VISUAL ACUITY (VA)

Measure of the ability of the eye to discriminate between two points. The normal limit for
the angle of resolution for the adult eye is one minute of arc (1’) = 1/60 of a degree.
VA is a function of the macular area of the retina – NB central fovea.

Distance Vision:
Snellen chart:
- Series of letters, each subtending an arc of 5 minutes at a specific distance; the
thickness of each part of a letter subtends an arc of 1 minute (1/60 of a degree).
- Top letter subtends this angle at 60m.
- Lowest line letters subtend this angle at 5m.
- Test usually performed at 6m.
Practical applications of testing with a Snellen chart:
- Test at 6m, usually with the subject’s refractive error corrected, i.e. using their
‘distance glasses’ if required, not ‘reading glasses’ (refractive error: where rays
of light from a distant target cannot be focused on the retina without a lens).
- Each eye should be tested individually (in certain cases it may be useful to
measure VA with both eyes open - e.g. very low vision, uncooperative child,
presence of nystagmus, testing for the driving licence standard).
- VA usually recorded as a numerator and a denominator, where the numerator is
the distance from the Snellen chart (usually ‘6’), and the denominator
corresponds with the lowest line the subject was able to read (this number
corresponds with the furthest distance that an individual with ‘normal’ VA
should be able to read the same line).
- For example, a VA of 6/24 means that a subject was able to read down to a line
at 6m that an individual with ‘normal’ VA could read at 24m.
- 6/6 is therefore considered ’normal’ VA.
Testing VA – challenging scenarios:
- Record any letters missed on the lowest line that was achieved by using a
superscript – e.g. 6/18-1 means the subject read down to the 6/18 line, but missed
1 letter on that line.
 - If the subject is unable to read the top line at 6m (usually implying VA of less
than 6/60), then test at a progressively closer distance until the top line is read
(i.e. 5, 4, 3, 2, then 1m – for example, if the top letter of the chart was only read
at 3m, this VA would be recorded as ‘3/60’).
- If VA is worse than 1/60 (i.e. can’t see the top letter from 1m, then test counting
fingers (CF).
- If worse than CF, test hand movements (HM).
- If worse than HM, test perception to light (PL).
- If unable to see light – record VA as ‘no perception to light’ (NPL).
- If VA was less than 6/6, check again using a pinhole (pinhole testing allows
only the passage of rays of light parallel and close to the visual axis, avoiding
refraction, and can be used as an estimate of corrected visual acuity, e.g. when
subject has forgotten their glasses, or their current glasses prescription is no
longer sufficient).

Important VA limits (ROI 2020):

- RSA guidelines on the minimum vision standards for a driving licence: a
binocular visual acuity, with corrective lenses if necessary, of at least 6/12 when
using both eyes together; the horizontal visual field should be at least 120
degrees, the extension should be at least 50 degrees left and right and 20 degrees
up and down; no defects should be present within a radius of the central 20
degrees.
- Blindness is defined as having a VA of 6/60 or less in the better seeing eye
and/or a visual field restricted to 20 degrees or less.

LogMAR Chart:
See https://en.wikipedia.org/wiki/LogMAR_chart
- LogMAR is an acronym for ‘Logarithm of the Minimum Angle of Resolution’.
- As the name suggests, there is a logarithmic change in letter size with each line
on the chart.
- This results in a doubling of the visual angle every 3 lines on the chart.
 - There are 5 letters per line, with each letter having a score value of 0.02 log
units; thus the total score of each line is 0.1 log units.
- Snellen acuity of 6/6 = 0.00 LogMAR; 6/60 = 1.00 LogMAR.
- Bailey-Lovie charts are a type of LogMAR chart that can check visual acuity at
normal and low contrasts.
- Practical applications include:
o Testing subjects with age-related macular degeneration (AMD) or other
causes of poorer levels of vision where there are more opportunities to
see any of the 5 letters on a particular line than would be possible with
traditional Snellen charts.
o Linear crowded logMAR VA test for children to better assess for
amblyopia*.
o Testing subjects involved in scientific research where mean VA
outcomes are easier to determine using logMAR values rather than
Snellen acuities.
*Ambylopia = impaired or dim vision without obvious defect or change in the
eye which arises in childhood, usually due to a refractive error or presence of
squint; treatment is with glasses prescription as appropriate and periods of
patching the stronger eye to encourage use of the amblyopic one (usually only
effective up to around 8 years of age).

Near Vision:
- Print to be read at 30cm from subject.
- Presbyopic patients must wear reading glasses if they have them.

Colour Vision:
 Red desaturation a quick and sensitive test of optic nerve function - useful in
unilateral disease, e.g. optic neuritis (note: bitemporal red desaturation can be seen
in cases of pituitary tumours).
 Ishihara pseudo-isochromatic plate test good for red-green confusion, tested at 2/3m
under good illumination for 4 seconds (requires VA of at least 6/18).
  Drugs affecting colour vision: digoxin, ethambutol, chloroquine, thioridazine.

Vision Testing in Pre-Verbal Children:

- Fixes & follows (best method for neonates) – use light source or human face
(NB – test in silence!).
- Optokinetic nystagmus (OKN) drum – baby should follow moving stripe, then
refixate on next stripe.
- Rotation (‘spinning baby’) test where vestibular nystagmus is induced and
should cease when rotation stops if vision normal (prolonged nystagmus if
vision poor).
- ‘Hundreds and thousands’ sweet test (sees object at 33cm, VA at least 6/24,
useful for infants over age of 9 months).
- Stycar rolling balls – white polystyrene balls of differing size rolled on a dark
background while observing child’s reactions.
- Preferential looking tests have grating patterns of variable thickness in one area,
whilst the other area is plain – check to see if child’s eyes moves towards where
the patterns are:
o Teller acuity cards (can be used in newborns)
o Lea paddles (used to test infants, e.g. from 10-30 weeks)
o Cardiff acuity cards (for use in children, e.g. from 6-30 months)

Vision Testing in Verbal Children:

Age 2-3 years: Kay single picture tests.
Age 3-4 years: Sheridan-Gardiner test:
- Card with seven letters held close to child within a distance they can point to.
- Book containing single letter on each page shown at distance of 6m
(corresponding in size to Snellen letters).
- Child is encouraged to point to which of the seven letters match the one being
shown in the book by the examiner.
Age 4-5 years+: Snellen chart (depending on the ability of the child).
Painful Loss of Vision:
Iritis
Keratitis (e.g. herpes simplex keratitis)
Corneal ulcer
Endophthalmitis
Acute angle closure glaucoma
Rubeotic glaucoma
Trauma

Sudden Painless Loss of Vision:

Central retinal vein occlusion (CRVO)
Central retinal artery occlusion (CRAO)
Vitreous haemorrhage
Retinal detachment (RD)
Optic/retrobulbar neuritis (painless, but can be associated with pain on eye movement)
Anterior ischaemic optic neuropathy (AION) - arteritic (i.e. GCA) vs non-arteritic
Choroiditis
Homonymous hemianopia

Gradual Loss of Vision:

Refractive errors
Cataract
Macular degeneration
Glaucoma (open angle)
Diabetic retinopathy
Retinitis pigmentosa
Choroidal malignant melanoma
Optic nerve/chiasmal disease

Transient Loss of Vision:

Migraine
Subacute angle closure glaucoma
Temporary vascular occlusion - amaurosis fugax
Papilloedema – visual obscurations worse on waking
Giant cell arteritis (GCA)

Causes of Blindness in the Developed World:

Age-related macular degeneration
Diabetic retinopathy (leading cause in younger age group)
Glaucoma
Myopic/retinal degeneration
Trauma
Congenital abnormalities

Causes of Blindness in the Developing World:

Trachoma - most important single cause of preventable blindness
Xerophthalmia - vitamin A deficiency, night blindness, conj./corneal xerosis, keratomalacia
Onchocerciasis - 'river blindness', caused by the parasitic worm Onchocerca volvulus
transmitted through the bites of the black fly (Simulium damnosum)
Cataract
Glaucoma

Method of Vision Assessment:

see http://webeye.ophth.uiowa.edu/eyeforum/video/Refraction/Visual-Acuity-
Testing/index.htm

Introduction/explanation to patient
Establishes if the patient has glasses
Accurately tests and records distance vision (with glasses if applicable),
adequately occluding each eye in turn
Tests with pinhole if distance VA not 6/6 or better
Present VA findings: e.g. ‘visual acuity was 6/12 in the right eye with
glasses, improving to 6/9 with pinhole, while the left was 6/9 with
glasses, no improvement with pinhole’
Accurately tests and records near vision (with reading glasses if
applicable), adequately occluding each eye in turn
Accurately tests and records colour vision (with reading glasses if
applicable), adequately occluding each eye in turn