Ophthalmic & Physiological Optics ISSN 0275-5408
EDITORIAL
The good (logMAR), the bad (Snellen) and the ugly (BCVA,
number of letters read) of visual acuity measurement
The journal continues to receive many papers that have
used Snellen charts as part of ophthalmic research studies,
despite logMAR (log of the Minimum Angle of Resolution)
charts being widely recognised as providing much more
reliable and discriminative visual acuity (VA) measure-
ments than Snellen charts1 and being long ago proposed as
standard for clinical research and clinical trials of oph-
thalmic devices or drugs.2–4 VA measurements using a log-
MAR chart have been shown to be twice as repeatable as
those from a Snellen chart1 and over three times more sen-
sitive to inter-ocular differences in VA and therefore sub-
stantially more sensitive to amblyopic changes for
example.5 LogMAR VA charts use the design principles
suggested by Bailey and Lovie,6 including 0.1 logMAR pro-
gression of letter size7 from 0.3 to 1.0 logMAR (equiva-
lent to Snellen 6/3 to 6/60 or 20/10 to 20/200), five letters
per line, letters of similar legibility and per-letter scoring.
Many logMAR charts have a ‘bottom line’ of 0.3 logMAR
(6/3 or 20/10), whereas many Snellen charts have a bottom
line of 6/5 or 20/15 and thus provide truncated data given
that the average VA of a young adult is about 0.14 log-
MAR (Snellen 6/4.5 or 20/15).8,9
The Bailey-Lovie6 or ETDRS10 (Early Treatment Diabetic
Retinopathy Study; this study was the first to use the chart)
charts are the most commonly used logMAR charts for
adults.3 All logMAR charts have used the 0.1 log progres-
sion of letter size, but various other design features differ
between the charts. For example, Bailey and Lovie’s original
chart adopted the ten 5 9 4 British Standard letters,
DEFHNPRUVZ and used a working distance of 6 m;6
whereas the ETDRS charts use the ten 5 9 5 Sloan letters,
CDHKNORSVZ at a standard distance of 4 m.10 The
ETDRS chart has become the most widely used in clinical
trials and population studies and was adopted as the gold
standard for VA measurement by the International Council
of Ophthalmology.2,4
Despite its importance as the principal measure for visual
function, VA measurement and reporting is variable1 and
there are several areas of confusion.
Confusion 1. Measuring with Snellen and reporting
data as logMAR
Many papers report measuring VA with a Snellen chart and
then analyse the data after converting it to logMAR.11–14
Snellen charts have an irregular progression in size and are
© 2016 The Authors Ophthalmic & Physiological Optics © 2016 The College of Optometrists
Ophthalmic & Physiological Optics 36 (2016) 355–358
often truncated, so that the data may not follow a normal
distribution and parametric analyses might be best
avoided.15 This is not changed merely by converting the
data to logMAR. The conversion of Snellen data to logMAR
can also be misleading as the abstract and results sections
of papers that use this process sometimes give the impres-
sion that data have been collected using logMAR charts
suggesting the data are more reliable that they actually
are.11
Confusion 2. BCVA
Best Corrected Visual Acuity or BCVA is common within
recent literature.16 A PubMed search of ‘BCVA’ (on 18th
May 2016) listed almost 4000 (3987) references dating back
to 1995 and its use is steadily increasing year-on-year from
22 in 1995 to 110 (2000), 178 (2005), 437 (2010) and 685
in 2015. The earliest papers using this term were all investi-
gating refractive surgery outcomes, so that the term was
used to differentiate VA after surgery (the patient’s new
unaided VA) with the best VA possible with a subjective
refraction result (measured to determine if the surgery was
reducing the optimal VA, perhaps by increased aberrations
or scarring etc.). The International Council of Ophthalmol-
ogy used the term throughout its 2002 Visual Standards
report4 and it is now used throughout the ophthalmology
(and to a lesser extent optometry13,14,17–19) literature.
Unfortunately in many cases, it would appear that by add-
ing the superfluous term ‘best-corrected’ to ‘visual acuity’,
authors of reports believe that there is no need for further
description. When the refractive correction used in the
measurement of BCVA is occasionally provided in the bet-
ter described papers, it has been reported as the habitual or
presenting correction (e.g., spectacles, contact lenses or cor-
neal transplant for patients with keratoconus19) or an
autorefraction result20 or a ‘standard refraction’.13,14 The
standard refraction is typically unspecified, but it would
appear that this can vary. For example, one submission to
this journal included data of BCVA after subjective refrac-
tion, which was subsequently clarified as a subjective over-
refraction using +0.50 DS and 0.50 DS over the patient’s
own spectacles21 and without the assessment of astigmatism
that most optometrists would consider part of a standard
subjective refraction. Particularly given that the VA with a
subjective refraction can be 0.20 logMAR or two lines better
than with the presenting or habitual correction in over
355
Editorial

20% of patients,22 there is a clear need to know whether and is a source of great confusion. Papers appear to use the
optimal or presenting/habitual VA is being presented. system most clearly described by Beck and colleagues,25
which is the scores shown in Table 1, with 6/6 or 20/20
equal to 85 letters. This is the score provided by the com-
Confusion 3. Decimal VA
puterized adaptation of the ETDRS method.26 To use this
Decimal VA is commonly used in Europe (except the UK system with the standard ETDRS chart with five letters per
which uses metric Snellen) and this can be easily confused line,10 you need to either measure VA at a non-standard
with logMAR in the region of 6/9 to 6/24 (see Table 1). It 1 m (for patients with poor VA)25 or measure VA at the
seems best avoided. standard 4 m and add 30 letters to the number of letters
read.27 This is clearly understood by researchers using the
system in wet AMD studies, but the system is now permeat-
Confusion 4. Negative logMAR?
ing into standard clinics and confusion abounds.
The fact that logMAR VAs better than 6/6 or 20/20 are neg- This measurement system is the standard in this area of
ative is counterintuitive. Two alternatives, the Visual Acuity research and has led to some strange results sections in
Rating (VAR) score23 or ‘the number of letters read’ (see publications. For example, in Peden et al., Snellen VAs
below), have been proposed to counteract this. were retrospectively collected from records and converted
VAR = 100 – 50 logMAR, so that 0.00 logMAR (6/6, 20/ to letter values ‘in a standard fashion for statistical analy-
20) = 100 VAR and each letter has a score of 1. However, sis’.12 Graphs misleadingly include Y-axes of ‘ETDRS let-
after a little use the logMAR system becomes relatively easy ters’ with figure 5 scores averaging around 60 letters (0.50
to use and understand.1 Indeed, our current 2nd year logMAR, Snellen 6/18, 20/60), whereas the patient has
undergraduate cohort, after using logMAR scores in their likely read about ten letters on the top four lines of a Snel-
first year of clinical training, much prefer it to Snellen. len chart. Their figure 4 suggests that patient with ‘blind-
ness (≤20/200)’ improved by an average 25 letters with
anti-VEGF treatments, but what this actually means is
Confusion 5. Number of letters read
guesswork given that there is no indication of how Snellen
The great majority of studies evaluating interventions for VA <20/200 was scored and subsequently converted to log-
age-related macular degeneration report VAs by the num- MAR and ‘letters read’.
ber of letters read correctly and report improvements by
the number of letters gained.12,24 This measurement scale
What to report for VA measurement
depends totally on the chart and the working distance used
In addition to the submission of papers that have used
Table 1. Distance visual acuity conversion table Snellen VA measurements, the reporting of the detail of VA
Snellen Snellen ~ Number of
measurements in submitted papers is often poor or non-
LogMAR VAR (Metric) (Imperial) Decimal letters* existent. Ideally, the following information should be pro-
vided with any paper reporting VA measurements1,3,23:
0.30 115 6/3 20/10 2.0 100
0.20 110 6/3.8 20/12.5 1.60 95 1. Chart type. This should be a logMAR VA chart (e.g.,
0.10 105 6/4.8 20/16 1.25 90 Bailey-Lovie or ETDRS).3,6,10
0.00 100 6/6 20/20 1.00 85 2. Chart luminance. About 160 cd m 2 with a range of
0.10 95 6/7.5 20/25 0.80 80 80–320 cd m 2.28
0.20 90 6/9.5 20/32 0.63 75
3. Testing distance. Typically 4 m or 6 m. A reduced dis-
0.30 85 6/12 20/40 0.50 70
0.40 80 6/15 20/50 0.40 65
tance should be used for poor VAs and ‘count fingers’
0.50 75 6/19 20/63 0.32 60 or ‘hand movements’ should not be used.29
0.60 70 6/24 20/80 0.25 55 4. Refractive correction used. Indicate whether you are pro-
0.70 65 6/30 20/100 0.20 50 viding presenting or habitual VA (with the patient’s
0.80 60 6/38 20/125 0.16 45 own spectacles, contact lenses, unaided) or unaided VA
0.90 55 6/48 20/160 0.125 40 (often called ‘vision’) or VA with a subjective refraction
1.00 50 6/60 20/200 0.10 35
result. If the latter, this should be described in detail or
1.30 35 6/120 20/400 0.05 20
1.60 20 6/240 20/800 0.025 5
a reference provided.
2.00 0 6/600 20/2000 0.01 – 5. Scoring rule. VA measured with a logMAR chart is best
scored by-letter rather than by-line.30
MAR, minimum angle of resolution; VAR, visual acuity rating. 6. Termination rule. A termination rule seems essential,
*Number of letters based on scoring system described in refs 25 and
particular when VA is being used to assess the efficacy
26.

356 © 2016 The Authors Ophthalmic & Physiological Optics © 2016 The College of Optometrists
Ophthalmic & Physiological Optics 36 (2016) 355–358

of an intervention, otherwise improvements in VA post-
intervention could simply be due to study participants
trying harder on retest. Some patients are more cautious
than others and only indicate those letters that they can
see easily and clearly. Unless you push patients to guess,
you could obtain different VA results depending on
how cautious your patient is. The standard termination
rule is when a patient makes four or more mistakes on a
line of five letters.31
7. The number of clinicians taking measurements (and their
training, if appropriate). Measurements taken by a range
of clinicians can be unreliable,32 particularly without a
standardised measurement system that includes a termi-
nation rule.
David B. Elliott
Editor-in-Chief, Ophthalmic & Physiological Optics and
Professor of
Clinical Vision Science, University of Bradford, Bradford,
UK
E-mail address: d.elliott1@bradford.ac.uk
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