VISUAL ACUITY

Noeh O. Fernandez Jr., OD,

MATS

What is Visual Acuity?

A measure of the ability of patients

visual system to resolve fine detail
Sometimes the only measurement
of visual function made by the
clinician
Nearly the first measurement in the
examination sequence

What is 20/20 vision?

To Patients signifies perfect vision

To Clinicians good visual acuity
provides assurance of an adequate
spectacle correction
criterion for a persons fitness to
drive and ability to gain entrance
into some professions

Physiological Limits to
Visual Acuity

Physiological Limits of Visual

Acuity
1.
2.

Optical
Retinal

Optical Limits of Visual

Acuity

Spherical Aberrations of the cornea

and crystalline lens
Size of the pupil
- To large a pupil degrades the
images as a result of greater
spherical aberration
- To small a pupil degrade an infocus image by diffraction

Retinal Limits of Visual

Acuity

Photoreceptor spacing
- increase in photoreceptor spacing
leads to poorer visual acuity

THE EFFECTS OF LUMINANCE

AND CONTRAST

Visual acuity is relatively constant at

high luminances
Sheedy et al. found that over a
normal photopic range of 40 to 600
cd/m2, visual acuity varies by less than 1
line.
- within this range, doubling of the
luminance improves visual acuity by
approximately 1 letter in a 5 letter row
on the acuity chart

The effect of luminance and

contrast continue

As luminance is reduced, visual

acuity decreases and is
increasingly facilitated by the
retinal rods
Reducing letter contrast has a
similar effect on visual acuity

VISUAL ACUITY AND AGE

20/20 Vision is not inborn

Visual acuity at birth is on 20/200 and
improves rapidly with age in normal
developing eye
Visual acuity may approach adult levels by
the age of 6 months
Elliot et. Al found that visual acuity
decreased by approximately 1 line on the
letter chart across the 3rd and 6th decades of
life

UNITS OF MEASUREMENTS

Snellen Notation
Partial Credit
M Units
Decimal Acuity
Minimum Angle of
Resolution (MAR)
logMAR

Gratings and
Cycles per degree
Visual Efficiency
Scales
Notations for Poor
Vision

SNELLEN NOTATION

Usually expressed as a fraction

Numerator represents the distance
in meters or feet and the
denominator represents the letter
size
Letter size the distance at which
the overall letter height subtends 5
minutes of arc

PARTIAL CREDIT

When patient reads all of the

letters on the given line and then a
subset of the letters on the next
line
Using of superscripts (e.g. +2, -1,
+3 etc)

M UNITS

Merely represents the denominator

of the snellen fraction specified in
meters.
Use commonly in the
measurement of near visual acuity
40 cm (0.4 m)

DECIMAL ACUITY

Calculated by simply converting

the snellen fraction into a decimal
20/40 = 0.5
Higher number represents better
vision
Popular in europe

MINIMUM ANGLE OF
RESOLUTION (MAR)

Divide the letter size to the test distance

(as specified in the snellen fraction)
20/40 = corresponds to a MAR of 2
minutes of an arc
40 (letter size) / 20 (test distance) = 2
Reciprocal of the decimal acuity

logMAR

Logarithm of the
minimum angle of
resolution
Popularized by
Bailey,
codeveloper of
Bailey-Lovie chart
E.g. 20/40 = 0.3
(log 2)

VISUAL ACUITY RATING

(VAR)

Alternative of visual efficiency

scales
Formula:
VAR = 100 (50 X logMAR)
Use in Bailey-Lovie chart

NOTATIONS FOR POOR

VISION

Bring patients closer to the chart

or vice versa
Counting finger
Hand movement
Light Projection
Light Perception
NLP

CLINICAL MEASUREMENT
PROCEDURE

VA testing

Measured under controlled and

constant testing conditions
Test distance should be measured
Patient should be seated in the
examination room chair
Done first monocularly eye not
tested should be covered with an
occluder

VA testing cont

Read from top to bottom

Patient should be encourage to try he
next line and to guess if not sure
Stop when the patient has missed at
least half of the letters on the given line
Squinting indicates potential for
uncorrected refractive error
Low vision patient frequently adopt
unique head postures

Letter Chart Designs

Typical letter chart contain 10 lines of

letters or OPTOTYPES which decrease
in size from the top to the bottom
Why use letters?
They are familiar to the patient and
the response is verbalized
Stroke width and the space between
the letters are constant

Visual acuity

Typically measured at a test

distance of 20 feet or 6 meters
Other test distance is like 4 meters
with a correction of -0.25 D for
optical infinity

BAILEY-LOVIE logMAR
CHARTS

Adopted ten 5:4 aspect ratio

letters DEFHNPRUVZ which has
relatively equal legibility
Constant 5 letter in a line and has
a characteristic V shape
Frequently referred as logMAR
charts

BAILEY-LOVIE logMAR
CHART

Bailey-lovie derivative
charts

ETDRS Chart
- 5:5 apect ratio
- (CDHKNORSVZ)
logMAR Chart
Illiterate E version
of the Bailey-lovie
chart

Pediatric Charts and

Special Populations

Landolt Cs and Tumbling

Es

Landolt C consist
of series of charts
with aspect ratio of
5:5 in four or eight
orientation
Tumbling E
employs a series of
Es with an aspect
ratio of 5:5 in four
orientations

Other Charts for Pediatric

patients

Glasgow Acuity charts

STYCAR test
Sheridan-Gardner test
HOTV chart

LETTER AND SYMBOL TEST

Lighthouse Chart (lighthouse NY)

LEA symbols (Precision vision)
- this tests are more fun or children

POINTING TEST

1.

2.

Test that requires the child to compare

two shapes or pictures and point at the
one that contains a particular feature
Broken wheel test depicts two cars, one
of which has complete wheels, the other
incomplete wheels (resembles landolt C)
The Bailey-Hall Cereal Test consists of
pairs of cards, one which depicts a
Cheerio and the other a square
- Effective way of maintaining a childs
interest in any acuity test

PREFERENTIAL LOOKING
TESTS

Relies on childs preference to

fixate patterns over plain stimuli

ELECTROPHYSIOLOGICAL
TESTS

Vision Evoke Potentials (VEP)

measured by attaching surface
electrodes to the back of the
childs head

WHEN ALL ELSE FAILS

A childs extreme resistance to having

his or her right eye occluded can
indicate poorer vision in the left eye
Is the infant fixating centrally or
eccentrically? Is the fixation steady and
maintained, and can a child track a
moving target?
Measurement are purely qualitative but
can be observed
Recording = Fix and follow (F&F)

Near Visual Acuity

NVA

Determines whether the patients

near vision is adequate for
everyday needs
In patients of all ages, near visual
acuity is typically measured at 40
cm.

CHARTS FOR NEAR

TESTING

Bailey-lovie word reading chart

Reduced snellens chart
Jaegers chart

Reduced Visual Acuity:

What could It mean?

Refractive error
- Myopia
- rule of thumb = one line of visual
acuity loss corresponds to -0.25 D of myopia
- Astigmatism
- rule of thumb = one line of visual
acuity loss corresponds to -0.50 D of
astigmatism
- Hyperopia rarely presents reduction of
visual acuity

Reduction continue

- Hyperopia rarely presents

reduction of visual acuity.

PINHOLE ACUITY TESTING

Reducing the effective pupil size by

placing a pinhole in front of the eye
Enables the clinician to determine
whether the reduced visual acuity is due
to refractive error or to more serious
ocular pathology
If pinhole improves visual acuity, then the
cause is refractive error
No improvement suggest problem with
ocular media, retina, or optic nerve

OCULAR DISEASE

Clarity of the media should be

assessed quickly by observing the
light reflex with retinoscope or
ophthalmoscope
A bright orange reflex is a sign that
the media are clear.
Elderly population age-related
macular degeneration (1/2 of all
cases of vision loss)

OCULAR DISEASE CONT

In children, primary concern is AMBLYOPIA

Amblyopia reduced vision in the
presence of full optical correction and the
absence of ocular pathology
usually monocular and associated with
strabismus or anisometropia
Hysterical amblyopia or Malingering
may be due to emotional problems in the
case of a child

VISUAL ACUITY
STANDARDS

VISUAL STANDARDS

Retaining a drivers license 20/40

in at least one eye
Police and firefighters standard of
20/40 uncorrected visual acuity
Legal blindness is 20/200 in the
better eye with best correction

SUMMARY

Visual acuity is a quick and familiar

test that can provide valuable
information
Good visual acuity does not guarantee
an intact and healthy visual system
Clinicians should place a great deal of
emphasis on the patients presenting
visual acuities