VISUAL ACUITY

At the end of this lecture, students should be able to

✓ List the different measures of visual acuity
✓ Outline the process of measuring visual acuity at various distances
✓ Describe alternatives for measuring visual acuity
✓ Appropriately record their findings

Introduction
Since we have obtained enough data from case history, we want to move on to the part marked 3 on the
case note – Visual acuity. We start off by assessing the visual function both at far and for near for the
individual.

Tip: Always keep this in mind

❖ Clinical procedure: Visual Acuity
❖ Objective: To know and record how well the patient see
❖ Instrument preparation:
❖ Patient preparation
❖ Room illumination: Bright
❖ Clinical procedure
❖ Recording
❖ Interpretation of Results

Distance visual acuity.

There are three principal measures of distance VA:
1. Unaided VA, often called vision.
2. Habitual VA, with the patient’s own spectacles.
3. Optimal VA, with the best refractive correction, i.e. after subjective refraction

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Procedure
1. Ensure the chart is at the appropriate distance and is calibrated correctly.
2. Leave the room lights on and illuminate the chart. The luminance of the chart should be between 80
and 320cd/m2. Seat the patient comfortably with an unobstructed view of the test chart. You should sit
in front and to one side of the patient in order to monitor facial expressions and reactions.
3. If you are going to measure both vision and habitual VA, measure vision first to avoid memorization.
To measure vision, ask the patient to remove any spectacles. To measure habitual visual acuity, ask the
patient to put their distance vision spectacles on.
4. Measure the visual acuity of the ‘poorer’ eye first, if a poorer eye is known from previous records or
from the case history (to avoid a patient memorizing the letters seen with the better eye and giving a
false visual acuity with the poorer eye). Otherwise, measure VA in the right eye first.
5. Explain what measurement you are about to take. This can be as simple as ‘now we shall find out
what you can see in the distance’.
6. Instruct the patient: ‘Please cover up your left/right eye with the palm of your hand/this occluder’. If
using the patient’s hand, make sure that the palm is being used as otherwise the patient may be able to
peek through their fingers. Some clinicians prefer to hold the occluder over the patient’s eye themselves
to ensure it is properly occluded.
7. Ask the patient: ‘Please read the chart from the top down to the smallest line that you can see on the
chart’.
8. Continually monitor the patient’s facial expressions and head position. Do not permit the patient to
screw their eyes up or look around the occluder or through their fingers. A hyperopic shift is common
in older patients and varifocal wearers adapt to this change by habitually raising their chin to improve
distance vision by viewing through the additional plus power in the intermediate section of the lens.
This can be seen when assessing habitual VA as these varifocal wearers will raise their chin during
measurements to improve VA. VAs should be measured through the distance portion of the lens. You
should make a mental note that these patients will likely require additional plus (or less minus) power
in their distance correction.
9. Once the patient has reached what they believe are the smallest letters they can see, they should be
pushed to determine whether they can see any more. Use prompts such as ‘Can you see any letters on
the next line?’ or ‘Have a guess. It doesn’t matter if you get any wrong’. 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.

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Ideally, you should stop pushing patients to read more if they make four or more mistakes on a line of
five letters (Carkeet, 2001).
10. If the patient cannot see the largest letters on the chart, ask them to move closer to the letter until
two or three lines can be seen (or use a printed panel chart at a reduced distance). The distance at which
this occurs should be noted. This is a more accurate assessment than determining the position that the
patient can ‘count fingers’ (Schulze Bonsel et al. 2006). If the patient cannot see the letters even at the
closest test distance, the following test sequence. Stop at the level at which the patient can accurately
respond.
a) Hand Movements (HM) @ Ycm: The patient can see a hand moving from a certain distance. Some
computerised VA tests can provide accurate measurements down to the hand movements level (Schulze-
Bonsel et al. 2006) and these should be used when available.
b) Light Projection (L proj.): The patient can report which direction light is coming from when you hold
a penlight about 50cm away. Ask the patient to point to the light and note the areas of the field in which
the patient has light perception.
c) Light Perception (LP): The patient can see the light but not where it is coming from. If they cannot
see light, the vision is recorded as no light perception or NLP.
11. Record Vision/VA.
12. Repeat measurements for the other eye and binocularly.

ALTERNATIVE PROCEDURES TO ASSESS VA IN CHILDREN

Amblyopia can be missed if single letters are used rather than a letter chart because of the lack of contour
interaction. Ideally logMAR-based charts with contour bars at the end of lines, such as the logMAR
crowded charts (McGraw & Winn 1993) should be used when measuring VA in children. The logMAR
crowded charts have been shown to be over three times more sensitive to inter-ocular differences in VA
than single letter Snellen charts and therefore substantially more sensitive to amblyopic changes
(McGraw et al. 2000). Crowded and standard LogMAR charts can even be used in children who do not
know their letters by providing them with a key card that includes a selection of the letters from the
chart. You then point to a letter on the chart and ask the child to identify the letter on their key card. For
children who are unable to use a key card, charts are now available in logMAR format that include
pictures rather than letters, such as the Kay crowded picture test, which has been shown to provide
comparable results to the logMAR crowded charts (Jones et al. 2003).
For children between the ages of about 3 and 6 years who cannot recognize enough letters to make the
use of a standard letter chart possible, tumbling Es can be used.

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The child is given a wooden or plastic letter E and instructed to point the “legs” of the E in the same
direction as those of the E on the chart. However, a child in this age group may not have developed the
concept of laterality and, therefore, may not be capable of pointing the wooden or plastic E in the
correct direction. Most children in this age group respond well if asked to state whether the legs of the
E point ‘up, down, towards the window or towards the door’ (or whatever objects are located to the
right or left of the acuity chart). An alternative to the tumbling E chart is the Landolt C chart.
For Pre-school child who fails to respond to the tumbling E chart or the Landolt C chart, various picture
charts are available. The Allen Preschool Vision test consists of a set of seven carts, each containing a
single picture, for use with children 2 years of age and older. The child is first shown the cards at close
range, with both eye open, and is asked to name each picture. One eye is then occluded, and the examiner
shuffles the cards and presents them individually at increasing distance. VA is recorded in terms of the
maximum distance at which one or more pictures are correctly named.

RECORDING
Acuity is recorded in terms of the smallest complete line of letters identified (e.g, 6/6 or 20/20), in terms
of number of letters not identified in the line of question (6/6 -2, or 20/20 -2) or the number of letters
identified in addition to those in the line in question (6/6 +3, or 20/20 +3).

NEAR VISUAL ACUITY

Most reading charts are truncated as the smallest print sizes are equivalent to distance VAs of about 6/9
(N5) and 20/20 (0.4M) when used at 40cm. There are three principal measures of near vision adequacy:
1. Unaided near VA or near vision.
2. Habitual near VA, with the patient’s own spectacles.
3. Optimal near VA, with the best refractive correction.

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Procedure

1. Sit in front and to one side of the patient in order to monitor facial expressions and reactions.

2. Keep the room lights on. DO NOT routinely use additional lighting. Although this is commonly
advocated in textbooks, you want to measure the patient’s habitual near VA and patients often read
without an additional angle poise or goose-neck light. Higher illumination can also increase the depth
of focus and artificially increase near VA in presbyopic patients. It is better to restrict the use of
additional lighting to patients who indicate that they commonly use such lighting when performing near
tasks and any patient who cannot easily read N5 (or 0.4M) in their optimal near refractive correction
without additional lighting. These latter patients must be encouraged to obtain additional light for near
tasks in their home.

3. Instruct the patient to place the near vision card at their normal near working distance. Measure and
record this distance (the Mallett near unit has a useful measuring device for this purpose).

4. Measure the near VA of the ‘poorer’ eye first, if a poorer eye is known from previous records or from
the case history. Otherwise, measure the right eye first. Use an occluder or the patient’s palm of their
hand to cover the other eye. If using the patient’s hand, make sure that the palm is being used as
otherwise the patient may be able to peek through their fingers.

5. Explain to the patient what measurement you are about to take. This may be a simple ‘Now we shall
find out what you can see at close distances’.

6. Instruct the patient to read the smallest paragraph they can.

7. Unless the patient can see the smallest print, push them to determine whether they can see any more.
Prompts such as ‘Try and make out some of the words on the smaller paragraph’ may be useful. 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 therefore obtain different near VA results depending on
how cautious your patient is.

8. Repeat measurements for the left eye and binocularly.

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RECORDING

Note the working distance and then record the smallest paragraph size seen by the right and left eyes
and binocularly.

Examples: Near vision @ 40cm OD: N14,

OS: N12

OU: N12

INTERPRETATION:

What does your result indicate? What are the possible refractive anomalies that can be inferred from the
results?

Read up - Visual acuity with pin hole, slit disc

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