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LOW VISION Defining and Understanding Legal Blindness The clinical criteria are well established, but the legal implications will vary by state. By Alexis Malkin, OD P atients who are visually impaired often ask whether they qualify as legally blind. Some patients ask because they are aware of the benefits they might be entitled to when classified as such; for others, the question may arise over a concern that their vision has reached a classifiable level of impairment. There is a certain amount of fear and stigma associated with being legally blind, although as eye care practitioners, we know that there are many levels of visual impairment, and people who are legally blind can have significant residual vision (Figure). CLINICAL CRITERIA The legal implications of blindness will vary by state. In the clinic, however, there are established criteria for classifying a patient as visually impaired. When classifying a patient as legally blind, it is helpful to remember the following key points: • legal blindness is defined by the vision in the better seeing eye • legal blindness is defined as best-corrected vision, and therefore someone cannot be “legally blind without their glasses” • legal blindness can be defined by acuity or visual field criteria The clinical criteria for legal blindness are based on visual acuity or visual field testing. Visual Acuity 1.BCVA of 20/200 or worse in the better-seeing eye measured on a standard Snellen chart, or worse than 20/100 visual acuity measured on ETDRS (Early Treatment of Diabetic Retinopathy Study), BaileyLovie, or another chart that has additional lines of letter sizes. If the patient is able to read a single 68 Advanced ocular care May/June 2014 Figure. Patients categorized as legally blind have moderate to severe vision loss, but many of these patients have significant residual visual ability. letter on the 20/100 line, he or she does not qualify as legally blind. 2.Contact lenses may be used as best-corrected vision if the patient is able to use the contact lens for “sustainable” wear (and not just for potential acuity measurements in an examination). 3.Telescopic correction, pinhole correction, and autorefractor results cannot be used to determine BCVA. Visual Field 1.Visual field criteria are determined by the maximum extent of visual field in the better seeing eye: 20º or less qualifies someone as legally blind. 2.Acceptable devices for assessing the visual field include the Goldmann Visual Field (size III4e); 24-2 or 30-2 Humphrey visual field test (Carl Zeiss Meditec); or an equivalent visual field (Octopus 32 [Haag-Streit] is accepted). The Humphrey equivalent of a III4e target is 10 dB, therefore anything lower than 10 dB is considered not seen. More information about these criteria can be found at the Social Security Administration’s website: www.ssa.gov/disability/professionals/bluebook/ 2.00-SpecialSensesandSpeech-Adult.htm. LOW VISION NEXT STEPS If a patient meets the criteria for legal blindness, it must be clearly communicated to him or her. Most states require a signed and dated letter that includes the diagnosis and either the visual acuity or visual field results that define the patient as legally blind. It is in the best interest of the patient to make sure that he or she understands that legal blindness does not change his or her visual status, but it does provide a classification. In turn, this designation may entitle the patient to certain benefits in terms of community resources and financial assistance such as tax deductions. Conversely, in most states, a person is not able to maintain a driver’s license once they reach the level of legal blindness; however, this is not universally true in all states, and in states with bioptic or other modified licensure, someone who is legally blind may be able to maintain a driver’s license. Some states require that the clinician register the patient as legally blind, and often this information is automatically transmitted to the local department of motor vehicles. There are often federal and state income tax deductions, property tax deductions, and reduced fare programs for public transportation available to those deemed legally blind. Once defined as legally blind, patients may qualify for a handicapped placard for a family member’s car, priority seating at concerts or events, and additional assistance at the airport. He or she may also qualify for services through his or her state’s blindness rehabilitation program or department for the blind. Programs such as talking books, guide dogs, and National Federation for the Blind’s Newsline may also be valuable resources. CONCLUSION It should never be forgotten that being declared legally blind comes with emotional consequences. Clinicians should provide information on support groups and counselors and be sure that patients and their families understand the details and implications of this particular designation. In the interest of complete patient care, eye care providers should find out what resources are available in their community and encourage patients to seek them out. n Alexis Malkin, OD, is a low vision optometrist at Low Vision Services, PLC, in the Washington, DC/metropolitan area, and is a part-time clinical instructor in ophthalmology, vision rehabilitation service at Wilmer Eye Institute, Johns Hopkins University, Baltimore. Dr. Malkin may be reached at [email protected]. 70 Advanced ocular care May/June 2014