Final-How to Fulfill Lecture for Webinar Rev. 8-25-12.Ppt

Western Occupational and Environmental Medical Association CME Webinar - August 29, 2012 HowHow toto FulfillFulfill thethe VisualVisual RequirementsRequirements ofof AmericanAmerican DisabilityDisability ActAct andand AmendmentsAmendments Bernard R. Blais, M.D., FAAO, FACOEM, FACS Clinical Professor Albany Medical College Albany, New York

Blais Consulting, Ltd. Phone: (518) 371-8147 4 Innisbrook Drive Fax: (518) 373-9347 Clifton Park, NY 12065 Email: [email protected]

PLEASE STAND BY - WEBINAR WILL BEGIN AT 12:00pm (Pacific Time) 1 FOR AUDIO: Call: 866-740-1260 / Access Code: 764 4915# Disclosure: I have no actual or potential financial conflicts of interests related to this presentation.

2 EveryEvery fitnessfitness forfor dutyduty certificationcertification mustmust

 FulfillFulfill thethe requirementsrequirements ofof thethe ADAADA

3 VisionVision

VisualVisual functionfunction –– HowHow EyesEyes andand VisualVisual SystemSystem FunctionFunction FunctionalFunctional VisionVision DescribesDescribes howhow thethe PERSONPERSON functionsfunctions AA reducedreduced functionalfunctional visionvision (visual(visual dysfunction)dysfunction)

4 VisionVision AspectsAspects

TheThe OrganOrgan ChangesChanges inin StructureStructure leadsleads toto ChangesChanges inin FunctionFunction TheThe PersonPerson ChangesChanges inin AbilitiesAbilities leadsleads toto PersonalPersonal ConsequencesConsequences

5 ParametersParameters ofof OcularOcular FunctionFunction

A. Central 1. Macular function 2. Provides Binocular Vision 3. VA better than 20/200 4. Central vision less than 10 degrees 5. Stereopsis 6. Color Vision B. Peripheral 1. VA worse than 20/200 2. Peripheral visual fields more than 10 degrees 3. Scotopic Vision - night vision – exclusion area of macula/fovea control

6 Evaluation of Visual Performance Based on

Appropriate vision for the job proficiency

Safely performing the task

7 HOW TO ACCOMPLISH THE ADAA OCULAR (VISUAL) SCREENING

REQUIREMENTS

The ADA and ADAA require that an individual fulfill the position’s essential tasks with or without accommodation without increased substantial risk or substantial threat to himself or herself or others.

How to accomplish state requirements for evaluation of children 7 years or less.

8 JobJob AnalysisAnalysis

Basic visual functions and essential activities of daily life

1. Acuity testing for: Monocular (each eye) and binocular (both eyes) vision Both distance and near visual acuity With and without correction (the person’s eyeglasses or contact lenses, intraocular lens)

2. Stereopsis findings as a baseline, note subsequent changes, if any

3. Color perception, of the 3 visual hues, as some color deficiencies interfere with safety and efficiency of the employees and all ADLs

4. Visual fields to determine visual acuity from the fovea to the ciliary body

5. Muscle balance (distance and near), also called binocular balance. The examination should be for vertical and horizontal phorias. ► General limits of normal functional balance are set for far and near vision when performing the tests. 9 Ocular (Visual) Screening Basics STEP-BY-STEP PROCEDURES Must be completed for all screened personnel

These steps are based on procedures instituted in the Purdue studies for WWII workers – 150,000 employees tested Verified by the US Army in 2002 and 2010 for usefulness for all active duty and civil service employees.

10 Preventive Medicine Guidelines CPT Codes Book’s Evaluation/Management Guidelines Requirements

1. Ocular history, which includes a general overview of the individual’s visual history

Visual History Questionnaire Name______Date ______Address ______Occupation ______Age ______Eye History Do you have a history of eye problem(s)? Yes  No If so, what is the diagnosis?  myopia (nearsightedness)  hyperopia (farsightedness)  astigmatism  lazy eye  presbyopia (needs reading glasses)  color vision (red/green deficiency)  color vision (blue/yellow deficiency)  cataract  macular degeneration  night blindness  congenital/acquired eye disease (specify) ______ eye injury (specify) ______ other eye condition ______ Ocular surgery: straightening eyes______cataracts – intraocular lens – type ______refractive surgery: type ______other surgeries – type ______ Surgical complication  Difficulty with night driving  Decreased contrast sensitivity  Double vision Family History Does your father’s family have an inherited eye condition?  Yes  No If yes, specify ______Does your mother’s family have an inherited eye condition?  Yes  No If yes, specify ______General History Do you have  diabetes  hypertension  glaucoma Do you wear glasses? Yes  No Do you own more than one pair of prescription glasses? Yes  No If so, for what do you use your second pair?  sunglasses  reading  occupational  sports Do you use safety or protective goggles? Yes  No If so, do you wear them over spectacles or contact lenses? Yes  No Do you use garden tools, such as weed whackers or lawn mowers? Yes  No Do you have a home workshop or power tools? Yes  No Do you use dangerous liquids such as alkalis or acids? Yes  No Do you have safety prescription glasses for use in your workshop, hobbies or home activities? Yes  No © American Medical What are you hobbies? ______Do you participate in any sports? Yes  No Association 2011. All If so, which ones? ______rights reserved. Do you wear protective sports goggles? Yes  No Have you ever heard of polycarbonate lenses? Yes  No 11 Figure 4-2

Phases of development of Bausch & Lomb Optical Company Ophthalmic Instruments – Bausch & Lomb Ortho-Rater provided by Bausch & Lomb Archives Library

Sperian Titmus Stereo Optical Co. Vision Assessment Co. Model V4 Optec 5000 Ciber Vision Tester Figure 4-3 Modified for presentation purposes. 12 2. Complete visual (ocular) screening examinations a. Visual acuity quantitative bilateral tests are measured for far, at infinity (at minimum and especially in pediatrics), for near, and for intermediate distances (based on job description); all examinations are performed with and without corrective devices (i.e. glasses, contact lenses, intraocular lens)

Alternate Optotypes – Sloan Letter Series Bailey-Lovie Layout ETDRS Type

Left Eye Right Eye

Source Stereo Optical Co., Inc. Slide 3000-037. Used with permission.

Figure 4-4 Monocular Vision Figure 4-5 Diplopia

Source: Archives of Titmus Optical Inc. and Stereo Optical Co.. Used with permission

15 RequirementsRequirements forfor colorcolor visionvision testing:testing:

·· ActivitiesActivities ofof dailydaily lifelife ·· SpecificSpecific jobjob requirementsrequirements

16 PurposePurpose ofof ColorColor VisionVision Testing?Testing?

 Historically to determine if one is safe, especially at driving: – i.e. Red/Green Hues  Present activities of life have changed – New polychromatic dials, gauges, safety devices – Reemphasis in the aviation & railroad industries as the purpose of colors. – Many job tasks now have varying needs.

17 WhyWhy areare youyou doingdoing colorcolor visionvision testing?testing?

 DetermineDetermine theirtheir activitiesactivities ofof dailydaily living?living? (ADL)(ADL)

 DetermineDetermine ifif oneone isis qualifiedqualified forfor aa specificspecific colorcolor visionvision task?task?

18  RetinalRetinal conescones – Contain classes of photo pigment – Overlapping spectral sensitivity – Have maximum sensitivity in the spectral regions – Classic photo pigment

19 VisualVisual SpectrumSpectrum DefectsDefects

 ThreeThree primaryprimary colorscolors – Blue – Green – Red

20 TrichromaticTrichromatic TheoryTheory

Mariotte (1681) Newton (1704)  All colors could be matched by three others.

Cut-away view of the Munsell solid. McIntyre, D., Color Blindness Causes and Effects, Dalton Publishing, Chester England, 2002 Figure 6 as modified from Britannica® DVD2000 © 1994-2000 Encyclopedia Britannica, Inc. 21 SoSo whatwhat doesdoes oneone actuallyactually seesee withwith eacheach ofof thesethese deficiencies?deficiencies?

22 A. Color Normal B. Red-Blind

Fruit stall. A fruit stall as seen by a color normal (A) and red- blind (B). McIntyre, D., Color Blindness Causes and Effects, Dalton Publishing, Chester England, 2002. Figure 32.

23 A. Color Normal C. Green-Blind

Fruit stall. A fruit stall as seen by a color normal (A) and green- blind (C). McIntyre, D., Color Blindness Causes and Effects, Dalton Publishing, Chester England, 2002. Figure 32.

24 A. Color Normal D. Blue-Blind

Fruit stall. A fruit stall as seen by a color normal (A) and blue- blind (D). McIntyre, D., Color Blindness Causes and Effects, Dalton Publishing, Chester England, 2002. Figure 32.

25 TodayToday’’ss needsneeds forfor

 DeterminationDetermination ifif colorcolor visionvision deficiencydeficiency isis anomalousanomalous oror fullfull defectdefect

 DeterminationDetermination ofof blueblue deficiencydeficiency asas wellwell asas red/greenred/green

26 IndustrialIndustrial NeedsNeeds ChangingChanging

 SoSo moremore specificspecific deficienciesdeficiencies mustmust bebe identifiedidentified

 NotNot ““ColorColor VisionVision FailureFailure””

27 Industry no longer is satisfied with these color vision blind reports. We must know more than what is determined in the following slides.

28 Traffic lights as seen with normal color vision on the left and, as they might appear with some types of color vision deficiency on the right. 29 SimplifiedSimplified terminologyterminology forfor thethe standardstandard poorlypoorly understoodunderstood colorcolor deficienciesdeficiencies

TABLE 2

Formal Term New Term

protanopic red-blind deuteranopic green-blind tritanopic blue-blind protanomalous red-weak deuteranomalous green-weak tritanomalous blue-weak achromatic achromatic

McIntyre, D., Color Blindness Causes and Effects, Dalton Publishing, Chester England, 2002 Table 7 as modified from ©Transport for London. Reproduced by kind permission of London’s Transport Museum. 30 TheThe NomenclatureNomenclature ofof ColorColor VisionVision DeficienciesDeficiencies

Table I Incidence of Color Defects in Caucasian Males

Heredity % (1) Trichromatism (a) normal 91.8 (b) anomalous - (i) protanomaly 1.0 (ii) deuteranomaly 4.6 (iii) tritanomaly 0.0001

(2) Dichromatism (a) protanopia 1.2 (b) deuteranopia 1.4 (c) tritanopia 0.0001

(3) Monochromatism (a) of the rods 0.003 (b) of the cones 0.000001

Acquired (a) tritanomalous or tritanopic possibly 5% (b) protanomalous, deuteranopic or anomalous

Duke Elder, S., Gloster, J. Weale, R. Physiology of The Eye, Chapter XVI on Color Vision, page 616, 1968 Table XIV and Birch, Jennifer, Diagnosis of defective color vision, Oxford University Press (1993). 31 AcquiredAcquired ColorColor VisionVision DefectsDefects ResultingResulting fromfrom OcularOcular PathologyPathology

 IntracranialIntracranial injuryinjury  ExcessiveExcessive useuse ofof therapeutictherapeutic drugsdrugs  ChemicalChemical toxicologicaltoxicological effectseffects

32 ChemicalChemical

 ChemicalChemical toxicologicaltoxicological effectseffects seenseen – Xylene, toluene toxicity – Blue-yellow color deficiency present prior to findings of peripheral neuropathy – At what toxic level does the color vision defect found  more research needed?

33 BasisBasis for what is the appropriate color vision test

 Is it a screening or diagnostic procedure?  Does it test for the three hues?  Does it primarily answer what are consistent with purpose?  What is the cost for performing the test? – Employee – Technical Administrator  What is the complexity of the procedure?

34 BasicBasic RequirementsRequirements ofof ColorColor VisionVision SCREENINGSCREENING

 Must be able to evaluate Red.Green.Blue hues  Must be technically simple to operate  Must take short period to complete – (1-2 minutes maximum)  Technician/nurse time normally 5 minutes.  Must be inexpensive to purchase test and special illumination  Screening for R.G.B. should be with one test

35 GoalGoal inin OccupationalOccupational MedicineMedicine

 AA screeningscreening testtest thatthat screensscreens forfor  Red  Green  Tritan (blue – yellow)

 FulfillsFulfills basicbasic requirementrequirement ofof screeningscreening

36 PrintedPrinted PseudoisochromaticPseudoisochromatic PlatesPlates

 MostMost widelywidely usedused screeningscreening forfor colorcolor visionvision  MostMost designdesign toto detectdetect congenitalcongenital Red-Red- GreenGreen  OnlyOnly sixsix teststests –– detectsdetects tritantritan (blue(blue defects)defects)

37 ScreeningScreening TestTest inin VisionVision ScreenersScreeners ArmedArmed ForcesForces *Titmus*Titmus *Stereo*Stereo OpticalOptical +Vision+Vision AssessmentAssessment Co.Co.

 IshiharaIshihara TestTest – Screens for only red and green

*HRR will be new option in newer plates +HRR screening and diagnostic and

Ishihara Test 38 HRRHRR PlatesPlates

 Consist of background colored circles  Range of size and lightness  HRR indicates severity of defect of any RG defect  Screen for tritan (blue- yellow)

39 HRRHRR PlatesPlates

 ByBy itselfitself cancan determinedetermine integrityintegrity ofof threethree hueshues  Red  Green  Blue

40 TwoTwo HRRHRR PlatesPlates AcceptableAcceptable

 OriginalOriginal AmericanAmerican OpticalOptical PlatesPlates (1954)(1954)  RichmondRichmond Products,Products, Inc.Inc. FourthFourth EditionEdition onlyonly (2002)(2002)

41 ACOEM Guidance for the Medical Evaluation of Law Enforcement Officers (LEO)

(No longer used)

42 Tests used for evaluation of congenital color deficiency (modified)

Function Scope Tests

Screening red-green defects Ishihara plates blue defects CU (City University) tritan plates HRR plates Screening & grading Ishihara + CU tritan plates HRR plates D15 test, Anomaloscope Evaluation D15, FM100 Anomaloscope Occupational transport & armed Ishihara plates screening services Falant

McIntyre, D, Color Blindness Causes and Effects, Dalton Publishing, Chester, England, 2002, p. 81. AlternateAlternate TestTest

 TwoTwo teststests neededneeded toto identifyidentify Red-Red- GreenGreen defectsdefects andand tritantritan (blue-yellow)(blue-yellow)

 MultipleMultiple testtest notnot satisfactorysatisfactory forfor non-non- ocularocular facilitiesfacilities – Not cost effective c. Color vision – for the 3 Hues – Red, Green, Blue

Figure A-12 Ishihara Color Perception

Source: Archives of Titmus Optical Inc. and Stereo Optical Co. Used with permission.

Figure A-13 Alternate Color Perception – Hardy, Rand, and Rittler (HRR)

Source: Richmond Products. Used with permission.

45 b. Depth of Perception Figure 4-11 Stereo Depth Perception – Far

Source: Archives of Titmus Optical Inc. and Stereo Optical Co.. Used with permission

Figure AA-1 Binocular vs. Monocular Field

Figure AA-3 Binocular Field Binocular Field

Point of Fixation

Right Eye Left Eye Peripheral 55° 55° Peripheral Field Field

95° 95° 47

4. Ordering of appropriate laboratory/diagnostic procedures or by referral to an appropriate eye specialist, depending on the defect, when an individual fails to meet standards.

5. A written summary of the case signed by the authorizing physician.

48 Risk Analysis/Job Standards Table 4-7 Visual Job Family Clerical and Administrative Profile #1

Clerical Snellen Decimal

Binoc 20/25 0.8 Both 20/30-32 0.63 Right 20/30-32 0.63 Left FAR Depth No Requirement Color 5 out of 8 Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

Binoc 20/20 1.0 Both 20/25 0.8 NEA Right 20/25 0.8 R Left Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP Tiffin J. Visual Skills. In: Kuhn H. Eyes and Industry, 2nd ed. St. Louis, MO: Mosby: 1950;:111-117. Binoc indicates binoculars; LH, left hyperphoria; RH, right hyperphoria; EP, esophoria; and XP, exophoria

Mobile Snellen Decimal

Binoc 20/20 1.0 Both 20/25 0.8 Right 20/25 0.8 Left FAR Depth 40” Color 5 out of 8 Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

Binoc 20/30-32 0.63 Both 20/32-35 0.63 NEA Right 20/32-35 0.63 R Left Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

Tiffin J. Visual Skills. In: Kuhn H. Eyes and Industry, 2nd ed. St. Louis, MO: Mosby: 1950;:111-117. Binoc indicates binoculars; LH, left hyperphoria; RH, right hyperphoria; EP, esophoria; and XP, exophoria 50 © American Medical Association 2011. All rights reserved. Table 4-9 Visual Job Family Inspection and Close Machine Work Profile #3

Inspection

Snellen Decimal

Binoc 20/30-32 0.63 Both 20/32-35 0.63 Right 20/32-35 0.63 Left FAR Depth 40” * Color 5 out of 8 Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

Binoc 20/20 1.0 Both 20/25 0.8 NEA Right 20/25 0.8 R Left Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

Tiffin J. Visual Skills. In: Kuhn H. Eyes and Industry, 2nd ed. St. Louis, MO: Mosby: 1950;:111-117. Binoc indicates binoculars; LH, left hyperphoria; RH, right hyperphoria; EP, esophoria; and XP, exophoria. Tiffin (Kuhn) requirement of 83 seconds of arc is not consistent with the job analysis nor is it consistent with bifoveal fixation as discussed in the book’s Appendix. Binoc indicates binoculars; LH, left hyperphoria, RH, right hyperphoria; EP, esophoria; and XP, exophoria. 51

Machine

Titmus (1) Snellen Decimal Binoc 20/25 0.8 Both 20/30-32 0.63 Right 20/30-32 0.63 Left FAR Depth 40” * Color 5 out of 8 Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

Binoc 20/25 0.8 Both 20/30-32 0.63 NEA Right 20/30-32 0.63 R Left Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

Tiffin J. Visual Skills. In: Kuhn H. Eyes and Industry, 2nd ed. St. Louis, MO: Mosby: 1950;:111-117. Binoc indicates binoculars; LH, left hyperphoria; RH, right hyperphoria; EP, esophoria; and XP, exophoria. Tiffin (Kuhn) requirement of 83 seconds of arc is not consistent with the job analysis nor is it consistent with bifoveal fixation as discussed in the book’s Appendix. Binoc indicates binoculars; LH, left hyperphoria, RH, right hyperphoria; EP, esophoria; and XP, exophoria.

Skilled

Titmus (1) Snellen Decimal Binoc 20/25 0.8 Both 20/30-32 0.63 Right 20/30-32 0.63 Left FAR Depth 40” Color 5 out of 8 Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

Binoc 20/20 1.0 Both 20/25 0.8 NEA Right 20/25 0.8 R Left 0.63 Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

Unskilled

Titmus (1) Snellen Decimal

Binoc 20/25 0.8 Both 20/30-32 0.63 Right 20/30-32 0.63 Left FAR Depth 40” Color 5 out of 8 Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

Binoc 20/30-32 0.63 Both 20/32-35 0.63 NEA Right 20/32-35 0.63 R Left Vertical 0.5 LH or 0.5 RH Lateral 4 EP or 5 XP

 FAAFAA -- PilotsPilots  DOTDOT -- CommercialCommercial DriversDrivers  NRANRA -- RailroadRailroad EngineersEngineers etc.etc.

NB: Multiple detailed listing can be found in Appendix C of AMA Guides

55 Impairment – Significant Disability, loss or less use of any structure or body function in any individual with a health condition, disorder or process.

Examples – 1. Cataract 2. Macular Degeneration 3. Retinitis Pigmatosa

A. The physician provides an independent, unbiased assessment of the individual’s medical condition B. including the effect on function C. Or inhibition to the performance of activities of daily living or ADLs

56 Disability – Inability

A. An altered ability to accomplish a given task successfully B. But would not help to distinguish what is being evaluated doing the disability process

57 Impairment – Generally Significant Disability, loss or less use of any structure or body function in any individual with a health condition, disorder or process.

Examples – Ophthalmic 1. Cataract 2. Macular Degeneration 3. Retinitis Pigmatosa

58 References

Rondelli R, Graves, Katz RT, et al. AMA Guides to the Evaluation of Permanent Impairment, 6th Edition, Chicago, IL, AMA 2008.

Blais BR, Color Vision in the Occupational Setting, Analysis and Testing, R.P. Press, Atlanta, GA.

Blais BR, AMA Guides to the Evaluation of Ophthalmic Impairment and Disability – Measuring the Impact of Visual Impairment on Activities of Daily Living, AMA Press, Chicago, IL, 2011.

Voke J, Colour vision testing in specific industries and profession, Keeler, London, 1980.

Vingrys AS, Cole BL, Are colour vision standards justified for the transport industry? Ophthalmic Physiol Opt. 1988;8(3):257-74.

59 Thank you!

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