Reading Acuity in Children: Evaluation and Reliability
Using MNREAD Charts
Gianni Virgili,1 Claudia Cordaro,2 Anna Bigoni,2 Sabrina Crovato,2 Paolo Cecchini,2 and
Ugo Menchini1
PURPOSE. To study reading acuity in children and assess the
reliability of its measurement using the Italian version of the
MNREAD reading chart.
METHODS. One hundred sixteen children from grades 3 to 8
with normal near vision were tested at a pediatric eye care
institution in northeastern Italy. Visual acuity was evaluated
with Early Treatment Diabetic Retinopathy Study (ETDRS)
charts and reading acuity with MNREAD charts. Examination
with charts 1 and 2 by the same examiner in the same visit
were used as test–retest measurements.
RESULTS. Mean improvement of performance from grades 3 to
8 was approximately 1 line for ETDRS acuity and 1.5 sentences
for reading acuity and critical print size. Mean maximum read-
ing speed increased from 96 to 167 words/minute. Regression
analysis showed that a stable reading speed was obtained
throughout sentences of decreasing size up to the critical print
size. Measurement error, expressed as 95% limits of agreement,
was ⫾0.136 logarithm of the minimum angle of resolution
(logMAR) and ⫾0.142 logMAR for ETDRS acuity and reading
acuity, respectively. Critical print size had the lowest reliability
(⫾0.193 logMAR). Maximum reading speed limits of agree-
ment were ⫾0.077 logarithm of words per minute (logWPM),
or a 19% change in words per minute. There were no detect-
able effects of grade and refractive error on measurement
errors.
CONCLUSIONS. In children, MNREAD charts provide measure-
ments of reading acuity as reliable as ETDRS chart measure-
ments of distance acuity on a logMAR scale. They also provide
highly reliable measurements of the maximum reading speed
across all grades, independent of its noticeable increase. (In-
vest Ophthalmol Vis Sci. 2004;45:3349 –3354) DOI:10.1167/
iovs.03-1304
R eading is a complex process involving several visual and
nonvisual aspects. Print size is one of the factors that
mainly influence reading speed in normal and low-vision sub-
jects.1,2 Typically, reading speed is stable across a wide range
of print sizes for one individual (maximum reading speed
[MRS]). As print size decreases, there comes a point where
reading starts to slow down, referred to as the critical print size
(CPS). The reading acuity (RA) limit has been reached when
From the 1Eye Clinic II, Department of Oto-Neuro-Ophthalmolog-
ical Surgical Sciences, University of Florence, Florence, Italy; and the
2 (MT) test (Organizzazioni Speciali, Florence, Italy) and were excluded
Neurophthalmology Unit, Scientific Institution E. Medea, La Nostra
Famiglia, Polo Friuli Venezia Giulia, Italy.
Submitted for publication December 2, 2003; revised March 2,
April 14, and April 30, 2004; accepted May 10, 2004.
Disclosure: G. Virgili, (P); C. Cordaro, None; A. Bigoni, None; S.
Crovato, None; P. Cecchini, None; U. Menchini, None
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be marked “advertise-
ment” in accordance with 18 U.S.C. §1734 solely to indicate this fact.
Corresponding author: Gianni Virgili, Eye Clinic, Department of
Oto-Neuro-Ophthalmological Surgical Sciences, University of Florence,
Viale Morgagni 85, 50134 Florence, Italy; gianni.virgili@unifi.it.
Investigative Ophthalmology & Visual Science, September 2004, Vol. 45, No. 9
Copyright © Association for Research in Vision and Ophthalmology
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the subject is no longer able to read. Print size corresponding
to CPS is typically two times larger than RA, a difference of 0.3
in logarithm of the minimum angle of resolution (logMAR).
The effects of age on visual function testing have been
studied in adults.3–10 The Bailey-Lovie near word chart11 was
used in these studies to evaluate reading ability. Recently, the
reliability of visual acuity measurement with an Early Treat-
ment Diabetic Retinopathy Study (ETDRS) chart in children has
also been assessed,12 but little is known about the age-specific
reading performance of children.
The MNREAD charts are continuous-text reading-acuity
charts suitable for measuring the RA and reading speed of
normal and low-vision patients, developed at the Minnesota
Laboratory for Low-Vision Research.13,14 Italian and Japanese
versions of the charts are currently commercially available.
The purpose of this study was to evaluate the reliability of
measurements of RA obtained with the Italian MNREAD charts
in children in grades 3 through 8. A second purpose was to
characterize the expected improvement of reading ability
across grades and compare it with an ETDRS chart, a world-
wide standard for visual acuity measurement.
METHODS
Subjects were recruited at the pediatric ophthalmic practice of La
Nostra Famiglia, a scientific institution providing eye care to normal
and visually impaired children in northeastern Italy. Children are re-
ferred by pediatricians for screening of ophthalmic and refractive
abnormalities to the center, which is the only high-volume pediatric
eye care institution in an area of approximately 300,000 residents, one
third living in the town of Udine.
Consecutive children from grades 3 through 8 were included in the
study. We planned to enroll 120 consecutive subjects who met inclu-
sion criteria, with a minimum of 10 children per grade. Children and
parents were informed about the purposes of the research and parents
signed an informed consent. The study adhered to the tenets of the
Declaration of Helsinki and was approved by the institution’s institu-
tional review board.
Inclusion criteria were visual acuity at least 0.3 logMAR (20/40)
with ETDRS charts, normal findings in an ocular examination, and
normal binocular motility and stereoscopic sense on the Lang II test
(complete test).15 The level of ETDRS acuity admitted in the study was
relatively low because compliance may not be optimal with children
using this chart. When tested with a single-letter presentation, all
children could see at least some letters at 20/20 level.
Subjects were screened for dyslexia using the Memory Transfer
if the reading speed score was less than 10 or if errors were more than
15, as recommended.
One hundred twenty children were evaluated. Four were excluded
because they tested positive for dyslexia with the MT test. Overall, 116
children were finally included. Mean age was 10.5 ⫾ 1.5 years. Of the
116 children, 68 (59%) were girls. The number of subjects from grades
3 through 8 were 26, 22, 22, 15, 20, and 11, respectively.
Refraction was first obtained with an autorefractometer (Retino-
max; Nikon, Tokyo, Japan) and then refined subjectively. Mean spher-
ical equivalent was ⫺0.44 and ⫺0.56 D in the right and left eyes,
3349
 3350 Virgili et al. IOVS, September 2004, Vol. 45, No. 9

TABLE 1. Crossing Scheme for Chart Presentation in the Study
Presentation
Subject Eye Chart Order
1 R 1 1
L 2 2 size corresponding to CPS or larger. MRS is measured in words per
2 R 2 1
L 1 2 used to make its progression linear, thus ensuring a proportional
3 R 1 2
L 2 1 recorded at 0.1 logMAR intervals. CPS was identified as the print
4 R 2 2
L 1 1
respectively, ranging from ⫺7.88 to ⫹5.25 D overall. Approximately
30% of both right and left eyes needed a cylinder of 1 D or more; in 5%,
the cylinder was 2 to 3.5 D. Subjects wore refractive error correction
during testing.
All psychophysical tests were conducted by the same examiner for
each child. A second examiner helped record reading data obtained
with the MNREAD chart.
The MNREAD sentences provide samples of reading material de-
signed to demand the visual processing capabilities and eye-movement
control required for normal text reading. Each sentence contains 60
characters (including a space between each word and at the end of
each line) printed as three lines with even left and right margins. The
vocabulary used in the sentences is selected from high-frequency
words that appear in second- and third-grade reading material. The
charts contain sentences with 19 different print sizes. From the rec-
ommended viewing distance of 40 cm (16 in.) the print size ranges
from ⫹1.3 to ⫺0.5 logMAR (Snellen equivalents 20/400 –20/6). This
range can be extended by using a shorter or longer viewing distance.
The MNREAD charts have already been used in clinical and low-vision
research.14 –18
To evaluate the reliability of the measurement, MNREAD charts 1
and 2 were tested on the same subject consecutively. The two charts
have the same layout but contain different sentences. Each child was
asked to use the right eye to read one chart and the left eye to read the
other. This design allowed us to evaluate whether laterality was asso-
ciated with reading performance. To our knowledge, this question has
not been addressed in psychophysical studies evaluating the associa-
tion of lateral preferences with reading.19 –21 The order of chart pre-
sentation was alternated in consecutive subjects, as shown in Table 1,
to avoid an association between chart, eye, and order of presentation.
Distance visual acuity was obtained with the ETDRS charts and
recorded in logMAR for all subjects. Charts 1 and 2 were presented
using the same method as for the MNREAD charts. Because the ETDRS
acuity score is based on the number of letters correctly identified, the
true unit of measure is 0.02 logMAR, because the difference in visual
angle between two adjacent lines is 0.1 logMAR and there are five
letters per line.
The difference in size between two MNREAD sentences is 0.1
logMAR. Each sentence comprises 60 characters, including spaces,
corresponding to 10 average-length words each worth 0.01 logMAR.
RA, or the smallest print size at which some words can still be
recognized, can be approximated at 0.01 logMAR after subtracting
the errors. These words are either missed or misread and are
typically clustered between CPS and acuity limit. The following
formula is used to compute RA in logMAR: RA ⫽ 1.4 ⫺ (sentences ⫻
0.1) ⫹ (errors ⫻ 0.01). There was no need to adjust the value
obtained with this formula by a factor accounting for viewing
distance, because a standard testing distance of 40 cm was adopted.
MRS is obtained by averaging the speed of the sentences with print
minute (WPM), but the logarithm of words per minute (logWPM) is
percentage of change, which is recorded in 0.01 log units. CPS is
size of the sentence at which both of the following conditions were
satisfied: (1) all the following (smaller) sentences were read at a
speed that was 1.96 times the standard deviation below the average
of the largest preceding sentences and (2) all the following (smaller)
sentences were read at a speed 5% slower (an approximate 25%
change in WPM) than this average. In approximately one third of
the eyes (32%) the two criteria disagreed, suggesting two different
sentences as potential CPS. In such cases, the sentence with the
larger print size was chosen, to avoid averaging some slower sen-
tences in MRS computation, although this usually has little bearing
on the estimate. An exception was made in five eyes in which the
smaller sentence seemed preferable after graphic examination of
the test result. Of note, with criterion 2, the larger sentence was
preferred in 69 of 75 eyes presenting such a discrepancy.
A paired t-test was used to test for equality of means of measures
obtained with charts 1 and 2 of ETDRS and MNREAD. The intraclass
correlation coefficient (ICC) was obtained as an index of reliability for
continuous variables.22 Error of measurement was calculated as the
square root of the error mean square from each ANOVA model.22
According to Arditi and Cagenello7 the standard deviation of the
distribution of the discrepancies between test and retest is equal to the
SE of measurement times 公2. This value must then be multiplied by
⫾1.96 to obtain 95% confidence limits for the agreement between test
and retest.
Univariate regression was used to evaluate whether the absolute
value of the difference between test and retest changed with grade or
with refractive error. Both a linear and a quadratic association with
grade were assessed. Because subjects were the unit of analysis in
these models, spherical equivalent and cylinder power were recorded
as the average of the two eyes.
To evaluate the effect of school grade on ETDRS visual acuity and
reading ability, a generalized least square (GLS) regression model was
used to take into account the correlation between multiple measures in
the same individual as a random effect. Multivariate models were then
fitted in which other variables were evaluated, such as age, sex,
refractive error (spherical equivalent and cylinder power of each eye),
chart (1 vs. 2), eye (right versus left), and order of presentation (first
versus second during individual test).
GLS regression was also adopted to evaluate whether a significant
slope existed in reading speed from larger to smallest sentences of the
MNREAD charts. Again, a random effect was attributed to intraindi-
vidual correlation. Cronbach’s ␣ was used as an index of the measure
of internal consistency of reading speed of sentences within each
chart.
Statistical analyses were performed on computer (Stata, ver. 8.1;
Stata Corp., College Station, TX).

TABLE 2. Mean (SD) ETDRS Acuity and MNREAD Variables for the Entire Sample

ETDRS Visual Acuity RA CPS MRS

(logMAR) (logMAR) (logMAR) (logWPM)

Mean for chart 1 (SD) 0.074 (0.091) 0.026 (0.093) 0.244 (0.097) 2.101 (0.122)
Mean for chart 2 (SD) 0.054 (0.089) 0.023 (0.089) 0.234 (0.097) 2.105 (0.130)
Mean difference (95% CL) 0.020 (0.007; 0.033) 0.003 (⫺0.009; 0.015) 0.010 (⫺0.010; 0.028) ⫺0.004 (⫺0.011; 0.004)
Paired-t-test 0.004 0.640 0.259 0.322

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 IOVS, September 2004, Vol. 45, No. 9 Evaluation of Reading Acuity with MNREAD Charts 3351

TABLE 3. Measurement Error for Visual Acuity and Reading Ability by School Grade

Grade

3 4 5 6 7 8 Overall
(n ⴝ 26) (n ⴝ 22) (n ⴝ 22) (n ⴝ 16) (n ⴝ 20) (n ⴝ 11) (n ⴝ 116)

ETDRS visual acuity logMAR ⫾0.130 ⫾0.103 ⫾0.180 ⫾0.170 ⫾0.138 ⫾0.161 ⫾0.146
RA (logMAR) ⫾0.163 ⫾0.124 ⫾0.134 ⫾0.126 ⫾0.104 ⫾0.109 ⫾0.132
CPS (logMAR) ⫾0.163 ⫾0.221 ⫾0.244 ⫾0.143 ⫾0.136 ⫾0.221 ⫾0.193
MRS (logWPM) ⫾0.069 ⫾0.094 ⫾0.065 ⫾0.069 ⫾0.083 ⫾0.075 ⫾0.077

Data are the 95% limits of agreement.

RESULTS
Reliability of Measurement
Table 2 presents the mean and the standard deviation of the
measures obtained with ETDRS charts 1 and 2 for RA, CPS, and
MRS. As seen in the table, the test–retest means were signifi-
cantly different for ETDRS acuity, but not for measures ob-
tained with the MNREAD charts. In any case, mean differences
were small and clinically unimportant, as indicated by their
95% confidence limits. The ICCs for ETDRS acuity (0.66, 95%
CL: 0.55; 0.73) and RA (0.73, 95% CL: 0.65; 0.82) were similar
and were consistent with good reliability. CPS yielded a lower
ICC (0.49, 95% CL: 0.35; 0.63). On the other hand, reliability
for MRS was very high (0.95, 95% CL: 0.93; 0.97).
The 95% confidence limits for agreement between test and
retest in one subject were ⫾0.136 logMAR for ETDRS acuity,
⫾0.142 logMAR for RA, and ⫾ 0.193 logMAR for CPS. MRS
was ⫾ 0.077 logWPM, which corresponds to ⫾19% change in
WPM.
Table 3 shows 95% limits of agreement in the overall sample
as well as by school-grade. Tables 4 and 5 present them for
categories of spherical equivalent and cylinder power. Test–
retest differences were not associated with grade or refractive
error. Only a tendency of RA to have narrower limits with
increasing grade approached statistical significance (P ⫽
0.075).
Performance of Single Sentences within
MNREAD Charts
Figure 1 shows mean reading speed of all sentences in charts 1
and 2 plotted as the mean reading speed of each sentence by
six groups of children in the same grade. For print size larger
than CPS, 0.4 logMAR or more, the mean reading speed of each
sentences was substantially similar. It can be noted that reading
speed increased with school grade, as described later. We
evaluated whether reading speed declined from largest to
smallest print size for sentences used to compute MRS. Only
the 10 largest sentences were included in this analysis (1.3– 0.4
logMAR at the test distance of 40 cm) so as to avoid print size
close to CPS, which obviously would have been read slowly.
Although a significant linear decrease of ⫺0.002 logWPM (95%
CL ⫺0.001; ⫺0.003 logWPM) was predicted for one smaller
sentence (corresponding to 0.1-logMAR steps), it was clinically
unimportant, as it predicted a decline of only 4% in WPM from
the largest sentence to the smallest one. Thus, the observation
that reading speed is stable across sentences of different size,
until the CPS is reached, is confirmed in children. The grade
variable was neither a confounder nor an effect modifier of this
estimate, although it influenced absolute values of MRS. This
result reinforces the choice of averaging the reading speed of
several sentences to obtain MRS.
To provide further support for the internal reliability of the
chart structure, the Cronbach ␣ was calculated for the same
sentences used in the regression model. Chart 1 yielded ␣ ⫽
0.96 and chart 2 ␣ ⫽ 0.97, indicating that the internal consis-
tency of the chart was very high with respect to speed mea-
surement. When all chart sentences are considered, corre-
sponding ␣ values were still very high: 0.93 and 0.95,
respectively.
Influence of School Grade on Performance
Evaluating the relationship between grade and performance
(Fig. 2) was one of the main objectives of the study and was
explored with univariate regression analysis. Because one
grade means one additional year of education, it was consid-
ered a discrete and quantitative variable, rather than a categor-
ical one.
Regression analysis predicted an improvement of ETDRS
acuity by ⫺0.016 logMAR (95% CL: ⫺0.025; ⫺0.007 logMAR,
P ⬍ 0.001) per grade, corresponding to a difference of approx-
imately 1 line from grades 3 through 8.

TABLE 4. Measurement Error for Visual Acuity and Reading Ability by Quartile of Spherical Equivalent

Quartile

1 2 3 4 Overall
(n ⴝ 29) (n ⴝ 28) (n ⴝ 29) (n ⴝ 30) (n ⴝ 116)

Median of quartiles (D)

(minimum/maximum) ⫺3.3 (⫺7.9/⫺2.1) ⫺1.1 (⫺2/⫺0.1) ⫹0.5 (0/⫹0.8) ⫹1.8 (⫹0.9/⫹4.6)
ETDRS visual acuity
(logMAR) ⫾0.166 ⫾0.145 ⫾0.131 ⫾0.142 ⫾0.146
RA (logMAR) ⫾0.111 ⫾0.152 ⫾0.119 ⫾0.141 ⫾0.132
CPS (logMAR) ⫾0.189 ⫾0.166 ⫾0.241 ⫾0.164 ⫾0.193
MRS (logWPM) ⫾0.079 ⫾0.063 ⫾0.095 ⫾0.066 ⫾0.077

Data for RA, CPS, and MRS are 95% limits of agreement.
* Mean spherical equivalent of each individual.

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 3352 Virgili et al. IOVS, September 2004, Vol. 45, No. 9

TABLE 5. Measurement Error for Visual Acuity and Reading Ability by Lovie-Kitchin and Brown4 provided data on age-related
Level of Cylinder Power changes of RA using the Bailey-Lovie near word chart in adults
aged 21 to 68. The mean value was 0.044 logMAR (SD: 0.057)
Cylinder Power
and it declined by 0.016 logMAR per decade. The standard
deviations of RA increased with age, but this was believed to be
<1 D >1 D Overall
(n ⴝ 87) (n ⴝ 29) (n ⴝ 116) the result of imperfect near correction, and overall test vari-
ability was not greatly influenced by age in their sample.
Median cylinder power (D) Overall, the 95% confidence limits for RA were ⫾0.114 log-
(minimum/maximum) 0.3 (0/0.9) 1.4 (1.0/3.4) MAR. Practice effect was also modest in this study—approxi-
ETDRS visual acuity mately ⫺0.013 logMAR improvement between the first and the
(logMAR) ⫾0.139 ⫾0.167 ⫾0.146 fifth of a series of measurements.
RA (logMAR) ⫾0.124 ⫾0.152 ⫾0.132 Camparini et al.23 conducted a study on measurement error
CPS (logMAR) ⫾0.190 ⫾0.199 ⫾0.193
MRS (logWPM) ⫾0.078 ⫾0.074 ⫾0.077 comparing full versus fast procedure for visual acuity measure-
ment using the ETDRS charts in Italian subjects. Confidence
Data are as described in Table 4. limits at the 95% level were approximately eight letters, or 1.6
* Mean cylinder power of each individual was used to group lines, for the full procedure. However, approximately one third
subjects. of the patients in the sample were affected by some form of eye
disease, and so these data cannot be assumed to be valid for
normal Italian adults.
A linear term (P ⫽ 0.003) and a quadratic term (P ⫽ 0.051)
were retained in the model evaluating the association of RA
with grade, accounting for a larger improvement of RA in early
grades and a tendency toward stabilization at higher grades.
The predicted difference in RA from grades 3 to 8 was ⫺0.156
logMAR (95% CL: ⫺0.224; ⫺0.088 logMAR)—approximately
1.5 sentences.
CPS increased linearly with grade by ⫺0.014 logMAR (95%
CL: ⫺0.023; ⫺0.005 logMAR, P ⫽ 0.003).
Grade was also a strong predictor of RS, accounting for 48%
of its variance. It increased by 0.052 logWPM (95% CL: 0.042;
0.062 logWPM, P ⬍ 0.001) per grade, corresponding to a 13%
increase in WPM and to an increase of the mean value from 96
to 167 WPM from grades 3 through 8.

Association of Other Variables with Performance

The association of performance with grade was strong in mul-
tivariate models, in which its coefficients were similar to those
from univariate analyses. RA worsened by approximately 0.029
logMAR for each additional diopter of astigmatism (95% CL:
0.017; 0.045 logMAR, P ⫽ 0.001). This value is almost identical
with that found for ETDRS visual acuity (0.032 logMAR, 95%
CL: 0.017; 0.048 logMAR, P ⬍ 0.001). Spherical equivalent
showed no association with any other independent variables
when grade was considered. CPS was found to be slightly
better in the left eye than the right eye (⫺0.021 logMAR, 95%
CL: ⫺0.003; ⫺0.038 logMAR; P ⫽ 0.021). No relationship
between reading speed and other covariates was found when
grade was considered in the model. Age was never as good a
predictor as grade. A small difference in visual acuity was
confirmed for ETDRS chart 1 versus chart 2, as seen in Table 2.

DISCUSSION
Several investigators have studied the reliability of visual acuity
measurement in adults.4 –9 In most studies, they found that
test–retest error is within 0.04 to 0.06 logMAR. Thus, a change
of 1 line or 0.1 logMAR is suggested to be clinically significant
in normal adults. A modest decrease in performance with older
age has been shown.4,10
A recent study12 has assessed the reliability of visual acuity
measurement with the ETDRS charts in children. Based on the
95% limits of agreement, the criterion for a statistically signif-
icant change in VA is no more than ⫾0.15 logMAR. These limits
were not found to be associated with age, but there was a small
difference between sexes, with boys approximately two letters FIGURE 1. Mean reading speed of all sentences in the MNREAD charts
more variable than girls. 1 (top) and 2 (bottom), across six groups of children in the same grade.

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 IOVS, September 2004, Vol. 45, No. 9
FIGURE 2. Box plots of ETDRS acu-
ity (top left), RA (top right), CPS (bot-
tom left), and MRS (bottom right), by
grade.
In this study, a change of 1.5 lines was significant for ETDRS
acuity, which is slightly larger than the limit allowed for adults
in published reports on English-speaking people4 –9 and is
identical with that obtained by Manny et al.12 in English-
speaking children aged 6 to 11 years.
The MNREAD charts allowed a precise measure of RA. In
logMAR units, their reliability was at least as good as that of the
ETDRS charts for normal children, beginning at grade 3. The
reliability of MRS measurement was the highest, whereas that
of CPS measurement was the lowest, although still acceptable.
This could be because CPS is recorded in discrete steps of 0.1
logMAR—that is, with a larger approximation than other read-
ing variables. The relatively low reliability coefficient for acuity
measures also results from a “range effect,” because vision was
restricted within a narrow normal range.
Both VA with the ETDRS charts and reading performance
increased with grade. Whereas measures of acuity improved
only slightly, MRS increased markedly from grades 3 to 8, in
accordance with the data previously published by Taylor24 and
reviewed by Carver.25 Although a trend toward stabilization
was shown graphically for most measures, a quadratic term
was retained in the model only for RA, indicating its tendency
toward a plateau at grade 8. It is possible that the number of
subjects in each grade was too small to detect a trend toward
stabilization of performance for other variables. It should also
be observed that a cross-sectional study is not the most appro-
priate design to obtain a precise estimate of the progression of
reading ability with age, which would be best achieved with
longitudinal studies.
Increasing astigmatism was found to be associated with
lower RA. A similar association with VA suggests that there
could be some residual optical blur, despite accurate refrac-
tion. No association was found between astigmatism and MRS,
as could be expected if mild blur is the only limiting factor.
Both regression analysis and Cronbach’s ␣ indicate that
different sentences in the MNREAD charts provided very sim-
ilar reading speeds for one individual, despite the fact that each
sentence contained only 60 characters. This finding supports
the decision of averaging over reading speed of several sen-
tences to obtain MRS. It also suggests that estimates of MRS
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Evaluation of Reading Acuity with MNREAD Charts 3353
could be obtained using sentences of any size, provided that
they are larger than the CPS.
In this study, one eye was used for test and the fellow eye
for retest to assess whether reading with right versus left eye
affects performance. Although this may cause the error esti-
mate to include true interocular differences, these were likely
to be small because subjects were best refracted and were
included only if no anomaly of the visual system was found.
Moreover, even a small systematic bias would have been in the
direction of a larger error, rather than toward its underestima-
tion. No difference of performance of right versus left eye was
found for all measured variables, except for CPS which was
better in the left eyes. This difference was clinically unimpor-
tant and could represent a chance finding. The confidence
limits of RA using the MNREAD charts were similar to those of
VA measured with the ETDRS charts, which are currently the
standard for distance acuity measure. They are also close to the
values found in English-speaking adults by Bailey and Lovie11
using a Bailey-Lovie word chart. No effect of practice was
detected on the second test. Gender and age did not affect
performance when grade was taken into account.
When results of reliability studies are considered, the char-
acteristics of the sample are relevant for their generalizability.
In this study, children were collected in an area in which
industrial, commercial, and agricultural activities all contribute
to provide one of the highest average incomes in Italy. The
institution in which the study was conducted is the only
high-volume eye-care service for children in this area. Its ser-
vices are largely covered by the public healthcare system, so
that access is not limited by family income. Children are thus
representative of a well-educated population with income lev-
els close to those of other industrialized Western countries.
Of course, the possibility of generalizing results to other
countries may be limited by the language. This may be partly
overcome by the use of the ETDRS charts, a worldwide stan-
dard tool, as a reference method for visual acuity testing. The
reliability of the ETDRS charts was similar to that found in a
recent U.S. study.12 Limitation to near normal acuity restricts
the generalization of the findings. Not only is true error ex-
pected to be larger as acuity worsens, but with the MNREAD
 3354 Virgili et al.
charts, there are also fewer data above CPS on which to
estimate maximum reading rate. This would increase measure-
ment error when estimating MRS and CPS.
Present results encourage more research on the validity of
the MNREAD charts for assessing reading performance. In
particular, reliability of measures from different examiners and
among low-vision patients should to be assessed. Ideally, stud-
ies to evaluate the reliability in patients with similar diseases
and visual loss should be conducted in different countries,
because MNREAD charts are already available in various lan-
guages and more are being developed. The ultimate goal of
such studies would be to test whether the MNREAD charts can
be a valid translinguistic tool. This would help multicenter
low-vision research and facilitate the adoption of reading per-
formance as an outcome measure in clinical research, given the
fact that reading is a primary activity of daily life.
Acknowledgments
The authors thank Greta Codutti, Simonetta Geotti, and Marta Makuc
(Neurophthalmology Unit, IRCCS, E. Medea, La Nostra Famiglia, Polo
Friuli Venezia Giulia, Italy) for examining subjects and for managing
study data; and Rodolfo Saracci (Director), and Franco Merletti, Euge-
nio Paci, Emanuele Crocetti and Annibale Biggeri, (teachers) in the
Masters Program in Epidemiology (University of Turin, Italy) for com-
ments on the manuscript.
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