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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].
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