The Sonksen logMAR Test of Visual Acuity:

I. Testability and reliability

Alison T. Salt, MSc, FRACP, FRCPCH,a,b Angie M. Wade, MSc, PhD,b Ruth Proffitt, DBO, BSc,c
Sally Heavens,c and Patricia M. Sonksen, MB, BS, MD, FRCPCH, FRCPa,b

PURPOSE To develop a standardized logMAR test of visual acuity for young children and establish
testability and reliability.
METHODS Two thousand nine hundred ninety-one children, aged 2 to 8 years 6 months, from a
population sample of 4671 were recruited from schools and preschool facilities and tested.
Ability to name or match letters, accept occlusion, and achieve binocular single and
binocular and monocular measures of linear visual acuity were recorded. Inter- and
intratester reliability was assessed for a random selection of 215 children.
RESULTS Two thousand nine hundred seventy-four (99.4%) matched or named letters, 2966 (99%)
achieved binocular single, 2940 (98%) achieved binocular linear, and 2807 (94%) achieved
monocular linear (for both eyes) measures. Binocular linear measures were achieved in
50% aged less than 3 years, 80% aged 3 to 3½, 92% aged 3½ to 4, and 99% aged 4 years
and over. Binocular linear measures were achieved in 86% of 2- to 3-year-olds and 96%
of 3- to 3½-year-olds who matched or named letters; monocular linear measures were
achieved in 86 and 95%, respectively, of these age groups who then accepted occlusion.
The median time for completion of the test ( binocular and monocular) was 3 minutes 55
seconds. The 95% limits of agreement for the same observer and for different observers
were ⫾0.13 and ⫺0.19, ⫹0.15 for binocular linear and ⫺0.16, ⫹0.15, and ⫺0.17, ⫹0.13
for monocular linear measures, respectively.
CONCLUSIONS The Sonksen logMAR Test provides reliable binocular and monocular measures of linear
visual acuity in a high proportion of children from the age of 2.5 years. ( J AAPOS 2007;
11:589 –596)

let.8 In 1995 our group demonstrated high testability even

T
esting the visual acuity of young children in accord
with adult standards has posed problems to test
designers over several decades.1-4 Many designers
have introduced stimulus modifications in attempts to sim-
plify the developmental content, for example, using sym-
bols instead of letters.5,6,7
The Sonksen Silver Acuity System successfully ad-
dressed many of the developmental problems of letter-
based tests for young children, while adhering strictly to
the specifications of the Snellen standard, and was the first
to introduce single-line test displays in a flip-over book-
Author affiliations: aGreat Ormond Street Hospital, NHS Trust, University College,
London, United Kingdom; bInstitute of Child Health, University College, London,
United Kingdom; cLifespan Healthcare NHS Trust, Cambridge, United Kingdom
This study was supported by The NHS Executive, Anglia and Oxford Division,
United Kingdom.
The Sonksen logMAR Test is produced commercially by Novomed UK. Once
production costs are recovered by the company, a research fund held by PS and AS will
receive 10% of profits from sales.
Submitted November 12, 2006.
Revision accepted April 30, 2007.
Published online August 3, 2007.
Reprint requests: Dr. Alison T. Salt, The Wolfson Centre, Institute of Child Health,
University College, Mecklenburgh Square, London, WC1N 2AP, UK (email: a.salt@
ich.ucl.ac.uk).
Copyright © 2007 by the American Association for Pediatric Ophthalmology and
Strabismus.
1091-8531/2007/$35.00 ⫹ 0
doi:10.1016/j.jaapos.2007.04.018
of the youngest children for this test and maturation in
visual acuity between 2 years 6 months and 9 years.9,10
The Consilium of Ophthalmologists decided that the
logMAR scaling devised by Bailey and Lovie in 1976
had advantages over Snellen scaling and is now the
accepted gold standard.11-14 When we decided to design
the Sonksen logMAR test, existing logMAR tests for
children were published without norms: in some the
spacing between optotypes was less than that specified
for adult tests, such as the ETDRS.15-18 Such factors
compromise the interpretation of measurement in terms
of the adult standard and the accuracy of monitoring
changes in visual acuity due to treatment or progress of
disease from childhood into early adult life. A standard
logMAR test system together with testability, reliability,
and norms was therefore needed for preschool and
young school-age children.
In this article we present the first two stages in the
development of the Sonksen logMAR Test: (1) test
design and standardized protocol and (2) testability and
reliability. We present the third stage—the develop-
ment of age norms—in the companion article.19 The
new test has logMAR scaling, uses international chart
design standard letter optotypes with constant contour
interaction, and uses a standard test protocol that in-

Journal of AAPOS 589

590 Salt et al
cludes features aimed at enhancing testability of the
youngest age groups.
Materials and Methods
Ethical approval was obtained from the Ethics Committees of
Cambridge District ( UK) and the Institute of Child Health
London. Data collection was organized and collated by the re-
search orthoptist and administrator. Five other community or-
thoptists assisted the research orthoptist with vision testing after
instruction in the standard test protocol (see e-Supplement 1,
available at jaapos.org); this ensured uniformity of test adminis-
tration throughout the study.
Design of the Sonksen logMAR Test
Developmental Features. In designing the Sonksen Sil-
ver Acuity System and the Sonksen logMAR Test, we adhered to
fundamental developmental principals of test design: when
adapting test design to suit an age or disability group, one
modifies/simplifies the instructions and response task to suit the
group while maintaining the fabric/standard of the test content.
The developmental features of the Sonksen logMAR Test and of
the test protocol are similar to those of the Sonksen Silver Acuity
System,8 with a training booklet, keycard, one single-letter, and
two linear flip-over test booklets, pointer, and occlusion specta-
cles. Each page of the linear test booklets presents a single line of
four letters with crowding bars. The letters O, X, H, T, U, and
V were selected as these are the easiest for young children to
match.2 A test distance of 3 m was chosen as this enhances
rapport and helps maintain the attention of the youngest children
without affecting contour interaction or decreasing sensitivity or
detection rate of myopia.20,21 A flip-over booklet of crowded
single letters was used to facilitate choosing a suitable starting
level in the linear booklet as young children are likely to tire and
give erratic responses if asked to identify all the test letters on an
eye chart.
Test Specifications. The specifications recommended by
the Consilium of Ophthalmologists and others were closely ad-
hered to in the test design.11,12,18,22 Optotypes and the spacing
between them conform to ETDRS specifications, that is, letters
are 5 minutes of arc square, without serifs, and with stroke width
equivalent to 1 minute of arc at every level. Spacing between
optotypes is equal to one letter width. Figure 1 illustrates a linear
test display. (For full design details, see e-Supplement 1 and the
Figure 1 legend.)
Test Protocol. Younger children are seated at a low table
and trained in letter matching using the training booklet and
keycard if unable to name letters. Children are then asked to
identify each of the letters in the booklet of single-letter displays
presented at 3 m starting with the 0.7 letter until a letter is not
seen correctly. The smallest letter seen is recorded as the child’s
binocular visual acuity for singles. The test display two logMAR
levels above the singles failure in the first linear test booklet is
then presented. If a child is unable to see some of the letters at
the starting level, the tester should present the preceding larger
displays until a full line is identified; the child is then shown each
letter in turn until three consecutive letters are failed. Every
Volume 11 Number 6 / December 2007
FIG 1. The Sonksen logMAR test linear display (size 0.7). The letter size
of test displays follows the standard logMAR geometric progression with
each step equal to 0.1 log units. The range of the letter size of the
prototype test was 0.7 to ⫺0.3 log units (11 levels). Uniform crowding
was assured with each single or line of optotypes surrounded by crowding
bars. At each level the thickness of the crowding bars is equal to that of
the stroke of the test letters; spacing above the test display (horizontal
bar) is equivalent to the height of the optotypes of the preceding larger
display and spacing from end of line letters (vertical bars) and below
(horizontal bar) is the width of the optotypes on the current display line.
letter correctly identified after the last whole line achieved con-
tributes to the score.23 Occlusion spectacles are then introduced
and monocular acuity is ascertained using the second booklet of
linear displays for the right eye and the first booklet for the left
eye. The time taken for each phase of testing was recorded. (For
fuller details, see e-Supplement 1.)
Study Design. The design of the study was cross-sectional
and population based.
Recruitment. Children aged 2 years to 8 years 8 months
were recruited through Cambridge ( UK) city, state, and private
sector schools, nurseries, and playgroups. No visual defect or
impairment criteria were applied. Parents/guardians who gave
consent provided information on demographics and prior vision
treatment via a questionnaire. Class listings were used to ascer-
tain the total population from which the responders were drawn
and to check demographic data, including gender and postal
code. Ethnicity was recorded at the time of testing. Socioeco-
nomic status was based on the Townsend Index, which provides
a material measure of deprivation and disadvantage based on data
from the 2001 UK population census. Higher Townsend index
scores are associated with higher deprivation and disadvantage.24
Testing. Ability to match or name letters, to accept oc-
clusion, and to achieve the four measures of visual acuity—
binocular singles, binocular linear, and monocular linear
(right eye then left eye)—were recorded together with the
measures achieved. Spectacles, if worn (4% of children tested),
were removed during testing. Patients who failed to meet
predefined visual acuity criteria were referred for ophthalmo-
logic evaluation.
Reliability. A random selection of 215 children were re-
tested within 11 days, 103 by the same orthoptist, to ascertain the
level of inter- and intratester reliability. These children came
from across the test sites to ensure a distribution of ages in line
with the overall population.
Journal of AAPOS
Volume 11 Number 6 / December 2007 Salt et al 591

99.5 (99, 100)

99.6 (99, 100)
100 (99, 100)
37.5 (18, 61)
51 (43, 60)
80 (74, 85)
93 (90, 95)
97 (95, 98)

94 (73, 99)
94 (93, 95)
Linear monocular:

%
left eye

351
6
68
168
337
689
633
553

16
2821
No.

99.7 (99, 100)

100 (99, 100)
100 (99, 100)
100 (82, 100)
50 (28, 72)
59 (50, 67)
86 (81, 90)
94 (91, 96)
97 (96, 98)

95 (95, 96)
Accept occlusion:

Testability is given for each stage of testing by age group. %: proportion of total children in each age group who participated in testing; No : number; 95% CI : 95% confidence intervals.
%
left eye

351
8
77
180
340
693
634
554

17
2854
No.

99.4 (99, 100)

99.4 (98, 100)
100 (99, 100)
37.5 (18, 61)
51 (43, 60)
81 (76, 87)
93 (90, 95)
97 (95, 98)

94 (73, 99)
94 (93, 95)
Linear monocular:
FIG 2. Recruitment flowchart.

%
right eye
Statistical Methods
Testability is given within age groups. Estimates are given with
95% confidence intervals. The differences in the two repeats of

552
351
6
68
171
336
688
632

16
2820
No.
binocular and monocular visual acuity from each child were
calculated. The differences were used to estimate limits of agree-

99.7 (99, 100)

100 (99, 100)
100 (99, 100)
ment, and these are presented with 95% confidence intervals

50 (28, 72)
60 (51, 68)
86 (84, 88)
94 (91, 96)
98 (96, 98)

100 (73, 99)

95 (95, 96)
Accept occlusion:
using methods described by Bland and Altman.25 Any tendency

%
for the difference between repeats to vary by acuity level, by age
of the child, by orthoptist taking the repeat measurement (same right eye
or different), by time interval between the repeat tests, and/or by
the gender of the child was investigated via regression analysis. 8
78
181
341
694
634
554
351
17
2858
No.

Differences in binocular and monocular visual acuity repeats

were regressed against each factor to determine the univariable
association. A significant association with more than one factor 99 (98, 100)
99 (99, 100)
100 (99, 100)
99.8 (99, 100)
100 (99, 100)
62.5 (39, 86)
80 (73, 86)
94 (91, 97)

94 (73, 99)
98 (98, 99)
was investigated with multivariable models to determine the
Linear binocular
%

independence of those associations.

Results
Participants
10
107
198
360
708
636
554
351
16
2940
No.

Sixty-eight of the 72 sites identified and approached were

successfully recruited. Of a potential 4671 eligible children
98 (96, 100)
99.7 (98, 100)
100 (99, 100)
100 (99, 100)
100 (99, 100)
100 (99, 100)
100 (82, 100)
99.4 (99, 100)
% (95% CI)
81 (64, 99)
94 (90, 98)

(Figure 2), a total of 2991 children were tested: 1500 boys

Able to letter match

and 1491 girls aged 24 months to 103 months (mean, 62

months; median, 61 months). Two children did not have
their ages recorded. The age distribution of the 3022
children who attended for testing is shown in Table 1.
13
123
206
362
711
636
555
351
17
2974

Ethnicity was recorded for 3018 children (4 not re-

No.

corded): white 2653 (88%), black (Afro-Caribbean) 37

Table 1. Testability by age group

(1.2%), Asian (Indian/Pakistani) 124 (4%), East Asian 82

participants

(2.7%), mixed 82 (2.7%), and other 40 (1.3%), a distribu-

16
131
210
363
711
636
555
351
17
2991
Total

No.

tion that closely reflects the UK population.26

Townsend index scores, assessed from postcode, were
available for 2883 children tested with a median ⫺0.3
(range, –7.1 to 7.27) compared with ⫺0.65 for the total
Age group

12

21⁄2 to ⬍3
3 to ⬍31⁄2
31⁄2 to ⬍4
2 to ⬍2 ⁄

UK population, covering the 1st to the 97th centile of

8 to 81⁄2
4 to ⬍5
5 to ⬍6
6 to ⬍7
7 to ⬍8
( y)

scores and therefore representative of all but the most

Total

extreme levels of deprivation or wealth.26

Journal of AAPOS
592 Salt et al Volume 11 Number 6 / December 2007

The number of children wearing glasses or already re-

ceiving ophthalmic treatment was 195/3014 (6.5%), which
is similar to the number of expected ocular or vision
defects requiring treatment or follow-up in the general
preschool population.27-29
For those who consented, there was no difference in the
presence of a known eye/vision problem or English as first
language between those tested and those who were absent
or “unwilling” to be tested on the day.

Testability
Table 1 presents testability with 95% confidence intervals
(CI) for each age group and the factors that influence
ability to complete the “test”—achieving binocular and
monocular linear visual acuity measures for both right and
left eyes. Of the total 2991 children tested, 2807 (94%)
completed the test. Almost all (2236/2270 [99%]) children
aged 4 years and older completed the test; 50% of children
under 3 years old, 80% of 3- to 3½-year-olds, and 92% of
3½- to 4-year-olds did so. FIG 3. Box-and-whisker plot of times taken to complete the binocular test
Developmental factors (ability to letter match and to ac- and all tests within each age group. The boxes show the interquartile
cept occlusion) influenced the ability of children less than 4 ranges and the line within each box indicates the median time. The
years old to complete the test. Letter matching was achieved whiskers show the range within which approximately 99% of the values
in 94 to 100% of children from 2½ years. Of those able to lie; outlying points are shown by the circles. The x-axis scale shows age
groups as for Table 1.
letter match, 87% (95% CI, 80-92) of children under 3 years
old, 96% (95% CI, 93-99) of 3 to 3½-year-olds achieved a
for both the same and different observers. The limits of
binocular linear visual acuity measure. Only 7 of the 2630
agreement show the range within which 95% of differ-
(0.3%) children aged 3½ and older who were able to letter
ences are expected to lie. The average difference and limits
match did not complete the binocular linear test.
of agreement are shown on the plots together with 95%
Acceptance of occlusion was lowest in children under
confidence intervals. The confidence intervals show the
3½ years. Of those who had achieved a binocular measure,
precision of the mean and limit estimates.
73% (95% CI, 65-81) of under 3 years old, 91% (95% CI,
For the same observer, the mean difference between
87-95) of 3- to 3½-year-olds, and 95% (95% CI, 92-97) of
repeat test scores for binocular linear visual acuity was
3½- to 4-year-olds accepted occlusion. Subsequently
0.0024 logMAR (95% CI, ⫺0.010-0.015) and the 95%
74/86 (86-95% CI, 79-93) of under 3-year-olds and 171/
limits of agreement were ⫾0.13 logMAR (⫾5.2 letters).
181 (94.5-95% CI, 91-98) of 3- to 3½-year-olds who had
For different observers the mean difference was ⫺0.016
accepted occlusion achieved monocular measures. From
(95% CI, ⫺0.032-0) and the 95% limits of agreement
the age of 3½ years, more than 99% of those accepting
were ⫺0.19, ⫹0.15 logMAR (⫺7.6, ⫹6 letters). For the
occlusion completed the test.
same observer the mean difference between repeat test
The median administration time, the range, and
scores for monocular linear visual acuity was ⫺0.0082
interquartile range by age group is given in Figure 3. In
(95% CI, ⫺0.024-0.007) and the 95% limits of agreement
children unable to name letters, time taken included train-
were ⫺0.16, ⫹0.15 logMAR (⫺6.4, ⫹6 letters). For dif-
ing to letter match. The median time for completion of a
ferent observers, the mean difference was ⫺0.0188 (95%
binocular single and linear measures was 2 minutes, 1
CI, ⫺0.034-0.004) and the 95% limits of agreement were
second and for completion of both binocular and monoc-
⫺0.17, ⫹0.13 logMAR (⫺6.8-5.2 letters).
ular testing was 3 minutes, 55 seconds. Even in children
There were no significant trends in differences with
younger than 3 years, the median time to complete both
average visual acuity level for single and linear binocular
binocular and monocular tasks was 6 minutes with a min-
and linear monocular measures ( p ⫽ 0.352, 0.106, and
imum of 3 minutes, 7 seconds.
0.269, respectively).
Regression analysis was used to determine whether the
Reliability differences in repeat measurements of single and linear
The Bland-Altman plots of within (A) and between (B) binocular and linear monocular visual acuity varied ac-
orthoptist reliability are shown in Figure 4 for binocular cording to whether the tested differed between repeats,
linear measures and Figure 5 for monocular linear mea- how long there was between repeats, the age of the child,
sures— only right eyes were retested. For all measures and/or their gender. The results for each of the four
there was good agreement on average between repeat tests factors are shown separately in Table 2. The p-values show

Journal of AAPOS
Volume 11 Number 6 / December 2007
FIG 4. Bland-Altman plots for binocular linear visual acuity measures of
agreement for (A) the same observer (N ⫽ 103) and (B) different observ-
ers (N ⫽ 111) showing difference in log units between repeat binocular
linear visual acuity scores plotted as a function of the mean of the two
scores in log units. (- - - -) Mean and 95% confidence limits of agree-
ment. (. . .) 95% confidence intervals around the mean and limits of
agreement. (A) Mean difference 0.0024 (95% CI, ⫺0.010-0.015); Lower
limit of agreement ⫺0.126 (95% CI, ⫺0.148-0.104); Upper limit of
agreement 0.131 (95% CI, 0.109-0.153). (B) Mean difference ⫺0.016
(95% CI, ⫺0.032-0); Lower limit of agreement ⫺0.187 (95% CI, ⫺0.215-
0.159); Upper limit of agreement 0.155 (95% CI, 0.127-0.183).
that there were no statistically significant differences at-
tributable to any of the four factors. The coefficients and
95% confidence intervals quantify the average size of dif-
ferences observed. There was no evidence that test-retest
agreement differed between the six orthoptists.
Journal of AAPOS
Salt et al 593
FIG 5. Bland-Altman plot for right eye monocular linear visual acuity mea-
sures of agreement for (A) the same observer (N ⫽ 100) and (B) different
observers (N ⫽ 100), showing difference in log units between repeat mon-
ocular linear visual acuity scores plotted as a function of the mean of the two
scores in log units. (- - -) Mean and 95% confidence limits of agreement. (. . .)
95% confidence intervals around the mean and limits of agreement. (A) Mean
difference ⫺0.0082 (95% CI, ⫺0.024, 0.007); Lower limit of agreement
⫺0.162 (95% CI, ⫺0.189-0.135); Upper limit of agreement 0.146 (95% CI,
0.119-0.172). (B) Mean difference ⫺0.0188 (95% CI, ⫺0.034-0.004); Lower
limit of agreement ⫺0.171 (95% CI, ⫺0.197-0.145); Upper limit of agree-
ment 0.133 (95% CI, 0.107-0.159).
Discussion
The Sonksen logMAR Test adheres more closely to log-
MAR standard specifications than many other tests de-
signed for children. The optotypes are letters as opposed
594 Salt et al Volume 11 Number 6 / December 2007

Table 2. Univariate associations between the differences in repeat measurements with test and child factors

Single binocular Linear binocular Linear monocular

Coefficient (95% CI) p-value Coefficient (95% CI) p-value Coefficient (95% CI) p-value
Same, as opposed to different, 0.024 (⫺0.003, 0.051) 0.087 0.0184 (⫺0.003, 0.039) 0.085 0.0105 (⫺0.011, 0.032) 0.337
orthoptist retesting
Time between repeats (d) ⫺0.0047 (⫺0.003, 0.012) 0.232 ⫺0.0054 (⫺0.001, 0.012) 0.097 0.00064 (⫺0.006, 0.007) 0.848
Age ( y) ⫺0.00098 (⫺0.002, 0.000) 0.06 0.0007 (0.000, 0.002) 0.076 0.00037 (⫺0.001, 0.001) 0.408
Male 0.0124 (⫺0.015, 0.04) 0.368 0.0088 (⫺0.012, 0.03) 0.413 ⫺0.0008 (⫺0.023, 0.021) 0.94
The associations between the differences in repeat measurements of single and linear binocular and linear monocular assessments with test (whether same or different
orthoptist, time between repeats) and child (gender, age) factors. All associations shown are univariable (ie, unadjusted for other factors). For continuous measurements (time
between and age), the coefficient is the estimated average increase per unit increase (ie, per time of day or per year of age) and for the binary factors (same vs different
orthoptist, male vs female), the coefficient gives the estimated increase attributable to those in the first category (same orthoptist, male) as opposed to the alternative (different
orthoptist, female). All coefficients are presented with 95% confidence intervals (95% CI) and p-values are given.

to symbols and are presented in single lines with constant
contour interaction. Other tests developed for pediatric
populations (eg, Kay and Lea symbol charts) use nonstand-
ard picture stimuli1,30 or reduced spacing (increasing con-
tour interaction) of letters (eg, the Keeler logMAR Test)7
compared with the adult standard. These variations make
accurate comparisons difficult as the child matures and
adult tests are used.
This large population-based study of children aged 2 to
8 years 8 months using the Sonksen logMAR Test shows
high testability for both binocular and monocular testing
even in children aged 2½ to 3 years. Sonksen introduced
features into the design of the Sonksen Silver Acuity Sys-
tem to reduce the developmental complexity of the test
task and proposed a test protocol that improved testability
in the youngest children.8 We incorporated similar devel-
opmental features and standard test protocol into the
Sonksen logMAR Test and again found high levels of
achievement for monocular measures—51% of 2½- to
3-year-olds, 80% of 3- to 3½-year-olds, and 92% of 3½-
to 4-year-olds. The important developmental features of
the protocol are: (1) sitting the child at a nursery table and
chair, (2) using the techniques described to train matching
and level finding, and (3) taking a full binocular linear
visual acuity measure before attempting occlusion.8,9 Ad-
ministration time for the test is very acceptable for a
screening or diagnostic program and similar to that re-
ported by others.9,31,32
Most studies have either not included33 or have reported
poorer testability than found in this study in under 3½-
year-olds.34-38 Groups who have looked at testability in
3-year-olds often fail to report separately on 3- to 3½-
year-olds and 3½- to 4-year-olds. In this study testability
was considerably better in the older group, suggesting that
testability is likely to be falsely high in a group of 3-year-
olds if the distribution is weighted in favor of the older age
bracket.
The rationale for starting with a monocular test even in
young children has been the clinical priority to identify
amblyopia. Our experience and the findings of our current
and previous studies suggests that completing binocular
testing first familiarizes a child with the test procedure
before adding the additional demands of occlusion and
thereby increases success with monocular testing.9 In this
study testability is higher in 2- to 5-year-olds than in
recent studies by others using protocols that start, as rec-
ommended by the Task Force12 with instruction in letter
matching ( binocular pretesting) at 1 or 3 m.30,31,36 The
clinical value of full binocular testing is highlighted by the
findings of two large epidemiologic surveys of visual acuity
in childhood and two evaluation studies, which show that
little reliability in detection of uniocular problems is
lost in patients without strabismus, by achieving a bin-
ocular measure only.27-29,39 On the basis of the above
evidence and as developmental experts with a major
interest in vision, we advocate that a full binocular
measure is undertaken before attempting occlusion or
monocular testing in under 5-year-olds.
The 95% limits of agreement of logMAR scores for the
Sonksen logMAR Test found in this study for monocular
visual acuity for the same (⫺0.16, 0.15) and different
observer (⫺0.17, 0.13) was in keeping with that previously
reported for logMAR-based tests in adult subjects and in
older children (5 to 9 years) (⫹0.14, ⫺0.14 to ⫹0.2, ⫺0.2),
despite the inclusion of young children in this co-
hort.12,40-42 A clinically relevant change in visual acuity
would from these results have to fall outside the 95%
limits of agreement, that is, for two measures made by the
same observer, a clinically relevant difference would be
that deemed to be outside the expected differences that
would be observed between repeats anyway: more than five
letters for binocular visual acuity and more than seven
letters for monocular visual acuity.
Differences in repeat measures were not significantly
influenced by any of the factors examined. The most
marginal results were for age; however, the point estimates
show that any differences are small. For example, the
estimated change with age for single binocular repeats is
negative, indicating better agreement for older children as
would be expected, yet the fall is only estimated to be
0.00098 per year and even over the entire age range in-
vestigated (2-9 years) this is an estimated change of less
than 0.007 (less than one letter). On the basis of these
results, it is reasonable to infer that clinically important
differences did not occur. Although the sample sizes are
not large for some subgroups, the coefficients and confi-

Journal of AAPOS
Volume 11 Number 6 / December 2007
dence intervals suggest that clinically important differ-
ences were not missed due to a lack of power.
The strengths of this study are the adherence to inter-
national test design standards, an acceptable response rate
(70%) with consent only withheld actively in 77 (1.6%),
and the size and representativeness in terms of ethnicity
and socioeconomic status of the population-based cohort
to that of the UK.
Limitations include lack of demographic data concern-
ing nonresponders as demographic details were only col-
lected with the returned consent. The potential bias of
parents of children with visual difficulties being less or
more likely to respond is unlikely given the prevalence of
defects found in the population tested.
Conclusions
This article presents the first two stages in development of
the Sonksen logMAR Test, a new test for children that
accords with the adult standard and with a standard test
protocol. Levels of testability are higher and reliability
data are comparable to other tests. Stage 3, the derivation
of age norms, is presented in the companion article.19
Acknowledgments
The authors thank the orthoptists, head teachers, and staff of partici-
pating schools and nurseries for enthusiastic support. Also, A. Nigge-
brugge, Information Specialist Geographical Information Systems,
Eastern Region Public Health Observatory, Cambridge, UK, and A.
Lovett, Reader in the School of Environmental Sciences, University of
East Anglia, Norwich, UK, for help in analysis of the SES of the
population.
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First Person

I saw a 6-year-old boy this morning for a routine eye exam. As usual, I chat with the kids
while examining them.
Me: Do you like to play sports?
Boy: Yeah, I like to play soccer.
Me: Anything else you like to do?
Boy: I like to be annoying
—Mark Silverberg, MD

Journal of AAPOS