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Opht hal mol Cl i n N Am 16 ( 2003) 155 170
Visual acuity and its measurement
Christoph Kniestedt, MDo' b, Robert L. Stamper, MDU' *
l Department
o/ Ophthul nol ogt' , Uni versi h o.f Cul i l rni a, Roon K301. l 0 Korer l l av. San Frant' i s<o. CA 94143-0730. L' 5.4
bDepartntent
oJ'Ophthulnologt'. Llniver.sitt Hospitul. Zurich. Suit:erland
Vision is one of the, if not the, most imponant
senses. It has been said that approximately 80% ofthe
inibrmation from the outside world is incorporated
through the visual pathrvays. Loss of vision has a
prolound effect on the quality of life. Yet, for all
vision' s importance to each of us, the most common
cl i ni cal measurement of i t i s rel at i vel y crude and
narrow. The process of vision includes many func-
t i ons. such as cent ral resol ut i on (vi sual acui t y). nri n-
imal light sensitiviry, contrast sensitivit-v. detection of
motion. color perception, color contrast. and peri-
pheral vision (divided into spatial, temporal, motion
detection) plus the interpretive processes that occur in
the inner retina and the cerebral cortex. In the nomtal
clinical sefting, we measure only one of these func-
t i ons-cent ral resol ut i on at hi gh cont rast (vi sual
acuity). That this one simple test does a pretty good
j ob of det ect i ng rnost vi sual dysf unct i on i s t ml y
amazing. Despite the fact that visual acuity is to all
of visual perception as the elephant' s trunk is to the
whole elephant, it works as an acceptable screening
test in the real world.
Millennia ago, our ancestors recognized that per-
sons di f f er i n t hei r abi l i ry t o see. The anci ent Egypt i ans
assessed visual function based on the ability o1' a
person to perceive the trvin stars Mizar and Alkor,
rvhich are situated inside the Big Dipper. In 1674 the
Englishman Robert Hooke reported the first systenl-
atically documented measurements of the visual power
of the human eye. He realized that hvo stars musl be
separated by more than 30 seconds ofarc to be detected
as t wo i ndependent l i ght st i mul i . To check vi sual
resolution in a more convenient manner. different
*
Corresponding author.
E-mail address: stamperadritsa.ucsledu (R.L. Stamper).
0896-1549/03/$ see front matter' !: 2003, El sevi er l nc. Al l ri ehts reserved.
doi : I 0. I 0l 6/ 50896- l 5. 19( 03) 000 I 3- 0
i nvest i gat ors proposed chart s cornposed of l et t ers.
The one with the first scientific basis rvas the Donde rs
"E. " Donders i nt roduced t he uni r I mi nut e of arc as
t he smal l est angl e of r esol ut i on i n humans and
desi gned hi s "E" l et t er on t hi s uni t . Snel l en and
Donders published their breakthrough in standardiza-
tion ofvisual acuity testing in I 862. but the chart based
on their work was not accepted until the Xth lnter-
nat i onal Congress of Opht hal mol oey i n Luceme 1904
[ 1. 2] .
Thev i nspi red several opht hal mol ogi st s t o f ur-
ther irrrprove visual testing procedures. On the occa-
si on of XI t h I nt ernat i onal Congress of Opht hal mol ogy
in Naples 1909, the Landolt C rin,qs rvere introduced
and accepted as the basis for visual acuity charts by the
i nt emat i onal communi t y of opht hal mol ogi st s (Fi g. 1).
For further specifications about Landolt C ring, see the
Chart s and scal es t o express vi sual acui ry sect i on.
Definition and terminologl' of visual acuitv
The nt ost basi c t brm of vi sual percept i on i s
det ect i ng l i ght . The si mpl est vi si bi l i t y t arget i s a poi nt
of light, sr,rch as a star. Although stars appear to have
different sizes and levels of blightness, theil visual
angl es are more or l ess t he same. Hence. seei ng t hem
depends on intensity rather than size. Indeed, when
the sky is perfectly dark, the r,,isibility of a star is a
measure of the absolute threshold of vision. As the
sky l i ght ens, t he st ar becomes i nvi si bl e. Because i t s
si ze has not changed, i t nl ust be t hat t he st ar' s
i nt ensi t y can no l onger be seen above t he l i ght er
surround. ln other words, tlre contrast (the difference
between lhe target and surror"rnd) has diminished. A
faint star is made visible with a telescope not so much
by magnifying but by the light gathering capacit-v of
the instn-rrnent.
T
I
5b
I
t_
C. Kniestedt, R.L. Sntmper / Ophthalmol CIin N Am l6 (2003) 155-170
Fi g. 1. Landol t C and mi ni mal angl e of resol uti on.
Visual acuity is more than
just
detecting light; it is
the measurement of the ability to discriminate two
stimuli separated in space at high contrast compared
with the background. The minimal angle of resolution
that allows a human optic system to identiflz two
points as different stimuli is defined as the threshold
of resolution; visual acuity is the reciprocal of the
t hreshol d of resol ut i on. Cl i ni cal l y. di scri mi nat i ng
letters on a chart determines this, but this task also
requires recognition of the form and shape of the
letters, which are processes that also involve higher
centers of visual perception. Discrimination at a
retinal level may therefore be determined by less
complex stimuli, such as confiast sensitivity gatings.
Theoretically, the maximum resolving power of the
human retina could be derived from an estimate of the
angle ofapproximately 20 seconds ofarc because this
represents the smallest unit distance between two
individually stimulated cones. Thus, the resolving
power of the eye could be much greater than what
is measured by visual acuity charts, as noted later in
this section on hyperacuity. Cones subserve the high-
est discriminatory capacity. but rods can also achieve
some resolution. The level of acuity falls off rapidly
the greater the distance from the fovea. At approx-
imately a 5o distance from the foveal center, visual
acui t y i s onl y one quart er of f oveal acui t y
[ 3] .
Because rod and cone longitudinal dimensions are
not sultciently different to explain the marked dif-
ference in acuity and because the resolving power of
the eye is greater than the theoretical limits based on
cell size, other mechanisms nust underpin visual
acuity. Luminance of the test object, optical abena-
tions of the eye, and the degree of adaptation of the
observ' er are examples
[4].
These considerations
illustrate that one simple definition of visual acuity
is not likely to satisfy.
Visual thresholds can be broadly classified into
three groups: light discrimination (minimum visible,
minimurn perceptible), spatial discrimination (min-
imum separable, rninimum discriminable), and tem-
poral discrimination, which refers to the perception of
transient visual phenomena such as flickering stimuli
[2].
Thus, many clinical tests of visual function assess
several functions simultaneously: Looking at the
sky, we see the visibility of stars, the contrast of
the moon, the shape and texture of the clouds, we
resolve the airplane and recognize its motion, and we
discriminate the manifold hues of the sunrise. Each of
these visual tasks uses different visual and neuro-
logic processes.
The mi ni mum vi si bl e i s a l i ght di scri mi nat i on
function. It includes brightness sensitivity and bright-
ness discrimination. Minimum visible acuity is the
ability to detect a small difference in the brightness of
fwo light sources (Fig. 2). It determines the presence or
absence ofa target against a background. The physio-
logic term is local brightness difference threshold (Al)
(Table 1). For a more practical example, we refer to the
experiment in which one measures the minimum width
of a telephone wire that can be seen against a uniformly
colored sky. The threshold value is on the order of
I second ofarc; this represents a very small fraction of
the diameter of a retinal photoreceptor.
Thus the minimum visible is not determined by
the visual angle subtended by an object but rather by
its brightness relative to background illumination.
Some authors use the term minimum perceptible fot
brightness discrimination and the term minimum
Object
(Spotl i ght)
Opti cs
Image
Receptors
Fi g. 2. Mi ni mum vi si bl e
C. Kni estedt. R.L. Sramper / Ophrhal mol Cl i n N Am 16
(2003) 155 170
Tabl e 1
Cl assi fi cati on of vi sual acui ty accordi ng to cri teri a
ts7
Cri teri on Mi ni mum vi si bl e Mi ni mum resol vabl e' Mi ni mum di scri mi nabl eb
Task
' Iypi cal
forced choi ce
psychophysi cal questi on
Physi ol ogi c basi s
Method of measurement
Magni tude of best threshol d
Il fl ect of i rnage degradati on
Determi ne presence or
absence of a target
l s there a l i ne i n thi s fi el dl l
If there was a l i ne i n the
fi el d. rvas i t hori zontal or
ver t i cal ? ( Fi g. 2)
Local bri ghtness
di fference threshol d
Vary object size
Approxi matel y I sec of arc
Moderate
Determi ne presence ot, or
di sti ngui sh between more
than one, i denti fyi ng
feature i n a vi si bl e target
Are there one or ti vo l i nes?
Is the gap i n the C up. down.
r i ght , or l ef t l ( Fi g. 3)
Detecti on of bri ghtness
differences between several
adj oi ni ng smal l areas.
Vary obj ect si ze or spaci ng
between object components
Approxi matel y 30 sec. of arc
Seri ous
Determi ne rel ati ve l ocati on ol
two or more visible features
wi th respect to each other
l s the upper l i ne to the ri ght
or the l eft of the l ower l i ne?
( Fi g. 4A)
Assi gnment of rel ati ve l ocal
si gns to two or more
suprathreshold visual feahrres
Vary relative location
of features
Approri matel y | 3 sec of arc
Sl i ght (except i n stereoacui ty)
'
Mi ni mum resol vabl e
-
mi ni mum seDarabl e
-
ordi narv vi sual acui tv.
n
Mi ni r num di scnmi nabl e
-
Vemi er acui r y
=
hyper acui t y.
Modi l i ed./i om Westhei merG. Vi suat Acui ty. In: Moses R, edi tor. Adl er' s physi ol ogy of the eye. St. Loui s: Mosbv: 1987. p.418.
visible for brightness sensitivity alone. Other exam-
ples of light discrimination are brightness conftast
and color discrimination.
Visual acuity as measured clinically is also called
minimum resolvable or minimum separable. It is a
spatial discrimination function representing the small-
est visual angle at which two separate objects can be
discriminated (Fig. 3). From a physiologic point of
view. it is the detection of brightness differences
bet ween adj oi ni ng smal l ar eas and. t her ef or e,
depends on object contrast and the packing densiry
of photoreceptors in the fovea. In a healthy observer
in best focus, the resolution limit or, as it is usually
called, the minimum angle of resolution (MAR) is
between 30 seconds of arc and 1 minute of arc.
Cl i ni cal l y, we use such syst ems t o assess vi sual
acuity, and examples of minimum resolvable include
the Landolt C and Snellen E.
T he m i n i m u m d i s c r i m i n a b I e (hyp e r a c u i t
1,*,
Ve r n i e r
acuiry) is another example of spatial discrimination. It
det ermi nes t he rel at i ve l ocat i on of t wo or more
visible feahrres with respect to each other. Astonish'
ingly, the eye is capable of subtle discrimination in
spatial localization and can detect misalignment ol'
two line segnents in a lrontal plane if these segments
are separated by as little as 3 to 5 seconds of arc,
considerably less than the diameter of a single foveal
cone. The mechanism subserving hyperacuity is still
bei ng expl ored
[ 5]
(Fi g. a).
Fi g. 4. Mi ni rnum di scnmi nabl e. (l ,B) Types of mi sal i gn-
ment detected by thi s functi on. (O The more conventi onal l y
used mi ni mum resol vabl e di stance betu' een two obi ects.
Objects
(2 Spotl i ghts)
Opti cs
Images
Receptors
) \
B
"1"
A
Fi g. 3. Mi ni r num r esol vabl e.
1 5 8 Kni estedt. R.L. Stamper Ophthal ntol Cl i n N.4n l 6 (2003) 155-170
Minimum legible or recognition threshold is used
commonl y cl i ni cal l y and i s i ncl uded i n vi sr. ral acu-
i t y measurement s usi ng opt ot ypes or shapes. I t
means the patient' s ability to recognize progressively
smaller optotypes. The angle that the smallest rec-
ogni zabl e l et t er subt ends on t he ret i na i s al so a
measure of vi sual acui t i r. Theref ore, t he cl i ni cal
measurement of visual acuity with a Snellen-rype
chart includes minimum resolvable and minimum
legible functions.
Chart s and scal es t o express vi sual acui t v
The Landol t C (Fi g. l ) uses a ri ng wi t h an out er
diametcr subtending 5 minutes of arc at the observ-
er' s eye and an inner diameter subtending 3 minutes
of arc as a reference target. A gap I minute of arc
wide is made as a ring. and the rine is presented with
its opening in one of tr.r,o horizontal and two vertical
possi bl e posi t i ons. The subj ect has t o i ndi cat e i n
which direction the gap rn the C is pointing. The
smallest C in which the subject can corectly identifo
the gap is the visual acuity. At an obsen' er distance of
20 feet (6 m). the overall size of the letter is 8.7J rnm
and t he gap i s 1. 75 mm. I f t hi s i s t he sub. j ect ' s
t hreshol d t hat i s, i f t he l ni ni mum angl e of resol ut i on
is I nrinute of arc the visual acuity is defined as
20120 (in feet) and 6/6 (in meters), respectively.
The most familiar examination chart is the Snellen
chart . I t i s desi gned t o measure vi sual acui t y i n
angul ar t enns. Thus. Snel l en acui t y i s commonl y
equat ed wi t h vi sual acui f y. l n a heal t hy obsen' er i n
best fbcus, the resolution limit is between 30 seconds
and I minute of arc. The Snellen chart consists of
letters ofdifferent visual angles. The letters (and their
part s) are proport i onat el y enl arged i n somewhat
inegular increments on each line up to the 201200
or 20/400 size. Commonly. the overall size of the
lefter is t-rve times the width of each limb (Fig. 5). The
subject is asked to read the chafi from easil_,- seen to
smaller and smaller letters. The smallest line on the
chart that the subject can read is usually said to
signify visual acuity. One or two mistakes per line
are often allowed.
As with the Landolt rings. acuity is recorded as a
fraclion. The number of feet at which the chart is
located (20 ft
[6
m] bv convention) becomc' s the
numeralor. The denorninator is the line with the
smallest letters in which all but fwo of the letters
are read correctly. Sometimes, especially in Europe
and other parts ofthe world. the acuity is recorded as
a deci mal . The deci mal syst em of acui t y not at i on
represent s t he reci procal of t he vi sual angl e i n
minutes or the numeric l' alue of the fractional Snellen
not at i on. For exampl e. a r, i sual acui t y of 1. 0 woul d
be equivalent Io 20120 (6/6) and one of 0.5 would be
20140 (6t 2).
If resolution is sharper than the 20120 line, the
notation still keeps the standard characteristic. Sup-
pose that one has a minimal angle of resolution of
0.75 minute of arc that is. at 20 feet he can resolve a
letter with a feature that subtends 1.3 mm and whose
overall size is 6.5 mm. Such a letter has a gap that
subtends I minute of arc at l-5 feet (4.5 m) and would
be resolvable by an observer rvith 1 minute of arc
resol ut i on at such a di st ance. The subj ect i s t hen sai d
t o have vi sual acui t y of 20/ 15 or 614. 5.
|
5 min. of arc
I
Fi g. 5. ) 0 20 Snel l en l ener
"F. .
T.
I
r mrn.
I
ofarc
C. Kni e.stedt, R.L. Stomper./Ophthal mol CIi n N Am I6 (2003) 155-170 159
Early Treatnrent Diabetic Retinopathy
St udy chart s
Standardization of visual acuity is difficult when
precise data are required. The standard Snellen eye
chart (Fig. 6) contains lines of letters that are not
related to one another by a linear size progression in a
geometric or logarithmic sense. The main disadvan-
t ages of t ' onner chart s are I nconsi st ent i ncrease i n
letter size frorn one line to another. Going from the
20/20 line to the 20/25 line is different from that
going from the 20125 line to the 20/30 line for
instance. In addition. all letters in the alphabet are
not equally legible. Certain letters (C, D, O, G, E) are
inherently harder to recognize than others (A, J. L).
Finally, they offer a dit-lerent number of lefters on
each l i ne. Al l owi ng one mi st ake per l i ne, t heref ore.
has a different meaning at different levels of visual
acuity. Furthermore, variability in background and
arrrbi ent i l l unri nat i on and cont rast changes as t he
charts age rnake it difficult to truly assess visual
acuity over time and fiom patient to patient. There-
f ore. researchers needed a more st andardi zabl e
method of measuring visual acuiry. This is especially
so in clinical trials in which visual acuiry is measured
over a period of time and changes represent an
outcome of the study, or in which several examiners
in different locations perform measurements.
For the Early Treatment Diabetic Retinopathy
Study (ETDRS) in the early 1980s
[6],
more stand-
ardized charts were inlroduced based on the design
created by Bailey and Lovie
[7].
Recommendations
of the Comrnittee on Vision of the National Academy
of Science National Research Council (NAS-NRC)
were also considered
[8.9].
The ETDRS light box
chart is seen in Fig. 7. ETDRS charts seftled most of
the disadvantages of the Snellen-type chart. Five
letters are presented on each line. Spaces between
letters and lines have been standardized so that the
space between letters is one letter rvide and the space
between lines is equal in height to the letters of the
next lower line. Letter sizes range from 58.18 mm to
2.92 mm, providing a visual acuity equivalent of 20l
200 to 20110 or, at a distance of 4 rn. 4/40 to 4i2, for
which this letter chart was designed. The progression
of letter height from line to line is geometric. Letters
on each line are 1.2589 times the height of the letters
on the next lower line. The multiplier is the tenth root
of 10, or 0.t log unit. Ten Sloan letters had been
chosen for the ETDRS chart, namely S, D, K, H. N,
O, C, V
R, and Z. The dit' ficulty score of each letter
is approximately equal to each other and to a Landolt
C ring. Two hundred fifty-two combinations of five
letters that can be lined up from the l0 Sloan letters
are possible. Trventy-eight of those level at the same
letter difficulty score and are therefore chosen for the
charts
[9]
(Table 2).
The charts are used in a standard light box. The
chart can be offered not only at 4 m but also, because
visual acuity is often severely impaired in low-vision
patients, at a reduced test distance of I m. Visual
acuities as low as 201800 can be noted in this way.
For proper examination, the examinee reads slowly
down the chart, letter by letter. Only one trial of each
letter is allowed. When a letter is read correctly,
even based on a vague guess, the examiner circles
this letter on his score slreet. Visual acuity is re-
corded as the smallest line read by each eye rvithout
any mistake.
In recent years, several variations on the Snellen
chart have been introduced. The oldest is the pro-
jector
chart. which is usually used with mirrors to
simulate a 20-ft (6-m) optical distance. These charts
have the advantage of being usable in lanes smaller
than 20 feet rvhile still maintaining the traditional
testing "distance"
optically. As the bulbs in projector
chafis age. however, their illumination decreases,
P
z
r
T
&
k
LPTD
PTCTD
TDFCZP
TALOPZD
Dt TPOTAC
t t r o ! ! c r { *
r ! r t ! e * o
S
t I ! o r s ! I ! . ] . l f f i
l
I
*
Fi g. 6. Standard Snel l en chart
160 C. Kniestedt, R.L. Stamper / Ophthalmol Clin N Am 16 (2003) 155 170
_=:_:r!F_
t a
!
t
EV
l,l O
c i
r $
r $
ct
O l,l
v c
6r {
I r $
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t a
3X
ov
OH
x l
t a
t l
t t
1 *
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t *
Fi q. 7. ETDRS vi sual acui tv chart.
Di ffi cul fy
Chart I score
Table 2
Difficulty scores for ETDRS charts I and 2
L nart I
Difticulty
score
410. I
407.8
4l 0. 5
411. 6
409. 5
408. 6
409.2
410. 8
412.6
410. 3
408. 8
408.2
409.7
4n. l
Si mi l ar di ffi cul ty score of each Sl oan l etter combi nati on.
(Froz Ferri s FL, Kassoff A. Bresni ck GH, Bai l ey I. Neu,
vi sual acui ty charts for cl i ni cal research. Am J Ophthal mol
1982:94:94\.
reducing the contrast befween the lefters and the
background. Furthermore, the projector slides, like
paper, yellow with age and become dusty and dis-
colored, causing additional reduction in contrast
between background and letters. Newer projector
charts using halogen bulbs and random selection of
letters by computer make testing easier and perhaps
somewhat more reliable.
Visual acuity can be specified with several di{:
ferent sc' ale.r and notations. The Snellen chart is
designed to measure visual acuity in angular terms.
Accept ed convent i on does not speci f y acui t y i n
angular units but uses notation in which the numer-
ator is the testing distance (in feet or meter. d), and
the denominator is the distance (in feet or meter, D) at
which a letter subtends the standard visual angle of
5 minutes of arc (Snellen visual acluiry, V
:
d/D).
Thus, on the 20120 line (6/6 in meters), the lefter
subtends an angle of 5 minutes when viewed at
20 feet. On the 20140 line
(6112
in meters) the letters
subtend an angle of I 0 minutes of arc when viewed at
20 feet, or 5 minutes of arc when viewed at 40 feet.
NCKZO
RHSDK
DOVHR
CZRHS
ONHRC
DKSNV
ZSOKN
CKDNR
SRZKD
HZOVC
NVDOK
VHCNO
SVHCZ
OZDVK
4 1 0 . 1
407. 8
410.7
4n. 6
409.6
408. 4
409. 3
410. 9
412.5
410. 3
408. 8
407.9
409.9
411. 2
DSRKN
CKZOH
ONRKD
KZUDC
VSHZO
HDKCR
CSRHN
SVZDK
NCVOZ
RHSDV
SNROH
ODHKR
ZKCSN
CRHDV
H V Z D S
NCVKN
CZSHN
ONVSR
KONRO
a a r e
C. Kni estedt. R.L
Tabl e l
Equi val ent l ,i sual acui ty measurements
Stumper i Ophthul mol CIi n N Am 16 (2003) 155-170
In Europe, the most clinically used description of
visual acuiry is the decimal fraction of Snellen visual
acuity. Decimal visual acuity is obtained by dividing
the numerator of the Snellen fraction by the denom-
inator. The reciprocal of the Snellen ftaction repre-
sents the minimurn angle of resolution or rccognition
(MAR). The base l 0 l ogari t hm of t he reci procal
Snellen fraction approximates the logarithrn of the
minimal angle of resolution (LogMAR), which rep-
resents a linear scoring systern in contrast to all other
nonlinear visual acuity scores. The ETDRS chart was
designed with LogMAR scoring in mind, and, as seen
in Table 3, there is a 0.1 LogMAR unit diff,erence
befween each iine. It is possible to get an interpolated
(between 0. I LogMAR unit) $,ith the ETDRS chart
with five letlers on every line, by assigning 0.02
LogMAR units for each single letter read correctly on
each line. This principle can be extended to situations
in which some letters on several lines are missed.
Near visual acuity
As with distance acuity. letter size and reading
distance are needed to calculate near visual acuity
properly. lt is a bad habit of many practitioners to
l 6 l
Snel l en vi suai acui t y
20 il 6 m 4 rn Deci mal MAR" LogMAR
20/640 6i192
20/500 6il52
201400 6tr20
20i320 6t96
20t250 6t76
20t200 6i60
201160 6t48
20n25 6/38
20/ r00 6/ 30
20t80 6i24
20t63 6t20
20t 50 6^5
20140 6t \ 2
20t 32 6/ l 0
20/25 6i7.5
20t20 616
20116 6/ 5
20^2.5 613.75
20t' 10 6i3
3 2 1 . 5
2- 5 t . 4
20. 0 1. 3
1 6 1 . 2
12.5 L I
10. 0 I . 0
8. 0 0. 9
6. 3 0. 8
5. 0 0. 1
1. 0 0. 6
3. 2 0. s
2. 5 0. 4
2. 0 0. 1
1. 6 0. 2
r . 25 0. 1
1 . 0 0
0. 8
-
0. 1
0. 63
-
0. 2
0. 5
-
0. 3
4t 128
.1/
I 00
4/80
4163
4t50
4/40
4t32
4t25
4t20
4i t 6
4112.6
4/ l 0
4t 8
4/6.4
115
414
4t 3. 2
4t 2. 5
/ / 1
0. 03
0. 04
0. 05
0. 063
0. 08
0. r 0
0. 125
0 . t 6
0. 20
0. 25
0. 32
0. 40
0. 50
0. 63
0. 80
0
25
60
2. 0
Snel l en Vi sual Acui ty i n meters and feet, deci nral notati on,
MAR. and IogMAR.
ETDRS charts are based on l i near LogMAR score.
'
MAR, mi ni mal angl e of resol uti on (mi nute of arc).
No. 2
No. 3
No. 4
b* . - 4bs. r b\ | * b L
b * r h i l i F ! t u - F . r d
r F, r t ' | .
5 e F E
r r a . b * d - b r q o b . ' E b b l
No. 5
o a b | t 4 b q BFd &+ U
. b & - a h t d D 4 h b . 4
b i l t u r d . . . 1 . . t u . - . d l 4 b
d q F h i b , b * b F - d l
N o . 6
&tua. d hq. ca h +&d d.k.
& ry. ulwlo.rt h dG bl
t u c $ E b u * - u s b l f l . t u
. f d. r ddn * y. r . 6f r r ycr Ep
No- 7
Dd di*oblod.tu oDticdcftlion ior
tho Et-&G.Eor i. fdnd in F&1.
lsra. Ia n.dLdnE . c@.v"
No. I
aphericd len. dll qu6
tl|e lcal
poiDt to Eed? util it trIr
dimtly on the Etiu
No, 12
while in far-eightednesa
the foal polnt mn b
No. to
advrnced with a
eonYexlens
.
concaYe,.
morn-
JAEGERS IESI TYPES
Fi g. l i . Jaeger near acui r y chan
t62
record just the letter size read without specifoing the
reading distance. Conventionally, reading vision is
exami ned at 40 cm ( l 6 i n, 2. 5 D add) or 35 cm ( l 4 i n,
3 D add). The testing distance of the preferred near
distance chart should be obsen,ed accurately. Snellen,
Jaeger, and point system (printer' s type) notations are
used for this. The Snellen notation is simply an
equivalent reduction for near, maintaining the same
visual angle. Most of the Snellen-based distance
acui t y chart s are al so commerci al l y avai l abl e as
"pocket"
charts to check the irear acuity at the
prefened distance for every patient or at defined
di st ances f or cl i ni cal t ri al purposes (see bel ow),
including ETDRS variants and Snellen letter "E."
The Jaeger notation is a historic enigma. and Jaeger
never committed himself to the distance at which the
print should be used. The numbers on the Jaeger chart
simply refer to the numbers on the boxes in the print
shop from which Jaeger selected his type sizes in
I 854; they have no biologic or optical foundation.
They have no mathematical background and are even
implemented inconsistently on different cards. Clin-
ically, they are still widely used and are well accepted
by patients (Fig. 8). Not much more precise is the
point system, doubtless useful to the printing trade for
which it was arbitrarily adopted but not for clinical,
much less scientific, measurements. Within one type
style, they are proportional to the letter size. How-
Table 4
Visual acuity equivalents for near
C. Knie.stedt, R.L. Stamper / Ophthalmol CIin N Am 16 (2003) 155-170
ever, actual letter size may vary for characters of
different styles.
M-units were introduced by Sloan
!01.
They are
the units used in Snellen' s visual acuity formula.
They are the same for distance charts and reading
charts. Characters with the same M-unit designation
have the same recognizability. M-units are explained
in detail later in this section.
Interconversion from one near system to another
is, unfortunately, approximate. Thus, 6-point type is
approximately equivalent to Jaeger 4 (J4), which is
approximately equivalent to Snellen 20/40, 0.5 in
decimal system, and 0.3 LogMAR, which is, more
practically expressed, the size of print in a telephone
directory. The letter size notation in this case would
be 0. 8 M. Tabl e 4 shows several vi sual acui t y
notations for near.
Reading charts are often more suitable than ordi-
nary letter charts for testing near acuity because they
take the patient' s daily reading needs into account.
Numerous reading charts are commercially available
based on the patient' s daily contemporary needs,
including Jaeger reading charts (Fig. 8). A full range
of near point tasks, including words, numbers, and
symbols, is also provided by the Lebensohn near
point chart (Fig. 9). Schrier and Panariello included in
their charts a crossword puzzle, schedules for trains,
flights, football and basketball, an obituary. stock
Snel l en vi sual acui ry
Jaeger Point Letter size 20f t b m 14 i n Deci mal LogMar
l 9
l 8
l 6
l 4
t 2
l 0
8
o
5
3- 4
2- 3
1 a
l +
60
40
26
24
l 8
t 4
17.
9
8
6
5
4
3
6. 3 M
5. 0 M
4. 0 M
3. 2 M
2. 5 M
2. 0 M
1 . 6 M
1. 25 M
1. 0 M
0. 8 M
0. 63 M
0. 5 M
0. 4 M
0. 32 M
0. 25 M
0. 2 M
20t320
20/250
20/200
20il60
20,l25
20il00
20i80
2Q/63
20/50
20t40
20t32
20t25
20/20
20/L6
20t12.5
20/ t 0
6t96
6/76
6/60
6t48
6/ 38
6/30
6/24
6t20
6/ 15
6/ 12
6l t o
6t 7. 5
6/6
6t 5
6/ 3. 7 5
6/3
t4t222
t 4/ l 7 5
t4t t40
t 4/ n2
t4187
14t 70
t 4t 56
t 4t 45
14/ 35
t4128
14122
t 4l t 8
t 4/ t 4
t 4l l t . 5
14t8.75
l 4t 7
0. 063
0. 08
0. 1
0. t 25
0 . 1 6
0. 20
0. 25
0. 32
0. 40
0. 50
0. 63
0. 80
1 . 0
t . 25
1. 60
2. 0
L 2
l . l
1 . 0
0. 9
0. 8
0. 7
0. 6
0. s
0. 4
0. 3
0. 2
0 . 1
0
-
0 . 1
-
0. 2
-
0. 3
Interconversion from Jaeger system to Point system is only approximative. Neither type is standardized, and various editions,
especi al l y ofthe Jaeger types, exi st that show consi derabl e di vergence i n si ze, shape, and character ofthe fonts used. The tabl e
displays an average of what is found in the literarure and on several near point test charts. LogMar is the only notation with a
l i near score. l 4 i nches
=
35.6 cm readi ng di stance.
t ,
&t 3
: , J .
ar r f l
t t t
,
fL'i
"rr
. - f . t ! r
i i
;.'.:: -i-.
: : i
C. Kni estedt, R.L. Stamper / Ophthal mol Cl i n N Am 16 (2003) 155-170
b
Fi g. 9. Lebenshohn readi ng chart. (a) Front. (r) Back
163
a
quotes, music bars. playing cards, telephone white
pages. and many ol her si mi l ar t asks.
Not at i on equi val ent s on most chart s i ncl ude
deci rnal , f ract i on i n f eet and met ers, I et t er si ze
M-unit, LogMAR, Jaeger, point size. or visual effi-
ciency percentages. For more scientific purpose the
bnumbers
fttm|Y
tant|.1.0.
l I E t . co. E
E & EE. ' - l t r t n r 6 E'
EOACTE
=- r - l nv=)
VVVYV
:: :65e68::
r b
9 B 5I 6
F&
I 5 6 5I
{ r -
g6gg5 - ,
6 g s 6 g
* r r
o r r 5 9 6 5 8 B -
f r r a 8 6 8 9 6 6
c t i 8 6 - 9 . -
- f . o 9 a o t a 6 . 4
r u &
:: ;
"'.:.'.'
----.
I.3
t . t z - \ E E
- . , -
t -
\ \ r u E
t r r t -
bnroery-*.=l$b.
Fi g. 10. Hyvaennen near acui t-v l etter chart
ETDRS charts might be useful or the rnodified Lea
numbers developed by lJyvaerinen (Fig.
l0) are used.
Visual acuity in low-vision patients
lndividual near acuity needs are dit' ferent among
different population groups. For low-vision patients
these differences are magnified. Two persons with the
sarne severe visual impairment may exhibit marked
differences in their ability to cope with the demands of
daily living. Visual ability loss, therefore. is the aspect
that must be addressed in individual rehabilitation
pl ans. Col enbrander
I l ]
subdi vi des several compo-
nent s of vi sual l oss i nl o i rrpai rnrent aspect s (how t he
eye functions), visual ability (how the person functions
in daily living), and social/economic aspects (how the
person functions in society) (Table 5). The simplest
scale of low vision has three main ranges: normal
vi si on. l ow vi si on. and bl i ndness. The Worl d Heal t h
Organization (WHO) adopted this scale in 1974. For
more detailed reporting, the three main ranges can be
divided inlo seven subranges, each equivalent to four
lines on a standardized acuity chart. These ranges are
summarized in Table 5 in the column "lmpairment
aspect" and are paft of the official US ICD-9-CM
classification. I.he term visual acuity score (VAS) is
used f or cl assi f oi ng soci al and economi c aspect s.
which is part of the functional vision score system.
On an ETDRS test chart, each letter seen correctly adds
one point to the VAS. In the fifth edition of the
American Medical Association Guides to the Evalu-
r*:
t l Ls
n
at rt t a.
t,
. l r f r ar
t at t nl
altr
r
ffic.
f f i
uilr
r * -
rH&B.
n n -
d l * t
* * -
l*t**itrE!!l6
**r*n
x
*&ltG
1 6 4 C. Kni esredt. R.L. Stomper
/
Ophthal nol Cl i n N1m l 6 (2003) 155 170
Tabl e 5
Ranges and aspects ofvi si on l oss
Impai rment aspects
(how the eye functi on)
Vi sual abi l i ty aspect/functi onal vi si on
(hou' the person functi ons-dai l y l i vi ng ski l l s)
Soci al and economi c aspects
(how the person functi ons
i n soci ety)
Ranges
( I CD- 9- CM)
Vi sual
acui ry
Nervspri nt Stati sti cal esti mate
( i M) of r eadi ng abi l i t y Vi sual ai ds VAS Comnrents
Normal vi si on
Mi l d vi si on l oss
20i12.5
20116
20120
20i 25
l 0' 32
20t10
20/ 50
20i63
Moderate vision loss l0/80
20, 1 00
t 0 [ 5
20i160
Severe vision loss 20/200
20t250
20/ 320
l0;-{00
Profund vision loss 20/500
20/630
20/800
20/ I 000
Near-bl i ndness 20i 1250
20/ 1 60
20i2000
Tot al bl i ndness NLP
Normal readi ng speed
Normal readi ng di stance
Reserve capaci ry for
smal l pr i nt
Normal readi ng speed
Reduced readi ng di stance
No reserve for smal l
Near-nomal wi th
appropnate readi ng ai ds
Low-porver magni fi ers
and l arge-pnnt books
Sl orver than normal wi th
readi ng ai ds
Hi gh-po*' er rnagni fi ers
(restri cted fi el d)
Margi nal wi th ai ds
Uses magni fi ers for spot
readi ng. but may prefer
tal ki ng books l br l ei sure
No vi sual readi ng
Must rel y, on tal ki ng
books or other
nonvi sual sources
None I l 0
ll:;
I ns
t::
t 19
J/)
Vi si on
' 70
enl rancerrent 65
ai ds 60
t;;
tti
t"
1,.
I
r 5
J, i:
Vi sron l 0
substitution 5
ai ds 0
Note that normal adul t
vi si on i s better than
20i20
Many functi onal cl i teri a
(whether tbr a dri ver' s
l i cense or l br cataract
surgery) l al l wi thi n
thi s range.
In the Uni ted States.
chi l dren i n thi s range
qual i fl , for sPeci al
educati on assi stance.
l n the Uni ted States.
persons i n thi s range
are consi dered l egal l y
bl i nd and qual i ty l br
tax-break di sabi l i ty
benefi ts.
In the EU, rnany benefi ts
stafi at thi s l evel . The
WHO i ncl udes thi s range
i n i ts bl i ndness category.
In thi s rarrge. resi dual
vi si on tends to beconre
unrel i abl e, though i t
may sti l l be used as
an adj unct to vi si on
subst i t ut i on ski l l s,
63 i n
50 i n
40 i n
l l i n
25 i n
20 i n
l 6 i n
1 2 . 5 i n
l 0 i n
8 i n
6 t n
5 r n
4 l n
l i n
2. - s i n
l i n
1 . 6 i n
1 . 2 i n
I i n
l c m
I crn
I cnr
The fi rst secti on shorvs the ranges of vi sual i mpai mrent. as defi ned i n ICD-9-CM. Each group covers fbur l i nes on an ETDRS
test chart. The second secti on l i sts readi ng abi l i ti es. Li sted performances represent stati sti cal averages and may di ffer between
i ndi vi dual performances. Vi si on enhancement ai ds and vi si on substi tuti on ai ds are used as vi si on begi ns to decrease
progressi vel y. Vi si on enhancement ai ds i ncl ude magni fi ers and hi gher i l l umi nati on. Vi si on substi nrti on ai ds i ncl ude canes. sui de
dogs. and tal krns books. The thi rd secti on l i sts addi ti onal comments and the vrsual acui fy score. On an ETDRS chart, each l efter
seen adds one poi nt to the vi sual acui l v score, u' hi ch i s part of the functi onal vi si on score system provi ded by the Ameri ean
Medi cal Associ ati on Gui des to Eval uati on of Permanent Imparrment (2000)
l l 2].
(Franr Col enbrander A. Presen' ati on of vi si on or preventi on of bl i ndness
fedi tori al ]?
Am J Ophthal mol 2002;133:2. p. 264.)
at i on of Per manent I mpai r ment
[ 2] ,
t hi s scor e
replaced the visual efficiency scale, which was based
on employability data from 1925.
Commonly uscd visual charls at the typical dis-
tance of 20 feet (6 n.)) are. therefore. mostly unsuit-
abl e t br pat i er r t s wi t h sever e vi sual l oss. The
measurement range can be raised by moving the test
chart s t o a cl oser di st ance. At l 0 f ' eet (3 m) a
magnification fctor of 2 and at I rn a fctor of 6
can be reached. For reproducing a patient' s everyday
function, under low-vision conditions, a printed chart
with extemal illumination should be used instead
[ 3] .
Usi ng a l -m exami nat i on di st ance al so f aci l i -
tates the calculations betu,een the feet/inches and the
metlic system that is comrronly used in low-vision
of f i ces. As ment i oned above. Loui se Sl oan
[ 0]
introduced the term M-unit. Its standard acuity is
defined as the ability to recognize a standard letter
(
I M-unit) at a standard distance of I m or a letter
with the sanle visual angle (-r N,[-units at .y rneters).
C. Kni estedt, R.L. Stamper / Ophthal mol CIi n N Am 16 (2003) 155 170
l o i
Using a leftel chart at a l-nr vierving distance
extends the measurable range down to l/50 (20li000)
if a chart rvith 50 M letters is used. It also makes more
letters per line available at each level.
Visual acuity testing in
!' oung
children
This section summarizes procedures for visual
acuity testing in preverbal infants and young children,
which can be a challenge tbr the examiner and for the
accornpanying parents. Early determination of vision
loss and refractive error is an essential component of'
assessing the infant' s ultimate visual development
potential. The examination is generally performed
on the parent' s lap. Older children may prefer to sit
alone, as long as a parent or another familiar person
remains present. The room should never be totally
darkened because this may provoke anxiety.
Measurement of visual acuiry is normally per-
formed in the course of determining the refractive
error of t he opt i c syst em. Obj ect i ve ret i noscopy
remains the best method of detennining a child' s
refraction. Even the most uncooperative child can
undergo retinoscopy if the examiner is patient, espe-
ci al l y i f t he chi l d has cycl opl egi a.
Other clinical methods involve estimation of fixa-
tion and following behavior. A test larget should
incorporate high-contrast edges. For infants younger
t han 6 mont hs. t he best t arget represel )t s t he exam-
iner' s fce. For the child of 6 months and older, an
interesting toy can be used. After assessment of the
binocular flxation pattent, the examiner should direct
attention to differences between the two eyes when
tested monocularly. Obiection to occlusion of one eye
may suggest abnormality with the less preferred eye.
To replace fixation preference testing with an
obiective and quantitative method of assessing visual
function, techniques using grating targets of varying
spatial fiequency have evolved. Such methods rely on
the detection of resolution acuity, a more sophis-
ticated measure of visual performance than only
detection of a target as used for fixation assessment.
Three common methods are used for determining
resolution acuity. They rely on behavioral techniques
(preferential looking), detecting optokinetic nystag-
mus (OKN), and recording visual evoked potentials
or responses (VEP or VER).
Preferential looking acuity tests use the infant' s
innate tendency to gaze at a pattem rather than a blank
field when the pattems are presented side by side in an
otherwise bland environment
[14].
By determining the
smallest grating the patient will fixate, resolution
acuity can be assessed and can be expressed in minutes
of arc, LogMAR. or Snellen equivalent. Testing dis-
tance is usually beween 30 cm and I m.
Unfortunately, preferential looking tests are time
and personncl consumi ng. For f ast er t esl rng. grat i ng
test stimuli cards are available
[15,16].
A range of
gratings from coarse to fine is used in each test'
Forced-choice preferential looking designed by Teller
(Fig. l l
) !
71 and operant preferential looking by
Mayer and Dobson
[18]
are two other widely used
testlng systems.
Visual acuity in children can also be estimated by
VEP recordings and by eliciting optokinetic nystag-
mus by stripes of various widths. Both nrethods are
hindered by the complicated apparatus necessary for
their performance.
VEP methods provide the examiner with the
summed cortical responses to temporal changes in
pattems. Typically, three gold cup electrodes are
placed over the occipital pole, at ground, and at a
reference point. Infants usually view pattem on an
oscilloscope or a TV screen high-contrast black-
and-white checkerboards or gratings. Personal com-
put ers equi pped wi t h appropri at e hardware and
software are used for signal averaging and filtering
Fi g. I l . Tel l er preferenti al l ooki ng test chan
ililililillllllll
l
I
I
l
t66 C. Kniestedt, R.L. Stamper / Ophthalmol Clin N An l6 (2003) 155-170
to improve the signalto-noise ratio. The VEP is
cont ami nat ed by ongoi ng el ect roencephal ogram
activity and by extemal noise sources.
Visual acuity of newboms is not the same as that
of adults. Normative data of newbom infants. as
measured by preferential looking, are in the range
of 30 minutes of arc (201600 Snellen equivalent)
|9
211. Acuity rapidly improves to 6 minutes of
arc (201120) by 3 months. Variability among healthy
infants is greatest during this early period of rapid
development. A steady but modest improvement
to approximately 3 minutes of arc (20160) occurs by
12 months of age. One minute of arc is usually
obtained at the age of 3 to 5 years. Interestingly,
acuities achieved with the VEP technique show more
rapid improvements of visual acuity in an infant' s
developing penod
[22,231.
VEP testing reports show
that acuity of 1 minute ofarc is even achieved by age
6 to 7 months. This discrepancy between rates of
acuity development might be that each technique taps
a different stage of neural processing. Furthermore
the preferential looking method requires not only
"seeing" but also requires a motor response based
on what is seen. Thus, preferential looking might
have the disadvantage of being influenced by imma-
turities of motor areas.
It is desirable to measure the visual acuity of
children sometime during their third year to detect
strabismic or sensory amblyopia and to recognize the
presence of severe refractive errors. In this age group
of preschool children, visual acuity testing is getting
easier to perform and charts can be used to determine
visual acuity fairly accurately. These charts are based
on symbols and pictures such as the Henry F. Allen
Preschool Test or the Osterberg Test (Fig. l2). Illit-
erate E charts by playing the "E" game or even
Landolt broken ring by playing the game in which the
mouse leaves the ring can be performed.
Testing of low vision or examining infants with
multiple handicaps can be discouraging, even starting
the examination with the coarsest and largest pattem
available. Ifthe infant fails to respond to the coarsest
paffem, it may mean that the infant' s visual potential
is poorer than this level. Altematively, it probably
means that a nonvisual handicap prevents the motor
response required by preferential looking test or that a
structural anomaly may be present and interfering
with the recording of the cortical potentials.
Factors affecting visual acuitv
A diminution of psychologic, physical, and phys-
iologic elements in any segment of the human visual
pathway and the brain may manifest itself in a reduc-
tion in visual acuity. Determination of visual acuity
is influenced by the judgment and experience of the
observer, the region of the retina stimulated, the in-
tensity and distribution of the illumination, the spectral
nature ofthe light, the time ofexposure, the effect of
ggg,
4
t,
?rh
B 4 tu
s 4
? f fb -
a r t - l a - a r l
- o a a a . a a r - a I
f
".S-
orf{
;"
a b
Fi g. 12. Symbol charts (Al l en
[a]
and Osterberg
[]
symbol s).
movements of the object, and whether the test is
performed on each eye individually or both eyes
together. Increased illumination not only sends more
light to the retina but also constricts the pupil, enhan-
ces depth of focus, modifies accommodation, shifts
color temperature, alters adaptation, and may induce
suflicient glare to cause the eye to close. Some stimuli
variables have effects that are of more universal and
clinical interest.
Pupil size
The pupil regulates the amount of light entering the
visual system. This control mechanism can influence
visual acuity considerably (Table 6). A smaller pupil
size increases the eye' s depth of focus and objects
remain in focus inside or outside the actual near point
ofthe eye, thus making visual acuity less dependent on
perfect refraction. Concomitantly, uncorrected or
incompletely corrected visual acuity rises. Ifa pinhole
aperture is placed immediately in front of the optical
system, it acts as an artificial pupil, and the size of the
blur circle is reduced correspondingly. Pinhole acuity
comes close to mimicking the best-corrected visual
acuity in a patient with ametropia. A difference
between uncorrected and pinhole acuity suggests that
refractive correction would improve visual acuity.
Assuming that the patient is using the pinhole cor-
rectly, if a pinhole does not correct the visual acuity
compared with the uncorrected visual acuity, then
refiaction is unlikely to significantly correct acuity.
In the presence of very large refractive errors, the
pinhole may not be able to correct the large ametropia.
Therefore, with very large refractive errors ( >
6 D),
additional lenses to approximate the refractive state
plus the pinhole may yield the best information.
The size of the blur circle on the retina generally
increases as the size of subject' s pupil increases,
particularly in a patient with ametropia. The advantage
ofthe pinhole eflect is reduced by pupil sizes smaller
Table 6
Correlation between size of pupil and depth of focus
Si ze of pupi l (mm) Depth of focus (Di )
2
3
4
5
6
7
167
Ametropia (diopters)
Fig. 13. Visual acuity as a function of spherical defocus.
(Fron Westheimer G. Visual acuity. In: Moses R. editor.
Adler' s physiology of the eye. St. Louis, MO: Mosby; 1987.
p. 423. Data
.from
Laurence L. Visual optics and sight
testing. In: School of Optics. 3rd edition. London: 1926;
with permission.)
than 2-mm diameter because of the increased diffrac-
tion of light at the edges of the pupillary aperture. In
general, maximum pinhole acuity is approximately
20125 because of this diffraction. On the other hand,
in pupil sizes greater than 6-mm diameter, spherical
and chromatic aberrations diminish visual acuity be
adding additional blur to the image.
Refi"active error
Uncorrected ametropia is a common cause of poor
acuity (Fig. l3). As soon as the optics of the eye are
defocused, the point-spread function widens, and two
stimuli, to be identified as separate, must be further
apart than in fully focused state. The width of the
defocused point-spread functions depends directly on
the amount ofdefocus and inversely on the pupil size.
Spherical and astigmatic refractive errors enlarge the
blurred area on the retina. Spherical errors produce a
blur circle, whereas astigmatisrn may produce a blur
ellipse or line. According to Westheimer
[5],
Laur-
ance
[24],
and Reiner
[25],
spherical errors of *0.5
D and astigmatic errors of +1.0 D, respectively,
reduce visual acuity by approximately one half the
Snellen fraction of maximum (Fig. la).
Retinal eccentricity
Only in the center of the fovea are conditions
appropriate for maximum acuiry. Even I
o
away from
C. Kni estedt. R.L. Stamper / Ophthul mol Cl i n N.4m 16 O003) 155 170
o
+ 0. 40
+ 0. 28
+ 0. 20
+ 0 . 1 6
+ 0. 14
+ 0. 13
(Fron Rassow B, Haase W. In: Straub W Kroll P, Kuechle
HJ, edi tors. Augenaerztl i che Untersuchungsmethoden.
2nd edition. Stuttgart, Germany: Enke Verlag Stuttgart:
1995. p. 354. )
168 C. Kni e.stedt. R.L. Stamper / Ophthal mol Cl i n N Am 16 (2003) 155-170
30' 50"
Deviation from Axis of Astigmatism (Degrees)
Fi g. l zl . Vi sual acui ty as a functi on of asti gmati sm. (Fronr Rei ner J. Ei nfl uss des Achsenfehl ers asti gmati scher Bri l l engl aeser auf
di e Sehschaer f e. Kl i n N4bl Augenhei l kd 19701157: 259 62: r vi t h oemi ssi on. )
1. 0
0.8
E
U. O
d o. 4
5
0.2
60' 40' 20" 10" 0'
it. there is a reduction to approximately 70To of
maxi nal cenh' al vi sual acui t y (Fi g. l 5). The peri pheral
decrease in visual acuiry results fiorn neural connec-
tivity rather than optical blur or receptor spacing, and
i t i s st eeper t han t he decrease of phot orecept ors
because of the strong cortical representation of the
cent r al r et i na
[ 3] .
As ear l y as 1894. Wer t hei r n
described this eflect as indircct visudl ocuih' L261.
Retinul delbcts
Contrast sensitivity lirnctions and laser interfer-
ence fringers hold promise in evaluating media opac-
i t i es and i n st udyi ng ret i nal and neural def ect s.
Specific spatial loss may occur because lrequency
channels are pref' erentially affected. Gratings are
useful potential screening tests. though many varia-
bles still have to be sorted out. The simple pinhole
may still be useful in separating optical from non-
optical dei-ects. Many retinal disorders, such as macu-
l ar edema and age-rel at ed macul ar degenerat i on.
contribute to a decrease in visual acuitv.
Opurlue ntedia
Comeal edema increases light scatter, produces
hal oes, and i nduces gl are sensi t i ' "' i t y. General l y,
reduced transparency of nredia, such as comea, lens,
and vitreous, increases the amount of scattered light
coming onto the retina. which may be superimposed
on t he sharpl y f ocused i mage causi ng i ncreased
vi sual conl usi on. I n addi t i on, opaque medi a may
magnily the scatter produced by disadvarrtageor.rs
environmental illumination. Clinically, patients with
opaque media often complain of glare in brightly lit
environments. Polaroid glasses reduce glare by 509/o
for outdoor activities, though they are not recom-
mended for driving at night. Driving during these
hours may have to be curtailed if glare is caused by
an unt reat abl e probl em. Fort unat el y, most medi a
opacities are treatable. Improper lighting while read-
ing or fiom computer or TV screens may also be a
Foveal Eccentricity (Degrees)
Fi g. 15. Vi sual acui t_v as a fl l ncti on of reti nal eccentri ci ty.
(Fron Westhei mer G. Vi sual acui ty. l n: Moses R, edi tor.
Adl er ' s physi ol ogy of ' t he eye. St . Loui s. MO: Mosby; 1987.
p. 123. Dat a. l i ozr Wer t hei m T. Ueber di e i ndi r ekt e
Sehschaerft. Z Psychol 1894:-l :172: u' i th permi ssi on.)
d
t\
t \
c y l +0,
\
I
_c y l
+ I , 0
I
- 6 y l
f 4 , 5
- c y l + 1 , 5
1l +2, 5
I
problem. Halogen bulbs that can be used with indirect
lighting (bounced off the ceiling) or with highly
directed and adjustable lamps may be helpful for
reading. Glare screens are available for computers
and TV to reduce glare from ambient lighting. The
effect of glare can be tested to some exlent in the
office by comparing visual acuiry in a dirnmed room
to that obtained when the lights are on. Commercial
devices such as the Marco glare tester are also useful
to estimate the et' fect of glare.
Erposure time
Exposure time is rarely a factor in clinical testing
but n.ray become significant in driving, flying, oper-
ating fast-moving machinery, or detecting a blip on a
radar screen. As we age, the ability to respond to
short stimuli decreases
[2]
Dvtamic actti^,
Acuity for rnoving targets dinrinishes approxi-
mately as a cubic function of target velocity and
correlates poorly with static acuity. Despite i1s obvious
importance. it is seldom nteasured clinically. Motion
threshold in empty fields is approximately 8.5 minutes
of arclsecond. Increasing illuminance may improve
perfonnance. Drifts and spikes ofthe fixating eye are
needed to maintain ongoing stimulation of the retina.
Experiments with unmoving eyes show that within
seconds, the eye becomes unable to detect anything
without this ocuiar drift and microsaccades [271.
Centrol defetts
Acuity defects associated rvith central nervous
system lesions, such as cortical def-ects, are generally
diagnosed by ancillary testing of visual fields, visr-ral
evoked potentials, and other neurologic and psychi-
atric symptoms. Motility disturbances may accom-
pany poor acui t y. as i n congeni t al nyst agmus.
Ph a rm a cologi c infl uence
Many drugs can af f ect acui t y. The l i t erat ure,
though enormous, is mostly descriptive. Among com-
mon agents that can change refractive error are miot-
ics, cycloplegics, phenothiazines, barbiturates, and
sull' onamides. Some anxiolytics can actually affect
t he ret i na, as can chl oroqui ne deri vat i ves, di goxi n.
and sildenafll. An extensive sumr.nary of drug-induced
ocular side eftbcts is given by Frauenfelder
[28].
169
Summary and practical recommendations
Distance acuity testing can still effectively be
accomplished with Snellen chans, either paper or
projectors. Care should be taken to replace bulbs that
are yellowing and charts that are losing contrast from
dirt or dust. Computerized projector systems may
make t he j ob
easi er. Many proj cct ors are commer-
cially available (Zeiss, Rodenstock, Marco, Reichert,
Topcon). They all are based on standardized back-
ground illumination, and they all offer a huge spec-
trum of letters, symbols, and figures.
It rvould be desirable to provide the computerized
projectors with the ETDRS test chart features. To our
knowledge, this is not yet done.
For clinical studies. the ETDRS charts are recom-
mended and. for many studies. mandatory. In these
circumstances, visual acuity should be noted in Log-
MAR uni t s. Because near vi si on i s of t en more
important in the daily life of older or infinn patients.
reading charts or other near vision testing charls
should be used as part of the routine assessment of
' r, i sual
abi l i t i es. I t i s cruci al al so t o not e t he t est i ng
distance to compare visual acuity data over a period
of time, especially if several exantiners are involved.
Although unstandardized. .Iaeger charts may be used,
but for assessment over time. care should be taken to
use the same system with similar lighting. Given that
reading charts differ u,idely in their comparability,
one shoul d use onl y one t ype of chan i n a gi ven
of f i ce and mai nt ai n t hat syst em over t i me.
For the lou,-vision patient, the clinician should
have the ability to test visual acuity at closer distances
than 20 feet (6 m). Movable light box charts (eg.
ETDRS with M-units) are best. but the patient can
also be moved closer to a fired chart. Visual acuiry
testing in the illiterate and developmentally challenged
should be performed with the tumbling "E" chart.
Thi s t est al so mi ght be appropl i at e f or preschool
chi l dren. especi al l y i f parent s are gi vcn t i mc t o pract i ce
with the child. Charts with symbols and pictures often
achieve more attention for the young examinee but are
difficult to standardize. In infnts and preverbal chil-
dren, preferential looking methods and estimation of
fixation and following behavior are the most practical
methodology for vision assessnlent in the oftlce.
Visual acuity measurement is often taken for
grant ed. Many pi t f al l s make t hi s most i mport ant
assessment subject to variabiliry. Anrbient illumina-
tion. aging bulbs, dirry charts or slides, srnall pupils.
and poorly slandardized charts are just some of the
factors that can lead to erroneous results. A little care
in ensuring the proper environment for testing can
signifi cantly improve accuracy.
C. Kni estedt. R.L. Stamper / Ophthal mol CIi n N Am l 6 (2003) 155-170
1 7 0 C. Kni estedt. R.L. Stamper l Ophthal mol Cl i n N Am 16 (2003) 155-170
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