5 sonia palmieri visual field assessment in the italian legislation on legal blindness

Visual field assessment in the Italian legislation on legal blindness Sonia Palmieri, Filippo Romani Introduction The law n 째 138/2001, in addition to the distinction among blindness, partial blindness and visual impairment, prescribed that the visual field assessment should be used as one of the tests required for the assessment of pensions benefits claims related to blindness.

In particular the law prescribes that the visual field test should be conducted according to the Zingirian-Gandolfo methodology. Over the years, some practical issues in applying this method have become apparent.

Methods Over the years the measurement of visual field has moved from manual methods (considered by many to be obsolete due to these being operator-dependent) to computerized methods.

It is generally well understood that pathologies such as glaucoma, retinitis pigmentosa and neurological diseases / trauma can cause a reduction in the visual field, while maculopathy determines a decline in visual acuity, but that in general residual field is sufficient to ensure proper spatial mobility of patients.

As a consequence, anamnesis and evaluation of the pathology of each claimant are essential in the assessment of a benefit case.

Commissioners have to assess whether these pathologies could determine an alteration of the visual field or visual acuity, which are compatible with the assignment of pension and other benefits, and would fall in the classification of Table 1.

Estermann introduced a method of assessment of the visual field which is binocular, as it measures the visual field of both eyes jointly.

This visual field assessment method is based on the perception of a single light pulse (seen / unseen) for a total of 120 pulses in different positions of the visual field. These are then converted into a percentile applying an calculation formula that is normally preprogrammed in the tools.

More recently Zingirian Gandolfo introduced a more complex method of assessment of the binocular visual field which is based on three thresholds: points with lower intensity (below threshold) that are correctly perceived are scored 1.0, those with greater intensity (threshold or above threshold) are scored 0.5, while bright spots perception is scored 0 . The method involves 100 points, 40 in the peripheral visual field and 60 in the central part, of which 40 positioned in the inferior central part, which coincides with macula and which is normally the area with the best visual perception.

Key issues The introduction of the visual field tests for the attribution of pension benefits was greeted with applause by the associations of the blinds.

However it determined practical application issues, as the examination of the visual field as well as the quantification of visual acuity can be subjective. It is also possible that claimant does not fully cooperate with the doctors conducting the assessment, given that

by doing so, it may reduce the probability of obtaining a pension benefit.

Although electronic instruments which measure the visual field are potentially able to detect any errors, they do not provide always provide accurate and reliable information: in clinical usage, false positives cases prevail (e.g. a person who chases the lights upper part of the perimeter, an area where there are no light points), while false negatives cases prevail in disability claims cases, where claimants give evidence of poor cooperation in conducting a reliable test.

A claimant with a residual visual field of less than 10% is unlikely to be able to move independently in a poorly lit environment that he/she is unfamiliar with (without help or assistance). A claimant with a residual visual field of less than 3-5% is unlikely not to turn their head towards their focal point.

Any narrowing of the visual field has to be consistent with the pathological conditions of each eye, as this test is performed with both eyes. Contrary to this principle, we sometimes assess claims in which the visual field test is supplied by claimants with pathologies, which do not determine any narrowing of the field itself.

Conclusions Visual fields exams are often conducted by an orthoptist, assistant in ophthalmology. These practitioners generally conduct these exams for medical reasons, which are very different from an assessment which aims at attributing a pension benefit.

Therefore specific guidelines for visual field assessment for pension benefits requests

assessment should be issued. In fact, the amounts of pensions for blindness are significant (see Table 2) and therefore claimants have really no incentive to cooperate to an accurate assessment of their visual field, as by doing so, they may reduce the probability of being awarded a pension benefit.

When claimants in very old age are involved, the cases are very complex to assess: these patients have often not performed an assessment of the visual field for clinical purposes for a long time, as, due to their neurological conditions, they are not able to react to light pulses with proper timing. For these patients an assessment of the visual field should still be required by the Disability Commission and the practitioner, who conducts the test, should clearly state any doubts about the reliability of the tests conducted.

For borderline cases (also in assessment conducted in a litigation) the use of manual visual field assessment is generally requested (separate for each eye) or documentation of past visual field exams is requested to the claimant (these exams were generally conducted for clinical purposes).

A comprehensive assessment of visual capabilities is at the basis of the overall medical assessment of blindness for the attribution of benefits.

Exposing false claimants and / or those with limitations in eyesight that are insufficient to access the economic benefits is in the common interest of both ophthalmologists and associations for the protection of the blind, as, in this way, the interests and the benefits of those in real need can be protected.

Table 1

Table 2 Type of benefit

Monthly Amount (â‚Ź) 2013

2014

Income Limit (â‚Ź) ( 2013

2014

Pension for the blind

298,33

301,91 16.127,30 16.449,85

Pension for the blind (living living in a care home)

275,87

279,19 16.127,30 16.449,85

Pension for the partially blind

275,87

279,19 16.127,30 16.449,85

Pension for complete and permanent disability

275,87

279,19 16.127,30 16.449,85

Pension for the deaf

275,87

279,19 16.127,30 16.449,85

Pension for partial permanent disability

275,87

279,19

4.738,63

4.795,57

Type of benefit Monthly allowance for minors with disabilities attending special schools

Monthly Amount (â‚Ź)

Income Limit (â‚Ź)

275,87

279,19

4.738,63

4.795,57

Monthly allowance to the companion of a blind beneficiary

846,16

863,85

None

None

Monthly allowance to the companion of a beneficiary with complete and permanent disability

499,27

504,07

None

None

Additional payment for the deaf

249,04

251,22

None

None

Additional monthly payment to the partially blind (Visual acuity of 1/20)

196,78

200,04

None

None

Beneficiaries affected by drepanocytosis or thalassaemia Major

495,43

501,38

None

None

About Sonia Palmieri Sonia Palmieri is an Ophtalmologist, who has worked as a representative of UIC (The Italian Association for the blinds) in the disability commissions that are carried out by the NHS (National Heath Service) and later for INPS (The Italian Social Security institute) in the same commissions, as well as in the extraordinary revisions of pension benefits for blindness carried out by INPS.