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CLINICAL SKILLS

How to measure distance visual acuity

Janet Marsden with or without correction (spectacles).

Heiko Philippin
Nurse Advisor: Community Eye Health For example: Right VA= 6/18 with
Journal, London, UK. correction, Left VA= 6/24 with
Email: [Link]@[Link]
correction.
Sue Stevens • If the patient cannot read the largest
Nurse Advisor (retired): Community Eye (top) letter at 6 metres, move him/her
Health Journal. closer, 1 metre at a time, until the top
letter can be seen – the VA will then be
Anne Ebri recorded as 5/60 or 4/60, etc.
West Africa Sub-Regional Manager: • If the top letter cannot be read at
Brien Holden Vision Institute, Calabar,
1 metre (1/60), hold up your fingers at
Nigeria.
varying distances of less than 1 metre
Visual acuity (VA) is a measure of the and check whether the patient can
ability of the eye to distinguish shapes count them. This is recorded as counting
and the details of objects at a given distance. fingers (CF): VA = CF
It is important to assess VA in a consistent • If the patient cannot count fingers, wave
way in order to detect any changes in your hand and check if he/she can see
vision. One eye is tested at a time. this. This is recorded as hand
Visual acuity should be measured from a movements (HM): VA = HM
Indications standard distance, using a standard • If the patient cannot see hand
• To provide a baseline recording of VA chart with a white background movements, shine a torch toward the
• To aid examination and diagnosis of eye eye and ask if they can see the light. If
disease or refractive error out of which eye they see best). This they can, record ‘perception of light’
• To assess any changes in vision ensures that the minimum is read with (VA = PL). If they cannot, record ‘no
• To measure the outcomes of cataract or the ‘worse’ eye, and more will be read perception of light’ (VA = NPL).
other surgery. with the ‘good’ eye. This means that no • After testing without any correction, test
letters are remembered, which could the patient while wearing any current
Equipment
make the second visual acuity appear distance spectacles and record the VA
• Multi-letter Snellen or E chart
better than it is. in each eye separately, with correction.
• Plain occluder, card or tissue
• Ask the patient to cover one eye with a • If 6/6 (normal vision) is not achieved,
• Pinhole occluder
plain occluder, card or tissue. They test one eye at a time at 6 metres using
• Torch or flashlight
should not press on the eye; this is not a pinhole occluder (plus any current
• Patient’s documentation.
good for an eye that has undergone spectacles). The use of the pinhole
Procedure surgery. It can also make any reduces the need to focus light entering
• Ensure good natural light or illumination subsequent intraocular pressure the eye.
on the chart. It is important to ensure reading inaccurate and it will distort • If the vision improves, it indicates the
that the person has the best possible vision when the occluded eye is tested. visual impairment is due to irregularities
chance of seeing and reading the test • Ask the patient to read from the top of in the cornea, a problem in the lens, or
chart as treatment decisions are made the chart and from left to right. If the refractive error, which is correctable with
based on the results of VA testing. patient cannot read the letters due to spectacles or a new prescription.
• If the test is done outdoors, the chart language difficulties, use an E chart. • Repeat the whole procedure for the
should be in bright light and the patient The patient is asked to point in the second eye
in the shade, with enough light to illumi- direction the 'legs' of the E are facing. • Summarise the VA of both eyes in the
nate the patient’s face during the test. Note: there is a one in four chance that patient's notes, for example:
• Explain the procedure to the patient. Tell the patient can guess the direction; Right VA= 6/18 without specs, 6/6
patients that it is not a test that they therefore it is recommended that the with pinhole and Left VA= NPL.
have to pass, but a test to help us know patient should correctly indicate the
how their eyes are working. Tell them orientation of most letters of the same Children
not to guess if they cannot see. size, e.g. four out of five or five out of six. • It is usually possible, with patience, to
• Ensure that any equipment that the • The smallest line read is expressed as a measure VA in children from about the
patient touches is clean and is cleaned fraction, e.g. 6/18. The upper number age of 5, although this does vary.
between patients. Infections can be refers to the distance the chart is from Children need praise and reassurance
passed between patients if equipment – the patient (6 metres) and the lower that it does not matter if they are wrong.
or the testers’ hands – are not clean. number (usually written next to the line • Ask the parent to cover the eye not
• Position the patient, sitting or standing, on the chart) is the distance in metres being tested, so that the child cannot
at a distance of 6 metres from the at which a ‘normal’ eye is able to read see around the occluder.
chart. The patient can hold one end of a that line of the chart. • Try to show only one line of the chart to
cord or rope of 6 metres long to ensure • Incomplete lines can be added to the the child at a time.
that the distance is maintained last complete line. e.g. 6/12+3,
• Test the eyes one at a time, at first indicating that the patient read the '12' VA testing measures one aspect of visual
without any spectacles (if worn). line at 6 metres and gained three of the function, but it is important that it is done
Note: Some people prefer to always letters on the '9' line. well and accurately. An incorrect VA can
test the right eye first. Others prefer to • Record the VA for each eye in the lead to inappropriate decisions and
test the ‘worse’ eye first (ask the patient patient’s notes, stating whether it is management.

© The author/s and Community Eye Health Journal 2014. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.

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