Sensory Impairment
Rekayasa Rehabilitasi
Teknik Biomedis Institut Teknologi Sumatera
Special Senses
The Eye
1” in diameter
Protected by orbital socket
of skull, eyebrows, eyelashes
and eyelids.
Bathed in fluid from
Lacrimal Glands
( tears empty into nasal cavity)
Conjunctiva – thin
membrane that lines the
eyelids and covers part of
the eye.
The Eye
Wall of Eye is made up of 3 layers or coats
Sclera, Choroid Coat, and the Retina
SCLERA- Outer layer
White of the eye
Tough, fibrous capsule helps maintain shape of eye and
protects the structure within.
EXTRINSIC MUSCLES- muscle responsible for moving the eye
that are attached to the sclera.
The Other Eye
Cornea – Front of
sclerotic coat (part of
sclera)
Clear part (no blood
vessels) – called the
“window of the eye”
Transparent so light rays
can pass through
Gets O2 and nutrients
through lymph
I can see you….
Choroid Coat
Middle layer
Contains blood vessels
Circular opening in front is the PUPIL
Colored, muscular layer surrounding pupil is IRIS
INTRINSIC MUSCLES - change size of iris to control amount of
light entering through the pupil – exposed to light =
constriction
Can you see me??
Lens
Crystalline structure located behind iris and pupil – focuses
light rays on retina – function is accommodation = adjusting
for near / far vision
Elastic, disc-shaped, biconvex
Situated between the anterior and posterior chambers
Hey…where did you go??
ANTERIOR CHAMBER filled with AQUEOUS
HUMOR, a watery fluid.
POSTERIOR CHAMBER filled with transparent,
jellylike substance - VITREOUS HUMOR
Both substances maintain eye’s spherical shape
and refract light rays
Oh no!! It’s dark in here!!
Retina
Innermost layer – 3rd coat of the eye – located between the
posterior chamber and choroid coat
Light rays focus an image on the retina
The image then travels to the cerebral cortex via the OPTIC
NERVE.
❖ If light rays do not focus correctly on the retina, the condition
may be corrected with properly fitted contact lenses, or
eyeglasses, which bend the light rays as required.
Finally…the eye is almost over!
Retina contains specialized cells, visual receptors - rods and
cones
RODS- sensitive to dim light…problems driving at
night….damage to rods
CONES – sensitive to bright light – responsible for color vision
OPTIC DISC- on the retina, known as the blind spot- nerve
fibers gather here to form the optic nerve, no rods or cones.
The Eye
Pathway of Vision
LENS (Light
LIGHT CORNEA PUPIL rays are
refracted)
RETINA RODS & CONES
OPTIC NERVE BRAIN
( Pick up stimulus)
The Ear
Outer Ear
PINNA (AURICLE)- outer ear,
collects sound waves
EXTERNAL AUDITORY
CANAL- ear canal
CERUMEN- earwax, protects
the ear
TYMPANIC MEMBRANE- ear
drum, separates outer and
middle ear.
Can you hear me??
Middle Ear
Cavity in temporal bone
Connects with pharynx by EUSTACHIAN TUBE - which
equalizes pressure in the middle ear with outside
atmosphere.
Bones in middle ear transmits sound waves from ear
drum to inner ear.
1. MALLEUS (hammer)
2. INCUS (anvil)
3. STAPES (stirrup)
I can hear you ☺
Inner Ear
Contains spiral shaped organ of hearing - the COCHLEA
The cochlea contains a membranous tube, the cochlear duct-
which is filled with fluid that vibrates when sound waves are
transmitted by the stapes.
ORGAN OF CORTI- in the cochlea - delicate hairlike cells that
pick up vibrations of fluid and transmit them as a sensory
impulse along the auditory nerve to the brain.
SEMICIRCULAR CANALS- three structures in the inner ear,
contain liquid that is set in motion by head and body
movements- impulses sent to cerebellum to help maintain
body balance (equilibrium).
The Nose & Tongue
Nose
Smell accounts for 90% of taste
Tissue in the nose, olfactory epithelium,
contains specialized nerve cell receptors.
Those receptors stimulate the OLFACTORY
NERVE to the brain.
Tongue
Mass of muscle tissue
Bumps, projections, on the surface are
papilla, they contain the TASTE BUDS.
Receptors in the taste buds send stimuli
through 3 cranial nerves to the cerebral
cortex.
Common Sensory Disorders
Disorders of the Eye
CONJUCTIVITIS
Pink eye
Inflammation of conjunctival
membranes in front of the eye
Redness, pain, swelling, and
discharge
Highly contagious
Rx- antibiotic eye drops
Low vision versus legal blindness
Legal blindness is simply a
Low vision, by definition, is a
term coined by the IRS for
condition that cannot be
people with visual acuity of
corrected by surgery, glasses,
20/200 or worse in order to
contact lens or medicine with
able to grant or deny benefits
20/80 or worse visual acuity.
based solely on acuity.
Macular degeneration
Progressive blurring or visual loss of CENTRAL vision.
MACULA – the “4 C’s of AMD”
“Cones”
Macular
“Central”
degenerat
“Color”
“Clarity”
ion
Macular Degeneration
Interventions
❖Eccentric Viewing Techniques: A method of scanning peripheral
visual fields to optimize vision using another point in the retina that
has not been damaged by AMD – also called a psuedofovea training.
❖Amsler Grid Training and Education
❖Optical/Non Optical Device Training to compensate for impaired
visual acuity
❖Environmental modifications –optimize lighting, decreasing
clutter, increasing contrast/high contrast
❖Patient education on condition and its prognosis
❖Community Resource Training/Support Groups
❖Psychosocial impact/implications secondary to vision loss
Eye disorders
Glaucoma
Excessive intraocular pressure causing destruction of the
retina and atrophy of the optic nerve
Caused by over production of aqueous humor, lack of
drainage, or aging.
Symps- develop gradually – mild aching, loss of peripheral
vision, halo around the light
TONOMETER- measures intraocular pressure
Rx – drugs or laser surgery to decrease intraocular pressure
Glaucoma interventions
❖Medication management – eye drops
❖Organized visual scanning patterns/visual sweep techniques to use central vision –
LIGHTHOUSE strategies
❖“Electronic magnification devices is often useful because it allows for increased
visability of text by increasing contrast and brightness rather than size of the text”
Safety during functional and community mobility
❖Environmental modifications, especially with lighting because night vision is
typically severely impaired with this population. (PHOTOPHOBIA!)
❖Patient education on the condition and its prognosis
❖Psychosocial impact/implications due to vision loss
❖Often referred to as “Swiss cheese vision”/”Cow
Patch” vision. Patients experience fluctuating,
distorted vision with multiple blind spots presented
in both central/peripheral vision due to diabetes.
❖Symptoms also include difficulty with
focusing/fixating on an object, loss of color vision,
Diabetic
Diabetic
impaired contrast sensitivity, and reports of
“floaters”.
❖ Also can experience photophobia
retinopat
retinopathy ❖ What other considerations do we have to keep in
mind for these folks??
hy
Diabetic Retinopathy
interventions
❖ Amsler Grid Training
❖Eccentric Viewing
❖Special Tinted glasses to reduce glare and sharpen acuity
❖Environmental Modifications (especially to address contrast
sensitivity, tactile bump dots to account for severe vision loss)
❖CCTV/Electronic Magnification Devices
❖Community Resource Training
❖Psychosocial Implications
Common Sensory Disorders
CATARACTS
Lens of eye gradually becomes cloudy
Frequently occurs in people over 70
Causes a painful, gradual blurring and loss of vision
Pupil turns from black to milky white
Rx- surgical removal of the lens
Macular Degeneration
Eye disorder that occurs with aging
The macula ( part of the retina responsible for sharp color vision) degenerates
Vision is reduced but usually doesn’t cause total blindness.
Still problems with the eye
Detached Retina
May occur with aging- accident can cause it at younger age
Retina detaches from choroid
Symps- loss of peripheral vision and then central vision
Rx- laser or freezing technique
STY ( HORDEOLUM)
Abscess at the base of an eyelash (in sebaceous gland)
Symps- red, painful and swollen
Rx- warm, wet compresses
Eye Injuries
Tears are effective in cleaning the eye
If glass or fragments get in eye, cover both eyes and
see medical treatment. (DO NOT remove the object)
Night blindness = NYCTALOPIA- due to inactive rods
Color blindness- cones are affected – genetic disorder
that carried by the female and transmitted to males.
Do you need glasses?
PRESBYOPIA
Lens loses elasticity, cant focus on close or distant objects
Usually occurs after age 40
Rx- bifocals
HYPEROPIA
Farsighted
Focal point beyond the retina because eyeball too short
Convex lenses help
MYOPIA
Nearsighted – can’t see far away
Eyeball too long
Concave lenses help
Still more eye problems
AMBLYOPIA
Reduction or dimness of vision
ASTIGMATISM
Irregular curvature of the cornea or lens, causing blurred vision and eye strain
Rx- corrective lenses
DIPLOPIA- double vision
STABISMUS ( cross-eyes)
Eye muscles do not coordinate their actions
Usually in children
Rx – eye exercises or surgery
Disorders of the Ear
Loud noise
Hearing is fragile! Loud noise over a period of time can cause
hearing loss.
Symptoms- TINNITUS (ringing in ears) and difficulty
understanding what people are saying
Conductive hearing loss….may be from excessive wax in ear
canal
Disorders of the Ear
OTITIS MEDIA
Infection of the middle ear
Often a complication of a common cold in children
Rx- antibiotics
If chronic or if fluid builds up- MYRINGOTOMY (opening in the
tympanic membrane) with tubes inserted will relieve the
pressure.
Sxs – fever, pain, fluid drainage
Other Sensory Problems
Phantom Pain
After an amputation your brain still sends signals to amputated
limb. Neural pathways are still intact.
◼ Rhinorrhea
◼ Allergies cause constant, clear drainage from nose
and down pharynx from maxillary sinuses. May
cause chronic pharyngitis.
Other Sensory Problems
Thrush (oral yeast infection characterized by white
patches on tongue and cheeks)
Antibiotics wipe out normal flora which allow fungi to
flourish…vaginal and oral yeast infections are common with antibiotic
use
Objectives
Review treatment options for common vision and hearing
disorders
Understand techniques to improve function for older people
with low vision and hearing loss.
Treatments for Visual Disorders
Cataracts
Treatment: Surgical Extraction
90% of patients achieve vision ≥ 20/40
Cataract extraction is one of the leading operations
performed on persons over 65 yrs of age-
1.5 million surgeries are performed annually in US.
Local or topical anesthesia, small incision
sonographic breakdown and aspiration of the lens,
placement of an artificial lens
Age Related Macular Degeneration
Treatment
➢ Vitamins, antioxidants, zinc AREDS study showed
vitamins decrease risk of advanced ARMD by 25% ( Dry)
500mg Vit C, 400 Vit E, 15 mg Beta Carotene, 80 mg zinc oxide, 2 mg
cupric oxide
➢ Laser or intraocular pharmacotherapy (wet)
Glaucoma
Management:
Intraocular pressure-lowering medications
➢ Local (eg, Xalatan, timolol, Alphagan)
➢ Systemic (eg, Diamox)
Argon laser trabeculoplasty
Intraocular surgery ± antimetabolites (mitomycin-C)
Drainage devices
Ciliary body destructive procedures
Diabetic Retinopathy
Treatment/prevention
Prevention:
Tight glucose control (A1C < 7 %)
and
BP control (≤140/80)
Treatment: laser photocoagulation to decrease macular
edema and inhibit growth stimulus for
neovascularization
Vision Rehabilitation
Available to those with vision worse than 20/60
Hearing Loss: Options for Treatment
Prosthesis: hearing aides
Assistive listening devices
Environmental changes
Cochlear implant
Hearing Rehabilitation
Hearing Aides
➢ Behind the ear
➢ In the ear
➢ In the canal
➢ Programmable
Hearing Aids
Two are better than one
Not everyone benefits, ie, those with:
➢ Central auditory processing problems
➢ Poor speech discrimination
➢ Dementia
Two types:
➢ Analog (less expensive)
➢ Digital (smaller, customizable)
Many available styles
Assistive Listening Devices
Pocket-sized, personal amplifiers
Telephone equipment: amplifiers, vibrating and flashing
ringer alert devices, text telephones (TTY)
Television listening devices
Vibrating and flashing devices for alarm clocks,
smoke alarms, doorbells, and motion sensors
Cochlear Implant
Electronic device that bypasses the function of
damaged or absent cochlear hair cells by providing
electrical stimulation to cochlear nerve fibers
Implantation requires extensive pre-implant testing,
post-implant training, and general anesthesia
Costs are partially covered by most Medicare carriers
and insurance companies; may require authorization
Outcomes for adults >65 years are comparable to those
of younger adults, with excellent audiologic
and quality-of-life measures
Improving Communication with
hearing impaired elderly
Be certain to have the person’s attention
Speak face-to-face
Repeat by paraphrasing
Speak at normal level to slightly louder
Speak a little more slowly
Stand within 2 - 3 feet
Improving Communication with
hearing impaired elderly
Reduce background noise
Pause at end of sentences
Avoid appearing frustrated
Write down key words if the person can read
Have the person repeat to be certain message was
understood
Summary
Acknowledgments
Slides adapted with permission from the American Geriatrics
Society, Geriatric Review Syllabus teaching slide set.
Permission granted 1-10-07
Post-test question 1
An elderly couple is seen in outpatient geriatric assessment
at the prompting of the wife. The 78-year-old husband was
diagnosed as having occupational hearing loss following his
retirement as a printing press operator 10 years ago, at
which time he purchased by mail a left-side in-the-ear
hearing aid. Initially he used the aide regularly; after he lost
the unit, however, he did not get a replacement. Since then
his wife feels that he has become more reclusive, refusing to
accompany her to social gatherings. He declined an offer
from his children to purchase a new aid as a holiday gift,
saying that the last one "didn't seem to help that much." The
wife feels both angry with his recalcitrance to obtain another
hearing aid and concerned about his possible depression.
Which of the following would be most appropriate to stress in
advising the patient about going for formal hearing
evaluation?
Used with permission from: Murphy JB, et. Al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Which of the following would be most appropriate to stress
in advising the patient about going for formal hearing
evaluation?
A. Bilateral hearing aids may significantly help with speech
recognition.
B. Newer, "hidden" in-the-canal hearing-aid models provide the
loudest amplification.
C. His prior experience with the older hearing aid means he will
do well with another one.
D. His wife should repeat misunderstood phrases more loudly
Post-test question 2
Which of the following is the most appropriate
device for an older patient who is primarily
homebound and has a severe bilateral, symmetric
sensorineural hearing loss; moderately severe
rheumatoid arthritis of the hands; and a strong
desire to minimize health care costs?
A. Body-worn hearing aid
B. Behind-the-ear hearing aid
C. Hard-wired system such as a Pocket Talker
D. Completely in-the-canal hearing aid
E. In-the-ear hearing aid
Post Test 1
Correct Answer: A. Bilateral hearing aids may significantly help
with speech recognition.
Use of hearing aids remains an underutilized rehabilitative
strategy for many elderly persons who otherwise might gain
important health benefits from some form of amplification.
Men typically underestimate both the degree and the
consequences of their hearing impairment. Reinforcement by
the physician of the need to improve poor hearing is an
important step. Speech discrimination is one of the most
important benefits than can result from binaural amplification.
While doubling the cost, two aides may jointly allow a lower,
more tolerable level of amplification with better overall speech
perception due to an improved signal-to-noise ratio.
The most appropriate type of hearing aid for a
patient is best determined after audiologic
assessment. The latest technology features very
small units placed inside the auditory canal with
only a small "tail" used for retrieval. Such units are
appealing cosmetically; however, they require
considerable manual dexterity to operate and are
easily lost, a recurring problem for this patient. In
addition, a person's prior successful use of one type
of hearing aid may not predict how well he will
tolerate new types of amplification devices.
Altered speech is rarely an effective way to improve
overall speech recognition in a hearing-impaired
person because it distorts the facial expressions,
intonations, and nonverbal cues. Most meaningful
portions of speech are contained in higher-pitch
consonant sounds. As these higher frequencies are
often missed with the common causes of hearing
loss in older age (eg, presbycusis), repeating the
exact phrases initially missed by the hearing-
impaired person is often not effective. A better
strategy is to attempt to rephrase the statement
using words that sound different but convey the
same meaning.
Post Test 2
Correct Answer: C. Hard-wired system such as a Pocket
Talker
Feedback:
The major complaints of persons with presbycusis are
difficulty hearing in noisy environments and when the
speaker is at a distance. Hearing assistive devices,
rehabilitative technologies, or assistive technologies are
devices that improve communication efficiency in quiet,
noisy, and reverberating environments when hearing aids are
not appropriate or are not sufficient. To explain, the intensity
of the desired signal relative to the intensity of background
noise is referred to as the signal-to-noise ratio. The more
favorable the ratio, the better speech understanding. A well-
recognized strategy for improving speech recognition in
rooms is the use of personal room amplification systems or
hearing assistive devices.
A hard-wired system is a device wherein a wire connects the
microphone of the speaker to the amplifier and the amplifier
to the receiver used by the listener. Thus, there is a direct
physical connection or hard wiring between the sound
source and the individual. These devices have proven
beneficial for persons who cannot manage hearing aids
because of manual dexterity problems or dementia. Some
advantages include their inexpensiveness, their helpfulness
for patients who cannot use hearing aids, their utility in
physicians' offices to ease communication with hard-of-
hearing patients, and their ease of connection, use, and
purchase. A body-worn hearing aid would be a poor choice
for this patient. These devices are presently limited in their
availability; in addition, they are bulky and too costly for the
person described in the case.
Behind-the-ear hearing aids (analog, programmable, or
digital) are excellent for active older adults with severe
sensorineural hearing loss who have significant
communication demands and who can afford the device. This
patient is unlikely to be able to manipulate such a hearing aid
comfortably and would likely find such a choice too
expensive. Completely in-the-canal and in-the-ear hearing
aids are excellent for persons with significant communication
demands or severe hearing loss, but they, too, are too costly
for persons on a limited income and too difficult for persons
with manual dexterity problems to manipulate
independently. Medicare does not pay for hearing aids. The
average price of traditional units in 1999 ranged from $782
for an analog nonprogrammable behind-the-ear unit (the
most simple) to $1270 for an analog nonprogrammable
completely in-the-canal unit to $2673 for a completely in-
the-canal unit that is digital signal-processing programmable.
The clinician must consider a host of factors, both audiologic
and nonaudiologic, when recommending hearing aids for a
particular patient. End
References
Brenda K. Keller, MD, Geriatrics and Gerontology
University of Nebraska Medical Center
