Eye Cancer (Malignant Neoplasm of Eyeball) C&P Exam Prep

Best-Corrected Visual Acuity (BCVA) - Distance and Near

What it measures: The sharpest vision achievable with the best corrective lenses in each eye, measured separately. This is the primary driver of the VA combined visual acuity rating table and directly determines the compensation percentage under 38 CFR 4.79 Tables I-VI.

What to expect: You will read a Snellen eye chart (letters or numbers at 20 feet for distance; near card for near vision) first without correction, then with your best glasses or contact lenses. Each eye is tested independently. The examiner documents results such as 20/20, 20/200, or counting fingers (CF), hand motion (HM), or light perception (LP).

Pain considerations: Ocular pain or discomfort from dry eye, socket irritation, or radiation-related changes may impair your ability to cooperate with acuity testing. Inform the examiner of any pain that prevents you from keeping your eye open or focusing during testing.

Visual Field Testing (Perimetry)

What it measures: The extent and integrity of your peripheral and central vision, measured in degrees from fixation in multiple meridians. Critical for detecting scotomas, field losses from retinal or optic nerve damage, or hemianopsia caused by tumor involvement or treatment sequelae.

What to expect: The examiner may use Goldmann perimetry (manual, kinetic), automated perimetry (Humphrey), or confrontation visual fields. You will fixate on a central target and indicate when you see a light or object in your peripheral vision. The examiner documents the extent of your visual field in degrees for each meridian of each eye.

Pain considerations: Radiation-induced dry eye or photophobia may make prolonged perimetry testing uncomfortable. Inform the examiner if pain or tearing is interfering with your ability to maintain fixation during testing.

Intraocular Pressure (IOP) Measurement

What it measures: The fluid pressure inside the eye, normally 10-21 mmHg. Elevated IOP indicates secondary glaucoma, which is a ratable separate condition that can develop after radiation therapy, neovascularization, or tumor infiltration of the trabecular meshwork.

What to expect: The examiner will instill numbing eye drops and apply a Goldmann applanation tonometer to the front of your eye, or use a non-contact air-puff tonometer. Each eye is measured. Normal is under 21 mmHg; glaucomatous damage typically occurs at sustained pressures above 21 mmHg.

Pain considerations: If you experience acute eye pain, halos around lights, or blurred vision with headache, these may indicate acute angle-closure or pressure spikes - report these symptoms clearly.

Slit-Lamp Biomicroscopy

What it measures: A magnified examination of the anterior and posterior segments of the eye, including cornea, lens, iris, vitreous, and retina. Used to evaluate treatment effects, tumor recurrence, radiation-induced cataracts, corneal damage, or posterior segment complications.

What to expect: You will rest your chin on a support while the examiner shines a narrow beam of light into your eye using a microscope. This may include fundus examination with a special lens after pupil dilation. The exam takes 10-15 minutes.

Pain considerations: If the slit-lamp light causes significant photophobia or pain, tell the examiner immediately - this is a ratable symptom and should be documented.

Extraocular Motility and Diplopia Assessment

What it measures: The alignment and full range of motion of both eyes together. Malignant tumors in or around the orbit, or surgical and radiation complications, can cause restrictive strabismus, cranial nerve palsies, or diplopia (double vision).

What to expect: The examiner will ask you to follow a target (light or pen) in multiple directions (up, down, left, right, obliques) and will note whether both eyes track together and whether you report diplopia in any gaze position.

Pain considerations: Diplopia with eye movement may be accompanied by headache or periorbital pain - document these associated symptoms.

100%

Active malignant neoplasm of the eyeball, OR surgery more extensive than enucleation performed (e.g., orbital exenteration), rated as 100% during the period of active treatment and for a minimum of 6 months following the completion of treatment. After the treatment period, the condition is rated based on residual conditions under the appropriate diagnostic codes.

From 38 CFR: Under DC 6014, malignant neoplasm of the eyeball is rated 100% while active and for 6 months following completion of treatment. Post-treatment residuals are then rated under the applicable diagnostic codes for visual impairment, field defects, or other residual conditions. A mandatory VA examination is required no later than the end of the 6-month period after completion of treatment.

60%

Post-treatment residual rating based on visual acuity in the remaining eye(s). If the affected eye has been enucleated (removed), the remaining eye's best-corrected visual acuity combined with any visual field defects determines the rating under Tables I-VI of 38 CFR 4.79. Visual acuity of 20/200 or worse in the remaining eye after enucleation of the other eye typically yields a 60% or higher combined rating.

From 38 CFR: Under Tables I-VI, various combinations of visual acuity in both eyes yield specific combined ratings. After enucleation of one eye, the rating is determined by the remaining eye's acuity. Visual acuity of 20/200 in the remaining eye with the other eye enucleated yields approximately 60% under the combined tables.

30%

Post-treatment residuals with moderate visual impairment. Visual acuity in the affected eye of 20/100 or the combination of both eyes at lower impairment levels per Tables I-VI. Significant scotomas, concentric visual field constriction to 31-40 degrees, or moderate secondary complications such as controlled glaucoma with mild visual impact may yield ratings in this range.

From 38 CFR: Combined rating tables under 38 CFR 4.79 determine exact percentage based on both eyes. A 30% rating typically results from combined visual acuity of one eye at 20/100 paired with the other eye near normal, or moderate field defects in both eyes. Scotoma affecting at least 1/4 of the visual field is rated as a reduced acuity level.

10%

Post-treatment residuals with mild visual impairment. Best-corrected visual acuity near normal (e.g., 20/40 to 20/70 in the affected eye) with minimal field defects, well-controlled secondary conditions, or minor symptomatic complaints. This level applies when the primary cancer has been treated and residual functional impairment is mild.

From 38 CFR: A 10% rating results from combined table entries where both eyes have near-normal or mildly impaired vision. Residual symptoms that are present but not functionally limiting may support a minimum compensable rating under 38 CFR 4.79.

Visual Acuity Loss

How to describe it: Describe exactly what you can and cannot see at various distances. Use specific functional examples: 'I cannot read a newspaper even with my glasses,' 'I cannot recognize my family members' faces across the room,' 'I cannot safely drive even with correction,' 'I struggle to read street signs.' Be specific about which eye is affected and whether the other eye compensates.

Example: On my worst days, my vision in the affected eye is so blurred that I see only shapes and light even with my glasses on. I cannot read anything up close, I bump into objects on my left side because I have no usable vision there, and I have completely stopped driving because I cannot judge distances safely.

Examiner listens for: Specific functional limitations, whether vision fluctuates, whether the loss is stable or progressive, whether correction helps or does not help, and how it impacts ADLs and employment.

Avoid: Do not say 'my vision is okay with glasses' if it is not. Do not minimize difficulty reading or driving. Do not say 'I manage fine' when you have significantly altered your life to accommodate the vision loss.

Ocular Pain and Discomfort

How to describe it: Describe the character (aching, stabbing, burning, pressure), frequency (constant, episodic, daily), severity (rate 1-10 on your worst days), location (in the eye socket, behind the eye, forehead, temporal area), and what makes it better or worse (light, eye movement, dry conditions, reading). Distinguish between phantom pain in an enucleated socket versus pain in a remaining eye.

Example: On my worst days, I have a constant burning and aching pain in my eye socket that I rate 7 out of 10. The pain prevents me from concentrating at work, disturbs my sleep, and is not fully controlled by my current medications. Looking at bright light or computer screens makes it significantly worse.

Examiner listens for: Frequency of incapacitating episodes, whether pain prevents normal activity, whether prescribed medications are needed, duration of episodes, and whether pain is a new or worsening symptom.

Avoid: Do not describe only your average pain - describe your worst typical day. Do not omit phantom eye pain after enucleation, as this is a legitimate and ratable symptom. Do not say pain is 'tolerable' if it limits your activities.

Visual Field Defects and Scotomas

How to describe it: Describe what areas of your vision are missing or dark. Use concrete examples: 'There is a dark spot in the center of my vision that blocks my ability to read,' 'I cannot see anything to my left without turning my head,' 'I have a missing area in the lower left of my vision that causes me to miss steps on stairs,' 'I have to turn my head fully to see what others see with a glance.'

Example: My central vision has a large dark area that makes reading impossible without magnification. I frequently misjudge the edges of doorways and have walked into objects on my left side. I cannot see a full page of text without moving my eyes and head extensively. Driving at night is impossible because I miss objects in my peripheral field entirely.

Examiner listens for: The functional impact of field loss, whether it is getting worse, specific gaze directions affected, and how field loss impacts safety (driving, walking, occupational tasks).

Avoid: Do not skip mentioning field defects because you have adapted to them - adaptation does not mean the defect is absent. Do not describe only the most obvious field loss; mention all areas of reduced or absent vision.

Photophobia and Glare Sensitivity

How to describe it: Describe how light sensitivity affects your daily life. Specify triggers (sunlight, fluorescent lights, headlights at night, computer screens), how long exposure causes symptoms, whether you need to wear sunglasses indoors or use blackout curtains, and whether it limits your ability to work or perform activities.

Example: On bright sunny days or under fluorescent office lighting, I experience such severe light sensitivity that my eye tears up uncontrollably and I cannot keep it open. I wear sunglasses even indoors and have had to decline social and work activities in brightly lit environments. Driving at night is impossible because oncoming headlights cause temporary visual incapacitation.

Examiner listens for: Whether photophobia is severe enough to cause incapacitating episodes, whether adaptive measures (tinted lenses, dark environments) are necessary for functioning, and whether it is a new or worsening symptom.

Avoid: Do not dismiss photophobia as a minor nuisance if it significantly limits your activities. Be specific about what activities you have stopped or reduced because of light sensitivity.

Treatment Side Effects and Residual Complications

How to describe it: Describe all side effects from cancer treatment that persist to today: radiation-induced dry eye (burning, foreign body sensation, discharge, need for frequent artificial tears), radiation cataract (progressive blurring, haze), secondary glaucoma (pressure symptoms, need for drops), eyelid changes, prosthesis-related socket discomfort, and any systemic chemotherapy side effects that affect the eye.

Example: Since completing radiation therapy, my eye is constantly dry, burning, and feels like there is sand in it. I use artificial tears 8-10 times per day and still have significant discomfort. I wake up with my eye crusted shut and need several minutes to open it. The dryness has made reading and computer work almost impossible for more than 15-20 minutes at a stretch.

Examiner listens for: Which treatments were received and their completion dates, which side effects are current and ongoing, frequency of symptom management interventions, and whether side effects are worsening or stable.

Avoid: Do not assume the examiner knows about your radiation or surgical history - volunteer this information clearly. Do not omit side effects you consider 'expected' from cancer treatment, as they are all potentially ratable.

Incapacitating Episodes

How to describe it: An incapacitating episode for ocular conditions is one that requires a physician's prescription treatment or that prevents you from performing your usual daily activities. Describe episodes of acute pain, sudden vision loss, pressure spikes (glaucoma), severe photophobia, or socket infections that require urgent medical care or rest. Document frequency (how many per month or year) and duration (how many days each).

Example: Approximately twice per month, my eye pain and light sensitivity become so severe that I cannot go to work and must rest in a darkened room. Each episode lasts 1-3 days. During these episodes, my doctor has prescribed additional pain medications and eye drops beyond my usual regimen. Over the past year, these episodes have caused me to miss at least 20 days of work.

Examiner listens for: Frequency and duration of episodes, whether medical care was sought, prescription medications required during episodes, and functional impairment during episodes.

Avoid: Do not fail to mention incapacitating episodes because they seem infrequent to you. Even 1-2 per month is highly significant for rating purposes. Do not fail to mention time lost from work or daily activities during these episodes.