VISUAL ACUITY

Dra. Amalia Lorente Velázquez

17/04/2007
Instituto Alcon 2

What is visual acuity?

Visual acuity (VA) is a measurement of the visual system's ability to detect, recognise and resolve
special details by means of a high contrast test with good lighting. A person with good visual acuity is
able to perceive small details of an image.

How do we assess it?

In order to determine a patient's Visual Acuity we put them through different high contrast tests of
different sizes at a fixed distance. The size of the smallest test that the patient is able to detect or
recognise is considered to be their threshold level. This level is usually measured in terms of minutes
of arc.

How do we measure it?

Various scales are used to measure VA depending on whether we are measuring distance vision or
near vision. We are going to look at the most important of these tests which are those that are most
commonly used by specialists.

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VA scales for Distance vision

Decimal acuity
This is the reciprocal of the angle subtended by the smallest detail that can be discerned, expressed
in minutes of arc:

AV=1/u (min) (1) or AV=5/ω (min) (2) where ω=5

A value of VA=1 is considered to be a normal VA value. Obviously, the finer the detail that the
patient can discern the greater their visual acuity.
Values (1) and (2) are ways of calculating VA depending on whether we are measuring the smallest
detail (1) or the size of the smallest letter that the eye can discern (2). This is because in most tests
the smallest detail is 1/5 the size of the letter.

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Logarithm MAR
On this scale, visual acuity is the decimal logarithm of the minimum angle of resolution, in minutes of
arc, of the smallest detail that the patient can discern (MAR=u). In abbreviated form:

AV= log MAR

For example:
• a patient who sees a detail that subtends one minute (MAR=u=1’) is considered to have a
visual acuity score of logMAR = 0
• a detail that subtends 10 minutes of arc (MAR=10’) results in a logMAR = 1.

NOTE: It should be pointed out that a decimal visual acuity of VA=1 is equivalent to a
logMAR=0

Snellen acuity
Another way of measuring VA is as a quotient between two distances:

VA = d/d0 (3)

Where d is the distance at which the chart, with the letters or letters and numbers that gradually
decrease in size, is usually placed from the patient and d0 is the value attached to each line of the
chart. This represents the distance at which the smallest symbol discernable at a standard distance
subtends to u = 1 minute.

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There are charts for different distances. The most common ones are 6 metres (or 20 feet) for
measuring distance vision and 40 centimetres for near vision. For these distances acuity units are
expressed as follows: 20/20, 6/6 and 40/40 respectively.

For example: a calibrated chart at 20 feet, a person with a visual acuity for 20/30, they can see well
at 20 feet a symbol of an angle size of 1 minute at 30 feet.

Symbol size
Once we know the size of the symbol the patient is able to see at a given distance we can then
calculate their VA. This is useful when we are obliged to place the optotype charts at other distances
that are not the standard distances. For example, when testing VA of patients with low vision the
chart may need to be placed at a nearer distance to the standard distance.

In such cases we can calculate VA if we know the size of the smallest letter the patient is able to see
(this is specified on the test) and the distance they are standing from the chart.

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Example: a patient who is able to see a 7.28 mm object at a distance of 6 metres has a VA of 1.2.
When calculating this you need to take into account the angle relationship reflected in the drawing:

The Keeler A scale

On this scale A1 means that the limit is reached with a 1’ size (log MAR = 0) and successive scores
are equivalent to 0’1 logMAR units each.

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Equivalence between the different VA scales

MAR LogMAR Snellen Snellen Decimal Keeler A

(min arc) (d = 6m) (d = 20 ft) notation
100 2.0 6/600 20/200 0.01
79 1.9 6/480 20/1600 0.0125 20*
63 1.8 6/380 20/1250 0.016 19*
50 1.7 6/300 20/1000 0.02 18*
40 1.6 6/240 20/800 0.025 17*
32 1.5 6/190 20/630 0.032 16*
25 1.4 6/150 20/500 0.04 15*
20 1.3 6/120 20/400 0.05 14*
15.8 1.2 6/95 20/320 0.063 13*
12.5 1.1 6/75 20/250 0.08 12
10.0 1.0 6/60 20/200 0.1 11
8.0 0.9 6/48 20/160 0.125 10
6.3 0.8 6/38 20/125 0.16 9
5.0 0.7 6/30 20/100 0.2 8
4.0 0.6 6/24 20/80 0.25 7
3.2 0.5 6/19 20/63 0.32 6
2.5 0.4 6/15 20/50 0.4 5
2.0 0.3 6/12 20/40 0.5 4
1.58 0.2 6/9.5 20/32 0.63 3
1.25 0.1 6/7.5 20/25 0.8 2
1.0 0.0 6/6 20/20 1.0 1
0.8 -0.1 6/4.8 20/16 1.25
0.63 -0.2 6/3.8 20/12.5 1.6
0.5 -0.3 6/3 20/10 2.0

*These notations correspond to slightly smaller letter sizes than those of logMAR.

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(Click on the image)

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VA scales for Near vision

Letter size: The size of the smallest letter the patient can see is measured in millimetres (mm) once
we know the distance at which the test is being given.

M Units
The letter size is measured using "xM" notation whereby x represents the distance in metres at which
the smallest letter subtends an angle of 5'. Letters of 1M size subtend an angle of 5’ of arc at a
distance of one metre. This corresponds to a letter size of 1.4 mm. This may be written in Snellen
notation so that the numerator corresponds to the distance at which the test is being given (in
metres) and the denominator to the letter size in M units. For example, 0.30/1 M tells us that the
patient is able to see a 1M sized letter at a distance of 30 cm.

Points system
Each point is the equivalent of a letter size of 1/72 inches. Hence, for example, a letter size of 1.4
mm corresponds in points notation to a letter of 8 points. The size measured in points can be easily
converted into M units by simply dividing by 8 (M units=points/8). Consequently, a letter of 8 points
is equal to the size of 1M.

N notation
This notation is used in some charts where the letter size is specified as N followed by a number. The
N indicates that the letter font is Times Roman as well as the number, the letter size in points. For
example, N8 stands for a letter of 8 points. Finally, in order to determine VA, we will need to indicate
the distance at which we have carried out the measurement (N8 at 40 cm means that the patient
sees an 8-point sized letter at 40 cm).

Reduced Snellen chart

The letter size is identified with the same Snellen fractions that are used to measure distance VA. In
this case, the 20/20 letter in reduced Snellen notation requires the same visual acuity as does the
20/20 line in the distance VA tests, the only difference being that this test is given at a distance of 40
cm.

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It is not often used because these tests are usually given at closer distances than 40 cm and in such
cases the resulting Snellen fractions are not appropriate. Table 2 shows the Snellen VA equivalent
when the test is given at 25 cm.

Keeler A System
Letter size is indicated using an A followed by a number. An "A1" size letter indicates the size of a
letter that subtends an angle 5’ of arc at 25 cm, in other words VA= 1 and logMAR = 0. Successive
numbers after the A indicate a size increase of 0.1 logarithmic units.

Table 2 compares the different abovementioned scales for near vision. Thus for example, a patient
whose VA is 1M can see a 1.4 mm letter at 40 cm which corresponds to a VA N8 point notation and
to A7 on the Keller system. The corresponding Sneller fraction would be 6/24.

Equivalence between the different VA scales for near vision

Letter size M Point Keeler A Equivalent Snellen

(mm) Notation system series visual acuity at
25cm
0.36 0.25 2 1 6/6
0.45 0.32 2.6 2
0.55 0.4 3.2 3
0.71 0.5 4 4 6/12
0.83 0.6 4.8
0.89 0.63 5 5 6/15
1.06 0.75 6 6/18
1.1 0.8 6.4 6
1.4 1.0 8 7 6/24
Newsprint
1.6 1.1 9
1.75 1.25 10 8

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2.15 1.5 12 9
2.5 1.75 14
2.7 1.9 15.4 10
2.8 2.0 16
3.2 2.3 18
3.4 2.4 19.3 11
3.5 2.5 20 6/60
4.2 3.0 24 12
5.3 3.8 30 13
5.6 4.0 32
6.4 4.5 36
6.6 4.7 37.5 14
7.1 5.0 40 6/120
8.3 5.9 47
8.5 6.0 48 6/150
9.7 7.0 56
10.3 7.3 58.4 16
11.1 8.0 64
12.5 9.0 72
12.9 9.1 73 17
13.9 10.0 80 6/240
16.1 11.5 92 18
20.1 14.5 116 19 6/350
25.2 18 143 20

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What are Visual Acuity tasks?

When we define visual acuity we refer to the tasks that can be applied to a patient to determine their
VA. These tasks are the following:

a) Detection: This involves saying whether an object is present or not in the patient's visual field.
Objects that are commonly used for this purpose are circles, lines and rectangles. The optotypes
may be different. Some have been designed with a light object against a dark background
whereas others show a dark object against a light background.

b) Recognition For this task the patient is asked to identify the test object they are shown (letter
chart) or to identify a spatial characteristic such as the orientation or position of a specific detail
(Landolt-C or Snellen-E chart). This task it most commonly used for clinical purposes.

c) Resolution: The patient has to determine the minimum distance between two objects in order
for them to be distinguished as separate. In this case the patient's VA is the inverse of the
minimum distance in minutes of arc.

Tests used for clinical purposes (recognition task)

Landolt Ring
An optotype chart where the optotypes are rings with a gap on one side (C). The gap changes
position and the rings get progressively smaller. The patient is asked to say in what position the gap
of the ring is: up, down, right or left. Other similar charts are the Snellen-U and the Snellen-E charts.
The most commonly used is the Snellen-E chart. This chart is highly recommended for testing VA
because it is more precise and reliable than the letter charts (for example, it is not as easy to
memorise) and also because it is very useful for testing elderly people, people who are illiterate or
who are not familiar with the language, who may find letter charts difficult.

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Landolt Ring

Snellen Letters
These charts use letters of the alphabet as optotypes. The chart is made up of letters in black print
against a white background which gives them a high contrast. The letters get progressively smaller.
The recognition task the patient carries out with these optotypes is very much influenced by the
letter they are asked to read because it has been demonstrated that certain letters are more familiar
to patients than others.

Various standard chart versions are currently available. These differ from one another in the
calibration distance and the letters they use. The patient is asked to correctly identify the letters as
they get progressively smaller. With the Sloan letters: C, D, H, K, N, O, R, S, V, Z you can obtain a
decimal acuity similar to that obtained with the Landolt ring.

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Other charts such as the Bailey-Lovie chart measure visual acuity in terms of logMAR. On this chart
the letter size changes from one line to the next. The progression is 0.1 logMAR, in other words, at
decimal intervals.

The Snellen letter chart calibrated for use at 6 metres, is made up of 6 lines of letters. Starting from
the top line, the letter size on each line gets smaller as you go down the chart. Hence, each line can
be identified by the number that appears on the right hand side of the line. The number represents
the distance at which the total letter size subtends 5 minutes. Consequently the minimum detail
subtends at 1 minute of arc. In this case, visual acuity is given in Snellen fractions.

Tests for measuring Visual Acuity in children

We can classify the tests for measuring VA in children into four categories depending on the
optotypes they use.
- Tests that use drawings of objects.
- Landolt ring tests or variations.
- Rotate E charts or similar.
- Snellen letter chart.

The choice of chart will depend on the child's age and their level of verbal development. With children
over the age 6 we can use the same charts as we normally use with adults whereas with smaller
children we need to use charts which will give us an accurate measure of the child's visual acuity
without relying on verbal responses or just very simple responses. We must therefore keep in mind
the following:
- The Landolt ring chart does not require letter recognition.
- Use isolated optotypes and not optotypes grouped in lines.
- With very small children avoid eliciting verbal responses.
- A shorter distance for the distance visual acuity test: 3 metres instead of 6 metres.

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In any event, the appropriate chart for each examination will be decided on by the professional in
question.

• From birth to the age of two or three

Preferential-looking test (Teller Acuity Cards)

The infant is shown a set of black-and-white stripes placed on the right or left side of a card, against
a contrasting grey background. The frequencies range from 38 to 0.32 cycles per degree. Each grid is
located to the right or to the left of the card with an opening in the centre from where the examiner
can observe the infant's eye movements. A version of this test is available that displays the grids on
a screen.

Clinical procedure:
• The child is placed in front of the screen which displays the grids with different spatial
frequencies.
• Through the hole, the examiner observes the infant's eye movements to the left or to the right
as it notices the presence of the grid on the screen.
• The child's VA is the highest frequency they are able to perceive. The test is carried out first
with the right eye, then with the left eye and finally with both eyes.

Optokinetic Nystagmus Test (OKN)

This uses a rotating drum covered with black and white vertical stripes. The test works in the
following way. When the drum begins to rotate the child will make nystagmus movements if it is able
to detect the stripes on the drum.

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• Children aged two to six

Lighthouse Cards
This test makes use of three drawings (an umbrella, a house and an apple). It is made up of a deck
of 10 cards. Each card has one of these optotypes printed on one side together with the
corresponding Snellen visual acuity notation (from 20/200 to 20/10)

Allen Preschool Vision Test

With the help of a projector, in each row, this test displays six of the eight drawings used in the test
(horses, birthday cake, hand, telephone, bird, car). The test measures VA values 20/200, 20/100,
20/70, 20/50, 20/40 and 20/30. There is also a version of the Allen test for assessing near vision.

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HOTV Test
This is one of a series of Stycar tests which uses the letters H, O, T and V. The test does not require
a verbal response. The child is simply asked to point to the letter on a card, that the examiner has
shown them.

Stycar VA test
This consists of a set of cards designed to be shown at 3 and 6 metres. Another version of the test
uses a set of cutlery or dolls.
- Stycar test with letters: The child is given a card with different letters and they are asked to
find the letter that is the same as the letter that they are being shown at a specific distance.
- Stycar test with objects: the examiner has a set cutlery identical to the ones given to the child.
The examiner stands 3 metres away and 6 metres away and shows a piece of cutlery. The
child is asked to choose an identical piece of cutlery to that being held up by the examiner.

Sheridan Gardiner Test

Like the Stycar letters test, it is made up of a set of cards contained in a notebook. A letter is printed
on each card and the cards are displayed to the child at a distance of 3 metres. The child has to
identify to the letter shown to them by the examiner by pointing to it on a card containing all the
letters in the test. There is a commercial version for assessing near vision.

Rotated E Test
This test has been designed so that the child only needs to indicate the direction of the E (where are
the sticks of the E pointing towards?) The answer is: up, down, right or left. The characteristics of
these tests are the same as those of tests used to measure VA in Adults.

Clinical procedure:
• The child is shown the drawings, objects or letters they are going to see at a distance of
50 cm and is asked to name them. If the child doesn't know the names, time must be
taken to familiarise them with the names before commencing the test. If the child is

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unable to name them you could try to carry out the test by showing them a card with the
optotypes and then ask them to identify on the card the one being shown to them by the
examiner.
• The examiner commences with the largest optotype at 3 metres and asks the child to
name the drawing they are being shown or to point to the corresponding drawing on the
card the child has been given.
• The test is carried out first with the right eye, then with the left eye and finally with both
eyes. The visual acuity score is that of the last card on which the child is able to name all
three drawings.

Broken wheel test

This test is made up of eight pairs of cards that use a car drawing as an optotype. Each pair of cards
shows the child two cars, one of which has broken wheels. The car with the broken wheels has
Landolt broken rings instead of circles. This test enables us to measure VA of 20/20, 20/25, 20/30,
20/40, 20/60, 20/80, 20/100 and 20/120.

Clinical procedure:
• The child is shown a pair of cards at 50 cm and with both eyes is asked to identify the car with
the broken wheels. Before proceeding with the test the examiner must make sure that the
child has understood the procedure well.
• The examiner begins at 3 metres with the pair of cards that correspond to a 20/120 VA. They
hold out a card in each hand and ask the child to identify which of them has the car with the
broken wells.
• The test is carried out first with the right eye, then with the left eye and finally with both eyes.

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The Fooks test

This test uses three optotypes (a circle, a triangle and a square) which the child can easily recognise.
These are drawn on the sides of two cubes. There is one drawing on each side. Given that the cube
has six sides there are twelve different sizes of drawings.

Clinical procedure:
• The child is seated comfortably on a table and is given the three optotypes (the circle, triangle
and square).
• The child is then asked to point to or raise the optotype that matches the one the examiner is
showing them on one of the sides of the cube.

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VA Test for patients with Low Vision

The projected cards used with patients with normal vision are not useful for assessing VA in patients
with low vision for the following reasons:
- The size of the largest letter in these tests is too small for these patients.
- The letter-size changes from one row to the next of the test are too small.
- The projection of the test does not allow us to assess VA at different distances because of a
lack of flexibility. This factor is of primary importance for measuring VA in patients with low
vision.
Below are various tests that have been specifically designed to assess VA in distance and near vision
of patients with low vision.

Tests for distance vision:

Feinbloom Test
This test consists of a flip chart with 13 pages. The sizes of the numbers used ranges from a number
that subtends 5 minutes of arc at 210 metres right up to 3 m. Hence the VA range available for the

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test taken at 3m (10 feet) ranges from VA 3/210 (10/700) to 3/3 (10/10). The optotypes (numbers)
are presented in the following fashion: the large numbers are shown one on each page, the
intermediate sizes are grouped in sets of three and the small numbers are ordered in rows.

Sloan and Keeler cards

These use letters with the same degree of difficulty so that they can be recognised by the patient. A
constant size progression is used from one line to the next (0.1 logarithmic units equivalent to a
Keeler unit). The number of letters and the space between letters varies from one line to the other.

Bailey-Lovie acuity chart

In this test the letter size only varies from one row to the other. Each row has five letters of the
same size and the space between them is equal to the width of each letter. The space between one
row and the next is equal to the size of the smaller letter size of the two rows. The letter sizes on this
test change with a logarithmic progression whereby the size relationship between one row and the
next is 0.1 logarithmic units. VA is measured in terms of the logarithm of the minimum angle of
resolution (logMAR).

Tests for measuring VA in near vision:

Most of the tests that have been designed to assess VA in near vision of patients with low vision use
words, sentences or paragraphs. What follows is a description of some of the most commonly used
tests:
- Feinbloom Test
This test presents number optotypes that are grouped according to size. There are rows with just one
number (the largest size) followed by numbers in groups of two (47, 35), in groups of three (823,
497) and groups of four in the case of the smallest numbers.

- Sloan M cards
This system introduces a new notation for naming the letter size, notation M. For a letter size, the
notation xM represents the distance in metres (x) at which the smallest letter that the patient can
see subtends an angle 5 minutes of arc. Hence, a 1M sized letter will be seen by the patient at 1 m

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subtending and angle 5 minutes of arc. This corresponds to a letter size of 1.4 mm. This test is
normally given at 40 cm. The letter size range is 10, 7, 5, 4, 3, 2.5, 2, 1.5 and 1M.

- Keller Test
This test uses logarithmic progression for letter size changes. Size is specified as ‘A1’ for a letter size
that subtends an angle of 5 minutes at 25 cm. Each subsequent number increase that accompanies
the A indicates a size increase of 0.1 logarithmic units. The test is made up of sentences or
paragraphs written in Times Roman letter font.

- Bailey-Lovie near word chart

This chart uses letters with logMAR sizes 1.6 to 0.0 (6/240 to 6/6) at 25 cm which vary progressively
by 0.1 logarithmic units. Translated into M notation this spans a range of sizes from 10M to 0.25M.
Two to six unconnected words appear on each line. Each word contains 4 to 10 letters. Since we are
not dealing with a text, it perfectly assesses the patient's ability to read words. However, when we
want to assess the patient's ability to read a text with meaning, this test is inappropriate.

- Pepper VSRT Test

This test was designed to assess visual functions in patients with macular scotoma by evaluating
their reading speed and the type of text the patient finds difficult. The text is available in letters sizes
1M-4M. The letter size is the same on each page and the letters are presented in 13 lines. The first
line presents isolated letters and successive lines order letters two by two, three by three and so on
until they are ordered into whole words without any connection. The space between the lines gets
progressively smaller.

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