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Optometry (2009) 80, 447-453

Clinician versus potential acuity test predictions of visual

outcome after cataract surgery
Marta Vianya-Estopa, Ph.D.,a William A. Douthwaite, Ph.D.,a Charlotte L. Funnell,
FRCOphth,b and David B. Elliott, Ph.D.a

a
University of Bradford, Department of Optometry, West Yorkshire; and bLeeds Teaching Hospitals Trust, Ophthalmology
Department, St. James’s University Hospital, West Yorkshire, United Kingdom.

KEYWORDS Abstract
Potential vision test; BACKGROUND: The aim of this study was to compare the ability of potential vision tests and clinical
Cataract; judgement to predict postoperative visual acuity after uneventful cataract surgery.
Super-illuminated METHODS: Sixty-two subjects (median, 74.5 years) were included in the study. Preoperative measure-
pinhole; ments included a clinical judgement prediction (based on case history and ocular examination alone), 2
Potential Acuity Meter; super-illuminated pinhole techniques (distance and near), Potential Acuity Meter and interferometer.
Laser interferometer Postoperative visual acuity was used as the outcome measure to evaluate the accuracy of the preoper-
ative predictions.
RESULTS: Subjects were categorized as follows: (a) moderate cataract (N 5 25); (b) moderate cataract
and comorbidity (N 5 18), and (c) advanced cataract (N 5 19). Preoperative predictions within 2 lines
of the postoperative visual acuity were as follows (a, b, and c respectively): clinical judgement (92%,
72%, 58%), super-illuminated pinhole distance (96%, 100%, 21%), super-illuminated pinhole near
(92%, 78%, 26%), Potential Acuity Meter (72%, 67%, 21%), and interferometer (56%, 61%, 37%).
CONCLUSIONS: Based on the preoperative predictions above, none of the potential vision tests was
useful compared with the clinical judgement in the advanced cataract group. The super-illuminated
pinhole (distance) provided additional information beyond clinical judgement in the moderate cataract
subgroup. The Potential Acuity Meter and interferometer were inaccurate even in the presence of mod-
erate cataract, and this and other recent findings suggest they should no longer be considered adequate
for potential vision assessment.
Optometry 2009;80:447-453

Clinicians usually predict the likely visual outcome to be
achieved after cataract surgery based on history and ocular
examination. However, it is not always easy to establish the
Conflict of interest: None of the authors have a financial or proprietary
interest in any method or material mentioned in this study.
Corresponding author: Marta Vianya-Estopa, Ph.D., University of
Bradford, Department of Optometry, Bradford BD7 1DP, West Yorkshire,
United Kingdom.
E-mail: martavianya@hotmail.com
contribution of ocular comorbidity to the subject’s
decreased sight, particularly when both cataract and reti-
nal/neural disease coexist. Schein et al. reported that 63%
of subjects predicted by ophthalmologic judgement to
obtain a visual acuity (VA) of 20/40 or worse after cataract
surgery (the level at which surgery is often considered to be
‘‘unsuccessful’’),1 actually achieved a VA of 20/30 or bet-
ter.2 Conversely, overestimation of the visual outcome
will undoubtedly result in patient disappointment and
should be avoided whenever possible. Mavroforou and
Michalodimitrakis3 reported that the most common cause

1529-1839/09/$ -see front matter Ó 2009 American Optometric Association. All rights reserved.
doi:10.1016/j.optm.2008.11.011
448
of patient litigation after cataract surgery (in the United
States) was poor visual outcome in patients who had cata-
ract and macular disease before cataract surgery.
Potential vision tests (PVTs) were developed initially in
the early 1980s in an attempt to improve the prediction of the
visual performance after cataract surgery.4,5 However, a ma-
jor review conducted by the Agency for Health Care Policy
and Research in 1993 concluded that there was insufficient
evidence to establish whether PVTs increased the accuracy
of the preoperative visual outcome prediction over and above
history and ocular examination alone.6 As a result, clinical
guidelines for the management of adult cataracts typically
do not include PVTs as part of the preoperative ophthalmic
evaluation.7,8 Since this major review, several newer tech-
niques have been developed.9-16 In most cases, developers
of PVTs have reported the value of newer techniques by com-
paring them with standard PVTs, such as the Potential Acuity
Meter.12,17 In addition, it is important to compare the results
of PVTs with clinical judgement to determine whether they
provide any additional useful information.
Pinhole tests have been suggested previously as PVTs,
given their resistance to moderate/dense cataract and sensi-
tivity to macular disease.18 However, there is variation in the
design of these tests ranging from the simple pinhole,19 to the
illuminated pinhole at near12,18,20 and retro-illuminated pin-
hole at distance18,10 (either at 3.2 m or at 1 m). Techniques
have also varied in the type of VA charts used (including re-
versed contrast polarity,10,18 Snellen12,20 and logMAR de-
signs10,18) and the luminance levels used10,20 (ranging from
1200 cd/m2 at 1 m to 1464 cd/m2 at 40 cm). Perhaps, not sur-
prisingly, Potential Acuity Meter predictions were found to
be more accurate than a conventional pinhole (81% versus
40% within 2 lines of best-corrected VA).19 The most likely
explanation for this is the lack of decreased retinal illumina-
tion with the Potential Acuity Meter. Conversely, the predic-
tions obtained with an illuminated pinhole at near were found
to be more accurate than the Potential Acuity Meter for a
range of cataract severities associated with a VA of better
than 20/50 to worse than 20/200 (for example, 100% versus
47% for the 20/60 to 20/100 subgroup).12
This study was undertaken to compare the predictive
ability of 2 versions of the super-illuminated pinhole
(distance and near), the standard PVTs of the Potential
Acuity Meter and interferometer, and clinical judgement
based on history and ocular examination alone. The aim
was to assess whether PVTs should be used in clinical
practice to guide clinicians when there is uncertainty over
the likely visual benefit of cataract surgery.
Methods
Subjects
An unselected sample of 74 subjects with age-related
cataract was recruited from the cataract surgery waiting
list at the Leeds Teaching Hospitals Trust, Eye Department,
Optometry, Vol 80, No 8, August 2009
Leeds, United Kingdom. The exclusion criteria for this
study included:
 Subjects unable to speak English
 Subjects with any physical or mental disability that
would make it arduous to perform the tests
 Upper age limit 90 years
Three subjects had postoperative complications (includ-
ing malposition of intraocular lens, intraocular lens ex-
change, and central retinal vein occlusion) and were
excluded from the study because the preoperative predic-
tions only apply to the visual result of an uneventful
surgery. One subject decided not to undertake the surgical
procedure, and 8 subjects were lost at the follow-up visit.
Thus, 62 subjects (median age, 74.5 years; range, 50 to 89
years) were included in this study. A total of 38 subjects
were listed for first-eye cataract surgery. Informed consent
was obtained in each case, and the study gained approval
from the Hospital Ethical Committee and followed the
Declaration of Helsinki for research involving human
subjects. The decision to perform cataract surgery was
independent of the findings of this study.
The 62 cataract subjects were divided into 3 groups as
suggested by the Agency for Health Care Policy and
Research:6 25 subjects with moderate cataract, 19 with ad-
vanced cataract, and 18 with moderate cataract and comor-
bid eye disease (see Table 1). Advanced cataract was
defined as a Lens Opacity Classification System (LOCS)
III21 grading for nuclear opalescence, nuclear color, and
cortical opacity R5.0 and/or a posterior subcapsular opac-
ity R3.0. All other cataracts listed for cataract surgery were
classified as moderate and had nuclear opalescence R2.0
(range, 2.0 to 4.8), nuclear color R1.7 (range, 1.7 to 4.9),
and/or cortical opacity R0.1 (range, 0.1 to 4.2), and/or a
posterior subcapsular opacity R0.1 (range, 0.1 to 2.5). Sub-
jects in the moderate cataract and comorbidity subgroup
presented with the following ocular comorbidities: 9 with
dry age-related macular degeneration, 6 with glaucoma,
and 1 each with amblyopia, wet age-related macular degen-
eration, and an epiretinal membrane. All clinical diagnoses
were made before surgical intervention and were confirmed
postoperatively when a clear view of the fundus could be
obtained. The clinical diagnoses of 8 subjects in the ad-
vanced cataract included dry age-related macular disease
(3 cases), glaucoma (2 cases), amblyopia (2 cases) and
epi-retinal membrane (1 case). The predictive ability of
PVTs and clinical judgement in the advanced cataract
only and advanced cataract with comorbidity subjects pro-
vided very similar results, and so the 2 groups were
combined.
Procedures
Subjects were examined a median of 3 weeks (range, 1 to
13 weeks) before surgical intervention and a median of 11
weeks (range, 10 to 20 weeks) after the cataract surgery. In
the preoperative visit, PVT measurements were taken in a
 Vianya-Estopa et al
Table 1 Demographic characteristics of the 62 subjects assessed preoperatively and postoperatively including mean (6SD) for the preoperative predictions of VA and the

Clinical Research
postoperative measurement of VA

Age Preoperative Predictions of postoperative VA* (mean 6 SD) Postoperative

LOCS III (median; VA (mean 6 VA (mean 6
(mean 6 SD) range; yrs) SD; logMAR) CJ SPHd SPHn PAM LI SD; logMAR)
Moderate NO 3.2 6 0.8 73.0; 50 – 83 0.22 6 0.14 0.04 6 0.08 0.11 6 0.07 0.07 6 0.10 0.11 6 0.11 0.16 6 0.15 20.02 6 0.07
cataract NC 3.2 6 0.9
(N 5 25) C 2.1 6 1.6
P 0.4 6 0.7

Moderate NO 3.0 6 0.7 78.0; 63 – 89 0.37 6 0.23 0.18 6 0.16 0.19 6 0.12 0.18 6 0.11 0.21 6 0.13 0.24 6 0.18 0.20 6 0.33
cataract NC 3.2 6 0.6
& co- C 2.4 6 1.6
morbidity P 0.6 6 0.7
(N 5 18)

Advanced NO 4.6 6 1.3 73.0, 56 – 85 0.88 6 0.54 0.19 6 0.11 0.27 6 0.13 0.25 6 0.22 0.27 6 0.19 0.35 6 0.46 0.02 6 0.11
cataract NC 4.9 6 1.5
(N 5 19) C 1.1 6 1.6
P 2.3 6 2.2

NO, nuclear opalescence; NC, nuclear color; C, cortical; P, posterior capsular opacity; LogMAR, logarithm of the minimum angle of resolution; CJ, clinician judgment; SPHd, super-illuminated pinhole
distance; SPHn, super-illuminated pinhole near; PAM, Potential Acuity Meter; LI, laser interferometer.
* The mean of the predictions of postoperative VA was calculated for those subjects able to obtain a score with all PVTs (25 in the moderate, 17 in the moderate and comorbidity, and 13 in the advanced
cataract subgroup).

449
450
Table 2 The accuracy of PVT predictions given as a
percentage of PVT preoperative predictions within 2 logMAR
lines of the postoperative VA measurement in the 3 ocular
subgroups compared with the clinical judgment prediction in
62 subjects
Moderate Moderate cataract Advanced
cataract & co-morbidity cataract
(N 5 25) (N 5 18) (N 5 19)
CJ 92% 72% 58%
SPHd 96% 100% 21%
SPHn 92% 78% 26%
PAM 72% 67% 21%
LI 56% 61% 37%
CJ, clinical judgment; SPHd, super-illuminated pinhole distance;
SPHn, super-illuminated pinhole near; PAM, Potential Acuity Meter;
LI, laser interferometer.
random order in the surgical eye after instillation of 1.0%
tropicamide and 2.5% phenylephrine. The cataracts were
graded using the Lens Opacity Classification System III.21
The LOCS III is a widely used classification system based
on a set of standard photographs that are used as a reference
to classify lens opacities at the slit lamp or in standardized
lens photographs. Pupil dilation is required before LOCS
III grading of the lens opacities. Grading using LOCS III
involves the assessment and estimation of 4 features:
nuclear opacification (i.e., brightness of scatter from the
nuclear region), nuclear color (i.e., brunescence), and the
extent of cortical and posterior subcapsular opacities.
Nuclear opalescence and nuclear color are graded against
6 photographs on a decimal scale of 0.1 to 6.9 (in 0.1 steps),
and cortical and posterior subcapsular opacity are each
graded against 5 photographs on a scale of 0.1 to 5.9 (in
0.1 steps). The final LOCS III scale comprises the values
given to each of these 4 features. Higher grade scores indi-
cate greater severity of opacification.
Subjective refraction, measurement of optimal VA, and
slit lamp biomicroscopy of the fundus were performed in
the pre- and postoperative visits. The postoperative VA
represented the visual performance measurement against
which the preoperative predictions could be compared. All
PVT tests, pre- and postoperative VAS, and LOCS III
assessment were made by one clinician. Information from
PVT results was not available at the postoperative visits to
limit potential bias.
Distance VA was measured at 3.2 m under monocular
conditions using an early treatment diabetic retinopathy
study (ETDRS) logMAR chart (mean luminance 200 cd/m2),
using a by-letter scoring system (0.02 log units per letter)
and a termination rule of no letters called correctly on a
line.22 The standard Potential Acuity Meter (Mentor Inc.,
Norwell, Massachusetts) procedure5 was used, and Snellen
VA was determined as the smallest line at which the major-
ity of letters were correctly identified. The Rodenstock Ret-
inometer (Rodenstock, London, United Kingdom) was the
Optometry, Vol 80, No 8, August 2009
interferometer used following the standard procedure23
with the gratings presented at 4 random orientations: hori-
zontal, vertical, or oblique (45 to the right or the left). The
highest spatial frequency at which the orientation of the
fringe pattern could be correctly identified on 2 separate
occasions gave a measure of the retinal/neural resolution.
Oblique orientations were not used at threshold level. The
super-illuminated pinhole at near was based on the test de-
scribed by Melki et al.12 The test measured logMAR near
VA using an ETDRS logMAR reading card held at 40 cm
and illuminated by an external light source with the subject
looking through a multiperforated pinhole (5 apertures of
1 mm). The external light source was moved by the exam-
iner onto the section of the chart that was being read by the
subject to give a luminance around 1,300 cd/m2. A super-
illuminated pinhole at distance was also used. It consisted
of measuring distance VA using a reversed polarity (white
letters on a black background) ETDRS logMAR chart,
with the subject looking through a multiperforated pinhole.
The letters were seen by retroillumination (luminance 500
cd/m2) in a darkened room at a working distance of 3.2 m.
To evaluate whether any of the PVTs provided information
beyond that obtained by history and ocular examination
alone, the PVT predictions were compared with a clinical
judgement. The clinical judgement required the ophthal-
mologist to choose a predicted postoperative VA from a
range, which followed a logMAR line progression (20/13,
20/17, 20/20, 20/25, 20/30, 20/40, 20/50, 20/60, 20/80,
20/100, 20/120, 20/160, 20/200, 20/250, and 20/400). The
clinical judgement was performed prospectively by the
ophthalmic surgeon undertaking the operation on the day
of the surgery using information from the case history
and ocular examination alone and with no input from the
PVT results. In total, the clinical judgement was completed
by 8 experienced cataract surgeons.
Results
Table 1 presents LOCS III categories and mean (6SD) data
for age, pre- and postoperative VA and PVT, and clinical
judgement predictions of postoperative VA in the 3 ocular
subgroups. Only those subjects able to obtain a result with
each of the PVTwere included in the calculation of the means
(6SD). The accuracy of the preoperative clinical judgement
prediction was further compared with the 4 PVT predictions
in terms of the percentage of subjects who achieved the post-
operative VA result within 10 letters (i.e., 2 logMAR lines) of
the predicted VA (see Table 2). Table 2 indicates that the pre-
dictive ability of all PVTs under investigation was severely
diminished in the advanced cataract subgroup where clinical
judgement offered the most accurate predictions. However,
some of the PVTs provide predictions as good as or better
than clinical judgement with moderate cataracts (see Table
2). The question is whether any PVT provides additional in-
formation beyond that provided by clinical judgement alone.
Hierarchical stepwise regression analysis was used to assess
Vianya-Estopa et al Clinical Research
the value of the 4 PVTs over and above clinical judgment in
subjects with moderate cataract (with and without comorbid-
ity). PVTs were used as predictors, and the postoperative VA
measurement was used as the outcome variable. Clinical
judgement was used as a forced first step, as it is the standard
judgement of potential vision in the decision-making process
for cataract surgery assessment. Subsequent to clinical
judgement being forced as a first step, all PVTs were consid-
ered for inclusion into the regression model. Thus, for a PVT
to be of clinical value, it must provide significant additional
information about postoperative visual acuity beyond clini-
cal judgement. Stepwise regression indicated that 46% of
the postoperative VA data could be correctly predicted by
clinical judgement alone. The hierarchical stepwise regres-
sion then indicated that 74% of the postoperative VA data
could be predicted by the super-illuminated pinhole distance
procedure combined with the clinical judgement. This means
that super-illuminated pinhole distance provides extra infor-
mation beyond clinical judgement to help predict the postop-
erative VA. However, the hierarchical stepwise regression
then indicated that none of the other PVTs provided signifi-
cant additional information beyond that provided by the clin-
ical judgement alone in subjects with moderate cataract (with
or without ocular comorbidity). Clinically, one may expect
that PVTs may be used particularly in the preoperative as-
sessment of cataract patients when clinicians suspect the
presence of retinal/neural abnormalities. Thus, we repeated
the hierarchical regression analysis in subjects with moderate
cataract and ocular comorbidity only. In this scenario, the
clinical judgement accounted for 52% of the postoperative
VA data and clinical judgment, and super-illuminated pin-
hole distance accounted for 90% of the postoperative VA
data. None of the others PVTs gave significant additional in-
formation to that provided by clinical judgment.
Discussion
A comparison of the means (6SD) obtained with the clinical
judgement and the PVTs against the postoperative VA result
indicates that with the exception of the interferometer, all
PVTs and the clinical judgement underestimate the postop-
erative VA by less than 1.5 lines of letters in the presence of
moderate cataract. Table 1 also indicates a larger underesti-
mation of postoperative VA with all PVTs and the clinical
judgement in the presence of advanced cataract. It is worth
noting that, despite poor penetration of even moderate cata-
ract, the interferometer increased its predictive ability in
the presence of moderate cataract and comorbidity. It has
been shown previously that the interferometer (and to a lesser
extent Potential Acuity Meter) overestimate the visual result
in the presence of clear media and macular abnormalities.
This suggests that the overoptimistic predictions obtained
in the presence of retinal abnormalities can compensate for
the poor cataract penetration in some cases.18,24,25
Table 2 illustrates the percentage of preoperative PVT
predictions and clinical judgement predictions that fell
451
within 2 logMAR lines of the postoperative VA for the
62 subjects. It can be seen that the super-illuminated pin-
hole distance test provided a similar prediction to clinical
judgement in the presence of moderate cataract and a better
prediction than clinical judgement in the presence of mod-
erate cataract with comorbidity. Hierarchical regression
analysis confirmed that the super-illuminated pinhole dis-
tance test provided additional improvement in VA predic-
tion compared with the clinical judgement alone in the
moderate cataract and moderate cataract with comorbidity
groups. This suggests that super-illuminated pinhole dis-
tance may be used as a confirmatory test when the clinician
is uncertain of the contribution of retinal/neural disease to
the existing disability in moderate cataracts. del Romo
et al.10 also noted that an enhanced pinhole technique pro-
vided information beyond that obtained by clinical judge-
ment in the presence of moderate cataract and ocular
comorbidity in 12 subjects attending for first eye cataract
surgery (83% versus 50% within 2 logMAR lines).
In contrast, in the presence of advanced cataract, the
predictions obtained with the clinical judgement were
superior to those found using any of the PVTs (see Table
2). Previous investigators have also reported less accurate
predictions in the presence of increasingly advanced media
opacities with the Potential Acuity Meter,6,26,27 the laser in-
terferometer,6,23,28-30 and enhanced pinhole techniques.12,20
Recent reports suggest that the critical flicker/fusion fre-
quency technique shows promising capabilities as a PVT
in the presence of advanced cataract.10,14,31
In this investigation, the super-illuminated pinhole dis-
tance predictions were superior to the ones obtained with
the super-illuminated pinhole near. The factors influencing
the pinhole measurement are pinhole diameter, test chart
illuminance, and the refractive status of the eye. Given that
the same multiperforated pinhole and optimal refractive
correction for the viewing distance was used in both tests,
the chart illuminance and chart contrast polarity remain as
the only factors responsible for the difference in predictive
ability between the tests. External illumination of the letter
chart may be less satisfactory than the retroillumination
used in the super-illuminated pinhole distance test. It would
also appear that a chart in reversed contrast polarity (white
letters on a black background) is preferable.
Ten subjects (6 moderate cataract and comorbidity and 4
advanced cataract) were predicted by clinical judgement to
achieve a postoperative VA of 20/40 or worse (the level of
outcome often deemed ‘‘unsuccessful’’), but 50% of them
achieved a postoperative VA of 20/30 or better after the
surgery, similar to the findings of Schein et al.2 Underesti-
mations of the retinal/neural function may result in surgical
delays or even discouragement toward undertaking the sur-
gery. The latter is supported by the high prevalence
(w19%) of patients found in low-vision clinic populations
presenting with both age-related macular degeneration and
cataracts.32
The clinical information provided by the VA measure-
ments and clinical examination after first-eye surgery may
452
have contributed to the correct clinical predictions for
second-eye cataract in this study. A higher percentage of
correct clinical judgment predictions were found after
second-eye surgery compared with first eye: 100% versus
88% (moderate cataract group), 88% versus 60% (moderate
cataract and comorbidity) and 71% versus 50% (advanced
cataract). This indicates that PVTs may be more beneficial
in the decision-making process of cataract surgery in
subjects presenting for first-eye cataract surgery. In view
of these results, future studies of PVTs are encouraged to
focus their investigations primarily in first-eye cataract
surgery subjects with and without ocular comorbidity.
Conclusions and clinical implications
All the evaluated PVTs were found to be adversely affected
by advanced cataract with no additional information be-
yond clinical judgement. These results and others from
several other studies18,23-28,30,33 also suggest that the stan-
dard techniques of the Potential Acuity Meter and interfe-
rometer should no longer be considered appropriate for
potential vision because of their low predictive ability
and inability to bypass moderate/advanced cataract.
Clinical judgement on its own provides a good predic-
tion of postoperative VA if a clear view of the fundus can be
gained. Currently, most patients undergoing cataract sur-
gery in developed countries are likely to present with early
to moderate cataracts. Thus, according to our findings,
clinical judgement on its own should provide reasonably
accurate prediction of the likely outcome to be achieved
after cataract surgery, particularly if the macula appears
normal for the patient’s age. During the presurgical assess-
ment of cataract patients, clinicians are encouraged to
consider the results of a variety of tests as predictors of
visual performance. For example, a dilated fundus exam-
ination with fundus biomicroscopy provides a superior
view of the posterior pole through a cataract than direct
ophthalmoscopy and is much preferred.34 The swinging
flashlight test (also known as relative afferent pupillary de-
fect test, RAPD) may also be of significant relevance in the
detection of abnormalities of the retina or optic nerve even
in the presence of a dense cataract.34 Note that patients with
unilateral cataract may show an RAPD in the noncatarac-
tous eye that is not reflective of visual pathway disease.35
Subtle pigmentary changes with the occasional drusen
may be normal in patients older than 65 years of age, but
these patients can still retain very good VA. The average
VA for elderly subjects (i.e., about 75 years of age) with
normal healthy eyes is actually 20/201.34 Another useful
indicator for patients undergoing second eye surgery is to
compare the appearance of the maculae in the pseudo-
phakic eye with that in the cataractous eye using the rela-
tive appearance plus the VA in the pseudophakic eye to
predict the postoperative VA in the cataractous eye. When
uncertain of the effect of any retinal/neural changes in the
presence of moderate cataracts, our results suggest that
Optometry, Vol 80, No 8, August 2009
the super-illuminated pinhole distance technique may pro-
vide additional information beyond the clinical judgement.
Finally, and based on the outputs of this study, we encour-
age those involved in the development of computerized eye
charts to further develop a simple super-illuminated pinhole
distance strategy that, combined with a pinhole, could be
used to provide accurate predictions of postoperative visual
outcome.
Acknowledgments
The authors thank the consultants and staff of the Eye
Department of Leeds Teaching Hospitals Trust for their
assistance.
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