Measuring Vision and Vision Loss

Colenbrander - Measuring Vision and Vision Loss 2009
Measuring Vision and Vision Loss

August Colenbrander, MD San Francisco
PART 1
INTRODUCTION, ASPECTS OF VISION LOSS

ASPECTS OF VISION LOSS
Anatomical and Structural Changes, Visual Functions, Functional Vision,
Societal and Economic Consequences
MEASUREMENT and ASSESSMENT
PART 2
2A
MEASURING VISUAL FUNCTIONS

VISUAL ACUITY MEASUREMENT
Basic Concepts
Historical Developments
Considerations for Letter Chart Testing
cognitive factors, test distance, progression, contrast and illumination,
notation, rounding, test symbols, chart layout, summary.
Considerations for Near vision Testing and Reading

near letter acuity, reading acuity, modified Snellen formula, letter size notations,
reading fluency, reading patterns, eccentric viewing, scotoma interference,
Testing Infants and Young Children

2B
VISUAL FIELD RELATED FUNCTIONAL PROBLEMS

Introduction
Central Field Defects
Scanning Laser Ophthalmoscope, macular mapping test, central tangent screen.
Peripheral Visual Field

Mental Model of the Environment
2C
CONTRAST SENSITIVITY
Introduction
Contrast Detection
The Contrast Sensitivity Curve
Measurement methods
determining the endpoints, determining intermediate points, determining
the slope, gratings vs. letters, contrast scales, interpreting CS findings.
PART 3
3A
ASSESSING FUNCTIONAL VISION and QUALITY of LIFE

FUNCTIONAL VISION
Introduction
estimating functional vision, direct assessment, classifications
Eligibility Guidelines, based on visual function measurements

legal Blindness,
Estimating a Visual Ability Scale from visual function measurements

visual acuity score, visual field score, functional acuity and functional
field score, functional vision score, AMA impairment rating.
Direct Assessment of Functional Vision

assessment of visual abilities, resource inventory, task inventory,
performance ranges, how many ranges, measuring performance,
Likert vs. Rasch scores, different settings, rehabilitation outcomes, outlook.
3B
QUALITY of LIFE
Introduction, Types of Quality of Life
Individual Health Care
questionnaires, indirect assessment
Health Policy
QALYs, Time Trade-off, Standard Gamble, Visual Analog Scale,
Burden of vision loss,
Closing thoughts
Figures
1.
Aspects of Visual Functioning
2.
Assessment of Visual Functioning
3.
Visual Acuity-related Scales of Visual Functioning
4.
Franciscus Cornelis Donders
5.
Eduard von Jaeger
6.
Donders Formula
7.
Herman Snellen and his charts
8.
Visual Acuity and Age
9.
John Green and his chart
10.
Decimal and other Visual Acuity Notations
11.
Landolts broken Ring
12.
Sloans Optotypes
13.
Bailey-Lovie and ETDRS charts
14.
Low Vision Letter chart with cord for 1 meter
15.
Various Letter Size Progressions
16.
Visual Acuity and Quality of Life
17.
Preferred Numbers
18.
Various Equivalent Visual Acuity Notations
19.
Rounding of Visual Acuity Values
20.
Various Optotypes
21.
Letter chart vs. Reading Acuity
22.
Modified Snellen formula
23.
Magnification Requirement for Letter Chart and for Reading Acuity
24.
Variability of Jaeger Numbers
25.
Variability of Printers Points
26.
Reading Cards with Proportional Paragraphs
27.
Improved hand-eye coordination
28.
Visual Behavioral Milestones
29.
Various Childrens Tests
30.
Micro-perimetry
31.
Macular Mapping Test
32.
Tangent Screen with Laser Pointer
33.
Optical vs. Retinal Causes of Contrast Sensitivity Loss
34.
Measurement Methods for the Contrast Sensitivity Curve
35.
Mixed Contrast cards.
36.
Measurement units for Letter charts vs. Gratings
37.
Various Blindness criteria
38.
Functional Vision Score and AMA Impairment Ratings
39.
The Visual Field Score
40.
Medical vs. Rehabilitative outcomes
41.
General Scale of Functioning, applied to Visual Abilities
42.
Visual Acuity and Visual Ability Ranges
43.
Timed Instrumental Activities of Daily Living
44.
Matching Tasks to Abilities
45.
Results of the LOVIT study
46.
Comprehensive Vision Rehabilitation vs. Low Vision Care
47.
Patient-based Time Trade Off Utility values

PART 1
INTRODUCTION, ASPECTS OF VISION LOSS
In epidemiology as in individual health care, it is important to know not only the cause and
nature of a condition, but also the severity of its impact and its functional consequences. In the
case of ophthalmology the question is how to assess how eye diseases and other conditions
affect the complex entity that is called vision. This chapter will discuss the accurate
measurement of various aspects of vision and of visual functioning, with the ultimate objective of
enhancing the patients Quality of Life.
ASPECTS OF VISION LOSS

Vision loss can be observed from many different points of view. Each point of view reveals a
different aspect. Consider a patient with AMD, who wants to make an appointment. The front
desk will think about when to schedule her. The doctor will think about which treatment to
select. The office manager may worry whether the insurance will pay. The daughter worries
whether mother can still drive. These aspects are very different, but they all belong to the same
clinical case. Each of these aspects tells us something about the subject, but also gives us
insight in the point of view of the beholder.
Similarly, when considering visual functioning, we can perceive many different aspects of vision
loss, depending on our point of view (Fig. 1).
First we may consider how various causes may result in structural changes, such as scarring,
atrophy or loss. Here the focus is on the tissue and we need the pathologist to examine these
changes.
However, the structural changes in its components do not tell us how well the eye as a whole
functions. We need to widen our view from the tissue to the organ. We need a clinician to
measure aspects of organ function, such as visual acuity, visual field, contrast sensitivity, etc.
Yet, knowing how the eye functions, does not tell us how the person functions. So we need to
widen our perspective again, this time to the person level. We need to consider tasks, such as
reading, mobility, face recognition. Here we need various vision rehabilitation professionals to
work with the patient.
Beyond that, we need to look at the person in a societal context. Do these changes impact on
the persons participation in society, causing job loss or a reduced quality of life? How can we
be sure that the patient is satisfied, which should be the end goal of all our interventions?
It is useful to draw a line in the middle of Fig. 1; on the left side we speak of visual functions,
which describe how the eyes and the visual system function; on the right side we speak of
functional vision which describes how the person functions. When organ functions are
reduced, we speak of impairments. Most common are ocular visual impairments due to ocular
disorders; they constitute the traditional domain of ophthalmology. More recently, increased
attention is being asked for cerebral disorders, which may cause cerebral visual impairment. In
infants and children the cause may be perinatal cerebral ischemia, in adults it may be traumatic
brain injury, in the elderly it may be the result of a stroke. Cerebral visual impairments may
cause abnormal visual functioning, which can be captured under the term of visual dysfunction.
Figure 1 Aspects of Visual Functioning
Visual functioning can be approached from different points of view. Depending on our point of
view we will see different aspects (see text). The arrows indicate relationships between the
aspects, but these relationships are not fixed. The oblique arrows indicate that there are other
influences (including rehabilitation) that can modify the relationships. Without this flexibility,
adaptation and rehabilitation would not be possible.
Various activities may cover more than one aspect. When we consider reading, the
measurement of the threshold print size refers to organ function. Measures like Critical (or
optimal) Print Size [ 1], reading speed (words per minute) and reading endurance (hours per day)
describe abilities of the person. Reading enjoyment, finally, is an aspect of Quality of Life.
Anatomical and Structural Changes
The first column of Fig. 1 describes the underlying disorders or diseases. At the organ level all
forms of vision involve three distinct stages.
First is the optical stage, where the optical components of the eye deliver an image of the
outside world to the retina. This stage can be disrupted by opacities or refractive errors.
Dealing with these problems by prescribing glasses or by removing cataracts has for centuries
been a main stay of ophthalmic practice.
Next is the receptor stage, where receptors in the outer retina transform the image into neural
impulses. Ophthalmoscopy and slitlamp biomicroscopy have given ophthalmology tools to
describe anatomical changes at this level in more detail than is possible for most other organ
systems. This stage can be disrupted by various retinal diseases, which today demand an
increasing proportion of the ophthalmologists time and attention.
Third is the neural processing, which starts in the inner retina and proceeds through the visual
cortex to higher visual centers and eventually gives rise to functional vision and vision-related
functioning.
Most of the ophthalmic literature, including this textbook, is devoted to the first two stages. Until
recently, the third stage has often been overlooked. Each of these stages involves different
anatomical structures and different functional mechanisms, which can create different problems
and need different therapeutic approaches
Visual functions
This aspect describes functional changes at the organ level. Here again, ophthalmology has
developed unique tools that can measure visual functions with great precision. The most
commonly measured functions that have the greatest impact on general functioning are visual
acuity and visual field, followed by contrast sensitivity. Many other functions such as color
vision, stereopsis, light and dark adaptation and their psychophysical and electrophysiological
tests (ERG, VEP) are discussed in other chapters.
Reflecting the fact that the organ function column is flanked by two other columns, organ
function measurements can be used for two purposes: to assist in diagnosing the underlying
disorder (to the left in Fig. 1) or to predict the functional consequences (to the right in Fig. 1).
Different tests perform differently in this regard. Tests such as ERG and VEP are helpful in
diagnosing the underlying condition, but are poor predictors of the functional consequences.
Visual acuity loss can have many different causes; this means that it is a good screening test,
but adds little to the differential diagnosis. Yet, whatever its cause, it can help in predicting the
impact on Activities of Daily Living (ADL). Similar differences exist for other tests: the Ishihara
color test is good at diagnosing even minor red-green deficiencies for genetic studies, but
overestimates the functional consequences. The D15 color test on the other hand, was
designed to detect only those defects that might have functional consequences. The discussion
in this chapter will be mainly oriented towards functional consequences.
Functional vision
This aspect reaches beyond the description of organ function by describing the skills and
abilities of the individual. It describes how well the individual is able to perform various
Activities of Daily Living (ADL). This aspect has been described under different names. In the
field of vision, the term functional vision is used. In ICIDH [ 2] loss (or lack) of ability was
described as dis-ability. Its successor, ICF [ 3] uses the term activities. Activities and abilities
are two sides of the same coin, describing one without the other is meaningless.
Again, the columns on either side help to clarify different ways in which this aspect can be
approached. On the left are the available resources (vision, touch, hearing, etc.); they define
the ability aspect and are important when defining the means to be used in a rehabilitation plan.
Should we facilitate reading with magnification (vision), with Braille (touch) or with talking books
(hearing)? The activity aspect, to the right, relates to the societal goal of the action, to
participation and Quality of Life. This is important in defining the needs and objectives of the
rehabilitation plan.
Societal and Economic Consequences

The last aspect in Fig. 1 describes the societal and economic consequences for the individual
caused by a loss of ability. In ICIDH this aspect was described as handicap and measured in
terms of loss of independence; in ICF it is described under the heading participation, which
points to interdependence in a societal context. Handicaps need not preclude participation.
The story of Helen Keller is one example of how some people can achieve full participation in
spite of extraordinary handicaps. This aspect is also described as Quality of Life.
While ability describes what people can do, participation describes whether they actually do it.
Participation can be described fairly objectively. Quality of Life, on the other hand, refers to a
highly subjective experience. Quality of Life depends not only on individual factors; it also
depends on factors in the environment.
Improving the participation and Quality of Life aspect is the ultimate goal of all medical and
social interventions. There clearly are links between the aspects: disorders may cause
impairments, impairments may cause a loss of abilities, a loss of abilities may cause a lack of
participation. However, these links are not rigid. Medical and surgical interventions can reduce
the impairment caused by a disorder. Assistive devices and special training may improve
abilities in the face of a given impairment. Changes in the human and physical environment
may increase participation, regardless of reduced abilities. The art of comprehensive
rehabilitation is to manipulate each of these links so that a given disorder results in the least
possible loss of participation and the best possible Quality of Life. Comprehensive Vision
Rehabilitation Fig. 46 involves much more than traditional Low Vision care. An orthopedic
surgeon could not function without the help of physical therapists, prosthetists and others.
Similarly, ophthalmologists must reach out to other professions to offer their patients
comprehensive rehabilitation.
MEASUREMENT AND ASSESSMENT

The different functional aspects are measured and assessed in very different ways.
Under the aspect of visual functions (Fig. 2, left), we measure parameters that define how the
eye functions. We do this by varying one parameter at a time in a simplified, artificial
environment. Consider that the visibility of test objects depends on their size, contrast and
illumination. If we vary the size, while keeping contrast and illumination constant, we create a
letter chart to measure visual acuity. If we vary the contrast, while keeping size and illumination
constant, we create a contrast sensitivity test, like the Pelli-Robson [ 4] or Mars cards [ 5]. If we
vary the illumination, while keeping size and contrast constant, we perform a dark adaptation
test. Each of these three different tests provides us with a threshold value for the measured
stimulus parameter. The threshold criterion is generally defined as the response level that is
50% above guessing. Threshold measurements are chosen, not because threshold
performance is the most relevant performance level for activities of daily living, but because they
enable more precise psychophysical calculations.
Under the aspect of functional vision (Fig. 2, center), we must assess how the person functions.
To do this, we must focus our attention on visual skills and abilities, such as reading, Orientation
and Mobility (O+M) and Activities of Daily Living (ADL). Such tasks always involve multiple
parameters, which can vary independently and which cannot be manipulated separately.
Measuring functional vision, therefore, is more complex than measuring visual functions. We
also notice that we are no longer interested in threshold performance, but in sustainable, supra-
threshold performance. When reading a book, print size, contrast and illumination all need to be
well above threshold, to provide a comfortable performance reserve [ 6].
Figure 2 Assessment of Visual Functioning
The different aspects of visual functioning require different approaches for their assessment
(see text). Their assessment should not be mixed.
For visual functions we measure the variable stimulus needed for a fixed response; for
functional vision we measure the variable performance for a fixed task, either objectively (timing,
error rate) or subjectively (questionnaires).
Finally, we must consider the societal context, also described as Quality of Life (Fig. 2, right).
For subjective judgments such as making and keeping friendships, social skills, self confidence,
etc. the concept of measurement is even more difficult. When we move a New Yorker to a
small rural community, and a rural farmer to the middle of Manhattan, both will complain that
their Quality of Life has deteriorated. The ultimate goal can best be described with the word
satisfaction, which describes the subjective balance between individual achievements and
individual expectations.
Part 2 of this chapter will deal with the measurement of visual functions, (how the eye
functions); part 3 will deal with the assessment of functional vision and Quality of Life (how the
person functions).
Among visual functions, visual acuity measurement is most prominent. Different visual acuity
related functions are measured on different scales. This can lead to confusion when each of
these different scales is labeled with the same undifferentiated term vision.
Fig. 3 previews and compares various scales and measurement units that will be discussed.
There are two ways in which the various scales differ. Some scales measure vision loss; on
these scales higher numbers indicate poorer vision; other scales measure functioning; on these
scales higher numbers indicate better vision. The other difference is between scales with an
arithmetic (linear) progression (e.g. 0, 1, 2, 3, 4, 5) and scales with a geometric (logarithmic)
progression (e.g. 1, 2, 4, 8, 16, 32). The first type is used to describe the performance of the
EYE (M-units, viewing distance, MAR, VA); the second type is used to estimate the
performance of the PERSON (logMAR, log(VA) = - logMAR, VAS).
Figure 3 Visual Acuity related Scales of Visual Functioning
Visual acuity measurement starts with defining the stimulus parameters: symbol size and
viewing distance. The reference standard for size was defined by Snellen; the name M-unit
was coined by Sloan. The reference standard for distance is the meter and its reciprocal, the
diopter.
Given these parameters, we can describe how the eye functions by calculating the
MAgnification Requirement (MAR) needed to bring the subject to the performance standard.
MAR provides a scale of vision loss that can range up to very high numbers; its reciprocal, the
visual acuity value, provides a scale of visual function limited to the range from 0 to 1.0 (the
reference standard) and somewhat beyond. The MAR and visual acuity scales are useful for
calculations regarding viewing distance, print size and magnification need.
From these linear measurement of visual function (how the eye functions) we can derive a
statistical estimate of the persons visual ability (functional vision, how the person may function).
This is done by taking the logarithm of the measurements in accordance with Weber-Fechners
law [7], which states that a proportional increase in stimulus intensity produces a linear increase
in sensation. Like MAR, logMAR is a scale of vision loss; higher values indicate poorer
performance; like visual acuity, the Visual Acuity Score (VAS) is a scale of visual functioning;
higher values indicate better performance. 0 logMAR = standard vision; 0 VA = blindness.
The statistical ability estimates can be used to average across a population, to determine the
difference between groups or to detect trends. They are also useful for administrative use, but
not for vision rehabilitation, since individual performance may be much better or much worse
than the statistical average.
To determine the need for rehabilitation and to assess its outcomes, direct assessment of actual
individual performance is needed. This can be done through observations or through questions
about the difficulties that are experienced. At this level, using visual acuity based scales is no
longer meaningful.
10

PART 2
MEASURING VISUAL FUNCTIONS
Visual Functions describe how the eye and the basic visual system function. They are
measured, one parameter at a time, in an artificial test environment. This chapter will discuss
the parameters that are considered most relevant to functioning in the real world: visual acuity,
visual field and contrast sensitivity. Other functions, such as color vision, stereopsis, dark
adaptation, and electrophysiological functions such as EEG, ERG and VEP are discussed in
other chapters.
2 A VISUAL ACUITY MEASUREMENT

BASIC CONCEPTS
The visual function that is measured most easily and most often is visual acuity. This chapter
discusses the clinical testing of visual acuity, based on letter recognition, using a letter chart or
similar technique. Other aspects, such as light detection, two-line separation, Vernier acuity
and other types of hyper acuity are discussed in other chapters.
Since letter chart acuity is measured so often, a common misconception has taken hold that
visual acuity would define the quality of vision in general or even the ability to function visually.
This is not true. Visual acuity is only one of many parameters that describe aspects of vision.
Letter chart testing compares the smallest line seen by the subject to a reference standard, i.e.
the line that can just be seen by a standard person. Letter chart testing thus determines the
MAgnification Requirement (MAR) for the recognition of detail; the reciprocal of this value is
known as visual acuity (VA = 1/MAR). A subject, who needs characters or symbols that are
twice as large, is said to have a visual acuity of 1/2 (20/40, 0.5). Conversely, a subject with a
visual acuity of 1/5 (20/100, 0.2) needs letters that are 5x larger, etc.
The ability to recognize letters or other symbols depends on the size of their retinal image. That
size depends on the ratio of the size of the object to its viewing distance. Visual acuity therefore
defines the visual angle under which an object is seen, not its absolute size. When the size of a
test object is made 10x larger, and the viewing distance is also made 10x longer, the visual
angle remains the same. When a constant object is brought twice as close, its visual angle
becomes twice as large.
Snellen fractions (Fig. 6) express this as:
reference standard
VA = ---------------------------size seen by subject
or:
size seen by subject

MAR = ---------------------------reference standard
He expressed the optotype sizes indirectly as the distance at which they subtend 5 arc min.
Letter recognition is a rather complex function; a normal test result requires proper functioning
of all three stages of vision: a healthy optical system to produce a sharp retinal image, healthy
retinal receptors to transform that image to neural impulses, a healthy nervous system to
11
analyze and recognize the image. Testing also requires the motor ability to respond. Many
different disorders can thus result in poor test results. Because of this, visual acuity is a good
screening test, but it is not a good diagnostic test. Other tests (such as ophthalmoscopy) are
needed for the differential diagnosis. Furthermore, letter chart acuity only informs us about the
tiny retinal area where the letter or symbol is projected; it does not tell us anything about the
surrounding or peripheral retina.
We will discuss how the current charts evolved, and then consider the requirements for accurate
measurement.
HISTORICAL DEVELOPMENTS
Reading tests have been used since before the Middle Ages to test the function of the eye.
Major changes started to occur in the middle of the 19th century.
1843. In 1843 Kuechler, a German ophthalmologist in Darmstadt, wrote a treatise advocating
the need for standardized vision tests [ 7]. He developed a set of three charts, to avoid
memorization. Unfortunately, he was a decade too early. His work was almost completely
forgotten.
1850. Around 1850 started what would later be called the Golden Age of Ophthalmology. In
1850, Donders [ 8], from Utrecht, the Netherlands, [Fig. 4] visited William Bowman [ 9], of
anatomical and histological fame, at an international conference in London. There he met
Albrecht von Graefe [ 10], who would become the father of German clinical ophthalmology.
Donders and von Graefe became lifelong friends. With Bowman and Hermann von Helmholtz
[ 11], who invented the ophthalmoscope in 1851, they became the foursome that would lead
ophthalmology to become the first organ-oriented specialty.
1854. Thus, the scene had changed considerably when Eduard von Jaeger [Fig. 5] in Vienna,
published a set of reading samples [ 12], initially as an appendix to his book about Cataract and
Cataract Surgery [ 13]. He labeled his reading samples with the catalogue numbers from the
Vienna State Printing House. They became an immediate international success as a means for
documenting functional vision and will be discussed in detail later.
1861. Meanwhile Donders, was working on his epoch making studies on Refraction and
Accommodation [ 14], in which he clarified the nature of hyperopia as a refractive error, rather
than as a form of asthenopia (weakness of the eyes), bringing the prescription of glasses
from trial and error at the county fair to a scientific routine.
For this work, Donders not only needed reading samples for presbyopes, but also distance
targets to determine the refractive error of myopes and hyperopes. He had used some of the
larger type samples from Jaegers publication as a distance target; however, he felt the need for
a more scientific method and for a measurement unit to measure visual function. Using the
term visual acuity to describe the sharpness of vision, he defined it as the ratio between a
subjects performance and a reference standard [see basic concepts]. In 1861 [ 15] he proposed
his formula (Fig. 6) and asked his co-worker and later successor Herman Snellen to devise a
measurement tool.
12
Figure 4 Franciscus Cornelis Donders
Franciscus Cornelis Donders (1818 1889) grew up under difficult circumstances (his father
died before he was 1 year old) and received his first education in a village school, where the
village schoolmaster triggered his lifelong intellectual inquisitiveness. He went on to study at the
University and at age 29 saw a special chair in Physiology created for him at the Medical School
of Utrecht University, the total faculty of which had only four members at the time. He
developed an interest in the physiology of the eye and after the experience quoted below,
decided to devote his life to Ophthalmology. He not only was an excellent scientist, he also had
a strong social conscience. In 1852, after his return from London he privately founded an Eye
Infirmary for the Indigent, which in 1858 became an independent foundation.
Donders most renowned work would become his book on The anomalies of Accommodation
and Refraction, in which he unraveled the difference between asthenopia and hyperopia and
put the correction of refractive error on a scientific footing. Donders was a gifted teacher and
explained his topics in ways understandable to practitioners.
In 1850 he visited London, where he met Bowman and von Graefe. He later wrote:
I had just seen Jaeger (Friedrich, Eduards father, ed.) performing cataract surgery
alternately with the left and the right hand, when a young man stormed into the room embracing
his preceptor. It was Albrecht von Graefe. Jaeger thought that we would fit well together and
we soon agreed. Those were memorable days. Von Graefe was my guide for all we heard in
practical matters, and in scientific matters he listened eagerly to the smallest detail. We lived
together for a month to separate as brothers. To have William Bowman and Albrecht von
Graefe as friends became an incredible treasure on my lifes path.
13
Figure 5 Eduard von Jaeger
Eduard Jaeger, Ritter von Jaxtthal (1818 1884) was born into a prominent family of Viennese
ophthalmologists. His father, Friedrich was one of the most distinguished ophthalmologists of
his days; Donders met him in London in 1850. In addition to his reading samples, Eduard is
known for an early Atlas of the Ocular Fundus. He was a strong advocate for the use of
Helmholtzs direct ophthalmoscope and spent many hours making very detailed drawings. He
may have inherited his artistic talent from his mother, who was a recognized artist and daughter
of another ophthalmologist.
Since his reading samples had no external standard, except the catalogue of the Vienna State
Printing House, others could only imitate them with locally available fonts. This explains the
enormous variability among later imitations (Fig. 23). While Snellens emphasis was on
measuring visual acuity, Jaeger emphasized reading ability; this may be one of the reasons why
he steadfastly refused to add Snellens letter size notation to his reading samples.
14
Figure 6 Donders Formula

Donders compared the letter size just recognized by the patient to a reference standard, the
size recognized by a standard person. The visual acuity is the reciprocal of this value.
(Angular) Size seen by subject / Size of reference standard = MAgnification Requirement
Visual Acuity = 1 / MAgnification Requirement

MAgnification Requirement:
2x
4x
10x
Visual Acuity:
1/2
1/4
1/10
0.5
0.25
0.1
20/40
20/80
20/200
Note that he reference standard is based on a physical measurement (letter height 5 of arc).
This choice was partly inspired by the work of the English astronomer Robert Hooke, who, two
centuries earlier [17], had found that the human eye can separate double stars when they are 1
apart. Since Snellen chose an external, physical standard, others could accurately reproduce
his charts.
1862. The next year, 1862, Snellen (Fig. 7) published his letter chart [ 16]. His most significant
decision was not to use existing typefaces, but to design special targets for visual acuity
measurement, which he called optotypes. He experimented with various targets designed on a
5x5 grid (Fig. 7, center). Eventually, he chose letters (Fig. 7, right). Some others also published
charts based on Donders formula, but used existing typefaces rather than optotypes. Snellens
chart prevailed and spread quickly around the world. One of the early big orders came from the
British army, wanting to standardize the testing of recruits.
To implement Donders formula, Snellen defined as the reference standard, the ability to
recognize one of his optotypes when it subtended 5 of arc with a stroke width of 1 of arc.
Since Snellen chose an external, physical standard, others could accurately reproduce his
charts.
15
Figure 7 Herman Snellen and his charts
Donders had chosen Herman Snellen, Sr. (1834 1908) as the co-director for his eye infirmary.
Snellen would later become his successor. Donders was a scientist and teacher, Snellen was
practically oriented and was an excellent surgeon.
The center images show two of Snellens experimental charts, preserved in the Museum of the
University of Utrecht. On the right is his chart as published in 1862.
Snellen advocated a fractional visual acuity notation V = d / D , in which d = actual viewing
distance in any measurement unit, and D = distance at which the optotype subtends 5 min of
arc. Louise Sloan introduced the name M-unit and changed the formula to V = m / M, to make
use of the metric system explicit and avoid confusion with D = Diopters. Today, actual Snellen
fractions are rarely used and are most often replaced by Snellen equivalents (Fig. 18).
See Fig. 15 to compare the letter size progressions on Snellens charts to those used today.
On his charts, Snellen marked the letter size for each line (the distance at which the optotypes
subtend 5 of arc); this is the denominator of the Snellen fraction for that line. He left it to the
user to supply the viewing distance as the numerator (Fig. 18).
Donders and Snellen were well aware that their reference standard represented less than
perfect vision and that normal, healthy eyes could do better. It is wrong therefore, to refer to the
reference standard of 20/20 (1.0) as normal vision, let alone as perfect vision. Indeed, the
connection between normal vision and the reference standard is no closer than the connection
between the standard American foot and the average length of normal American feet.
From his studies on refraction and accommodation and related topics, Donders knew that
normal acuity decreases with age. While Snellen was preparing his chart, Donders
commissioned a study by one of his PhD students to document the changes with age [ 17], using
prototypes of Snellens symbols. The study was published in 1862, the same year that Snellen
published his chart. The similarity with more recent data (Fig. 8) is remarkable.
16
Figure 8 Visual Acuity and Age
This chart compares the relationship between visual acuity and age in various studies. The
horizontal bands represent one-line intervals on a standard chart with logarithmic progression.
The dark band represents the reference standard (20/20, 6/6, 1.0).
The markers show the data from de Haans study in1862.
The markers show a recent meta-analysis of healthy subjects participating in various
research protocols [20]. The coincidence in the younger age groups is striking. In the older
groups, the recent data show better visual acuity, because the research protocols rejected
subjects with any pathology.
The markers refer to a recent study of an unselected older population [21]. The coincidence
with the data from 1862 is, again, striking. There has been no change in the average acuity with
age over a century and a half.
The data show that until 60 or 70 years of age normal vision for Caucasians is substantially
better than the reference standard. The M and F symbols near the top of the chart indicate
even better visual acuities for male and female Australian aborigines [22].
Since Snellens days few major improvements in visual acuity measurement have been made.
Many tried to devise better optotypes, but, as Bennet remarked in an exhaustive review of
historical developments [ 18], while preparing for the British standard of 1968 [ 19], the road of
17
visual acuity measurement is littered with stillborn charts. Some developments, however, are
worth mentioning.
1868. John Green of St. Louis had traveled Europe after his training in Boston, and had spent
some time with Donders and Snellen, where he wrote a small paper about the measurement of
astigmatism. In 1868 he presented a new chart to the American Ophthalmological Society [ 20],
modifying a prior proposal from 1867 (Fig. 9).
Greens chart featured sans-serif letters (Snellen used letters with serifs), proportional spacing
of the characters and a geometric progression of letter sizes (10 steps = 10x); on the smaller
lines he used a fixed number of letters per line, all features that are now part of standardized
letter chart design (Fig. 9). He was a century too early; his proposals gained little acceptance.
Green went back to letters with serifs, because letters without serifs were said to look
unfinished. A century later, the British standard would choose sans-serif letters, because
letters with serifs look old fashioned.
Figure 9 John Greens and his chart
The lower lines of Greens chart are shown. Note that he combined sans-serif letters and
proportional spacing with a geometric progression, principles that a century later would be
incorporated in international standards.
Green 1868
Current Standard (ETDRS)
Proportional spacing
Geometric progression (1010)
Sans-serif letters
Up to 11 letters / line
Proportional spacing
Geometric progression (1010)
Sans-serif letters
5 letters each line
Too early forgotten
International standard
18
1875. Snellen originally calibrated his charts in Parisian feet. In the 1860s there were some
twenty different measurement systems used in Europe. It is not surprising that the uniform
Metric system [ 21] was gaining ground. When the Treaty of the Meter was signed in 1875,
Snellen changed the distance for his charts to 5 meters, for adherents of the decimal system, or
to 6 meters for those who wanted to stay closer to 20 Parisian feet. Today, the 20 ft distance
prevails in the U.S.A., 6 meters prevails in Britain, and a 5-meter distance is commonly used in
continental Europe.
1875. Since comparing the visual acuity values for different distances is awkward, when using
Snellens fractional notation, Felix Monoyer of Lyons, France, proposed replacing the fractional
notation with its decimal equivalent. (E.g. 20/40 = 0.5, 6/12 = 0.5, 5/10 = 0.5) [ 22]. His decimal
notation (Fig. 10) made it simple to compare visual acuity values, regardless of the original
measurement distance and is commonly used in Europe.
Figure 10 Decimal and other Visual Acuity Notations
In true Snellen fractions the numerator indicates the test distance. 5m is commonly used in
Europe, 6m in Britain and 20ft in the USA. For patients with low vision a 1 meter distance is
recommended to extend the measurement range.
When Snellen equivalents are used, the numerator is a standard value, regardless of the test
distance. Decimal equivalents are common in Europe, 20/20 equivalents in the USA.
See Fig. 18 for a more extensive listing.
1888. Edmund Landolt had worked with Snellen in Utrecht and later became professor of
ophthalmology in Paris. In 1874 Snellen and Landolt had cooperated in publishing a major
chapter on Optometrology [ 23], the science of measuring vision. Recognizing that not all of
Snellens optotypes were equally recognizable, Landolt, in 1888, proposed his broken ring
symbol, that has only one element of detail and varies only in its orientation [ 24]. Landolts Cs
(Fig. 11) would become the preferred visual acuity measurement symbol for laboratory
experiments, but gained only limited acceptance in clinical use.
Relatively little happened in the period that followed. Efforts at standardization were made,
such as a standard proclaimed by the International Council of Ophthalmology in 1909 [ 25], but
such documents were filed and never gained a wide following. That clinicians did not feel an
urgent need for standardization can be explained by the fact that the most common letter chart
uses do not require it. For refractive correction any set of targets will do, since the only question
19
is better or worse? For screening the distinction between within normal limits and not within
normal limits is the most important. Snellens reference standard at the lower limit of normal
vision is well positioned for screening purposes. For screening, the difference between 20/100
(0.2), 20/200 (0.1) and 20/400 (0.05) is unimportant; they all indicate a marked vision loss.
Figure 11 Landolts broken ring
Landolts C or broken ring is designed on Snellens 5x5 grid and has only one element of
detail, the gap, which is 1 unit wide. It can be presented in 4 or in 8 positions.
Low Vision Rehabilitation

After World War II the interest in Low Vision rehabilitation was gaining ground. It was
recognized that the majority of those considered industrially blind actually had some level of
useable vision. In 1953 the first Low Vision services were opened in New York at the Industrial
Home for the Blind and at the New York Lighthouse. For rehabilitation purposes the difference
between 20/100, 20/200 and 20/400, which was unimportant for screening, became very
important, since the patient with 20/200 needs twice as much magnification as the patient with
20/100 and the patient with 20/400 needs twice as much again. It is not surprising then, that
major refinements in clinical visual acuity measurement came from clinicians involved in Low
Vision rehabilitation.
1959. In 1959 Louise Sloan, the founder of the Low Vision service at the Wilmer Eye Institute of
Johns Hopkins University designed a new optotype set of 10 letters [ 26] (Fig. 12). She chose
sans-serif letters, while maintaining Snellens 5x5 grid. She recognized that not all letters were
equally recognizable and therefore proposed to use all ten letters on each line. This causes
long lines, with many letter sizes requiring more than one physical line.
20
Figure 12 - Sloans optotypes
Sloan designed a series of letters without serifs that are widely used in the U.S. They were
designed on Snellens 5x5 grid. Although the difficulty of individual letters varies, the average
difficulty approximates that of Landolt Cs.
Sloan also introduced the term M-unit. Snellen had defined visual acuity as:
V=d/D
where d = test distance and D = distance at which the letter subtends 5 or arc.
To make this definition less verbose and to avoid confusion with D = diopters, Sloan proposed:
V=m/M
where m = test distance in meters and M = letter size in M-units.
1 M-unit subtends 5 at 1 m (1.454 mm, about 1/16 inch). Sloans M is thus equivalent to
Snellens D, provided that the measurements are made in meters.
1974. In the 1960s the WHO had surveyed national definitions of legal blindness and found
that 65 countries used as many different definitions. In 1974 the World Health Assembly
approved the 9th Revision of the International Classification of Diseases (ICD-9) [ 27]. In it, the
old dichotomy between legally sighted and legally blind was abandoned for a series of
ranges of vision loss. In the same year, the International Council of Ophthalmology (ICO) [ 28]
adopted the same ranges, extended them to include normal vision, and used the named ranges
used in this chapter and in ICD-9-CM [ 29] (the US extension of the WHOs ICD-9) (Fig. 18).
1976. In 1976, Ian Bailey and Jan Lovie (then at the Kooyong Low Vision Service in
Melbourne) published a new chart [ 30], featuring a novel layout with five letters on each row and
spacing between letters and rows equal to the letter size. This layout standardized the crowding
effect and the number of errors that could be made on each line. Thus, the letter size became
the only variable between the acuity levels. Their charts have the shape of an inverted triangle
and are much wider at the top than the traditional rectangular charts. Like Sloan, they followed
a geometric progression of letter sizes.
That same year, Hugh Taylor, also in Melbourne, used these design principles for an illiterate E
chart [22], used to study the visual acuity of Australian Aborigines. He found that, as a group,
Australian Aborigenes had significantly better visual acuity than Europeans (Fig. 8). This is
another reason not to regard 20/20 visual acuity as normal or as perfect vision.
21
1982. Based on the above work, the National Eye Institute chose the Bailey-Lovie layout,
implemented with Sloan letters, to establish a standardized method of visual acuity
measurement for the Early Treatment of Diabetic Retinopathy Study (ETDRS) [ 31]. These
charts were used in all subsequent clinical studies, and did much to familiarize the profession
with the new layout and with the logarithmic progression (Fig. 13). Data from the ETDRS were
later used for a revised set of charts where all lines have the same average difficulty [ 32] . Since
the Sloan letters (designed on Snellens 5x5 grid) are wider than the British letters (designed on
a 4x5 grid) used by Bailey and Lovie, the ETDRS chart was designed for a 4m distance, not the
6m used by Bailey and Lovie.
Figure 13 Bailey-Lovie and ETDRS charts
The ETDRS chart (right) implemented the layout of the Baily-Lovie chart (left) implemented with
Sloan letters (Fig. 11). The Bayley-Lovie chart has 4x5 letters and goes to 60M for use at 6 m;
the ETDRS chart has 5x5 Sloan letters and goes to 40M for use at 4 m. Both follow the same
logarithmic progression (Fig. 8).
1984. The International Council of Ophthalmology (ICO) approved a Visual Acuity

Measurement Standard, which also incorporates the above features [ 33].
2002. The International Council of Ophthalmology (ICO) explicitly recommends the ETDRS
protocol as the international standard in a report on Aspects and Ranges of Vision Loss that
also asks attention to the aspects of vision loss beyond visual acuity [ 34].
22
CONSIDERATIONS FOR LETTER CHART TESTING

Having discussed the historical developments, we will now discuss several aspects that need to
be considered for letter chart design. This discussion will not be strictly limited to letters or to
charts, but will consider all methods for presenting letters or other symbols at distances of 1
meter (3 ft) or more.
Letter recognition, upon which clinical visual acuity measurement is based, is a rather complex
function, which involves optical, retinal, neural and cognitive factors. The functional significance
of visual acuity is best understood as the reciprocal of the MAgnification Requirement (MAR).
The term MAR is best known for its logarithm (logMAR), which will be discussed later. The
acronym MAR can be explained in different ways. It is often interpreted as Minimum Angle of
Resolution. This term, although widely used, has two problems. Resolution refers mainly to the
clarity of the retinal image, i.e. to the optical part of the process, while the reference to angle is
more applicable to gratings than to letters, where shape, rather than just stroke width affects the
recognizability. Our interpretation of MAR as MAgnification Requirement emphasizes the
functional significance, whether the cause is optical, retinal or cerebral.
The MAgnification Requirement simply is the ratio of the smallest line the subject can see to the
smallest line a standard person can see (i.e. the 20/20 line). When making a measurement, it
is important to keep all other, possibly confounding stimulus parameters well above threshold.
We will discuss cognitive factors, the choice of test distance, letter size progression, success
criterion, contrast and illumination, visual acuity notation, and the choice of test symbols.
Cognitive factors
The effect of cognitive factors should be minimized. For most adults letter recognition is trivially
easy. In cases where it is not (infants, pre-school children, illiterate adults, stroke victims), we
need to employ other methods. We may consider grating detection or picture recognition. It is
important to realize that these are different tasks, which may have different magnification
requirements. Finally, the ability to respond may play a role. For some developmentally
delayed individuals the motor concept of directionality that is required to respond to tumbling Es
may be a limiting factor. Comparing the results of tests with different modalities, may provide
some insight into such confounding factors. In elderly patients with a stroke and macular
degeneration, the question may arise whether inability to read is the result of the macular
degeneration or of the stroke. Better performance with larger print may point to an optical or
retinal cause; if the confusion persists, this may point to the stroke. In the following discussions
it will be assumed that cognitive and motor factors are indeed trivial.
Choice of test distance for general practice
The vast majority of patients seen in ordinary practice has visual acuities in the range from
normal to moderately impaired vision (MAR <5, VA >1/5, >20/100). Traditional chart designs
reflect this emphasis on screening and on refractive use. In the near-normal range the steps
between letter sizes are small, for lower acuities they become larger; for acuities worse than
20/200 (0.1) vague statements such as count fingers and hand motions are used.
Since the magnification requirement is an angular measure, it can be measured at any distance,
provided that the viewing distance is properly accounted for in the Snellen formula.
Snellen originally chose a test distance of 20 Parisian feet. Distance testing was chosen
because it relaxes accommodation and because the optical difference with infinity may be
23
ignored. Remember that the stimulus for the development of the letter chart came from
Donders work on refraction. A long viewing distance also reduces the effect of any movements
the subject may make. After the introduction of the metric system, many went to 5 meter
(convenient with the decimal system), others chose 6 meter because it is close to 20 ft.
In 1973 Hofstetter proposed a 4-meter test distance [ 35] for use in smaller rooms. Sloan liked
the 4-m distance because it made for easy conversion to a 40-cm reading distance. The
ETDRS charts adopted it because charts with the Bailey-Lovie layout would have to be
substantially wider if designed for 5 m or 6 m. For visual acuity measurement a 4 meter
distance is as valid as any other distance. However, at 4 meters the accommodative demand is
0.25 diopters and can no longer be ignored. The alternative for small rooms is the use of
mirrors.
For young children, a test distance of 3 meters (10 ft) is often recommended, because it is
easier for holding their attention. For this group acuity measurement is the most important
application; because of their ample accommodative ability, cyclopegic retinoscopy is the
preferred mode for accurate refraction.
The above distances hold for printer charts, which have to be designed for a specific distance.
The widespread use of projector charts, which can be adjusted for any distance, has been a
strong factor for changing from the use of true Snellen fractions to Snellen equivalents (Fig. 18).
Choice of test distance for Low vision
A much smaller group of patients has visual acuities in the Low Vision range (MAR >3, VA <1/3,
<20/60). Snellen recognized that the steps for lower acuity values were rather large on his chart
and recommended to bring the chart closer. A 2-meter distance is sometimes used for this
group by bringing a 4-m ETDRS chart half as close. At these short distances small movements
of the patient become significant. It is therefore more desirable to move even closer, to 1 meter
(40), where the test distance can be accurately controlled with a cord attached to the chart [ 36].
Without a cord, a movement of only 10 cm (4) at 1 m would introduce a 10% error (half a visual
acuity line).
Many patients with Low Vision have been found to have improper correction for refractive error;
a subjective refraction for this group is difficult, since the question better or worse loses
significance when the patient cannot see the letters on a chart at 20 ft. Bringing the chart to 1
meter provides a far greater measurement range; being able to see several lines on a 1-meter
chart is encouraging to patients and provides better responses for subjective refraction.
Presbyopic patients need a 1 D correction for the 1-meter distance. This is easier to provide
than a 1/3 D correction for a 10 ft (3m) distance [ 37].
The greater measurement range also means that vague terms like count fingers or hand
movements can be eliminated. Measuring at 1 meter has the additional advantage that the
Snellen fraction is as simple as possible (1/...) and can be converted easily to an equivalent for
any other distance by multiplying numerator and denominator by the same number (e.g.: 1/20 =
20/400 = 5/100 = 6/120 = 0.05). Since visual acuity is defined as the reciprocal of the
magnification requirement, the denominator of the 1-meter Snellen fraction indicates the
magnification requirement, which is a good starting point for the prescription of magnifiers. This
relationship is often referred to as Kestenbaums rule [ 38] , stating that the magnification needed
for reading of newsprint (1 M) should be at least the reciprocal of the visual acuity value (e.g.:
20/100 requires at least 100/20 = 5x, 20/200 requires at least 200/20 = 10x).
24
Figure 14 Low Vision Letter chart with cord for 1 meter
This chart, designed for measurement at 1 meter, allows accurate measurement of visual
acuities from 1/50 (20/1000, 0.02) to 1/1 (20/20, 1.0). This is not only important for Low Vision
patients, but also for follow-up of various conditions; vague statements, such as Count Fingers
or Hand Movements are no longer needed. A 1-meter cord is attached to accurately maintain
the viewing distance.
Choice of Letter size progression

Snellens original charts (Fig. 7) had small steps for the normal range and larger steps for the
lower ranges. Introduction of the decimal acuity notation [27] led to charts with visual acuity
steps in 0.1 increments. On these charts the steps at the top of the scale (bottom of the chart),
such as 0.9 1.0 1.1, are too small to be practical; at the other end, the reverse is true. Only
a logarithmic scale (Fig. 15) span the full range is evenly.
Snellen advocated reducing the viewing distance to improve measurement for lower acuities.
Use of a logarithmic scale, which maintains the same accuracy at all levels, was first proposed
by Green (1868) [25]; it was advocated by many subsequent researchers, including Sloan and
Bailey-Lovie, but did not gain wider recognition until its adoption in the ETDRS protocol, which
has become the de-facto world-wide standard.
Use of a logarithmic (geometric) progression of stimuli is in accordance with Weber-Fechners
law [7], which states that geometric (proportional) increments in stimulus give rise to linear
increments in sensation. Westheimer [ 39] has shown that this also holds for visual acuity.
Massof [ 40] showed that it also applies to the relation between visual acuity and visual (dis)ability
(Fig. 16).
25
Figure 15 Various Letter Size Progressions
On a geometric (often called logarithmic) scale each step represents the same ratio (e.g. 2 4
8 16 32); on a linear scale each step represents the same increment (e.g. 2 4 6 8
10). Only a geometric progression can span a wide range of values with equal steps
throughout. The logarithms of a geometric scale yield a linear scale with equal increments
throughout. Examples are the log(MAR) scale and the VAS scale (Fig. 18).
Figure 16 Visual Acuity and Quality of Life
The diagram demonstrates that there is a linear relationship between Functional Vision (NEIVFQ after Rash analysis) and visual acuity on a logarithmic scale. The diagram also shows that
there is no natural breakpoint in this relationship and that the spread of Functional Vision ratings
is much larger than the amount explained by the acuity loss alone.
26
Various geometric progressions are possible. The one that fits best with the decimal system is
one in which 10 steps equal 10x. This is the sequence used by Green and by Sloan, BaileyLovie and the ETDRS. It is known as the Preferred Numbers series (Fig. 17).
Figure 17 Preferred Numbers

Many different geometric progressions are possible. The one that fits best with the decimal
system is know as the Preferred Numbers series. Its step size is 1010, so that 10 steps equal
exactly 10x. Thus, when the series is extended from 1 to 10 to 100 to 1000 etc., the same digits
repeat in each of these intervals with only a shift in the decimal marker.
The series is widely used in industrial standards and is the subject of an international standard
itself [46]; it also is the series used by Green, by Sloan and for the ETDRS charts. For general
use, the Preferred Numbers series is advantageous because with minimal rounding (<1%) its
terms can be represented by simple numbers; each step equals approximately 1.25x (a 4:5
ratio), most 3-step intervals equal 2x (1 octave) and 10 steps equal exactly 10x. In the diagram
below the numbers for each interval have been spread over three lines to demonstrate that of
the 3-step intervals only two (from 32-63 and from 63-125) are slightly less than 2x, and to show
the shift in the decimal marker between intervals.
For visual acuity measurement an additional advantage is that the product or quotient of two
preferred numbers is again a preferred number. Thus, for any acuity measurement, if the letter
size and the viewing distance are expressed in preferred numbers, the resulting values for the
visual acuity value, the magnification requirement (MAR = 1/V) and the viewing distance in
diopters (D = 1/m = reading add or accommodation requirement) will also be preferred numbers.
This greatly facilitates the various calculations, as can be seen in Fig. 18. Visual acuity charts
specifically based on this feature were published by M.C. Colenbrander in 1937 [47] and 1955
[48].
Choice of Contrast and Illumination

Contrast and illumination both influence visual acuity. Fortunately, at normal illumination levels
for an office or school, the influence is minimal. Most printed visual acuity charts have contrasts
of 80% or better; visual acuity is usually not affected until contrast drops below 40% Weber
27
(20% Michelson). When contrast is reduced to a level where it does affect visual acuity, the test
becomes a contrast sensitivity test, which is discussed later in this chapter.
Front lighting is the most common way to illuminate printed charts. Care should be taken that
there is no glare and that there are no bright spots or dim spots on the chart. For most patients
a high illumination level is advantageous. However, for patients with conditions such as
albinism or rod dystrophy, it should be possible to reduce the illumination, which may result in a
significant increase in visual acuity.
Back lighting of a translucent chart on a light box gives the most even and most reproducible
illumination. The usual backlit ETDRS chart has an illumination level of about 200 cd/m2. For
more portable applications, as in school testing, smaller rear illumination cabinets are available
also.
Projector charts in a dim or darkened room are the preferred presentation mode in professional
offices. For these charts, stray room light may significantly affect the test. If that is the case,
measurements made in different rooms with different amounts of stray light may no longer be
comparable. In the U.S. the average projector chart has a luminance of about 85 cd/m2;
European charts are generally brighter, up to 300 cd/m2. The lower luminance has the
advantage that the pupil may be wider, so that refractive errors may be more obvious; the
brighter charts have the advantage that they suffer less from stray light. In most situations the
difference is negligible. The ICO Visual Acuity Measurement Standard [38] recommends a
range, which includes both the lower and the higher values.
Projector charts are convenient for routine eye exams; however for vision rehabilitation, where
the goal is to predict the everyday performance of patients, a lighted printed chart in a lighted
room is preferred, since it is closer to normal conditions.
Presentation on a computer screen is gaining ground. This method is less sensitive to stray
light and allows easy switching between different optotypes as well as control over parameters
such as crowding, contrast and brightness. The earliest implementations were the E-ETDRS
system [ 41] and the E-HOTV system [ 42]. Both use single letter presentation with crowding bars.
Newer systems offer more varied presentation modes.
Choice of visual acuity notation

The result of the visual acuity measurement may be recorded in a variety of ways. It should be
noted here that although some may refer to the Snellen system as being different from the
ETDRS or logMAR system, the two measure exactly the same visual acuity value, but report it
on a different scale. This can be compared to the Fahrenheit and Centigrade scales, which
measure the same temperature, but report it on different scales.
True Snellen fractions
Snellen preferred a true Snellen fraction, in which the numerator indicates the actual test
distance and the denominator indicates the actual size of the letter seen. The advantage of this
notation is that it indicates the actual test conditions. The disadvantage is that it becomes
awkward to compare visual acuity values, measured under different conditions. This is
especially true since the advent of projector charts where the viewing distance is dictated by the
geometry of the room and the projector magnification is adjusted to accommodate fractional
viewing distances.
Snellen equivalents
To overcome this difficulty, Snellen equivalents are used. In Europe, the decimal equivalent
[27] of the Snellen value is used most often. This notation is clear, because there is no
28
numerator or denominator. The notation becomes confusing when the decimal notation is
converted back to a pseudo-Snellen fraction. E.g. 5/25 0.2 2/10; the 2/10 fraction would
suggest that the subject saw a 10 M letter at 2 meter, instead of a 25 M letter at 5 meter.
The U.S. notation uses a 20 ft. fraction as a Snellen equivalent. If two examination lanes have
viewing distances of 18 ft. and 21 ft. respectively, the true Snellen fractions for standard acuity
would be 18/18 or 21/21. Instead the visual acuity is recorded as 20/20 in both cases. Thus,
seeing 20 as the numerator of a visual acuity fraction rarely implies that the actual
measurement was made at 20 ft.
In Britain and related countries, the 6/6 notation is similarly used as a Snellen equivalent.
Visual angle notation was used by Louise Sloan. It refers to the visual angle of the stroke
width of 5x5 letters. This angular value is the same as the MAgnification Requirement (MAR),
discussed earlier.
LogMAR notation was introduced by Bailey [35]. As the name implies, it is the logarithm of the
MAR value, thus converting a geometric sequence of letter sizes to a linear scale of perception.
It provides a more scientific equivalent for the traditional clinical statement of lines lost or lines
gained and has gained widespread use in psychophysical studies and for statistical
calculations.
On an ETDRS-type chart each line interval is equivalent to 0.1 logMAR; therefore +1.0 logMAR
means 10 lines lost or 20/200 (0.1) and +2.0 logMAR means 20 lines lost or 20/2000 (0.01).
Since higher logMAR values indicate poorer vision, the logMAR notation should be considered a
notation of vision loss, rather than a notation of visual acuity. 0 logMAR = no loss = standard
vision, while 0 VA = NLP = blindness.
Since Bailey used the logMAR notation with a geometric progression of letter sizes, the term
logMAR chart is often used to imply a geometric progression. However, the MAR and logMAR
notations can be used with any letter size progression.
Visual Acuity Score (VAS) [ 43] and Visual Acuity Rating (VAR) [ 44] are two names given to a
more user-friendly alternative to the logMAR scale. Like the logMAR scale it converts the
geometric progression of visual acuity values to a linear scale. However, the VAS scale is more
intuitive, since it is a scale of visual functioning, where higher numbers indicate better vision.
For VAS or VAR the reference standard (20/20, 1.0) is rated as 100, a 10-line loss (20/200,
0.1) is rated as 50 and a 20-line loss (20/2000, 0.01) is rated as 0. While this 0 value is not
total blindness, MAR = 100x, hardly is a measure of detail vision anymore. On ETDRS type
charts, where each line has five letters, the Visual Acuity Score can be interpreted as a count of
the total number of letters read, starting from 20/2000 (0.01).
Similar letter-count scores are used in many studies and population surveys; however, they are
often anchored arbitrarily; the original ETDRS score was anchored at 40 M at 1 m (20/800) = 0,
so that 20/20 = 85. VAS and VAR are anchored so that the reference standard = 100. (Fig. 18)
compares these different notations.
29
Figure 18 Various equivalent visual acuity notations
The table compares the different visual acuity notations discussed in the text.
Note that the MAR and logMAR scales indicate vision loss (higher values indicate poorer
vision); the VAS scale indicates functioning (higher values indicate better vision).
The progression of visual acuity values (rows) follows the preferred numbers series (Fig. 17).
Note that when the viewing distances (columns) also follow this series (1, 4, 5 or 6.3 m; 20 ft),
the required letter sizes (numerator of the Snellen fraction) are also preferred numbers. When
the chart is designed for 6 m (5% less than a preferred number) the required letter sizes also
have to be reduced by 5% and are no longer preferred numbers.
For chart design, the exact numbers, as shown in this table, should be followed. For clinical
naming it is acceptable to round 32 to 30, 63 to 60, etc. The error involved is 5% or 1/5 line
interval, and corresponds to 1 letter seen or not seen on a standard chart, a difference much
smaller than the measurement accuracy of clinical measurement.
30
Which notation to use?

For everyday clinical practice, the direct visual acuity values are most useful (Fig. 3). They
allow simple calculations about viewing distance, letter size and magnification need. E.g. an
eye with 20/20 acuity can, by definition, just see a 1 M letter (1.5 mm) at 1 m; a road sign with
letters that are 100x larger (100 M, 150 mm, 6) can therefore be seen at 100x that distance
(100 m, 300 ft). A person with 20/40 (1/2) acuity can see the same letters at half the distance
(1/2 x 100 m = 50 m, 150 ft); to read normal print the person with 20/40 acuity needs 2x
magnification.
Today, true Snellen fractions, in which the numerator indicates the actual testing distance, are
rarely used anymore. Snellen equivalent notations are preferred, since they can be compared
regardless of the testing distance used. Decimal notation (Europe), US fractions (20/) and
British fractions (6/) are the notations most people are familiar with.
For graphical displays with a very limited acuity range, any scale might be used. However, for
displays that cover a wider range a scale based an the logarithm of the visual acuity (log(VA),
logMAR, VAS or lines) is preferable.
For statistical calculations using log(VA), logMAR or VAS is the only option. The difference
between using a linear and a geometric scale for calculations can best be shown with an
example:
What is the average of 20/20 and 20/200?
Using VAS, the average of VAS 100 (20/20) and VAS 50 (20/200) is VAS 75 (20/63).
Averaging the decimal values: (1.0 and 0.1), the average = 0.55 (20/40 +) would be too high.
Averaging the denominators of 20/20 and 20/200, the average = 20/110 would be too low.
The table in Fig. 18 clearly shows that the first answer is the most appropriate.
What not to use? In most offices, the viewing distance is never varied. This means that each
line can be labeled with the visual acuity value for that distance. On many charts this has led to
omission of the actual letter size, as it was always listed on Snellens charts. When the chart is
used at any other distance, determining the acuity value without knowing the letter size involves
some calculations. The lack of letter size designations has led to the habit of using visual acuity
notations to describe letter sizes. This is erroneous, since any letter size can reflect any acuity
value, depending on the viewing distance (Fig. 22).
Choice of criterion and rounding of values

The recorded visual acuity value can also be influenced by the choice of the completion criterion
and by rounding. Most clinicians will record visual acuity in line-increments and consider a line
read if more than half of the letters are read correctly (e.g. 3 of 5 on an ETDRS type chart). A
suffix such as 1 or +2 is often added to indicate 1 letter missed or 2 letters read on the next
line. On older charts, where the line intervals and the number of letters per line may vary, these
suffixes have no constant meaning. (At the top of most traditional charts (Fig. 7), +1 would be 3
ETDRS lines; for Greens bottom lines of 11 letters (Fig. 9), +5 would still be less than half a
line). Thus, when averaging visual acuity values across patients or over time, these suffixes
should be ignored.
On ETDRS-type charts, the line intervals and the number of letters per line are fixed and the
value of each additional letter read may be assumed to be equal. This provides the opportunity
to record the test results in letter-increments rather than in line-increments. Such letter-count
scores are used in many research studies; on the VAS scale each letter read increases the
score by one point. In this case the suffixes -, - -, + and ++ are recommended [ 45]. Omitting the
31
suffix will automatically round to the appropriate Snellen equivalent; use of these suffixes is
preferred over the use of interpolated values, which convey a sense of spurious accuracy.
Figure 19 Rounding of Visual Acuity Values

The question is sometimes asked is 20/63 worse than 20/60? The answer is that they are
equivalent within the measurement error. They differ by only 1 VAS point (one letter), which is
5x smaller than the 95% confidence interval for clinical measurement error (one line). To bring
the accuracy down to 1 letter, one would have to average 52 = 25 measurements.
The following table represents a small segment of the table in Fig. 18; it is expanded from 1 line
(5 letters) per row to 1 VAS point (one letter) per row.
The bold values indicate the line values for a strict logarithmic progression; the horizontal bands
indicate line intervals. Because of the rule that a line is considered read if more than half of the
characters (3 of 5) are correctly identified, all values within a band should be considered
equivalent for clinical recording and may be rounded to the same value.
Thus, all values from 20/63 ++ to 20/63 (20/57 to 20/70) may be rounded to 20/63; this
includes the more traditional value 20/60. A rule that says better than 20/60 should be
mathematically interpreted as better than 20/56 (> 0.35); a rule that says worse than 20/60
should be mathematically interpreted as worse than 20/71 (< 0.28). Fortunately, all traditional
values are close (+/- 1 letter) to a logarithmic value.
The only exceptions are 20/70 and the decimal values 0.7 and 0.9, which represent half steps.
The 20/70 value is a remnant of Snellens original chart (Fig. 15), which had no lines for 20/60
and 20/80, but went from 20/50 to 20/70 to 20/100 and 20/200.
Also note that to indicate letter count steps, the notation with + and suffixes (in the US +/
column) is easier to understand than the use of interpolated numerical values, as shown in the
US interpol. column and in the decimal column); they suggest spurious accuracy.
32
It should be noted that, although the letter-count score improves the precision with which the
result is recorded, it does not improve the accuracy of the underlying measurement method. On
any measurement scale, a 1 point difference may or may not be significant; a change from 2 to
3 might indicate an insignificant change from 2.4 to 2.6 or a significant change from 1.6 to 3.4.
Since the accuracy of common one-time clinical measurements is about 1 line interval, the
results may as well be rounded to the nearest line. The use of a letter count score is
advantageous, however, when sequential measurements are compared to detect a possible
trend.
Another factor that may affect the score is whether subjects are encouraged to guess. Since
different subjects may vary in their willingness to guess, forcing all to guess (a forced choice
paradigm) will produce more homogeneous results.
When a subject cannot read a line on a chart, some clinicians will present an isolated line or an
isolated letter. This makes the task easier and can improve the visual acuity score. One should
be aware that using different presentation modes at different times reduces the comparability of
the scores.
To make sure that the actual threshold is reported, the chart should be presented close enough
so that there is at least one line the subject can see, or far enough so that there is at least one
line the subject cannot see. Terminating testing at the 20/20 level is a mistake, since, Snellen
chose the reference value of 20/20 (1.0) so that most healthy eyes can do better (Fig. 8).
Choice of test symbols

Most visual acuity charts utilize letters. For the patient, this choice gives a sense of immediate
validity, since the primary objective of most patients is to read. For the practitioner, errors are
easy to spot, since most practitioners know their chart by heart. Use of letters, however, is
warranted only if the assumption can be made that letter recognition is trivially easy. The
ETDRS charts use the Sloan letter set (Fig. 12), which has made this the preferred set for many
studies. Many other letter sets exist, including sets for non-roman alphabets.
For less literate adults the use of a number chart may be more appropriate. Number charts can
also be used for deaf patient who use sign language, since they can respond by holding up the
appropriate number of fingers.
An alternative is the use of various symbol sets.
Internationally used symbol sets
Landolt Cs [29] (Fig. 11) have become the symbols of choice for many scientific
measurements. They are much less frequently used in a clinical setting. When used in a chart
format it is harder to detect errors, unless the observer points to the symbol. However, pointing,
like single presentation, affects the difficulty of the test.
The 1984 Visual Acuity Measurement Standard of the International Council of Ophthalmology
[38] recommended that letter charts in non-Roman alphabets (Cyrillic, Arabic, Hindi, Kanji,
Hebrew, etc.) be calibrated against Landolt Cs for equal recognizability. Since the ETDRS
chart has become a de-facto standard, calibrating against an ETDRS chart is another option.
Tumbling Es are probably the symbols most often used for the testing of children. They are
also widely used in developing countries and in countries where the Roman alphabet is not
33
used. Tumbling Es and Landolt Cs require a sense of laterality, which can be a stumbling
block for young and for developmentally delayed children. They can be presented in a chart
format or as single symbols. When comparing findings, it should be remembered that
presentation as single symbols is an easier test than presentation in a chart format.
Symbol sets often used in the US
The HOTV test uses the four letters H, O, T and V as symbols with distinctive shapes that can
be recognized even by pre-literate children; these letters were chosen because they do not
require a sense of laterality [ 46]. For children who are shy or have difficulty naming symbols,
matching cards can be used where the child only needs to point at the matching symbol.
For illiterate patients and pre-school children, pictures may be used. However, it is difficult to
judge the equivalence of letters and various pictures and a childs performance may depend on
their familiarity with the objects. Most pictures cannot be designed on Snellens 5x5 grid.
Figure 20 Various Optotypes
This chart depicts a selection of commonly used optotypes.

First row: three types of H, Snellen H (with serifs, 5x5), Sloan H (no serifs, 5x5), H on BaileyLovie chart (no serifs, 4x5) [35]. Note that the 5x5 non-serif design appears wider than normal
print; the 4x5 design, based on the 1968 British standard [24], more closely resembles normal
print. Yet, the 2003 British standard [58] went back to the 5x5 Snellen design.
Second row: Number, tumbling E, Landolt C. These groups have fewer symbols, so that the
guessing level is notably higher than with letter charts.
Most optotypes approximate the recognizability of Landolt Cs; they represent 20/20 (1.0) acuity
when their height subtends about 5 [59].
Patti Pics form a set of five stylized pictures, designed on the 5x5 Snellen grid, that provide a
middle ground between letters and pictures [ 47]. They are left-right symmetrical and require little
naming ability. They have been calibrated for equal recognizability with Sloan letters. As a
result, no shift in visual acuity is observed when a child graduates from Patti Pics to letters.
They can also be used for adults who are not familiar with the Roman alphabet.
34
LEA symbols were devised by Lea Hyvrinen [ 48]. The set has only four symbols that have
narrower lines than Snellen symbols. They are widely used for pediatric testing and are
available in a variety of formats, from game formats for the very young to letter chart formats.
However, since they are somewhat easier than Sloan letters, there may be a difference when
children make the transition from symbols to letters [ 49].
Grating acuity presents a different form of visual acuity measurement. The subject is asked to
detect the difference between a fine grating and an even gray surface or is asked to detect the
slant of a grating. Grating acuity is expressed in cycles per degree (cpd), where each cycle =
one light + one dark bar. Mathematically, 30 cpd = 20/20; however, grating acuity is often better
than recognition acuity. In young infants, a reason may be that gratings offer a detection task,
rather than a recognition task, and therefore require less cognitive processing [ 50]. In adults with
retinal disease a reason may be that gratings cover a larger retinal area and thus have a better
chance of catching a good area. Teller cards [ 51] provide a well-known preferential looking test
for infants; they have also been used for demented elderly.
Electro-physiologic tests in infants record the VEP response to a visual stimulus. Here too it
has been found that a simple grating stimulus may overestimate later recognition acuity.
Vernier acuity has been found to be a better predictor.
Chart layout
Snellens charts (Fig. 7) and most subsequent charts had a rectangular format with few large
characters at the top and many small ones on the bottom lines, and with spacing dependent
upon the available space. Bailey and Lovie [35] introduced a new format (Fig. 13) that combined
the logarithmic progression with a fixed number of characters per line and with proportional
spacing. This resulted in a large chart in the shape of an inverted triangle, where every
character is surrounded by a white space equal to the width of the character. In this format,
which was also followed for the ETDRS charts, the crowding effect is the same for all characters
and the only variable from line to line is the letter size.
Although the Bailey-Lovie and ETDRS carts are often recognized for their logarithmic
progression, it was their layout that was new, not the logarithmic progression, which had been
used earlier (Fig. 9).
For projector charts and computer screens this format is possible only for the smallest lines,
since the projection area is not large enough. The logarithmic progression, however, can and
should be maintained [ 52].
When symbols are presented in isolation, the crowding effect of the surrounding letters is lost.
For single letter presentation, the letters are therefore often surrounded by crowding bars. For
adult charts the crowding bars are generally placed at one character width [49]. For children, the
spacing is generally 1/2 character width [50], because of the interest in detection of amblyopia.
Summary
The measurement of visual acuity involves determining the MAgnification Requirement (MAR)
that allows a subject to reach a standard performance. Visual acuity is defined as the reciprocal
of the MAgnification Requirement (VA = 1/MAR). The measurement tool is usually a letter chart
or similar instrument. The test is usually a distance measurement. Distance testing was
35
chosen because it relaxes accommodation and facilitates refractive measurement, not because
distance vision is most representative for activities of daily living.
Charts with a logarithmic (geometric) progression of letter sizes are recommended. Where
space permits, the triangular format of the Bailey-Lovie / ETDRS layout is preferred. Results
are best recorded in Snellen equivalents; in the US this means use of the 20/20 notation, in
Britain the 6/6 notation and in Europe decimal notation.
For occasional use, printed charts are the simplest solution. For more standardized testing and
school tests rear illumination cabinets may be used. In professional offices projector charts are
preferred. In the future many of these will probably be replaced by computer displays.
The choice of other test parameters depends on the setting and the purpose for which visual
acuity is to be measured. For refraction and testing of mainly normally sighted subjects, test
distances in the range of 5 m to 6m (16 to 20 ft) are preferred. When a small room does not
allow this distance, use of mirrors is recommended. For children, 3 m (10 ft) is often used. For
testing in the low vision range, testing at 1 m (40) is recommended. This distance not only
allows a much wider measurement range, it also is a better average of common distances
involved in the performance of activities of daily living.
Since many activities of daily living involve near activities, assessment of near vision is also
important. The next section will discuss near testing.
CONSIDERATIONS for NEAR VISION TESTING AND READING

Although the testing of reading vision predated the development of letter charts to measure
distance vision, the methodology to accurately measure reading acuity has lagged behind.
Several interrelated factors contribute. Firstly, measurement tends to be less accurate, since
relatively small differences in viewing distance can cause large changes in the measured acuity.
Secondly, the prescription of a reading correction for normally sighted individuals is aimed more
at achieving a comfortable, supra-threshold reading performance (functional vision) than at
accurate measurement of the visual acuity threshold (a visual function). Thirdly, there also is a
lack of accurate measuring tools. Reading distances are more often estimated than measured,
while the Jaeger numbers, which are widely used in the U.S., have no numerical meaning.
Under these circumstances, it is not surprising that many practitioners believe that reading
acuity and distance acuity have little in common. We will show that this is not so.
Near letter-chart acuity
Many eye professionals carry a pocket card with a miniature letter chart. If this chart is properly
calibrated, if the viewing distance is properly measured and if the subject has the proper
refractive correction for this viewing distance, there is no reason that the threshold visual angle
measured at a close distance should be any different from that measured at a longer distance.
As noted earlier, letter chart acuity is a good test for the integrity of the optical system of the
eye, since defocus at the fovea predicts equal defocus in the periphery of the image. A pocket
letter chart is an easy test for presbyopic subjects in whom we have good reason to believe that
the retina is normal. However, as the population ages and we are confronted with more retinal
problems, the limitations of letter chart acuity have become more obvious, since the
performance of the retinal area where the letter is projected, does not tell us anything about the
function of other retinal areas.
36
Reading acuity
If there is a suspicion that there may be retinal problems, a near letter chart alone is no longer
adequate. As a functional test, a reading test is far superior to a test of letter chart acuity.
Functional reading requires not only the recognition of individual letters, but of words and
preferably of parts of a sentence. This requires a larger retinal area.
Consequently, making the distinction between distance and near acuity is relevant for the
diagnosis of presbyopia, but distinguishing between letter-chart and reading acuity, is more
relevant for functional vision. The various combinations are summarized in Fig. 21.
Figure 21 Characteristics of Letter chart vs. Reading acuity
Note that letter chart tests and reading tests do not test the same qualities. They differ in the
scoring criterion, which explains part of the different measurement results. They also differ in
the problems for which they are most useful. See also Fig. 22 and Fig. 23.
Note that the criterion used for letter chart acuity is different from that for reading acuity. This
difference is often overlooked and accounts for some of the difference between the two
measurements. For letter chart acuity we usually press for threshold performance and
encourage guessing. This is done because threshold (forced choice) performance is better
suited for psychophysical calculations, not because threshold performance is the most relevant
performance level for activities of daily living. In reading tests we aim for a supra-threshold level
of comfortable and sustainable performance that is more relevant to everyday functioning, but
less precisely defined. Except for Olympic athletes, people rarely perform at the limit of their
capabilities. Reading a book with a marginal print size and marginal contrast under marginal
illumination is not an acceptable performance level.
Modified Snellen Formula for near acuity

Before we can discuss reading acuity in more detail, we need an easy way to measure it. As is
the case for distance vision, this requires two variables: letter size and viewing distance. For
37
distance vision the viewing distance for a particular office is usually standardized, so that the
acuity value for each line can be noted on the chart. For reading tests the viewing distances are
less standardized. Today, many clinicians use 40 cm (16, 2.5 D reading add), some use 14
(35 cm, 2.75 D add), others use 33 cm (13, 3 D add) or 30 cm (12, 3.25 add) or even 25 cm
(10, 4 D add, the reference point for the power of magnifiers). Individuals in the Low Vision
range often need distances that are even shorter and certainly cannot be handled with a one
size fits all distance. We therefore need a formula in which both the letter size and the viewing
distance can be varied easily.
The standard Snellen formula V = viewing distance / letter size becomes awkward to use
when the numerator (viewing distance in meters) is itself a fraction within a fraction. This can be
overcome by using the reciprocal value of the viewing distance, recognizing that the reciprocal
of a metric distance is known as the diopter (2 diopters = 1/2 m, 5D = 1/5 m, etc.) [ 53].
The traditional formula: V = m / M thus becomes: 1 / V = M / m = M x 1/M = M x D
or: 1 / V = M x D = letter size (in M-units) x viewing distance (in diopters).
Use of this modified Snellen formula has several advantages.
Use of reciprocal values turns the usual Snellen fraction into a multiplication, while the
viewing distance changes from a fraction into a whole number. Both changes make the
formula far easier to calculate in ones head.
Expressing the reading distance in diopters relates directly to the reading add and/or the
amount of accommodation that must be used for this distance.
The value 1/V relates directly to the letter chart acuity measured at 1 meter; the numerator
indicates the magnification (MAR) required to bring the subject to standard performance and
is an initial guide to the choice of magnification aids (Kestenbaums rule [43]).
The results of these calculations are listed in Fig. 22. This table is based on the use of
preferred numbers, so that the same values appear for the viewing distances, the letter sizes
and the resulting visual acuity values.
Many reading cards are calibrated for a specific reading distance, i.e. for a specific column in
Fig. 19. This has led to the erroneous habit of using visual acuity values to refer to letter sizes.
For instance, a letter size that would represent 20/100 at 40 cm might be referred to as a
20/100 letter. The table shows that the same letter at 25 cm would represent an entirely
different acuity value. A 20/100 letter on a 20 ft. chart is very different again.
As visual acuity drops (MxD = MAR increases), subjects can compensate in two ways. They
may move to a different column, i.e. bringing the same print size closer by increasing the
reading add (or the amount of accommodation in younger people). They can also move to a
different row, i.e. enlarging the print size, while maintaining the reading distance. Large print
books enlarge the physical print size; various magnification devices enlarge the virtual print size.
Under most circumstances letter chart acuity and reading acuity if measured appropriately and
with the proper refractive correction will be similar. However, since reading tests aim at a
level of comfortable performance, the magnification requirement for reading may be somewhat
greater than for letter recognition. The difference, known as the magnification reserve [ 54], is
needed for reading fluency. While 20/20 (1.0) acuity by definition implies the ability to read 1 M
print at 1 m, comfortable reading of newsprint (1 M) is generally done at 40 cm, indicating a 2.5x
magnification reserve (4 line-intervals) (Fig. 23). Traditionally, the power of magnifiers is
referenced to the ability to read at 25 cm (10). 1 M at 25 cm denotes 20/80 (0.25). Note that
this is the top value in the Low Vision band in Fig. 18.
38
Figure 22 Modified Snellen Formula
1 /V = M x D
for Near Vision
Columns indicate reading distances. Rows indicate letter sizes. The resulting reading acuity
values are found at the intersections. The large numbers represent the MxD value (= 1/V); the
small number the visual acuity value. Note that the visual acuity values are arranged in
diagonal bands and that the same visual acuity value can result from many different
combinations of viewing distance and letter size. In the first column, pts refer to printers points
for Arial or Courier print; the outer edge indicates the ranges of vision loss in ICD-9-CM.
39
Figure 23 MAgnification Requirement for Letter Chart and Reading Acuity
The table compares the magnification need found for letter chart testing (1/V) with the
magnification need for continuous text reading (MxD) for 150 consecutive Low Vision patients.
The numbers indicate the number of patients in each cell.
Each row indicates a level of letter chart acuity. The spread of numbers on that line indicates
the levels of magnification different patients found most comfortable. On each line the spread is
considerable, leading to the conclusion that letter chart acuity alone is a poor predictor of
magnification need for reading. When comparing the various rows, however, a more consistent
pattern emerges. For the majority of patients the two acuity levels fall within the diagonal gray
band, i.e. the two are within one line from each other. For many patients the magnification need
for reading is larger than the magnification need for letter recognition (spread to the right of the
diagonal). This difference is the magnification reserve needed for reading fluency; it appears
that the range of this reserve is constant across all acuity levels. For a few patients the
magnification need for continuous text was significantly greater (isolated gray cells). Their
findings should not be discarded as outliers; for most of them letter acuity was obtained in a
small island surrounded by scotoma, while reading acuity utilized a larger, more eccentric area,
requiring more magnification. This finding is significant for rehabilitation training.
40
Letter size notations for continuous text

For letter charts with metric notation the unit for letter size measurement is the M-unit, as it was
defined by Snellen and named by Sloan. A corresponding F-unit for charts with feet notation
was never defined, and would probably only lead to confusion since calculating with non-metric
measurements is so much harder. The situation for continuous text letter sizes is more diverse.
Jaeger numbers
In the U.S. Jaeger numbers are widely used. We have seen that these numbers have no
numeric meaning since they refer to item numbers in a printing house catalogue in Vienna in
1854. They cannot be used for calculations. Furthermore, since Jaeger did not establish an
external reference, those who wanted to produce similar samples had to approximate Jaegers
samples with fonts that happened to be available at their local print shop; they often chose a
slightly larger font. The result is great inconsistency in the use of Jaeger numbers. Fig. 24
summarizes the variability in the use of Jaeger numbers in a random sample of 20 different
current Jaeger cards. It is clear that Jaeger numbers cannot be used as a reliable reference
standard. Other countries have used similar samples, such as de Wecker samples in
Germany and Parinaud samples in France.
Figure 24 Variability of Jaeger numbers
This table summarizes the letter size measurements made on 20 randomly chosen cards with
Jaeger notation. Each vertical column indicates the range of actual letter sizes (rounded to the
nearest logarithmic M-size notation) for each J-descriptor. For J4 to J7 each column covered a
3x range. The horizontal bands indicate the range of J-descriptors found for each letter size.
Four of the cards described 1 M letters (newsprint) as J2, four others described it as J8. The
black markers indicate the size of Jaegers original samples. Almost all current samples are
larger than the original.
It is clear that the variability precludes use of the J-notation as a measurement standard and
that reverting to the original measurements is not an option, since it would make all current
ratings worse.
41
Printers points
The need for a numerical designation lead some practitioners to the use of printers points.
This might have been useful if printers points referred to the letter height; instead they refer to
the height of the slug on which letters used to be mounted. On average, lower case letters tend
to be about 50% of the slug height. Since 1 inch = 6 pica and 1 pica = 12 points, it follows that:
1 point (slug height) = 1/72 inch
and
1 point (letter size) = about 1/144 inch
However, this relationship varies with the type font (Fig. 25). Another problem is that the point
notation does not apply to the optotypes used for distance vision, so that comparison of far and
near measurements is not possible.
Figure 25 Variability of Printers Points
Printers points are inconsistent from type face to type face, since they refer to the slug height
on which fonts were mounted, rather than to the actual letter height. Furthermore, they do not
allow a comparison of the capital letters used in letter charts to the lower case letters used in
reading samples. These samples are only for comparison; the actual size on your screen
depends on the resolution of your monitor.
A and N series
On British type samples the letter size may be indicated by A or N. The N = notation is a
direct measure of the print size, equivalent to printers points. The A = notation is a linecount notation based on a logarithmic progression.
M-units
Considering these problems, the M-unit, as defined by Snellen and named by Sloan, remains
the only well defined unit that applies to distance charts as well as to reading samples and thus
allows comparisons between the two tests. It is the letter size unit used in this chapter and on
an increasing number of newer reading cards.
By definition 1 M-unit subtends 5 of arc at 1 meter and equals 1.454 mm. Useful
approximations are: 7 M = 10 mm (error 2% or 0.1 line-interval) and: 1 M = 1/16 inch (error
+10% or 0.4 line-interval). It is convenient that 1 M is the size of average news print, but that is
not the basis of its definition.
42
Reading Fluency
For reading tests, the level at which subjects can read with reasonable speed and fluency is
important. Many traditional reading cards have short paragraphs with large letters and longer
paragraphs with smaller letters. On such cards comparison of reading fluency with different
levels of magnification is only possible subjectively.
Cards on which all paragraphs have the same length offer allow more objective measurement of
the reading speed and fluency (Fig. 26).
Figure 26 Reading Cards with Proportional Paragraphs.
Reading cards with proportional paragraphs to measure reading speed and reading fluency are
available in several formats. At left is a card with a 40 cm cord attached for patients with normal
or near normal vision. To the right is a larger card for Low Vision patients, which comes with a
ruler with a diopter scale to facilitate measurement at non-standard distances and verification of
the reading add.
The cards shown here are available in multiple languages and are also available in the Mixed
Contrast format (Fig. 36). The MNread and Radner reading cards also have proportional
paragraphs. They are available only in the high-contrast format.
Several reading cards with proportional paragraphs of continuous text are available. They all
follow a logarithmic progression of print sizes.
MNread. This was the first such card. It was developed by Legge and Mansfield [ 55]. It is
available in black-on-white and in white-on-black contrast. It is labeled for use at 40 cm, but
does not include a cord or ruler for this distance.
43
Colenbrander reading cards. Its sentences are rated at 4th grade level. The cards come in
two formats [ 56]. A smaller card is for subjects in the normal and near-normal range; it has a 40
cm cord attached for a standard reading distance. A larger, folding card is meant for use in a
low vision service. Since low vision patients often require short reading distances, the card
comes with a ruler, so that it can be used at any distance. The ruler has a diopter scale for use
with the modified Snellen formula, and to compare the reading distance to the reading add (Fig.
36). Similar cards are also available in the Mixed Contrast format. The MNread and
Colenbrander cards use the Times Roman font, which is used in most newspapers.
Radner reading cards. The Radner cards were originally developed in Vienna [ 57]. They use a
Helvetica font, which is closer to letter chart optotypes, but slightly easier than most newspaper
fonts. The sentences have been rigorously standardized to give equal reading times for normal
subjects. As a consequence, the sentences are at a more adult reading level.
Reading patterns
Any of these cards can be used to record reading times for each print size; the usual pattern will
be that the subject reads at a reasonably stable rate at larger print sizes. At smaller sizes
reading becomes slower and then impossible (fast fast slow). The print size just before the
reading speed starts to drop off is known as the Critical Print Size (CPS), a term introduced by
Legge [1]. Providing magnification of ordinary print to the critical print size will give the best
reading performance with the least magnification (largest field of view).
Some subjects will show a different pattern that can be characterized as slow fast slow.
This pattern occurs when macular degeneration patients read in a small island of vision
surrounded by a scotoma. For large text the island is not large enough to cover a whole word;
this slows reading down. At medium print sizes more letters are covered and reading speeds
up. At the smallest sizes reading slows down again. The same pattern can be seen in patients
with extreme tunnel vision in end-stage glaucoma or RP. In these cases it is very important not
to prescribe too much magnification, since this would slow reading down again.
Occasionally, the pattern is slow slow slow. This pattern, which results from multiple
scotomata with limited useful areas in between, can be seen in patients with scattered drusen.
With this pattern magnification will only move the patient from slow at one size to slow at
another size, so magnification alone will be of limited benefit. In these patients, other means
such as underlining to facilitate tracking, together with training and practice in the most effective
use of the available retinal areas can lead to more improvement than the use of magnification
alone.
Eccentric viewing
When the foveal area is damaged by a scar from macular degeneration or any other process,
the eye must use another retinal location for fixation outside the scotoma. This new fixation
area is then known as Preferred Retinal Locus or PRL. Using a PRL has several effects. Since
it is away from the original fovea, it will have a coarser cone mosaic; this will result in a reduced
visual acuity, even if the area is not affected by the disease process. Often the new area is
partly affected, which may result in a relative scotoma and further reduced visual acuity. This
reduced visual acuity can be compensated for by magnification.
However, there are other significant effects that cannot be eliminated by magnification. If the
PRL is in an area of relative scotoma, increasing the illumination may recruit cells with marginal
44
sensitivity. This explains why many patients with AMD benefit from increased illumination. In
some cases, different PRLs may develop for dim and for bright illumination [ 58].
Another effect affects eye movement. In normal vision, any object that attracts attention is
automatically brought to the fovea for more detailed examination. In an eye with a central
scotoma such a movement is counterproductive; instead of providing more detail, the object
disappears in the scotoma. Therefore, effective use of a PRL requires the reprogramming of
reflex eye movements. This process cannot be helped by magnification or illumination, but
requires training and practice.
Most patients are not consciously aware of their scotoma, yet will spontaneously develop a
PRL. Making them aware of the location and extent of their scotoma can help them to develop
and use their PRL more effectively. It can help them not only to develop more effective eye
movements, but also to transfer hand-eye coordination to the PRL. This can dramatically
improve their handwriting, as shown in Fig. 27.
Figure 27 Improved Hand-Eye Coordination
The upper images show examples of tracing performance of the same patient, before and after
two weeks training of hand-eye coordination. The lower images show similar improvements in
handwriting.
Scotoma Interference
Yet another important consideration is the location of the PRL relative to the scotoma, since this
affects the efficiency of the scanning eye movements necessary for reading. This effect can be
captured under the heading of scotoma interference. How much scotomata will interfere with
reading fluency depends on the configuration of the scotomata. SLO studies have greatly
increased our insight in this effect (see Fig. 30).
45
A very simple test for scotoma interference can be found in the SKread card [ 59]. This card,
developed by Fletcher at the Smith Kettlewell Institute, has paragraphs of unrelated short words
and single letters. The lack of contextual cues slows down the reading speed, but greatly
increases the number of errors. The pattern of errors (right or left) gives a simple indication of
the position of scotomata relative to fixation.
TESTING INFANTS and YOUNG CHILDREN

In infants, both the physical basis of visual acuity and the cognitive skills to use it are still
developing. Standard visual acuity testing is impossible, yet early detection of deficits is
extremely important. Not acting on a suspicion of vision loss may cause developmental delays,
since it deprives the infant of its most abundant source of stimulation.
One solution is to record the visually evoked potential resulting from visual stimulation. Stimuli
are often presented on a computer screen. One method uses moving gratings of variable
spatial frequencies and determines which frequencies elicit a cortical response. It has been
found that simple gratings often overestimate later development. A Vernier stimulus, which
requires more cortical processing, appears to better predict later recognition vision [60].
A test method based on behavior observation is the Preferential Looking technique, where the
infant is shown a grating on one side and a gray surface on the other. If the infant spends more
time looking at the grating, this means that the visual system can discern the grating. This can
be done with standardized Teller cards; each of these cards has a grating of a certain frequency
on an even gray background [61]. Another way is the use of paddles [55] with various gratings,
which can be moved through the infants field of view, if two paddles with different gratings (or a
gray one) are used, the reaction to different gratings can be observed.
Another approach is the use of behavioral observations, comparing them to established
milestones. The list in Fig. 28 was provided by Dr. Lea Hyvrinen, who has also developed
various games that can be played with somewhat older children to assess their visual
development when regular letter chart testing is not yet possible.
When letter chart testing becomes feasible around the age of three, it is advantageous to use
symbols or pictures instead of letters. In the US the H O T V set is often used. Although these
are letters, for the child they appear as a four character symbol set. Internationally, tumbling Es
(4 options) are often used. Another alternative are stylized pictures, such as Patti Pics (5
options) or LEA symbols (4 options). Actual pictures are not recommended, since they are hard
to compare to regular optotypes and since the ability to name pictures also depends on whether
the child is used to doing this in its home environment.
In young children the detection of amblyopia is important, since it may be a sign of strabismus
or other conditions that require early treatment. Amblyopic eyes are known to be more sensitive
to crowding. Presenting symbols in a chart format provides a crowded environment, but it often
is difficult to direct the childs attention to successive symbols. The alternative of presenting the
symbols one by one removes the crowding effect. One solution is to surround each symbol with
four crowding bars; for childrens tests these bars are usually placed at one half the symbol
width. For children who are old enough to name successive symbols in a row, the Mass VAT
format [55] may be used, where each row of five symbols is surrounded by a rectangular frame.
46
Figure 28 Visual Behavioral Milestones

What I See Visual milestones for the first and second year
0 3 months
As a newborn infant, I look at light sources and turn my eyes and head toward them. I develop
eye contact between 6-8 weeks and follow objects that move slowly, first horizontally, later
vertically. By the end of the second month, I become interested in looking at mobiles.
3 6 months
I discover my hands, reach towards objects, then grasp hanging objects. I watch toys fall and
roll away. My visual interest sphere widens gradually. If my vision is equal in both eyes, I dont
mind it if you cover my eyes with a cap or a patch, one at a time.
7 10 months
I notice small bread crumbs. First I touch them, then I try to grab them. I like to watch you
draw simple pictures for me. I also recognize objects that are partially hidden.
11 12 months
I love to play hide and seek and know my way around my home. I can look out the window
and recognize people. I also start to recognize some people.
18 months
I can play with simple puzzles. I am interested in books and pictures and I can recognize that
pictures are representations of real objects. I like to watch you draw while you tell stories. I
may be able to name pictures and objects (such as my LEA puzzle shapes: apple, house, block
and ball).
24 months
I love to scribble and color. I understand that pictures can be large and small and still represent
the same thing. I can also arrange similar pictures in groups. At this age, my vision can be
tested while I play if I am in the mood! When my vision is tested, I see small pictures equally
well with my right and left eye.
Courtesy of Lea Hyvrinen, MD
47
Figure 29 Various Childrens tests
To keep childrens attention a variety of formats may be used. At left is an HOTV test. The flip
charts show one character at a time with crowding bars. The child can point to the large
characters underneath. The cord maintains the correct viewing distance.
In the center are paddles with different gratings and faces with different contrast. Moving them
and observing which one best attracts the infants attention gives an impression of visual
potential.
At right are cards with Patti Pics symbols (star, apple, house, square, circle). Each line is
surrounded by a frame (MassVAT format). The line format is a little harder than single symbol
presentation, but easier than a full chart format.
48
2-B VISUAL FIELD MEASUREMENT

INTRODUCTION
The discussion of scotoma interference in reading tests already introduced the importance of
the topography of the visual field. The traditional clinical visual field tests were refined to give
useful diagnostic information for diseases such as glaucoma, retinitis pigmentosa, or neuroophthalmic conditions. Their use has been discussed in other chapters. This chapter will focus
on the functional consequences of visual field defects. The discussion will be divided between
central and peripheral field defects.
For tests concerned with the localization of defects in the retina or in the visual pathways, the
eye must maintain a steady fixation; eye movements during testing (fixation losses) invalidate
the results. To appreciate the functional significance of visual field defects one has to consider
that in actual vision the eye is never stationary, but constantly moving either with saccades or
with pursuit movements. Inability to make eye movements is a significant visual impairment and
interferes with scanning while reading and with taking in the entire environment for orientation
and mobility. Amazingly, very few clinical tests exist to assess the efficacy of scanning the
visual environment.
CENTRAL FIELD DEFECTS
Any defects in the central 10 degree (radius) area of the visual field are considered central
defects. This retinal area corresponds to about 50% of the primary visual cortex. Some defects
include the fovea. In that case, the patient is forced to use eccentric viewing. Other defects
may include only parafoveal areas. Even these defects may have significant functional
consequences, as discussed earlier under in reading.
Scanning Laser Ophthalmoscope
Much information about the relation of retinal function to retinal topography has been obtained
from studies with the Scanning Laser Ophthalmoscope (SLO), which allows the projection of
various stimuli on the retina, while observing the retinal image in real time [ 60]. This allows the
plotting of scotomata directly onto the retinal image and is also known as micro-perimetry.
Figure 30 provides examples of SLO images. The eccentric retinal area that is used for fixation
is known as a Preferred Retinal Locus or PRL. When describing SLO images, one should
remember that a PRL, which on the retina is above the scar, results in a point of fixation in the
visual field that is below the scotoma. Different patients may place their PRL in different
positions in relation to the scotoma. Recent SLO studies have shown that 39% of patients
spontaneously keep their scotoma above their point of fixation, 34% to the right, 20% to the left
and 7% below [ 61]. However, these numbers can be changed through training. Studies in
Sweden [ 62] have reported that a majority of patients can be taught to fixate below their
scotoma. This is advantageous since for such a Trained Retinal Locus (TRL) the horizontal
extent of viable retina is larger, which results in easier scanning and improved reading rates.
SLO studies have shown that 40% of patients have a scotoma on one side of fixation, 20% on
two sides, 10% on three sides and 15% on four sides. Patients with multiple scotomata are the
ones most likely to exhibit the slow-fast-slow phenomenon described earlier. These numbers
did not change much from 1997 (before the onset of anti-VEGF therapy) to 2007, however,
49
today more of the scotomata are relative, rather than dense, which has resulted in easier
trainability, even if the visual acuity is not necessarily better [ 63].
SLO equipment is expensive and only available in a limited number of locations. Fortunately,
less expensive ways to plot the central field are available also.
Figure 30 Micro-perimetry
The top left image shows a fundus photograph. The right image shows the corresponding SLO
study in which stimuli were projected on the fundus under direct visual control. DS indicates a
dense scotoma. The cross indicates the fixation area, which is still close to the fovea, but
surrounded on three sides by scotomata. Although letter recognition may still be reasonably
good, the scotoma pattern will cause scotoma interference when reading.
The lower two images show smaller central scotomata with semi-automated testing. Red dots
show stimuli that were missed. Green dots were seen. In both eyes the new point of fixation
(PRL,, cross) is in corresponding positions to the left of the scotoma.
Macular Mapping test

This test can be run on any PC [ 64]. Since patients may have a central scotoma, the usual
central fixation point would not work. Instead, the patient is asked to look at a wagon wheel with
spokes and an empty center; this can provide good gaze stability. Letters are then presented at
various points in the central field (up to 8 degrees). Typical findings will show losses extending
50
from the center. However, it is also possible to find extra-foveal islands of loss, indicating that
AMD does not necessarily start in the fovea. The position of these scotomata can then be taken
into account for eccentric viewing training.
Figure 31 Macular Mapping test
The Macular Mapping test shows a steady wagon wheel to stabilize gaze (left top image) upon
which letters are briefly presented at a size that is above threshold for the eccentric position.
The right top image shows a completed test. Black/half/white squares indicate positions that
where not seen/detected, but not recognized/correctly recognized. The position with a star
suggests a good candidate spot for eccentric fixation, close to the original center.
The lower images show the apparently normal fellow eye of an eye with AMD. The diagram
shows irregular losses, well outside the fovea.
Note that the peripheral stimuli of the wagon wheel tend to bring the original fovea to the center
of the screen, whereas a fixation dot (as in Fig. 31) tends to bring the Preferred Retinal Locus to
the center of the screen.
Central tangent screen

Even simpler is a central tangent screen test. The examiner sits opposite the patient so that
eye movements can be observed. A laser pointer is used to shine through the paper screen to
51
present stimuli in various locations. Since the patient is likely to use a PRL to fixate the center
of the fixation cross, the center of the sheet will not correspond to the fovea and a central
scotoma will appear eccentrically on the plot.
Figure 32 Tangent Screen with laser pointer
The top left image shows a patient seated for the test; the observer sits opposite to observe eye
movements. Laser pointers of different intensity are used to place stimuli on the screen.
The top right image shows a test result after anti VEGF injections. The red area shows a small,
dense peripheral scotoma (bright laser pointer); the blue area shows a larger relative scotoma
(weaker laser pointer). The peripheral scotoma is unlikely to interfere with reading; the larger
relative scotoma will interfere in dim light, but may still function in bright light. Visual acuity is
20/200 with normal illumination.
The bottom left image shows a dense scotoma due to a macular scar. The patient fixates
eccentrically at the edge of the scotoma, turning the eye turned up and to the right; the original
point of fixation (fovea) is within the scotoma. Visual acuity is 20/500. This scotoma will
interfere with following the line to the right. The patient will need training to increase scotoma
awareness and to re-orient eye movements to the new PRL (Preferred Retinal Locus) before
magnification can be optimally effective.
The bottom right image shows a ring-shaped scotoma due to geographic atrophy. Visual acuity
is 20/70. Too much magnification will reduce the overview and slow reading down.
52
PERIPHERAL VISUAL FIELD

While the central visual field is most important for reading and for activities that require handeye coordination (as shown in Fig. 27), the peripheral field is most important for Orientation and
Mobility (O + M).
The methods discussed above present variable stimuli on a fixed retina. This is important to
determine the relation of the visibility of the stimuli to the retinal pathology. Unfortunately,
modern static perimetry, which was refined for diagnostic purposes, rarely measures outside
300. This means that clinical information about the peripheral field is often unavailable. For
awareness of the environment the field outside 300, while low in resolution, is very important.
Losses in this area cannot be ignored when calculating an ability estimate.
When actually using vision in activities of daily living, it is important to realize that the eyeball is
constantly moving and that the image of any object is never fixed on one point of the retina.
Therefore, the usefulness of the peripheral field depends on the combination of the visual field,
the field of gaze and the attentional field.
MENTAL MODEL OF THE ENVIRONMENT
If the retinal image is constantly moving, how can we nevertheless perceive a stable visual
environment? This must mean that there is an intermediate step between the retinal image and
our actions in the environment. That intermediate step, which often is overlooked, is the
creation of a Mental Model of the environment. When looking around, visual and proprioceptive
inputs are used to update the mental model; the mental model then guides our actions in the
environment. In the constant interaction of bottom-up and top-down activity in the brain, the
updating of the mental model is mainly bottom-up, the guiding of actions is mostly top-down.
Most often both occur simultaneously.
The transition from retinal image to mental model is largely subconscious. Only at the level of
the mental model do we become consciously aware of the environment. The characteristics of
the Mental Model are different from those of the retinal image in many important respects.
First of all, the mental model is stable, while the retinal image is constantly changing. The
retinal image sees an egocentric picture of the world; the mental model is environment
centered. When moving through the environment, we do not perceive the image of the
environment moving over our stationary retina. Rather we perceive ourselves as moving
through a stable environment. This conversion involves a remarkably complex set of processes
in the brain, which combine visual with somato-sensory input and happen automatically without
conscious input. Although normally the majority of the input is visual; this is not necessary.
Even the blind have a mental model of their environment.
At any moment, the retinal image is a snapshot of the environment; the mental model
accumulates information from successive fixations, and also incorporates long term memory. In
a familiar environment, we need only a glance to be adequately oriented. The role of the mental
model is not limited to vision. When we walk up a flight of stairs, we do not perceive the
variable pressure of the steps against our feet; we perceive our body moving relative to a stable
set of steps.
The retinal image is filled with 2-dimensional shapes; the mental model is filled with 3dimensional objects. When we look at objects in a display window and take a 2-dimensional
picture, details of our own reflection are mixed with details of the displayed items. Yet, in our 3dimensional mental model, the spatial location of the display objects is clearly separate from
that of our own reflection. We can shift our attention at will from the display to our image. Shifts
53
in attention therefore must take place in the mental model, not in the retinal image, where the
object of regard changes position with every eye movement.
Finally, the retinal image has gaps, where there are scotomata, whether from the physiologic
blind spot or from retinal scars. The space behind us represents a 180 degree blind spot for
the retinal image. The mental model has no gaps and extends all around us. The area behind
us has less detail, because we only have information from the last time we looked in that
direction, but we do not experience it as a gap. This also explains why people do not
experience their scotomata as gaps in their environment; they are only aware that there is less
detail, since every area only has the amount of detail that was available in the last eccentric
fixation.
It is a common assumption that saccades can only be made to points that fall on viable retina.
Yet, in a recent study [ 65] using a head borne recorder to measure the frequency and extent of
saccades, it was found that RP patients with tunnel vision, when walking around, made one
third of their saccades to points outside their available field; for a visual search task this even
was two thirds. Thus, it is clearly possible to make a saccade to a point in the mental model
that is outside the retinal image, like it is possible to make a head-eye movement to a point
behind us. It is not yet clear to what extent this is a natural ability and to what extent RP
patients honed this ability by living with tunnel vision for many years. Undoubtedly, saccades to
a visible point will be more precise than saccades to a remembered point in the mental model.
Yet, this finding may ask for a reevaluation of the tendency of many patients to place their
fixation to the left of their scotoma, even though this requires scanning saccades into the
scotoma when reading. It also raises the question to what extent this ability is trainable, as was
shown for hand-eye coordination (Fig. 27). What would be the best training modalities?
Similar considerations may apply for patients with hemianopia from an occipital stroke. Some
may also have hemi-neglect, i.e. part of their mental model is missing. Those patients will have
no incentive to make saccades to their blind side. Hemi-neglect is more hazardous in daily life
than a condition of pure hemianopia where the awareness of the world on the blind side persists
and occasional saccades to the blind side are made.
54
2-C CONTRAST SENSITIVITY

INTRODUCTION
Letter chart acuity measures the ability to see very small, high contrast letters on an empty
background. In general activities of daily living, except reading, this task is not encountered
very often. Seeing larger objects of lesser contrast, against an irregular or patterned
background is a more common task. Many have argued that the consequences of contrast
sensitivity loss are more relevant to daily living and that contrast sensitivity loss is a more
serious impediment than visual acuity loss, since it cannot be compensated for by simply
bringing the object closer or by magnification. Yet, visual acuity measurement has won out as a
screening tool, mainly because it is such an easy test and because it detects so many
underlying disorders. Contrast screening is more involved and less easily standardized. To be
competitive for general screening, contrast testing would have to be as simple and would have
to detect more problems. That is not likely to happen. The challenge then is to identify those
situations where the extra information gleaned from contrast testing is worth the extra time and
effort of testing it.
CONTRAST DETECTION
Recognition of shapes, including letters, depends on the detection of edges. Edge detection
depends on the contrast between adjacent areas. This process can be disrupted at all stages of
vision. At the optical stage, the retinal image can be degraded by uncorrected refractive errors
or by scatter from various sources. At the receptor level, detection can fail if the sensitivity of
the receptors is reduced. At the neural level, detection may fail if the mechanisms that compare
the signals from adjacent areas are not optimized. The changes at these different stages have
different effects, as shown in Fig. 33.
THE CONTRAST SENSITIVITY CURVE

The relationship between the two variables contrast and target size can be plotted on a graph
that is known as the Contrast Sensitivity (CS) curve. On this plot the target size decreases
along the x-axis (from left to right), contrast decreases along the y-axis (from bottom to top);
large, high-contrast symbols that are easily seen appear on the lower left, while small, low
contrast symbols that are too dim and/or too small to be seen, appear on the upper right. The
CS curve, which extends from the upper left to the lower right, connects all points on the
threshold between seen and not seen. There is a trade-off between size and contrast; a small,
dim symbol beyond the curve (the star in the diagram) can be made visible by making it larger
(move to the left), or by increasing its contrast (move down).
This plot ignores the third relevant variable: illumination. If illumination were taken into account,
we would need a three dimensional plot. Fortunately, for common levels of daylight illumination,
the effect is usually minimal. Commonly, the same illumination range is accepted as for visual
acuity testing: 85 300 cd/m2. Under mesopic conditions, however, we may find different
values. Also, some patients with contrast deficits due to macular degeneration benefit from very
high light levels that can still activate marginal receptor cells, so that the effective size of relative
scotomata is reduced.
55
Figure 33 Optical vs. Retinal Causes of Contrast Sensitivity Loss
The top diagrams demonstrate the effect of optical blur (whether from defocus or from scatter)
on the retinal image. A sharp transition will become a gradual transition, but the brightness
difference between extended areas will not change. This explains why for most patients the
legibility of very large print (extended stoke width) on the Mixed Contrast cards is similar for HC
and LC.
For a small details, such as two lines with little separation, the energy will be spread over a
larger area and the two lines may no longer be visible as separate. Thus, the visual acuity will
decrease. This explains why for small LC print the legibility is less than for small HC print.
The bottom diagrams demonstrate the effect of decreased retinal sensitivity. In this case, sharp
edges will remain sharp, but the perceived brightness difference will be reduced. Thus, even for
large areas the brightness difference may not be perceived. This may explain why for some
AMD patients the legibility of even the largest letters on the Mixed Contrast test is reduced.
For small details the perceived brightness differences may no longer be sufficient. Therefore,
the legibility of small print is reduced, even if the image remains sharp. Retinal elements with
partial sensitivity loss may still be stimulated by increased illumination. This explains why many
AMD patients benefit from very high illumination, but many cataract patients do not, since for
them the extra illumination increases both the brightness and the blur. This contrast sensitivity
effect is in addition to any visual acuity deficit due to use of an eccentric retinal area.
Note that the effects of optical blur are generally diffuse over the entire image, but that retinal
sensitivity changes may vary between retinal areas. In patients with retinal conditions, these
topographic differences and their effects (scotoma interference) should also be explored. See
Figs. 29, 30 and 31.
56
MEASUREMENT METHODS
Describing the entire contrast sensitivity curve is more complex than describing visual acuity,
since two, mutually interactive variables are involved. Most clinical measurements, therefore
are limited to measuring the endpoints, which can be specified with one parameter each.
Figure 34 Measurement Methods for the Contrast Sensitivity Curve
The Contrast Sensitivity Curve defines the visibility threshold of objects, based on size and
contrast. (See text.)
The lower right point of the curve (A) represents the familiar high-contrast acuity. The upper left
point (B) defines the threshold contrast for large letters. Low-contrast letter charts (C) define
intermediate points along the curve. Several points can be obtained with tests (D) that utilize
gratings of various spatial frequencies. Mixed Contrast cards (E) compare the high-contrast
(HC) and low-contrast (LC) acuity; the HC-LC difference defines the slope of the curve.
Determining the End Points

The lower end of the CS curve is nearly vertical. This means that for high-contrast letter chart
acuity, small variations in contrast can be ignored. The arrow in Fig. 34A shows how the CS
curve is anchored at the acuity value determined on a high-contrast letter chart, as was
discussed earlier.
For large letters and other objects with sharp edges, the upper left end of the CS curve is
horizontal, i.e. independent of the exact letter size. This level is known as the Peak Contrast
Sensitivity. Fig. 34B shows how the Pelli-Robson [4] chart and the Mars test [5] take advantage
57
of this fact. They present large letters (2.80 for Pelli-Robson, 20 for Mars) with variable contrast
to determine the peak sensitivity. The Pelli-Robson chart is a wall chart for use at 1 meter; the
Mars test is hand-held, for use at 50 cm. Both follow a logarithmic progression of contrast levels
(equal log(CS) steps, see below). The Pelli-Robson changes by 0.15 log(CS) steps for every 3
letters; the Mars test changes by 0.04 log(CS) from letter to letter.
When introducing their chart in 1988, Pelli and Robson argued that very little extra information
could be gained from the middle part of the curve. Hence they recommended determining only
the endpoints: high-contrast acuity and peak contrast sensitivity. They also recommended the
use of a letter chart over the use of gratings, since letter charts are more familiar and require
less explanation in the clinical environment. The Pelli-Robson chart has since become a
standard part of many clinical studies.
Determining intermediate points
One approach to determine intermediate points is to use a letter chart at reduced contrast, as
shown in Fig. 34C. By varying the contrast level, different parts of the curve can be probed.
The letter chart format can provide small horizontal steps, but measuring several contrast levels
requires several charts, which may be too time consuming in a clinical setting. Different users
may prefer different levels; 20% Weber (10% Michelson) is a commonly used level.
Others, who had previously used gratings, maintained that these are superior since they allow
for easier mathematical calculations. They also maintained that measuring at several spatial
frequencies, as shown in Fig. 34D, provides important additional information. Several contrast
levels and several spatial frequencies can be combined on one chart. There has been little
convincing information, however, that specific spatial frequencies provide specific relevant
information, either for diagnostic, or for functional purposes.
Determining the Slope of the Curve
Fig.34E shows that comparing a low-contrast (LC) acuity measurement to its high-contrast (HC)
equivalent can provide information about the slope of the CS curve. This could be done by
comparing readings from two charts, or by using the Mixed Contrast method [ 66], which presents
HC and LC side-by-side on the same chart. This method of presentation is not only easier and
faster than using two charts; it also guarantees that the HC targets and the LC targets are both
seen under the same illumination and at the same viewing distance. When using two charts
patients may unconsciously reduce the viewing distance for the LC chart, so that the two
measurements are no longer comparable.
The Mixed Contrast method provides three measurements from a single chart:
1.
The high-contrast (HC) threshold this replaces the use of the usual HC only tests, and
is relevant for fine detail, high contrast tasks, such as reading.
2.
The low-contrast (LC) threshold this value may be more relevant for many ADL tasks,
where the detail is not as small and the contrast not as stark as on a letter chart.
3.
The HC-LC difference (measured in lines) this value is very obvious and clearly
demonstrates to the patient and family members what situations may present problems.
A decreased slope (greater HC-LC difference) may point to a retinal, rather than an
optical cause.
Determining the slope has an important second advantage. When considering a LC acuity
value in isolation, one can only compare it to a population average. A reduction of the LC acuity
can either mean that the whole CS curve is shifted to the left, or that the slope of the curve is
58
flattened. Using the HC-LC difference, the LC acuity is judged in relation to that patients own
HC acuity. For any clinical measurement, using the patients own reference value is always
more informative than is comparison to a population average.
Figure 35 The Mixed Contrast chart format
Several charts are shown in the mixed Contrast format that shows high (HC) and low (LC)
contrast (20% Weber, 10% Michelson) side by side. At the top is a large card with Patti Pics
symbols. To the side are a simple reading card for beginning readers and a letter card with cord
to check the performance of various presbyopia corrections at defined distances. At the bottom
is a reading card (same as in Fig. 26) with alternating HC and LC lines of the same size to
compare reading speed.
Gratings vs. Letters

Early CS tests were done using gratings, which had a long history of use for testing of optical
lenses. Sine wave gratings are convenient for lens calculations, since the blurred image of a
sine wave is again a sine wave, and because any other repetitive wave form can be described
as the sum of a series of sine waves (known as Fourier analysis). Sine wave gratings are still
used for calculations about the optics of the eye and the effects of various refractive surgery
procedures. In these conditions the implicit assumption is that the retinal and neural processing
of the projected image is entirely normal.
For the purpose of calculations, gratings are usually specified in cycles per degree (cpd).
Mathematically, 30 cpd, is considered equivalent to 20/20 visual acuity (Fig. 36). Note however,
that this is only a mathematical equivalent, since grating detection is different from letter
recognition.
59
The shape of the CS curve is somewhat different for gratings. While the CS curve for large
letters and other sharp-edged targets is flat, for sine wave gratings the curve has a peak at
about 3 4 cpd and dips for wider gratings (lower spatial frequency). This may be because the
limiting factor for visibility is no longer the distance between the brightest and the dimmest part
of the grating, but the slope of the transition between the two. When this slope becomes too
shallow, the eye no longer detects an edge between the bright and the dim parts of the grating.
The fact that no edge is seen on the shallow slope of a sine wave of low spatial frequency is
comparable to the fact that a gradual decrease in brightness of a wall away from the window,
does not cause the perception of an edge, although we may easily detect the difference
between the brightest and the dimmest part of the wall from successive fixations.
In the natural world, repetitive wave forms are extremely rare. Clinical testing, therefore, has
increasingly gravitated to the use of letters, most prominently in the Pelli-Robson wall chart [4]
used in many research studies and in the newer Mars hand-held cards [5].
Contrast Scales
When letters or other sharp edged symbols are used, the size of each symbol is most
appropriately expressed in M-units; the visual angle for a specific viewing distance can then be
expressed on the MAR or VA scale. The left hand side of Fig. 36 lists equivalent visual acuity
notations for letters and for gratings. Depending on the stimulus used, either can be used for
the X-axis of the CS curve.
For specifying the contrast level along the Y-axis, there is a choice of two different scales:
Michelson and Weber, as shown on the right side of Fig. 36. Unfortunately, the significant
difference between these scales is rarely discussed or explained.
Early contrast testing evolved from lens testing and was mainly done with gratings. To specify
the contrast of a grating Michelsons formula is used:
or:
brightness amplitude / average brightness

(bright dim) /2 / (bright + dim) /2 = (bright dim) / (bright + dim).
When Pelli and Robson introduced their chart with letters, they found it more appropriate to
express the contrast using Webers formula, which applies to an object (foreground) seen
against a background:
(background foreground) / background.
Note that Michelsons formula for gratings is symmetrical in regard to the bright and the dim
parts. This is appropriate, since in a grating the bright and the dim parts are equal in area and
the grating (whether square or sine wave) does not change in character when black and white
are reversed. In Webers formula, foreground and background are not interchangeable. A letter
chart changes considerably when black and white are reversed, because the background area
is many times larger than the foreground area.
Unfortunately, when low contrast letter charts were first introduced, these charts often continued
the use of Michelsons formula for gratings. When Pelli and Robson introduced their chart, they
appropriately switched to the Weber formula. Today, many publications mention objects of
% contrast without mentioning which formula was used. This leads to confusion when
comparing the contrast thresholds found on a low contrast acuity chart with those found on a
Pelli-Robson chart.
On both scales 0% contrast indicates no contrast and 100% contrast indicates the maximum
possible. However, the brightness amplitude (Michelson) is only half the brightness difference
60
(Weber). This means that for the clinically most interesting range, the range of low contrast
stimuli, the relationship is:
Weber contrast = 2x Michelson contrast
This is confusing. We therefore recommend that all charts mention both the Michelson and the
Weber value.
Since the contrast values for the two scales differ, their derived values will also differ:
log(Weber contrast) = log(Michelson contrast) + 0.3
The right-hand side of Fig. 36 shows the significant difference between the Weber scale for
letters and the Michelson scale for gratings. Because of these differences, any chart should
state which scale is used and preferably list both values.
Interpreting Contrast Sensitivity Findings
Contrast perception, like any visual perception, goes through three stages, each with distinctly
different processes and problems. First there is the optical stage, where the optical system of
the eye projects an image on the retina. Opacities and even minor refractive anomalies can blur
this image and result in decreased CS. Contrast testing therefore plays an important role in
intraocular lens design and in judging the need for and the results of refractive interventions.
For optical problems the use of grating-based measurements remains appropriate. However,
since gratings do not occur in the natural world, their use to predict functional consequences
remains limited. For a functional perspective, the use of letters and similar symbols is more
appropriate.
Next is the receptor stage in the outer retina, where the optical image is translated into neural
impulses. Various retinal diseases can disrupt this process and result in decreased CS. Agerelated macular degeneration (AMD) is often accompanied by reduced contrast sensitivity.
Contrast deficits in parafoveal islands have even been found in fellow eyes of AMD [ 67].
Finally, there are the various neural processes that start in the inner retina and proceed upward
to end in visual perception. We know that glaucomatous changes in the inner retina can affect
CS; we also know that after optic neuritis, return of normal CS can lag behind the return of
normal acuity. We know little about the role of higher cortical centers with regard to CS.
Since CS can be influenced by so many different factors, it is not good at resolving a differential
diagnosis. CS may, however, play a role in early detection and early diagnosis. This is a
potentially important role, since the population is aging and many age-related conditions
(cataracts, AMD, glaucoma) carry the risk of reduced CS.. Some longitudinal studies have
found that losses in contrast vision are correlated with vision loss in the next five years [ 68].
Reduced CS is also a risk factor for driving, especially at night. Reliably and economically
screening older drivers for CS problems remains a problem without a solution in many
countries.
There is an interaction between the size and the contrast of stimuli. We do not know, however,
how this affects various activities of daily living and whether it is the same for all activities. A
report about disability for the Social Security Administration [ 69] recommends considering CS in
disability evaluation, but is vague as to the weight it should carry. Since there is no single
accepted standard for CS measurement and since the impact on activities of daily living is not
well defined, the impairment ratings in the AMA Guides [ 70] (see part 3) are primarily based on
visual acuity and visual field, but CS can be considered under other factors.
61
Figure 36 Measurement units for Letter charts vs. Gratings
The left-hand columns compare the scales used for letter charts (visual acuity) with the cycle
per degree (cpd) scale used for gratings.
The right-hand columns compare the contrast threshold, contrast sensitivity and log(CS) for the
Weber and Michelson formulas. The Weber formula applies to letter charts, including the PelliRobson (P-R) and Mars cards; the Michelson formula applies to gratings. Note however, that
many older low contrast cards are still labeled using the Michelson formula.
In the clinically most important range, the following approximations may be used:
CS(Weber) = 2x CS(Michelson) and log(CS)(Weber) = log(CS)(Michelson) + 0.3.
Most clinical studies have found some level of correlation between visual acuity and various CS
measurements. This is certainly true for optical factors. Some have concluded that measuring
CS is therefore superfluous; this opinion probably throws out the child with the bath water.
A study of mainly AMD patients in a Low Vision setting, measured the slope of the CS curve by
comparing the HC-LC difference to the HC acuity; this study found that in this population the two
62
were largely unrelated [ 71]. This may mean that for retinal disease the slope of the curve is an
independent parameter that may have diagnostic significance.
One hypothesis is that the HC visual acuity value reflects the density of the receptor mosaic,
while the slope of the CS curve reflects the sensitivity of individual receptors. This hypothesis is
admittedly difficult to prove, but could explain why the two factors can vary independently. If CS
loss is a precursor of AMD, this would be significant for early detection and early interventions,
which may become possible in the future. The question remains, what is the most effective and
efficient way of screening for CS loss. Is it peak sensitivity, or low contrast acuity or some other
method?
63

PART 3A
ASSESSMENT of FUNCTIONAL VISION
INTRODUCTION
Part 1 of this chapter discussed the various aspects of visual functioning, as summarized in
Figs. 1 and 2. Part 2 discussed various visual functions, notably visual acuity, visual fields and
contrast sensitivity, which are the traditional main stays of clinical vision assessment. This part
will discuss Functional Vision and Quality of Life, topics that traditionally have received only
minimal attention in ophthalmic practice.
Increasingly, however, attention is being asked for the fact that medical care should extend
beyond restoring organ function, and should make Quality of Life considerations an essential
part of medical decision making. Refractive surgeons are learning to consider life style issues,
since their choice of procedure for an avid reader may be different from that for a sailor or
golfer. With the increasing incidence of Age-related Macular Degeneration (AMD), retina
specialists with few therapeutic options for the dry form are learning that vision rehabilitation
services can greatly enhance the Quality of Life of their patients, even if their retinal condition
remains unchanged.
Estimating Functional Vision
To connect Visual Functions to Functional Vision, two approaches are possible. The first tries
to estimate the visual abilities of the person from the measured visual functions. Since the
parameters for the various aspects are very different in nature (Fig. 2), there cannot be a direct
relationship; only a statistical relationship may be estimated. The estimation approach is taken
for many eligibility rules. Such estimates are useful for administrative rule making. One should
not forget, however, that these estimates refer to statistical averages and that individual
performance may be significantly better or worse than the statistical average. The Guides of the
American Medical Association [80] (see below) provide a model for detailed disability estimates.
Direct Assessment of Functional Vision
For decisions regarding the treatment of an individual patient, statistical averages are
meaningless. To ascertain the individual need for rehabilitation and to assess rehabilitation
outcomes, direct assessment of individual performance is essential. At a time when patients,
practitioners and third parties demand the practice of evidence based medicine, the
effectiveness of vision rehabilitation must be adequately documented. How this can be done
will be discussed in this section.
Classifications
These questions are not new. In the 1960s and 1970s insurance carriers asked: if the
admission diagnosis was rheumatoid arthritis and the discharge diagnosis is still rheumatoid
arthritis, how do we know that patients benefitted from their stay in a rehabilitation facility? In
response, the World Health Organization (WHO) developed the International Classification of
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Impairments, Disabilities and Handicaps (ICIDH) [2] as a companion to the International

Classification of Diseases (ICD) [32]. More recently, the International Classification of
Functioning, Disability and Health (ICF) [3] became the successor to ICIDH. The importance of
functional vision assessment was further emphasized in a 2003 WHO consultation [ 72] and in
resolutions of the World Health Assembly in 2005 [ 73], 2006 [ 74] and 2009 [ 75]. Other
contributions were made in reports of the International Society for Low Vision Research and
Rehabilitation (ISLRR) [ 76] and the International Council of Ophthalmology (ICO) [39] [ 77].
The ICF provides categories to classify the type of functioning. However, its tools for the
assessment of the degree of functioning or function loss remain rudimentary, mostly confined to
terms like mild, moderate or severe difficulty in performing tasks. This section will explore the
basic concepts and methods for a more precise assessment of functional vision.
ELIGIBILITY GUIDELINES, based on Visual Function Measurements

Statistical ability estimates based on measured visual functions are often used to define
eligibility guidelines for individuals. To fly a plane generally requires 20/20 acuity; to drive a car
requires 20/40 in most states. In the US 20/200 triggers various visual disability benefits; in
many other countries the threshold is 20/400. There are several reasons why such fixed rules
constitute an oversimplification.
We already saw that there is no one-to-one relationship between visual functions and functional
vision. Secondly, visual functions are measured using a threshold paradigm; functional vision
requires supra-threshold, sustainable performance. Thirdly, statistical averages obscure
individual differences, whereas individual eligibility must take individual differences into account.
One example may be drivers license requirements. Although 20/40 is a common requirement
in many states and many countries, there is little evidence that this requirement would reflect a
dividing line between safe and unsafe drivers. Rather, this requirement reflects a safety margin
between performance on a letter chart in an office and expected on-the-road performance. The
requirements for professional drivers are usually more restrictive, not because they drive in a
different visual environment, but because a broader safety margin is considered desirable.
Setting a safety margin is a policy decision, hopefully supported by, but not determined by
scientific measurements.
Other factors, both visual and non-visual, are also important. Young drivers probably have the
best average acuity; yet they also have the highest accident rate. For older drivers [ 78], visual
field loss, glare sensitivity and contrast sensitivity loss are probably important factors. Yet most
agencies test only visual acuity, because the other tests are too difficult or too expensive to
administer routinely.
Since individual performance can be much better or much worse than the statistical average,
the usual requirements can be a useful starting point to determine individual eligibility, but there
should be an opportunity to make exceptions. If the safety margin cannot be improved by
improving vision, it is also possible to improve it by eliminating hazardous conditions. This can
be done with a conditional license, for instance limiting driving to daytime conditions and/or
familiar environments, where orientation is by landmarks, rather than by reading street signs.
Similar considerations should apply to many other license requirements.
65
Legal Blindness
In many countries the government offers assistance to those who have lost some or all of their
sight. In this context the term blindness is often used. Unfortunately, the word blindness
refers to a black-and-white distinction between those that are considered blind and those that
are not; the term blindness does not allow modifiers, such as mild, moderate, severe to indicate
a continuous scale. As a consequence, those who want to map the dichotomous distinction
eligible / not eligible onto the continuum of vision loss have often extended the word blindness
to include levels of vision loss that are far from actual blindness.
The images in Fig. 37 show that vision loss happens along a continuous scale and that there is
no dichotomous division between those that are sighted and those that are blind. It is not
surprising then, that it has been said that More people are blinded by definition than by any
other cause [ 79]. How can we bring order in this confusing terminology? Recognizing two
ranges sighted vs. blind, although simple for administrative use, denies the value of residual
vision and the continuum of ranges of vision loss.
The diversity of definitions is confusing. In the USA, the Social Security Administration (SSA)
considers a person statutorily blind when visual acuity is less than 20/100 (< 0.2); other US
agencies consider a person legally blind at 20/200 or less (< 0.1). Yet, in Australia legal
blindness is defined as less than 6/60 (< 20/200, < 0.1), while the WHO applies the term
blindness for visual acuity less than 3/60 (< 20/400, < 0.05). All of these criteria leave the
person with a significant level of residual vision.
Since two ranges do not acknowledge the continuum, the WHO introduced the Low Vision
category in ICD-9 [32], now 30 years ago. The word low indicates that vision in this range is not
normal. The word vision indicates that it is not blindness. However, the WHO classification still
relates these terms to numerical visual acuity measurements. . When we shift to functional
vision and to the abilities of the person, we must consider quite different categories such as face
recognition, Activities of Daily Living (ADL) and Orientation and Mobility (O&M).
The distinction between low vision and blindness is more than just a play with words. These
terms have important psychological effects. We say You are blind, but You have Low Vision.
The verbs to be and to have have different implications. Compare the statement that you are a
problem with the statement that you have a problem. The first statement sounds irreversible;
there is nothing we can do about it. The second statement leaves room for hope, and naturally
leads to the question: What can we do to alleviate your problem?
Common sense demands that the term blindness not be used for persons with useable residual
vision. In 2002 the ICO adopted a resolution calling for replacement of the visual acuity based
definitions by definitions based on functioning [39].
The term BLINDNESS should be used only for those with little or no residual vision, who
have to rely predominantly on vision substitution skills such as Braille, a long cane or talking
books to perform activities of daily living.
The term LOW VISION is appropriate for the much larger group with residual vision, for
whom vision enhancement tools can be used to improve the performance of daily living
skills.
For finer distinctions, the ICO recommends the general term VISION LOSS, which can be
used with modifiers, ranging from mild to moderate, severe, profound and total loss (Fig.
18).
66
Figure 37 Various Blindness criteria
Blindness is not an all-or-none phenomenon. Different jurisdictions define blindness very

differently. All of these definitions include significant amounts of residual vision.
The above images represent different levels of vision loss, but they should not be described as
blindness. The term Vision Loss is more appropriate, since it can be combined with various
modifiers from no loss, through mild, moderate, severe and profound loss to total loss or
blindness. The term blindness cannot be used with modifiers.
Different tasks are affected differently by the loss of visual acuity. Reading the letter chart is
moderately restricted at the 20/125 level and severely restricted at the 20/200 level, but seeing
the books in the book case is still possible with 20/200. At the 20/400 level the entire letter
chart, as well as the books are blurred; face recognition is also severely limited, but this level of
vision is quite sufficient for mobility and for not bumping into a person.
Note that these images offer only an approximation and that their proper rendition may be
compromised by the resolution of your monitor. A more detailed scale and discussion are
available at: http://www.mdsupport.org/presentation-howblind1/index.html .
67
ESTIMATING A VISUAL ABILITY SCALE from Visual Function Measurements

While dichotomous distinctions are often used for eligibility purposes, other applications need a
more individualized approach and more detailed visual ability estimates. This need is not new.
At the end of the 19th century Magnus developed detailed formulas in the context of visual
economics and workers compensation in Germany. The first US translation appeared in 1902
[ 80]. In 1925 Snell proposed simpler formulas [ 81] [ 82] for calculating visual efficiency; his
formulas were adopted by the AMA [ 83]. Much later, in 1971, these visual efficiency formulas
were combined with chapters for other organ systems in the AMA Guides to the Evaluation of
Permanent Impairment [80]. With minor changes Snells visual efficiency formulas remained
through the 4th edition. In 2000 the 5th edition adopted the Functional Vision Score (FVS)
system [51] [86], which better conforms to current standards of measurement and has been
shown to provide better estimates [ 84]. The principle of the FVS calculations is shown in Fig. 38.
Figure 38 Functional Vision Score and AMA Impairment Ratings.
The Functional Vision Score calculations estimate a visual ability score from measured visual
functions. The AMA Guides convert the ability estimate to an impairment rating for use in
workers compensation and similar applications. Explanation: see text.
The Functional Vision Score (FVS) is derived from a Functional Acuity Score (FAS) and a
Functional Field Score (FFS). These scores provide ability estimates for the person. They, in
turn, are derived from Visual Acuity Scores (VAS) and Visual Field Scores (VFS) determined on
the basis of visual acuity and visual field measurements.
Note that all of these scores estimate visual ability (standard ability = 100), while the AMA
Guides estimate disability or ability loss (standard ability = 0 = no loss). We prefer to avoid the
term disability since it means different things to different people. In the Americans with
Disabilities Act (ADA) it is practically equivalent to impairment (column 2 in Fig. 1). In ICIDH it
68
was used to indicate ability loss (column 3 in Fig. 1); the same meaning is encountered in
Disabled Veterans and similar terms. Being on disability refers to a socioeconomic
consequence (column 4 in Fig. 1). We prefer the term ability loss, since it specifically refers to
the ability aspect (column 2 in Fig. 1)
Visual Acuity Score (VAS)
The Visual Acuity Score (VAS) (Fig. 18) was discussed earlier. It is based on the logarithm of
the visual acuity measurement. The logarithmic transform is based on Weber-Fechners law,
which states that proportional increases of the stimulus result in linear increases in sensation.
One VAS point is equivalent to one letter recognized on an ETDRS or similar chart. It is a more
intuitive alternative to the logMAR scale, where one point indicates a loss of 10 lines. On the
VAS scale 20/20 is rated as 100 and 20/200 as 50. This scale differs from Snells scale, on
which 20/200 was rated as 20. Snells scale was based on employability estimates in 1925.
The current scale is based on estimated visual ability. While patients with 20/200 may have lost
80% of their employability, they have not lost 80% of their visual abilities. Estimating a 50% loss
is more realistic.
Visual Field Score (VFS)
The Visual Field Score (VFS) is similarly calculated. Its progression approximates the logarithm
of the visual field area. Each VFS point represents one point seen on a special visual field grid
(Fig. 39). The VFS deals better with irregular field losses than the visual efficiency scale, which
was mainly designed for concentric losses and gave equal weight to each degree of loss,
whether in the far periphery or in the center.
Functional Acuity Score (FAS) and Functional Field Score (FFS)
These scores estimate the remaining abilities of the person. The FAS and FFS are the
weighted average of the underlying VAS and VFS values. Since visual perception is the result
of input from both eyes, 60% of the weight of the FAS and FFS is attributed to binocular acuity
(both eyes open) and to the binocular visual field. To reflect the fact that monocular losses are
also significant, each eye separately contributes 20%. The 60% weight for binocular vision is in
good agreement with a study [ 85] that found that visual acuity in the better eye explained 56% of
the variance in the VF-14 survey instrument.
Functional Vision Score (FVS)
The Functional Vision Score (FVS) reflects the combined impact of visual acuity and visual field
loss. It is derived by multiplying the remaining abilities. Thus, a FAS of 60 and a FFS of 40
would combine to a FVS of 24, since 60% x 40% = 24%. Note that this calculation is done
using the ability estimates; using the ability loss (impairment rating) would give erroneous
results. Adding, subtracting, or averaging would also give erroneous results and might result in
values over 100 or under 0.
At this point the FVS system allows a correction for any other vision problems that are not
reflected in the acuity or field measurements. The old system had a scale for diplopia, but not
for any other problems; the FVS system allows consideration of diplopia, as well as for other
factors such as night blindness, extreme contrast loss and glare sensitivity. There are no
specific scales for these problems, since there are no standardized methods of assessment and
since their impact may vary in different settings.
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Figure 39 The Visual Field Score
The points of the Visual Field Score are distributed along 10 meridians; 2 in each of the upper
quadrants, 3 in each of the lower quadrants. This gives the lower field 50% more weight than
the upper field.
Of the 10 points along each meridian, 5 are located in the central field (up to 100), 5 are located
in the peripheral field (beyond 100). Thus, 50 points are allocated to the central field and 50 to
the peripheral field. The central field, which occupies 50% of the primary visual cortex, is most
important for reading and manipulation tasks; the peripheral field is most important for
orientation and mobility.
This arrangement maintains the traditional equivalence between a visual acuity loss to 20/200
and a visual field loss to a 100 radius. It extends this equivalence to hemianopia, which was
poorly handled on the old scales; it also deals better with irregular field losses.
Combining many different vision problems into a single score obviously discards significant
details. This may make sense for compensation purposes; it does not make sense for individual
patient care, since the effects of visual acuity and visual field losses are quite different, as are
the means for amelioration and rehabilitation. When using such visual ability estimates, one
needs to make sure that discarding the details is compatible with the purpose for which the
score is used. That these methods are used nevertheless is because visual acuity and visual
field measurements are far better standardized than are disability assessments. In the context
of workers compensation, it should also be considered that individuals who have made a good
adaptation to a vision loss may have better abilities than those who have not adapted well; yet,
their compensation should not be reduced because of the better adjustment.
AMA Impairment Rating
The AMA impairment ratings are primarily used for workers compensation and similar programs.
They are based on the Functional Vision Score, but while the FVS is an estimate of visual ability
(20/20 = 100); the AMA ratings are estimates of vision loss (20/20 = 0 = no loss). The AMA
rating for visual system impairment (VSI) is obtained by subtracting the FVS from 100. To
obtain a rating for the whole person (WPI), this rating may be combined with impairment ratings
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from other systems and adjusted for the fact that 100% VSI does not equal 100% WPI (100%
WPI = death).
To determine monetary compensation for these losses is a separate step, beyond the scope of
the Functional Vision System or the AMA Guides.
DIRECT ASSESSMENT OF FUNCTIONAL VISION

The Functional Vision Score and the AMA calculations are still based on statistical averages.
For vision rehabilitation we need a direct assessment of each individuals visual abilities. We
need this to assess the rehabilitation needs, to make a rehabilitation plan and to judge the
outcome of rehabilitative interventions. Assessing rehabilitative outcomes is different from
assessing medical and surgical outcomes, as shown in Fig. 40.
Figure 40 Medical vs. Rehabilitative outcomes
The primary outcomes for rehabilitation are different from those for medical interventions,
although the ultimate goal, improved quality of life, is the same.
The traditional medical focus is on the organ of vision, its structure and its functioning. Medical
and surgical interventions mainly affect the link between organ structure and organ function;
their primary outcome measure, therefore, is an improvement of organ function. Visual acuity is
commonly used as the primary outcome measure in clinical trials, but other visual functions
such as contrast and scotoma interference in retinal disorders should be considered also. A
secondary outcome is improved visual abilities, while improved Quality of Life, which is the
ultimate goal, is a tertiary outcome.
Moving from medical to rehabilitative interventions requires a shift in focus from the functioning
of the eye to the functioning of the person and in particular to means for improving that
functioning. In a rehabilitation setting the functional status of the eye is usually a given, so the
assessment must move to visual abilities and functional vision. To assess the need for
rehabilitative interventions we must ask broad questions that expand the traditional medical
71
history. We must then define specific rehabilitative goals and document the rehabilitation
outcomes in relation to these specific goals. Asking global, generic questions about Quality of
Life is important for a general assessment, but is not sensitive enough to evaluate specific
interventions.
Rehabilitation also requires a shift in the doctor-patient relationship. Under the medical model,
the doctor acts and makes decisions; on the patients side, we only ask for compliance. In
rehabilitation, there is nothing the doctor can do for the patient; there are only things patients
can do for themselves. We can give a patient crutches; the patient has to do the walking. We
can give a patient a magnifier; the patient has to do the reading. The doctors role is not less
important, but it shifts from doing to guidance and instruction.
The measurement methods used for the different aspects also differ considerably.
Under the aspect of visual functions (Fig. 2, left), we measure parameters that define how the
eye functions. As we have seen previously, we do this by varying one parameter at a time in a
simplified, artificial environment. Each of these tests provides us with a threshold measurement
for that stimulus parameter; the targeted response level is fixed at 50% above guessing.
Threshold measurements are used because they enable more precise psychophysical
calculations, not because threshold performance is the most relevant performance level for
activities of daily living.
Under the aspect of functional vision (Fig. 2, center), we must assess how the person functions.
To do this, we must focus our attention on visual skills and abilities, such as reading, Orientation
and Mobility (O+M) and Activities of Daily Living (ADL). Such tasks always involve multiple
parameters, which can vary independently and which cannot be separated. Assessing
functional vision, therefore, is more complex than measuring visual functions. We also notice
that we are no longer interested in threshold performance, but in sustainable, supra-threshold
performance. When reading a book, print size, contrast and illumination all need to be well
above threshold, to provide a comfortable performance reserve [6].
Finally, we must consider the societal context. We may describe this aspect as Quality of Life
(Fig. 2, right). Here we must consider elements such as making and keeping friendships, social
skills, self-confidence, etc. In this last domain the concept of measurement is even more
difficult, since Quality of Life involves highly subjective judgments. When we move a New
Yorker to a small rural community, and a rural farmer to the center of Manhattan, both may
complain that their Quality of Life has deteriorated. The ultimate goal can best be described
with the word satisfaction, that is the subjective balance between individual achievements and
individual expectations. It should be noted that many so-called Quality of Life questionnaires
expand their concept of Quality of Life by including items that actually belong in one of the other
categories.
Many questionnaires and survey instruments combine items from all three domains. When
analyzing such instruments, responses that relate to different aspects should not be lumped into
a single score as if they all assessed the same aspect.
Assessment of Visual Abilities

When looking more closely, we will note that within the aspect of visual abilities, there are other
sub-aspects. Rehabilitation for an activity such as reading can be approached from different
points of view. When we contrast reading print with reading Braille, we differentiate based on
the resources used. When we contrast reading poetry with reading manuals or with reading
maps, we make a distinction based on the goal that is served.
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Therefore, when considering visual abilities, we must ask two further questions. What are the
tasks that must be accomplished, so that societal participation is enhanced? And what are the
resources available for accomplishing these tasks? These two questions reflect the two
columns that flank the ability column in Fig. 2.
The resources include visual resources (to the left in Fig. 2), which are the traditional focus of
Low Vision care. However, they should also include non-visual resources, such as touch (cane,
Braille), hearing (talking books) and memory. Beyond that we need to strengthen, where
possible, the persons attitudinal and coping skills. Under the task aspect (to the right in Fig. 2)
we may consider changes in both the human and the physical environment that serve to modify
the task requirements (Fig. 46).
In ICIDH [2] the ability aspect was described as dis-ability (= ability loss). In ICF [3] the
descriptor was changed to activities. Abilities and activities are two sides of the same coin; one
cannot be described without the other. Abilities relate to the resources that are available;
activities relate to the tasks that need to be accomplished.
ICIDH was said to use the Medical model of disability. ICF adopted the Social model. The
difference may be explained by the following comparison. The Medical model may say: these
wheel chair users are handicapped because they are paraplegic. The social model may say:
these wheel chair users are handicapped because there are not enough curb cuts. We
sometimes hear that the social model has replaced the medical model. This is a misconception.
The two models are not exclusive, but rather complementary and serve different purposes.
Providing wheel chairs is the responsibility of the Health Care system; providing curb cuts is the
responsibility of the Public Works department.
The medical model (ICIDH) sees disability as a challenge for individual rehabilitation; it
emphasizes the assessment and enhancement of the individually available resources and is
thus relevant for individual health care. The social model (ICF) sees disability as a social
challenge in defining public policy and in fighting discrimination; its emphasis is on modifying the
physical and also the social environment so that people with an ability loss experience fewer
obstacles when completing tasks. It is relevant for public health and for health care policy
The focus of the ICF on tasks and participation is important, but for rehabilitation it is not
sufficient by itself. For instance, the ICF considers reading as a subcategory of applying
knowledge and groups it with other activities, such as thinking and problem solving. When
planning vision rehabilitation, we also need to know which resources are to be used, be it visual
(using magnification), non-visual (Braille) or instrumental (talking books). Similarly, when
discussing products and technologies, the ICF specifies the purpose of the technology (for
mobility, for education, for ADL, etc.). When we provide individual vision rehabilitation, we also
need to specify the means used, which may be task dependent. The same person may use a
magnifier to read bills or price tags and talking books for recreational reading.
Resource inventory
To list the available resources, the traditional eye exam offers a starting point for visual
resources. But the list has to be expanded with other visual skills, such as visual search
strategies and higher cerebral functions, such as the distinction between hemianopia and hemineglect. Too often these other aspects of vision receive little attention.
Furthermore, we need to list non-visual resources (Braille, long cane, guide dog, etc.). A person
with retinitis pigmentosa (RP) may travel adequately during the daytime, but may need cane
travel skills after dark. Here, seemingly subtle variations in the questions asked may be
important. When the RP patient is asked whether his night vision has improved, the answer is
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no. When asked whether night travel has improved, the answer is yes. Psychological
support and coping skills are important also, since it is known that vision loss often leads to
depression and depression may hinder successful adaptation.
Task inventory
ICF provides a broad classification of tasks and environmental factors, covering all aspects of
human functioning. For a more detailed analysis of vision-related tasks, the Activity Inventory
of Massof [ 86] should be mentioned. This is a list of more than 500 tasks, grouped under 50
goals and 3 objectives (Daily living, Social interactions, Recreation). It has been tested and
validated on over 1800 patients at Johns Hopkins University.
Since asking all questions from all patients is impractical, the strategy is to first ask whether a
particular task or goal is needed and/or difficult. Tasks and goals that are not difficult or not
needed are skipped. Thus, this tool provides a comprehensive, standardized, yet individualized
analysis of each patients problems
Performance Ranges
When discussing functional abilities, it must be recognized that not all manifestations are
equally severe. Some deficits preclude most functioning, other deficits are mild and may
become manifest only when the subject is tired or under stress. For a gross classification the
three ranges normal / low vision / blindness may be sufficient. For clinical purposes a finer
classification of performance ranges is needed.
Various numerical labels can be used. The first choice must be between a positive and a
negative scale, between grading ability and grading dis-ability. In the medical field deficit scales
are common; a Grade 4 condition is generally considered to be worse than a Grade 1
condition. Extending the medical model, we can use impairment ratings (as in the AMA Guides
[80]) by assigning 0 to normal and 100 to total impairment. In the spirit of ICF, however, a
scale of functioning, in which 0 indicates no functioning and 100 indicates normal functioning
is more appropriate.
A general scale of functioning is shown in Fig. 41. This scale can be applied to any functional
domain; here it is applied to vision.
This scale is similar to the Karnofsky scale [ 87], which has long been used for cancer patients,
where 0 indicates coma or dead and 100 indicates normal functioning. The ranges are as
follows:
Normal range the reference standard is set at 100. It should be recognized that normal
performance includes a reserve capacity and is not the same as threshold performance. The
scale can be extended beyond 100 to indicate exceptional performance.
Mild ability loss In this range the usual reserve is lost, but most daily activities can still be
performed.
Moderate ability loss In this range some difficulties are experienced, but near-normal
performance can still be maintained with occasional use of aids.
Severe ability loss In this range performance becomes restricted, even with the use of aids
or assistive devices.
Profound ability loss In this range the options for vision enhancement become limited; for
some tasks vision substitution skills are more appropriate. Note that in ICD-9-CM this range is
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labeled as Profound Vision Loss or Profound Low Vision, but that in the WHO classification it is
already part of the blindness category.
Near-total and total loss Individuals in this range have no vision or so little that they must
rely on blind skills (vision substitution skills).
Figure 41 General Scale of Functioning, applied to Visual Abilities
The general ability scale can be applied to various functional domains. Here it is applied to
general visual skills. See text for detailed discussion.
The ranges of this general scale can easily be fitted with a score from 0 to 100. Since it is an
ability scale, it can be extended beyond 100 for exceptional performance (as for an Olympic
athlete). With a disability scale this would not be possible, since normal functioning would be
scored as zero and negative numbers are counterintuitive for denoting better than normal
performance. When used in an abilities profile, where various abilities are compared, it can also
accommodate a savant, who is under-performing in some areas, but over-performing in others
[ 88].
In ICF modifiers can be used to indicate the degree of difficulty. Although ICF suggests
accuracy by providing percentage values, it leaves the definition of the various modifiers to the
user. Since the ICF scale is a deficit scale, it cannot easily accommodate better than average
performance. Like many other impairment scales, ICF does not differentiate between severe
and profound loss. For rehabilitation purposes, this distinction is important, since it reflects the
transition from enhancement to substitution tools and thus a definite shift in rehabilitation
strategy.
For clinical use an ability profile with separate scores for separate abilities is more useful than
a single number approach as used in the AMA Guides. If the profile is uneven as will often be
the case the profile will help in the planning and prioritizing of individual education or
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rehabilitation plans. In the case of isolated deficits, those deficits will stand out in a profile,
whereas calculating a single number average would hide them.
When defining the level of functioning for an ability profile, it is important to be precise in
specifying the abilities to be considered. Subjects with profound or with total vision loss cannot
function visually under most circumstances, but they can still function by using non-visual skills.
A person with very low or no vision will score low or zero on the scale for visual reading.
However, if that person has good Braille skills, the score for Braille reading will be high and the
score for reading in general (as used in ICF, without specifying the modality) will also be high.
The general reading score in ICF is relevant when considering the ability to access
information; separate visual and Braille scores are important when planning the educational
environment.
Fig. 42 applies the general ability scale to visual reading skills, combining the ability ranges of
Fig. 41 with the visual acuity scale of Fig. 18. When seeing the neat dividing lines between the
ranges, one should not mistake those for stepwise increments in ability. Rather, the dividing
lines may be compared to mileposts along a road. They are useful reference points, but the
landscape does not change suddenly at each milepost. The landscape changes gradually in
the area between the mileposts.
How many ability ranges?
The visual acuity scale in Fig. 18 follows a logarithmic progression of letter sizes. This
progression, consistent with Weber-Fechners law [7], was first proposed by Green in 1868 [25]
and is now part of the ETDRS protocol [36], which is the de-facto international standard.
For visual acuity the listed line increments have proven to be clinically convenient and useful; on
an ETDRS chart where each line represents 5 letters, they are of the same order of magnitude
as the average accuracy of clinical measurement, which has a 95% confidence interval of 5 or 6
letters [ 89] [ 90].
When rating visual ability, we shift our criterion from threshold measurement to sustainable
performance and other factors than just visual acuity start to play a role; in retinal disease
reading fluency can be significantly influenced by scotoma interference. Under these conditions
a coarser scale is indicated. It is a legitimate question to ask how many subdivisions an ability
scale should have. Having an ability scale with too many subdivisions (e.g. as many as used for
visual acuity) results in a spurious sense of accuracy; having too few subdivisions discards
valuable information.
Six ranges, comprising four lines each, as shown in Fig. 42, seem to provide an appropriate
scale. Note again, that the estimates of reading performance in that table refer to statistical
averages. Individual performance may be considerably better or considerably worse than the
statistical average. It is the role of rehabilitation to move individuals to better performance
levels, even if their visual functions remain the same.
Epidemiological studies have found that uncorrected or under-corrected refractive errors are the
most frequent cause of visual impairment. They cause mostly mild or moderate vision loss. All
traditional blinding eye diseases together are about equally frequent, but cause much more
significant levels of vision loss. Health policy decisions about the allocation of scarce health
resources need to consider both the frequency and the severity of each condition. The use of
six ranges can capture these differences, and is also useful when discussing the Burden of
Vision Loss, both at the individual and at the societal level. Collapsing the six ranges to three
(as in normal / low vision / blindness) may be useful for broad initial screening and for simplified
tabulations; it is too coarse for many clinical applications.
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Figure 42 Visual Acuity and Visual Ability Ranges
The visual acuity ranges recognized in ICD-9, ICD-9-CM and ICD 10 do not represent stepwise
increments in ability. They do provide convenient reference points on a continuous scale.
The indicated ranges coincide with other common descriptors.
Moderate Vision Loss in ICD-9-CM has the same definition as Low Vision (WHO),
Severe Vision Loss (ICD-9-CM) has the same definition as legal blindness (USA),
Profound Visual Impairment (ICD-9-CM) is equivalent to blindness (WHO).
In ICD-9-CM, based on recommendations of the ICO, the ranges are named (as shown above).
In WHO publications (ICD-9, ICD-10) the same ranges are identified with numbers (moderate =
1, severe = 2, profound = 3, less = 4, no light perception (NLP) = 5), since numbers are easier
for translation into various languages.
Distinctions such as between mild and moderate difficulty can be important when prioritizing
rehabilitation goals for a specific patient. Statistical analysis has shown that in most instances
respondents to questionnaires or surveys cannot reliably distinguish between more than 4
categories of difficulty and 3 categories of importance [ 91]. Some researchers collapse study
results to binary or dichotomous variables (yes/no, true/false, greater than/less than). It has
been shown that this approach often achieves simplicity at the expense of accuracy [ 92].
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Measuring Performance
So far, we have described ability ranges and even attached numerical labels to them. The AMA
Guides use these labels to calculate statistical estimates. For individual rehabilitation we need
to go further; we need to measure individual performance for various tasks and score these on a
reliable scale. How can we develop such scales?
To measure visual functions we varied the stimulus parameters (size, contrast) to reach a fixed
performance level (threshold). For assessment of functional vision, the tasks or questions are
standardized and the performance level is the variable. There are two basic ways to rate this
performance.
Timing the performance provides an objective assessment [ 93] and an easy numerical score, but
it is only feasible for a limited number of tasks. An example of a simple set of timed ADLs that
requires only a limited amount of time and no elaborate equipment is given in Fig. 43. Many
other examples could be given.
Figure 43 Timed Instrumental Activities of Daily Living
One example of a simple set of Timed Instrumental Activities of Daily Living (TIADLs) that can
be easily and inexpensively implemented in any Low Vision service is the set constructed by
Fletcher [104] [105].
The test consists of six common tasks: (1) reading a bill, (2) writing a check for the amount, (3)
paying the amount in cash, (4) finding a telephone number in the phone book, (5) dialing that
number and (6) finding all four of the Kings, Queens or Jacks from the 12 royal playing cards.
Subjects generally experience these tasks as relevant; they are allowed to use any tools or aids
that they have available.
The tasks range from easy to difficult. The total completion time can be compared before and
after provision of aids and training; it ranged from 48 to 639 seconds with a median of 4
minutes. This is not a prohibitive time in a low vision clinic. If the subject takes more than two
minutes for a task, that task is skipped. Thus, the maximum time is twelve minutes.
In addition to timing the performance, observing the subject can provide valuable insights into
their problem solving skills and motivation; it quickly separates those who aggravate their
complaints from those who deny their problems.
The other approach is to ask the subject for a self-report about the difficulty experienced in
performing various tasks. This approach is often referred to as Patient Reported Outcomes
(PRO); it allows exploring a much wider variety of tasks. However, the responses are
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subjective; some subjects aggravate their problems, others deny them. Nevertheless, the
questionnaire approach is widely used. The number of questions varies widely. The EQ-5D
(EuroQol) [ 94] has five questions, the NEI-VFQ [ 95] has 25, the Activity Inventory [96], mentioned
earlier, has hundreds.
To make administration of the Activity inventory manageable, questions about tasks that are not
difficult or not necessary are skipped. This means that all patients receive questions that are
relevant to their particular problems and circumstances, but nevertheless part of a larger
validated set that ensures that no possibly important areas are skipped.
There are dozens of visual function questionnaires [ 96] [ 97]. Massof [ 98] used four commonly
used ones ADVS [ 99], VAQ [ 100], VF-14 [ 101] and NEI-VFQ [107] on 407 low vision patients.
Extensive statistical analysis showed that all four essentially measured the same visual ability
variable, although there were differences in the validity and accuracy of their scales. It was
found that the visual ability variable is different from and independent of the physical health and
the mental health parameters measured with the SF-36 [ 102]. The same findings will probably
apply for all other, similar questionnaires. Given the large number of questionnaires that exist
already, it is not advisable to generate additional ones, unless their development is properly
evaluated as discussed below.
Likert vs. Rasch scores
Deriving a score from the subjects responses is not as simple as it may seem, since there are
two unknown variables: tasks may be more or less demanding and subjects may have greater
or lesser abilities. On top of that, there are many unknown factors that add statistical noise to
the responses. A common approach is to simply add the number of positive responses for each
subject. This is called a Likert score. This type of scoring is simple, but not very reliable. If two
subjects each answer 3 of 5 questions, but not the same ones, are their abilities the same?
Also, consider a group of subjects, who are asked a set of questions of varying difficulty.
Adding some difficult questions will not change their abilities, but it will depress their average
score; adding some easy questions will do the opposite.
More appropriate, but statistically more complicated, is the method of Rasch analysis [ 103] [ 104].
This is a statistical method, aimed at deriving the best estimates of the subjects abilities as well
as of the difficulties of the tasks. Application of this method for low vision subjects has been
advocated and employed by Massof [ 105] [ 106]. Applications for refractive surgery have been
explored by Pesudovs [ 107]. A common way of representing the results is in a diagram with
subjects on the left, ranked by ability, and tasks or questions on the right, ranked by difficulty,
with a common scale in the center. The diagrams in Fig. 44 follow that convention.
Fig. 44a shows three subjects responding to a standardized task. They will find the task easy,
possible or hard, depending on their level of ability relative to the demands of the task.
Different patient groups have different abilities. Fig. 44b shows that cataract patients will have
better abilities after surgery than before. The same is true of AMD patients after rehabilitation.
But the abilities of an AMD patient after successful rehabilitation will still be less than those of a
cataract patient after successful surgery. This means that we need a variety of tasks that are
evenly spread over the difficulty scale.
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Figure 44 Matching Tasks to Abilities
The difficulty of tasks needs to be matched to the abilities of the population to be tested. Rasch
analysis provides a means to do this. See text for discussion.
What happens if we have too narrow a range of difficulties as in Fig. 44c? Cataract patients
before surgery will rate the tasks as easy; after surgery the tasks will be very easy. This may
lead us to conclude that cataract surgery has only a very limited effect.
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However, if we test these patients on more demanding tasks that are difficult before surgery and
easy after surgery (Fig. 44d), we get a different result. The revised test will lead us to conclude
that cataract surgery is indeed effective.
There are many questionnaires available that have been designed for cataract surgery [108],
although the psychometric validity of several has been questioned [109]. Could we use those for
AMD? When we present the cataract questions to AMD patients before rehabilitation, they will
find them hard ([Fig. 44e). After rehabilitation, they will still find them hard, and we may
conclude that rehabilitation has had little effect. Again, we need to adjust the level of difficulty;
this time selecting easier tasks. If we do that, we will find that tasks that were hard have
become easier, and that rehabilitation is indeed effective (Fig. 44f).
The opposite effect may occur if we use questions designed for cataract surgery on the first eye
for cataract surgery on the second eye. Second eye surgery will indeed improve performance,
but not by as much as surgery on the first eye. If we use questionnaires designed for the first
eye, we might conclude that second eye surgery is not very effective.
Selecting questions that are evenly spaced along the difficulty axis and that are matched to the
ability range of the population to be tested is essential for these measurements. Rasch analysis
provides a means for doing this.
Different Questions for Different settings
The above considerations point to the fact that different question sets may be needed for
different diseases or different target populations. There also is a need for different question sets
for different settings.
For initial screening there is a need for one or two very simple questions that should be
asked of every patient with reduced vision to determine the possible need for rehabilitation.
An example of such a simple question might be: Can you read the newspaper? If the
answer indicates a need, this should lead to further exploration and possibly referral.
When the patient has been referred to a rehabilitation service, there is a need for a list of
intake questions. That list should be broad and comprehensive, so that the responses can
be used to prioritize needs, based on difficulty and perceived need. From there, a
rehabilitation plan with specific objectives can be formulated. Too often the way intake
interviews are conducted is inconsistent and not comprehensive. Too often rehabilitation
plans do not specify specific goals. The Activities Inventory [96] that has been mentioned
provides a means for insuring comprehensive coverage.
When the rehabilitation plan has been completed, the result should be evaluated with a set
of outcome questions. In contrast to the intake questions, those questions should not be
global in nature, but targeted at the specific objectives of the rehabilitation plan. If a generic
instrument is used, the outcome measure will be diluted by the responses to areas that were
not addressed [ 108].
Rehabilitation Outcomes
Many studies of rehabilitation outcomes have shown only moderate effectiveness. This should
probably not be interpreted as a failure of the rehabilitation, but as a failure of adequately
measuring its effect.
There is a need for well-designed studies of rehabilitation outcomes that meet the requirements
for randomized control studies [ 109]. Such studies unfortunately are still rare in vision
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rehabilitation. The Low Vision Intervention Trial (LOVIT) [ 110] of the Veterans Affairs Department
was such a study; its results are shown in Fig. 45.
Figure 45 Results of the LOVIT study
In this study patients were randomly assigned to an outpatient vision rehabilitation program or to
a 4-month waiting period (the usual waiting period for patients who were not in the study). The
6-week protocol was well defined and documented and implemented in the same way in the
various participating centers. The evaluation took place at 4 months, to avoid the immediate
post-treatment effects, and was done by telephone by interviewers who did not know whether
they were talking to a treated or to a control subject. The questions used were validated by
Rasch analysis. A total of 126 patients participated. They each were seen for about 10 hours in
the clinic, did about 17 hours of homework and received one home visit.
The arrows are proportional to the effect sizes for the different groups and objectives. The gray
arrows show slight deterioration in the control group; this is a reason to start vision rehabilitation
interventions as soon as possible. The black arrows represent the remarkably large effect sizes
for the treated group. These effect sizes were markedly larger than those in other vision
rehabilitation related studies.
For studies of this type an effect size of 0.8 is often considered a large effect [ 111]. By this
measure the effect for visual reading tasks in the LOVIT study was exceptionally large; it also
was larger than for any of the other domains. This is consistent with the fact that the protocol
was aimed at improving reading performance. The fact that the effect sizes also were
substantially larger than those reported in other studies, probably reflects the more rigorous
design of this study. There were significant spill-over effects to other domains; not surprisingly,
the smallest effect was seen for mobility, a domain that has least in common with reading. This
comparison demonstrates how important it is to focus the outcome measures on the goals of
the rehabilitation plan. If the study had used a global assessment tool that averaged over all
domains, the effect size would have been smaller.
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It is hoped that this study will not remain the only randomized control study of vision
rehabilitation outcomes.
Outlook
Ophthalmology was the first organ based specialty and was first in the accurate measurement
of organ functions, such as visual acuity. It has achieved remarkable success in treating
diseases of the eye. These advances may have contributed to an exclusive focus on visual
functions (how the eye functions) and neglect for the assessment of functional vision (how the
person functions).
In an age of evidence based medicine it is important to document the effectiveness of vision
rehabilitation. Often outcome studies are hindered by the fact that the interventions were not
standardized, which makes replication difficult, or by lack of well-defined objectives, which
makes it difficult to determine whether the goal was reached. Too often also the assessment
has been limited to counting responses on questionnaires. Recently, more sophisticated
methods, including Rasch analysis, have been used and have resulted in more convincing
evidence of the effectiveness of vision rehabilitation.
The requirements for a good study should include the following.
Well-defined interventions, targeted at well-defined goals.
Questions relating to visual functions (how the eye functions), functional vision (how the
person functions) and Quality of Life (individual satisfaction), should be evaluated
separately.
The difficulty of questions or tasks should match the ability range of the subjects. Rasch
analysis is a technique to achieve this.
Different settings and different disorders may require different questions. One size does not
fit all.
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PART 3B
ASSESSMENT of QUALITY of LIFE
Introduction, Types of Quality of Life

In Part 1 it was established that improving the Quality of Life of our patients is the ultimate goal
of all health care interventions. Those who have to make individual health care decisions as
well as those who set health care policy would benefit greatly if there were a simple way to
unequivocally measure Quality of Life. At the individual level dramatic decisions, such as
choosing between aggressive treatments and palliative care are important, but even minor
decisions like choosing between progressive lenses, bifocals or separate reading glasses need
to consider what will fit best with the lifestyle of a particular patient. At the policy level, a
minister of Health may need to decide whether to spend limited resources on childhood
vaccinations, on cataract surgery or on a transplant program. Unfortunately, although Quality of
Life is the most important of the various aspects we have discussed, it also is the most difficult
to define and measure.
Like vision, Quality of Life can be approached from different points of view. Living in a war zone
definitely affects Quality of Life. For an economist, Quality of Life may be related to the
standard of living. For a sociologist it may be related to prejudices and conflicts between
groups.
In our context we are mainly interested in Health-related Quality of Life. And even in that
context there are variants. Massof [ 112] has shown that visual abilities can vary independently of
general health and mental health variables. Each of those three can influence Quality of Life.
Even if our interest is further limited to Vision-related Quality of Life, vision may not be the only
variable. Eye drops may preserve vision in glaucoma, but the eye drop regimen may be
perceived as diminishing the patients Quality of Life.
INDIVIDUAL HEALTH CARE
In the context of individual health care, Quality of Life considerations are prominent for Vision
Rehabilitation. Among the aspects of vision loss ()ig. 2], the Quality of Life column is flanked by
the column of individual abilities and by the environmental column. The best definition of
individual Quality of Life probably is that it represents the satisfaction with the balance between
individual abilities and individual expectations. Fig. 46 shows the many factors that can
contribute.
First are the traditional vision enhancement aids, such as magnification, contrast and
illumination, which enhance visual abilities and are part of traditional low vision care. Low vision
care is an important first step. Comprehensive vision rehabilitation, however, must also look
beyond the optical solutions.
Vision substitution skills and techniques, using memory with skills and senses other than vision,
also have a place. The choice between vision enhancement and vision substitution is not an
either/or choice. A patient may use a magnifier for price tags and talking books for recreational
reading, or may use Braille to label cassettes for auditory learning. A long cane may be a
mobility aid, but can also be used for identification, since vision loss is an invisible handicap.
Patient attitudes and motivation are important modifiers. The balance between self-assessed
abilities and self-imposed expectations can be shifted by making patients aware of the things
they can still do; shifting their perception from the glass is half empty to the glass is half full.
An elderly person may accept as natural certain physical limitations that would be devastating to
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a young adult. The balance can also be shifted by providing achievable goals and by letting go
of unrealistic expectations. The latter applies particularly to patients who shop around for care
and postpone working on their own rehabilitation while waiting for a miracle. It is known that
vision loss often is a cause of depression and that depression may be a barrier to effective
adaptations.
Figure 46 Comprehensive Vision Rehabilitation vs. Low Vision Care
Traditional Low Vision care addresses mainly the optical aspects of vision loss, through
magnification, illumination, contrast, filters, etc.
Comprehensive Vision Rehabilitation also addresses non-visual substitution skills and the
motivation and attitudes of the patient. Additionally, attention must be given to the interaction
with the human as well as the physical environment at home, in school and work and in social
settings. This involves many aspects that are not part of a traditional ophthalmological medical
record.
Not all of the items listed below need to be collected by the ophthalmologist, but
ophthalmologists need to be aware of them so that they can involve appropriate allied health
professionals, either in their office or through appropriate referrals.
On the environmental side, we must consider the human as well as the physical environment.
The human environment, be it family members, friends, teachers or employers, can make a
major difference if they can be made to understand the patients capabilities as well as their
limitations. The influence of an over-protective parent can be as negative as that of an overdemanding one.
The physical environment is also important. A wheel chair user is far more handicapped in a
house with stairs than in a level bungalow. A person with visual impairment does better in an
uncluttered environment with good contrast and good illumination.
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All of these factors may affect the perceived Quality of Life. Determining how the factors
interact and which factor is the predominant one at any one time makes the assessment of
Quality of Life far more complex than the assessment of vision related abilities.
Fig. 47 summarizes the factors that need to be considered for a comprehensive assessment.
Figure 47 A VISION REHABILITATION TEMPLATE

Medical history
medical / ophthalmic (onset, duration, progression)
Functional history
difficulty with tasks, difficulties in school or job
devices, adaptations used
effect on Quality of Life, social participation
Eye (and visual system) condition
eye exam / optic nerve / cerebral condition (if applicable)
Visual Functions (how the EYE functions)
letter chart acuity, reading performance
peripheral field (for Orientation and Mobility)
central field (scotoma interference in reading; hand eye coordination)
contrast
Functional Vision (how the PERSON functions)
preferably based on a structured questionnaire (information from the patient, family,
and/or others; collected by the examiner, allied health professionals, or combinations)
observed performance (TIADLs)
Quality of Life, social Participation
concerns, fears, depression
RECOMMENDATIONS
Treatment
Devices
Training, Practice
Follow-up
medical / surgical
glasses / magnification / lighting / contrast
by support personnel / home work
for eye condition / for rehabilitation
Questionnaires
Since satisfaction is the criterion to be assessed for quality of life, observation is not an option.
Questionnaires must be used to gather patient reported outcomes. Broad questionnaires, such
as the SF-36 [ 113] have the advantage that they can be compared across various organ
systems. General vision oriented questionnaires, such as the VF-14 [ 114] and the NEI-VFQ [107]
can be used across various vision problems; they generally are more aimed at task
performance than at Quality of Life in a narrower sense. A newer questionnaire, the MacDQol
[ 115] is specifically designed for macular degeneration; its 23 questions are all phrased like If I
did not have macular degeneration my friendships and social life would be: better worse
with a corollary: My friendship and social life are: very important unimportant. Since
the questions are AMD specific, it does not allow comparison to other diseases, such as
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glaucoma, however the inclusion of questions about importance might make it better at
prioritizing the areas that need attention. A similar instrument, ADDQoL [ 116] exists for adult
diabetes.
Indirect assessment
We have seen how the Functional Vision Score system in the AMA Guides uses the
measurement of visual functions to estimate their impact on functional vision. Similarly,
assessments of Functional Vision, based on the observed or patient reported performance of
various activities of daily living, are often used as substitutes for the direct assessment of
Quality of Life.
Since many so called Quality of Life questionnaires do not clearly distinguish the aspects
discussed in this chapter, they may mix questions about visual functions (e.g. can you see at
night?) with questions about functional vision (e.g. can you travel at night?) and questions
about Quality of Life (e.g. does difficulty with night travel affect the things you want to do?).
Each of these questions is valid, but they address different aspects, that should be evaluated
separately, as was discussed in part 1. For vision rehabilitation the emphasis on the importance
of or need for specific activities is advantageous, since it points at the areas that must be
addressed in a rehabilitation plan.
HEALTH POLICY
In the context of vision rehabilitation it is relatively unimportant to compare the impact of
different diseases, since patients are only dealing with their own diseases. A very different
interest in Quality of Life comes from health policy and health economics. To distribute scarce
health resources most effectively, it is necessary to know where they will have the greatest
impact. This approach is also known as Value-based Medicine and requires among other
things a measure of Quality of Life that can be applied consistently across many health
conditions. Since health policies should be applied consistently across populations, they must
deal with statistical estimates that blur individual differences.
QALYs
QALYs or Quality Adjusted Life Years are an important topic in health economics. QALYs
combine the number of years that a patient will live with the expected quality of life over that
period. Various interventions or events that affect the life expectancy and/or the quality of life,
will affect the number of QALYs. When the cost of an intervention is known, one can then
presume to be able to calculate the cost-benefit of the intervention (be it a pair of glasses or an
organ transplant) in $$ per QALY. The cost of the intervention and the patients life expectancy
can be derived from various sources. It is more difficult to obtain an estimate of the Quality of
Life. Since many QALY calculations deal with life threatening diseases, a comparison is often
made between the Quality of Life and survival.
Time Trade Off method (TTO)
One method for estimating the QoL is the Time Trade Off (TTO) method. This method asks the
patient: how many years at the end of your life would you be willing to give up for complete
healing of your health condition right now? If a patient with a 20 year life expectancy feels that
20 years with the current condition is equivalent to 16 years of good health, it is argued that the
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current condition has reduced the utility of his or her life to 16/20 = 80%. So that 20 years with
a utility of 80% would be equivalent to 16 years with a utility of 100% (full health). If after an
intervention the patient is only willing to trade 2 years, the utility of the remaining years has
increased to 90%, a gain of 10%. Thus, the benefit of the intervention over the expected 20
years is calculated as 20 x 10% = 2 Quality Adjusted Life Years (QALYs).
Since the Time Trade Off method can be applied across many different health conditions, it has
obvious appeal for health economics and often is the preferred tool in that context. Prioritizing
interventions based on their cost/utility ratio seems reasonable, however, obvious questions to
be asked include:
Is it reasonable to compare the quantity of future years to the quality of present years?
When data from different respondents are pooled, is it reasonable to expect that they all
value longevity similarly?
Is trading 1 year of a life expectancy of 10 years equivalent to trading 5 of 50 years?
How should co-morbidities be incorporated?
How should the other factors listed in Fig. 46 be accounted for?
Standard Gamble (SG)
Another method for estimating the QoL asks the patient to gamble. The question is: if there
were a procedure that could either restore you to perfect health or kill you, what chance of death
would you accept? As with the TTO method it is unknown what factors drive the patients desire
for a long life. It has been said that some health conditions may be worse than death, should
those have a negative utility value?
Depression is one of the obvious factors that may affect a persons choice. It also is known that
people may differ significantly in their willingness to gamble. Some may prefer the certainty of a
small gain over a statistically equivalent small chance at a big gain. Others may have the
opposite preference.
Visual Analog Scale
This is the simplest method, but also the most subjective one. Patients are asked to place a
cross somewhere along a line to indicate their current Quality of Life. If they place the cross at
6 cm on a 10 cm line, this would indicate a QoL estimate of 60%.
Note that these different methods do not necessarily give similar results. When comparing
QALYs for different conditions, one must be certain that they were obtained with the same
methodology.
The Burden of Vision Loss
Before a cost benefit analysis can be made, we also need to define the cost element, in our
case often defined as the Burden of vision loss. This too poses questions about which
burdens to include.
The burden to the patient, which can be broken down into actual costs, lost wages, etc. and
the burden of pain and suffering.
The medical costs, often defined as the costs that might be covered by insurance, and
The societal costs of lost productivity, social services, need for care givers, etc. This
component may vary in different societies. Some societies consider it an honor to care for
elderly relatives, others consider it a burden.
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When defining the burden to the patient, it is also important whom to ask. Most favor asking
patients who experience the condition. Others, however, have asked experts (such as
ophthalmologists) who have observed, but not experienced the condition. The differences can
be dramatic. One study [ 117] gathered TTO estimates from AMD patients and from observers
(community members, general clinicians, ophthalmologists). Patients with mild AMD (> 20/40)
rated their TTO utility at 83%, the observers rated it at 93 to 98%. For moderate AMD (>
20/100) the numbers were 60% vs. 88 to 92%; for severe AMD (< 20/200) they were 47 vs. 73
to 86%.
Utility values have been gathered for many conditions. Fig. 47 compares the TTO values for
AMD to those for several other conditions [ 118]. Even if the validity of the absolute numbers can
be questioned, they can, at least, give us an estimate of the relative individual burdens of
various health conditions.
Fig. 47 Patient-based Time-TradeOff utility values
The table compares utility values for selected diseases with utility values for different degrees of
visual acuity loss. See text for discussion. Note that the listed utility values were obtained from
patients with the disease. In instances were surrogate responders are used better utility values
(less utility loss) may be expected. The increasing utility loss with decreasing visual acuity is as
expected, as it is for increasing symptoms of stroke or angina. This may be taken as a
validation of the scale; the relation across diseases (stroke vision loss angina) is much
harder to validate.
89
Notwithstanding the fact that questions can be raised and that utility values that were obtained
with different techniques should not be compared, advocates of value-based medicine maintain
that even an imperfect system is better than no system at all.
CLOSING THOUGHTS
This chapter discussed the measurement and assessment of various aspects of vision and
vision loss and pointed to various possible pitfalls.
The discussion started with Visual Functions, such as visual acuity, visual field and contrast
sensitivity, which describe how well the eye and visual system function. Measurement methods
are well developed for these areas, but improvements are still possible.
The next aspect is that of Functional Vision, which describes how the person functions in visionrelated activities. Measurement and assessment of these activities is not yet as well developed
as the measurement of visual functions, since functional vision is more complex and may
involve non-visual components. Assessment instruments should be calibrated to reflect the
ability range of the patient group; Rasch analysis is a way to achieve this.
Finally, we moved to Quality of Life, which is the ultimate goal of all medical interventions, but
also the most difficult to define and measure. The existing methodologies leave significant
unanswered questions.
Even though there are questions, it must be realized that any measurement becomes
meaningful only when compared to a reference value, be it a population average, a previous
measurement on the same patient (before and after an intervention or event) or the expected
outcome of a planned intervention. This means that relative values are more important than
absolute ones, and that even an imperfect system may be better than no system at all. Since
improved Quality of Life is the end goal of all ophthalmic interventions, we need to acknowledge
that the phenomenon of VISION involves much more than just visual acuity alone. The
practice of ophthalmology needs to embrace the concepts of comprehensive vision
rehabilitation to address the many additional concerns beyond the confines of the traditional
eye doctor (Fig. 46).
90
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