LOW VISION

EXAMINATION
LECTURE
Lecture 2 & 3
24 January & 31 January 2018
LVIS 4802
Mrs MB Mokhua
Session outcomes
• Discuss 5 main areas
of case history in detail
• Design a pre-
examination sheet for
each patient
• Discuss Visual
functions and their
scoring methods
• Discuss two commonly
used methods of
refraction
Discuss training with the low vision devices

Discuss problems encountered during training

and management thereof.
LV exam sequence
• Case history
• VA’s (distance, near and continuous text)
• Refraction
• Central field test (scotomas)
BCVFT (Computerized): New
Tangent 1m
Tangent 50cm: New
• Magnification response
Case history
a. Distance vision
b. Near vision
c. Orientation and mobility skills
d. Glare/illumination
e. Lifestyle
External observation

• What do we look at?

Discussion
VISUAL ACUITY
VA’S
• Distance
• Near
• Continuous text (Bailey-Lovie)
 REVIEW

Visual Acuity-LogMAR format

Optotypes
• Letter optotypes
• Landolt rings
• Tumbling E
Visual acuity designation
• Snellen fraction
• Decimal notation
• Minimum Angle of resolution (MAR)
• Logarithm of the Minimum Angle of Resolution
Minimum Angle of resolution (MAR)
• It expresses the angular size of critical details
within the optotypes at threshold in minutes of
arc.

• The MAR in minutes of arc is equal to the

reciprocal of the decimal acuity value. For 6/18,
the MAR is equal to 3 minarc.
Logarithm of the Minimum Angle of
Resolution
• Expresses the visual angle and does not define the size
of the letters.

• The logMAR is equal to the log10 (1.0) which is equal to

0.0.

• LogMAR scores decrease with better visual acuity and for

visual acuity score better than 6/6, scores will become
negative.

• The size progression ratio in other charts is 0.1 log units

for each row and 0.02 logMAR for each letter
 Conversions

• logMAR = - log (decimal)

• Decimal acuity= antilog (-logMAR) = 10 -logMAR

 Conversions
Review

• Snellen acuity:
• Decimal:
• logMAR:
• MAR
Snellen MAR foot Decimal logMAR
6/12 2 20/40 0.5 0.3
1.00 0.0
6/3.8 20/12.5 1.6 -0.2
Method of scoring distance visual acuity
results
Row-row scoring

• In this method, the visual acuity score is the smallest

line that the patient identified correctly.

• A credit is given to the patient by adding plus to

indicate that the patient read additional letter(s), or
minus is used to indicate that they missed some
letters.

• Example: 6/9 +1 if the patient has read additional

letter and 6/9-2 if they have missed two letters.
Letter-by-letter scoring
• Used in logarithmic system

• A preferred method of scoring visual acuity-

provides more sensitive results in detecting the
changes.

• The patient is still credited if they have read

additional letter(s) on the smallest line by using
plus, and minus if they have missed letter(s) on
the smallest line.
• Each letter is equal to 0.02 logMAR units, and for
additional letter read, 0.02 is deducted from the logMAR
score

Formulae

• VA (LogMAR) – n (0.02) 0.8 + 2

• VA (LogMAR) + n (0.02) 0.8 - 2

• 0.8– 2 (0.02)= 0.76 (VA is better compared to VA below)

• 0.8 + 2 (0.02)= 0.84 (VA is getting worse)

More discussion!!!
• Although logMAR is often presented as a measure of VA

• It actually is a measure of visual loss

• A logMAR value of 0 indicates “no loss”

NEAR VISUAL ACUITY
SCORING OF NEAR VA
M-units (method of choice)
• M units indicate the size using the distance in
meters.

• This is the distance at which the height of the

smallest letter read subtends 5 minutes of arc.

• Each letter is 1.45mm high.

• Can be recorded in a form of a Snellen fraction,
having the testing distance as the numerator and
M unit size as the denominator.

• If a patient has read 2.0 M at 40 cm, then visual

acuity will be scored as 0.40/2.0.
Points
• Used to specify the size of typeset print.

• With the newspapers, the print style used is 8 point size,

which is equivalent to 1 M units.

• Therefore, for print font style that is used for newspapers

M Unit rating can be calculated by dividing the point size
by 8,
• 1.0 M units = 1.45mm which is equivalent to 8 points
(lowercase, newspaper style).
N notation
• Uses a Times New Roman font style.

• The smallest line that the patient has read is

recorded in N notation and the distance will be
specified.

• N notation can be converted to M Unit by dividing

the number by 8
Conversions
• M TO N: X8

• N to M: Divide by 8

• (1M = 8N)

• 1mm letter = 0.7 M

• i.e. can measure height of lowercase letters in mm and
multiply by 0.7 for M value.
CONTINUOUS TEXT
CHART
Vision assessment for reading
1. To establish patient’s specific goal(s)
2. Define goal reading rate
3. Determine required threshold print size for
required reading rate
4. Measure near VA at different illumination levels.
How?
1. Calculate equivalent viewing distance (EVD)
REFRACTION
1. Objective refraction
2. Subjective refraction
• Objective refraction
Radical retinoscopy
-- search for useful reflex
-- start from standard working distance , then move
in to as close as 5cm
Example:

Examiner neutralizes a movement at 20cm, and

gets +2.00/-1.00 x 90
= [+2.00-(+5.00)]/-1.00 x 90
= -3.00/-1.00 x 90
SUBJECTIVE REFRACTION
• Use trial lenses
• Keep lenses clean and make sure correct lenses
are used
• Use large steps and bracketing method
Spherical powers
Cyl powers
• Refine the following from Retinoscopy results
Sphere
Cyl axis and
Cyl power
 Instructions
Do things look clearer
OR
Do things look blurred?
OR
No difference? Or is it difficult to tell?
• Examiner should pay attention to:

• Patient’s responses: Assess patient’s certainty

and uncertainty ( speed, tone and words) will
determine all

• Progressively reduce size of bracket

• e.g. +6.00DS & -6.00DS/+4.00DS/-4.00DS

Presentation of lenses

Note the following:

• the examiner presents Plus lens first and wait for

the patient’s response
• the examiner presents Minus lens secondly and
wait for the patient’s response
• the examiner presents Plano lens thirdly and wait
for the patient’s response
ASTIGMATISM
• Principal meridians- Estimating Axis

• Flip 1: 90 and 180

• Flip 2: 45 and 135
• Then refine axis using the same bracketing method
• Estimating Cyl power
• Start with high power -1.50D cyl
Functional tests
• Contrast sensitivity testing
• Visual field testing
• Colour vision testing
Contrast sensitivity testing
• Mars test

It is portable
It is a 22.8 cm x 35.6 cm measuring card.
Testing distance is 50cm, but a tolerance of 40-
59cm is suggested in the user manual
The patient reads the chart from top to bottom,
scoring 0.04 logCS units for every correct letter.
• Patients can be assessed using their usual
reading correction, because letters are large.

• Patient should be encouraged to guess.

• Testing stops when the patient makes two errors

in a row.
Mars Test
 Mars test results

• Normal middle/young adults 1.72-1.92

• Normal >60 : 1.52-1.76
• Moderate CS loss: 1.04-1.48
• Severe CS loss : 0.52-1.00
• Profound CS loss<0.48

Analysis by Drs. J Winters and T Matchinski

 FACT CHART
The FACT sine-wave grating chart tests:
• five spatial frequencies (sizes)
• has nine levels of contrast

spatial frequency refers to the number of black-

and-white bars (1 cycle) within a degree of
angular subtense.
FACT test
 The patient determines the last grating seen for
each row (A, B, C, D and E)

Reports the orientation of the grating: right, up or

left. The last correct grating seen for each spatial
frequency is plotted on a contrast sensitivity
curve.

• The decrements of the grating contrast are 0.15

logCS
Visual fields testing
Peripheral visual fields
Goldmann perimetry
Humphrey's visual fields testing

Central visual fields

Tangent screening test @1m
Amsler grid test
Tangent screening test @50cm
Types of Perimetry
• Static,
• Kinetic,
• Manual or Automated
• There are two basic types of visual field tests
commonly used in the clinic.

• Depending on whether or not the stimulus

moves, the test can be classified as static or
kinetic.
Static perimetry: Measurement of the visual field with
a target that can be varied in dimension and luminance.
The target can be presented in any part of the visual
field

Isopter: In the determination of visual fields, it is the

contour line representing the limits of equal retinal
sensitivity to a given test target
• kinetic perimetry is measurement of the visual
field with a moving target of fixed luminance
• Perimeters can also be classified as manual or
automated, depending on whether the stimulus is moved
by hand as in the Goldmann,
or

• If the stimulus location is changed by a computer, as in

the Humphrey visual field (HVF).
 55

Goldmann Visual Field

Goldmann Perimetry
• The patient must be able to understand the test,
maintain fixation and respond appropriately.

• Calibrate the stimulus and the background

illumination at least once a week to maintain
consistency of lighting.
• Goldmann visual field testing is preferred over
automated visual field testing for low vision
patients with central scotoma because:

1) fixation is easier to monitor

2) Also due to difficulties with fixation, an examiner
is able to map the size and shape of the central
scotoma.
The size and shape of the central scotoma helps
in:
• Guide the patient and examiner during eccentric
viewing training in locating a preferred retinal
locus (PRL).
Tangent screen test
• Tangent at 1m

Black felt screen with a pattern of radians and circles

sewn in black.

Tangent screen perimetry evaluates the central 30

degrees field at 1m.

The test is done on each eye separately.

The patient is instructed to maintain gaze on the white

button in the center of the screen.
 62

Tangent Screen Visual Fields

Humphrey's VF test
• Humphrey’s visual fields testing

Measures the entire area of peripheral vision that

can be seen while the eye is focused on a central
point.

Lights of varying intensities appear in different

parts of the VF while the patient's eye is focused
on a certain spot.
• Detect signs of glaucoma-related vision loss
earlier than other tests.

• Can also be used to detect conditions within the

optic nerve of the eye, and certain neurological
conditions as well.
Humphrey’s visual fields
Amsler’s grid testing
 DISCUSSION!!
Amsler grid testing

• Illumination set up:

• Testing distance?
• Prescription required?
• Recording?
• Interpretation?
Types of scotomas that you can get
• Relative scotoma
• Often described as “misty” vision.
• Macula is working but at reduced level.
• Only lighting and magnification will be required.
• If significant, conduct eccentric viewing training.
Absolute scotoma
• Results in absence of central vision
• EV training required.

Wavy lines due to oedema

• If It disrupts reading, then EV training is necessary.

Ring scotoma
• Normal central macular functioning surrounded by
damaged area.
• EV not appropriate, rather steady eye strategy (SES)
Multiple scotomas

• Described as “patchy” vision

• Do not benefit from higher levels of magnification.
• EV and SES may be beneficial.
ECCENTRIC VIEWING (EV)
TRAINING
• Also known as Preferred retinal loci (PRL)

• What does it mean?

EV training
• Necessary before optical device could be
prescribed.

• Determine the most successful strategy

• Then incorporate devices when the EV training

makes progress.
• Eccentric viewing training for distance

• Use a relevant method to conduct training.

• Identify the most viable retina of a patient

• Emphasize the functional rather than the

damaged area of vision.

• Let the Pt describe his/her own vision and

challenges.
Patient disability types
1. Good VA in both eyes; scotoma in one or both
eyes
2. Good acuity in one eye, with scotoma; and poor
acuity or blind in the other eye.
3. Poor acuity in both eyes; scotoma in both eyes.
4. Poor acuity in one eye with scotoma; blind in
other eye.
Methods

• Face to face
• Face clock
• Amsler grid
Face to face method
• Use one eye at a time

• Ask the patient to look straight at your nose and

describe any parts of your face that are clearer or
distinct.

• This enable the examiner to identify the better

eye and the clearest area of vision to use as a
PRL.
Amsler grid
• Amsler grid with diagonal lines and a dot in the centre.

• Patient to wear a near prescription.

• Avoid using a bifocal or progressive for this training as it

will confuse the patient.

• Use the better eye

• The patient should concentrate on the centre of the grid

and describe the location of the clearest areas.
Face clock
• Draw a clock on the board with a spot at the centre,
12., 3, 6, and 9.

• The size of the clock numbers should be appropriate to

VA.

• Align patient 1m away from the board.

• Asks patient to look straight ahead and focus on the

centre of the clock.
• Asks the Pt to compare the clarity of the black spot when
viewing in the direction of the 12, 3, 6 and 9.

• Ask the Pt to move his/her head or eyes to the direction of

the 12, 3, 6 and 9 until the black circle is visible.

• Refine the best eccentric point by adding in the numbers

around the best seen number. E.g. 6 was best seen, add
5 and 7 until you get the best point.
Colour vision defects
• Distinguishing faces becomes a problem.

• Difficulty with reading or any other activity that

requires fine vision.

• Increased need for illumination, sensitivity to

glare, decreased night vision or poor colour
sensitivity.
 84

Color Vision Testing

Colour vision testing
• Methods of testing available and why and when is a
particular test indicated?

• Procedure?

• Management?
D-15 record sheet
 87

Ocular health Assessment

Selection of an appropriate device

Selection is based on:

Age of the patient

Physical status
Preference
VA of the patient
Ability to use the device effectively
The cost of the device etc.
General guidelines for the training

1. Motivation
2. Explanation
3. Demonstration
4. Practice
5. Transfer