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M21-1, Part III, Subpart iv, Chapter 4, Section C – Conditions of the Eyes

Overview

In This Section
This section contains the following topics:

1.   Basic Rating Principles for Eye Conditions

Introduction
This topic contains basic rating principles for eye conditions, including

Change Date
May 14, 2018

III.iv.4.C.1.a.  Evaluating Visual Acuity
Evaluate central visual acuity on the basis of corrected distance vision with central fixation, even if a central scotoma is present.
Exception:  Evaluate the visual acuity of the poorer eye using either its uncorrected or corrected visual acuity, whichever results in better combined visual acuity, when
  • the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye
  • the difference is not due to congenital or developmental refractive error, and
  • either the poorer eye or both eyes are service-connected (SC).
Reference:  For more information on evaluating based on visual acuity, see 38 CFR 4.76.

III.iv.4.C.1.b.  Measuring Field of Vision
The examining medical facility retains discretion in the exact method used to measure visual fields.  However when visual field testing is required, the facility must use one of the following:
  • Goldmann Bowl kinetic perimetry
  • automatic perimetry (Humphrey Model 750, Octopus Model 101), or
  • later versions of the Humphrey or Octopus machines with simulated Goldmann kinetic perimetry.
Notes:
  • Follow the guidelines in M21-1, Part III, Subpart iv, 3.D.4.b to determine when an examination report must contain visual field measurements.
  • Results from visual field testing may be reported in chart or table format.  Inclusion of the Goldmann chart or equivalent charting is not a requirement in any circumstance.
References:  For more information on
  • visual field standards, see 38 CFR 4.77, and
  • examinations for visual impairment and specifically visual field, see 38 CFR 4.77.

III.iv.4.C.1.c.  Examination Requirements for Diplopia
38 CFR 4.78 requires use of Goldmann Bowl kinetic perimeter testing or the Tangent Screen for examination of muscle function.  The examiner must document the results of muscle function testing by identifying the quadrant(s) and range(s) of degrees in which diplopia exists.  Documentation on a Goldmann Perimeter Chart is not required but is acceptable.
A diagnosis of diplopia that reflects the disease or injury that is the cause of the diplopia must be of record.

III.iv.4.C.1.d.  Evaluating Diplopia With Impairment of Visual Acuity or Field
When the affected field with diplopia extends beyond more than one quadrant or range of degrees, evaluate diplopia based on the quadrant and degree range that provides the higher (or highest) evaluation.  When diplopia exists in two separate areas of the same eye, increase the equivalent visual acuity under 38 CFR 4.79, diagnostic code (DC) 6090 to the next poorer level of visual acuity, but not to exceed 5/200.
Follow the steps in the table below when assigning an evaluation to visual impairment when a claimant has both
  • diplopia, and
  • a ratable impairment of visual acuity or loss of visual field in either eye.
Step
Action
1
Assign a level of visual acuity for diplopia for only one eye under 38 CFR 4.79, DC 6090
2
If the visual acuity level assignable for diplopia is …
Then assign a level of corrected visual acuity for the poorer eye (or affected eye, if only one is SC) that is …
20/70 or 20/100
one step poorer than it would otherwise warrant, not to exceed 5/200.
20/200 or 15/200
two steps poorer than it would otherwise warrant, not to exceed 5/200.
5/200
three steps poorer than it would otherwise warrant, not to exceed 5/200.
3
Determine the evaluation for visual impairment under 38 CFR 4.79, DC 6065 or 6066 by using the
  • adjusted visual acuity of the poorer eye (or affected eye, if only one is SC), and
  • corrected visual acuity for the better eye (or visual acuity of 20/40 for the other eye, if only one eye is SC).
 
Example:
  • The Veteran has an SC evaluation for diplopia.
  • Diplopia in both eyes is in the 31 to 40 degree range of upward vision and in the 31 to 40 degree range of lateral vision.
  • The diplopia in the upward vision is equivalent to visual acuity of 20/40, while the diplopia in the lateral vision is equivalent to visual acuity of 20/70.
Result:
  • Based on 38 CFR 4.78(b)(2) and (3), the overall equivalent visual acuity for diplopia is 20/100, which is one step poorer than the diplopia (in this case, the lateral) that provides the higher evaluation.
  • The overall evaluation for diplopia is, therefore, 10 percent, based on visual acuity of 20/100 for one eye and 20/40 for the other eye (diplopia is only taken into consideration for one eye).
Note:  Diplopia that is occasional or that is correctable with corrective lenses is evaluated at zero percent.
Reference:  For examples of rating decisions for diplopia, see M21-1, Part III, Subpart iv, 4.C.4.

III.iv.4.C.1.e.  Considering Impairments of Both Visual Acuity and Visual Field
When there are impairments of both visual acuity and visual field
  • determine for each eye the percentage evaluation for visual acuity and for visual field loss (expressed as a level of visual acuity under 38 CFR 4.79, DC 6080), and
  • combine the evaluations under 38 CFR 4.25.
The combined evaluation for visual impairment can then be combined with any other disabilities that are present.
Example
Situation:
  • Corrected visual acuity is 20/40 in the right eye and 20/70 in the left eye, warranting a 10-percent evaluation.
  • Visual field loss in right eye is remaining field 38 degrees (equivalent to visual acuity 20/70) and loss in left eye is remaining field 28 degrees (equivalent to visual acuity 20/100), warranting a 30-percent evaluation.
Result:  Under 38 CFR 4.25, combine the 30-percent evaluation for visual field loss with the 10-percent evaluation for visual acuity, which results in a 40-percent combined evaluation for bilateral visual impairment.

III.iv.4.C.1.f.  Incapacitating Episodes of Eye Disease
An incapacitating episode, for the purpose of evaluating diseases of the eye, is a situation in which symptoms are severe enough to require a clinic visit to a provider specifically for treatment purposes.
Notes:
  • A clinic visit for diagnostic, monitoring, or screening purposes is not sufficient to satisfy the criteria for a clinic visit for treatment purposes.
  • The definition of incapacitating episode was updated effective with the May 13, 2018, revision to 38 CFR 4.79.  This and other changes made in that update were not liberalizing changes.
Reference:  For more information on incapacitating episodes of diseases of the eye, as well as examples of treatment sufficient to meet the criteria for incapacitating episodes, see 38 CFR 4.79, General Rating Formula for Diseases of the Eye, Notes 1 and 2.

III.iv.4.C.1.g.  Citing Disease or Injury in the Diagnosis
Cite the actual disease, injury, or other basic condition as the diagnosis, rather than a mere citation of impaired visual acuity, field of vision, or motor efficiency.
Note:  Actual pathology, other than refractive error, is required to support
impairment of visual acuity.  Impaired field of vision and impaired motor field function must be supported by actual appropriate pathology.

III.iv.4.C.1.h.  Evaluating Anatomical Loss of One Eye With Inability to Wear a Prosthesis
When the evidence shows anatomical loss of one eye together with inability to wear a prosthesis, increase the evaluation for visual acuity under 38 CFR 4.79, DC 6063 by 10 percent.
Notes:
  • The maximum evaluation for visual impairment of both eyes will not exceed 100 percent.
  • Assignment of the 10-percent increase under 38 CFR 4.79, DC 6063precludes an evaluation under 38 CFR 4.118, DC 7800 based on gross distortion or asymmetry of an eye.  A separate evaluation may be assigned under 38 CFR 4.118, DC 7800 based on characteristics of disfigurement separate from gross distortion or asymmetry of an eye.
Reference:  For information on consideration of special monthly compensation for anatomical loss of an eye, see M21-1, Part IV, Subpart ii, 2.H.4.j.

III.iv.4.C.1.i.  Considering Visual Acuity in an NSC Eye When the Other Eye Is SC
When visual impairment of only one eye is SC, either directly or by aggravation, consider the visual acuity of the non-service-connected (NSC) eye to be 20/40, subject to the provisions of 38 CFR 3.383(a).
Example 1 (Direct incurrence)
Situation:
  • Pre-service, a Veteran had visual acuity of 20/70 in the right eye and 20/20 in the left eye, with a history of bilateral inactive chorioretinitis.
  • The Veteran developed a cataract in the left eye in service.
  • Post-service, visual acuity was 20/70 in the right eye and 10/200 in the left eye.
  • At the time of the rating determination, the left eye cataract was pre-operative.
Result:
  • The SC evaluation is 30 percent for the left eye cataract that was incurred in service, based on visual acuity of 10/200.
  • Since the right eye is NSC, it is considered to have normal vision (20/40) for the purposes of this calculation.
Example 2 (Aggravation)
Situation:
  • Pre-service, a Veteran had visual acuity of 20/50 in each eye due to scarring from an old injury.
  • The Veteran’s left eye was re-injured in combat.
  • Post-service, visual acuity was 20/50 in the right eye and 10/200 in the left eye.
Result:
  • The SC evaluation is 20 percent for left eye aggravation (30 percent for 10/200 (current left eye) minus 10 percent for 20/50 (left eye on entrance)).
  • Since the Veteran’s right eye is NSC, it is considered to have normal vision (20/40) for the purposes of this calculation.
References:  For more information on

 2.  Congenital or Developmental Defects and Refractive Error of the Eyes

Introduction
This topic contains information on congenital or developmental defects and refractive errors of the eyes, including
Change Date
 February 2, 2018

III.iv.4.C.2.a.  Excluding Congenital or Developmental Defects
Defects of form or structure of the eye that are of congenital or developmental origin may not be considered as disabilities or SC on the basis of incurrence or aggravation beyond natural progress during service.
The fact that a Veteran was supplied with glasses for correcting refractive error from any of the eye defects named above is not, in itself, considered indicative of aggravation by service that would warrant compensation.
Exception:  Malignant or pernicious myopia may be considered SC.

III.iv.4.C.2.b.  Definition:  Refractive Errors
Refractive errors are
  • due to anomalies in the shape and conformation of the eye structures, and
  • generally of congenital or developmental origin.
Examples:  Astigmatism, myopia, hyperopia, and presbyopia.

III.iv.4.C.2.c.  Refractive Errors
The effects of uncomplicated refractive errors must be excluded in considering impairment of vision from the standpoint of service connection (SC) and evaluation.
Exception:  Myopia may progress rapidly during the periods of service and lead to destructive changes, such as
  • changes in the choroid
  • retinal hemorrhage, and
  • retinal detachment.
Notes:
  • Children are usually hyperopic at birth and subsequently become less so, or they become emmetropic, or even myopic.
  • In adults, refractive errors are generally stationary or change slowly until the stage of presbyopia, also a developmental condition.
  • When dealing with refractive error only, if the best corrected vision on any examination by the Department of Veterans Affairs (VA) is better than prior determinations, view these prior determinations to be erroneous or at least as not representing best correction.
Reference:  For more information on considering SC for refractive error of the eye, see 38 CFR  3.303(c).

III.iv.4.C.2.d.  Amblyopia
Ascertain the etiology of amblyopia in each individual case since a diagnosis may refer to either developmental or acquired causes of lost visual acuity.

III.iv.4.C.2.e.  Establishing SC for Unusual Developments 
Long-established policy permits establishment of SC for such unusual developments as choroidal degeneration, retinal hemorrhage or detachment, or rapid increase of myopia producing uncorrectable impairment of vision.
Consider refractive error SC only under these unusual circumstances and when combined with uncorrectable residual visual impairment.
Note:  Irregular astigmatism may be due to corneal inflammation due to injury or operation.

3.  Other Eye Conditions

Introduction
This topic contains information on specific eye conditions, including

Change Date
May 14, 2018

III.iv.4.C.3.a.  Glaucoma
Glaucoma is recognized as an organic disease of the nervous system and is subject to presumptive SC under 38 CFR 3.309(a).
Consider glaucoma, manifested to a compensable degree within one year of separation from an entitling period of service, to be SC on a presumptive basis unless there is
  • affirmative evidence to the contrary, or
  • evidence that a recognized cause of the condition (also known as an intercurrent cause) was incurred between the date of separation from service and the onset of the disability.
Notes:
  • Angle-closure glaucoma is evaluated under the General Rating Formula for Diseases of the Eye.
  • When evaluating glaucoma, assign a minimum evaluation of 10 percent if the evidence shows that continuous medication is required.

III.iv.4.C.3.b.  Cataracts
38 CFR 4.79, DC 6027, requires that preoperative cataracts are to be evaluated under the General Rating Formula for Diseases of the Eye.  If cataracts are postoperative in nature, evaluate under the General Rating Formula for Diseases of the Eye if a replacement lens is present (known as pseudophakia).  If there is no replacement lens, evaluate based on aphakia under 38 CFR 4.79, DC 6029.

III.iv.4.C.3.c.  Dry Eye Syndrome
Keratoconjunctivitis sicca, more commonly known as dry eye syndrome, occurs when the surface of the eye becomes dry due to lack of quality tears.
Dry eye syndrome may be due to a variety of causes to include
  • an underlying disease, such as diabetes mellitus or rheumatoid arthritis
  • medications, such as certain hypertensive and antidepressant medications, non-steroidal anti-inflammatory drugs, decongestants, or antihistamines, and
  • environmental exposures such as wind, high altitude, dry air, sun, or prolonged eye concentration.

Treatment for dry eyes may include use of over-the-counter artificial tear drops, use of prescription medications, use of special contact lenses, use of plugs to block the tear ducts through which tears drain, or even surgical procedures.

III.iv.4.C.3.d.  Decision Making Principles – Dry Eye Syndrome
SC can be established for dry eye syndrome when it is directly incurred in, or aggravated by, service or when secondary to an SC condition.
Exception:  Elective procedures, such as laser eye surgery (e.g., LASIK), without unusual results or additional disability attributed to elective procedures are noteligible for SC.  Dry eye syndrome is a common result of laser eye surgery, and thus would not be eligible for SC if the etiology of the dry eye syndrome is due solely to an elective procedure.
The disability picture present with dry eye syndrome varies and, therefore, an appropriate analogous DC must be selected dependent on the symptoms noted and etiology.  Appropriate DCs may include 38 CFR 4.79, DCs 6013, 6018, or 6025, depending upon the nature and symptomatology.  It may also be appropriate to evaluate as a symptom under the evaluation of the underlying condition.
Minimal symptomatology only requiring treatment by non-prescription eye drops would typically only warrant a zero percent evaluation under 38 CFR 4.79, DCs 6013, 6018, or 6025, as it clearly does not approximate the criteria required for a compensable evaluation.
References:  For more information on the

III.iv.4.C.3.e.  Retinitis Pigmentosa
SC may be awarded for diseases of congenital, developmental, or familial origin that either first manifest themselves during service or that preexist service and progress at an abnormally high rate during service so as to demonstrate aggravation.
If no other cause is shown for retinitis pigmentosa, consider it to be hereditary, and determine SC based on whether or not there has been aggravation of this preexisting condition during service.

4.   Exhibit 1:  Examples of Rating Decisions for Diplopia

Introduction
This exhibit contains three examples of rating decisions for diplopia.

Change Date
August 3, 2011

III.iv.4.C.4.a.  Example 1
Situation:  The Veteran filed an original claim for bilateral impairment of visual acuity on June 1, 2009.  VA examination reveals the best distant vision obtainable after correction is 20/200 (6/60) in the right eye and 20/70 (6/21) in the left eye.  Diplopia secondary to thyroid myopathy has been diagnosed and is within 24 degrees in the upward quadrant.  Diplopia within 24 degrees in the upward quadrant is ratable as 20/70 (6/21) under DC 6090.
Rationale:  Because the evaluation for diplopia is 20/70, evaluate visual acuity in the poorer eye (right) as 15/200 per 38 CFR 4.78, one step poorer than it would otherwise warrant.
Coded Conclusion:
1. SC (VE INC)
6066
Visual impairment secondary to thyroid myopathy, bilateral, with diplopia
40 percent from 06/01/2009

III.iv.4.C.4.b.  Example 2
Situation:  The same facts as in Example 1, except the diplopia exists within 24 degrees in the downward quadrant.  Diplopia within 24 degrees in the downward quadrant is ratable as 15/200 (4.5/60) under DC 6090.
Rationale:  Because the evaluation for diplopia is 15/200, evaluate visual acuity in the poorer eye (right) as 10/200 per 38 CFR 4.78, two steps poorer than it would otherwise warrant.
Coded Conclusion:
1. SC (VE INC)
6066
Visual impairment secondary to thyroid myopathy, bilateral, with diplopia
50 percent from 06/01/2009

III.iv.4.C.4.c.  Example 3
Situation:  The Veteran is SC for impairment of the visual field in the right eye secondary to trauma.  The average contraction of the visual field is to 50 degrees, and is ratable equivalent to 20/50 (6/15) at 10 percent.  Diplopia has been diagnosed secondary to trauma and exists within 20 degrees in the central area.  Diplopia within 20 degrees in the central area is ratable as 5/200 (1.5/60).
Rationale:  Since the evaluation for diplopia is 5/200, evaluate the visual field impairment in the SC eye (right) as 20/200 per 38 CFR 4.78, three steps poorer than it would otherwise warrant.
Result:  Assign a 20-percent evaluation under 38 CFR 4.79, DC 6090-6066 for diplopia with impairment of the visual field, right eye.  Do not assign a separate 10-percent evaluation for contraction of the visual field.
Coded Conclusion:
1. SC (VE INC)
6090-6066
Diplopia secondary to trauma, with impairment of visual field, right eye
20 percent from 06/01/2009
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in Chapter 4 Rating Specific Disabilities, Part III General Claims Process, Subpart iv General Rating Process
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