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Special Senses Disorders
Home Full Impairment Discussion Special Senses refers to any and all impairments involving
speech, balance, vision or hearing. To properly
evaluate impairments in this category, you must have an
understanding of how these impairments are viewed and
interpreted by the Social Security Administration. In this
chapter we'll discuss the restrictive aspects of this category
of impairments and review some of the testing methods used in
their evaluation. We'll begin this chapter with a list of terms
that will help you to better understand these types of
disorders. For a more detailed discussion of special senses
disorders, visit chapter seventeen in the Social Security Guide. Central visual acuity Visual acuity is defined as an individual's ability to see an object directly in front of him at a distance of approximately twenty feet. Normal visual acuity is expressed as acuity over distance tested or 20/20. 20/20 actually measures a person's ability to see a testing object at twenty feet and is compared with what most normal sighted people can see at the same distance. If the claimant has 20/40 vision for example, this means that he can only see at twenty feet what most normal sighted people can see clearly at forty feet. This person is said to have reduced vision or a reduced visual acuity. Social Security uses the following scale to determine the extent and seriousness of a visual impairment. This scale is referred to as the Snellen test. The Snellen test results must be determined with best correction. Best correction means that the claimant must be tested with glasses if needed or with the doctor's optical corrector. Visual acuity on a person with decreased vision is not considered accurate unless tested with best correction. Social Security considers the claimant's best corrected vision score as the value used to determine the severity of the visual impairment. The scale below shows how Social Security values visual acuity results as they pertain to disability. 20/20 to 20/40 --- Non-severe impairment. Does not cause any significant visual restrictions. 20/50 to 20/100 --- Significant visual loss. SSA will include in RFC. 20/100 to 20/190 --- Represents a severe visual loss and could interfere with jobs requiring good vision. Truck drivers, heavy machine operators, etc. 20/200 and above --- Statutory blindness. Listing level severity. The Snellen visual acuity test is acceptable to SSA for visual acuity. In most disability cases you'll deal with individuals with visual acuityies ranging from 20/100 to 20/190. Always judge the seriousness of a visual impairment by the results in the better eye. If one eye has a visual acuity of 20/400 and the other 20/30, this claimant has only a significant visual impairment despite the fact that he is blind in one eye at 20/400. The exception to this rule is if the claimant alleges decreased peripheral vision due to the loss of vision in the one eye or other eye problems associated with the remaining good eye. Evaluation of an individual with decreased vision should center on how the remaining visual acuity may interfere with that person's ability to perform work. Near vision is important because a significant decrease here could prevent a person from performing sedentary work. A significant decrease in near vision can directly affect a person's ability to do fine or detailed work, including reading. If near vision is not correctable to an acceptable level, the claimant would be limited in his ability to do sedentary work. Near vision restrictions are most important if the claimant has a work history of only sedentary work as is true with many professionals. Near vision restrictions must also be given strong consideration when the claimant cannot physically perform light work. If the claimant cannot perform light work, the claimant with reduced vision may also be restricted from many forms of sedentary work that require good close vision. If a claimant has documented
near-sightedness and has problems with reading and other
detailed work, you may be able to further reduce the claimant's
residual functional capacity based on his visual limitation.
There are tests such as the Jaeger test that place a value on
the degree of near-sightedness. Remember, all visual test
results must be determined with best correction.
Visual fields A visual field represents an individual's ability to see in the peripheral areas of the eye. An impairment that decreases the peripheral vision will result in a contraction of the visual fields. Try to picture a circle in your mind with a dot at its center. The dot represents the focus point of the eye where a person sees most clearly. All around the central dot is the area called the periphery. If an individual has a blind spot or restriction in his ability to see in the peripheral areas of the eye, he is said to have a decreased visual field or field defect. The contraction of the visual field may be either symmetrical or irregular in shape. The remaining visual field is determined by using a perimetric method at a distance of 330mm. Under a specified degree of illumination, an eye doctor can test the claimant's ability to see an object out of the corner of his eye. By moving his finger or a digital tool along the perimeter of the claimant's eye, the doctor is able to determine the degree of field restriction. On a visual field chart (left + right) eye, you'll notice a drawn-in result in the form of an irregular circle. The circle drawn around the scale of the field represents the remaining visual field. The smaller the circle on the field, the more restricted the peripheral vision. Any field decrease of more than fifty percent is significant and can be used to further restrict a claimant's RFC. A significant loss in visual field would prevent the claimant from performing jobs that require good peripheral vision. Examples of these types of jobs are machine operators, moving vehicle operators, assemblers and any other jobs that require a person to work with moving objects. (For visual field example figure 1, Social Security Guide section 17/7) If a claimant is suffering from a condition that has resulted in a paralysis or ptosis of the eye muscles, this can significantly interfere with vision. Again, the claimant's suffering from diseases affecting eye muscles may have a reduced residual function capacity as a result of this condition.
Monocular vision If for whatever reason a claimant has lost sight in one eye, you must first evaluate the vision of the remaining eye before determining the extent of disability. If the vision in the remaining eye is 20/20, SSA may consider his visual impairment to be non-severe. However, if a claimant only has vision in one eye, it does have a negative effect on the peripheral vision in the remaining eye, causing a restriction for some types of work activity. If the claimant's past work was as a
truck driver, for example, it would be safe to say that he can
no longer perform this type of work due to loss of peripheral
vision. When driving a truck, peripheral vision is extremely
important for the safe operation of the vehicle. A person must
also have vision in both eyes in order to have depth
perception. Depth perception is crucial to performing jobs
with moving objects or machinery. Common visual impairments The following is a list of commonly seen visual impairments. Following this list will be a brief discussion of the effects and characteristics of these types of disorders. Retinal detachment
Retinal detachment A retinal detachment is a condition where the retinal lining inside the eye is detached from its cellular base causing a significant visual disturbance. This condition is most often seen in eye trauma, but can be caused by disease states. Evaluate this condition as to the remaining visual acuity. Claimant may also have to be restricted in physical activity to prevent further damage.
Many individuals who are suffering from a diabetic condition experience visual disturbances. Some of the most common problems associated with this condition are capillary micro aneurysms (bleeding from small vessels in the eye), macular edema (swelling of the macular region of the eye) and even retinal detachment in the advance state of diabetic disease. Diabetic retinopathy is a serious condition that is progressive. This condition can be expected to worsen over time and with poor diabetic control. Diabetic retinopathy can cause significant visual interference and progress to total blindness.
Glaucoma is characterized by an increase in the intra-ocular pressure within the eye. This disorder can cause slight to very serious visual loss, including complete blindness. You should evaluate this condition as to the remaining visual acuity. Physical restrictions such as medium to light lifting may also be restricted in more serious cases of glaucoma in order to prevent further eye damage.
A cataract is a condition in which a
person forms an opacity on the lens of the eye which slowly
reduces vision. This disorder is characterized by a progressive
and painless growth of a grayish white lesion on the lens of the
eye. This condition can progress to a total visual occlusion.
Most cataracts can be surgically removed. If a claimant is not
scheduled for cataract removal and his visual acuity is
significantly reduced, this condition can be considered to cause
a significant restriction to work activity. The claimant cannot
be forced to undergo surgery even if this operation would
improve the condition. Visual disturbance Any condition of any cause which interferes with visual acuity is considered to be a visual disturbance. This is important because you do not want to overlook a visual disorder just because its cause is not readily apparent. If a claimant complains of significant visual loss, add this allegation to his list of impairments. This will force SSA to send the claimant to an evaluation at SSA's expense if the claimant's records do not address the issue. If a serious visual problem is discovered, this can be used to further reduce the claimant's residual functional capacity.
Low vision regardless of cause is defined
as visual acuity of less than 20/40. From the perspective of
a disability case, visual acuities of 20/70 to 20/190 best
corrected, are considered significant. Visual acuities in this
range can significantly interfere with a claimant's ability to
perform many types of work, especially work of a sedentary
nature. Hearing Impairments Hearing ability should be evaluated in terms of the claimant's ability to hear speech. Loss of hearing is determined by an audiometric examination that meets the standard of the American National Standards Institute for air and bone conducted stimuli. Hearing at a specific level is required in order to perform many types of sedentary work. If the claimant is unable to hear normal speech, he/she would find it very difficult to perform many types of work. Common sense tells us that an inability
to hear speech would eliminate phone work, direct customer
contact and other jobs that require good hearing and verbal
communications. A claimant with severe hearing loss should also
be restricted from dangerous jobs where hearing is the primary
source of warning. In most cases, you'll encounter claimants
with only a slight degree of hearing loss. You must be able to
determine just how restrictive the hearing loss is before
creating a residual functional capacity based on a hearing
restriction.
Disability allowances based on speech and balance disorders are rare, but not impossible. Loss in the ability to speak may be caused by a number of diseases or direct trauma. Inability to speak is often related to a serious hearing disorder or even a psychiatric problem. Regardless of what caused the loss of speech, keep in mind that it may interfere with work activity of a certain type. If a job requires the ability to speak, the claimant would be restricted from performing that type of work. If a claimant has a balance disorder, it would restrict his ability to work at heights, but would not affect his ability to do most types of sedentary work. If you address the issues as set forth in this report concerning claimants with severe special senses disorders, you'll be able to extract enough supportive evidence to produce at least a fair argument for disability. There are several other important considerations when evaluating special senses disorders that are not discussed here. For additional information about special senses disorders and how they are evaluated by Social Security, see full discussion link.
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