Snellen test charts

 Snellen VA charts are widely used in clinical practice

 They consist of letters of diminishing size.
 The height and width of the optotype (letter) is five times the thickness of the line, each
entire letter subtends 5’ at its prespecified distance
 Each letter on the chart has a distance at which it subtends 5’ at the nodal point.
 In order to resolve this letter (e.g., differentiate ‘C’ from an ‘O’) the eye must be
able to resolve the constituent parts down to 1’.

Snellen type variations

 The different test types (or symbols

on a chart) are called ‘optotypes’.
 So, if the first letter on the Snellen
vision chart subtends 5’ at 60 m, do we need to check VA @ a distance of 60m?
o No because it’s not practical, if someone can’t see the first letter at 6 meters
they are considered as legally blind

Undertaking a VA assessment (Instruction)

 Place patient 6 or 3 meters from the eye chart.

 Use distance correction is normally worn also reading glasses should not be worn during
distance testing (VA acuity is tested with or without correction)
 Use adequate illumination (chart & room lighting)
 You will be asked to cover the left eye so the RIGHT eye can be tested first with the palm
of your hand, or a piece of paper, or a small paddle, pirate patch, occluder, fold tissue
into a triangle, trial frames to test someone with glasses
 Ask patient to read the lowest line they can
o e.g. Please read down to the lowest line you can see on the chart (in the mirror)”
or“What is the lowest line you can read”orStart to read the chart from the
lowest line you can see
 Could be either Numbers, lines, or pictures are used for people who cannot read,
especially children.
  Keep going until they cannot read the line clearly and start to make multiple errors. The
previous line is the line you document.
 If patient isn’t sure of the letter, they may guess. Encourage patient to keep going as
some give up easily, encourage patient to relax and blink regularly
 This test is done on each eye, one at a time or both eyes. If needed, it is repeated while
you wear your glasses or contacts.
 If the 6/6 line is not reached, use pinholes to see if vision improves 
 If yes, continue testing vision until the patient is unable to clearly identify further
letters/ numbers
 If the patient cannot see the top line 6/60 of the chart, move the chart toward the the
patient from 3 meters
o the Snellen fraction distance changes e.g. 3/60
 Still can’t read the chart? Ask patient to count how many fingers you are holding up at 1
metre. Keep fingers still. Recorded as Count Fingers (CF @1m)
 If they cannot count fingers see if they can see a moving hand. Recorded as Hand
Movements (HM @1m)
 Still no result: can they see a pen torch light: Light perception (LP)
 Unable to perceive light: No Light Perception (NLP)
o For example:VAR NPL VAL 6/24 (Snellen Chart) RVA cc HM@1m LVA cc 6/60
PH 6/60 PH 6/9
Documentation of visual acuity
RVA s cl 6/60 LVA s cl prosthesis
 Record visual acuity (VA) for each eye
PH no improvement
 Include pinhole (PH) if used
 If wearing glasses or contact lenses please document RVA s gls 6/9 LVA s gls 6/6
 Artificial eyes need to be noted too
 Documentation Examples: PH 6/6

VA recording techniques
• BEO= both eyes
C = ‘with’ S = ‘without’ • OD= right eye
 cc  sc • RVA= right visual acuity
 c gls  s gls • OS= left eye
 c CLs  s CLs • LVA= left visual acuity
• OU= both eyes
The Snellen Fraction (VA recording)

VA = Distance patient sits away from the chart VA (i.e., viewing distance)

Distance at which the test type subtends 5’

Interpretation examples
  VAR 6/18
o the patient sees at 6m, what a person with normal visual acuity would see if they
were at 18 m from the chart’
o vision is not very good but good enough to walk around and do most things, but
unable to have a driving license.
 VAR 6/36
o The patient sees at 6m, what a person with normal visual acuity would see if
they were at 36m from the chart
o The patient has low vision
o What if the patient is only able to see part of a line? What then?

LogMAR VA chart: Logarithm of the Minimum Angle of Resolution (Bailey-Lovie LogMAR

chart)

 Considered ‘more precise’ than the Snellen chart

 Regular progression in size & shape of the letters
 Same number of letters on each line
 The space between the LETTERS on the line is equivalent to the size of the letter on that
line
 The space between the LINES is equivalent to the size of the letters on the line above
 Line value noted at the end of the line
 E.g. VAR cc 6/12 VAL cc 6/6 (LogMAR chart)
BEO cc 6/5

Visual acuity scales

 Converting from Snellen to log

o -log (6/60) = 1.00
 converting from LogMAR to Snellen
  converting to decimal
o 6/6 = 0.10
 converting meters to feet
o 1m=3.28
o 60 times 3.28 = 200
 converting feet to meters
o 1m=3.28
o 80 divided 3.28 = 24

Reduced VA

 VA testing not only assesses the refractive ability of the eye.

 The VA result is also a function of the retina, nerve paths and brain.
 In the clinical setting, it is possible to differentiate between an abnormality of the eye’s
refractive ability and a disorder of the neural mechanisms (i.e., retinal disease, etc).
 By using a pinhole, the clinician is able to differentiate between an abnormality of the
eye’s refractive ability and a disorder of the neural mechanisms

Using the pinhole: optical considerations

 When looking through the pinhole, only a small pencil of paraxial rays are permitted
through
 If there is an error of refraction in the eye, the ‘blocking out’ of peripheral rays with the
use of the pinhole (PH) causes the foveal image to be more ‘focussed’. Pinhole reduces
the blur circle (circle of diffusion) on the retina.
 VA will not improve if the reduced VA is a result of pathology at the retina (or beyond)

RVA HM @1m LVA 6/60

PH6/60 PH 6/9

Near VA testing

 When you have assessed the patient’s distance VA, you should also assess their near VA
(NVA).
 There are variations in the type of reading card you may use, but choose an appropriate
one for your patient’s age.
Undertaking a near VA assessment
 Ensure the patient is wearing their reading gls (if required)
 Have the patient hold the reading card where they normally hold their reading material.
(Generally speaking, this should be 30cm from the patient’s face slightly depressed
position)
 Cover the left eye first.
 Ask patient to read the smallest print size they can.
 Near reading card
o N5 is the smallest here

The near recording

Written just beneath the distance VA result for the respective eye as follows:

VAR cc 3/24 VAL cc 6/24 (Snellen Chart)

N48 N10 (Faculty Ophthal)

Illiterate test types:

 Landolt C, E chart
 What’s the instruction now? The recording?
o Tell me to which side is the letter facing (left,
right, up, down) using your fingers or hand.

VA results can be influenced by a number of factors:

 Patient cooperation & attention
 Use of refractive correction
 Patient understanding of the test requirement
 Examiner instruction & encouragement
 Patient squinting
 Patient position from the chart
 Recording the wrong result
 Room lighting
 Chart lighting (consider even illumination also)
 The VA result may differ depending upon chart illumination

Some closing remarks

  There are different test types available – that which you choose to use can vary for a
number of reasons
 Be careful with the instruction you use
 Use a pinhole in cases of reduced vision, to determine whether an error of refraction is
present.
 Use a hierarchical approach to vision assessment in cases of reduced vision.

Notes

 Clinically, the standard distance for a VA test is 6 m away, most rooms are 3 meters in
length therefore a mirror is used to double the distance
 Patient sees better with an illuminated chart, it stimulates the foveal region better
 The assessment of visual acuity in the clinical setting is most important. As a rule, it is
performed on all patients you see.
 One letter is referred to as an optotype
 Each number represents the distance in meters that letter could be seen in a healthy
adult
 Individuals with glasses that read the lower letters on the Snellen’s chart may be read
incorrect this is because the eye can’t resolve down to that 1 minute of arc
 1 minute of arc stimulates one cone
 Reading glasses (magnifiers) should not be worn during distance testing
 If the 6/6 line is not reached, use pinholes to see if vision improves
 If patient is unable to see 6/60 than use CF, HM, LP
 Be aware that frequent presenters may memorise the chart. Use different charts if
available or ask them to read it backwards. Be aware of mothers prompting children and
relatives prompting culturally and linguistically diverse (CALD) patients.
 Test each eye separately
 Use distance correction if normally worn
 Use an occluder, cupped hand or patch
 Pinholes are ideally not less than 2mm in diameter.

Visual Acuity Review

 Provide the clinical recording for the following:
o “Using a rear-illuminated Snellen chart & with current glasses, the patient could
read all of the 18 line with the right eye at 3m, and read the 6 line with the left
eye at 6 m, though missed 2 letters in this eye.”
– RVA c gls 3/18 LVA C gls 6/9 (-2)

o “The patient’s visual acuity was hand movements in the right eye and no
perception of light in the left.”
– RVA HM@1m LVA NPL