Potential Acuity Pinhole

A Simple Method to Measure Potential Visual Acuity in

Patients with Cataracts, Comparison to Potential
Acuity Meter
Samir A. Melki, MD, PhD,1 Ammar Safar, MD,1 John Martin, MD,1 Anastasia Ivanova, PhD,2 Marwa Adi, MD1

Objective: To describe the potential acuity pinhole (PAP) test and compare its accuracy to the potential
acuity meter (PAM) in predicting visual outcome after cataract surgery.
Study Design: Prospective case series.
Participants: A total of 56 preoperative patients with cataracts participated.
Main Outcome Measures: Accuracy of predicting postoperative distance visual acuity was measured.
Methods: Lines of inaccuracy were calculated by subtracting actual postoperative best-corrected distance
visual acuity (BCVA) from predicted values. Variables analyzed were method of prediction, preoperative BCVA,
and preoperative spherical equivalent.
Results: The PAP test predicted visual outcomes within 2 lines in 100%, 100%, and 56% of eyes with
preoperative BCVA of 20/50 and better (group I), 20/60 to 20/100 (group II), and 20/200 and worse (group III),
respectively. The PAM predictions within 2 lines for the same groups were 42%, 47%, and 0%, respectively.
Mean lines of inaccuracy of PAP predictions were 0.83, 1.11, and 3.50 lines for groups I, II, and III, respectively.
Mean lines of inaccuracy for PAM predictions were 2.50, 2.68, and 6.22 lines for the same groups. Differences
in lines of prediction between PAM and PAP were 1.67 (P ⫽ 0.004), 1.58 (P ⫽ 0.0002), and 2.72 lines (P ⫽ 0.0001)
for groups I, II, and III, respectively. There was no statistically significant correlation between PAP predictions and
preoperative myopic spherical equivalent.
Conclusions: The PAP test is a simple, inexpensive, and relatively reliable method to estimate visual
outcome after uncomplicated cataract surgery in eyes with no coexisting disease. It is less accurate in patients
with preoperative BCVA worse than 20/200. It appears to be more predictive than PAM.
Ophthalmology 1999;106:1262–1267

It is of great importance to predict postoperative visual acuity
in patients with cataracts before proceeding with cataract sur-
gery. Early methods of gross recognition using entopic phe-
nomena did not have the sensitivity to distinguish between
relative degrees of impairment. More sophisticated instruments
were recently developed. The one used most often is the
potential acuity meter (PAM) by Minkowski et al.1
The pinhole aperture increases the eye’s depth of focus
by decreasing the size of blur circles of unfocused light
Originally received: September 24, 1998.
Revision accepted: March 22, 1999. Manuscript no. 98584.
1
Center for Sight, Georgetown University Medical Center, Washington,
DC.
2
Department of Epidemiology and Biostatistics, Case Western Reserve
University, Cleveland, Ohio.
Presented in part at the American Academy of Ophthalmology annual
meeting, New Orleans, Louisiana, November 1998.
The authors have no proprietary interests in any material mentioned in this
article.
Address correspondence to Samir A. Melki, MD, PhD, Cornea and Refractive
Surgery Service, Massachusetts Eye & Ear Infirmary, Harvard Medical
School, 243 Charles Street, Boston, MA 02114. E-mail: melki@rcn.com.
pencils overlapping as they strike the retina.2 It is also
thought to decrease the light-scattering effect of lenticular
opacities. The major limitation of pinhole acuity testing is
the diminished retinal illumination associated with its use.3
Hofeldt and Weiss4 and McIntyre5 described pinhole tech-
niques using enhanced illumination to measure potential
acuity in patients before cataract extraction4,5 or neody-
mium (Nd):YAG capsulotomy.6 In this report, we describe
a simple method to measure potential visual acuity in pa-
tients with cataract using a pinhole occluder, a near reading
card, and a Finoff transilluminator (muscle light). We call
this method the potential acuity pinhole (PAP). In a pro-
spective study, we compare this method’s accuracy to the
PAM in patients with various amounts of visual impairment
due to cataracts.
Subjects and Methods
Fifty-six patients undergoing cataract surgery who met entry cri-
teria were included in the study. They were sporadically selected
over a 6-month period at three different hospitals (Fairfax Hospi-
tal, VA; Andrews Air Force Base, MD; The Veterans Adminis-

1262
 Melki et al 䡠 Potential Acuity Pinhole
Figure 1. The potential acuity pinhole test. The near reading card— held
at 14 in from the eye—is closely illuminated line by line with a Finoff
transilluminator. Larger numbers are illuminated first to acquaint the
patient with the test.
tration Medical Center, Washington, DC). A complete ocular
examination was performed before and after cataract surgery. This
included best-corrected distance visual acuity (BCVA), slit-lamp
evaluation, applanation tonometry, and funduscopy. The BCVA in
the text refers to the best-obtained distance vision with manifest
refraction on the last examination before cataract extraction or in
the 8 weeks after the surgery as indicated. In three patients, both
eyes were included in the analysis as independent data, assuming
that possible correlation does not affect the results. No Institutional
Review Board was required for the current study.
Inclusion criteria were patients undergoing manual extracapsu-
lar cataract extraction or by phacoemulsification with intraocular
lens implantation, preoperative BCVA of 20/40 or less, and no
coexisting ocular disease. Exclusion criteria were inability to have
either PAM or PAP performed (patient unable/machine not avail-
able), intraoperative or postoperative complications resulting in
BCVA less than 20/30 in the 8-week postoperative period (to
minimize falsely good predictions resulting from suboptimal vi-
sual outcome), and failure to follow-up in the 8 weeks after
surgery.
Potential Visual Acuity Testing
Both PAM and PAP were performed in a random sequence in each
patient at the last visit before cataract extraction. Pupillary dilation
was achieved with 2.5% phenylephrine and 0.5% Mydriacyl (Al-
con, Ft. Worth, TX). Potential acuity was tested either before
funduscopy or at least 20 minutes afterward to avoid influence of
photoreceptor pigment bleach. The PAM test was performed as
described previously.1 In cases in which difficulties were experi-
enced with testing, a second observer was asked to perform the test
independently and the better-obtained acuity was noted. For both
tests, credit was given for a line if the majority of letters was
correctly identified. The decision to proceed with the surgery was
based on a general clinical assessment independent of potential
acuity results.
Potential Acuity Pinhole Test
After pupillary dilation, the examination room was illuminated.
The patient was given a multiperforated pinhole ocular occluder
(1.0-mm aperture) and a Rosenbaum pocket vision screener to hold
at a distance of 14 in from each other. This ensured against
magnification and overestimation since the near card used was
calibrated at that specific distance. The same near card (Graham–
Field Surgical Co., Inc., Hauppauge, NY) was used by all exam-
iners at all times to prevent disparity related to existing variability
in optotype size in commercially available near cards.7 A Finoff
transilluminator (referred to as ‘muscle light’ in the text) was used
to closely illuminate individual lines on the near card (Fig 1).
Larger optotypes were illuminated first. As the patient correctly
recognized the numbers on the near card, the light was progres-
sively moved to smaller optotypes.
Data Analysis
The Snellen chart was used to measure preoperative and post-
operative BCVA. The various levels of visual acuity are not
equally represented on the Snellen chart, the Rosenbaum near
card, or the PAM panel. For example, the near card used was
different from the Snellen chart since the 20/60 and 20/80 lines
are not noted. Similarly, the 20/300 line on the PAM panel is
not present on the Snellen charts. The data were always calcu-
lated to favor the larger difference between predicted and actual
postoperative visual acuity.
To assess the efficiency of the two methods according to
preoperative vision, the data were divided into three groups of
preoperative BCVA: 20/50 and better (group I), between 20/60 and
20/100 (group II), and 20/200 or worse (group III). The distribu-
tion of eyes according to preoperative BCVA is listed in Table 1.
To quantify the quality of prediction for each method, lines of
inaccuracy were calculated in the following manner: Lines of
inaccuracy ⫽ Postoperative BCVA ⫺ Predicted postoperative
BCVA (absolute lines of inaccuracy, refer to the above definition
regardless of overestimation or underestimation).
Accuracy Comparison. The absolute lines of inaccuracy for
each method were compared for each of the three groups of eyes.
The t test analysis for paired data was performed to calculate
whether the difference between predictions varied significantly
from zero. The null hypothesis of no difference between absolute
predictions by PAM and PAP was tested against a two-sided
Table 1. Lines of Vision Used to Calculate Difference in
Preoperative Best-corrected Visual Acuity (BCVA), Predicted
Postoperative BCVA, and Actual Postoperative BCVA*
Preoperative BCVA No. of Eyes
20/20 N/A
20/25 N/A
20/30 N/A
Group I 20/40 3
20/50 9
20/60 9
Group II 20/70 3
20/80 5
20/100 2
20/200 8
20/400 4
Group III 20/800 0
CF 6
HM 0
LP 0
N/A ⫽ not applicable; CF ⫽ count fingers; LP ⫽ light perception.
*Eyes meeting inclusion criteria were divided in three groups according to
preoperative BCVA: Group I (20/50 and better), Group II (20/60 –20/
100), and Group III (20/200 and worse).
1263
 Ophthalmology Volume 106, Number 7, July 1999
Table 2. Patient Characteristics
No. of patients (eyes) 46 (49)
% female 28
Age (yrs)
Mean ⫾ SD 65 ⫾ 11
Range 33–86
alternative.
Correlation with Preoperative Spherical Equivalent for Po-
tential Acuity Pinhole. A correlation analysis was performed for
all eyes tested with PAP to investigate whether the magnitude of
uncorrected refractive error influences the quality of prediction.
Preoperative spherical equivalents were calculated and divided in
the following groups: low myopia, ⫺0.25 to ⫺1.50; high myopia,
⫺3.0 and above; low hyperopia, ⫹0.25 to ⫹1.50; and high hy-
peropia, ⫹3.0 and above. Lines of inaccuracy were calculated and
compared for each of the above groups.
Results
Patient Characteristics
Fifty-six patients (60 eyes) were initially entered in the study. Four
eyes were excluded because of intraoperative or postoperative
complications resulting in less than 20/30 BCVA in the 8-week
period after surgery. Seven eyes did not have PAM measurements
and were therefore excluded (four patients could not perform the
test and the machine was unavailable for the other three patients).
The demographic characteristics of the remaining 46 patients (49
eyes) are listed in Table 2. The mean patient age was 65 years
(range, 33– 86 years). All eyes were divided into three groups as
described above. Group I (20/50 or better) included 12 patients
(25%) compared to 19 patients (39%) and 18 patients (37%) for
each of groups II and III, respectively (Tables 1, 3). Preoperative
BCVA ranged from 20/40 to counting fingers as shown in the
distribution in Table 1.
Prediction of Postoperative Best-corrected Visual
Acuity for All Patients
Table 3 shows that PAM was correct in 5 (10%) of 49 eyes in
predicting within 1 line of the postoperative BCVA in all patients.
PAP was correct in 27 (55%) of 49 eyes. For prediction within 2
lines, PAM was correct in 14 (29%) of 49 eyes, and PAP was
correct in 41 (84%) of 49 eyes. Predicting postoperative visual
acuity within 3 lines was correct in 57% of eyes for PAM com-
pared to 88% for PAP (Table 3).
The average absolute inaccuracy of prediction for PAM was
3.94 lines (standard deviation [SD] ⫽ 2.47) for all eyes compared
to 1.92 lines (SD ⫽ 2.27) for PAP. The difference in absolute
predicted lines PAM–PAP ⫽ 2.02 (P ⬍ 0.0001).
Effect of Preoperative Best-corrected Visual
Acuity on Predictions
The PAP test predicted postoperative visual acuity within 2 lines in
100%, 100%, and 56% of eyes with preoperative BCVA of 20/50
and better, 20/60 to 20/100, and 20/200 and less, respectively.
Equivalent predictions for the PAM were 42%, 47%, and 0%,
respectively (Table 3). For predictions within 3 lines, PAP was
correct in 100%, 100%, and 67% of eyes in groups I, II, and III,
1264
respectively. Equivalent predictions for the PAM were 75%, 84%,
and 17%.
The mean inaccuracy of prediction for group I was 2.50 lines
(SD ⫽ 1.31) with PAM and 0.83 line (SD ⫽ 0.71) with PAP (Fig
2). The difference is 1.67 lines (P ⫽ 0.004). There were no
predictions with an inaccuracy worse than 4 lines for both tests.
For group II, mean inaccuracy was 2.68 lines (SD ⫽ 1.42) for
PAM and 1.11 lines (SD ⫽ 0.74) for PAP (Fig 2). The difference
between predictions was 1.58 lines (P ⫽ 0.0002). There were no
predictions with an inaccuracy worse than 4 lines for PAP. Only
one of the three PAM patients with prediction greater than 3 lines
of actual postoperative acuity was more than a 4-line difference.
The most inaccurate predictions were in group III (preop
BCVA 20/200 or worse). The mean inaccuracy for PAM was 6.22
lines (SD ⫽ 2.29) compared to 3.50 lines (SD ⫽ 3.07) for PAP
(Fig 2). The difference in prediction was 2.72 lines (P ⫽ 0.0001).
Fourteen of 15 eyes in group III for PAM with prediction greater
than 3 lines of actual postoperative acuity were more than a 4-line
difference compared to only 5 eyes with PAP.
Figure 3 shows the distribution of mean lines of inaccuracy as
a function of various lines of preoperative BCVA. Mean lines of
inaccuracy for PAM were below 3.0 lines until preoperative
BCVA reached the 20/200 level, which coincides with a rise
beyond the 5.0 lines inaccuracy. For PAP, the mean lines of
inaccuracy were at or below the 2.0-line threshold until preoper-
ative BCVA reached the 20/400 level corresponding to a rise
beyond the 3.0-line inaccuracy.
Overestimation. None of PAM predictions and 4 of 49 PAP
predictions overestimated postoperative BCVA. All overestimates
were within 1 line of actual postoperative BCVA. If the data are
calculated to exclude overestimates, mean lines of underestimation
by PAP would be 0.75 line for group I, 1.05 lines for group II, and
3.44 lines for group III.
Accuracy Correlation with Preoperative Spherical Equiva-
lent. The PAP predictions for eyes with spherical equivalent of
high/low myopia and hyperopia were compared using t test anal-
ysis for paired data (Table 4). The mean of absolute inaccuracy in
prediction for high and low myopia was 1.72 lines and 1.40 lines,
respectively (P ⫽ 0.72). The mean of absolute inaccuracy in
prediction for high and low hyperopia was 2.9 and 1.47 lines,
respectively (P ⫽ 0.167).
Discussion
The pinhole aperture test is routinely used in visual screen-
ing to determine potential acuity in eyes with uncorrected
refractive error for distance. It improves vision by contract-
ing the image cone and enhancing the eye’s depth of focus.
The optimal pinhole size was determined to be between 0.94
mm and 1.75 mm.3 A larger aperture diminishes the depth-
of-field-enhancing effect, and a smaller size results in loss
of resolution and blur from diffraction. The PAP test de-
scribed in the current study takes advantage of the minute
aperture to measure retinal function and subsequently de-
termines the visual prognosis in eyes undergoing cataract
extraction. Using a bright transilluminator on a near card
compensates for the reduction in illumination described
above. The enhanced illumination also supplements for the
decreased light transmission known to occur in cataracts.8
In addition, the minute pinhole aperture is possibly helpful
in diminishing the scattering effect of cataracts as well as in
allowing the patient to look through small areas relatively
 Melki et al 䡠 Potential Acuity Pinhole

Table 3. Distribution of Postoperative Distance Best-corrected Visual Acuity (BCVA) Predictions for PAM and PAP
According to Preoperative Distance BCVA

Patient Group All Patients 20/50 or Better 20/60–20/100 20/200 or Worse

No. of patients 46 12 18 16
No. of eyes (%) 49 12 (24%) 19 (39%) 18 (37%)

Method PAM PAP PAM PAP PAM PAP PAM PAP

Exact prediction 2 (4%) 9 (18%) 1 (8%) 4 (33%) 1 (5%) 4 (21%) 0 0
⫾1 line 3 (6%) 18 (37%) 2 (17%) 6 (50%) 1 (5%) 8 (42%) 0 5 (28%)
⫾2 lines 9 (18%) 14 (29%) 2 (17%) 2 (17%) 7 (37%) 7 (37%) 0 5 (28%)
⫾3 lines 14 (29%) 2 (4%) 4 (33%) 0 7 (37%) 0 3 (17%) 2 (11%)
⬎3 lines 21 (43%) 6 (12%) 3 (25%) 0 3 (16%) 0 15 (83%) 6 (33%)
Overestimation 0 4 (8%) 0 1 0 1 0 2

Overestimation was within 1 line in all cases.

free of lenticular opacities. By dilating the pupil, such area
is expanded, allowing the patient to search for the path of
best acuity.
The PAM remains the most widely used instrument to
predict postoperative acuity in patients with cataracts. The
instrument mounts on a slit lamp and projects an image of
a Snellen visual acuity chart through a light beam that
narrows to a diameter of 0.1 mm. In their original report,
Minkowski et al1 reported predictions within 2 lines of the
order of 90% for patients with preoperative visual acuity of
20/200 or better and 47% for those with less than 20/200
vision. The evaluation of the PAM by Severin and Severin9
in 210 patients showed a prediction within 2 lines in 59.7%
of the patients with preoperative acuity of 20/200 and less.
Conversely, Miller et al10 found that PAM predicted out-
comes of cataract surgery in elderly persons within 1 line in
only 26% of their patients. A similar figure of 33% was
reported by Graney et al.11 This contrasts with a finding of
92% in a study by Christenbury and McPherson.12 Simi-
larly, Asbell et al13 found poor PAM correlation with
Snellen chart letter acuity in patients with glaucoma when
PAM visual acuity readings were worse than 20/60. Be-
cause of dense cataracts, Tetz and coworkers14 were unable
to measure PAM in 17% of a series of 343 patients. Cuzzani
et al15 recently reported 100% predictions within 2 lines and
33% within 1 line for patients with preoperative acuity of
20/40. These figures dropped to 17% in eyes with preoper-
ative acuity of 20/200 or worse. The wide variation in the
above studies could be related to multiple factors. The
accuracy of PAM was shown by many investigators to be
related to the preoperative visual acuity, severity and type of
cataract, and presence of ocular comorbidity. Many of the
above studies did not correlate their results with the latter
factors, making it difficult to draw adequate comparisons.
Other variables often not controlled for were patient’s age,
socioeconomic status, and examiner’s proficiency in using
the instrument.
The data from our study better compare with studies
reporting lower accuracy for the PAM. Our PAM results
might not reflect the full potential of the instrument because
of several factors. More than one third of our patients had a
preoperative distance visual acuity of 20/200 or worse.
Many of our patients had difficulty understanding the test,
which could be related to the lower socioeconomic and
literacy status of the population studied. We also noticed
that elderly patients with poor systemic health had more
difficulty with the PAM. This was because of conditions
such as labored breathing (resulting in head movement and
constantly fleeting image) and arthritis (patients uncomfort-
able at the slit lamp, thus leading to poor concentration).
These problems were not as limiting with PAP. The latter
was found to be easier to understand and perform than PAM
by most patients studied. An added advantage was the
shorter testing time with PAP (approximately 2 minutes)
compared with that of PAM (approximately 10 minutes).

Figure 2. Mean lines of inaccuracy in predicting postoperative best-

corrected visual acuity (BCVA) for potential acuity meter and potential
acuity pinhole according to preoperative BCVA. Inaccuracy was calcu-
lated by subtracting postoperative BCVA measured by manifest refraction
from the predicted value by the two tests in the 8-week period after
cataract extraction.
Figure 3. Mean lines of inaccuracy as a function of preoperative
best-corrected visual acuity. The number of eyes in each group is listed
in Table 1.

1265
 Ophthalmology Volume 106, Number 7, July 1999
Table 4. Distribution and Mean Lines of Inaccuracy According
to Preoperative Myopic Refractive Error*
No. of Mean Lines of 95% Confidence
Eyes Inaccuracy P Interval
Low myopia 14 1.73 0.720 (⫺1.56),(2.21)
High myopia 16 1.40
* The number of eyes with hyperopia was too small to draw reliable
conclusions.
The PAP test also offers the possibility of testing poten-
tial acuity in patients who are not familiar with the Latin
alphabet.
To ensure the fullest pinhole acuity, previous investiga-
tors have devised tests similar to PAP. In eyes with precap-
sulotomy distance acuity better than 20/200, Hofeldt’s Illu-
minated Near Card (INC) with pinhole predicted
postoperative distance acuity within 1 Snellen line in 97%
of eyes.6 In his Super-Pinhole test, McIntyre used a transil-
luminated box at 5 ft viewed through a 1.5-mm pinhole. He
spoke of good results in measuring potential acuity in pa-
tients with cataracts.5 Recently, Hofeldt and Weiss4 re-
ported results on using their INC to measure potential acuity
in eyes with cataracts. The INC is a hand-held instrument
containing a brightly transilluminated vision chart that is
transported across a 7-mm by 38-mm viewing window. It
predicted distance acuity to within 2 lines in 98% and 53%
of eyes with preoperative distance acuity of 20/100 or better
and 20/200 or worse, respectively. These figures are very
similar to our results (100% and 56%). The average inac-
curacy was 1.4 and 3.7 lines for both groups for the INC
compared to 1.0 line and 3.50 lines for PAP. For both tests,
mean inaccuracy is approximately or below 2.0 lines for
patients with preoperative BCVA of 20/200 and better. The
INC has standardized letter size and lighting. This contrasts
with the variability in optotype scaling prevalent among
commercially available near reading cards.7 In addition, the
intensity of the beam of light projected from the Finoff
transilluminator gradually diminishes the further away from
the tip, which results in variable luminance across the tested
line. This is sometimes helpful as the tip can be moved
closer to the letters, thereby titrating illumination to the
patient’s response.
In contrast to Hofeldt, we used the pinhole without
corrective glasses. Preliminary studies by us had shown no
effect of refractive error on the efficacy of the test. In
theory, this allows the pinhole aperture to be closer to the
eye, which brightens the image and diminishes the restric-
tion in the field of vision.3 In addition, it helps exclude
peripheral light, which might interfere with image discern-
ment. Our data reveal poor correlation between PAP’s ef-
ficacy and different degrees of preoperative myopia. This
supports our initial impression that correcting refractive
error does not necessarily improve the quality of prediction.
Eyes with preoperative hyperopia point to a similar conclu-
sion. The smaller number of eyes in this group lends itself
to further investigation. Future studies could also verify this
conclusion by testing PAP with and without correction of
refractive error.
1266
Several sources of bias could have affected our results.
This was not a masked study, and the knowledge of preop-
erative BCVA or the general ocular status of the subject
examined could have influenced the examiners’ administra-
tion of either test. A selection bias could have magnified the
difference in accuracy between the two tests secondary to
the characteristics of the population studied as explained
above. Most of our patients had no known coexisting ocular
pathology, and PAP would have to be validated, especially
in patients with maculopathies (e.g., age-related macular
degeneration, cystoid macular edema). All examiners had
adequate experience with the PAM before the study. Nev-
ertheless, one has to account for the level of experience with
the PAM, which could have influenced our results. We did
not notice, however, a change in the quality of the PAM
data collected as the study progressed and as examiners
could have become more proficient at using the device.
In summary, our study describes a simple, inexpensive,
and easy-to-perform test to estimate potential acuity after
uncomplicated cataract extraction. It confirms previously
reported results on the usefulness of pinhole techniques at
predicting postoperative acuity in eyes with cataracts. PAP
appears to provide a high level of accuracy similar to studies
in which the best PAM results could be obtained. Further
studies should provide a better appreciation of its accuracy
in cases of cataracts with coexisting ocular disease.
Acknowledgment. The authors thank Hameed U. Peracha,
MD, for introducing them to potential acuity testing with illumi-
nated pinhole.
References
1. Minkowski JS, Palese M, Guyton DL. Potential acuity meter
using a minute aerial pinhole aperture. Ophthalmology 1983;
90:1360 – 8.
2. Azar DT, Strauss L. Principles of applied clinical optics. In:
Albert DM, Jakobiec FA, eds. Principles and Practice of
Ophthalmology: Clinical Practice. Philadelphia: Saunders,
1994; v. 5. Chap 291.
3. Lebensohn JE. The pinhole test [editorial]. Am J Ophthalmol
1950;33:1612– 4.
4. Hofeldt AJ, Weiss MJ. Illuminated near card assessment of
potential acuity in eyes with cataract. Ophthalmology 1998;
105:1531– 6.
5. Lowry J. Pinhole techniques are called reliable, easy, and
inexpensive. Ophthalmology Times 1986;11:1,31,35.
6. Hofeldt AJ. Illuminated near card assessment of potential
visual acuity. J Cataract Refract Surg 1996;22:367–71.
7. Horton JC, Jones MR. Warning on inaccurate Rosenbaum
cards for testing near vision. Surv Ophthalmol 1997;42:169 –
74.
8. Sadun AA, Libondi T. Transmission of light through cataracts.
Am J Ophthalmol 1990;110:710 –2.
9. Severin TD, Severin SL. A clinical evaluation of the potential
acuity meter in 210 cases. Ann Ophthalmol 1988;20:373–5.
10. Miller ST, Graney MJ, Elam JT, et al. Predictions of outcomes
from cataract surgery in elderly persons. Ophthalmology
1988;95:1125–9.
11. Graney MJ, Applegate WB, Miller ST, et al. A clinical index
for predicting visual acuity after cataract surgery. Am J Oph-
thalmol 1988;105:460 –5.
 Melki et al 䡠 Potential Acuity Pinhole
12. Christenbury JD, McPherson SD. Potential acuity meter for
predicting postoperative visual acuity in cataract patients [let-
ter]. Am J Ophthalmol 1985;99:365– 6.
13. Asbell PA, Chiang B, Amin A, Podos SM. Retinal acuity
evaluation with the potential acuity meter in glaucoma pa-
tients. Ophthalmology 1985;92:764 –7.
Discussion
by
David J. McIntyre, MD
Over the past 25 years, the safety of cataract treatment has been
dramatically elevated by the development of a variety of extracap-
sular surgical techniques. Simultaneously, the evolution of artifi-
cial lens implantation has spectacularly enhanced visual rehabili-
tation. Cataract surgery has thus become a truly elective procedure,
challenging us to improve our skills in both diagnosis and prog-
nosis.
This need has generated the development of several highly
technologic means to evaluate macular function, which Dr. Melki
has reviewed for us. It has also pressed us to further analyze the
ancient stenopeic hole.
The classical understanding of the pinhole (PH) was nicely
reviewed by Lebensohn 48 years ago! A great deal was said of the
PH improvement of ametropic blur, irregular refractive media, and
overall reduction of retinal light levels. But little was mentioned of
finding the clearest pathway through irregular opacities or of
minimizing the glare produced by axial opacities.
Some 15 years ago, my personal observations convinced me
that the usefulness of the PH was greatly increased by more
intensely illuminated targets at an intermediate distance and the
Address correspondence to David J. McIntyre, MD, 1920 - 116th NE,
Bellevue, WA 98004.
14. Tetz MR, Klein U, Völcker HE. Measurement of potential
visual acuity in 343 patients with cataracts. A prospective
clinical study. Ger J Ophthalmol 1992;1:403– 8.
15. Cuzzani OE, Ellant JP, Young PW, et al. Potential acuity meter
versus scanning laser ophthalmoscope to predict visual acuity in
cataract patients. J Cataract Refract Surg 1998;24:263–9.
Super Pinhole (SPH) was born. At the same time, Norman Ballin
showed that the PH was a good macular function predictor when
used at near with normal reading illumination.
Since the SPH was developed, the examination protocol for
patients with cataract at my office has included both the dilated
distance PH with standard Snellen chart and the dilated SPH.
Experience with this information has left me with two strong
clinical impressions. First, PH testing can provide a good predic-
tion of macular function except in dense cataracts. Second, there is
a group of patients with mild-to-moderate maculopathy who can
be identified by a disparity between a poor response on standard
PH and a better response to the intensely illuminated SPH.
It seems that there are two questions about the PH test that
deserve further scientific study: What is the best technique for use
of the PH in predicting macular function in the preoperative
cataract patient, and is there a technique of PH testing that can
identify modest maculopathies in preoperative patients with cata-
ract?
The PH is ancient, a model of simplicity, and has the highest
value/cost ratio of any ophthalmic instrument. I hope that Dr.
Melki will continue his studies, expanding the number of subjects,
including a group of maculopathies and, perhaps, controlling and
comparing various illumination levels. It would be a great satis-
faction to know that our clinical impressions are not only intu-
itively obvious but also true.
1267