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Chapter 13: Special Senses Secondary Conditions
Chapter 13
Special Senses Secondary Conditions
Introduction to Special Senses Secondary Connections
Special senses—vision, hearing, balance, taste, and smell—frequently develop secondary conditions related to service-connected disabilities. These sensory systems are particularly vulnerable to cascading effects from various primary conditions, whether through direct physiological impact, medication side effects, or neurological mechanisms.
Key Concepts
Special senses secondary conditions typically develop through these pathways:
- Medication effects on sensory organs or neural pathways
- Vascular changes affecting sensory organ perfusion
- Neurological effects on sensory processing
- Immune system dysregulation affecting sensory structures
- Metabolic changes affecting sensory function
- Mechanical effects from musculoskeletal conditions
This chapter explores the most common special senses conditions that develop secondary to service-connected disabilities and provides the medical evidence and documentation strategies needed to successfully claim these conditions.
Vision Conditions Secondary to Diabetes, Hypertension, or Medication Effects
Vision conditions—including retinopathy, cataracts, glaucoma, and other ocular disorders—frequently develop as secondary conditions to service-connected diabetes, hypertension, and medication side effects.
Medical Connection
The development of vision conditions as secondary effects occurs through several established mechanisms:
Secondary to Diabetes Mellitus
Diabetes affects vision through:
- Diabetic retinopathy: Microvascular damage to retinal blood vessels
- Diabetic macular edema: Fluid accumulation in the macula
- Accelerated cataract formation: Lens protein changes from elevated glucose
- Neovascular glaucoma: Abnormal blood vessel growth affecting drainage
- Cranial nerve palsies: Affecting extraocular muscles
- Fluctuating refractive errors: From glucose-related lens changes
Secondary to Hypertension
Hypertension affects vision through:
- Hypertensive retinopathy: Vascular changes in the retina
- Choroidopathy: Affecting the vascular layer beneath the retina
- Optic neuropathy: Damage to the optic nerve from poor perfusion
- Increased risk of retinal vein occlusion: Blockage of retinal veins
- Increased risk of retinal artery occlusion: Blockage of retinal arteries
- Contribution to glaucoma: Through effects on intraocular pressure
Secondary to Medication Effects
Various medications can affect vision:
- Corticosteroids: Cataracts, glaucoma, central serous retinopathy
- Hydroxychloroquine/Chloroquine: Retinopathy
- Ethambutol: Optic neuropathy
- Sildenafil: Color vision changes, non-arteritic anterior ischemic optic neuropathy
- Tamoxifen: Crystalline retinopathy
- Amiodarone: Corneal deposits, optic neuropathy
- Topiramate: Angle closure glaucoma, myopia
Case Study: Diabetic Retinopathy Secondary to Diabetes
A veteran with service-connected diabetes mellitus (40% rating) developed progressive vision changes. His successful secondary claim included:
- Ophthalmology evaluation diagnosing moderate nonproliferative diabetic retinopathy
- Retinal imaging showing microaneurysms, dot hemorrhages, and cotton wool spots
- Optical coherence tomography (OCT) showing early macular edema
- Visual field testing documenting peripheral vision deficits
- Ophthalmologist’s opinion stating that “the veteran’s retinopathy is directly caused by his service-connected diabetes mellitus, as evidenced by the classic retinal findings and absence of other risk factors”
- Documentation of required laser treatments
- Evidence of visual acuity changes and functional limitations
The VA granted service connection for diabetic retinopathy as secondary to diabetes mellitus with a 30% rating based on visual field deficits and acuity changes.
Common Patterns of Secondary Vision Conditions
| Primary Condition | Vision Condition | Characteristics |
|---|---|---|
| Diabetes mellitus | Diabetic retinopathy | Microaneurysms, hemorrhages, exudates, neovascularization in later stages |
| Hypertension | Hypertensive retinopathy | Arteriolar narrowing, AV nicking, flame hemorrhages, cotton wool spots |
| Inflammatory conditions requiring corticosteroids | Steroid-induced cataracts | Posterior subcapsular opacities, often bilateral |
| Inflammatory conditions requiring corticosteroids | Steroid-induced glaucoma | Elevated intraocular pressure, optic nerve changes |
| Autoimmune conditions requiring hydroxychloroquine | Hydroxychloroquine retinopathy | Bull’s eye maculopathy, paracentral scotomas |
Documentation Strategies
To establish vision conditions as secondary, focus on documenting:
- Comprehensive ophthalmology evaluation
- Objective testing:
- Visual acuity measurements
- Visual field testing
- Retinal imaging (fundus photography, fluorescein angiography)
- Optical coherence tomography (OCT)
- Intraocular pressure measurements
- Baseline vision status prior to primary condition
- For diabetes-related vision conditions:
- Duration and control of diabetes
- Hemoglobin A1c levels
- Progression of retinal changes
- For hypertension-related vision conditions:
- Blood pressure records
- Duration and severity of hypertension
- Evidence of other end-organ damage
- For medication-induced vision conditions:
- Complete medication history
- Dosages and duration
- Cumulative exposure calculation
- Monitoring performed during treatment
- Treatment requirements:
- Laser procedures
- Intravitreal injections
- Surgical interventions
- Ongoing monitoring frequency
- Functional impact:
- Effect on daily activities
- Driving restrictions
- Reading difficulties
- Work limitations
- Specialist opinions addressing the causal relationship
- Research literature supporting the specific connection
Rating Consideration
Vision conditions are rated under various diagnostic codes (6000-6091) based on visual acuity, visual field, and other factors. The rating system for vision is complex and considers both central visual acuity and peripheral vision. Document all visual testing thoroughly, including both corrected and uncorrected vision, to support proper rating.
Hearing Loss and Tinnitus Secondary to Medication Effects or TBI
Hearing loss and tinnitus—can develop as secondary conditions to medications prescribed for service-connected conditions or as a result of service-connected traumatic brain injury (TBI).
Medical Connection
The development of hearing loss and tinnitus as secondary conditions occurs through several mechanisms:
Secondary to Medication Effects
Various medications can cause or contribute to hearing loss and tinnitus:
- Aminoglycoside antibiotics: Direct ototoxicity damaging cochlear hair cells
- Loop diuretics: Affecting fluid balance in the inner ear
- Platinum-based chemotherapy: Damaging cochlear structures
- Salicylates (high-dose aspirin): Temporary effects on hearing and tinnitus
- NSAIDs: Some may affect hearing in susceptible individuals
- Antimalarials: Some can affect auditory function
- Certain antidepressants: May cause or worsen tinnitus
Secondary to Traumatic Brain Injury
TBI can lead to hearing loss and tinnitus through:
- Direct trauma to auditory structures: Damage to middle or inner ear
- Damage to auditory neural pathways: Affecting central processing
- Temporal bone fractures: Affecting ear structures
- Vascular injury: Affecting blood supply to auditory system
- Central auditory processing disorders: Affecting interpretation of sounds
Case Study: Hearing Loss and Tinnitus Secondary to TBI
A veteran with service-connected TBI (70% rating) developed progressive hearing difficulties and constant tinnitus despite no significant noise exposure. His successful secondary claim included:
- Audiology evaluation documenting sensorineural hearing loss and tinnitus
- Pure tone audiometry showing asymmetric hearing loss
- Speech discrimination testing showing reduced word recognition
- Neuroimaging from TBI workup showing temporal lobe involvement
- Otolaryngologist’s opinion stating that “the veteran’s hearing loss and tinnitus are at least as likely as not secondary to his service-connected TBI, as evidenced by the pattern of hearing loss, absence of other risk factors, and well-established connection between TBI and auditory dysfunction”
- Documentation of functional impact on communication and daily activities
The VA granted service connection for hearing loss (30% rating) and tinnitus (10% rating) as secondary to TBI.
Common Patterns of Secondary Hearing Loss and Tinnitus
| Primary Condition | Mechanism | Characteristics |
|---|---|---|
| Infections requiring aminoglycoside antibiotics | Ototoxicity | Bilateral, high-frequency hearing loss, often permanent |
| Cancer requiring platinum chemotherapy | Ototoxicity | Progressive, bilateral, high-frequency hearing loss |
| Hypertension or heart failure requiring loop diuretics | Effects on inner ear fluid balance | Often temporary, may become permanent with long-term use |
| Traumatic brain injury | Direct trauma or neural pathway damage | May be asymmetric, often includes tinnitus and hyperacusis |
| Chronic pain requiring high-dose salicylates | Temporary effects on cochlear function | Reversible hearing loss and tinnitus, dose-dependent |
Documentation Strategies
To establish hearing loss and tinnitus as secondary conditions, focus on documenting:
- Audiology and ENT evaluations
- Objective testing:
- Pure tone audiometry
- Speech discrimination testing
- Tympanometry
- Otoacoustic emissions
- Auditory brainstem response
- Baseline hearing status prior to primary condition
- For medication-induced hearing loss:
- Complete medication history
- Dosages and duration
- Temporal relationship to hearing changes
- Monitoring performed during treatment
- For TBI-related hearing loss:
- TBI evaluation records
- Neuroimaging results
- Temporal relationship to injury
- Pattern of hearing loss
- Tinnitus characteristics:
- Constant vs. intermittent
- Unilateral vs. bilateral
- Description (ringing, buzzing, hissing)
- Severity and impact
- Functional impact:
- Communication difficulties
- Work limitations
- Social effects
- Need for hearing aids
- Specialist opinions addressing the causal relationship
- Research literature supporting the specific connection
Rating Consideration
Hearing loss is rated under Diagnostic Code 6100 based on a combination of pure tone thresholds and speech discrimination scores. Tinnitus is rated under Diagnostic Code 6260 with a maximum rating of 10%. Document all audiometric testing thoroughly, including both pure tone thresholds at 1000, 2000, 3000, and 4000 Hz and Maryland CNC speech discrimination scores, to support proper rating.
Vestibular Disorders Secondary to TBI or Medication Effects
Vestibular disorders—conditions affecting balance and spatial orientation—frequently develop as secondary conditions to service-connected traumatic brain injury (TBI) or as a result of medications prescribed for service-connected conditions.
Medical Connection
The development of vestibular disorders as secondary conditions occurs through several mechanisms:
Secondary to Traumatic Brain Injury
TBI can lead to vestibular dysfunction through:
- Direct trauma to vestibular structures: Damage to inner ear
- Damage to vestibular neural pathways: Affecting central processing
- Temporal bone fractures: Affecting labyrinthine structures
- Concussive forces: Disrupting otolith function
- Central vestibular processing disorders: Affecting integration of balance information
- Post-traumatic endolymphatic hydrops: Fluid imbalance in inner ear
Secondary to Medication Effects
Various medications can cause vestibular dysfunction:
- Aminoglycoside antibiotics: Vestibulotoxicity damaging hair cells
- Loop diuretics: Affecting fluid balance in the inner ear
- Certain antidepressants: Affecting central vestibular processing
- Anticonvulsants: Some can affect balance and coordination
- Chemotherapy agents: Some have vestibulotoxic effects
- Anti-hypertensives: Can cause orthostatic effects affecting balance
Case Study: Vestibular Dysfunction Secondary to TBI
A veteran with service-connected TBI (50% rating) developed chronic dizziness, vertigo, and balance problems. His successful secondary claim included:
- Neurotology evaluation diagnosing post-traumatic vestibulopathy
- Vestibular testing:
- Videonystagmography showing abnormal vestibular responses
- Rotational chair testing confirming vestibular hypofunction
- Computerized dynamic posturography showing balance deficits
- Neuroimaging from TBI workup
- Neurotologist’s opinion stating that “the veteran’s vestibular dysfunction is directly caused by his service-connected TBI, as evidenced by the pattern of vestibular deficits, temporal relationship to injury, and absence of other causes”
- Documentation of multiple falls and safety concerns
- Evidence of required vestibular rehabilitation therapy
- Functional impact assessment showing severe limitations in mobility and activities
The VA granted service connection for post-traumatic vestibulopathy as secondary to TBI with a 30% rating based on dizziness and occasional staggering.
Common Types of Secondary Vestibular Disorders
| Primary Condition | Vestibular Disorder | Characteristics |
|---|---|---|
| Traumatic brain injury | Post-traumatic vestibulopathy | Chronic dizziness, imbalance, motion sensitivity, often with cognitive symptoms |
| Traumatic brain injury | Benign paroxysmal positional vertigo (BPPV) | Brief episodes of vertigo triggered by specific head positions |
| Infections requiring aminoglycoside antibiotics | Bilateral vestibular hypofunction | Imbalance, oscillopsia (visual bouncing with head movement), worse in dark |
| TBI with temporal bone fracture | Perilymph fistula | Pressure-induced vertigo, fluctuating hearing, sound/pressure sensitivity |
| TBI or barotrauma | Post-traumatic Meniere’s syndrome | Episodic vertigo, fluctuating hearing, tinnitus, aural fullness |
Documentation Strategies
To establish vestibular disorders as secondary conditions, focus on documenting:
- Neurotology or specialized ENT evaluation
- Objective vestibular testing:
- Videonystagmography (VNG)
- Rotational chair testing
- Vestibular evoked myogenic potentials (VEMP)
- Video head impulse test (vHIT)
- Computerized dynamic posturography
- Dix-Hallpike and other positional testing
- Detailed symptom description:
- Type of dizziness (vertigo, lightheadedness, imbalance)
- Frequency and duration of episodes
- Triggers and alleviating factors
- Associated symptoms
- For TBI-related vestibular disorders:
- TBI evaluation records
- Neuroimaging results
- Temporal relationship to injury
- Pattern of vestibular symptoms
- For medication-induced vestibular disorders:
- Complete medication history
- Dosages and duration
- Temporal relationship to symptom onset
- Response to medication changes
- Treatment history:
- Vestibular rehabilitation therapy
- Medications for symptom control
- Surgical interventions if any
- Response to treatments
- Functional impact:
- Fall history and risk
- Mobility limitations
- Driving restrictions
- Work limitations
- Need for assistive devices
- Specialist opinions addressing the causal relationship
- Research literature supporting the specific connection
Rating Consideration
Vestibular disorders are typically rated under Diagnostic Code 6204 (peripheral vestibular disorders) with ratings of 10% or 30% based on frequency and severity of symptoms. The 30% rating requires dizziness and occasional staggering. Document all episodes of dizziness, balance problems, and falls to support proper rating. If hearing loss or tinnitus is also present, these may be rated separately.
Evidence Checklist & Documentation Strategies
Special Senses Secondary Conditions Evidence Checklist
- Medical diagnosis of the secondary special senses condition
- Treatment records for the primary service-connected condition
- Specialist evaluations (ophthalmology, ENT, audiology, neurology)
- Objective testing results specific to the sensory system
- Medication history showing drugs prescribed for service-connected conditions
- Baseline sensory function prior to primary condition or treatment
- Medical opinion linking the sensory condition to the primary condition
- Timeline showing primary condition preceded sensory symptoms
- Documentation of treatment for the sensory condition
- Functional impact assessment
- Safety concerns related to sensory loss
- Personal statement describing how the primary condition led to sensory symptoms
- Relevant medical literature supporting the sensory connection
Effective Documentation Approaches
For special senses secondary conditions, these documentation strategies are particularly effective:
Specialist Involvement
Special senses conditions require specialist evaluation:
- Ophthalmologist for vision conditions
- Audiologist and ENT for hearing conditions
- Neurotologist for vestibular disorders
- Neurologist for TBI-related sensory issues
- ENT specialist for smell and taste disorders
Objective Testing
Objective test results provide compelling evidence:
- For vision: Visual acuity, visual fields, OCT, retinal imaging
- For hearing: Audiometry, speech discrimination, tympanometry
- For vestibular: VNG, rotational chair, posturography
- For smell/taste: Standardized smell identification tests, taste testing
Functional Impact Documentation
Document how sensory conditions affect function:
- Safety concerns (driving, fall risk, inability to detect hazards)
- Communication difficulties
- Navigation and mobility challenges
- Work limitations and accommodations needed
- Social effects and psychological impact
- Need for assistive devices (hearing aids, glasses, mobility aids)
Temporal Relationship
Document the timeline clearly:
- Baseline sensory function before primary condition
- Onset of primary condition or start of medication
- First appearance of sensory symptoms
- Progression of sensory condition
- Response to treatment of primary condition
Expert Tip
For special senses conditions, particularly those related to TBI, obtaining baseline testing results from before the injury can be extremely valuable evidence. If available, include pre-injury vision tests, hearing tests, or other sensory evaluations, followed by the post-injury testing showing the changes. This clear “before and after” evidence strongly supports the causal relationship between the TBI and the sensory condition.