Professional Documents
Culture Documents
Eye Anatomy
Eye Examination
Patient History
A good examination of the eye consists of three steps, and the examination should be done in
this order:
1. Patient History
2. Checking Vision
3. External Examination
As health workers you are already familiar that the patient history is important because it
can help you to identify the problem and help you to make a diagnosis and make the proper
treatment plan. The patient history always comes first. Even when you need to act quickly, such
as in the case of an accident or injury, you need to find out the cause of the accident before you
begin examination or treatment. The patient history for eye problems is about the same as the
patient history for other health problems. A basic outline for a patient history is as follows:
What is the problem/complaint?
How long have you had this problem?
Did it start suddenly or gradually?
What does the eye fell like (pain, itch, burning, sensitive to light, etc?)
Is there any change in vision?
Is the problem getting better or worse?
Did you try any medicine or treatment already? (What did you try?)
The patient history is about the same as a patient history for other health problems. One
important thing to remember about the eyes is that each eye is a separate patient and the history
for one eye may not be the same as the history as the other eye.
You want to record the reason that the person is coming for the eye examination in the
medical records. You also want to document any important information you get from the patient
history. You do not need to write down everything that the patient tells you, but you need to
make sure that your notes in the medical record have enough information that if another medic is
following up on your patient, they will understand what is going on.
Checking Vision
To check vision you need to use an eye chart. There are many kinds of eye charts. Look
carefully at the eye chart that you have available to use. On the chart there will be instructions
about what distance to use. Most charts are made to be used at 6 meters. Some charts are
made to be used at 3 meters. Here are the important steps in checking vision.
Preparing
Chart must be placed at the proper distance, with good light and no glare. It is
best to put the chart about the same height as the eyes. If the chart is too close, it is too easy to
see the letters. It the chart is too far, it is too difficult to see the letters.
Instructing
Explain to the patient that you need to determine what the vision is like in each
eye. Instruct the patient to point their finger in the same direction as the E that you point to on
the chart. If the patient does not understand, you can bring them close to the chart and show
them how the E points in different directions.
Testing
Test the vision EYE BY EYE. Check the right eye first. Do not block the view of
the chart with your body or with your pen or pointing stick.
Recording
Record results eye by eye in the medical record. Write a large V with an R and
an L to indicate right and left eye. Put the best vision measured for the right eye next to the R.
Put the best vision measured with the left eye next to the L. The vision is the number next to the
smallest line that the patient can see clearly. To record the vision you can write like this:
R 20/50
L 20/30
Eye Chart
Some charts will use different kinds of numbers for measuring vision. The charts used in
this program will use 20 measurements, which is the most common measurement for vision.
Some charts will use numbers like6/6, 6/12, 6/18 etc. or numbers like .9, .8, .5, etc. Some charts
will use English letters, numbers, letters from other languages, or pictures to measure vision.
Because you want to check the vision EYE BY EYE, the eye that you are not testing needs to be
covered. When checking vision, check the vision of the right eye first. To do this you must cover
the left eye. The patient can cover the left eye with their hand. Have them cover the eye with the
palm of their hand. They should not cover their eye with the fingers of their hand.
Pinhole Test
Pinhole testing is another way to check vision. Pinhole testing is useful because it can
help you to decide if bad vision is due to needing eyeglasses, or if bad vision is due to a health
problem inside the eye. If the vision is normal, you do not need to do the pinhole test. Vision that
is 20/40 or better is normal. We do the pinhole vision test the same was that we do the regular
vision testing. The only difference is that we must put the pinhole in front of the eye that we are
checking.
If the vision is bad, the cause of the bad vision might be because the patient needs
eyeglasses, or might be because there is another problem with the eye. If there is a problem on
the outside of the eye, we can usually determine this from the external eye examination.
Sometimes there is a problem inside the eyeball, but we do not have special instruments to look
in side the eye. Doing the pinhole test in cases of bad vision can help us to decide if the patient
should be referred for eyeglasses or other problems.
If the vision improves when looking through the pinhole, then at least part of the problem
is because the patient needs eyeglasses. If the vision does not improve when looking through
the pinhole, then eyeglasses may not help and there may be another problem.
We write the results of the pinhole test the same way that we write the results of the
regular vision test, only we add the note pinhole under the V:
R 20/40
L 20/30
Pinhole
Even if you do not have an eye chart to check the vision, the pinhole test can be used. Have the
patient look through the pinhole and ask them if their vision is better with the pinhole, or better
without the pinhole.
External Examination
After you have taken the patient history
and have checked the vision, you will
need to do an external examination of
the eyes. Before touching the patient
or the patientCs eye, you should always
wash your hands. Washing your hands
will help prevent the spread of infection.
You will actually start examining the eyes during the patient history. When you are
taking the patient history, sit or stand in front of the patient and look at the eyes. Do the eyes
appear normal and healthy as you sit or stand across from the patient during the patient history?
When you are ready to take a close look at the eyes, you will need to have good light. If
you have a good torch, you can examine the eyes by using the light of the torch. If you do not
have a good torch, you will need to use sunlight to examine the eyes. If you do not have a torch,
you will want to move the patient next to a window, a doorway, or take the patient outside in the
patient next to a window, a doorway, or take the patient outside in the sunlight to examine the
eye.
Another thing to remember about to external examination of the eye is to get close to the
eye. If you are one or two meters away from the patientCs eyes, you cannot see the details of the
eye well enough to know if they are normal or not. Do not be afraid to get very close to the
patients eye. The closer you are to the eye, the easier it is to see small details. What you want to
determine with the external examination is if the eye looks normal and healthy.
You want to look at each part of the eye carefully. You want to check to see if everything
looks normal or not normal. Start with the general appearance. Is there any redness. Swelling or
discharge around any parts of the eye?
Are the white parts of the eye white? Do the eyelids look normal and open and close
normally? Do the eyelashes look normal? The eyelashes should always point out, away from the
eye. Is there any crust or discharge around the eyelashes or at the edge of the eyelids?
Come closer to the eye and look at the cornea. Is the cornea clear? Is the cornea wet
and shiny? (Remember - a wet cornea is a happy cornea!) Do the iris and pupil look normal?
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Once the eyelid is up, you can keep it in place by using your finger or thumb. Hold the
lid up by the lashes, not by the conjunctiva in side the eyelid. You want to avoid holding up the
eyelid by the conjunctiva because you want to be able to see all of the conjunctiva and because
you want to avoid touching a conjunctiva that might be infected. Look very carefully at the
conjunctiva under the eyelid.
Examining Children
Examining the eyes of small children can be difficult. To examine small children, wrap
the child in a cloth or blanket. Have the mother hold the child on her lap, with the head of the
child on your lap.
Trachoma
Cause of trachoma
Trachoma is an infection that occurs in the eyelid and is caused by the Chlamydia
organism which is closely related to bacteria. It is one of the leading causes of blindness in the
world. Trachoma spreads very easily from one person to another person.
There are many ways to spread the trachoma infection. We can reduce the amount of
trachoma and prevent the spread of the infection by learning how this infection is spread.
Discharge from the eye can carry the trachoma infection. If you have trachoma, you can rub
your eye with a cloth, and then another person rubs their eye with the cloth, the trachoma
infection can spread to the other personCs eye. If you rub your eye with your hand and then touch
another personCs hand, then the other person rubs their eye with their hand, the trachoma
infection can spread. Some types of flies like to land near the eye. These flies can spread the
trachoma infection from one eye to another personCs eye. People who play close together or
sleep close together can spread to trachoma infection easily by direct con tact or by bed cloths
such as sheets or pillows.
Diagnosis of trachoma
Sometimes people with trachoma will have red eyes and may look like they have
conjunctivitis. Sometimes the eyes will be itchy and there may be mild watery discharge.
Sometimes there are no symptoms at all. The only way to know for sure is to look carefully
underneath the top eyelid. You must look underneath the top eyelid of any person who
complains about eye problems.
1. The first sign you will see in the trachoma infection is the presence of follicles, or small bumps
underneath the top eyelid. These small bumps are white or yellow. If you have five or more
follicles in the middle part of the top eyelid, you can make a diagnosis of trachoma. We can
abbreviate this stage of the trachoma infection as TF, for trachoma with follicles.
TT (Trichiasis)
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Co (Corneal Opacity)
Removing Eyelashes
To pull out eyelashes, you need to have good light. If you do not have a good
torch, use sunlight. To be safe, you should have the patient lie down on a bench and keep
children and other people away who may disturb you. You do not want anyone to bump into you
when you are pulling the eyelashes.
To pull eyelashes out of the top eyelid, you will want the patient to look down so
that the cornea is safely out of the way when pulling the eyelashes. If you are pulling lashes from
the lower lid, you will want the patient to look up. With tweezers, pull from as near the base of the
eyelash as you can. It is better to put gently and steadily that it is to pull fast. If done well, the
patient will not feel anything. Tweezers with a wide tip generally are better to use than tweezers
with a small pointed tip.
Prevention of Trachoma
Trachoma is the leading cause of preventable blindness in the world. Trachoma
can be prevented by improving personal, family and community hygiene. Washing the hands
and face every day in very important in preventing trachoma. Families need to understand that
making sure the children wash hands and face every day will help prevent the spread of
trachoma. When you see trachoma in a child, you should suspect that the trachoma infection
might be in other children in the same house. You should ask to see all the brothers and sisters
of the child with trachoma so that you can treat all who are infected and give instructions
regarding improving hygiene.
Treatment of Trachoma
TF (Trachoma with follicles) and TI (Trachoma with inflammation)
1. Give four tubes of terramyacin ointment (tetracycline) to be used four times a day in
both eyes. Return to clinic after ointment finished for re evaluation. (May need
another round of treatment.)
2. Eyes and face to be washed four times a day (before putting in ointment). Discuss
importance of good hygiene with patient and family.
3. Examine all members of the family of the trachoma patient. Treat all with signs of
active trachoma infection, consider treating entire family if you have enough ointment,
even if signs of infection not present.
Xerophthalmia
Vitamin A deficiency and Xerophthalmia
Your eyes and your body need vitamin a to stay healthy. Without vitamin A, you
can go blind or die. Vitamin A is also needed to help children grow. The eye is the only place
that you might see signs of vitamin A deficiency. It is possible to have vitamin A deficiency and
to look normal and healthy. Xerophthalmia is the name of the eye problems that are associated
with vitamin A deficiency.
Diagnosis of Xerophthalmia
Without vitamin A, you will not see very well at night. This is called night
blindness. Sometimes people will have a special way to say this, such as saying a person has
chicken eyes. Night blindness is often the first sign of xerophthalmia. A mother may notice that
her child is not very active and does not want to play like the other children as it is first starting to
get dark. If a mother reports this to you, assume vitamin A deficiency.
The next stage of xerophthalmia is dryness of the conjunctiva. The eye needs
vitamin A to stay wet. When there is not enough vitamin A, The tear layer will not be able to keep
the conjunctiva wet as usual. The conjunctiva and maybe the conjunctiva will also look old and
have a brown color. To diagnose this stage, you need to look carefully for an area of the
conjunctiva that does not stay wet after blinking.
BitotCs spots are the next sign you will see in xerophthalmia. BitotCs spots are
bubbles or foam on the conjunctiva. These spots will usually appear close to the cornea. They
might be white or gray or other colors. Sometimes you can remove part of the foam with a cotton
bud.
Dryness of the cornea is the next stage of xerophthalmia. It is easy to see if the cornea becomes
dry as it does not reflect light well and does not look smooth.
If the cornea stays dry too long, it is in danger of getting infections from bacteria
or viruses. These infections are called corneal ulcers. If the cornea stays dry a long time, it can
start to become thin and develop holes. When the cornea becomes thin, we call this
keratomalacia. When there are corneal ulcers or keratomalacia, the eye can suffer permanent
vision loss.
When the cornea heals, there will be scarring on the cornea and it will not be
clear. The corneal scars are what cause blindness in vitamin A deficient eyes. Cornea scars are
permanent and are not a sign of active vitamin A deficiency.
The Stages of Xerophthalmia
1. Night Blindness
2. Conjunctival dryness (conjunctival xerosis)
3. BitotCs spots
4. Corneal dryness (corneal xerosis)
5. Corneal ulcer / keratomalacia
6. Corneal scarring
Vitamin A deficiency can last a long time and slowly cause damage to the eye.
Sometimes there can be vitamin A deficiency and the eye shows only a little drying and maybe
no damage will occur. Sometimes when there is Vitamin A deficiency, if the child gets sick from
other causes, the eye signs can become rapidly worse and the eye can go blind in just a few
days.
Vitamin A deficiency can occur in anybody, but usually it will be in small children.
Most of the time those who suffer from vitamin A deficiency will be between one and six years
old. Most babies who are breast feeding will not have a problem with vitamin A deficiency as
breast milk contains vitamin A.
Treatment of Xerophthalmia
Treatment for Vitamin A Deficiency
All active forms of xerophthalmia, children age 1 year or more give
Day 1 200,000 IU
Day 2 200,000 IU
Day 8 200,000 IU
For child less than one year old (6 months - 12 months)
Day 1 100,000 IU
Day 2 100,000 IU
Day 8 100,000 IU
Children who are very sick (measles, severe diarrheas, respiratory tract
infections) and live in laces where xerophthalmia occurs, should be treated for xerophthalmia.
Children with corneal ulcer should also be treated for xeropthalmia, even if other signs of
xerophthalmia are not seen.
For treatment of women of reproductive age give
10,000 IU daily for two weeks
(or 25,000 IU once week) for 8 weeks
Prevention of Xerophthalmia
Children with vitamin A deficiency get sick easier than children who do not have
vitamin A deficiency. Of the children who are seriously ill, the children who have vitamin A
deficiency. This is especially true when the child is sick with measles, severe diarrheas or
respiratory tract infections. Preventing vitamin A deficiency not only keeps children from going
blind, but also keeps children healthier and helps children to be less likely to die from serious
illnesses.
Distributing vitamin A capsules to each child every six months is one way to
prevent vitamin A deficiency. This takes work and good record keeping. Even when vitamin A is
distributed this way, you need to be concerned about vitamin A deficiency. There are always
children absent when vitamin A is distributed and there may be new children in the area that you
do not know about.
Prevention for Vitamin A deficiency
Children 6 months to 1 year 100,000 IU every 4-6 months
Children 1 year and up
100,000 IU every 4-6 months
Newborn
50,000 IU at birth
Women child bearing age 200,000 IU within 1 month of birth
To avoid vitamin A deficiency in your camp or village, you need to encourage
people to eat green vegetables and orange or yellow fruit. These kinds of food are good sources
of vitamin A and should be eaten daily. Eggs and liver are also good sources of vitamin A.
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Use of Vitamin A
Anytime that you give vitamin A, you must document the DATE and the DOSE
given on the patientCs medical record. Before giving vitamin A, check the patientCs medical
record to see if vitamin A has been given recently. This is very important. Too much vitamin A
might be been approved by WHO as being safe.
When you treat for vitamin A deficiency, the eye signs such as dry conjunctiva
should usually disappear in a few weeks. Night blindness might even go away in a few days.
Sometimes BigotCs spots may go away go away more slowly, maybe months. Because it may
take for the signs of exophthalmia to go away after treatment, there is a chance that another
medic will see the patient, diagnose exophthalmia and decide to give vitamin A. If you did not
document your treatment with vitamin A or if the other medic does not check the medical record
carefully, there is a danger of giving too much vitamin A.
The strength of vitamin A is given in International Units (IU). Look carefully at the
label on your vitamin A bottle. Check the dose carefully. You must calculate your dose correctly.
Most of the border area uses 25,000 IU vitamin A capsules. There are some areas that have
50,000 IU tablets and some areas that have 20,000 IU capsules. In the future, we hope to have
200,000 IU vitamin A capsules. Much other strength is available.
If using 25,000 IU capsules, 8 capsules = 200,000 IU
Cataracts
Cataract is the leading cause of blindness in the world. A cataract is cloudiness
in the lens inside the eye. When you get older, the lens becomes less clear. This happens
naturally because of age and age related cataracts are the most common type of cataracts.
Other factors such as exposure to sunlight, general health, history of smoking, diabetes, use of
drugs such as steroids, and dehydration can all help cataracts to develop in people who are not
yet old. Cataract can also develop after trauma. Occasionally, cataracts are present at birth.
The lens needs to be clear or light cannot pass through the eye to the retina. As
the cataract develops and the lens becomes cloudy, vision is reduced. In very severe cataracts,
the patient cannot see anything. To see a cataract, you have to look very carefully in the pupil.
The pupil should be black. If you see grey or white in the pupil, then you are probably seeing a
cataract.
Unfortunately, cataracts are not treatable with medicines. Surgery is the only
care for cataracts. It might be possible to delay the development of cataracts by eating well,
staying healthy, not smoking and avoiding sunlight exposure to the eyes by wearing wide
brimmed hats, glasses or sunglasses.
Name
Age Sex
Address
Diagnosis
Glaucoma
We are learning about glaucoma because
1. It is one of the leading causes of blindness in the world
2. We have seen a lot of cases of blind eyes from glaucoma on the border
This course if for advanced students and is not included in the primary eye care course because
1. The diagnosis of glaucoma can be very difficult
2. We do not have the drugs needed to treat glaucoma in the camps
3. Glaucoma is not preventable
The Learning Objectives for Reading this Lecture are
To know there are several types of glaucoma
To know the importance of the aqueous humour and the angle in glaucoma
To know what the normal range of pressure in the eye is
To know the basic cause of open angle glaucoma
To know the clinical signs and symptoms of open angle glaucoma
To know the basic cause of closed angle glaucoma
To know the clinical signs and symptoms of angle closure glaucoma
To know how to recognize an eye that is blind from glaucoma
After some clinical skills practice, you also should be able
To know how to check the angle of the eye with a torch
To know how to feel if an eye has normal pressure or very high pressure
To know if peripheral vision is present or absent
To know how to treat in basic treatment and planning for referral system
Introduction to Glaucoma
Glaucoma is a word that is used to describe several different diseases of the eye. To make a
simplified statement, glaucoma is what happens when there is more pressure in side the eye
than the eye can tolerate safely.
In many cases, this means that the pressure in the eye is higher than normal. In few days, the
pressure in the eye is normal, but the eye cannot tolerate normal pressure. The most sensitive
area to pressure is the nerves at the optic nerve head. When there is damage to the optic nerve,
the eye will loose vision. If there is too much damage to the optic nerve the eye will become
blind.
Anatomy
To have a better understanding of glaucoma, we need to review some of the anatomy
and physiology of the eye. The aqueous humour is the fluid inside the eye that fills the anterior
chamber. The anterior chamber is the space between the lens and the cornea. The aqueous
comes into the eye through the ciliary body and is made from the clear serum of our blood. (See
drawings on the next page)
The eye makes new aqueous humour all of the time. We need fresh aqueous in the eye
because the aqueous provides nutrition to the lens and the inside layer of the cornea, which do
not have a blood supply. The pressure from the aqueous also helps to keep the shape of the
eye. If the eye were too soft, it would not keep its round shape and the optics of the eye would
not be correct.
The aqueous goes out of the eye through the Canal of Schlemn. This canal is all around
the eye and is located where the iris and the cornea and the conjunctiva meet. After going into
this canal, the aqueous re joins with our blood. We refer the place where the iris, cornea and
conjunctiva meet as the angle of the eye. If the angle is open, it means that there is enough
space between the iris and the cornea for the aqueous to reach the canal of Schlemn os it can
leave the eye.
If there is only a slight increase in the pressure of the eye, the patient may not have any
symptoms at all. If there is a mild increase in the pressure of the eye, there can be swelling of
the cornea tissue. This may cause the patient to experience halos around lights at night. This
may be the only symptom in some glaucoma patients. A halo around lights is like looking at the
moon on a night where there are a few clouds around the moon.
In some types of Glaucoma, there is a big increase in the pressure. If there is a big
increase in the pressure of the eye, the patient will usually feel pain or even severe pain around
the eye. There will be clinical signs when the pressure in the eye is very high.
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What you want to look at is the amount of shadow you see on the iris on the other side of
the pupil from the torch (as seen in the drawing above). The top example, you have no shadow
and the angle is completely open. In the second (middle drawing) example, you have a small
amount of shadow; the angle is open, but not 100% open. On the bottom drawing example, the
shadow covers most of the iris on the inside of the pupil. If the shadow is touching the pupil,
then the angle is closed. Below are two photographs of angles. Can you tell which one is open
and which one is almost closed?
The photo above on the left is an open angle. The white line shows you where the
shadow is. See how there is very little shadow on the iris on the opposite side that the light is
coming from. The photo above on the right is an angle that is closed or almost closed. The
white line showing the shadow almost touches the pupil. If the shadow does come to the pupil,
the angle is closed.
We then use the first fingers or the middle fingers of each hand to feel the eye
thought the closed eyelid. You can rest your third and fourth fingers on the forehead just above
the eye. You can also rest our thumbs on the cheek of the patient, just below the eye. Feel with
the fingers of both hands. Do not be afraid to press a little bit hard on the eye to get a good feel.
Compare the right eye to the left eye of the patient. This will not allow you to measure the
pressure in the eye accurately, but it might give you an idea if the pressure in the eye is near
normal or very high.
You should practice this several times on normal eyes, so that you will have an idea what
the pressure in a normal eye feels like. If you know what the pressure in the normal eye will feel
like, it will make it easier for you to feel when the pressure in the eye is very high.
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Conjunctivitis
The most common type of eye infection is conjunctivitis People will often say pink
eye or red eye. It is not always possible to know if conjunctivitis is caused by bacteria or a
virus or an allergy. Whenever you see a patient with conjunctivitis, be sure to look under the
eyelid for signs of trachoma. Trachoma and conjunctivitis can occur together.
Conjunctivitis caused by bacteria will respond well to the ointment and get better
in a few days. Bacterial conjunctivitis will often have a pus discharge.
Conjunctivitis caused by virus cannot be treated and the eye will have to get
better by itself. Viral conjunctivitis will ofte3n have a watery discharge. The ointment will make
the eye feel better and will prevent a secondary bacterial infection. Viral conjunctivitis will usually
take about a week to get better.
Conjunctivitis from allergies will feel better when using ointment, but the ointment
will not treat the allergy. Allergic conjunctivitis will often have a ropey or stringy discharge. The
allergy problems in the eye can be reduced by washing the eyes carefully. Allergic conjunctivitis
will often be worse during certain times of the year. It is usually not possible to determine what
the eye is allergic to.
Eyelid Infections
Stye
One type of eyelid infection is usually called a stye and looks like a bump on the
eyelid. The stye may come up on the outside of the eyelid or on the inside of the eyelid.
Sometimes this is an infection and can be treated with ointment. These styes develop quickly
and are often painful. Sometimes the stye is chronic, and will not go away with treatment. The
chronic stye may feel hard, like a stone. It may last for many months. It is possible to remove the
stone with surgery.
To treat a stye, have the patient use Terramycin ointment four times a day on the
stye and on the edge of the eyelid until two tubes are finished. The patient should also wash
carefully around the eyes each time before applying the ointment. Hot compresses may help
speed up the healing of a stye. Hot compresses can be used many times a day.
Blepharitis
Sometimes the edge of the eyelid will become infected. The edge of the lid, near
the lashes will look very red. Sometimes you will notice crust on the eyelashes. This is a
stubborn type of infection that may come and go many times. The patient should use Terramycin
ointment four times a day on the edge of the eyelids. The patient also needs to wash at the edge
of the eyelids, at least four times a day.
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Eye Injuries
When there has been an injury to the eye, your goal is to prevent infection. The
injury may have caused some damage to the eye, but often, an infection to the site of the injury
causes the most damage. When somebody comes to you with an eye injury, your first concern is
to clean the eye well. Your next concern is to make sure that there are no foreign bodies present.
Foreign bodies often stick to the cornea or to the conjunctiva underneath the eyelid. Always look
under the eyelids, both the top and bottom eyelids.
Very serious eye injuries should be referred. If you need to move the patient to
another location, you should place a shield over the eye to prevent additional injuries to the eye
during transportation.
2.
1.
3.
4.
1.
2.
3.
4.
5.
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You can photocopy or trace the letters of an eye chart. You can also draw your
own letters. The E in the eye chart is square. The height of the E is the same size as the width of
the E. The size of each arm and space between the arms is 1/5 of the size of the E. Here are
letter measurements for a 6 meter chart:
Letter size
E size
arm/space size
20/200
9.0 cm.
1.8 cm.
20/100
4.25 cm.
0.85 cm.
20/50
2.25 cm.
0.45 cm.
20/30
1.25 cm.
0.25 cm.
20/20
0.9 cm.
0.18 cm.
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