Visual acuity (V.A.

)-definitions is defined as the ability to discriminate one object from another and to appreciate the details of objects. It is a measure of the smallest object that can be seen at a given distance. It is also the ability to resolve the details of an object by distinguishing spatially separated parts of that object. The minimum angle resolvable by the normal human eye is about 1 minute (min) of arc.

Why 1min of arc? Histologically, the diameter of the a cone in the foveal region is 0.004 mm representing the smallest distance between 2 cones In order to produce an image of minimum size of 0.004mm(resolving power of the eye), the object must subtend a visual angle of 1 minute at the nodal point of the eye This is called the minimum angle of resolution (MAR) Visual acuity The optotypesletters, numbers, pictures, etcused on standard visual acuity charts are constructed so that each section of the symbol subtends 1 min of arc, and the whole symbol subtends 5 min of arc Because the testing distance is fixed, the size of the objects on the chart are varied to reflect different levels of visual ability. The size is expressed as the reciprocal of the distance at which the letter subtends 5 min of arc (eg, the 6/60 letter subtends 5 min of arc at 60 m) and is written as the denominator. The numerator is the actual test distance,6m. Retinal images The retinal receptors are not exposed directly to light from the object, but rather to the energy distribution in the image formed by the eyes optical system. In dealing with visual acuity then, one has to specify the relativity between the objects and their retinal images. Components of Visual acuity (a) Minimum Visible This is the ability to determine whether an object is present or not (b) Minimum Resolvable or Ordinary Visual Acuity. Discrimination of two spatially separated targets is termed resolution. The minimum separation between the two points, which can be discriminated as two, is known as minimum resolvable Measurement of the threshold of discrimination is an assessment of the function of the fovea centralis and is termed ordinary visual acuity. e.g. Snellens letters, Landolts C. ( c )Minimum Discriminable or Hyperacuity Refers to spatial distinction by an observer when the threshold is much lower than the ordinary acuity Best e.g is vernier acuity, which refers to the ability to determine whether or not two parallel and straight lines are aligned in the frontal plane Prerequisite for Visual Acuity of 6/6 or better.

Good optical imagery Good foveal fixation Intact receptor structure and function Photopic luminance levels. Full integrity of the involved neural pathways TESTS OF VISUAL ACUITY MEASUREMENT OF V.A. IN CHILDREN Objection to occlusion Fixation- central, steady, maintained (CSM) Following of light Hundreds and thousands sweet test Preferential looking tests: Cardiff and Teller acuity cards Optokinetic nystagmus test Landolts broken C test Illiterate E test VA in preverbal children Hundreds and thousands sweet test Preferential looking with Cardiff cards Visual acuity tests in verbal children OPTICAL AXES AND VISUAL ANGLES Definitions The eye has 3 principal axes and 3 visual angles Optical axis (OR)- is the line passing through the centre of the cornea, centre of the lens and meets the retina on the nasal side of the fovea Visual axis (FM) is the line joining the fixation point (object of regard), nodal point and the fovea Fixation axis (FC)- is the line joining the fixation point and the centre of rotation Definitions Nodal point: This is the optical centre of the eye. It lies on the optical axis slightly in front of the centre of the eyeball and is adjacent to the posterior surface of the lens. Centre of rotation: This is the point around which the eye rotates. It is situated slightly behind the centre of the eye on the optical axis. It lies behind the nodal point. Visual angles Angle alpha- is the angle (ONF) formed between the optical axis and the visual axis at the nodal point (N) Angle gamma- is the angle (OCF) between the optical axis and fixation axis at the centre of rotation of the eyeball (C) Angle kappa-is the angle (ADF) formed between the visual axis (FM) and the pupillary line (AD). The point D on the centre of the cornea is considered equivalent to the centre of the pupil Clinical importance Only angle kappa can be measured and is of clinical significance Positive angle kappa results in pseudo-exotropia: normally the fovea is situated temporal to the posterior pole. The eyes are therefore slightly abducted to achieve bifoveal fixation causing a corneal reflex just nasal to the centre of the cornea in both eyes. When large, may stimulate an exotropia Negative angle kappa in pseudo-esotropia: fovea situated nasal to posterior pole. Here corneal reflex is situated temporal to centre of cornea. E.g high myopia JACKSON'S CROSS

CYLINDER INTRODUCTION This is a device used to refine the power and axis of the cylinder in a trial lens during refraction. HISTORY Strokes first invented the cross cylinder in 1849 but it was Edward Jackson who described its use for determining the power and later the axis of the connecting cylinder in a refraction. It can also be used to confirm the absence of a cylinder in refraction Spherocylindrical lens in which the power of the cyl is 2x the power of the sphere and is of opposite sign with their axes at right angles Uses Check axis of cyl prescribed Check power Verify that no cylindrical correction is required if no cyl was detected Axis of the JCC is at 45o to the axes of the cylinders and this is in line with the handle White slash-minus cyl, red slash-plus cyl The power of each cylinder lies at 90o to the marked axis and coincides with the marked axis (of no power) of the other cylinder (of opposite sign) Available in powers of +/- 0.25, +/- 0.50 and +/- 1.00 DC. Power used depends on pxs VA. VA 6/9 and better-0.25, lower vision-0.50,1.00 To check axis Insert the sphere and cylinder appropriate for the eye to be tested into the trial frame Occlude or blur the other eye Instruct px to look at 6/12 or 6/18 letter O ,U or C. Show the 2 views using JCC. Px should say which of them is sharper or less blurry Place JCC in front of trial frame with handle in line with the axis of the trial lens cylinder and px views thro-lens1. Do for lens2 Px chooses a position. The cylinder is held in this preferred position and the axis of the trial lens cyl is turned 10o towards the axis of the same sign on the JCC Repeat until the trial cyl is in the correct axis. At this point, both views give the same distinctness of image To check power After refining the axis, place the JCC so that the marking for the first cylinder eg the minus cylinder, is in line with the axis of the trial lens cylinder (Lens 1) Then twirl the lens so that the marking of the other cylinder now lies over the axis of the trial lens cylinder (Lens 2) If the clarity is unimproved in either of these positions the trial cylinder in the trial frame is correct If one position is clearer, eg the letters appear clearer when the plus cylinder was over the axis of the trial lens cylinder, add the power of the plus cylinder to the cylinder in the trial

frame eg if trial lens cyl is +1.00 x 90 add +0.50 (if +/- 0.50 JCC) to make + 1.50 x 90 or if 1.00 x 90, will be -0.50 x 90 Note As cyl power is altered, alter sphere power to maintain the same spherical equivalent of the refractive correction- to keep the circle of least confusion on the retina. This is achieved by changing the sphere as much in the opposite direction as the cylinder power is changed eg if cyl power increases by + 0.50, need to add -0.25DS to the sphere With this new combination continue refining until both views are the same To check for presence of astigmatism Apply the axes of the cross cylinders (first with one cylinder and then with the other) in line with first, axis 90o on the trial lens(sphere) then axis 180o then axis 45o then axis 135o If vision remains the same, there is no need for cylindrical correction If vision improves in any position, add the cyl with the equivalent power in the trial frame and check vision or clarity of letters again Conditions in which result of JCC may be unreliable Px does not understand the technique or is uncooperative Small pupils (2mm or less) Best VA 6/12 or worse Small degree of astigmatism PIN-HOLE PRINCIPLE The pin-hole theoretically allows only one ray from each point on an object to pass through to the screen. Thus, a clear image is formed regardless of the position of the screen. Likewise the use of the ideal pin-hole leads to the formation of a clear retinal image irrespective of the refractive state of the eye. Optics Clinical use In practice the pin-holes available clinically allow a narrow pencil of light to pass through them, rather than a single ray. in low degrees of refractive error the pin-hole's effect is sufficient to improve the clarity of the retinal image to such an extent that a good visual acuity results. errors outside the range +4 D to 4D sphere are not corrected to 6/6 with a pin-hole. STENOPAEIC SLIT Stenopaeic Slit can be used to determine the refraction and principal axes in astigmatism The slit aperture acts as an elongated 'pin-hole', only allowing light in the axis of the slit to enter the eye. Hence, when the slit lies in one principal axis of the astigmatic eye, the second line focus is eliminated and the blur of Sturm's conoid reduced thus allowing a clearer image to be formed Clinical use 1. During the refraction of a patient with astigmatism, the slit is first rotated to a position in which the clearest vision is obtained. Spherical lenses are added to give furtherimprovement in acuity. The slit is then rotated through 90 and the spherical lens power adjusted to give best subjective acuity. The cylindrical correction required by the eye equals the algebraic difference between

the two spherical corrections used, and its axis is that of the original direction of the slit. Clinical use 2. Corneal scarring: the stenopaeic slit may be used to determine the meridian along which the cornea is least deformed. Where an optical iridectomy is indicated, it should be performed in this meridian