## Section B. Conditions of the Organs of Special Sense

#### Overview

+------------+---------------------------------------------------------+
| #          | > This section contains the following topics:           |
| #### In th |                                                         |
| is Section |                                                         |
+------------+---------------------------------------------------------+

  ------------ ---------------------------------------------- ------------
  Topic        Topic Name                                     See Page

  10           General Information About Eye Conditions       4-B-2

  11           Specific Eye Conditions                        4-B-5

  12           Hearing Impairment                             4-B-7

  13           Exhibit 1: Examples of Rating Decisions for    4-B-12
               Diplopia                                       
  ------------ ---------------------------------------------- ------------

#### 10. General Information About Eye Conditions

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains general information about eye     |
| troduction | > conditions, including                                 |
|            |                                                         |
|            | -   measuring field of vision                           |
|            |                                                         |
|            | -   citing disease or injury in diagnosis               |
|            |                                                         |
|            | -   excluding congenital or developmental defects       |
|            |                                                         |
|            | -   considering service connection for refractive       |
|            |     errors                                              |
|            |                                                         |
|            | -   reconciling inconsistent findings with refractive   |
|            |     error, and                                          |
|            |                                                         |
|            | -   establishing service connection for unusual         |
|            |     developments.                                       |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 29, 2007                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > In all claims, when the extent of the field of vision |
| # a. Measu | > is measured by the Goldmann Bowl perimeter and not a  |
| ring Field | > tangent screen, employ the Target III/4e in the       |
|  of Vision | > kinetic mode. The examiner should record perimeter    |
|            | > type, illuminating light level, test object size,     |
|            | > color, and test distance with testing done, unseen to |
|            | > seen, with at least 16 meridians, 22 ½ degrees apart, |
|            | > charted for each eye.                                 |
|            | >                                                       |
|            | > ***Notes***:                                          |
|            |                                                         |
|            | -   If the above guidelines are adhered to, the results |
|            |     equate with those found by the methods of testing   |
|            |     required in [38 CFR                                 |
|            |     4.76](http://                                       |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_76.DOC). |
|            |                                                         |
|            | -   The examining medical facility may use an automated |
|            |     perimetric device, such as the Humphrey Model 750   |
|            |     or the Octopus Model 101, to determine visual field |
|            |     loss as long as the results are reported on a       |
|            |     standard Goldmann chart.                            |
|            |                                                         |
|            | > ***Reference***: See Rating Job Aids for a Visual     |
|            | > Field Calculator that may be used to calculate the    |
|            | > field of vision.                                      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Show the actual disease, injury, or other basic       |
| b. Citing  | > condition as the diagnosis, rather than a mere        |
| Disease or | > citation of impaired visual acuity, field of vision,  |
|  Injury in | > or motor efficiency.                                  |
|  Diagnosis | >                                                       |
|            | > ***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.                                |
+------------+---------------------------------------------------------+

Continued on next page

10\. General Information About Eye Conditions, Continued

+------------+---------------------------------------------------------+
| #####      | > Defects of form or structure of the eye that are of   |
|  c. Exclud | > congenital or developmental origin may *not* be       |
| ing Congen | > considered as disabilities or SC on the basis of      |
| ital or De | > incurrence or aggravation beyond natural progress     |
| velopmenta | > during service.                                       |
| l Defects  | >                                                       |
|            | > 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.                                     |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #          | > Refractive errors are                                 |
| #### d. Co |                                                         |
| nsidering  | -   due to anomalies in the shape and conformation of   |
| Service Co |     the eye structures, and                             |
| nnection f |                                                         |
| or Refract | -   generally of congenital or developmental origin.    |
| ive Errors |                                                         |
|            | > ***Examples***: Astigmatism, myopia, hyperopia, and   |
|            | > presbyopia.                                           |
|            | >                                                       |
|            | > The effect of uncomplicated refractive errors must be |
|            | > *excluded* in considering impairment of vision from   |
|            | > the standpoint of service connection 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.         |
|            |                                                         |
|            | > ***Reference***: For more information on considering  |
|            | > service connection for refractive error of the eye,   |
|            | > see [38 CFR                                           |
|            | > 3.303(c)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_303.DOC). |
+------------+---------------------------------------------------------+

Continued on next page

10\. General Information About Eye Conditions, Continued

+------------+---------------------------------------------------------+
| ####       | > When dealing with refractive error only, if the best  |
| # e. Recon | > corrected vision on any examination by the Department |
| ciling Inc | > of Veterans Affairs (VA) is better than prior         |
| onsistent  | > determinations, assume these prior determinations to  |
| Findings w | > be erroneous or at least as not representing best     |
| ith Refrac | > correction.                                           |
| tive Error |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Long-established policy permits establishment of      |
| f. Establi | > service connection for such unusual developments as   |
| shing Serv | > choroidal degeneration, retinal hemorrhage or         |
| ice Connec | > detachment, or rapid increase of myopia producing     |
| tion for U | > uncorrectable impairment of vision.                   |
| nusual Dev | >                                                       |
| elopments  | > Consider refractive error service-connected (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.      |
+------------+---------------------------------------------------------+

#### 11. Specific Eye Conditions

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information on specific eye       |
| troduction | > conditions, including                                 |
|            |                                                         |
|            | -   considering amblyopia                               |
|            |                                                         |
|            | -   considering impairment of central vision and field  |
|            |     of vision                                           |
|            |                                                         |
|            | -   considering glaucoma                                |
|            |                                                         |
|            | -   considering diplopia, and                           |
|            |                                                         |
|            | -   substituting the evaluation of diplopia.            |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 29, 2007                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a. C | > Ascertain the etiology of amblyopia in each           |
| onsidering | > individual case since a diagnosis may refer to either |
|  Amblyopia | > developmental or acquired causes of lost visual       |
|            | > acuity.                                               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### b.   | > Request an examination if, in addition to the         |
| Considerin | > differences between distant and near visual acuities  |
| g Impairme | > mentioned in [38 CFR                                  |
| nt of Cent | > 4.84](http://w                                        |
| ral Vision | ww.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_83a.DOC), |
|  and Field | > there are other impairments of both best corrected    |
|  of Vision | > central visual acuity and fields of vision.           |
|            | >                                                       |
|            | > The examination                                       |
|            |                                                         |
|            | -   must include best-corrected central visual acuity   |
|            |     at near and far by the Snellen method or its        |
|            |     equivalent, such as Jaeger or Point, and            |
|            |                                                         |
|            | -   will be used together with field of vision showing  |
|            |     accurate plotting of any scotoma.                   |
|            |                                                         |
|            | > ***Note***: Following completion of the examination,  |
|            | > refer the claims folder for evaluation of visual      |
|            | > efficiency to Compensation and Pension (C&P) Service  |
|            | > (211B).                                               |
+------------+---------------------------------------------------------+

Continued on next page

11\. Specific Eye Conditions, Continued

+------------+---------------------------------------------------------+
| ##### c. C | > Glaucoma is recognized as an organic disease          |
| onsidering | > affecting the nervous system and is subject to        |
|  Glaucoma  | > presumptive service connection under [38 CFR          |
|            | > 3.309(a)](http://w                                    |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_309.DOC). |
|            | >                                                       |
|            | > 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   |
|            |     was incurred between the date of separation from    |
|            |     service and the onset of the disability (that is,   |
|            |     evidence of intercurrent cause).                    |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### d.   | > A diagnosis of diplopia that reflects the disease or  |
| Considerin | > injury that is the cause of the diplopia must be of   |
| g Diplopia | > record.                                               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ####       | > Under the circumstances shown below, substitute the   |
| # e. Subst | > evaluation of diplopia for the evaluation of          |
| ituting Ev | > impairment of visual acuity or visual field.          |
| aluation o |                                                         |
| f Diplopia |                                                         |
+------------+---------------------------------------------------------+

+---------------------+----------------------+-------------------------+
| If \...             | And \...             | Then \...               |
+---------------------+----------------------+-------------------------+
| -   diplopia is     | the evaluation       | substitute the          |
|     diagnosed, and  | assignable for       | evaluation of diplopia  |
|                     | diplopia is greater  | for the evaluation of   |
| -   both eyes have  | than the evaluation  | the visual impairment   |
|     a ratable       | assignable for       | or visual field deficit |
|     impairment of   |                      | in the *poorer* eye.    |
|     either          | -   visual           |                         |
|                     |     impairment, or   |                         |
| -   visual acuity,  |                      |                         |
|     or              | -   visual field     |                         |
|                     |     deficit          |                         |
| -   visual field    |                      |                         |
+---------------------+----------------------+-------------------------+

+-----------------------------------------------------------------------+
| > ***Note***: If only one eye has a ratable impairment, apply the     |
| > rating for diplopia to that eye but not in combination with any     |
| > other eye rating.                                                   |
|                                                                       |
| ***Reference***: For examples of rating decisions for diplopia, see   |
| M21-1MR, Part III, Subpart iv, 4.B.13.                                |
+-----------------------------------------------------------------------+

#### 12. Hearing Impairment

+------------+---------------------------------------------------------+
| ##### In   | > This topic contains information about hearing         |
| troduction | > impairment, including                                 |
|            |                                                         |
|            | -   determining impaired hearing as a disability        |
|            |                                                         |
|            | -   requesting audiometric examinations or second       |
|            |     opinions                                            |
|            |                                                         |
|            | -   handling changed criteria or testing methods        |
|            |                                                         |
|            | -   applying revised hearing loss tables                |
|            |                                                         |
|            | -   reviewing for functional disturbances               |
|            |                                                         |
|            | -   granting service connection for functional hearing  |
|            |     impairment                                          |
|            |                                                         |
|            | -   considering service connection for development of   |
|            |     subsequent ear infection                            |
|            |                                                         |
|            | -   determining the need for a reexamination, and       |
|            |                                                         |
|            | -   compensation payable for paired organs under 38 CFR |
|            |     3.383.                                              |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 13, 2005                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Per [38 CFR                                           |
| ## a. Dete | > 3.385](http://w                                       |
| rmining Im | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_385.DOC), |
| paired Hea | > impaired hearing is considered a disability for VA    |
| ring as a  | > purposes when                                         |
| Disability |                                                         |
|            | -   the auditory threshold in any of the frequencies    |
|            |     500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or |
|            |     greater                                             |
|            |                                                         |
|            | -   the auditory thresholds for at least three of the   |
|            |     frequencies 500, 1000, 2000, 3000, or 4000 Hertz    |
|            |     are 26 decibels or greater, or                      |
|            |                                                         |
|            | -   speech recognition scores using the Maryland CNC    |
|            |     Test are less than 94 percent.                      |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > Request                                               |
| ## b. Requ |                                                         |
| esting Aud | -   an audiometric examination whenever                 |
| iometric E |                                                         |
| xamination | -   service connection is at issue, and                 |
| s or Secon |                                                         |
| d Opinions | -   service records demonstrate the advancement of any  |
|            |     degree of hearing impairment, and/or                |
|            |                                                         |
|            | -   a professional opinion regarding the significance   |
|            |     of prior audiological findings if the evidence of   |
|            |     record is unclear on any point.                     |
+------------+---------------------------------------------------------+

Continued on next page

12\. Hearing Impairment, Continued

+------------+---------------------------------------------------------+
| ###        | > If a decrease in evaluation is due to changed         |
| ## c. Hand | > criteria or testing methods, rather than a change in  |
| ling Chang | > hearing impairment, apply the old criteria and make   |
| ed Criteri | > no reduction.                                         |
| a or Testi | >                                                       |
| ng Methods | > ***Reference***: For more information on handling     |
|            | > changed criteria or testing methods, see [38 CFR      |
|            | > 3.951](http://w                                       |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_950.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| #####      | > Veterans Health Administration (VHA) ceased           |
|  d. Applyi | > converting audiology examinations to American         |
| ng Revised | > Standards Association (ASA) standards after December  |
|  Hearing L | > 31, 1975.                                             |
| oss Tables | >                                                       |
|            | > Use the table below to apply revised hearing loss     |
|            | > tables to claims of hearing loss.                     |
+------------+---------------------------------------------------------+

+----------------------------------+-----------------------------------+
| If the examination results are   | Then apply ...                    |
| dated ...                        |                                   |
+----------------------------------+-----------------------------------+
| before January 1, 1976           | the rating tables in effect prior |
|                                  | to September 9, 1975.             |
+----------------------------------+-----------------------------------+
| from January 1, 1976, through    | evaluation tables VI and VII.     |
| December 17, 1987                |                                   |
|                                  | ***Note***: The evaluations used  |
|                                  | ISO/ANSI, W-22 word               |
|                                  | discrimination and speech         |
|                                  | reception threshold standards     |
|                                  | exclusively.                      |
+----------------------------------+-----------------------------------+
| after December 18, 1987          | evaluation tables VI and VIa.     |
|                                  |                                   |
|                                  | ***Note***: Examiners use the     |
|                                  | speech discrimination or          |
|                                  | recognition ability of Maryland   |
|                                  | CNC with the results of the       |
|                                  | puretone auditory test.           |
+----------------------------------+-----------------------------------+

Continued on next page

12\. Hearing Impairment, Continued

+------------+---------------------------------------------------------+
| ##         | > If, following an examination at an audiology clinic,  |
| ### e. Rev | > a drastic reduction in rating for a hearing           |
| iewing Fun | > impairment is in order, thoroughly review the claims  |
| ctional Di | > folder for evidence of a psychiatric disease entity,  |
| sturbances | > which might be manifested in part by a nonorganic     |
|            | > hearing impairment.                                   |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### f. G | > Determine entitlement to service connection for a     |
| ranting Se | > psychiatric disability, manifested in part by a       |
| rvice Conn | > hearing impairment, by the usual regulations          |
| ection for | > pertaining to the grant of service connection.        |
|  Functiona | >                                                       |
| l Hearing  | > It is anticipated the psychiatric disorder will be    |
| Impairment | > identifiable by manifestations other than those       |
|            | > relating to hearing complaints alone. Base the rating |
|            | > either on the organic hearing loss or the psychiatric |
|            | > disorder, but not both in combination.                |
|            | >                                                       |
|            | > ***Reference***: For more information on evaluating   |
|            | > psychiatric disorders, see [38 CFR                    |
|            | > 4.126](http://w                                       |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKC/PART4/S4_126.DOC). |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ###        | > If the disease of one ear, such as chronic catarrhal  |
| ## g. Cons | > otitis media or otosclerosis, is held as the result   |
| idering Se | > of service, the subsequent development of similar     |
| rvice Conn | > pathology in the other ear must be held due to the    |
| ection for | > same cause if                                         |
|  Developme |                                                         |
| nt of Subs | -   the time element is not manifestly excessive, a few |
| equent Ear |     years at most, and                                  |
|  Infection |                                                         |
|            | -   there has been no intercurrent infection to cause   |
|            |     the additional disability.                          |
|            |                                                         |
|            | > ***Note***: If there is continuous SC infection of    |
|            | > the upper respiratory tract, the time cited for the   |
|            | > purpose of service connecting infection of the second |
|            | > ear should be extended indefinitely.                  |
+------------+---------------------------------------------------------+

Continued on next page

12\. Hearing Impairment, Continued

+------------+---------------------------------------------------------+
| ##### h    | > Use the table below to determine whether              |
| . Determin | > reexamination is necessary.                           |
| ing the Ne | >                                                       |
| ed for Ree | > ***Note***: A single examination is often sufficient  |
| xamination | > to meet the qualifying conditions of permanence under |
|            | > [38 CFR                                               |
|            | > 3.327](http://w                                       |
|            | ww.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_327.DOC). |
+------------+---------------------------------------------------------+

+----------------------------------+-----------------------------------+
| If ...                           | Then ...                          |
+----------------------------------+-----------------------------------+
| the extent of hearing loss in an | do not routinely schedule         |
| individual claim has been        | reexamination.                    |
| satisfactorily established by an |                                   |
| examination                      |                                   |
+----------------------------------+-----------------------------------+
| the veteran has hearing loss     | -   permanency can be conceded,   |
| evaluated 100 percent under      |     and                           |
| diagnostic code 6100 with a      |                                   |
| numeric designation of XI & XI   | -   Special Monthly Compensation  |
|                                  |     (SMC) granted unless          |
|                                  |     extenuating circumstances are |
|                                  |     present.                      |
|                                  |                                   |
|                                  | ***Note***: If hearing loss is    |
|                                  | functional, such as psychogenic,  |
|                                  | schedule at least one future      |
|                                  | examination to ensure that        |
|                                  | permanency is established before  |
|                                  | granting SMC.                     |
+----------------------------------+-----------------------------------+
| there is evidence that the       | -   schedule a reexamination, and |
| hearing loss is likely to        |                                   |
| improve materially in the future | -   include justification for     |
|                                  |     such reexamination in the     |
|                                  |     *Reasons for Decision*        |
|                                  |     section of the rating         |
|                                  |     decision.                     |
+----------------------------------+-----------------------------------+
| the veteran has had middle ear   | -   consider that hearing acuity  |
| surgery                          |     will have reached a stable    |
|                                  |     level one year after surgery, |
|                                  |     and                           |
|                                  |                                   |
|                                  | -   schedule reexamination for    |
|                                  |     one year after such surgery   |
|                                  |     under [38 CFR                 |
|                                  |     3.32                          |
|                                  | 7](http://www.warms.vba.va.gov/re |
|                                  | gs/38CFR/BOOKB/PART3/S3_327.DOC). |
+----------------------------------+-----------------------------------+

Continued on next page

12\. Hearing Impairment, Continued

+------------+---------------------------------------------------------+
| #####      | > Even if only one ear is SC, compensation may be       |
| i. Compens | > payable under [38 CFR                                 |
| ation Paya | > 3.383](http://                                        |
| ble for Pa | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_383.DOC) |
| ired Organ | > for the other ear, as if SC, if the veteran's hearing |
| s Under 38 | > impairment                                            |
|  CFR 3.383 |                                                         |
|            | -   is compensable to a degree of 10 or more in the SC  |
|            |     ear, and                                            |
|            |                                                         |
|            | -   meets the provisions of [38 CFR                     |
|            |     3.385](http://                                      |
|            | www.warms.vba.va.gov/regs/38CFR/BOOKB/PART3/S3_385.DOC) |
|            |     in the non-SC ear.                                  |
|            |                                                         |
|            | > ***Reference***: For more information on compensation |
|            | > payable for paired SC and non-SC organs, see          |
|            |                                                         |
|            | -   M21-1MR, Part III, Subpart iv, 6.B.4, and           |
|            |                                                         |
|            | -   M21-1MR, Part IV, Subpart ii, 2.K.66.               |
+------------+---------------------------------------------------------+

#### 13. Exhibit 1: Examples of Rating Decisions for Diplopia

+------------+---------------------------------------------------------+
| ##### In   | > This exhibit contains three examples of rating        |
| troduction | > decisions for diplopia.                               |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### C    | > December 29, 2007                                     |
| hange Date |                                                         |
+------------+---------------------------------------------------------+

+------------+---------------------------------------------------------+
| ##### a.   | > ***Situation***: The veteran is service-connected for |
|  Example 1 | > bilateral impairment of visual acuity. VA examination |
|            | > reveals the best distant vision obtainable after      |
|            | > correction is 20/100 (6/30) 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).                                               |
|            | >                                                       |
|            | > ***Rationale***: Since the vision in the poorer eye   |
|            | > (right) is ratable at 20/100 (6/30), it is to the     |
|            | > veteran's advantage to rate the degree of visual      |
|            | > impairment, rather than the diplopia.                 |
+------------+---------------------------------------------------------+

  -------------------------- --------------------------------------------
  ***Coded Conclusion***:    

  1\. SC (VE INC)            

  6078                       Visual impairment secondary to thyroid
                             myopathy, bilateral, with diplopia

  30% from 12/01/2006        
  -------------------------- --------------------------------------------

+------------+---------------------------------------------------------+
| ##### b.   | > ***Situation***: The same facts as in Example 1,      |
|  Example 2 | > 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).      |
|            | >                                                       |
|            | > ***Rationale***: Since it would now be to the         |
|            | > veteran's advantage, substitute the rating for        |
|            | > diplopia for the degree of visual impairment 20/100   |
|            | > (6/30) in the poorer eye (right).                     |
+------------+---------------------------------------------------------+

  -------------------------- --------------------------------------------
  ***Coded Conclusion***:    

  1\. SC (VE INC)            

  6090-6076                  Diplopia secondary to thyroid myopathy with
                             bilateral visual impairment

  40% from 12/01/2006        
  -------------------------- --------------------------------------------

Continued on next page

13\. Exhibit 1: Examples of Rating Decisions for Diplopia, Continued

+------------+---------------------------------------------------------+
| ##### c.   | > ***Situation***: The veteran is service connected for |
|  Example 3 | > impairment of the visual field in the right eye       |
|            | > secondary to trauma. The average contraction of the   |
|            | > visual field is to 20 degrees, and is ratable         |
|            | > equivalent to 20/100 (6/30) at 10 percent. Diplopia   |
|            | > has been diagnosed secondary to trauma and exists     |
|            | > within 28 degrees in the downward quadrant.           |
|            | >                                                       |
|            | > ***Rationale***: Since diplopia within 28 degrees in  |
|            | > the downward quadrant is ratable equivalent to 15/200 |
|            | > (4.5/60), it is more advantageous to rate the         |
|            | > diplopia rather than the average concentric           |
|            | > contraction.                                          |
|            | >                                                       |
|            | > ***Result***: Assign a 20 percent evaluation under    |
|            | > diagnostic code 6090-6077 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)           

  6090-6077                 Diplopia secondary to trauma, with impairment
                            of visual field, right eye

  20% from 12/01/2006       
  ------------------------- ---------------------------------------------