final-how to fulfill lecture for webinar rev. 8-25-12.ppt [read-only]

How to Fulfill the VisualHow to Fulfill the VisualRequirements ofRequirements of

American Disability Act andAmerican Disability Act andAmendmentsAmendments

Bernard R. Bernard R. BlaisBlais, M.D., FAAO, FACOEM, FACS, M.D., FAAO, FACOEM, FACSClinical ProfessorClinical Professor

Albany Medical CollegeAlbany Medical CollegeAlbany, New YorkAlbany, New York

Blais Consulting, Ltd.Blais Consulting, Ltd.4 Innisbrook Drive4 Innisbrook DriveClifton Park, NY 12065Clifton Park, NY 12065

Phone: (518) 371-8147Phone: (518) 371-8147Fax: (518) 373-9347Fax: (518) 373-9347Email: bblais@nycap.rr.comEmail: bblais@nycap.rr.com

Western Occupational and Environmental Medical AssociationCME Webinar - August 29, 2012

PLEASE STAND BY - WEBINAR WILL BEGIN AT 12:00pm (Pacific Time)FOR AUDIO: Call: 866-740-1260 / Access Code: 764 4915#

Disclosure: Disclosure: I have no actual or potentialfinancial conflicts of interests related tothis presentation.

Every fitness for dutyEvery fitness for dutycertification mustcertification must

Fulfill the requirements of the ADAFulfill the requirements of the ADA

VisionVision

Visual function Visual function –– How Eyes and How Eyes andVisual System FunctionVisual System Function

Functional Vision DescribesFunctional Vision Describeshow the PERSON functionshow the PERSON functionsA reduced functional vision A reduced functional vision

(visual dysfunction)(visual dysfunction)

Vision AspectsVision Aspects

The OrganThe OrganChanges in Structure leads toChanges in Structure leads to

Changes in FunctionChanges in FunctionThe PersonThe Person

Changes in Abilities leads toChanges in Abilities leads toPersonal ConsequencesPersonal Consequences

Parameters of Ocular FunctionParameters of Ocular Function

A. Central1. Macular function2. Provides Binocular Vision3. VA better than 20/2004. Central vision less than 10

degrees5. Stereopsis6. Color Vision

B. Peripheral1. VA worse than 20/2002. Peripheral visual fields more than 10 degrees3. Scotopic Vision - night vision

– exclusion area of macula/fovea control

Evaluation of Visual Performance Based on

Appropriate vision for the job proficiency

Safely performing the task

HOW TO ACCOMPLISH THE ADAAOCULAR (VISUAL) SCREENING

REQUIREMENTS

The ADA and ADAA require that an individual fulfill theposition’s essential tasks with or without accommodationwithout increased substantial risk or substantial threat tohimself or herself or others.

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

Job AnalysisJob Analysis

Basic visual functions and essential activities of daily life

1. Acuity testing for:Monocular (each eye) and binocular (both eyes) visionBoth distance and near visual acuityWith 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 deficienciesinterfere with safety and efficiency of the employees and all ADLs

4. Visual fields to determine visual acuity from the fovea to the ciliarybody

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

Must be completed for all screened personnel

These steps are based on procedures instituted inthe Purdue studies

for WWII workers – 150,000 employees testedVerified by the US Army in 2002 and 2010 forusefulness for all active duty and civil serviceemployees.

Ocular (Visual) Screening BasicsSTEP-BY-STEP PROCEDURES

Visual History QuestionnaireName__________________________________________________________ Date __________________Address ______________________________________________________________________________Occupation _________________________________________________________________ Age ______

Eye HistoryDo you have a history of eye problem(s)? Yes NoIf 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 visionFamily HistoryDoes your father’s family have an inherited eye condition? Yes NoIf yes, specify _______________________________________________________________________________________________________________________________________________________________________________Does your mother’s family have an inherited eye condition? Yes NoIf yes, specify _______________________________________________________________________________________________________________________________________________________________________________

General HistoryDo you have diabetes hypertension glaucomaDo you wear glasses? Yes NoDo you own more than one pair of prescription glasses? Yes NoIf so, for what do you use your second pair? sunglasses reading occupational sportsDo you use safety or protective goggles? Yes NoIf so, do you wear them over spectacles or contact lenses? Yes NoDo you use garden tools, such as weed whackers or lawn mowers? Yes NoDo you have a home workshop or power tools? Yes NoDo you use dangerous liquids such as alkalis or acids? Yes NoDo you have safety prescription glasses for use in your workshop, hobbies or home activities? Yes NoWhat are you hobbies? __________________________________________________________________________Do you participate in any sports? Yes NoIf so, which ones? _______________________________________________________________________Do you wear protective sports goggles? Yes NoHave you ever heard of polycarbonate lenses? Yes No

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

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

Vision Assessment Co.Ciber Vision Tester

Figure 4-2

Sperian Titmus Stereo Optical Co. Model V4 Optec 5000

Figure 4-3

Modified for presentation purposes.12

2. Complete visual (ocular) screening examinationsa. 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 withoutcorrective devices (i.e. glasses, contact lenses, intraocular lens)

Alternate Optotypes – Sloan Letter SeriesBailey-Lovie Layout ETDRS Type

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

Left Eye Right Eye

a. 1. BinocularityFigure 4-3 Vision Testers for Binocularity - Far

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

Figure 4-4 Monocular Vision Figure 4-5 Diplopia

Who is doing color visionWho is doing color visiontesting?testing?

Requirements for color visionRequirements for color visiontesting:testing:

· Activities of daily life · Activities of daily life · Specific job requirements · Specific job requirements

Purpose of Color VisionPurpose of Color VisionTesting?Testing? Historically to determine if one is safe,Historically to determine if one is safe,

especially at driving:especially at driving:–– i.e. Red/Green Huesi.e. Red/Green Hues

Present activities of life have changedPresent activities of life have changed–– New polychromatic dials, gauges, safety devicesNew polychromatic dials, gauges, safety devices–– Reemphasis in the aviation & railroad industriesReemphasis in the aviation & railroad industries

as the purpose of colors.as the purpose of colors.–– Many job tasks now have varying needs.Many job tasks now have varying needs.

Why are you doing colorWhy are you doing colorvision testing?vision testing?

Determine their activities of dailyDetermine their activities of dailyliving? (ADL)living? (ADL)

Determine if one is qualified for aDetermine if one is qualified for aspecific color vision task?specific color vision task?

Retinal conesRetinal cones–– Contain classes of photo pigmentContain classes of photo pigment–– Overlapping spectral sensitivityOverlapping spectral sensitivity–– Have maximum sensitivity in the spectralHave maximum sensitivity in the spectral

regionsregions–– Classic photo pigmentClassic photo pigment

Visual Spectrum DefectsVisual Spectrum Defects

Three primary colorsThree primary colors–– BlueBlue–– GreenGreen–– RedRed

Trichromatic TheoryTrichromatic Theory

Mariotte (1681) Mariotte (1681) Newton (1704) Newton (1704) All colors couldAll colors could

be matched bybe matched bythree others.three others.

Cut-away view of the Munsell solid. McIntyre, D., Color Blindness Causes and Effects, Dalton Publishing, ChesterEngland, 2002 Figure 6 as modified from Britannica® DVD2000 © 1994-2000 Encyclopedia Britannica, Inc. 2121

So what does one actuallySo what does one actuallysee with each of thesesee with each of thesedeficiencies?deficiencies?

B. Red-BlindA. Color Normal

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, ChesterEngland, 2002. Figure 32.

A. Color Normal

Fruit stall. A fruit stall as seen by a color normal (A) and green-blind (C).

C. Green-Blind

A. Color Normal

Fruit stall. A fruit stall as seen by a color normal (A) and blue-blind (D).

D. Blue-Blind

TodayToday’’s needs fors needs for

Determination if color vision deficiencyDetermination if color vision deficiencyis anomalous or full defectis anomalous or full defect

Determination of blue deficiency asDetermination of blue deficiency aswell as red/greenwell as red/green

Industrial NeedsIndustrial NeedsChangingChanging

So more specific deficiencies must beSo more specific deficiencies must beidentifiedidentified

Not Not ““Color Vision FailureColor Vision Failure””

Industry no longer issatisfied with these colorvision blind reports.

We must know more thanwhat is determined in thefollowing slides.

Traffic lights as seen with normal color vision on the leftand, as they might appear with some types of color

vision deficiency on the right.2929

Simplified terminology for theSimplified terminology for thestandard poorly understoodstandard poorly understoodcolor deficienciescolor deficiencies

TABLE 2TABLE 2

Formal TermFormal Term New TermNew Term

protanopicprotanopic red-blindred-blinddeuteranopicdeuteranopic green-blindgreen-blindtritanopictritanopic blue-blindblue-blindprotanomalousprotanomalous red-weakred-weakdeuteranomalousdeuteranomalous green-weakgreen-weaktritanomaloustritanomalous blue-weakblue-weakachromaticachromatic achromaticachromatic

McIntyre, D., Color Blindness Causes and Effects, Dalton Publishing, Chester England, 2002McIntyre, D., Color Blindness Causes and Effects, Dalton Publishing, Chester England, 2002Table 7 as modified from ©Transport for London. Reproduced by kind permission ofTable 7 as modified from ©Transport for London. Reproduced by kind permission ofLondonLondon’’s Transport Museum.s Transport Museum.

The Nomenclature ofThe Nomenclature ofColor Vision DeficienciesColor Vision Deficiencies

Table IIncidence 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, 1968Table XIV and Birch, Jennifer, Diagnosis of defective color vision, Oxford University Press (1993).

Acquired Color Vision DefectsAcquired Color Vision DefectsResulting from OcularResulting from OcularPathologyPathology

Intracranial injuryIntracranial injury Excessive use of therapeutic drugsExcessive use of therapeutic drugs Chemical toxicological effectsChemical toxicological effects

ChemicalChemical

Chemical toxicological effects seenChemical toxicological effects seen–– Xylene, toluene toxicityXylene, toluene toxicity–– Blue-yellow color deficiency present priorBlue-yellow color deficiency present prior

to findings of peripheral neuropathyto findings of peripheral neuropathy–– At what toxic level does the color visionAt what toxic level does the color vision

defect founddefect found more research needed? more research needed?

BasisBasis for what is the appropriate color for what is the appropriate colorvision testvision test

Is it a screening or diagnostic procedure?Is it a screening or diagnostic procedure? Does it test for the three hues?Does it test for the three hues? Does it primarily answer what are consistentDoes it primarily answer what are consistent

with purpose?with purpose? What is the cost for performing the test?What is the cost for performing the test?

–– EmployeeEmployee–– Technical AdministratorTechnical Administrator

What is the complexity of the procedure?What is the complexity of the procedure?

Basic Requirements ofBasic Requirements ofColor Vision Color Vision SCREENINGSCREENING Must be able to evaluate Red.Green.Blue huesMust be able to evaluate Red.Green.Blue hues Must be technically simple to operateMust be technically simple to operate Must take short period to completeMust take short period to complete

–– (1-2 minutes maximum)(1-2 minutes maximum)

Technician/nurse time normally 5 minutes.Technician/nurse time normally 5 minutes. Must be inexpensive to purchase test andMust be inexpensive to purchase test and

special illuminationspecial illumination Screening for R.G.B. should be with oneScreening for R.G.B. should be with one

testtest

Goal in OccupationalGoal in OccupationalMedicineMedicine

A screening test that screens forA screening test that screens for RedRed GreenGreen Tritan (blue Tritan (blue –– yellow) yellow)

Fulfills basic requirement of screeningFulfills basic requirement of screening

Printed PseudoisochromaticPrinted PseudoisochromaticPlatesPlates

Most widely used screening for colorMost widely used screening for colorvisionvision

Most design to detect congenital Red-Most design to detect congenital Red-GreenGreen

Only six tests Only six tests –– detects tritan (blue detects tritan (bluedefects)defects)

Screening Test in VisionScreening Test in VisionScreenersScreeners

Armed ForcesArmed Forces*Titmus*Titmus*Stereo Optical*Stereo Optical+Vision Assessment Co.+Vision Assessment Co.

Ishihara TestIshihara Test–– Screens for only red and greenScreens for only red and green

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

Ishihara TestIshihara Test3838

HRR PlatesHRR Plates

Consist of backgroundConsist of backgroundcolored circlescolored circles

Range of size andRange of size andlightnesslightness

HRR indicates severityHRR indicates severityof defect of any RGof defect of any RGdefectdefect

Screen for tritan (blue-Screen for tritan (blue-yellow)yellow)

HRR PlatesHRR Plates

By itself can determine integrity ofBy itself can determine integrity ofthree huesthree hues

RedRed GreenGreen BlueBlue

Two HRR PlatesTwo HRR PlatesAcceptableAcceptable

OriginalOriginal American Optical Plates American Optical Plates(1954)(1954)

Richmond Products, Inc. FourthRichmond Products, Inc. FourthEdition only (2002)Edition only (2002)

ACOEM Guidance for the Medical Evaluationof Law Enforcement Officers (LEO)

(No longer used)

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.

Alternate TestAlternate Test

Two tests needed to identify Red-Two tests needed to identify Red-Green defects and tritan (blue-yellow)Green defects and tritan (blue-yellow)

Multiple test not satisfactory for non-Multiple test not satisfactory for non-ocular facilitiesocular facilities–– Not cost effectiveNot 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.

b. Depth of PerceptionFigure 4-11 Stereo Depth Perception – Far

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

Figure AA-3Binocular Field

Right Eye Peripheral Field

Left Eye Peripheral Field

Point of Fixation

Binocular Field

Left Eye Peripheral Field

Point of Fixation

d. Gross visual fields

Figure AA-1 Binocular vs. Monocular Field

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

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

Risk Analysis/Job Standards

Clerical Clerical

SnellenSnellen DecimalDecimal

FARFAR

BinocBinocBothBothRightRightLeftLeftDepthDepthColorColorVerticalVerticalLateralLateral

No RequirementNo Requirement5 out of 85 out of 80.5 LH or 0.5 RH0.5 LH or 0.5 RH4 EP or 5 XP4 EP or 5 XP

20/2520/2520/30-3220/30-3220/30-3220/30-32

0.80.80.630.630.630.63

NEANEARR

BinocBinocBothBothRightRightLeftLeftVerticalVerticalLateralLateral

0.5 LH or 0.5 RH0.5 LH or 0.5 RH4 EP or 5 XP4 EP or 5 XP

20/2020/2020/2520/2520/2520/25

1.01.00.80.80.80.8

Table 4-7 Visual Job FamilyClerical and Administrative Profile #1

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

Table 4-8 Visual Job FamilyOperator of Mobile Equipment

Profile #2

Mobile Mobile

FARFAR

4040””5 out of 85 out of 80.5 LH or 0.5 RH0.5 LH or 0.5 RH4 EP or 5 XP4 EP or 5 XP

20/2020/2020/2520/2520/2520/25

1.01.00.80.80.80.8

NEANEARR

20/30-3220/30-3220/32-3520/32-3520/32-3520/32-35

0.630.630.630.630.630.63

InspectionInspection

FARFAR

4040”” * *5 out of 85 out of 80.5 LH or 0.5 RH0.5 LH or 0.5 RH4 EP or 5 XP4 EP or 5 XP

20/30-3220/30-3220/32-3520/32-3520/32-3520/32-35

0.630.630.630.630.630.63

NEANEARR

20/2020/2020/2520/2520/2520/25

1.01.00.80.80.80.8

Table 4-9 Visual Job Family Inspection and Close Machine Work Profile #3

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 bifovealfixation as discussed in the book’s Appendix.Binoc indicates binoculars; LH, left hyperphoria, RH, right hyperphoria; EP, esophoria; and XP, exophoria.

MachineMachine

Titmus (1)Titmus (1) SnellenSnellen DecimalDecimal

FARFAR

4040”” * *5 out of 85 out of 80.5 LH or 0.5 RH0.5 LH or 0.5 RH4 EP or 5 XP4 EP or 5 XP

20/2520/2520/30-3220/30-3220/30-3220/30-32

0.80.80.630.630.630.63

NEANEARR

20/2520/2520/30-3220/30-3220/30-3220/30-32

0.80.80.630.630.630.63

Table 4-10 Visual Job Family Machine Operators Profile #4

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 consistentwith bifoveal fixation as discussed in the book’s Appendix.Binoc indicates binoculars; LH, left hyperphoria, RH, right hyperphoria; EP, esophoria; and XP, exophoria.

SkilledSkilled

FARFAR

20/2520/2520/30-3220/30-3220/30-3220/30-32

0.80.80.630.630.630.63

NEANEARR

20/2020/2020/2520/2520/2520/25

1.01.00.80.80.80.80.630.63

Table 4-11 Visual Job Family Mechanics & Skilled Tradesmen Profile #5

UnskilledUnskilled

FARFAR

20/2520/2520/30-3220/30-3220/30-3220/30-32

0.80.80.630.630.630.63

NEANEARR

20/30-3220/30-3220/32-3520/32-3520/32-3520/32-35

0.630.630.630.630.630.63

Table 4-12 Visual Job Family Laborers Profile #6

Specific Ocular Standards bySpecific Ocular Standards byVarious Regulatory BodiesVarious Regulatory Bodies

FAAFAA - - PilotsPilots DOTDOT -- Commercial DriversCommercial Drivers NRANRA -- Railroad Engineers etc.Railroad Engineers etc.

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

Impairment –Significant Disability, loss or less use of anystructure or body function in any individual with ahealth condition, disorder or process.

Examples –1. Cataract2. Macular Degeneration3. Retinitis Pigmatosa

A. The physician provides an independent, unbiasedassessment of the individual’s medical condition

B. including the effect on functionC. Or inhibition to the performance of activities of

daily living or ADLs

Disability Disability –– Inability Inability

A. An altered ability to accomplish agiven task successfully

B. But would not help to distinguishwhat is being evaluated doing thedisability process

Impairment – GenerallySignificant Disability, loss or less use of anystructure or body function in any individual with ahealth condition, disorder or process.

Examples – Ophthalmic1. Cataract2. Macular Degeneration3. Retinitis Pigmatosa

A. The physician provides an independent, unbiasedassessment of the individual’s medical condition

B. including the effect on functionC. Or inhibition to the performance of activities of

daily living or ADLs

Rondelli R, Graves, Katz RT, et al. AMA Guides to the Evaluation ofPermanent 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 andDisability – Measuring the Impact of Visual Impairment on Activitiesof 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 transportindustry? Ophthalmic Physiol Opt. 1988;8(3):257-74.

References

Thank you!Thank you!

Thank you for participating in today’s webinar.At the conclusion of this call you will receive an email

with a link to a post-webinar questionnaire.

You will need to complete this questionnaire in order toreceive CME for this webinar.

This webinar presentation can be downloaded atwww.woema.org

Thank you!Thank you!

Thank you for participating in today’s webinar.At the conclusion of this call you will receive an email

with a link to a post-webinar questionnaire.

You will need to complete this questionnaire in order toreceive CME for this webinar.

This webinar presentation can be downloaded atwww.woema.org

final-how to fulfill lecture for webinar rev. 8-25-12.ppt [read-only]

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