Int Ophthalmol

DOI 10.1007/s10792-016-0247-y

ORIGINAL PAPER

Comparison of distance and near visual acuity in patients

with vision loss due to cataract
Carmel L. Mercado . Pavle Doroslovački . Jiangxia Wang .
Aazim A. Siddiqui . Andrew F. Kolker . Richard J. Kolker

Received: 12 December 2015 / Accepted: 3 May 2016

Ó Springer Science+Business Media Dordrecht 2016

Abstract The purpose of this study was to assess
whether there is a disparity in distance and near best-
corrected visual acuity (BCVA) in cataract eyes. 102
patients with cataract (N = 121 eyes) were seen in
clinic between January and November 2013 at the
Wilmer Eye Institute Comprehensive Eye Service. An
age-related macular degeneration (ARMD) group
(N = 27 eyes) was also identified for comparison.
Distance and near BCVA were measured as part of the
standard ophthalmic evaluation. Snellen measure-
ments were converted to their LogMAR equivalents
for statistical analysis. Near was better than distance
BCVA with mean difference of 1.38 lines (P \ 0.001)
in the cataract eyes. This disparity was not seen in the
ARMD eyes. Near–distance BCVA disparity is a
statistically significant finding seen with cataracts.
C. L. Mercado
P. Doroslovački
J. Wang

A. A. Siddiqui
R. J. Kolker
Wilmer Eye Institute, Johns Hopkins University, 1800
Orleans Street, Baltimore, MD 21287, USA
C. L. Mercado
P. Doroslovački
J. Wang

A. A. Siddiqui
R. J. Kolker (&)
The Wilmer Eye Institute, The Johns Hopkins Hospital,
600 North Wolfe Street, Maumenee 327, Baltimore,
MD 21287, USA
e-mail: rikolker@jhmi.edu
A. F. Kolker
Department of Ophthalmology, George Washington
University, Ambulatory Care Center 2150, Pennsylvania
Avenue Suite#2A, Washington, DC 20037, USA
This may have further implications in patients with
both cataract and ARMD as the presence of disparity
may suggest a cataract etiology playing a greater role
in vision loss. This comparison may be useful for
surgical prognostication and as a quick triage tool in
conjunction with, or in place of, a potential acuity
meter and dilated near-pinhole test.
Keywords Cataract
ARMD
Macular
degeneration
Vision acuity screen
Introduction
Cataracts are among the most common conditions that
cause vision loss in older adults [1]. Moreover, it has
become increasingly common in the eye clinic to see
older adults with both cataracts and coexisting retinal
disease like age-related macular degeneration
(ARMD). When a patient with both cataract and
retinal disease comes into the clinic with visual
decline, the clinician must discern whether it is the
cataract, the retinal disease, or a combination of the
two conditions that is affecting the patient’s vision.
This distinction is important as vision loss due to the
presence of cataract is easily reversible with surgery.
Trans-illuminated Amsler grids, entoptic imagery,
interferometers, and electrophysiological tests have
been used to assess the relative contribution of retinal
disease to decreased visual acuity in the setting of lens

123

Table 1 Clinical characteristics of study patients
Characteristics Cataract
By patient, N 82
Age, mean (SD; range) 75 (8.9; 50–95)
Female gender, N (%) 44 (54 %)
White race, N (%) 74 (90 %)
By eye, N 121
Distance BCVA, median 20/30 (20/25–20/40)
(25th percentile–75th percentile)
Near BCVA, median 20/25 (20/25–20/20)
(25th percentile–75th percentile)
* P value from Student’s t test
** P values from Fisher’s Exact tests
*** P values from Kruskal–Wallis equality-of-populations rank tests
opacity [2]. Today, the two most common methods of
assessing retinal function in patients with cataracts are
testing with the potential acuity meter (PAM) [3] and
the potential acuity pinhole test, more commonly
known as the ‘‘dilated near-pinhole’’ test [4]. Both
tests have their disadvantages. The PAM is a relatively
expensive instrument that requires dilation, additional
training, and several additional minutes per patient to
set up and use. While very convenient, simple, and
readily available, the dilated near-pinhole test also
requires dilation and is highly dependent on proper
patient instruction and reading distance.
We have clinically observed that eyes with
cataract tend to have a better near than distance
best-corrected visual acuity (BCVA). As the assess-
ment of near and distance BCVA is a fundamental
part of the basic ophthalmic examination, we
surmised that near–distance BCVA disparity could
be useful as a screening method in conjunction with,
or in place of, a PAM and dilated near-pinhole test
for assessing the contribution of a cataract to a
patient’s vision loss. Herein, we compared statisti-
cally the clinical observation of near–distance
BCVA disparity seen in cataract eyes.
Methods
Appropriate Institutional Review Board (IRB)
approval was obtained for this retrospective chart re-
view study. This study was HIPAA compliant and
123
Int Ophthalmol
ARMD Total P value
20 102
81 (6.5; 71–94) 76 (8.8; 50–95) 0.004*
12 (60 %) 56 (55 %) 0.80**
19 (95 %) 93 (91 %) 0.69**
27 148
20/50 (20/30–20/80) 20/30 (20/25–20/40) \0.001***
20/30 (20/25–20/100) 20/25 (20/30–20/20) \0.001***
adhered to the tenets of the Declaration of Helsinki.
Patients with cataract who were seen for follow-up by
one ophthalmologist (RJK) at the Wilmer Eye Institute
Comprehensive Eye Service between January and
November 2013 were identified. A small group of
patients with ARMD was also selected for a compar-
ison group. Inclusion criteria included the presence of
cataract or ARMD causing a reduction in vision
(distance BCVA of 20/25 or worse). Exclusion criteria
were the presence of coexisting cataract and ARMD,
ocular disease other than cataract or ARMD judged to
be affecting vision, and age less than 18 years. Best-
corrected distance and near acuity were determined for
each patient as part of the standard evaluation.
Distance acuity was assessed with Snellen letters at
20 feet, and near acuity was measured with a Jaeger
near-point test card at 14 in. Jaeger units were
converted to Snellen equivalent using the equivalen-
cies reported on the Rosenbaum near-vision screening
card. Patient cataracts were classified based on the lens
opacities classification system III [5]. The AREDS
system of classification was used for classification for
our ARMD patients [6].
We compared age, gender, race, distance BCVA,
and near BCVA between cataract and ARMD patients.
Student’s t test was used to compare the age between
the two groups. Fisher’s exact tests were used to
compare the categorical variables including gender
and race. Kruskal–Wallis equality-of-populations
rank tests were performed for comparing near and
distance best-corrected visual acuity. To test the
Int Ophthalmol
(A)
N Mean SD
LogMAR at near 121 0.16 0.21
LogMAR at distance 121 0.47 0.26
Cataract Line difference
between near and
distance 121 1.38
* P values are from Wilcoxon signed-rank tests.
(B)
Fig. 1 a Comparison of distance and near BCVA in cataract
eyes. P value for LogMAR values tests whether the near and
distance LogMAR are equal. Since it is less than 0.001, it means
they are not equal. Summary stats show that near vision is better.
P value for line difference between near and distance tests the
hypothesis whether the near distance and near difference are one
line. Since it is smaller than 0.05, it means it is different, which is
consistent with the median difference of 1 line and mean
difference of 1.38 lines. b Boxplots for near and distance
LogMAR of ARMD and cataract patients. The darker boxes
hypothesis that cataract patients have better near
vision than their distance vision, Wilcoxon signed-
rank tests were used to compare the near and distance
LogMAR. These tests account for the fact that for each
patient a near vision was paired with a distance vision.
Wilcoxon signed-rank tests were also used to test
whether the disparities were different from a one-line
difference or not. A P value of 0.05 or less was
considered statistically significant. All data were
analyzed using STATA software version 13.1 (Stat-
Corp, College Station, TX).
Median Min. Max P value*
0.22 0 1.61
<0.001
0.41 0.22 1.25
1.04 1 -2 4.5 <0.001
represent distance LogMARs and the lighter ones represent
near. The lines in the middle of the box are medians and the ends
of the whiskers are the most extreme values within 75th
percentile (plus 1.5 times the inter-quartile range) and the 25th
percentile (minus 1.5 times the inter-quartile range), respec-
tively. In contrast to cataract group which has statistically
significant difference in near and distance BCVA, ARMD group
here graphically was shown to not have statistically significant
disparity
Results
In total, 102 patients with cataract (N = 121 eyes) or
ARMD (N = 27 eyes) were identified, for a total of
148 eyes. The clinical characteristics of the study
patients are summarized in Table 1. Although data on
the grade of cataract or ARMD were collected, these
were not used in the final analysis or for subgroup
analysis due to the relatively small sample size.
In the cataract group, near was better than distance
BCVA with a mean difference of 1.38 lines
123

(P \ 0.001). This disparity was not seen in the ARMD
eyes. These data are summarized in Fig. 1.
Discussion
The purpose of this study was to assess whether there
is a statistically significant disparity in distance and
near BCVA in cataract eyes as has been previously
observed in the clinical setting. This study shows that
statistically cataract eyes have significantly better near
than distance BCVA. While the exact mechanism for
this disparity remains to be elucidated, the progression
of a cataract is thought to in part improve near BCVA
by increasing the dioptric power of the lens, resulting
in a myopic shift.
Some shortcomings of our study include the
relative homogeneity of our patient population, which
may limit the applicability of our findings to other
populations. Further directions for this study would
include assessment of the effects of the type and grade
of cataract on near–distance BCVA disparity. More-
over, while we did use a small ARMD group as a
comparison group, evaluation for near–distance
BCVA disparity in other retinal diseases may provide
more insight regarding the generalizability of our
study findings.
Conclusion
A statistically significant difference in near and
distance BCVA in cataract eyes implies that compar-
ison between near and distance BCVA may be useful
as a simple and inexpensive screening method in
patients with decreased vision to identify who may
benefit from further cataract evaluation. This method
has particularly profound implications in patients with
both cataract and retinal disease as the presence of
disparity may suggest cataract etiology playing a
greater role in vision loss and could aid in surgical
prognostication. When near acuity is better than
distance, the diagnosis of visually significant cataract
123
Int Ophthalmol
is more likely. In addition, given that our method does
not require dilation or anything more than basic
refraction, it may be useful in resource-poor settings,
clinics in developing countries, or during triage
situations in which a PAM or other diagnostic testing
is unavailable.
Acknowledgments We thank JianTian, MS, of the Wilmer
Eye Institute, Johns Hopkins University, Baltimore, MD, for
assistance with parts of the statistical analysis.
Compliance with ethical standards
Conflict of interest The authors declare that they have no
conflict of interest.
Ethical approval All procedures performed in studies
involving human participants were in accordance with the eth-
ical standards of the institutional and/or national research
committee and with the 1964 Helsinki declaration and its later
amendments or comparable ethical standards. As this was a
retrospective study, formal consent was not required.
References
1. Congdon N, O’Colmain B, Klaver CC, Klein R, Munoz B,
Friedman DS, Kempen J, Taylor HR, Mitchel P, Eye Diseases
Prevalence Research Group (2004) Causes and prevalences
of visual impairments among adults in the United States.
Arch Ophthalmol 122(4):477–485
2. McGraw PV, Barrett BT, Whitaker D (1996) Assessment of
vision behind cataracts. Ophthal Physiol Opt 16(suppl
2):S26–S32
3. Minkowski JS, Palese M, Guyton D (1983) Potential acuity
meter using a minute aerial pinhole aperture. Ophthalmology
90:1360–1368
4. Melki SA, Safar A, Martin J et al (1999) Potential acuity
pinhole: a simple method to measure potential visual acuity in
patients with cataracts, comparison to potential acuity meter.
Ophthalmology 106:1262–1267
5. Chylack LT, The Longitudinal Study of Cataract Study
Group et al (1993) The lens opacities classification system III.
Arch Ophthalmol 111:831–836
6. Age-Related Eye Disease Study Research Group (2001) The
Age-Related Eye Disease Study system for classifying age-
related macular degeneration from stereoscopic color fundus
photographs: the Age-Related Eye Disease Study Report
Number 6. Am J Ophthalmology. 132(5):668–681