Visual Acuity in Adults

Dr. Awantika Subedi

1st year Resident,
LEIRC, NAMS
PRESENTATION LAYOUT
• Introduction
• History
• Components of VA
• Clinical Uses
• Factors affecting VA
• Measurement of VA
• Color Vision
• Contrast sensitivity
 Introduction to vision

• Vision or visual perception is a complex integration of :

• Light sense
• Form sense
• Sense of contrast
• Color sense
LIGHT SENSE

• Light sense is the ability of the eye to detect presence or absence of

light.
FORM SENSE

• Form sense is the ability to discriminate

shapes of objects

• It is the function of cones

• Visual acuity recorded by Snellen's test

chart is a measure of the form sense.
SENSE OF CONTRAST
• It is the ability to perceive slight changes in
luminance between areas though separated
by definite border.

COLOR SENSE
• It is the ability to discriminate between
different colors.
• Function of the cones.
Introduction to Visual Acuity
• Visual acuity is a measure of the spatial resolution of the eye.

• It is an estimation of the ability of eyes to discriminate between two

points.
History of Visual Acuity
• In 1861 Franciscus Donders coined
the term visual acuity to describe
the sharpness of vision.

• In 1862 Dutch Ophthalmologist

Hermann Snellen introduced a system
for measuring visual acuity.
Continue…
• He laid out letters in 5x5 grid pattern which are known as optotypes.

• He also defined “standard vision” as the ability to recognize one of his

optotypes from distance of 20 feet when it subtended 5 minutes of
arc.
• In mid 20th century, American vision scientist Le Grand Riggs gave out
different components of visual acuity.
Visual Angle
• Visual angle is an angle subtended at the nodal point of the eye by
the physical dimensions of an object in the visual field.
• It specifies the spatial extent of objects or elements in the visual field.
• Two adjacent points can be seen clearly only when the two points
produce a visual angle of 1 min of arc or more.
Riggs’ Components of Visual Acuity
• Minimum Detectable ( visible)

• Minimum Separable (resolution)

• Minimum Recognizable (recognition)

• Minimum Discriminable ( hyperacuity)

MINIMUM DETECTABLE FUNCTION/MINIMUM VISIBLE

• Ability to determine whether or not an object is

present in a visual field. It is the absolute
threshold of vision.
• The limit for this kind of acuity is ~ 1 arc second.
• Example: A black dot against a white background
or a white point on a black background can only be
detected if its diameter is 30 arc second or more.
MINIMUM SEPARABLE (RESOLUTION)
• Discrimination of 2 spatially separated targets is called resolution.
• It is the normal angular threshold of discrimination for resolution of
30-60 seconds of an arc known as minimum angle of resolution
(MAR).
• In clinical practice, the measurement of visual acuity is considered
synonymous with measurement of minimum resolvable.
MINIMUM RECOGNIZIABLE

• Faculty by the virtue of which the individual not only discriminates

the spatial characteristics of the test pattern but also the pattern with
which he has previous experience (Identification of faces, letters,
symbols, pictures etc.) using his cognitive functions.
Minimum Discriminable (Hyperacuity)
• Minimum discriminable refers to spatial
distinction by an observer when the threshold is
much lower than the ordinary acuity.
• The best example of minimum discriminable
is vernier acuity, which refers to the ability to
determine whether or not two parallel and
straight lines are aligned in the frontal plane.
Clinical Uses of Visual Acuity
• To assess and quantify the eye’s ability to resolve varying letter sizes.

• To determine the pt. refractive status & precise refractive correction.

• To formulate a diagnosis in pt. with eye disease, trauma or congenital

defects.
Factors affecting Visual Acuity

Stimulus related factors:

• Luminance of test object
• Geometrical configuration of the stimulus
• Contrast of the stimulus from the surrounding
• Influence of wavelength of stimulus light
• Exposure duration of stimulus
• Interaction effects of the two targets
Continue…
Observer Related Factors:
• Retinal locus of stimulation
• Pupil size
• Accommodation
• Effect of eye movements
• Meridional variation in acuity
• Optical elements of the eye
• Developmental aspects
Tests for Far Vision
• Snellen’s Chart
• Landolt’s C ring Chart
• Tumbling’s E Chart
• LogMAR Chart
1. Bailey-Lovie LogMAR Chart
2. ETDRS Chart
Tests for Near Vision
• Jaeger’s Chart
• Roman test
• Snellen’s near vision Chart
Snellen’s Chart
• Chart consists of a series of letters of diminishing size.

• Each letter is of such a shape that it can be enclosed in

a square.

• The size of the square is five times the thickness of

lines composing the letter.
Principle of Snellen’s Chart

• Snellen’s chart is based on a

minimum angle of resolution of 1
minute of arc.
Snellen’s Fraction
Visual Acuity = Testing distance
Distance at which an optotype would subtend 5’ of
arc at retina
Procedure of taking visual acuity
• Snellen’s chart should be at a distance of 6
m or 20 feet.
• General illumination of the room should not 6m
be less than one-fifth the illumination of the distance
chart
• The chart should be placed above the
patient’s head at eye sight level.
• The RE is tested conventionally first ( except
if pt’s complain is defective LE vision)
Continue…
6/60 Top line (1 letter)
6/36 2 letters
6/24 3 letters
6/18 4 letters
6/12 5 letters
6/9 6 letters
6/6 7th line (approx. 7 letters)
Where the numerator denotes the distance at
which the test is performed i.e. 6 meters and the
denominator denotes the distance at which a person
with a normal vision sees.
Continue…

• If one cannot see the top line from 6m, he or she is asked to slowly
walk towards the chart till one can read the top line. Depending upon
the distance at which one can read the top line, the vision is recorded
as 5/60, 4/60, 3/60, 2/60 and 1/60.
• Finger counting close to face: If the patient
is unable to read the top line even from 1 m,
he or she is asked to count fingers (CF)of the
examiner and the vision is recorded as
Finger counting close to face (FCCF).
• Hand Movement: When the patient fails to
CF, the examiner moves his or her hand
close to the patient’s face. If one can
appreciate the hand movements (HM),
visual acuity is recorded as HM positive.
Continue…
• Perception of light: When the patient can not distinguish the HM, the
examiner notes whether the patient can perceive light (PL) or not. If
yes, vision is recorded as PL positive and if not, it is recorded as PL
negative.
LogMar Acuity
• LogMAR is an acronym for the base-10
logarithm of the minimum angle of resolution
(MAR) and refers to the ability to resolve the
elements of an optotype using Sloan letters.
• LogMAR charts address many of the
deficiencies of the Snellen chart and are the
standard means of VA measurement in
research.
LogMar Charts
• Bailey-Lovie Chart
• The ETDRS (Early Treatment Diabetic Retinopathy Study)
Bailey-Lovie Chart

• It is used at 6 m testing distance.

• Each line of the chart comprises 5
letters and the spacing between
each letter and each row is related
to the width and the height of the
letters.
• The letter signs are rectangular
rather than square, as with the
EDTRS chart. A 6/6 letter is 5 inch in
height by 4 inch in width.
ETDRS
• The chart is calibrated for 4
meters.
• ETDRS Uses Sloan letters
(C,D,H,K,N,O,R,S,V,Z)
• ETDRS letters are square,
based on a 5 × 5 grid.
Scoring of LogMAR Chart
• Each letter correctly read: Add 0.02
• If a patient identifies all the letters in a row correctly, subtract 0.1
from base logMAR value of that row.
• logMAR score= base value-(0.02*no. of letters correctly identified)
Conversion of Snellen Visual Acuity from LogMAR
Snellen’s Chart vs LogMAR Chart
Snellen’s Chart LogMAR Chart
Shorter test time Longer test time
More letters on the lower causing Equal numbers of letters on different lines
‘crowding’ effect controls for ‘crowding’ effect

Irregular progression of letter size Uniform progression of letter size

Variable legibility (difficulty) of test letters All letters with similar legibility

6m testing distance: longer testing lane (or 4m testing distance on many charts:
a mirror) required smaller testing lane (or no mirror) required
Straightforward scoring system More complex scoring
Easy to use Less user-friendly
Landolt’s C ring Chart

• It is similar to Snellen’s test except that in it instead

of the letter, the broken circles are used.
• Landolt’s Cs are presented with the opening of the
optotype at 3, 6, 9 or 12 o’ clock.
• Each broken ring subtends an angle of 5 min at the
nodal point and is constructed similar to letters of
Snellen’s chart.
• The patient is seated at 6m distance and asked to
detect of the orientation of the break in the circle.
Tumbling’s E Chart

• It consists of different sizes of E in one of the four

positions (right, left, upward and downward) .
• The patient is kept at a 6m distance and asked to
Identify the direction of E.
• It is used in illiterates.
Pin hole VA
• If the vision is subnormal, the visual acuity is again determined by
asking the patient to read the letters through a pinhole aperture of
size 1-1.5mm to determine if a decrease in vision is correctable by
lenses.
Near Vision
• Jaeger’s Chart
• Roman test
• Snellen’s near vision Chart
Jaeger’s Chart
• In this chart, prints are marked from 1 to 7
and accordingly patient’s acuity is labelled as
J1–J7, depending upon the print one can read.

• For testing the near vision, the patient is

seated in a chair and asked to read the near-vision
chart kept at a distance of 25–35 cm, with a good
illumination thrown over his or her left shoulder.

• near vision (NV) is recorded as

NV= J1 at 30cm
Roman Test
• It consists of ‘Times Roman’ type fonts with
standard spacing.

• According to this chart, the near vision is

recorded as N5, N6, N8, N10, N12, N18, N36
and N48.
Snellen’s near vision Chart

• Snellen’s near vision Chart is based on the same principles as the

distant chart.
• The graded thickness of the letters of different lines is about 1/17th of
the distant-vision chart letters.
• In this chart, the letters equivalent to 6/6 line subtend an angle of 5
min at an average reading distance 35 cm (14 inches).
Color Vision
• Color vision is the subjective sensory ability of the eye to discriminate
between colors excited by lights of different wavelengths.

• Primary colors include: Red (Prota), Green (Deutra) and Blue (Trita).

• The most commonly recognized color vision abnormalities are the x-

linked congenital red-green deficiencies.
Objectives of color vision test:

• There are two objectives in testing for color blindness:

1. To find the exact nature of the defect.
2. Whether the subject is likely to be a source of danger to the
community.
Tests for Color Vision
• The lantern test: The subject names various
colors shown by a lantern, and is judged by the
mistakes he makes. It depends upon the size of the
apertures of the lantern and the nature and
Intensity of the light source.
• Holmgren wools: These consist of a selection of
colored wool from which the candidate is
required to make a series of color matches.
• The Farnsworth–Munsell 100-hue test:
It identifies hue discrimination by an error
score; the greater the score the poorer the
color vision. It is the most sensitive test to
detect color blindness.
• Pseudo-Isochromatic charts: These consist of colored
graphic plates in which bold numerals are
represented in dots of various tints that are set
against dots of the same size but of different color with
numbers or patterns which are easily confused by color
defective people.
Examples: Japanese test of Ishihara which largely
identifies red–green abnormalities and The American
Hardy–Rand–Ritler (H–R–R) test that identifies blue
color abnormalities.
Ishihara’s Color Vision Test
Plate Plate type Remarks
1 Introductory Read by both trichromat and
color defective observer
2-9 Transformation 2 symbols are present, one
seen by trichromat, other by
patient
10-17 Vanishing Read by trichromat not by
color defective observer
18-21 Hidden design Visible to only color
defective observer
22-25 Qualitative diagnostic Differentiates protan from
deutan defect
26-38 Tracing Tracing symbols for
illiterates or children
Contrast Sensitivity
• Contrast sensitivity is a measure of the ability of the visual system to
distinguish an object against its background.

• Many conditions reduce both contrast sensitivity and VA, but under
some circumstances (e.g. amblyopia, optic neuropathy, some
cataracts), visual function measured by contrast sensitivity can be
reduced whilst VA is preserved.
Tests for Contrast Sensitivity
• Pelli–Robson contrast sensitivity Chart:
It is a letter chart viewed at 1 metre and consists
of rows of letters of equal size but with decreasing
contrast of 0.15 log units for 3 groups of letters.
The patient reads down the rows of letters until
the lowest-resolvable group of 3 letters is reached.
• Sinusoidal (sine wave) gratings: It requires the
test subject to view a sequence of increasingly
lower contrast gratings in the form of bars.

• Spaeth Richman contrast sensitivity test

(SPARCS): Each patient is supplied with an
identification number and instructions on how
to do the test. The test takes 5–10 minutes per eye
and measures both central and peripheral contrast sensitivity. Since the test is
based on gratings it can be used on illiterate patients.
References
• Kanski’s Clinical Ophthalmology, 10th Edition, 2025
• Parson’s diseases of the eye, 22nd edition, 2015
• American Academy of Ophthalmology Practical Ophthalmology, 7th edition (2015)
section 4 visual acuity examination
Thank you