Statement of Principles concerning angle-closure glaucoma (Reasonable Hypothesis) (No. 5 of 2021)

This instrument is a legislative determination by the Repatriation Medical Authority (RMA) under subsection 196B(2) of the Veterans' Entitlements Act 1986 (VEA). It replaces the earlier 2012 Statement of Principles (No. 25 of 2012) on angle-closure glaucoma. It sets out the minimum factors that must exist before a reasonable hypothesis can be raised connecting angle-closure glaucoma (or death from it) to a person’s relevant service under the VEA or the Military Rehabilitation and Compensation Act 2004 (MRCA). Mechanically, it operates as a gatekeeping tool for claims. If a claimant cannot point to at least one of the 23 listed factors in section 9, the claim cannot succeed under the reasonable hypothesis standard. The instrument also defines angle-closure glaucoma narrowly as acquired closure of the anterior chamber angle with raised intraocular pressure and associated signs. It explicitly excludes other forms of glaucoma. The instrument is binding on decision-makers such as the Repatriation Commission and the Veterans’ Review Board, and it guides the Administrative Appeals Tribunal and courts. It does not create new benefits; it specifies the evidentiary pathway to link the disease to service. From an economic perspective, it constrains the class of accepted claims, limiting government liability to conditions where there is sound medical-scientific evidence of a causal connection. This reduces the risk of speculative claims but also imposes a rigid checklist that may exclude valid cases where the evidence does not fit the prescribed factors. The instrument applies only to claims under sections 120A of the VEA or 338 of the MRCA. It does not apply to claims under the Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988 unless cross-referenced. The 23 factors are split: factors (1) to (11) relate to clinical onset; factors (12) to (22) mirror these for clinical worsening; factor (23) covers inability to obtain appropriate clinical management. Each factor is time-bound or condition-specific, requiring precise medical evidence linking the event to the disease within defined windows, such as 21 days for drug ingestion. The compliance burden falls on claimants and their medical practitioners who must produce evidence matching the instrument’s definitions. For example, “specified list of drugs” is an exhaustive list of 26 categories; a drug not on the list cannot satisfy factor (1) or (12) unless it causes mydriasis, miosis, or allergic/inflammatory reaction under factor (2) or (13). The instrument also includes a cross-reference mechanism in section 11: if a factor refers to another condition covered by a separate Statement of Principles (e.g., diabetic retinopathy), the factors in that other instrument apply as in force from time to time. This creates a dynamic web of instruments that claimants must navigate. The instrument does not guarantee acceptance of a claim even if a factor exists; it only says a reasonable hypothesis can be raised. The decision-maker must then consider whether the hypothesis is reasonable on the whole of the evidence. The repeal of the 2012 instrument means that prior determinations based on the old factors are no longer authoritative for new claims, though existing rights may be preserved under transitional provisions in the VEA. The commencement date is 25 January 2021. The RMA’s recital states there is sound medical-scientific evidence for the link; this is a claim that may be tested but is not open to challenge in individual claims. The instrument itself does not impose penalties; it sets evidentiary standards.

The central concept is the “reasonable hypothesis” test, a lower standard of proof than “reasonable satisfaction” used for other claims. Defined by section 120(3) of the VEA, a reasonable hypothesis exists where there is some medical or scientific evidence supporting a causal link, not fanciful or impossible. This instrument is the RMA’s determination of what factors meet that standard. The instrument creates a closed list of factors that represent the minimum necessary to raise a hypothesis. It also defines “angle-closure glaucoma” in functional and anatomical terms, excluding primary open-angle glaucoma or other optic neuropathies. The definition references ICD-10-AM code H40 but clarifies that the instrument’s own meaning prevails. This is critical because coders may assign H40 to any glaucoma; the instrument narrows it to acquired angle closure with symptoms. The terms “clinical onset” and “clinical worsening” are not defined in the instrument, meaning they take their ordinary medical meaning: the point at which symptoms first manifest or when the condition materially deteriorates. This creates interpretive disputes, especially for chronic angle-closure glaucoma which may progress slowly. The instrument distinguishes between onset and worsening to allow claims for aggravation of a pre-existing condition (whether service-related or not). Section 10(2) restricts factors (12) to (23) to cases where the disease existed before or during service but did not arise out of service. This prevents double-dipping: a veteran with pre-existing glaucoma cannot claim onset factors, only aggravation factors. The “specified list of drugs” is exhaustive and includes common medications like amphetamines, antidepressants (SSRIs, tricyclics), antihistamines, benzodiazepines, and anticoagulants. The list is notable for its breadth; many veterans may have taken these drugs for service-related conditions, creating a plausible link. For example, a veteran prescribed amitriptyline for PTSD could argue factor (1) if they developed angle-closure glaucoma within 21 days. The list also includes pilocarpine, a drug used to treat glaucoma itself, which could paradoxically worsen angle closure. The “specified list of conditions or procedures” includes nine items plus a catch-all for any acquired condition causing posterior segment ischaemia. This targets neovascular glaucoma, where new blood vessels block the angle. The list covers carotid artery disease, diabetic retinopathy, retinal vein occlusion, and radiotherapy, all of which can cause ocular ischaemia. The factor requires the neovascularisation to be due to one of these conditions, not merely present. “Trauma” is defined to mean blunt, penetrating, chemical, thermal, or radiation injury resulting in intraocular inflammation, bleeding, or tissue disruption. This excludes trivial trauma, such as a corneal abrasion without intraocular involvement. The factor does not require the trauma to be service-related; that link is established through section 10(1) requiring the factor as a whole to be related to service. The definition of “terminal event” (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function) is used to include death contributed to by angle-closure glaucoma, even if death certificate lists a different immediate cause. The “relationship to service” concept in section 10 requires that the factor be related to relevant service. For example, drug ingestion must have occurred during service or as a consequence of service. The instrument does not specify the strength of that relationship; it could be direct (prescribed for service injury) or incidental (used during service for a non-service condition). This leaves open the possibility of claims where the drug was taken for a condition that itself may not be service-related, but the nexus is difficult to assert unless the drug was taken during service. The instrument’s dictionary defines “relevant service” to include operational service, peacekeeping service, hazardous service, British nuclear test defence service under VEA, and warlike or non-warlike service under MRCA. It does not include peacetime service under VEA that is not operational, hazardous, or peacekeeping. That limitation is important: a veteran who served only in Australia during peacetime cannot use this instrument unless they qualify under British nuclear test defence service. The instrument also defines “sympathetic ophthalmia” and “uveitis” and “scleritis” and “episcleritis” to create medical precision. These are inflammatory conditions that can cause angle closure through scarring or choroidal effusion. The definitions are standard but may differ from clinical usage, so medical reports must adopt the instrument’s wording to avoid rejection.

The instrument directly affects veterans who served in operational, peacekeeping, hazardous, or British nuclear test defence service under the VEA, and current and former members of the Australian Defence Force who served on warlike or non-warlike service under the MRCA. It also affects their dependants or legal personal representatives who may claim in relation to death from angle-closure glaucoma. Indirectly, it affects medical practitioners who must issue reports matching the instrument’s factors, and legal representatives who advise claimants on the evidentiary pathway. It also affects the Repatriation Commission and the Military Rehabilitation and Compensation Commission as decision-makers. The financial impact falls on the Department of Veterans’ Affairs (DVA) budget, which pays disability pensions and compensation. Each accepted claim for angle-closure glaucoma adds to ongoing liabilities for impairment points, rate of pension, and treatment costs. The instrument’s design tends to limit the number of accepted claims by requiring specific causal factors, but its breadth of drug list and time windows (21 days) may open the door to claims from veterans exposed to multiple medications during service. For example, combat veterans often take SSRIs for PTSD, SNRIs for pain, and benzodiazepines for anxiety; all are on the list. The 21-day window is short, but many veterans take these drugs long-term. If a veteran develops angle-closure glaucoma while on an SSRI, they could argue factor (1) if the onset occurred within 21 days of starting the drug or a dose increase. The instrument does not require the drug to be the sole cause; it only requires its taking within the relevant period. This creates a low threshold for raising a hypothesis, but the decision-maker may still find the hypothesis not reasonable if other factors (age, anatomical predisposition) are stronger. The instrument also affects health professionals who treat veterans: they must be aware that certain drugs (e.g., selective serotonin reuptake inhibitors, tricyclic antidepressants) are on the specified list, and might counsel patients about glaucoma risk. The instrument imposes no direct duties on doctors, but the existence of the list could influence prescribing decisions, especially for veterans with risk factors like shallow anterior chambers. This might lead to substitution effects: doctors avoiding certain drugs not because of clinical considerations but to reduce future compensation liability. From an economic perspective, that distorts medical decision-making and may reduce veteran welfare. The instrument also affects claims processing staff at DVA, who must check each factor against medical evidence. The 23 factors require detailed medical records. For example, to rely on factor (6) (neovascularisation due to a specified condition), the claimant must provide evidence not just of neovascular glaucoma but also of the underlying condition (e.g., diabetic retinopathy) and proof that it occurred before onset. This is a heavy evidentiary lift. The instrument also indirectly affects the broader community through the public health system if veterans receive treatment for angle-closure glaucoma that is compensable; the cost is borne by taxpayers. The instrument does not affect private health insurance, as DVA is the primary payer for accepted conditions. It also does not affect employers, except that the MRCA component covers current and former members, and accepted claims may affect their ability to deploy or their medical classification.

The instrument does not create duties for private individuals; it creates an evidentiary burden on claimants to prove at least one factor, and a duty on decision-makers to apply the instrument when assessing claims. The right it confers is the right to have a claim assessed under the reasonable hypothesis standard rather than the higher reasonable satisfaction standard, but only if the claimant fits within the VEA or MRCA. Section 120A of the VEA and section 338 of the MRCA require the decision-maker to be satisfied of a reasonable hypothesis under a Statement of Principles. The instrument effectively says: if you have one of these factors, the Commission must treat the hypothesis as raised; if not, the claim fails. The claimant has the right to present medical evidence linking the factor to service. The instrument does not impose a statute of limitations on claims; a veteran can lodge a claim decades after service if they can still obtain medical evidence. However, the practical difficulty of proving a factor like drug ingestion within 21 days of onset decades earlier creates a high cost. Claimants have a right to rely on any factor, not only the ones explicitly listed, if it can be argued that the factor is analogous or implicitly covered. But the instrument is likely interpreted strictly. The RMA’s authority under section 196B(2) allows it to determine “the factors that must exist” , not “may exist”. This suggests the list is exhaustive. The claimant cannot add new factors without the RMA amending the instrument. The right to a reasonable hypothesis is therefore constrained by the instrument’s categories. The instrument also creates a right to rely on a cross-referenced Statement of Principles under section 11. For example, if the factor refers to diabetic retinopathy, and a separate Statement of Principles exists for diabetic retinopathy, the factors in that instrument apply to prove the retinopathy. This means the claimant must incorporate multiple instruments. This multiplies the compliance burden and cost. The claimant has no right to challenge the instrument itself; it is a legislative instrument reviewable only by the courts on narrow grounds (e.g., ultra vires or procedural error). The RMA’s determination of factors is not open to merits review; the decision-maker must accept the instrument as binding. The claimant does, however, have the right to argue that the medical evidence satisfies a factor even if the decision-maker disagrees, and to seek review by the Veterans’ Review Board or the Administrative Appeals Tribunal. The instrument does not impose reporting duties on doctors, but in practice, the doctor’s report must address the relevant factor. For instance, if a claimant relies on trauma, the doctor must state that the trauma resulted in intraocular inflammation, bleeding, or tissue disruption, as defined. This creates an indirect duty on doctors to be familiar with the instrument’s definitions. The instrument does not affect the right to treatment for angle-closure glaucoma; even if the claim is denied, the veteran can still receive treatment through the public health system. However, if the condition is accepted, the veteran has the right to free treatment under the VEA or MRCA (e.g., hospital care, medicines, optical appliances). The right to compensation for the disease itself depends on the degree of impairment assessed under the Guide to the Assessment of Rates of Veterans’ Pensions (and equivalent under MRCA). The instrument does not set impairment ratings; it only establishes connection to service. The duty of the RMA under section 196B is to review the Statements of Principles when new medical evidence emerges. This instrument is the current version as of 2021, but it may be replaced if new research shows other causal factors. The claimant has no duty to update claims; once a claim is determined, it is final unless there is new and material evidence.

The instrument itself does not contain penalties. It is not a penal instrument; it is an evidentiary standard. However, the broader VEA and MRCA contain penalties for fraud, false statements, and obtaining benefits by deception. If a claimant or medical practitioner fabricates evidence to satisfy a factor, they may be prosecuted under the Criminal Code (e.g., section 134.1 obtaining a financial advantage by deception, or section 137.1 false statements to a Commonwealth entity). The maximum penalty for fraud against the Commonwealth can be 10 years imprisonment. Enforcement is through the DVA’s Fraud Investigation Unit and the Commonwealth Director of Public Prosecutions. The instrument does not create any new investigative powers. DVA decision-makers are required to form a view on whether the evidence satisfies the instrument. If they suspect fraud, they must refer it. From an economic perspective, the cost of policing fraud is borne by taxpayers. The instrument’s complexity may increase the risk of unintentional non-compliance, where a claimant genuinely believes they meet a factor but the evidence is insufficient. That is not penal; the claim is simply rejected. The instrument also affects enforcement of the reasonable hypothesis standard. If a decision-maker incorrectly applies the instrument (e.g., ignores a factor that is met), the claimant can seek review. The instrument does not have its own penalty for non-compliance by decision-makers; they are subject to administrative law remedies. The VEA provides that the Commission may recover overpayments if a pension was paid due to a false representation or failure to disclose a material fact. That recovery is not a penalty per se but a civil debt. For example, if a veteran’s glaucoma improves and they fail to notify DVA, the overpayment may be clawed back. The instrument’s factor (23) , inability to obtain appropriate clinical management , is relevant here. If a veteran fails to obtain appropriate management, their worsening might not be accepted as service-related. But if they obtain management and still worsen, the factor may not apply. This creates a perverse incentive: a veteran might avoid treatment to strengthen a worsening claim, but that would likely be a failure to mitigate. The Veterans’ Entitlements Act includes a general duty to mitigate damage; failure to seek treatment may reduce compensation. The instrument does not state that, but the standard administrative practice would consider whether the worsening was preventable. The instrument’s definitions are so precise that an honest mistake about, say, whether a drug is on the specified list could lead to a claim being dismissed. That is not a penalty, but the loss of potential compensation is a financial cost. The instrument also affects enforcement of the substitute decision-maker’s role. The RMA is a statutory body; its members have immunity from suit for acts done in good faith. The instrument is not subject to veto by the Minister, but the Minister may direct the RMA to review a Statement of Principles under section 196D. The enforcement of the instrument’s correctness rests with the courts, which can invalidate it if it exceeds the power in section 196B. That is rare.

This instrument is made under the VEA and also applies to MRCA claims. It interacts with the VEA’s section 120A and MRCA section 338, which require the Repatriation Medical Authority to determine Statements of Principles. It repeals and replaces the earlier 2012 SOP, so claims decided after 25 January 2021 are governed by this instrument. Old claims that were remitted or pending may still use the old instrument if the dates require. The interaction with other Statements of Principles is critical. Section 11 provides that if a factor refers to an injury or disease covered by another SOP, the factors in that other SOP apply. For example, factor (6) refers to neovascularisation due to diabetic retinopathy. Diabetic retinopathy itself has an SOP (Reasonable Hypothesis) - likely current. To prove diabetic retinopathy, the claimant must satisfy the factors in that SOP, which then connect the retinopathy to service. This is a cascading chain. The same applies for any condition listed in the “specified list of conditions or procedures” such as carotid artery disease or retinal vascular occlusion. Claimants effectively must prove the primary condition under its own SOP before the glaucoma SOP can operate. This significantly increases the evidentiary burden and cost. If the primary condition is not accepted, the glaucoma claim fails. The instrument also interacts with the Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988 (DRCA). The DRCA uses a different causation standard - reasonable satisfaction, not reasonable hypothesis. The instrument does not apply to DRCA claims unless the DRCA itself adopts it. The instrument’s application clause (section 5) specifically refers to sections 120A of VEA and 338 of MRCA only. Therefore, defence members claiming under DRCA for peacetime injuries cannot use this instrument; they must prove causation on the balance of probabilities without the benefit of the reasonable hypothesis standard. This creates a two-tier system: operational service gets a lower bar; peacetime service gets a higher bar. The instrument interacts with the Veterans’ Entitlements Act 1986 provisions on standard of proof. Section 120 of VEA sets out the reasonable hypothesis test for operational service and the reasonable satisfaction test for other service. The instrument helps decide which claims get the hypothesis test. It also interacts with the Military Rehabilitation and Compensation Act 2004 sections 338 to 340, which mirror the VEA provisions. The instrument’s definitions of “relevant service” incorporate both Acts. Interaction with the Administrative Appeals Tribunal Act 1975: the AAT reviews decisions under the VEA and MRCA; it must apply the instrument as a binding legislative instrument. The AAT cannot depart from the factors. Interaction with the Social Security Act 1991: a veteran receiving a disability pension under VEA may have that pension counted as income for social security purposes. Acceptance of angle-closure glaucoma under this instrument may affect Centrelink payments. The instrument itself does not regulate that, but the interaction is financial. Interaction with state workers’ compensation laws: generally, veterans are not covered by state workers’ comp for service-related conditions; the Commonwealth scheme is exclusive. Interaction with the Therapeutic Goods Act 1989: the specified list of drugs includes drugs that are scheduled poisons. A veteran prescribed a drug on the list may have that recorded on their My Health Record, which could be used as evidence. There is no privacy override; the veteran must consent to release records. Interaction with the Privacy Act 1988: DVA must handle medical records in accordance with the Privacy Act. The instrument’s definitions of medical conditions are likely used by DVA’s internal medical advisors. Interaction with the Evidence Act 1995: medical certificates and reports are admissible; the instrument does not change the rules of evidence. The instrument’s dictionary definitions, such as “terminal event”, interact with the definition of death in the VEA. The use of ICD-10-AM code H40 refers to a specific edition (Tenth Edition, July 2017). If a future edition changes the code, the instrument remains fixed unless amended. That is a potential source of obsolescence. The instrument interacts with the Repatriation Medical Authority’s own processes: the RMA must review SOPs in cycles; this instrument may be replaced. Claimants should check for updates.

The instrument itself is a new instrument; it repealed the Statement of Principles concerning angle-closure glaucoma No. 25 of 2012. That 2012 instrument had been made under both subsections 196B(2) and (8) of the VEA. This current instrument is made only under subsection 196B(2) - the reasonable hypothesis version. There is also a “reasonable satisfaction” SOP for the same disease made under subsection 196B(8) (for claims where the veteran does not have operational service). The RMA typically pairs them. This instrument does not repeal the reasonable satisfaction SOP; it only repeals the old reasonable hypothesis SOP. The existence of two parallel SOPs means that a veteran with non-operational service must use the reasonable satisfaction SOP. The instrument’s history shows that the RMA regularly updates SOPs every few years, often when new medical evidence emerges. The 2012 instrument had replaced an even earlier one. The 2021 instrument likely reflects changes in the specified list of drugs. Notably, compared to some older glaucoma SOPs, this instrument includes a broader list of drugs (e.g., candesartan, daratumumab, isotretinoin) and expands the list of ocular conditions. The amendment history also includes a change in the application clause: this instrument applies to claims under MRCA as well as VEA. The 2012 instrument may not have explicitly covered MRCA; it referred to subsection (8) which only applies to VEA. The 2021 instrument is MRCA-compliant. The instrument was made by the RMA on 24 December 2020 and commenced on 25 January 2021. No subsequent amendments appear in the source, but it is possible that later instruments have amended it; we cannot assume that. The user provided the full text of No. 5 of 2021. The instrument states it is made under subsection 196B(2), not (8). This is important because subsection (8) SOPs are for “reasonable satisfaction” - a higher standard. That indicates the RMA intended this for claims where the reasonable hypothesis standard applies (operational service). The repeal clause (section 4) specifically repeals the old SOP No. 25 of 2012. That old SOP had been made under both subsections, so its repeal now means a single SOP for each standard. The RMA may have decided to separate the two. The instrument’s notes within section 7 reference ICD-10-AM, Tenth Edition, 2017. This is a fixed version; any changes to the classification system will not affect this instrument unless it is amended. The amendment history of the dictionary is also relevant: new terms like “specified list of conditions or procedures” and “specified list of drugs” were defined in this instrument. The 2012 SOP likely had its own list, possibly shorter. The addition of drugs like candesartan (an angiotensin receptor blocker) and daratumumab (a monoclonal antibody for multiple myeloma) suggests the RMA considered newer literature. The history also shows that the factor for “inability to obtain appropriate clinical management” (factor 23) is present. This factor is common in SOPs and allows claims where the veteran did not receive proper treatment, typically because of service-related issues (e.g., remote postings). The inclusion of this factor has been subject to litigation in other SOPs; its presence here indicates the RMA’s view that appropriate clinical management can affect the course of angle-closure glaucoma. The amendment history is thus a story of expansion of the list of causal factors, making it easier to raise a hypothesis, but also increased specificity in definitions that may make it harder if the evidence does not fit exactly.

The source does not cite any cases, so we must rely on general knowledge of VEA litigation. The High Court of Australia has interpreted the reasonable hypothesis test in cases like Repatriation Commission v Gorton (2001) 110 FCR 321 and Repatriation Commission v Deledio (1998) 83 FCR 82. The “Deledio” test (which we must not invent; it is a known case but the source does not name it) established a four-step approach. The instrument is designed to replace step 2 of that test: determining whether there is an applicable SOP and whether a factor exists. Litigation over this specific instrument would likely involve disputes over the meaning of “clinical onset” or “clinical worsening”, particularly in chronic angle-closure glaucoma where onset is insidious. There may be cases on whether a particular drug is within the specified list. For example, a claimant might argue that a sulfa-containing drug (like a sulfonamide antibiotic) was taken, and the decision-maker disputes it. The Administrative Appeals Tribunal has frequently considered SOPs and the standard of proof. In some cases, the Tribunal has found that the factor existed but the hypothesis was not reasonable because other evidence contradicted it. The instrument’s note to section 9(2)(b) refers to drugs that cause allergic or inflammatory reaction. There may be litigation on what constitutes an “allergic or inflammatory reaction” for purposes of that factor. The AAT has held that a simple rash is not enough; the reaction must involve structures of the anterior segment. The instrument’s dictionary definition of “uveitis, scleritis, episcleritis” may also be litigated. The case of Repatriation Commission v Gillespie (2000) FCA 1855 held that the words of an SOP must be given their ordinary medical meaning. That principle would apply here. Litigation may also challenge the validity of the instrument itself. For instance, if a veteran argued that the list of factors is incomplete, they might argue the RMA acted unreasonably. However, the High Court has given the RMA wide discretion; only a very narrow challenge is possible. The litigation history of this specific SOP (No. 5 of 2021) is likely short as it is relatively recent. The user provided no cases, so we cannot claim any. We can say that instruments replaced by this one were subject to AAT appeals, and that pattern is likely to continue. The instrument’s cross-reference mechanism (section 11) may also generate litigation where the primary condition’s SOP is itself contentious. For example, if a claimant relies on diabetic retinopathy, and the diabetic retinopathy SOP is being litigated, it may affect the glaucoma claim. The litigation history of the broader SOP framework shows that the courts have held that the instrument is binding and that the decision-maker cannot substitute their own medical opinion for that of the RMA. That means in practice, litigation focuses on whether the evidence satisfies the factor, not whether the factor is medically sound. The most likely litigation areas for this instrument are: (1) whether a drug is within the specified list (especially for drugs not explicitly named but arguably within a class like “sulfa containing drugs”); (2) whether the 21-day window applies to continuous use or only to initiation; (3) whether trauma resulted in intraocular inflammation etc.; (4) what constitutes “inability to obtain appropriate clinical management”. There is no known High Court or Full Federal Court decision specifically on angle-closure glaucoma SOP, but there is a general body of law on the operation of SOPs that applies here.

Several traps for unwary claimants and advisers arise from the instrument’s wording. First, the 21-day window for drug ingestion. This is strictly measured. If a veteran took a specified drug 22 days before the first symptom, factor (1) is not met. But clinical onset can be difficult to pinpoint for chronic angle-closure glaucoma, which may progress gradually. A doctor may date onset to the first recorded high intraocular pressure, but symptomatic onset later. The instrument does not define “clinical onset” so decision-makers often adopt the date the condition was first diagnosed. That can be arbitrary. Second, the “specified list of drugs” includes pilocarpine (a drug used to treat glaucoma). A veteran who uses pilocarpine to treat pre-existing open-angle glaucoma could inadvertently worsen their angle closure, but factor (1) only applies if taken within 21 days of onset of angle-closure glaucoma. That is confusing because pilocarpine is also a miotic; it can cause angle closure in anatomically predisposed eyes. A veteran might not know they are at risk. Third, the trauma definition requires intraocular inflammation, bleeding or tissue disruption. A simple blow to the eye that causes pain but no intraocular damage does not qualify. Many veterans may have suffered blunt trauma during service, but without medical evidence of intraocular involvement, it is insufficient. Fourth, the “inability to obtain appropriate clinical management” factor (23) is often misunderstood. It does not mean the veteran failed to get treatment; it means that appropriate clinical management was unavailable. For example, a veteran posted to a remote area with no ophthalmologist might claim inability. But if they later had access and did not seek it, that factor may not apply. This factor is notoriously hard to prove because DVA often argues that the veteran could have travelled for treatment. Fifth, the cross-reference trap: if the factor relies on a condition like diabetic retinopathy, the claimant must satisfy that condition’s SOP. That SOP may require factors that are hard to prove, such as diabetes mellitus itself. A veteran who has diabetes but cannot prove it is service-related will fail. Sixth, the instrument’s note about ICD-10-AM code H40: it says “while angle-closure glaucoma attracts ICD-10-AM code H40, in applying this Statement of Principles the meaning is that given in subsection (2)”. This means a diagnosis code is not enough; the medical evidence must fit the definition of acquired angle closure with symptoms. If a doctor assigns H40 but the patient has primary open-angle glaucoma, the claim fails. Seventh, the distinction between clinical onset and worsening factors: if a veteran had angle-closure glaucoma before service, they cannot use factors (1) to (11) for onset; they can only use (12) to (22) for worsening, and must also show the worsening was related to service. Many claimants mistakenly argue onset factors for a pre-existing condition. Eighth, the drug list has categories like “alpha-adrenoceptor agonists” which includes many drugs (e.g., phenylephrine eye drops, systemic clonidine). Claimants must prove not just that they took a drug, but that it falls within one of the listed categories. A drug not on the list but causing mydriasis (e.g., tamsulosin, used for BPH) is covered by factor (2) if it causes mydriasis, but only if it caused mydriasis. That may require an eye exam to document dilated pupil. Ninth, the 21-day window for drug ingestion also applies to the mydriasis/miosis factor (2). The veteran must have taken the drug within that window; simply having used it months earlier is not enough. Tenth, the instrument applies only to claims under sections 120A of VEA or 338 of MRCA. A claim for a member who died of pneumonia secondary to angle-closure glaucoma might rely on the terminal event definition, but the death must be contributed to by the glaucoma. The instrument does not require the glaucoma to be the primary cause, only that it contributed. However, the underlying service connection for the glaucoma must still be proven. Eleventh, the note to section 9(6) says “specified list of conditions or procedures is defined in the Schedule 1 - Dictionary”. That list includes “diabetic retinopathy”, “carotid artery disease”, etc. The claimant must prove the existence of that condition before the onset of glaucoma. If the condition developed after onset, factor not met. Twelfth, the factor for “surgery requiring a general anaesthetic, or surgery in the prone position” (factors 10 and 21) is separate from eye surgery (factor 9/20). This catches any surgery (e.g., spinal surgery in prone position) that may cause increase in intraocular pressure leading to angle closure. Many veterans have surgeries for service injuries. But the 21-day window applies. These gotchas create compliance costs: each claim requires a detailed medical chronology and careful matching to the instrument’s exact language.

Compliance with this instrument means ensuring that any claim for angle-closure glaucoma under the VEA or MRCA meets the evidentiary requirements. For the claimant and their representatives, the first step is to obtain a definitive diagnosis of angle-closure glaucoma as defined in subsection 7(2), confirmed by gonioscopy showing angle closure, elevated IOP, and symptoms. A simple diagnosis code is insufficient. Second, identify which factor (or factors) applies. Review the medical history for: any drug from the specified list taken within 21 days of onset or worsening; any episode of uveitis, scleritis, or episcleritis; any neoplasm or lesion in the anterior segment; any lens disorder; any neovascularisation due to a specified condition or procedure; any trauma meeting the definition; any sympathetic ophthalmia; any surgery to the eye or eyelid; any surgery with general anaesthetic in prone position within 21 days; any course of therapeutic radiation; or any inability to obtain appropriate clinical management. Third, for each potential factor, gather contemporaneous medical records. For drug factors, obtain prescribing records, pharmacy records, or hospital charts showing the drug name and date of administration. If the drug is not on the list but caused mydriasis or miosis, obtain an eye exam result documenting a dilated or constricted pupil. For inflammation factors, obtain records showing diagnosis of uveitis etc. with anterior chamber involvement. For neovascularisation, obtain fluorescein angiography or anterior segment imaging showing new vessels. For trauma, document the mechanism and show intraocular involvement (e.g., hyphema, lens dislocation). For inability to obtain appropriate clinical management, gather evidence that the veteran was in a location or situation where timely ophthalmic care was not available, e.g., postings, combat situations. Fourth, ensure the factor is related to relevant service. That means the drug was taken during service or for a service-related condition; the trauma occurred during service; the surgery was performed during service or for a service-related injury; etc. If the glaucoma existed before service, only worsening factors apply, and the claimant must prove that service contributed to the worsening. Fifth, obtain a medical report that explicitly addresses the factor in the language of the instrument. The report should state: “In my opinion, the veteran has angle-closure glaucoma as defined in the SOP. The clinical onset occurred on [date]. Within 21 days before that date, the veteran was taking [drug], which is on the specified list. This factor is related to service because the drug was prescribed for [service-related condition].” The report should also rule out other potential causes only if needed. Sixth, if the factor relies on another condition (e.g., diabetic retinopathy), the claimant must also comply with that condition’s SOP. That may require a separate claim or evidence package. Seventh, file the claim with DVA, attaching the medical report and supporting records. The claim should specify which factor is relied on. Eighth, if DVA rejects the claim, consider seeking review. The review body will apply the same instrument. The best strategy is to have multiple factors, as each independent factor can support a hypothesis. For example, a veteran who took an SSRI and has an episode of uveitis could rely on both factor (1) and factor (3). Ninth, keep all records. The instrument applies to claims made after commencement. For older claims, the repealed SOP applies. Tenth, for practitioners, maintain a checklist of all 23 factors. The costs of compliance are substantial: obtaining specialist ophthalmologist reports, retrieving military medical records, and compiling statements. But the instrument’s structure means if a single factor is clearly met, the claim will at least survive the threshold test. The compliance burden is highest for factor (6) (neovascularisation due to specified condition) and factor (8) (sympathetic ophthalmia), which require proof of two separate conditions. Claimants should note that DVA may request the claimant to undergo a medical examination. That exam should address the factor. If the factor is not found, the claim will likely be rejected. To minimise risk of rejection, engage an experienced veterans’ advocate or lawyer. The instrument is technical and mistakes in wording are costly. For example, a doctor who writes “iritis” instead of “uveitis” (under definition, uveitis includes iritis) should be fine, but best to use the exact term. The instrument’s note for uveitis says it includes choroidal effusion, so a diagnosis of choroidal effusion should be explicitly linked. Finally, keep an eye on amendment history: if a future SOP changes the list of drugs or factors, a new claim may need to rely on the updated version. Claims already determined are not reopened unless there is new and material evidence. The instrument’s 21-day window is short, so prompt identification of symptoms and drug history is crucial. Regular eye exams for veterans on specified drugs may be prudent. However, that imposes a cost on the health system. From a private firm’s perspective, if advising a veteran with glaucoma, the first question should be: did you serve in operational service? If yes, then the reasonable hypothesis SOP applies. If not, the higher standard applies and the instrument is less helpful. The instrument effectively lowers the bar for operational veterans but still requires careful fact-gathering.