaluation criteria to provide an alternative measure of disability outside the realm of visual impairment for this disability, allowing VA to more accurately and adequately capture the disabling effects. VA intends to retain the minimum evaluation of 10 percent in the presence of pain, photophobia, and glare sensitivity.

H. External Eye Diseases, Including the Eyelash, Eyelid, and Eyebrow

The external eye disease category consists of a group of conditions involving the ocular-related structures, which have direct contact with the environment, and includes the eyelids, eyelashes, and eyebrows. While the cornea has direct contact with the environment as well, VA has provided a separate category for diseases of the cornea. The external eye diseases category includes nine conditions of the eyelashes, eyelids, and eyebrows listed in the current VASRD. This category includes the following diagnostic codes in which no change is proposed to the current evaluation criteria: DC 6020, Ectropion; DC 6021, Entropion; DC 6022, Lagophthalmos; DC 6023, Loss of eyebrows, complete, unilateral or bilateral; DC 6024, Loss of eyelashes, complete, unilateral or bilateral; DC 6032, Loss of eyelids, partial or complete; and DC 6037, Pinguecula. It also includes the following diagnostic codes with specific proposed changes.

Current DC 6034 states to evaluate pterygium on the basis of visual impairment, disfigurement (DC 7800), conjunctivitis (DC 6018), etc., depending on the particular findings. Similarly, current DC 6091 states to evaluate symblepharon on the basis of visual impairment, lagophthalmos (DC 6022), disfigurement (DC 7800), etc., depending on the particular findings.

In both cases, VA proposes to replace the direction to evaluate on the basis of visual impairment with the General Rating Formula for Diseases of the Eye, which includes evaluation on the basis of visual impairment or incapacitating episodes, whichever provides a higher evaluation. This proposal expands the evaluation criteria to provide an alternative measure of disability outside the realm of visual impairment for these disabilities, allowing VA to more accurately and adequately capture the disabling effects. VA also proposes to include the phrase “and combine in accordance with § 4.25” to the rating instructions of DCs 6034 and 6091. The current language allows for multiple evaluations to be assigned and combined depending on the particular findings, but it is not entirely clear to the reader. Therefore, this addition would ensure consistency and clarity for field application.

VA proposes no other changes to these diagnostic codes.

I. Disease of the Lens

The lens is a crystalline, transparent structure covered by a capsule and suspended by a ligament that weakens with age. Henry Gray, Anatomy of the Human Body, 1019-20 (20th ed. 1918). The lens capsule is lined in the anterior portion by an epithelium that generates new lens fibers at the equators. Id. In addition to malformation and malposition, the main lens pathology is cataract formation. A cataract is a lens opacity which produces visual impairment by obscuration and altered light refraction. Facts About Cataract, National Eye Institute, https://www.nei.nih.gov/​health/​cataract/​cataract_​facts.asp (last visited Apr. 29, 2014). This category includes evaluation criteria for DC 6029, Aphakia or dislocation of crystalline lens for which VA proposes no changes. It also includes the following diagnostic codes with specific proposed changes.

Current DC 6027 states to evaluate preoperative cataracts on the basis of visual impairment. VA proposes to direct evaluation of preoperative cataracts under the General Rating Formula for Diseases of the Eye, which includes evaluation on the basis of visual impairment or incapacitating episodes, whichever provides a higher evaluation. This proposal expands the evaluation criteria to provide an alternative measure of disability outside the realm of visual impairment for this disability, allowing VA to more accurately and adequately capture the disabling effects.

Current DC 6027 also provides two evaluation options for postoperative cataracts depending on the presence or absence of a replacement lens. If a replacement lens is present, current DC 6027 states to evaluate on the basis of visual impairment. VA proposes to direct the evaluation of postoperative cataracts with a replacement lens under the General Rating Formula for Diseases of the Eye for the same reasons discussed above. If there is no replacement lens present, current DC 6027 states to evaluate based on aphakia (DC 6029). VA proposes only to insert the applicable DC. No substantive change is proposed.

J. Neuro-Ophthalmic Conditions

This category includes a listing of the most common and pertinent neuro-ophthalmic conditions, to include diseases of the anterior visual pathways, optic nerve disorders, cranial nerve palsies resulting in visual impairment, disorders of eye movements, and pupillary disorders. The field of neuro-ophthalmology bridges the gap between neurology and ophthalmology by providing particular attention to visual impairment due to diseases of the neural structures involved in vision. Since a substantial portion of the brain is involved with vision, many brain disorders produce visual impairment. This category includes the following diagnostic codes in which no change is proposed to the current evaluation criteria: DC 6016, Nystagmus, central; DC 6019, Ptosis, unilateral or bilateral; and DC 6030, Paralysis of accommodation (due to neuropathy of the Oculomotor Nerve (cranial nerve III)). It also includes the following diagnostic code with specific proposes changes.

1. Diagnostic Code 6026

Current DC 6026 states to evaluate optic neuropathy on the basis of visual impairment due to this condition. VA proposes to direct evaluation under the General Rating Formula for Diseases of the Eye, which includes evaluation on the basis of visual impairment or incapacitating episodes, whichever provides a higher evaluation. This proposal expands the evaluation criteria to provide an alternative measure of disability outside the realm of visual impairment for this disability, allowing VA to more accurately and adequately capture the disabling effects.

2. New Diagnostic Code 6046

VA proposes to add a new DC 6046, titled “Post-chiasmal disorders.” This category includes a variety of central visual disorders with brain involvement. This category incorporates ophthalmic residuals from traumatic brain injury (TBI) or other causes of cerebral injury, such as infectious, vascular conditions, or degenerative conditions. Post-chiasmal disorders may be associated with cognitive changes caused by the structural or functional alteration of the brain tissue, which are often associated with TBI. See James Garrity MD, Overview of Optic Nerve Disorders, The Merck Manual Home Health Handbook, http://www.merckmanuals.com/​home/​eye_​disorders/​optic_​nerve_​disorders/​overview_​of_​optic_​nerve_​disorders.html (last visited Apr. 29, 2014) (each optic nerve splits at a structure in the brain called the optic chiasm). The alteration can lead to brain dysfunction which can manifest as a variety of visual impairments. Given the increased awareness and understanding of the chronic residuals of TBI in the medical community, particularly amongst the Veteran population, VA proposes this new diagnostic code to provide adequate and proper evaluations for Veterans with post-chiasmal disorders. Due to the varying presentation of post-chiasmal disorders, VA proposes to evaluate these conditions under the General Rating Formula for Diseases of the Eye to maximize the options available for an accurate evaluation.

IV. Technical Amendments

VA also would update Appendix A, B, and C of part 4 to reflect the above noted proposed amendments.

Executive Orders 12866 and 13563

Executive Orders 12866 and 13563 direct agencies to assess the costs and benefits of available regulatory alternatives and, when regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, and other advantages; distributive impacts; and equity). Executive Order 13563 (Improving Regulation and Regulatory Review) emphasizes the importance of quantifying both costs and benefits, reducing costs, harmonizing rules, and promoting flexibility. Executive Order 12866 (Regulatory Planning and Review) defines a “significant regulatory action,” which requires review by the Office of Management and Budget (OMB), as “any regulatory action that is likely to result in a rule that may: (1) Have an annual effect on the economy of $100 million or more or adversely affect in a material way the economy, a sector of the economy, productivity, competition, jobs, the environment, public health or safety, or State, local, or tribal governments or communities; (2) Create a serious inconsistency or otherwise interfere with an action taken or planned by another agency; (3) Materially alter the budgetary impact of entitlements, grants, user fees, or loan programs or the rights and obligations of recipients thereof; or (4) Raise novel legal or policy issues arising out of legal mandates, the President's priorities, or the principles set forth in this Executive Order.”

The economic, interagency, budgetary, legal, and policy implications of this proposed rule have been examined, and it has been determined not to be a significant regulatory action under Executive Order 12866. VA's impact analysis can be found as a supporting document at http://www.regulations.gov, usually within 48 hours after the rulemaking document is published. Additionally, a copy of this rulemaking and its impact analysis are available on VA's Web site at http://www.va.gov/​orpm/​, by following the link for “VA Regulations Published From FY 2004 Through Fiscal Year to Date.”

Regulatory Flexibility Act

The Secretary hereby certifies that this proposed rule would not have a significant economic impact on a substantial number of small entities as they are defined in the Regulatory Flexibility Act, 5 U.S.C. 601-612. This proposed rule would not affect any small entities. Only certain VA beneficiaries could be directly affected. Therefore, pursuant to 5 U.S.C. 605(b), this proposed rule is exempt from the initial and final regulatory flexibility analysis requirements of sections 603 and 604.

Unfunded Mandates

The Unfunded Mandates Reform Act of 1995 requires, at 2 U.S.C. 1532, that agencies prepare an assessment of anticipated costs and benefits before issuing any rule that may result in the expenditure by State, local, and tribal governments, in the aggregate, or by the private sector, of $100 million or more (adjusted annually for inflation) in any one year. This proposed rule would have no such effect on State, local, and tribal governments, or on the private sector.

Paperwork Reduction Act

This proposed rule contains no provisions constituting a collection of information under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3521).

Catalog of Federal Domestic Assistance

The Catalog of Federal Domestic Assistance program numbers and titles for this rule are 64.009, Veterans Medical Care Benefits; 64.104, Pension for Non-Service-Connected Disability for Veterans; 64.109, Veterans Compensation for Service-Connected Disability; and 64.110, Veterans Dependency and Indemnity Compensation for Service-Connected Death.

Signing Authority

The Secretary of Veterans Affairs, or designee, approved this document and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs. Robert A. McDonald, Secretary of Veterans Affairs, approved this document on May 10, 2015, for publication.

List of Subjects in 38 CFR Part 4

• Disability benefits
• Pensions
• Veterans

Approved: June 2, 2015.

William F. Russo,

Acting Director, Office of Regulation Policy & Management.

For the reasons set out in the preamble, VA proposes to amend 38 CFR part 4, subpart B as set forth below:

PART 4—SCHEDULE FOR RATING DISABILITIES

Subpart B—Disability Ratings

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

Authority: 38 U.S.C. 1155, unless otherwise noted.

2. Amend § 4.77 by revising paragraph (a) to read as follows:

§ 4.77

Visual fields.

(a) Examination of visual fields. Examiners must use either Goldmann kinetic perimetry or automated perimetry using Humphrey Model 750, Octopus Model 101, or later versions of these perimetric devices with simulated kinetic Goldmann testing capability. For phakic (normal) individuals, as well as for pseudophakic or aphakic individuals who are well adapted to intraocular lens implant or contact lens correction, visual field examinations must be conducted using a standard target size and luminance, which is Goldmann's equivalent III/4e. For aphakic individuals not well adapted to contact lens correction or pseudophakic individuals not well adapted to intraocular lens implant, visual field examinations must be conducted using Goldmann's equivalent IV/4e. The examiner must document the results for at least 16 meridians 221/2 degrees apart for each eye and indicate the Goldmann equivalent used. See Table III for the normal extent (in degrees) of the visual fields at the 8 principal meridians (45 degrees apart). When the examiner indicates that additional testing is necessary to evaluate visual fields, the additional testing must be conducted using either a tangent screen or a 30-degree threshold visual field with the Goldmann III stimulus size. The examination report must document the results of either the tangent screen or of the 30-degree threshold visual field with the Goldmann III stimulus size.

* * * * *

3. Amend § 4.78 by revising paragraph (a) to read as follows:

§ 4.78

Muscle function.

(a) Examination of muscle function. The examiner must use a Goldmann perimeter chart or the Tangent Screen method that identifies the four major quadrants (upward, downward, left and right lateral) and the central field (20 degrees or less) (see Figure 2). The examiner must document the results of muscle function testing by identifying the quadrant(s) and range(s) of degrees in which diplopia exists.

* * * * *

4. Amend § 4.79 Schedule of ratings—eye by revising the tables Diseases of the Eye and Ratings for Impairment of Muscle Function to read as follows:

Diseases of the Eye

	Rating
Unless otherwise directed, evaluate diseases of the eye under the General Rating Formula for Diseases of the Eye.
General Rating Formula for Diseases of the Eye:
Evaluate on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation.
With documented incapacitating episodes requiring 10 or more medical visits for monitoring or treatment of an active eye disease or complications per year	60
With documented incapacitating episodes requiring at least 7 but no more than 9 medical visits for monitoring or treatment of an active eye disease or complications per year	40
With documented incapacitating episodes requiring at least 4 but no more than 6 medical visits for monitoring or treatment of an active eye disease or complications per year	20
With documented incapacitating episodes requiring 3 medical visits for monitoring or treatment of an active eye disease or complications per year	10
Note (1): For the purposes of evaluation under 38 CFR 4.79, an incapacitating episode is one which requires clinic visits for an active eye disease, as documented in the medical record by a physician or other health care provider, and relates to the monitoring of progress, administration of treatment(s), and to the development of complications related to the underlying active eye disability. Examples of treatment may include but are not limited to: Systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions.
Note (2): For the purposes of evaluating visual impairment due to the particular condition, refer to 38 CFR 4.75-4.78 and to § 4.79, diagnostic codes 6061-6090.
Diseases of the Uveal Tract
6000 Choroidopathy, including uveitis, iritis, cyclitis, and choroiditis.
6002 Scleritis.
6010 Tuberculosis of the eye:
Active	100
Inactive: Evaluate under § 4.88c or § 4.89 of this part, whichever is appropriate.
Diseases of the Retina, Macula, and Vitreous
6006 Retinopathy or maculopathy not otherwise specified.
6008 Detachment of retina.
6011 Retinal scars, atrophy, or irregularities:
Localized scars, atrophy, or irregularities of the retina, unilateral or bilateral, that are centrally located and that result in an irregular, duplicated, enlarged, or diminished image	10
Alternatively, evaluate based on the General Rating Formula for Diseases of the Eye, if this would result in a higher evaluation.
6040 Diabetic retinopathy.
6042 Retinal dystrophy (including retinitis pigmentosa).
Glaucoma
6012 Angle-closure glaucoma.
Evaluate under the General Rating Formula for Diseases of the Eye. Minimum evaluation if continuous medication is required	10
6013 Open-angle glaucoma.
Evaluate under the General Rating Formula for Diseases of the Eye. Minimum evaluation if continuous medication is required	10
Ocular Neoplasms and Trauma
6007 Introacular hemorrhage.
6009 Unhealed eye injury.
Note: This code includes orbital trauma, as well as penetrating and non-penetrating eye injury.
6014 Malignant neoplasms of the eye, orbit, and adnexa (excluding skin):
Malignant neoplasms of the eye, orbit, and adnexa (excluding skin) that require therapy that is comparable to those used for systemic malignancies, i.e., systemic chemotherapy, X-ray therapy more extensive than to the area of the eye, or surgery more extensive than enucleation	100
Note: Continue the 100-percent rating beyond the cessation of any surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure. Six months after discontinuance of such treatment, the appropriate disability rating will be determined by mandatory VA examination. Any change in evaluation based upon that or any subsequent examination will be subject to the provisions of § 3.105(e) of this chapter. If there has been no local recurrence or metastasis, evaluate based on residuals.
Malignant neoplasm of the eye, orbit, and adnexa (excluding skin) that does not require therapy comparable to that for systemic malignancies:
Separately evaluate visual impairment and nonvisual impairment, e.g., disfigurement (diagnostic code 7800), and combine the evaluations.
6015 Benign neoplasms of the eye, orbit, and adnexa (excluding skin):
Separately evaluate visual impairment and nonvisual impairment, e.g., disfigurement (diagnostic code 7800), and combine the evaluations.
Conditions of the Lacrimal System
6025 Disorders of the lacrimal apparatus (epiphora, dacrocystitis, etc.):
Bilateral	20
Unilateral	10
Corneal Diseases
6001 Keratopathy.
6017 Trachomatous conjunctivitis:
Active: Evaluate under the General Rating Formula for Diseases of the Eye, minimum rating	30
Inactive: Evaluate based on residuals, such as visual impairment and disfigurement (diagnostic code 7800).
6018 Chronic conjunctivitis (nontrachomatous):
Active: Evaluate under the General Rating Formula for Diseases of the Eye, minimum rating	10
Inactive: Evaluate based on residuals, such as visual impairment and disfigurement (diagnostic code 7800).
6035 Keratoconus.
6036 Status post corneal transplant:
Rate under the General Rating Formula for Diseases of the Eye.
Minimum, if there is pain, photophobia, and glare sensitivity	10
External Eye Diseases, Including the Eyelash, Eyelid, and Eyebrow
6020 Ectropion:
Bilateral	20
Unilateral	10
6021 Entropion:
Bilateral	20
Unilateral	10
6022 Lagophthalmos:
Bilateral	20
Unilateral	10
6023 Loss of eyebrows, complete, unilateral or bilateral	10
6024 Loss of eyelashes, complete, unilateral or bilateral	10
6032 Loss of eyelids, partial or complete:
Separately evaluate both visual impairment due to eyelid loss and nonvisual impairment, e.g., disfigurement (diagnostic code 7800), and combine the evaluations.
6034 Pterygium:
Evaluate under the General Rating Formula for Diseases of the Eye, disfigurement (diagnostic code 7800), conjunctivitis (diagnostic code 6018), etc., depending on the particular findings, and combine in accordance with § 4.25.
6037 Pinguecula:
Evaluate based on disfigurement (diagnostic code 7800).
6091 Symblepharon:
Evaluate under the General Rating Formula for Diseases of the Eye, lagophthalmos (diagnostic code 6022), disfigurement (diagnostic code 7800), etc., depending on the particular findings, and combine in accordance with § 4.25.
Disease of the Lens
6027 Cataract:
Preoperative: Evaluate under the General Rating Formula for Diseases of the Eye.
Postoperative: If a replacement lens is present (pseudophakia), evaluate under the General Rating Formula for Diseases of the Eye. If there is no replacement lens, evaluate based on aphakia (diagnostic code 6029).
6029 Aphakia or dislocation of crystalline lens:
Evaluate based on visual impairment, and elevate the resulting level of visual impairment one step.
Minimum (unilateral or bilateral)	30
Neuro-Ophthalmic Conditions
6016 Nystagmus, central	10
6019 Ptosis, unilateral or bilateral:
Evaluate based on visual impairment or, in the absence of visual impairment, on disfigurement (diagnostic code 7800).
6026 Optic neuropathy: Evaluate under the General Rating Formula for Diseases of the Eye.
6030 Paralysis of accommodation (due to neuropathy of the Oculomotor Nerve (cranial nerve III))	20
6046 Post-chiasmal disorders: Evaluate under the General Rating Formula for Diseases of the Eye.

Ratings for Impairment of Muscle Function

Degree of diplopia	Equivalent visual acuity
6090 Diplopia (double vision):
(a) Central 20 degrees	5/200
(b) 21 degrees to 30 degrees	(1.5/60)
(1) Down
(2) Lateral	15/200
(3) Up	(4.5/60)
(c) 31 degrees to 40 degrees	20/100
(1) Down	(6/30)
(2) Lateral	20/70 (6/21)
(3) Up
Note: In accordance with 38 CFR 4.31, diplopia that is occasional or that is correctable with spectacles is evaluated at 0 percent	20/200 (6/60) 20/70 (6/21) 20/40 (6/12)
(Authority: 38 U.S.C. 1155).

5. In Appendix A to Part 4, add §§ 4.77, 4.78, and 4.79 to read as follows:

Appendix A to Part 4—Table of Amendments and Effective Dates Since 1946

Sec.	Diagnostic code No.
*         *         *         *         *         *         *
4.77		Revised [insert effective date of final rule].
4.78		Revised [insert effective date of final rule].
4.79		Introduction criterion [insert effective date of final rule]; Revised General Rating Formula for Diseases of the Eye [insert effective date of final rule]; General Rating Formula for Diseases of the Eye NOTE revised [insert effective date of final rule]; Organizational categories added [insert effective date of final rule].
	6000	Criterion [insert effective date of final rule].
	6001	Criterion [insert effective date of final rule].
	6002	Criterion [insert effective date of final rule].
	6006	Title [insert effective date of final rule]; criterion [insert effective date of final rule].
	6007	Criterion [insert effective date of final rule].
	6008	Criterion [insert effective date of final rule].
	6009	Criterion [insert effective date of final rule].
	6011	Evaluation [insert effective date of final rule].
	6012	Evaluation [insert effective date of final rule].
	6013	Evaluation [insert effective date of final rule].
	6014	Title [insert effective date of final rule].
	6015	Title [insert effective date of final rule].
	6017	Evaluation [insert effective date of final rule].
	6018	Evaluation [insert effective date of final rule].
	6019	Evaluation [insert effective date of final rule].
	6026	Evaluation [insert effective date of final rule].
	6027	Evaluation [insert effective date of final rule].
	6034	Evaluation [insert effective date of final rule].
	6035	Evaluation [insert effective date of final rule].
	6036	Evaluation [insert effective date of final rule].
	6040	Added [insert effective date of final rule].
	6042	Added [insert effective date of final rule].
	6046	Added [insert effective date of final rule].
	6091	Evaluation [insert effective date of final rule].
*         *         *         *         *         *         *

6. In Appendix B to Part 4, The Eye, Diseases of the Eye, revise diagnostic codes 6000, 6003-6005, 6006-6009, 6011-15, 6017-6018, 6026-6027, 6034-6036, and add diagnostic codes 6040, 6042, and 6046 to read as follows:

Appendix A to Part 4—Numerical Index of Disabilities

Diagnostic code No.
*    *    *    *    *
THE EYE
Diseases of the Eye
*    *    *    *    *
6000	Choroidopathy, including uveitis, iritis, cyclitis, and choroiditis.
6001	Keratopathy.
6002	Scleritis.
6006	Retinopathy or maculopathy not otherwise specified.
6007	Intraocular hemorrhage.
6008	Detachment of retina.
6009	Unhealed eye injury.
6010	Tuberculosis of eye.
6011	Retinal scars, atrophy, or irregularities.
6012	Angle-closure glaucoma.
6013	Open-angle glaucoma.
6014	Malignant neoplasms of the eye, orbit, and adnexa (excluding skin).
6015	Benign neoplasms of the eye, orbit, and adnexa (excluding skin).
*    *    *    *    *
6025	Disorders of the lacrimal apparatus (epiphora, dacrocystitis, etc.)
6026	Optic neuropathy.
6027	Cataract.
*    *    *    *    *
6034	Pterygium.
6035	Keratoconus.
6036	Status post corneal transplant.
*    *    *    *    *
6040	Diabetic retinopathy.
6042	Retinal dystrophy (including retinitis pigmentosa).
6046	Post-chiasmal disorders.
*    *    *    *    *

7. In Appendix C to Part 4, revise the disability entries for diagnostic codes 6006, 6014, and 6015, and add disability entries for Retinopathy, diabetic; Retinal dystrophy (including retinitis pigmentosa); and Post-chiasmal disorders to read as follows:

Appendix C to Part 4—Alphabetical Index of Disabilities

	Diagnostic code No.
*    *    *    *    *
New growths:
Benign
*    *    *    *    *
Eye, orbit, and adnexa	6015
*    *    *    *    *
Eye, orbit, and adnexa	6014
*    *    *    *    *
Post-chiasmal disorders	6046
*    *    *    *    *
Retinal dystrophy (including retinitis pigmentosa)	6042
Retinopathy, diabetic	6040
Retinopathy or maculopathy not otherwise specified	6006
*    *    *    *    *