Diagnostic Code 6019 · 38 CFR §4.79
Ptosis is a drooping of the upper eyelid that can partially or completely obstruct vision. It can affect one eye (unilateral) or both eyes (bilateral). In veterans, ptosis commonly results from nerve damage from head injuries or TBI, surgical complications, muscle damage from shrapnel or other eye area trauma, or neurological conditions like myasthenia gravis. Under the CFR, the VA rates ptosis based on the resulting visual impairment, or in the absence of visual impairment, on disfigurement under DC 7800. This means there is no fixed rating specific to ptosis itself; the percentage depends entirely on how much the drooping eyelid affects your vision or appearance.
| Rating | Criteria |
|---|---|
| 0% | The VA does not assign a fixed rating under DC 6019 itself. Instead, ptosis is evaluated based on the visual impairment it causes (using visual acuity and visual field codes), or in the absence of visual impairment, on disfigurement under DC 7800. Your rating depends on how much the drooping eyelid obstructs your vision or affects your appearance. |
An ophthalmology examination measuring the degree of eyelid droop (margin-to-reflex distance) is essential. Photographs showing the ptosis in primary gaze position, visual field testing if the lid obstructs the superior visual field, documentation of the service-connected cause (TBI, nerve injury, trauma), and neurological evaluation if the ptosis is from a nerve condition all strengthen your claim.
Yes. If a traumatic brain injury during service damaged the nerve controlling the eyelid (the oculomotor nerve), the resulting ptosis is a direct secondary condition to the TBI and can be service-connected.
Surgical correction is available and often effective. If you have surgery through the VA, the VA will re-evaluate afterward. If ptosis recurs or the surgery leaves complications, those can be rated. If you choose not to have surgery, the VA rates based on the current condition.