Special senses refers to any and all disabilities which involve speech, vision or hearing.   To properly evaluate these impairments, you must have an understanding of how these disabilities are interpreted by the Social Security Administration.  In this chapter we will discuss the restrictive aspects of this category of impairments and will also cover the testing methods used in their evaluation.  We will begin this chapter with a list of terms which will help you to better understand these types of disorders.

Visual impairments:

 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 means that a person is able to see the testing object at twenty feet which compares with what most normal sighted people can see at twenty feet.  If the claimant has 20/40 vision, this means that he can only see at twenty feet what most people can see at forty feet.  This person is said to have reduced vision or a reduced visual acuity.  

    SSA 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.

     A visual acuity on a person with decreased vision is not considered accurate unless tested with best correction. Best correction means testing with visual devices such as glasses or contact lenses.  The scale below shows how SSA values visual acuity results as they pertain to disability.

20/20 to 20/40 ---Non-severe impairment.  Does not cause any visual restrictions.

20/40 to 20/100 ---Significant visual loss, but will not  interfere with work.

20/100 to 20/190 --- Represents a severe visual loss and would interfere with jobs requiring good vision.  Truck drivers, etc.

20/200 and above --- Statutory blindness.  Vision this bad would meet the listings.

     The Snellen visual acuity test is acceptable to SSA for visual acuity.  In most disability cases you will deal with individuals with visual acuity's 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 a non-severe visual impairment despite the fact that he is blind in one eye at 20/400.  The exception to this non-severe rule is if 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 around how the remaining visual acuity may interfere with that person's ability to perform past or other work.

 
Near vision:

     Near vision is very important because a significant decrease here could prevent a claimant from doing sedentary work.  A significant decrease in near vision can directly affect a person's ability to do fine or detailed work which includes reading.  If near vision is not correctable to an acceptable standard, the claimant would be limited in his ability to do sedentary work.  Near vision restrictions are most important if claimant has a work history of only sedentary jobs.  Near vision restrictions must also be given strong consideration when the claimant cannot physically perform light or medium work.  If this were the case, the claimant would have an RFC for sedentary work which would require good close vision.

     If the claimant has documented near-sightedness and has problems with reading, you may be able to give a visual restriction which prevents sedentary work.  There are tests such as the Jaeger test which places a value on the degree of near-sightedness.  Remember, all visual test results must be determined with the best correction possible.

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 focused 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 along a perimeter of the claimant's eye, the doctor is able to determine the degree of field restriction.  You will find in the medical evidence of most claimants with a visual impairment, a copy of what is called a visual fields test along with the visual acuity results.  

     On a visual field chart (left + right) eye, you will notice a drawn in result in the form of an irregular circle.  The circle drawn around the scales of the field show a remaining visual field of about forty percent.   The smaller the circle on the field, the more restricted is the visual field.  Any field decreased by more than fifty percent is significant and can be used to restrict claimant's work activity.  A significant loss in visual fields would prevent the claimant from performing jobs which require good peripheral vision.  Examples of these types of jobs are machine operators, moving vehicle operators, assemblers and any other job which requires a person to work with moving objects.

(Visual field example below.)

     The above visual field shows an individual with a significant visual field reduction in the right eye.  Note that the values from ten at the center of the chart to seventy at the outer edge.  Also note the irregular line which represents the actual results of this claimant's visual field testing.  To determine a visual field value, simply add the values of the irregular line results at each point of intersection with the degree lines on the  chart.

     Our example shows an irregular line which has a value of 48 at 90 degrees, 50 at 135 degrees, 38 at 180 degrees and so on.  Add together the 48, 50, 38, etc. and divide by eight.  In this case, the value will be less than fifty which represents a significant decrease in this person's visual field in the right eye.   You would repeat this procedure for the left eye as well.  The two figures combined will give you a persons average visual field.

 
Eye muscles:

     If a claimant is suffering from a condition which has resulted in a paralysis or ptosis of the eye muscles, this can significantly interfere with vision.  Evaluate this condition as to the extent of the visual interference.

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 considers this to be a non-severe impairment.  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, it would be safe to say that he can no longer perform this type of work due to his visual loss.  A person must have vision in both eyes to have depth perception.   Depth perception is crucial to performing jobs using machinery or moving vehicles.

Common visual impairments:

     The following is a list of commonly seen visual impairments.  Following this list there will be a brief discussion of the effects and characteristics of these types of disorders.

Retinal detachment
Diabetic retinopathy
Glaucoma
Cataracts
Visual disturbances
Low vision
 

Retinal detachment: 

     A retinal detachment is a condition whereby 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.

Diabetic retinopathy:  

     Many individuals who are suffering from a diabetic condition experience visual disturbances associated with this condition.  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 advanced disease.  Diabetic retinopathy is a serious condition which gets worse with time or poor diabetic control.  This condition can cause significant visual interference or blindness.

Glaucoma:

   This condition 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 heavy to medium lifting may also be restricted in more serious cases to prevent eye damage.

Cataracts:

     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 it does not appear in our list above.

Low vision:

     Low vision regardless of cause is defined as visual acuity of less than 20/40.  From the perspective of a  disability case, visual acuity's of 20/100 to 20/190 are considered significant.  Visual acuities in this range can significantly interfere with a claimant's ability to perform some types of work, even 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 audiometer which meets the standard of the American National Standards Institute for air and bone conducted stimuli.  Hearing of a specific level is required in order to perform sedentary work.   If the claimant is unable to hear normal speech, he/she would find it very difficult to perform most types of sedentary work activity.

     Common sense tells us that an inability to hear speech would eliminate phone work, direct customer contact, and other functions which require good hearing and verbal communications.  Most cases you will encounter will show a claimant who only has a certain degree of hearing loss.  You must be able to determine just how restrictive the hearing loss is, before presenting your case argument.  In other words, you must learn to interpret a hearing test.

Hearing test:

     Hearing, like vision must be tested with best correction which in this case means with a hearing aid if possible.  When a claimant is given a hearing test, the tester will normally fit a device to the claimant's ear to test the degree of hearing improvement, if any.  The results you will see on a hearing chart are normally best corrected.  The hearing chart is in scale form with decibel readings in the Y axis and hertz values on the X axis.  The decibel and hertz measurements are given certain values which form a grid.  Where the claimant's hearing results fall on this grid determines degree of hearing loss. 

10db   |_____________________________________|                       
20       |_____________________________________|                       
30       |_____________________________________|     
40       |____+_<______________________________|  
50       |_______ +_<__________________________|
60       |____o_______+ <_____________+<_______|
70       |____>___o_______ + <___+<_>__>_______|
80       |________>___>____>__________________|                          90       |____________o____o____o______________|
100     |____________________________o________|

          0  100   500   1000    2000   3000   4000    5000hz
              + = right ear.      < = right ear bone conduction 
              o = left ear.        > = left ear bone conduction  

      The hearing scale above shows the results of our hypothetical claimant with an allegation of poor hearing. Let's review and interpret the results.  

      Forty decibels or lower is considered the speech range. In other words, if claimant has a reading which falls between 10 and 40dbs on the scale, that person will have no problems hearing speech.

      If the results fall below 40 but above 60dbs, that person has a moderate loss in his ability to hear speech.  If the results are 65dbs or higher, the claimant will have great difficulty hearing the normal spoken word.  

      You should only be concerned with the readings at the 500, 1000, and 2000hz levels.  If the results at these levels are above 60dbs in both ears, you have a significant hearing loss that could interfere with some types of work activity.

      The results on the example scale show an individual with poorer hearing in the left ear as compared to the right.  The bone conduction results are also poorer on the left, indicating that this person's hearing loss is sensorineural (nerve origin) in nature.  Nerve origin implies damage to the inner ear as the cause of the hearing loss.  Damage to the middle ear is considered to be mechanical, and is less serious.  Middle ear hearing losses usually do not show a significant depression in bone conduction levels on testing.

      Also on this example scale, the claimant would have a poor chance of being allowed because the right ear hearing scores average out at 60dbs which represents only a moderate loss of hearing in the better ear.  When determining the extent of a hearing loss using the hearing scales, add the results for each ear at 500hz, 1000hz, and 2000hzs.  Then divide by three to get the average result in each ear.  It is the value of the average result that is used to determine the extent of the disability.  Always judge the seriousness of a hearing impairment by the results of the better ear.

Speech disorder:

    Loss in the ability to speak may be caused by a number of disorders or direct trauma.  Inability to speak is often related to a serious hearing disorder or even a psychiatric problem.  Whatever the cause for the loss of speech, keep in mind that it may interfere with work activity of certain types.  If the job requires the ability to speak (per DOT), the claimant would be restricted from performing that type of work.