APPENDIX G

Guidelines for ConsultingOphthalmologist and Medical Consultants

1. Guidelines for Consulting Ophthalmologist
   1. A consulting ophthalmologist will have the primary responsibility of providing the following services:
      1. Reviewing eye reports, or other eye specialty examinations, with comments and recommendations relating to the consumer's eye condition(s).
      2. Consulting with DBVI staff relating to the medical problems of the consumer/patient as they may impact on rehabilitation and related agency services.
      3. Serving as a liaison to the medical community to assist with the dissemination of information on the role and function of the Department for the Blind and Vision Impaired.
   2. Review of eye reports will include the following:
      1. The most current eye report indicating the visual condition(s) must be used as preliminary diagnostic referral information for various agency service programs. The eye report is to be reviewed to discuss findings with agency staff and to determine (certify) whether or not the consumer/patient is legally blind. All initial eye reports must be reviewed by the consulting ophthalmologist; however, if a subsequent eye report does not indicate any change in the visual condition, it does not have to be reviewed.
      2. In determining whether or not the eye report establishes legal blindness, the federal and state definitions of legal blindness are to be closely followed. These definitions state legal blindness exists when the individual does not see better than 20/200 in the better eye with best correction using conventional lenses; or the individual sees better than 20/200 in the better eye but the visual field is restricted to the extent that the widest diameter of vision in the better eye subtends an angle no greater than 20° in diameter or a 10° radius from the point of fixation.
      3. On the DBVI eye report form, and any other written eye examination, the medical consultant must date, sign, and check the appropriate box at the bottom of the page. On other eye examinations, the same information must be provided near the examiner's signature.
      4. To be considered an eye report, the following minimum information must be included:
         1. Acuity with/without correction (near and distant) for OD, OS, and OU
         2. Diagnosis and prognosis
         3. Peripheral visual field (when needed)
         4. Recommendations
      5. The consulting ophthalmologist, when appropriate, shall provide written recommendations to the agency staff member concerning eye surgery or treatment, comments, or instructions on additional diagnostic procedures. The medical consultant is to discuss his/her findings as they relate to the provision of training and/or other DBVI services. The appropriate staff member must provide the medical consultant with information concerning the goal/training needs of the consumer when he/she is requesting consultation regarding an individual's eye condition and how it may impact on a training program or employment objective.
   3. Determining legal blindness:
      The standard for determining legal blindness by measurement of distance vision is based generally on the Snellen System. There are several other standards for measuring visual function and, due to this, confusion and uncertainty may occur in the determination of legal blindness. Following are some examples of a typical visual measurements which may occur on eye reports, and also comments about how they might be judged by the DBVI consulting ophthalmologist. In some situations, it may be necessary for the consulting ophthalmologist to request that the DBVI worker secure additional information before legal blindness can be determined.
      1. Counts fingers at "X" inches or feet: this would be safely interpreted as legal blindness since it indicates that the individual could not see the standard measurement at 20 feet.
      2. Hand movements: this would be appropriately interpreted as legal blindness since it indicates that the individual is not able to see the standard measurement at 20 feet, or even to count fingers.
      3. 20/200 in the left eye, 20/200 in the right eye, 20/100 in both eyes: this would appropriately be interpreted as legal blindness since the law specifies that the vision should be based on the measurement in the better eye with correction, rather than both eyes. Correction obtained by special visual aids (e.g., contact lenses) will be considered if the individual has the ability to wear such aids.
      4. 20/200 +2 or 20/100 -1 or 2: this type of measurement requires a judgement call by the DBVI consulting ophthalmologist. Technically, this would indicate that the individual is slightly above the limits of legal blindness. In reality, however, the person very probably is functionally legally blind when operating under less than ideal conditions. A contact with the examiner who prepared the eye report might be indicated to clarify the legal blindness status of the individual.
      5. 10/80, 15/120,and other such measurements not using 20 as the first number in the measurement: such measurements should be computed out to 20 over whatever the resultant projection of the numbers should be, and then legal blindness should be decided by the Snellen measurement, or the consideration of technical versus functional factors, as outlined in Item No. 4.
      6. Impairment of peripheral vision may result if there is contraction of the visual fields. The contraction may be either symmetrical or irregular. The extent of the remaining peripheral visual field will be determined by visual perimetric methods at a distance of 330 mm. under illumination of not less than 7-foot candles. For the phakic eye (the eye with a lens), a 3 mm. white disc target will be used and for the aphakic eye (the eye without a lens), a 6 mm. white disc target will be used. In neither instance should corrective spectacle lenses be worn during the examination but this fact must be stated if they have been used.
      7. Visual impairments in children: Impairment of central visual acuity should be determined with use of the standard Snellen test chart. Where this cannot be used, as in very young children, a complete description should be provided of the findings using other appropriate methods of examination, including a description of the techniques used for determining the central visual acuity for distance.
      The accomodative reflex is generally not present in children under six months of age. In premature infants, it may be not present until six months plus the number of months the child is premature. Therefore, absence of accomodative reflex will be considered an indication of visual impairment only in children above this age (six months). Documentation of a visual disorder must include description of the ocular pathology.
   4. Medical consultation may be provided as follows:
      1. When the DBVI staff needs specific information relating to the medical condition which may impact on agency services.
      2. At the regional office, at an agency facility, at any rehabilitation medical facility, in the consulting ophthalmologist's office, by written communication, or by telephone. The DBVI staff worker is the key person in determining where the consultation will occur and how it will be communicated.
      3. All face-to-face consultations must be prearranged by the agency staff member.
2. Guidelines for Medical Consultants Who Review Medical and Specialty Reports
   1. Medical consultants will have the primary responsibility of providing the following services:
      1. Reviewing general medical or specialty reports with comments and recommendations relating to the consumer/patient condition(s).
      2. Consulting with DBVI staff relating to the medical problems and functional capacities of the consumer/patient as they might have impact on rehabilitation and related agency services.
      3. Serving as a liaison to the medical community to assist with the dissemination of information on the role and function of the Department for the Blind and Vision Impaired.
   2. Review of general medical and specialty examinations will includethe following:
      1. The DBVI medical consultant is to review general medical examinations and other specialty medical examinations for agency service programs when requested.
      2. General medicals must be no older than 12 months when they are used as preliminary diagnostic information for various agency training and related programs. The only exception is when the medical consultant reviews the older medical information to determine if the information continues to describe the current conditions of the consumer adequately. DBVI staff will make the decision as to when to request the review of medical reports by the consultant.
      3. On the DBVI Health Checklist General Medical Form (Word) and any other specialty examination, the medical consultant shall write the word "reviewed," the date, and signature near the signature of the medical examiner. This procedure only occurs when the DBVI staff member sends medical information to the consultant.
      4. The medical consultant shall provide written recommendations to the DBVI staff member concerning surgery or treatment, comments, or instruction on additional diagnostic procedures when requested to provide such recommendations, or when he/she wishes to comment regarding the report.
      5. The medical consultant is to provide information regarding the impact of non-visual disabilities pertaining to the consumer/patient's participation in training and/or employment. The appropriate staff member must provide the medical consultant information regarding the consumer/patient's training and/or employment objectives when requesting consultation regarding the impact of the secondary disability.
   3. Medical consultation may be provided as follows:
      1. When the DBVI staff needs specific information relating to the medical condition as it may impact on agency services.
      2. At the regional office, at any agency or rehabilitation medical facility, in the medical consultant's office, by written communication, or by telephone. The DBVI case manager is the key person in determining where the consultation will occur and how it will be communicated.
      3. Face-to-face consultations must be prearranged by the agency staff member