CLV, VF Assessment 2021

Unit Three
Low vision Assessment

By Gizachew T.
clinical low vision ,2021

JAN. 2021 1
Objective of the session
At the end of this session you will be able to:
• List components of low vision assessment
• Describe the purpose of LV assessment
• Differentiate different LV charts
• Analysis and recording of Log MAR chart
• Explain near vision assessment
• List possible test objects used to assess low vision
• Refraction techniques in low vision
clinical low vision ,2021 2

Outline
• Purpose of low vision assessment
• Components of low vision assessment
• Distance and near visual acuity charts and test
• Refracting low vision patients

Components of low vision assessment
1. Case history and goal setting

2. Assessment of visual function and functional vision
3. Explore ways of achieving goals
magnifiers, providing help, counselling and rehabilitation
4.Office training, reality check and demonstration

What are the purposes of low vision
assessment?

Purpose of low vision assessment
• To know the residual vision
• To correlate residual vision with individual’s social, educational,
vocational and others needs
• To detect the level, diagnose the cause and monitor the progress of vision
loss
• To predict functional impairment and set goal of rehabilitation
• To identify ways and means to enhance visual function
• To prioritize individuals to use their residual vision to maximize potential

Low Vision Exam
• Preparation • Other VF tests, prn
• History – Fields, color, glare, adaptation,
– Goal setting binocularity, motility, perception
– Patient orientation • “Reality check” w/pt’s device
• Preliminary testing • Device evaluation
– DVA & CS
– Distance
– Rx verification
– SLE & fundus eval – Near
• Refraction – Others: esp. writing & TV watching
– for any D correction • Rehabilitation plan
– Final Rx • Ocular health testing
• Reading assessment
• Counseling
– Initial & re-test
• Coordination of cares
Observation and interview (Identification of needs)
• Non-procedural and non-organized evaluation
• Functional questions
• Overall
• Is he/she go out and travel unaidedly ?
• What component of activities are affected ?
• What the patients can do with the vision they had?
• What concerns they do had?
• Distance vision demand e.g. bus number, notice board…
• Problem with recognizing face from distance, watching television

Low vision exam….
• Review of medical records

• How long have been the problem?
• Does it progress?
• What investigation have been done
• Any drug therapy
• Surgery
• Laser
• Spectacles
• LVAs, rehabilitations
• Vocational trainings
Cont’d…
• Near visual scanning ability and needs
• Special tasks and literacy
• What does the patient read?
• What the patient wish to read?
• At what distance the patient read ?
• What difficulty does he/she has while reading?
• Other intermediates activity computer use, cooking, sewing, etc

Independent travelling ability and needs
• General mobility and independence
• How did the person travel?
• Did able to cope with traffic roads to cross?
• Any known field defect that affect mobility ?
• Any ability to detect obstacles?
• Did the Px know his/her living env’t?

Others conditions
• Light and color
• Basic daily activities/ADLs
• Occupational/educational needs
• Social considerations
• Emotional status (what feel about their vision)

Cont’d...
 Patient details, occupation, GH and meds.
 Detailed visual history
• As per LVA clinic record card/format

• Diagnosis if known
• Onset
- sudden, gradual
• Duration
-recent, longstanding
• Hospital visits, any previous treatment
• Registration (sight impaired / severely sight impaired), when?
Managing patients’ expectations/setting goals
• “I just want some stronger glasses”
• There’s no point to do this
• Nothing could be done
• Manage the Px’s
– Denial – Depression
– Grief – Acceptance
– Anger – Rejection
We have to
• empathise
• discuss, demonstrate
• repeat information as necessary
• involve relative/care givers
• be positive and realistic
Common goals
• Reading
 Survival
e.g. bills, post, medication labels, food packets
 Leisure
e.g. books, newspapers, magazines
• Watching Tv
• Walking
• Watching games

Other needs /special requirements
• Typing • Sorting money

• Newsprint • Menus
• Phonebooks • Receipts
• Books • Directions
• Large print books • Labels
• Mail • Price & clothing tags
• Bills • Forms
• Bank statements • Unique items
• Computer monitor • Handwritings

Goals of COLV Care and Rehabilitation (AOA Guidelines )
• Eval. functional status of eyes/visual system
• Assess ocular/systemic status as relates to vision
functioning
• Provide optometric interventions to improve visual functioning
• Counsel patients regarding to all the visual/ocular status,

recommendations.
• Refer for services outside one’s area of expertise

Case history and goal setting: summary
• Summarise main goals
• Check goals with the person: do we all agree?

• How motivated the person is?
• Outline the rest of assessment plan to the patient

Visual Function Assessment
 Visual acuity
 Distance
 Intermediate Visual Bhr. and adaptation
 near
• Pinhole assessment
• Visual field assessment
• Contrast sensitivity
• Colour vision
• Refraction
• Additional tests
• Prescription and final decision
clinical low vision 19
,2021
Importance of accurate VA testing in LV
• Indicator of degree of impairment
• Deciding educational possibilities
• Starting point for determining magnification required
• Monitor the effect, progression or treatment of disease
• To verify a persons eligibility for tasks and legal accontablity
• Clue of productivity loss and means of compensation

Assessing visual function
 Distance visual acuity
• Monocular and binocular
• With habitual correction
• Unaided- common sense(may not work)
• Maintain adapted position
• Halberg clips are useful
• Use standard chart
e.g logMAR

Purposes of VA in Low Vision Care
• Refraction:
– baseline for considering changes
– useful in predicting staring power, but sometimes less
sensitive in low vision
• relationship between VA and dioptric blur not simple or well-
understood for visually impaired
• Evaluating performance with low vision devices:
– gives a baseline
– reveals whether proposed devices can help

Purpose…..cont’d
• Ocular status:
– stable? progressing? remitting?
• Describing/understanding visual capabilities:
– to educate patient, family, teachers, etc.
• Classification/eligibility:
– benefits, privileges, services, compensation

What is Different about Acuity Testing in Low Vision Care?
• Chart selection and procedures often must be adapted. Why?

– Bigger letters
– Results more sensitive to stimulus conditions
e.g. crowding, lighting, and contrast
– Results are more sensitive to patient behavior
e.g. eccentric viewing, head positioning, and guessing
– Interpretation of VA scores more complex

VA chart options (For Distance)
• Snellen acuity chart
• Projected-o-Chart
• Electronic chart:
• Fein bloom
• Log MAR Chart
• Bailey Lovie
• ETDRS

,2021 25
Key Features of a Good VA Chart for LVC
• Letter sizes
• wide range of letter sizes
• Multiple letters of each size( adequate number per row)
• Same number of letters per row
• Letter size progression down the chart

• Reasonable in magnitude
• Uniform in magnitude

Key feature cont’d…
• Spacing
• Proportional between letters
• Proportional between rows
• Equal letter legibility
• Moveable

1. Projected-O- Chart (POC)

Cont.…
• All letters and symbols are embedded in a single remote control
• Had letters, numbers and symbols
• Had targets and test units for refraction and binocularity
• Projected on a wall/curtain with a good contrast
• Can be used at the intended distance

Problems of POC for LVC
• Limited sampling with large letters
• Large steps in size progression at the top
– 400, 300, 200, 100
• Non-uniform size progression
– 400, 300, 200, 100, 80, 70, 60, 50, 40, 30, 25, 20, 15
– subsequent lines smaller by as much as 50% and as little as 12.5%
• Non-uniform spacing among adjacent letters
• Letters not equally legible eg. “L” vs “G”
• Hard to use at alternate test distances
2. Fein bloom Acuity Chart
• Spiral-bound booklet
• AKA SVOSH chart
• 13 pages (original)
• 700 ft letter to 10 ft letter and the latest version has metric value

Cont.…
Advantages: Disadvantages:
• Non-uniform size progression
• good for very poor vision
• Non-uniform spacing
 largest number is 700 foot size
• Non-uniform legibility
• Can boost pt confidence  ‘7’ is not as difficult as ‘8’
• “Look how many pages you were able to read!”
• Handling is awkward
• Can transfer to other chart if pt sees surprisingly well
• Can easily change test distance
• Arabic numerals widely recognized
• Even by those not familiar with alphabets

3. Electronic charts
• Are electronic based Software charts
• Targets and standards can be updated
• Mainly functional on the Canela’s software
e.g Canela's 2020 Vision Acuity Testing System
• It can be
• Snellen mode
• ETDRS mode

4. LogMAR chart
• Difference b/n snellen and logMAR acuity charts????

LogMAR chart….cont’d
Advantages compared with Snellen
• 5 letters on each row
• Plenty of large letters
• Equal VA steps
• ‘Crowding’ same whatever VA
• Can score individual letters (esp. research)
• Can be used at different distances
• Psychologically better
clinical low
low3v5ision
vision ,2021
,2018 35
Log MAR chart
Photograph courtesy of National Eye

clinical low
low3v6ision
vision ,2021
,2018
Institute, National Institutes of Health 36
Standard marks and Recording
• Letter sizes: (marked at left side)

• in meters
• in feet (marked in parenthesis)
• Can use either feet or meters
• LogMAR score (marked at right side)
• Assumes the chart as at 20 feet

A) Bailey- Lovie Chart
• First comprehensive chart attempt to correct
problems with charts for low vision.
• Developed by Ian Bailey and Lovie- Kitchin

(1976)
• A translucent chart with 10% contrast of at the
back)
• Uses British Standard of 10 non- serif letters
(DEFHNPRUVZ
• Designed on a 5 × 4 grid
Letters are 5x4

Bailey- Lovie Chart Design : Advantages
• 5 letters at and each letter has same meaning at all
levels
• Letters of approximately equal legibility
• Non- serif Vs san serif
• Proportional spacing between letters:

• 1 letter width between letters:
• 1 letter height(letter height in the lowest line)
• Suitable for various viewing distances

Letter size progression :
• Geometric (logarithmic) progression
• A three line improvement is a 50% change in denominator /halved (e.g. 20/200
to 20/100)
• A three line worsening is a 100% change denominator doubled (e.g. 20/100 to

20/200)
• Going down the chart
 20% smaller than line above
• Going up the chart
 25% larger than line below

Cont’d :Recording
• At half the distance, expect three lines improvement
Add 0.3 (3 lines) if the chart is moved by half
• At twice the distance, expect three lines worse
 Substract 0.3 (3 lines) if the distance is doubled
• As going down the chart, each line is 0.1 log unit smaller than line
above
• (1.2589)x larger than the lower row(same unit)

B) ETDRS Chart/ Lighthouse or Ferris Bailey Chart
• Designed for clinical research
• Bailey- Lovie principles
• Uses 10 non-serif Sloan letters
• Relative with equal legibility (CDHKNORSVZ)
• designed on a 5 × 5 grid scale
• Uses standardized back illumination
•Translucent charts can also be wall-mounted,
but not hand-held
• Also available with Landolt rings, numbers,
LEA symbols, HOTV, low contrast letters, etc.

Cont.….
ETDRS Procedures
• Test at any known metric distance

• Most common practical choice = 2 meters
• Second most common choice = 1 meter
• Use if pt can’t get at least two rows at 2 meter
• NB: never uses the feet scale
• under-estimates acuity by about 2 lines

Recording visual acuity in LogMAR
• Record VA in each eye separately
• If patient reads 5 letters in a row, record LogMAR unit on the

right of the chart
• Each letter on the chart contribute 0.02log unit
• If Px read 4 letters only in a row, then add 0.02 to LogMAR

unit to the right of the chart

Cont.….
• Stopping rules
– stop if >3 errors on a row.
– continue if <2 errors on a row.
• Consider the “errors” & “extras” letters read
–give one line credit for each 5 net “extras”
– credit for each “extra” letter or each “error”as 1/5th of the line

Example 1
1. Patient can read 3 letters in a row of 0.9 unit log MAR at 4 meter,
then visual acuity of the patient is………….
2. Another patient reads 3 letters in a row of 0.7 unit Log MAR at 2
meter, then visual acuity of this patient is…………….
3. If a patient reads 2 letters in a row of 0.4 unit Log MAR at 0.5
meter, then visual acuity of this patient is………..

Answers
1. 0.9 + 0.04= 0.94

2. @2m=0.7 + 0.04=0.74 and then 0.74 +0.3= 1.04
3. 0.4+0.06= 0.46 then @0.5 m= 0.46+0.3+0.3+0.3=1.36

VA assessment-pin hole
• Vision usually not improved and may mislead
• Improve vision => refractive error
• No improvement => amblyopia/pathology
• Decrease vision=>central media opacity
• Multiple pin hole may be used

Near visual acuity
Letter acuity Vs Word Acuity
Lovie-Kitchin and Ian Bailey (1981)
• Individuals letter acuity often much
better than word for low vision pts
• both near VA and reading rate • 16 AMD patients: have diff. avg.
should be assessed under good NVA with diff. test charts
illumination • 20/80 gratings
• This should always be tested at • 20/115 single letter
standard distance (40cm) • 20/190 letters
• If the patient habitually performs • 20/400 word reading
near tasks at other distances, it is
valuable to assess acuity at these
distances

NVA…
• In low vision, do not bother in measuring a near letter (or word)
acuity as part of initial examination
• Do it only as crude screening
• Instead, refract and then measure reading performance

Problems with near acuity charts
• Historically, similar issues as with distance acuity charts.
• Insufficiently large print
• Non-standard spacing and sizes
• Also, big problems w/ near acuity designs
• Reduced Snellen
• Jaeger
• Assisting the reading tasks is the most common request from low
vision patients
• Record both print size (using either M units or point size) and
viewing distance is very important

During near vision assessment
• Use appropriate vision charts
• Use single character visual acuity charts
• Evaluate word recognition abilities
• Measure with continuous text visual acuity
• Select appropriate testing distances
• Use M system along with metric testing distance for

recording VA
• Assess the effects of illumination

Charts Used for Near Vision Assessment
 Reduced Snellen chart
 M-notation
 Log MAR
 Point notation(N-notation)
 Jaeger chart

1. Reduced Snellen chart/equivalent Snellen notation
• Uses the same principle as the distance and the standard
testing distance is 40cm (16in)
• 6/6 letter subtends 5 minutes of arc at a test distance of 40cm
• A print size of 6/15 (20/50) represents 1.0 M at 40cm when

expressed in reduced Snellen form.
(1M=20/50=6/15)
• It is only valid for the recommended distance
2. M-notation
• Defined as a metric distance at which lower case letter (“x height”)
would subtend 5 minutes of arc.
• This notation of “M” units was introduced by Sloan and Habel
• The M number specifies the distance in meters at which the
letter subtends 5 minutes of arc
• 1M letter would subtend 5 minutes of arc at distance 1 meter and
had a height of 2.82mm.
• Use: Able to express as Snellen fraction with metric testing distance
as numerator
eg. 0.40/0.40 M means reads 0.4 M at 40 cm
eg. 0.50/1.0 M means reads 1.0 M at 50 cm
,2018 58
5
Bailey Lovie Word Reading Cards

Why and When to Measure Near Visual Acuity
• Why:
• To describe patients’ habitual functioning
• To predict what is needed to improve reading (most important reason!)
• When:
• After refraction- patient needs to be in focus for valid predictions
eg. +2.50 add 0.40/2.0 M

• An add and reading distance may not correlate

3. N -Notation
• Corresponds to the point size(Computer pixelated letter size)
• One point is being 1/72 of an inch or 0.353mm= in printer system

(1inch=25.4mm)
• The smallest size used when measuring VA is generally N5 ( i.e.
5/72inches) height
• Newsprint is usually 8 points in size(letter alphabets)
• Gothic characters(in Arabic numbers, Amharic alphabets, Hebrew
alphabets and some Latin symbols are larger than letter alphabets
 Newsprint size represents 7 points
 (1M=7points,thik and large stroke)
Jaeger chart
• An Obsoleted chart low vision practice due high inconsistency
• Letters vary in size from 0.5 – 19.5mm
• 20 different optotype sizes are used( J1 – J20)
• Dimensions are not standardized ---- limited value

Other near vision charts
• Bailey Lovie Word Reading Cards
• MN READ Acuity Charts
• Sloan cards (very big print)
• Bernell Vocational Test Card (std print)
• Colenbrander Continuous Text Card
• Lighthouse Continuous Text Card for Adults

Conversion factors
(from M-notation to reduced Snellen form)
D=6
S X
Where D= distance in meter S= letter size in M-unit

X= denominator of Snellen fraction
1.0 M units=2.82mm≈8points ≈typical newsprint(letters)
How to change N-notation to reduced snellen form?

Example
• If a patient read 3M at 40cm, then the visual acuity in reduced
Snellen is ______________
Remember: D/S=6/X

Key Parameters of Patients’ Reading Performance
• Peak reading speed

• Critical print size
• Threshold print size
• Lighting issues and criticality
• Binocularity issues
extra features
• Non-visual issues

Peak reading speed
• Peak Speed = the fastest speed attained with sufficiently large print
• For normals, it is the height of a long fairly flat plateau for
intermediate sizes
–ignore minor deviations along plateau
–average for fully sighted = about 200 to 250 wpm
• Non-visual factors affect Peak Speed
–literacy, motivation, confidence and speech

PRS

Critical Print Size
• Aka Last Good Reading (LGR)
• For a given distance, CPS is the smallest letter size which can be read at
peak speed before slowing or making errors.
• Expressed as acuity fraction
–Test distance / letter size
• listen carefully for “last good reading”
Examples from the last slide:
CPS = 0.40 / 0.8 “normal”
CPS = 0.40 / 1.6 albinism
CPS = 0.40 / 2.0 AMD with scotoma

Threshold Print Size/TPS
• Largest print size (sometimes smallest size) read correctly or almost

correctly with full effort. eg. 0.40 / 0.8 M threshold for normals
–loosely defined and doesn’t used much
• CPS is very important than TPS to determine the patients’ needs.

Lighting needs and criticality
• Determine optimal lighting and its criticality.

– Select initial lighting level based on Hx.
• Usually with bulb about 2 or 3 ft away.
– Assess PRS, CPS, and TPS with appropriate light

Software based recording and calculations

Summary
1. Peak reading speed
– Best case scenario for reading efficiency or fluency
2. Critical print size: (CPS)
– point beyond which significant drop in speed occurs
– indicates minimum size for maximum speed
– allows prediction of power of optical system required
3. Threshold print size:
– normals: 0.2 to 0.3 log units (about factor of 2) smaller than CPS
– low vision: separation between CPS and threshold is often
nearly normal but can be much larger
4. Lighting needs and criticality
5. Binocularity check
6. Non-visual factors check
– if literacy or motivation is questionable
Any Question?
Thank you
Visual Function Examination ….Cont’nd…#2
Contrast Sensitivity (CS)
• Contrast
- The difference in visual properties that makes an object
distinguishable from other objects and from the background
- Is determined by the difference in the colour and brightness of the

object and other objects within the same field of view
 Objects /targets contrast can be evaluated as:
• Color contrast
• Luminous contrast
• The contrast difference b/n targets can be expressed in terms of contrast
threshold(contrast sensitivity function (CSF))
1. Color/chromatic contrast
- The difference between colors

positioned on a colour wheel
- Patients with color vision defect had
poor color contrast
- Enhancing the color contrast of
targets may help patients

2. Luminous contrast
• LC is the difference in luminance by the amount of reflected light from two
adjacent surfaces
• It is the property of an object that distinguishes from other objects
• Usually we use the Michelson formula : Research and lab
Luminance contrast= L max - L min
L max + L min
Lmax = luminance on the lighter surface
Lmin =luminance on the darker surface
• But most contrast sensitivity charts use the Weber contrast formula
Weber contrast = (Lmax –Lmin) / Lmin

Cont.……
• When the darker surface is black and no light reflects then the Contrast ratio
is 1
• Contrast is usually expressed as percentage (%), so ratio is multiplied by 100
• Max contrast can be 100%
• The optotypes on the VA chart is usually close to a max. contrast
• If a person can see details at very low contrast, the contrast sensitivity is
high, and vice versa
• Declines with age, VF reduction and ocular disorders

Cont’d…

Contrast Sensitivity Tests
• Pelli –Robson
• Mars Letter Contrast Tests
• Low – Contrast Bailey – Lovie
• Heidi – Heidi Lea Chart
• Reagan Chart
• Veistech
• Digital/Electronic Versions

Cont’d……
• Most CS tests reflect the peak of CS function
– Are sensitive to low and medium frequency losses which
are not reflected in VA
– PR and Mars CS charts are widely used in research and low
vision rehabilitation services.

Pelli Robson
• Easiest test to determine contrast threshold
• Test distance: 1 meter
• Triplet letters had equal ST ( each subtending 2.8
degrees)
• Each group of three letters has 0.15log units less
contrast than the preceding set
• Contrast ranges 100% to 0.56%
• Letter size
– about 32 meter letters @testing distance
– 20 ft equivalent: 20/640 (=1/32)
– Patient selection – OK if about 20/400 or better

Pelli Robson: Scoring

Mars Letter Contrast Chart
• Test distance 50 cm
• Letter size
– about 12 meter letters @testing distance
– 20 ft equivalent: 20/480 (=0.5/12)
• Patient selection
– OK if about 20/250 or better.

• Test chart is small, durable, easily
transported
- Good agreement with Pelli-Robson
- Excellent alternative
Note: do not let pts to hold the

card; fingerprints on letters can
ruin it!

Mars Contrast Sensitivity Scoring
• Reported based log contrast sensitivity values
• Can be computed based on:
– Weber contrast = (Lmax –Lmin) / Lmin
– Contrast sensitivity = 1 / threshold contrast (CSF)
– individual’s CS is Log base 10 of that sensitivity
Example:
– If Weber contrast = 1.6% = 0.016,
– Then sensitivity = 1 / 0.016 = 62.5, and
– log contrast sensitivity = log10 62.5 = 1.80 (normal)
Range of Contrast Scores on Pelli Robson and Mars Charts
• Pelli Robson: log CS from 0.00 to 2.25
• Worst scores: Must read first triad to earn log CS of 0.00.
• Must read more than that even to get a positive score.
• Clinically, no one ever reads 2.10 or 2.25.
• Mars: log CS from 0.04 to 1.92

Comparison b/n PR and Mars CS charts
 Pelli Robson  Mars

• Each triad = 0.15 log CS • Each letter = 0.04 log CS
• Two triads = 0.30 log CS • Each row = 0.24 log CS
• Used at 1m • Used at 50cm

Log Contrast Sensitivity

CS: How Bad is Bad?
Based on the Mars Chart

result : Flom and
Hopkins CS Guidelines

• When contrast sensitivity is reduced, there are limited
strategies to improve performance
• Optimum lighting
• Minimizing glare
• Reversing/increasing print contrast
• Using electronic devices(CCTVs)
• If CS is severely reduced, non visual techniques may be

required.

Contrast Reserve
• For fluent reading you need a contrast reserve of 10x of your contrast
threshold
i.e. the print needs to be bold.
• For spot or survival reading you only need 3x your contrast threshold
• When text is both small and of poor contrast, it becomes very difficult.to identify

Visual Field
• VF is the area of space in which all objects are visible simultaneously
• Many equipment to measure VF
• VF is important for orientation and mobility and help in

environmental scanning and searching

Major VF tests
Confrontation
- Easy and fast
- Screening test=gross assessment
- Compare the VF of examiner with the patient
- Can also use light as a target
- Can provide estimations in VF losses in different quadrants

Cont.……
Amsler grid
• Hand-held chart used to
evaluate central 20° of visual
field
• Can identify early changes
• Metamorphopsia
• small central scotoma
• 20 blocks x 0.5mm each
• held the charts at 28-
30cms from the eye

Cont.……
 Bernell’s perimetry
- Easy and fast
- More accurate than confrontation
- White target (different size) with central fixation is moved along
a black curved scale
- Recognition along its path measured the extent of VF of patient
at usually 8 meridians

Bernell’s
Perimetry

Other VF tests and equipments
• Bjerrum Screen
• Frequency Doubling Technologies (FDT)
• Humphrey Visual Field Analyzer

Bjerrum Screen
Goldmann Bowl Perimeter

,2021 10
0
Color Vision
• It is extremely rare to be totally colour blind
• Colour deficiency: In developed countries is about 8% in male

and 0.4% in female
• Approximately 4% of the total population has congenital colour

deficiencies, out of which about 95% are male
• Congenital vs acquired

10
1
Cont.….
• Assessed for functional limitation (non- diagnostic purposes)
• to illustrate the patients ability of discriminate colors
• to know the color confusion they might made
• The Farnsworth Panel D15 is the best test of choice when VA is 6/12 or less.
• Matching the appropriate numbered discs with similar color hues.

10
2
CV……cont’d
• Color blindness(anopia) Vs Color Vision Deficiency (CVD)(anomalous)
• Is color vision deficiency is related to visual acuity?
 Protanopia
 Deuteranopia
 Tritanopia

10
3
protan (R) Deutran(G) Tritan(B)

10
4
Ishihara
clinical low
clinical low vision
vision ,201
,20218 10
104
5
De-saturated D-15
D-15
PV-16 Colour pens

10
6
Refraction in Low vision
• The presence of uncorrected presbyopia could affect magn.t success
• Significant uncorrected refractive error rates with low vision devices
• Both objective and subjective refraction should be tried for all low
vision patients irrespective of the type and degree of VI
• But one shouldn’t spent much time by refracting LV when

prescribing it is not possible.
107
High ref. errors and big changes in Rxs more
common in low vision. Why?
High RE Big changes in Rxs
– failed emmetropization – refractive neglect
•lack of sharp image disrupts • lack of testing
emmetropization • inadequate testing
• so, congenitally visually impaired at – surgically induced
greater risk • PK, scleral buckle
– lid posture (high WTR astigmatism) – disease induced
• albinism, aniridia •nuclear sclerosis: can have large
– post-surgical patients myopic shifts (eg. –5.00!)
• s/p PK or scleral buckle •(macular edema: fairly small
– very high myopes develop hyperopic shifts)
maculopathy
10
8
Role of Refraction in Low Vision
 Study of changes in refractive error & VA (Raasch/Flom findings)
– 100 consecutive LV patients at tertiary care center
– Median age: 74 yrs
– AMD (48%), DR (14%), glaucoma (8%)
– Trial lens refraction with bracketing
– Acuity with logMAR / ETDRS charts
 Results: – some percentage benefited from new Rx
– easiest way to improve visual function!

10
9
Result: Refractive and VA changes
Refractive changes:
• 23% at least 1D of change
Acuity improvement with refractive change:
• 30% at least ½ line
• 20% at least 1 line
• 10% at least 2 lines
• 5% at least 3 lines

11
0
Cont.….
Traditional procedures for the objective and subjective assessment

of refractive error are less effective due to:
• Poor fixation
• Eccentric viewing postures
• Media opacities
• What is the difference b/n normal and low vision refraction?

11
1
Potential Challenges in Refraction with Visually Impaired Patients
• High Rxs
• Large ΔRxs
• Odd optics(media irregularities, pupil location )
• Reduced response consistency
• Patients’ JNDs are usually larger
• Cannot easily predict Rx based on acuity
• Pinhole testing may mislead
• No obvious endpoint
• More awkward physically
• Requires a somewhat different logic
11
2
Objective Refraction
Retinoscopy with lens bar or loose lenses over Rx or trial

Fundus reflex may be small or dim: probe for big refractive errors
If the medial and the optics allows , follow the traditional refraction
technique and procedure

11
3
Special techniques of LV refraction
Near Retinoscopy (move closer) = Radical Retinoscopy
Why Radical Retinoscopy is important?

• Facilitate detection or neutralization of motion
• can be helpful when
• media opacities are present
• pupils are small
• the reflex is dull
e.g. 20 cm, so subtract 5.00 D from result
11
4
Cont.……..
• Move off axis(off axis refraction)- elicit a brighter reflex

• Over refraction to maintain fixation (trial clip over-refraction)
• Start refraction on the better eye
• Try to obtain approximate RE: hard to get the end point!
• Entire subjective refraction: lack of reflex

11
5
Additional procedures
• Keratometry
• Corneal topography
• Auto-refraction: if the media is clear
• Photo-refraction

11
6
Choice of techniques of refraction
• Retinoscopy
• Autorefraction
• Trial frame
• Phoropter
• Stenopaeic slit

11
7
Auto refraction Vs trial frame refraction
• Methods : Retrospective review
–N = 440
–Trial frame refraction by low vision expert Vs hand held auto ref
• Results:
– Overall, similar results
• for spherical equivalent
• cyl power
• axis within 10 degrees for most.
• For about 5%, spherical equiv. off by >2.00 DS!
• Conclusion:
– Auto refraction is good starting point and comparable with TF refraction
– Trial frame refraction remains “Gold Standard”

11
8
why you should not use phoropter in LVC
Optometrist can’t see: Optometrist can’t do:
• eccentric viewing • make large lens changes efficiently
• search behavior • control vertex distance

• go beyond range of phoropter
• lid posture
• Patient perception: "I saw better
• nystagmus with that machine than w/glasses”
• facial expressions • “I hate that machine.”

11
9
Cont.…..

12
0
Subjective refraction
Basic Steps
1. Sphere check
2. Gross cyl axis
3. Gross cyl power
4. Refine axis
5. Refine cyl power
6. Refine sphere
7. Record over-refraction
8. Measure resultant/sum up the power if over refraction
9. Finalize in trial frame (prn)

12
1
Subjective refraction
 Sphere
 Use large steps with very clear instructions
e.g. +/- 2.00, 4.00, 6.00, 10.00 DS until you get a response
 Bracketing technique gives better result

 Remind Px what and where they’re looking at
 Cyl check
 Use +/- 0.75 or 1.00 crossed cyl(JCC)
 Sensible target e.g. round letter, larger than best acuity
 Can also use comparisons for cyl power and axis
12
2
Spherical Refraction: Bracketing
• Systematic presentations of “too much plus” and “too much minus”
• How Large Should Initial Brackets Be? “JND Rule”
•JND: is the smallest dioptric step that a patient is able to discriminate
It depends!
• How suspicious the patient and the examiner are
• How poor is the acuity
• Trial lens options

12
3
Targets
• At close distance than the usual one

• Single targets
• Circular targets are preferable
(Raasch Dots)
• Larger targets

12
4
JND Rule of Thumb : Bracketing width and lens
1. AOA guideline - Bracket width = Snellen denominator / 100
• 20/200 patient---bracket width = 2 D; start with +/-1.00
• 20/400 patient---bracket width = 4 D; start with +/-2.00
• Bracketing lens is half of the BW
2. Flom’s Rule- double the AOA rule
Bracket lens = Snellen denominator / 100
• example: 20/200 patient---bracket +/-2.00
• example: 20/400 patient---bracket = +/-4.00
Need to double the BL to know the BW

12
5
Take a care
• Not to Over-minus low vision patients
• Balancing- if binocularity helps
• Binocular refraction

12
6
A Brief Flowchart of Patient management

12
7
Final Verification and decision
• If there is a VF improvement- full prescription
• Try all options to maintain binocularity
• Combine with other devices
• Make changes from the previous Rx either VA or quality of vision is
improved
• Double check for any power and axis changes
• Consider the availability of lenses and frames
• Lens treatment and light control
• Demonstration and reality check
• Recalculate the predicted add and magnification
12
8
Difference b/n low vision and normal refraction
In low vision

• Time consuming => need patience
• Change distance(very close WD)
• Off axis refraction/ difficult to get exact axis
• Closer VA chart
• Blur sensitivity
• No obvious end point

12
9
Cont.…
• Prescription may not improve vision but can improve quality of
vision
• Reduced sensitivity to small power change
• Clip mount refraction over spectacle
• Stenopaic slits often used
• Best to use trail frame with lenses than phoropter

13
0
Summary
• What is the difference Low vision assessment vs standard
assessent?
 Time consuming
 Patience
 Emphasis on functional approach
 Assessment under favorable condition
 Tasks which cause poor outcome of refraction?
• Selection of patients
• Poor Refraction
• Poor Dispensing

13
1
Visual acuity scales
Foot Metre Decimal LogMAR
20/200 6/60 0.10 1.00
20/160 6/48 0.125 0.90
20/125 6/38 0.16 0.80
20/100 6/30 0.20 0.70
20/80 6/24 0.25 0.60
20/63 6/19 0.32 0.50
20/50 6/15 0.40 0.40
20/40 6/12 0.50 0.30
20/32 6/9.5 0.63 0.20
20/25 6/7.5 0.80 0.10
20/20 6/6 1.00 0.00
20/16 6/4.8 1.25 -0.10
20/12.5 6/3.8 1.60 -0.20
20/10 6/3 clinical llow

ow13vision
v1ision ,2021
,2018 2.00 -0.30 13
2
Any question???
Thank you!!
3

CLV, VF Assessment 2021

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CLV, VF Assessment 2021

Uploaded by

Copyright:

Available Formats

Unit Three

Low vision Assessment

clinical low vision ,2021

clinical low vision ,2021 2

clinical low vision ,2021 3

1. Case history and goal setting

clinical low vision ,2021 4

clinical low vision ,2021 5

clinical low vision ,2021 6

clinical low vision ,2021 8

• Review of medical records

clinical low vision ,2021 10

• General mobility and independence

• How did the person travel?

• Did able to cope with traffic roads to cross?

• Any known field defect that affect mobility ?

• Any ability to detect obstacles?

• Did the Px know his/her living env’t?

clinical low vision ,2021 11

• Basic daily activities/ADLs

• Emotional status (what feel about their vision)

clinical low vision ,2021 12

 Detailed visual history

• As per LVA clinic record card/format

clinical low vision ,2021 15

• Typing • Sorting money

clinical low vision ,2021 16

• Counsel patients regarding to all the visual/ocular status,

clinical low vision ,2021 17

• Check goals with the person: do we all agree?

clinical low vision ,2021 18

clinical low vision ,2021 20

clinical low vision ,2021 21

clinical low vision ,2021 22

clinical low vision ,2021 23

• Chart selection and procedures often must be adapted. Why?

clinical low vision ,2021 24

clinical low vision ,2018

• Multiple letters of each size( adequate number per row)

• Same number of letters per row

• Letter size progression down the chart

clinical low vision ,2021 26

• Proportional between rows

• Equal letter legibility

clinical low vision ,2021 27

clinical low vision ,2021 28

clinical low vision ,2021 29

clinical low vision ,2021 31

clinical low vision ,2021 32

clinical low vision ,2021 33

• Difference b/n snellen and logMAR acuity charts????

clinical low vision ,2021 34

Photograph courtesy of National Eye

• Letter sizes: (marked at left side)

• Can use either feet or meters

• LogMAR score (marked at right side)

• Assumes the chart as at 20 feet

clinical low vision ,2021 38

• Developed by Ian Bailey and Lovie- Kitchin

Letters are 5x4

clinical low vision ,2021 39

• Proportional spacing between letters:

clinical low vision ,2021 40