Good afternoon, everyone. Welcome to this session of thalmic impairments, is what we're going to be talking about. Our objectives today are eye-related questions that you should be asking injured workers, the AMA guides of thalmic factors and how they relate to that. And we will go over the fifth and sixth edition of the AMA guides for rating of thalmic factors. I'm Bobak Komkar. I'm an optometrist in practice for 35 years. And I'm a QME, Qualified Medical Evaluator, in California for 17 years. I've done expert witness work, and I'm an inventor of a little device called APD tester. It's pictured here, and I'm holding it here. So if you'd like to play with it, come on up afterwards. And as an optometrist, I'm always, when I'm in the front of people, they come up to me and they say, I know I have this problem with my eye, and you know, I like to be prepared. So I ask them to cover one of their eyes and look at my tie, and then we can decide right then and there if there's a problem. So that's, and then with my pupil tester, we can pretty much come up with a conclusion and preliminary diagnosis. And then I ask them for their insurance information. So today, we will talk mostly about vision problems that injured workers have. And we need to ask them a lot of questions to be able to gather that information. For example, we just ask them, what vision problems do you have? We ask them, what, if you have any difficulties with bright lights or glare at night, if your eyes itch or are bothered by watery, burning, those are symptoms that are very common. If you have distortions in their vision, halos, and if they have flashes of light, and of course if they have floaters, these little black spots that we all have that they move around and we follow them, don't catch up to them sometimes, and we don't know what they are. And they, you know, are harmless most of the time, 97% of the time, and those 2 or 3%, it could be a retinal detachment. And if they have had a head injury or some kind of a problem, or just out of the blue, retinal detachment can happen often without any injuries or any trauma. So we ask them, are your eyes the same between the two eyes, or do you see the same? And many people think that that's the way it's supposed to be. They've always had it. They think other people have the same, you know, they don't have the same vision between the two eyes because they don't know any better. But each eye has to be 20-20, and if it's not, we need to find out why. So history of eye injury and eye diseases, we should ask about that in our history form. And any use of any eye drops. Many people use eye drops, and they don't think of it. They don't think it's related to their health problems. Sometimes they have things missing off to the side, and again, they're not aware of that, or they may say that to you when you ask them. And then we ask them, is there anything else? So this list is a partial list that we should be at least asking these questions. And we have two handouts for you today as part of this session, and one of them has all this on there. So the reference for evaluators has those listed, and then the other handout is a patient questionnaire that I like the people to fill out before their evaluation, and they come and see me. And it's 12 pages. It's pictured here. It's very detailed, and it, you know, it goes through all sorts of things about the eyes as well as their systemic health and their injury, for example. And then after we have gathered all this information, you know, an eye doctor, optometrist, ophthalmologist will have to issue a medical legal report. And that's similar to any other specialty, and it has all its factors of disability and apportionment, causation, everything, but it also has a work preclusion area, just like anybody else. In this case, with eyes, we use our eyes for practically every part of the activities of daily living and in our jobs. So that list sometimes is very extensive, and I've actually had to do the opposite in my evaluation sometimes, and I write work preclusions. I write, well, instead of saying the preclusions, I will list the things this injured worker can do because they can't do anything else, and that basically is using their hearing or smell or touch or other senses, they may be able to have a function in the workplace. So it's very similar to that. Now what do we do? How do we do visual impairments? There are a few things we absolutely have to do under AMA guides. Visual acuity is very important. Visual fields is another very important category, and then we have a few other things, a few other factors, individual adjustments, ocular pain, burden of disease, and facial disfigurement all go into our report and rating, and we'll go over all these. So visual acuity is a very simple test. As you all know, we have a Snellen eye chart, and if it's not possible to do at 20 feet, you can adjust for distance and do a little math, and you figure out if it's 20-20 or less. 20-20 is normal vision, and this test needs to be done with the corrective lenses, so you have to do with the best glasses that they have, and in 0% 20-20, in 20-40 level, we get to 15%, and 15% of 20-40 is the DMV line, the motor vehicle test that they do, so if they see 20-40, they can generally pass in most states and operate, but they have 15% disability in that eye, impairment in that eye, so then we will see how that translates to actual disability rating. 20-200 is the big E on the eye chart, and that's 50% for impairment for that eye. Of course, beyond that, we have worse vision. 20-200, we all know is called legally blind, but it's not really, it's not blindness. Hand motion is really bad, all they can see is your hand moving in front of their face, and that's like 20-100, or 1,250, that's a 90% impairment rating, and beyond that is light perception. If you ask them, are the room lights on or off, or do you have the brightest light that you shine at? If they say, oh yeah, it's on, then they have light perception, they have 5% ability to see in that eye, and then last one is no light perception, when there is no eye to talk about and no visual perception at all, and you have 100% disability in that case in that eye. Now, we can go to visual fields, and it's not as simple. This is where it gets a little bit harder to test a person, needs special equipment, and you have to do each eye separately, but the AMA guide says after you've done each eye, now put it together mentally, so the evaluator has to do that, and figure out how this person sees with both eyes open, because the instruments don't give us that information, and then after that you can do the rating. So here are some of the common instruments you may have seen when you go to get your own eyes tested. Humphrey Visual Field is a bulky unit that is basically gold standard. This is what most eye doctors use in their offices, because it's really good at disease detection and monitoring, and glaucoma, for example, we have to have this instrument in our offices, but it's not that great for impairment rating. In fact, it's really cumbersome, and you probably have one printout from that machine and give it to two different eye doctors, and you're going to get two different ratings. There's a lot of subjective. It's not one plus one equals two in that case. In Goldman Visual Field, it's an older unit. That was the gold standard before, and it's really cumbersome to use. It's a big machine, and it's cumbersome for the patient, and it's cumbersome for the doctor to be able to do this test, but it gives really good results, and it actually can be related to impairment ratings much better. However, it is so difficult to do for both patient and the doctor that I often see erroneous results in that testing. That's just my personal opinion on that. This is the third one here is, thank goodness for technology. Now we have head-worn instruments, and that's what I use in my practice, and this is what it looks like. Very easy, portable, 10 minutes, really good in detecting all the way to the sides, and not just like the Humphrey, for example. The first one is only limited to 30 degrees, central 30 degrees most of the time, and when it wants to test you from the outside, those programs don't work that well, but in this case it goes all the way to the side, all around for each eye, and it gives us a very nice printout that we can easily interpret into what's the visual impairment, and we're going to do that here together in a few minutes. So there are questions, if there are questions on live session Zoom, I've been told I have to look, and there's no questions yet. And you guys, please interact with me if you like. I can answer questions as we go forward. Here's an example of a case, injured worker came in, and we have a visual acuity of 20-25 in the right eye, 20-40 in the left, and both eyes together they see 20-20, because the brain actually adds the two images together, and the person sees better than their good eye, they see 20-20. And we need to do this with one of these devices called a phoropter, and therefore they actually have the best corrected visual acuity, because legally we need to do that. A lot of times eye doctors don't prescribe the same power between the two eyes in the glasses that people are wearing, or the same, the absolute correction for each eye. We try and make it easy for the person to adapt to, therefore sometimes one eye is not as 100% as it should be, but with this device we can measure exactly what they can see. Then this injured worker happens to have had a retinal detachment in the past, and their visual field is restricted, because of that part of the retina is no longer functioning, and we will go over that. So they're also sensitive to glare at night. During our questioning they say, I don't drive at night, I can't. If somebody asks me to go somewhere, I say, nope, thanks, I'll see you in the morning. They avoid driving at night. So that's something that needs to be rated, that's an impairment. Moderate dry eyes in this case, they use eye drops, that's a very common issue, and they get temporary relief when they use that. So how do we rate this kind of a case? So the visual acuity calculations are really straightforward. 20-25, the guides tell us it's 95% rating, 20-40 is 85, and 20-20 is 100. Now there's a formula, but the formula wants to really pay attention to that binocular vision. Someone has both eyes open, it really matters how they see, so they multiply by three. So that last, that binocular vision is worth a lot, so we make it three. So we get 300 for that. For the right eye and left eye, the multipliers are just one. And then we add them all up together, we get 480. And of course, we used three parts here, one part here, one part here, we want just one number, so we divide it by five, and we get a rating of 96. This is called a functional acuity score, and it really, you know, it subtracts from 100, basically it's 4% acuity-related visual impairment in this case. Really easy to achieve, to get to this point. Now visual fields for this example, as you can see, the right eye is very full, very complete in this case, and the left eye has a contraction superiorly because the retinal detachment happened there. They went through and fixed it, and the remaining field is this way. So what does this mean in terms of rating? So we go to this formula that the guides give us, and we have 10 different meridians we have to evaluate. And this is the job of the, you know, evaluator like myself. I don't think other specialties go through this, but I just want you guys to be aware and familiar with it. So when you get the reports, someone says this is the visual field impairment is this much. You know what went into it. So in the 25-degree meridian, this person saw all the points, and they get a score of 10. That's the maximum. It goes up to 11, but you can bring it down to 10 for calculation purposes. And then in the 65-degree meridian, they missed one. They missed one, so they get a score of 9. But in the 115-degree meridian, they missed more. They missed two, and now they get a score of 8. The rest of it is all full, so we all get 10. So we get a total of 97. That's how we get the impairment rating, 97 for that eye. But that's just that eye. So let's combine them. And the combination in this example one, right eye we had 100, left eye 97, binocular is 100. We care about the two-eye vision a lot more, so we multiply by three, and we get 497 as a total. We divide by five, and we get 99.4. So in this case, the functional field score is 99.4, and that means the field-related visual impairment is only 0.6. The person had a retinal detachment. Part of their vision is missing. But it's less than 1% impairment in that eye. So something kind of doesn't make sense when you think about it, but that's how the guides tell us to do it. And yes? Just very quickly, which edition of the guides are you referring to? Are all five and six the same? Okay. Great question. Obviously, you came in late. So we'll go over the differences between guides five, fifth, and sixth, and all the other ones. And we'll go over that at the end. But basically, in this calculation, they're both the same. So what I'm talking about goes for all versions. And here's the formula for figuring out together visual acuity and visual field added together. Now, again, we're interested in just one number because that's how our legal system works. We just want to know how much is something not working. And we use the 96 we got for the acuity. We use the 99.4 that we got for the visual field impairment. We multiply them together, divide by 100, and we get 95.42%. So impairment rating based on visual acuity loss as well as visual field loss is in this case 4.58%. And that's it. And that's all there is. That's how much this person cannot see. But there is more to it because they told us they have glare and they have dry eyes. And we need to factor those things in now. And there's another section in our report that goes over that. The individual adjustment is a big part of what we do. Individual adjustment, when I say big, I mean 15%, up to 15% is allowed for things like this, photophobia, glare sensitivity, reduced or delayed light and dark adaptation, and binocular vision disorders. So for example, binocular vision disorders, someone cannot see the same between the two eyes. They don't add the images together. They don't have stereopsis. They can't see depth. But they function fine. They can drive. They can do everything else. What they can't do is maybe be an electronic assembly, you know, soldering and other things that are very close. So dental hygienist or somebody who really needs depth to see what's behind what in cases that are close to them. So within arm's length, that's where stereopsis affects our visual system, not outside. Outside of one meter, we have many other clues that gives us depth. The number one is overlap. You're all further away from me, but you all know one hand is in front of the other one. And if you close one of your eyes, you still see that. So it has nothing to do with depth perception of the two eyes. When somebody comes and says, I have bad depth perception, I'm driving, and I go over the curb or something, you know, there's other problems. But this category can be up to 15%. And in this case, the doctor, you know, evaluator needs to decide how much is that worth for this case. When they say they can't drive at night, they're really glare sensitive, they've always been that way, and it also documented in their medical records from prior to this evaluation that we have, then you can justify it and write down, for example, 5% glare sensitivity as an individual adjustment for this. And that's a judgment call, but you need to be able to support it. And dry eyes, it comes under ocular pain. And it's the same chapter as other parts of the body. And that's, as you all know, is 3%. So that's up to 3%. And in this case, we can allow 2% because it was moderate, moderate amount of dry eye. And you have signs for that, symptoms. We can do all these tests, Shermer tests and other tests that tells us how much dry eye they have. Now we're going to combine them. And combining all of these, pretty straightforward, 4.58 was the visual acuity, visual field impairment, 5% for glare, 2% for ocular pain, and added together, 11.58%, which we round up to 12%. So I'm going to go over, here's the summary. You can all see this slide as I see the questions. Okay. So people want to know where to buy one of these, the PalmScan G2. I don't have the URL as they're requesting, but this is made, there are several companies. I'm not here for them, but this is made by Micromedia in Southern California, Micromedia Devices, Micromedia Devices. And then it says, how do you get binocular fields? Well, you don't get binocular fields. You have to mentally put it together. So if the right eye was full in this case, and the left eye had a slight problem, you put it together. Well, you're still going to see up there, because your right eye sees all of that. So it's completely full. That's how you got the 100% for both eyes together. I don't know how to scroll with this. One second. I think that's it. All right, so that's basically the summary of example one. Let's go over another one, so that we really, this one I'll go quickly. And it's very similar. Basically, that's correct acuity 20-20, left eye 20-200, both eyes 20-20. So this person has one bad eye. And visual field is restricted in one of their eyes, because they happen to have a droopy eyelid. Nothing happened to them. That's just anatomically, they've got one eye that is a little droopier. And then they have moderate dry eyes as well. So we look it up. 20-20 is 100. And 20-200 was 50 as an acuity score. We multiply them according to that formula, 100 and 50. And then the two eyes together was 100. So that you need to multiply by 3. You add it up for 50, divide by 5, you get 90. So one eye is now 20-200. But the acuity-related visual impairment is only 10%. You have a question, sir? Yes. If you're evaluating a worker's compensation case, and the person has congenital ptosis, whatever, do you ignore that part? OK, the question is, someone is there for their worker's comp case, and they happen to have a congenital ptosis. Do we ignore that? You know, you need to evaluate it. You need to figure out how much of the ptosis is causing the visual field impairment. We usually generally tape up the eye and do another visual field to make sure the person can actually see up there if that eyelid was not in the way. And then we make a decision whether this is pre-existing or not. And then we put that in our report. And if the injury happens to have some other things that affects the peripheral vision or the eye itself, we know that part of it at least was not related. So you have to account for it. You have to go through the process. All right, so with this information, keep that in mind. You have a number 90 as your functional acuity score. And now we're going to go over the fields, visual fields. In this case, one eye is completely full. The other has a little ptosis, a little droopy eyelid. And it looks really similar to the post-retinal detachment case, doesn't it? So they can't see part of the superior field. So we'll go over that again. Yeah, we got 10. We got one meridian 8, the other one 9. And add it up together, and again, we get 97. So this case is really pretty much exactly the same. You get 99.4 for your functional field score with only 0.6% field-related impairment. And practically the same thing as you had before. Here, we have the 90 that was our acuity score. Field score is 99.4. Multiply together, divide by 100, you get 89.46. And the impairment based on visual acuity loss and visual field loss is 10.54%. You just subtract that from 100. And you're rounding it up to 11%. So in this case, we also have other things, but none of these four. So the big category doesn't apply in this case. We can't use any of the 15%. But we have pain. That's 2% again, just your regular moderate dry eye. There is no burden of disease. There is no facial disfigurement here. The droopy eyelid is not a facial disfigurement. And there are rules on how bad your face has to look before we can rate you. And you combine all these factors, and you get basically the same thing. 11% was our acuity and field, 2% ocular pain, and you have 13% as your combination. So here's the summary of what we just went through. Very similar to example one. And that's how it is. Questions in here? OK. Looks like there is the AV people for this Zoom. Somebody's texting us that the signal's interrupted, and they're not able to see the slides. And my thing keeps going round circle. So that means something's not working on the Zoom. So we'll go on with our live audience. Example three. Here, we get a little bit trickier. And you're going to get some, I'm going to say, what? What's going on here kind of out of the audience here, because this person has acuity of 20-20 in one eye. The other eye, end-stage glaucoma. No light perception. Zero. You put the brightest light in their eye, they can't tell it's on. And 20-20 both eyes together. Actually, this happens. We have cases like this. It's not out of the ordinary. Visual field is also restricted in the good eye, because they happen to have glaucoma in both eyes. And that's affecting their peripheral vision in their good eye. So they also have severe irritation, because they have to use these eyedrops several times a day. And believe me, if anybody of you uses eyedrops or glaucoma, they're sight-saving. But they burn. They're irritating. And a lot of people don't use them because of that. And then they have vision problems. There is a burden of disease in this case that we can go over that and say why that is. So visual acuity, we look it up. 20-20 is 100. 20, well, nothing. And no light perception is 0. So then we calculate that. That's easy. 100, 0, 100. So we have 300 plus 100, we get 400. You get divided by 5, you get 80. And you now have 20% acuity related visual impairment. This person is blind in one eye completely, but they have 20% acuity related impairment, not 50%. Usually you say, oh, you have a glass one eye. It should be 50%. No, it's only 20%. That's because one-eyed people can do a lot of stuff. They can drive. They can do a lot of stuff. They're everywhere. And it kind of makes sense that we don't have it that higher than this. Here's your visual fields. In this case, the right eye is both. Both these figures are for the right eye because the left eye has no light perception. Obviously, we can't do a visual field. Here's the right eye periphery. We can see somewhat constriction of the superior and inferior fields. But we also investigate within this circle, is there any area that has scotomas or areas that they can't detect? And this field, this printout tells us that. This is a graphic version. Here's the numbers. And we can see pattern deviation down below. And that kind of allows us to interpret this into visual field impairment. And how that's done is through, again, the same kind of formula we did earlier. In the 25 degree meridian, we have a few. We have one missing there, but there's more. This area is very dark in that area. So they're missing more points in those areas. So the score they get in this meridian is only 5 out of 10. In the other meridian, the 65 degree meridian, again, it's a little bit constricted here. But there's a little bit of grayish area here, too. It's not as dark. It's not as depth. The depth of loss is not as high. And they get a score of 7 here. They missed three points in that meridian. The rest of the way, they're completely full. You go around the circle. There's nothing in that side. And then they get to the lower portions. And then we have 9, 8, 9, 9, because there's some constriction in this area. And there's just a little bit of an area missing in this, just below there. So the total number, you get 87. 87 for that eye. Now, here comes the tricky part. What about the bad eye, the eye that doesn't exist, that has no light perception? What visual field impairment rating do we give to that? Everybody would agree that it would be 0. But it's actually the opposite. We have to give 100. So it's as if they can see. This is very, very weird. There is a rule called central scotoma rule. And it applies to this case. Basically, even though this eye cannot see, the visual field rating has to be 100. We have to give the score of 100. And we'll go over that why. So if we go through the calculations, we have to use this as 100 times 1. The right eye, 87, because we scored it. What about the two eyes together? Well, put it together and do that mental thing? No. There is another rule. And that rule says, if you're missing an eye, that's called 80%. So again, this is one of those things that when you're going through school, and they say, take it. Don't think it. Just 80. OK, 80. And now, we get a 427 as a total. And divide by 5, and you get 85.4. And that's your functional field score. 14.6% field-related visual impairment, even though this person has one eye only and missing some parts of the vision in the other eye. So it's not as bad as we would have thought this person would be rated. But what is this rule? What is this rule? This rule says you cannot count an inability to see twice. So if they can't see with that eye at all, because it doesn't exist, that's a visual acuity that you gave zero. So you already counted it. Now, for the visual field to come and again count it as zero, that's counting twice. And that's not fair. In legal system, we always want to think fair. So they give 100. So this is what that rule says. And I had to read it five times to figure out what are they trying to tell me. And I think I still need to read it a sixth time. So it is what it is. So you have to count it as 100 and go through exactly these calculations I showed you. So we have to use the 100 for that eye and 80 for the two eyes. And then we come up with this value that can be legally supported, because it's in the AMA guides. Yes, sir? I call that jurisdictional impairment. Jurisdictional what? Impairment. Impairment. Jurisdictional impairment is another category we need to worry about. So the visual impairment rating in this case, very similar to what we've done earlier, you have the 80 and 85.4 for the visual field part. And you multiply together, divide by 100, you get 68.32. So the impairment rating based on visual acuity loss and visual field loss is 31.68, or rounded up to 32%. So this person has no light perception in one eye, has basically, oh, there's more stuff. So we have other things, too. But they have one eye missing, but they're 32% impairment. Now, here, severe irritation. Severe irritation, you can go up with 3% for bodily pain. And burden of disease, in chapter 2, page 20, rule 2.5g, it states that there are diseases that we treat for the injured workers. And they do well. They improve. But they still are diseased. They're still ill. They have to live with it. It's an ailment. And the doctor, the evaluator, can assign up to 3% for that factor. So this person has no eye because of glaucoma, has a glaucoma disease that is progressing, is going to keep getting worse, has to keep putting drops in their eyes all the time. We're holding on to them, to their vision, with these eye drops and surgeries, whatever we do to keep them intact. That is a burden that we can assign up to 3% compared to someone else that has the same functionality. Basically, has no eye. And the other eye has this kind of visual field. But they're not getting worse. They're not putting eye drops in their eyes. They're not worried about their future vision and making decisions in their lives because of how they're going to see 15 years from now. So they may not get the burden of disease in that case as much. So this is something that is judgmental, in my opinion. So combining the three factors, we had 32% with 3% eye pain, 3% burden of disease, and we come up with 38%. And here's the summary of example three. Again, best corrected acuity was 20-20, one eye. The other eye couldn't see anything. Both eyes 20-20. Visual field restricted in the good eye because of glaucoma. And they have very dry eyes, and they have burden of disease. We add it all up together. Questions? Yes, sir? Ma'am? Is that whole person impairment? Whole person impairment. Very good question. So once we come up with visual impairment, what does that mean as whole person impairment? Chapter 12 has this wonderful, I don't remember the page number, table that says whole person impairment for this percent, for this percent, for this percent. And then for under 50%, it's always exactly the same. So 38% in this case will be exactly whole person impairment. But let's say someone had 52% or 60% impairment, visual impairment. Then there's a very small print underneath the table that gives us one little formula. And you need to read that, and you need to have that in your mind. Because over 50%, you now have to use that calculation, and it becomes less. And it reduces the whole person impairment because of that formula. And I discovered that little print a few years back, and I'm like, oh my god, I didn't know about this. So we always learn. OK. And any other questions there? Yes, sir? If a person is totally blind, multi-eyed, what's the total eye impairment? Total, that's 100%. That's 100%. How can you double-eyes outside of vision? Well, that's 100% visual impairment. The whole person impairment, I have to, is it? OK, thank you. 85%, according to the audience. I've never had that patient because they don't find my front door somehow. They don't want to come in. I can't help them. So it's easy. Yes, ma'am? So if the person went on to lose all the vision in their other eye, they would need to go to travel prevention. Now, when you get their new impairment, which would be that 100%, would you subtract all this for you? So it depends on what you're trying to do. If this is a case, the question is, what if the person lost their good eye, too, because time passed or something happened, and now they are blind in both eyes completely? And how do you rate that? Do you subtract the 38% from that? So this has less to do with what you do. It more has to do with what lawyers do. And they are going to decide which part of it is pre-existing, which part of it is related to the injury they have suffered at work, which part of the injury at work, how much of it is apportioned as well to it. So maybe all of this 38%, some of it is apportioned to the injury at work because it made their glaucoma worse. So need to have apportionment, it gets complicated. And then afterwards, what caused the vision to get worse? Was it just natural causes, progression of disease we couldn't have prevented, or did they get another injury? So you have to categorize and say, this is what happened at this time, and this was the cause of it. This is what happened here, and this is the cause of it. And then apportion as well. OK, back to the question from the audience that was, what about fifth and sixth editions and other versions? This is what I found. Sixth edition is used in most states. Fifth edition is used in, I think, fewer, 19 states or something, 13 states. I can't remember. But California is one of them. That's where I am. And there's still fourth editions used. I don't know why Colorado and Oregon are still using third edition. Maybe you guys can educate me on that. But anyway, these are still prevalent like this, and it's different use of state by state. Now, what about the visual impairment? So the visual impairment, chapter 12, fifth versus sixth, what do you guys think? Here's the answer. As far as chapter 12, there is no changes. They're the same. I read them both. I couldn't figure out anything different. If you guys know a difference, please educate me, because I'm here to learn from you as well. All right, any other questions from the audience? Yes? So with the burden of disease among the hearing of the person who didn't see light, when you use chapter 2, I was not aware of that chapter 2 burden of disease in the fifth edition. Is that from the sixth edition? He's asking which edition is the burden of disease, chapter 2. And I have looked it up in version edition 5, fifth edition. I have not looked for that in the sixth edition, because it's not relevant to my practice. But I think it probably is. I don't know if other people know difference. Probably in both. All right, so far so good. I have good news for you guys. That's it. That's it. If you have questions, please continue discussing here. Let me see. It says, second time live stream offline, very irritating. Oh, OK, it's not a question. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

optometrist

visual impairments

worker's compensation

visual acuity

visual field

impairment rating

ocular pain

AMA guides