Visual Acuity

and
Auto Chart Projector
 Definition
• Visual acuity:
– Measure of the spatial resolution of the visual
processing system
– Usually tested in a manner to optimize and
standardize the conditions.
– Black symbols on a white background are used (for
maximum contrast)
– At a sufficient distance allowed to approximate
infinity
 Definition
• Visual acuity:
– Ability to see fine details
– Dependent on the sharpness of the retinal focus
within the eye and the sensitivity of the
interpretative faculty of the brain.
 Why VA
• Clinically it is essential to detect any ocular
disease or injury .e.g. cataract, corneal
disorder, refractive errors….
• It is essential to qualify for certain occupations
.e.g. firefighters, aircraft pilot, taxi drivers…
 Types of VA
• Types of visual acuity:
1- Visibility
2- Resolution
3- Recognition
4- Direction
 Charts for measuring VA
- Snellen chart, ETDRS, Bailey-Lovie
- Tumbling E (illiterate E), Landolt C
- Picture chart, Allen chart, Sheridan-Gardiner
- Near test cards
 Designation of VA
• VA expresses the angular size of the smallest
target that can be resolved and is specified by
clinicians in many ways:
1) Snellen fraction:
VA= Test distance/distance at which letter
subtends 5 min of arc.
 VA
• In the term "20/20 vision"
– Numerator refers to the distance in feet between the
subject and the chart.
– Denominator is the distance at which the lines, that make
up those letters, would be separated by a visual angle of 1
arc minute,
– For the lowest line that is read by an eye with no
refractive error (or the errors corrected) is usually 20 feet
• The metric equivalent is 6/6 vision where the
distance is 6 meters.
 VA
• A visual acuity of 20/20 is frequently described
as meaning that a person can see detail from
20 feet away the same as a person with
normal eyesight would see from 20 feet. If a
person has a visual acuity of 20/40, he is said
to see detail from 20 feet away the same as a
person with normal eyesight would see it from
40 feet away.
 VA
• It is possible to have vision superior to 20/20:
the maximum acuity of the human eye
without visual aids is generally thought to be
around 20/10 (6/3); however, recent test
subjects have exceeded 20/8 vision. Some
birds, such as hawks, are believed to have an
acuity of around 20/2; in this respect, their
vision is much better than human eyesight
 VA
• 2) Decimal notation: simply converts the
snellen fraction to the decimalized form.
• 3)Minimum Angle of Resolution(MAR):
expresses the angular size of the critical detail
within the just-resolvable optotype.
20/20= 1 min of arc = 1 MAR
20/200= 10 min of arc
 VA
• 4) LogMAR: is the logarithm of the MAR
• Commonly used scale which is expressed as the logarithm of the
minimum angle of resolution.
• LogMAR scale converts the geometric sequence of a traditional
chart to a linear scale.
• Measures visual acuity loss; positive values indicate vision loss,
while negative values denote normal or better visual acuity

If MAR = 10 min of arc then,

logMAR= log10 (10)=1.0
 VA
• This scale is rarely used clinically; it is more
frequently used in statistical calculations
because it provides a more scientific
equivalent for the traditional clinical
statement of “lines lost” or “lines gained”,
which is valid only when all steps between
lines are equal, which is not usually the case
VA
 VA
5) Another common system of measurement in
Europe is the Monoyer scale: it is the
indication in fractions with the denominator
10 for the values expressed in the decimal
form.
 VA
M.A.R. [Link] [Link]

α = 1' 1/1’ = 1,0 10 / 10

α = 2' 1/2 ‘ = 0,5 5 / 10

α = 10' 1/10’ = 0,1 1 / 10

M.A.R. [Link] [Link] Metric Imperial
Snellen Snellen
 
α = 1' 1/1’ = 1,0 10 / 10 6/6 20/20
α = 2' 1/2 ‘ = 0,5 5 / 10 6 / 12 20/40
α = 10' 1/10’ = 0,1 1 / 10 6 / 60 20/200
 VA Chart Designs
• Beginning was with Snellen in 1826. the chart
had 7 size levels starting the level with one
letter and adding a letter with decreasing the
size to reach 7 letters/line on line 7
corresponding to 20/20.
• The size sequence was
200,100,70,50,40,30,20
 VA Chart Designs
• Bailey-Lovie in 1976 proposed a set of principles
that will make the task at each letter size the
same:
1- A logarithmic size progression
2- Same number of letters on each line
3- Between letter and Between line spacing
proportional to letter size
4- Equal average legibility for optotypes at each
level
VA Chart Designs
VA Chart Designs
 Testing VA
• 1) Printed Panel Charts
• 2) Video Display Charts
• 3) Projector Charts
 Testing VA
• The method most currently used to determine
the correct optical prescription for an
ametropic patient is, in part, determined by
ascertaining the appropriate visual acuity with
screen projected optotypes
 Testing VA
• Besides containing the traditional optotypes,
the projector has a number of tests that
produce an accurate refractive exam, and
further allow for a determination of a
multitude of the patient’s visual functions
Testing VA
Testing VA
 Testing VA
• In modern projectors, the operator is able to
choose the number and sequence of the tests
to be presented, and he is able to program
them according to his needs and clinical
preferences
 Types of visual acuity charts present in auto
projectors
• Morphoscopic Visual Acuity

• Angular Visual Acuity

Morphoscopic Visual Acuity
 Morphoscopic VA
• Present great advantage in their simplicity of use,
even if they do require a minimum degree of
education on the part of the patient.
• The patient’s recognition involves
– Stimulated physical area of retinal separation
– Complex psycho-physiological factors of perception in
the form of interaction between the physical
characteristics of the test, the ocular optical system,
the analytic properties of the brain, and the patient’s
individual experience
 Morphoscopic VA
• Same angular value
• Not every symbol presents the same level of difficulty of recognition, it is easier
to recognize an isolated symbol than the same one presented among other
symbols.
• For the same degree of difficulty of single alphabetical letters, the following chart
of Rönne can be referred to, where the errors for single letters recognition are
indicated in percentages:
 
• L = 1% Z = 7% C = 13% Y = 19%
• I = 2% F = 8% N = 14%S = 20%
• A = 3% D = 9% X = 15% R = 21%
• U = 4% V = 10% H = 16%M = 22%
• T = 5% O = 11%K = 17% B = 23%
• P = 6% E = 12% G = 18%
 Morphoscopic VA
• The figures for children should be utilized
when it is not possible to use either the
illiterate E optotypes, or Landolt C, due to age
or low patient reliability.
• The visual acuity values found to the sides of
the figures are merely approximates and do
not correspond exactly to the more accurate
tests
Angular Visual Acuity
 Angular VA
• The other two configurations for existing
optotypes, the illiterate E, and Landolt C,
present a constant degree of difficulty of
recognition because they employ fewer
perception psycho-physiological factors, and
they can therefore be easily utilized with pre-
school age children or illiterate patients.
 Angular VA
• With these tests, the angular visual acuity is
actually evaluated by the separation of two
adjacent points of the symbol.
• Each symbol, separately seen, just as with
numbers and the alphabetical letters, is
constructed inside a square where the
thickness of the mark is one-fifth of the side of
the square which contains it.
 Background Screen Illumination
• There are many different factors that influence the
measurement of visual acuity, among these, is the
structure of the optotypes.
• Also of great importance is the screen background
illumination level
• In order to obtain the maximum resolution of the
projected images in the absence of annoying reflections, it
is advisable to use the screen supplied with the projector,
which also permits the best execution of the tests using
polarized and duochrome red-green filters.
• These two tests indeed lose a great deal of effectiveness if
they are projected onto a wall or other type of screen
 Ambient Room Illumination
• Fundamental importance because it changes the screen
background illumination.
• This affects, indirectly, the level of the spatial retinal
interaction.
• The optimal value for the ambient illumination corresponds
to that of the screen background. It is further indispensable
in order to obtain the correct values for visual acuity that the
eye is completely adapted to the ambient room illumination.
• Up to several minutes may be necessary, depending upon
the ambient illumination. It is therefore not advisable to
measure visual acuity in complete darkness
 VA
• Factors affecting VA:
1- Condition of patient: mood, fear, depression,
anxiety, intelligence, awareness.
2- Facial expression and symmetricity
3- Visual receptor: size and sensitivity
4- Optical factors: aberrations, diffraction…
5- Illumination
6- Pupil size
7- Refractive errors
 Conditions affecting VA
1-Optical: a) Refractive Errors
b) Irregular or opacified ocular media
 Conditions affecting VA
• 2- Retina: swelling or cell loss
 Conditions affecting VA
3- Neural: a) Optic nerve: papilloedema
b) Brain
 Conditions affecting VA
• 4- Infections: conjuctivitis, blepharitis…
 Conditions affecting VA
• 5- Non vision related. Eg: mental retardation
 Refractive Correction
• 1- Uncorrected VA: done with no visual aids to
see how well or how poor patients can see
deprived from correction. Dimming the light
help better to detect it.
• 2- Habitual VA: Done with the glasses or
contacts already used by the patient.
 Refractive Correction
• 3- Corrected VA: Is measured at the clinic.
Recording it provides a benchmark for any future
progression of the acuity
• 4- Pinhole VA: used to detect the reason behind
not reaching 20/20 vision.

• Note: sometimes special illumination of the chart

or room is used in the test .e.g. postlaser/LASEK
surgery, retinal diseases…
 Refractive Correction
• 5) Near Vision: ability to see clear at normal
reading distance (40 cm)
 Name Abbreviation Definition
Counting Fingers CF Ability to count fingers at a given
distance(4M)
Hand Motion HM Ability to distinguish a hand if it is
moving or not in front of the patient's face.(1/2M)
Light Perception LP Ability to perceive any light.(15
INCHES)
Light Perception with projection(LPP)Tell direction of light
No Light Perception NLP Inability to see any light. Total
blindness.
 Testing Distance
• Twenty feet is essentially infinity from an
optical perspective (the difference in optical
power required to focus at 20 feet versus
infinity is only 0.164 diopters)
 Testing Procedure
• The test is always done checking the monocular
vision starting with the right eye first. Binocular
vision is tested when done refracting both eyes
separately.
• The patient is asked to read either starting from
largest letter to smallest or starting from the
size larger than the expected VA.
• Refractive lenses are used to improve the letters
at any stage.
 Recording VA
• Recording the VA score is done by writing the
row that is best read .e.g. 20/25 or 20/80.
• If a patient did not read 20/20 fully or missed
some letters in a row the a plus and minus
notation are used
.e.g. 20/25 was fully read and 2 letters from
20/20. The score will be 20/25+2 or 20/20-3
 Exercises to be done
• Recording Va