Visual Field Assessment and Disability Evaluation (2025)
Chapter: Front Matter
Consensus Study Report
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COMMITTEE ON THE REVIEW OF STANDARDS FOR VISUAL FIELD PERIMETRY DEVICES AND THEIR USE IN DISABILITY EVALUATIONS
ROGER J. LEWIS (Chair), David Geffen School of Medicine, University of California, Los Angeles
ROBERT CHUN, The State University of New York College of Optometry
STUART K. GARDINER, Devers Eye Institute
EVE J. HIGGINBOTHAM, Scheie Eye Institute, University of Pennsylvania
TIANJING LI, University of Colorado Anschutz Medical Campus
JULIUS T. OATTS, Children’s Hospital of Philadelphia
ERIC L. SINGMAN, University of Maryland School of Medicine
Study Staff
BERNICE X. CHU, Senior Program Officer/Study Director
CAROL MASON SPICER, Senior Program Officer
TINA M. WINTERS, Program Officer
LYLE CARRERA, Research Associate
CHIDINMA CHUKWURAH, Senior Program Assistant
JOSEPH GOODMAN, Senior Program Assistant
SHARYL NASS, Senior Board Director, Board on Health Care Services
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Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft
before its release. The review of this report was overseen by ROBERT S. LAWRENCE, Bloomberg School of Public Health, Johns Hopkins University, and THOMAS D. ALBRIGHT, Salk Institute for Biological Studies. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
3 CURRENT AND EMERGING PRACTICE IN VISUAL FIELD TESTING
Current Practice in Perimetry Assessment
Variability and Challenges in the Clinical Assessment of Visual Fields
4 EVALUATING NEW PERIMETRY TECHNIQUES
Design of Studies for Assessing Diagnostic Test Accuracy
Performance Considerations for Evaluating New Perimetry Techniques
Quantity and Characteristics of Validation Studies Needed to Find a Perimeter Acceptable
Optical Projection Versus Screen-Based Stimuli
Semiautomated Kinetic Perimetry
Alternatives to Kinetic Perimetry for Testing Visual Field Efficiency
Boxes, Figures, and Tables
BOXES
S-1 Definitions of Key Terms Used in This Report
1-2 Definitions of Key Terms Used in This Report
3-1 Types of Visual Field Losses
FIGURES
1-1 Diagram of the eight principal meridians for each eye
3-1 Simulation of selected types of visual field losses
3-2 Normal hill of vision for a right eye
3-4 Static automated threshold perimetry testing experience
3-6 Humphrey visual field printout
3-7 Example of Goldmann visual field plot
3-8 Examples of testing patterns (right eye)
Preface
It is projected that the number of individuals who will become visually impaired will double by the year 2050, affecting nearly 7 million individuals within the United States. Among these affected individuals will be a significant proportion of adults who rely on their vision to support themselves and their families. Visual field loss, even to a degree that fails to meet the criteria for statutory blindness, can have profound impacts on virtually all aspects of life, including the ability to be gainfully employed; for many adults the ability to maintain normal or nearly normal visual function is critical for performing the vast majority of tasks associated with their employment. As noted in the 2016 National Academies of Sciences, Engineering, and Medicine report entitled Making Eye Health a Population Health Imperative, the impact of visual impairment is increased when it is coupled with other chronic conditions such as depression, stroke, and cardiac conditions, which plague many working adults. Similarly, for children, the ability to see is critical for their everyday activities, including participation in educational and social activities. It has been estimated that as many as 5 percent of preschool aged children suffer from visual impairment. Accordingly, the Social Security Administration (SSA) has established standards for defining disabling, uncorrectable visual field loss, relative to that required for gainful activity in adults, or for participation in age-appropriate activities in children.
The assessment of visual function is key in identifying and assessing limitations in an individual’s ability to complete tasks that require unimpaired vision. While the measure of correctable visual acuity satisfies the question of clarity of vision, the measure of visual field provides additional information regarding the boundaries of an individual’s entire visual
landscape. The importance of the visual field is underscored by the definition of statutory blindness, which can be met by a sufficiently constricted field of vision, even when visual acuity is normal. The assessment of one’s visual field, as measured using perimetric testing, is a core metric to determine one’s level of visual impairment.
There are important variations in the availability and use of tests to assess visual field loss across populations and geographic locations. Progress in the field of perimetry, defined as the measurement of the ability to perceive contrasting stimuli across specific locations of the visual field, holds out the promise to improve the availability of testing to identify applicants for disability benefits who meet SSA criteria based on visual field loss. Because visual field loss can take many different forms, e.g., scotoma or blind spots, decreased sensitivity to light in the periphery or in specific areas of the visual field, SSA standards include multiple potential routes to qualification for benefits, with different standards being most applicable to different patterns of visual field loss. Moreover, new technology provides more effective strategies for determining visual field defects that meet SSA requirements. Barriers to the assessment of visual field loss relative to SSA disability standards could be lowered if acceptable testing could be conducted in a wider variety of settings, and with a wider range of providers, perimetry techniques, and devices. Thus, SSA requested that an ad hoc committee of the National Academy of Sciences, Engineering, and Medicine be convened to address specific questions regarding the use of perimetry, including the use of newer devices and technologies, in assessing qualification for SSA disability benefits based on visual field loss.
On behalf of the entire committee, I would like to extend my sincere thanks to the many individuals who shared their time and expertise to support and inform our work and deliberations. The study was sponsored by SSA, and I thank Vincent Nibali and Michael Goldstein for their guidance and support. I also acknowledge Vincent Nibali at SSA for verifying the accuracy of relevant technical content pertaining to the disability determination process. The committee also benefited greatly from discussions with individuals who participated in the committee’s open sessions: Sylvia Groth, Chris Johnson, Yao Liu, Paula Anne Newman-Casey, George Spaeth, and Varshini Varadaraj, as well as the individuals who shared their experiences with accessing care for visual field impairments and applying for disability: LaQuilla Harris, Christopher Hord, and Zelda Kitchens.
I thank all members of the committee for generously contributing their time and expertise to this task, for the benefit of those living with visual impairment. I also thank the reviewers of this report for their invaluable feedback on an earlier draft and the monitor and coordinator who oversaw the report review, as well as committee member Eve J. Higginbotham for help with this preface.
Also on behalf of the committee, I would like to acknowledge the many staff within the Health and Medicine Division (HMD) who provided support in various ways to this project, including Bernice Chu (study director), Carol Mason Spicer (senior program officer), Tina Winters (program officer [Board on Cognitive and Behavioral Sciences, Division of Behavioral and Social Sciences and Education]), Lyle Carrera (research associate), Violet Bishop (research associate), Chidinma Chukwurah (senior program assistant), and Joseph Goodman (senior program assistant). I also extend my appreciation to Sharyl Nass, senior board director, Board on Health Care Services, who oversaw the project. Greysi Patton (finance business partner), Julie Wiltshire (senior finance business partner), and Ron Brown (deputy director, HMD program finance) oversaw finances for the project, and the report review, production, and communications staff all provided valuable guidance to ensure the success of the final product. Rona Briere, Allison Boman, and Danielle Nasenbeny provided superb editorial guidance in preparing the final report. Crystal Mitchell (University of Maryland Ophthalmology) lent her time and expertise to ensure the report included high-quality perimetry testing images.
Roger J. Lewis, Chair
Committee on the Review of Standards for Visual Field Perimetry Devices and Their Use in Disability Evaluations
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Acronyms and Abbreviations
| ADA | Americans with Disabilities Act |
| AIZE | Ambient Interactive ZEST |
| AMA | American Medical Association |
| asb | apostilb |
| cd | candela |
| dB | decibel |
| DCM | Disability Claims Manual |
| EEOC | Equal Employment Opportunity Commission |
| FAA | Federal Aviation Administration |
| FDA | Food and Drug Administration |
| FDP | frequency doubling perimetry |
| FDT | frequency doubling technology |
| FDT1 | first-generation frequency doubling technology |
| FDT2 | second-generation frequency doubling technology |
| FERS | Federal Employees Retirement System |
| FMCSA | Federal Motor Carrier Safety Administration |
| FRA | Federal Railroad Administration |
| HFA | Humphrey Field Analyzer |
| HRQoL | health-related quality of life |
| Hz | hertz |
| IDEA | Individuals with Disabilities Education Act |
| LCD | liquid-crystal display |
| LED | light-emitting diode |
| MD | mean deviation |
| M-pathway | magnocellular pathway |
| NHANES | National Health and Nutrition Examination Survey |
| OLED | organic light-emitting diode |
| OSEP | Office of Special Education Programs (Department of Education) |
| OWCP | Office of Workers’ Compensation Programs (Department of Labor) |
| P-pathway | parvocellular pathway |
| PSD | pattern standard deviation |
| QUADAS-2 | Quality Assessment of Diagnostic Accuracy Studies 2 |
| RRB | Railroad Retirement Board |
| SAP | static automated threshold perimetry |
| SITA | Swedish Interactive Thresholding Algorithm |
| SSA | Social Security Administration |
| SSDI | Social Security Disability Insurance |
| SSI | Supplemental Security Income |
| SVOP | saccadic vector optokinetic perimetry |
| SWAP | short-wavelength automated perimetry |
| TOP | tendency-oriented perimetry |
| U.S. | United States |
| USPSTF | United States Preventive Services Task Force |
| VAE | visual acuity efficiency |
| VAI | visual acuity impairment value |
| VFE | visual field efficiency |
| VFI | visual field impairment value or visual field index |
| VR | virtual reality |
| ZEST | Zippy Estimation by Sequential Testing |
