UNIVERSITY OF THE CONTESTED - UnC

CLAUDIO ALEX WAGNER MALLMANN

HENRIQUE DA COSTA SISTI
MARIANA FURLANETTO TEIXEIRA

VISUAL ACUITY

UNIVERSITY OF THE CONTESTED - UnC

2019
 CLAUDIO ALEX WAGNER MALLMANN
HENRIQUE DA COSTA SISTI
MARIANA FURLANETTO TEIXEIRA

VISUAL ACUITY

Research Project presented as

requirement for obtaining a grade in
Optometry I discipline, of the course of
Optometry, offered by the University of
Contested – UnC, Canoinhas Campus, under
Guidance do Professor Nidia
Alexandra Bohórquea Espinosa.

UNIVERSITY OF CONTESTADO - UnC

201
INTRODUCTION
2 THEORETICAL REFERENCE................................................................................5
2.1 Visual Acuity Concept...............................................................................5
2.2 Division of Visual Acuity.................................................................5
2.3 Criteria for Measuring Visual Acuity.....................................................6
2.3.1 Measurement of Visual Acuity
2.4 Snellen Optometric Scale
2.4.1 Snellen Notation.....................................................................................8
2.5 Evaluation Distance....................................................................................9
2.5.1Tabeauty of Notation in Different Systems...............................................9
2.6TaOptotype Chart........................................................................................9
2.7 Types of Visual Acuity
2.7.1 According to the lighting...............................................................................10
2.7.2 According to the type of optotype used.........................................................10
2.7.3 According to the vision of one or both eyes.......................................11
2.7.4 According to the correction.................................................................11
2.7.5 According to the distance of the optotype...............................................................12
2.8 Lighting and Contrast.................................................................................12
2.8.1 Type of illumination of the optotype..................................................................12
2.9 Types of Optotypes........................................................................................12
2.9.1. Snellen Optotype and Directional..............................................................12
3.0 Protocol for Visual Acuity Assessment........................................18
3.0.1 Table selection......................................................................................18
3.0.2 Distant visual acuity (SC)..................................................................18
3.0.3 Distance visual acuity (CC)..................................................................18
3.0.4 Near visual acuity (SC).........................................................18
3.0.5 Acuidade visual de perto (CC)...................................................................19
3.1 How to Measure Visual Acuity.................................................................19
3.1.1 Distant view (first SC and then CC)...............................................19
3.1.2 Conversão.................................................................................................19
3.1.3 Close-up view (first SC and then CC)................................................19
3.2 Visual Screening Form...............................................................................20
3.2.1Teabbreviated rmos on the screening form....................................................20
BIBLIOGRAPHIC REFERENCES..................................................................21
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INTRODUCTION

Visual acuity has a very important impact on our vision,

because it is with her that we are able to see the shapes of objects and their

details, with this, we clearly identify the image. Always to people

with doubts about this subject, many of them do not even know the meaning.
This work will present information about Visual Acuity,
measurements, optotypes, among other topics addressed.
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2 THEORETICAL FRAMEWORK

2.1 Concept Visual Acuity

Vision is the response to the appropriate light stimulus that crosses the
transparent layers of the retina, when reaching the cones and rods,
triggers photochemical reactions, transformed into nerve impulses,
transmitted by optical fibers to the higher brain centers.
One can quantify vision through the assessment of visual acuity that
it is the most common procedure among all those used by professionals of the
vision for being the simplest, the fastest, and the cheapest.
From a physiological point of view, visual acuity measures the ability of
visual system for recognizing a target and, therefore, this visual perception is
based on three essential functions:
Light sensitivity: the ability to appreciate possible differences in
simultaneous stimuli, without however distinguishing the shapes (presence of light)
Sense of form: the ability of the optical system to shape an image of the
the observed object is a sensitive membrane, to transmit the impulses
nervous to the higher visual centers (shape and size).
Chromatic census: constitutes an attribute of the cones and can only exist in the mechanism.

photopic (color)

2.2 Division of Visual Acuity

The ability that the visual apparatus has to discriminate form, the
detail and still distinguish two objects placed a certain distance from each other,
therefore, this discriminatory capacity is an attribute of the cones that are
responsible for visual acuity.
Central Visual Acuity: corresponds to the visual acuity of the macular area.
more precisely foveal, in which objects are discriminated with the
maximum clarity. It includes shape vision and color vision. Region
rich in cones.
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Peripheral Visual Acuity: corresponds to the visual acuity of the region

periphery of the entire retina. This region, which is rich in rods, is the
responsible for black and white vision and night vision.
There are certain factors that affect the measurement of visual acuity and
when ignored, their results vary. The summary below
these factors.

MODIFYING FACTORS CHARACTERISTICS

Dependent on lighting
The longer you observe something, the better.
Exposure time one recognizes oneself

Maximum Visual Acuity with red light or

Wavelength
yellow. More pleasant white light
Greater lighting, greater visual acuity without
Intensity
unclutch
Lighting about It must be uniform
Increasing the contrast decreases the angle of
discrimination, therefore increases the Acuity
Contrast
Visual
Ideal optotype = white background with black letters
Mid lighting
It takes place under photopic vision conditions.
Environment

2.3 Criteria for measuring Visual Acuity

To subjectively determine whether the examined eye is emmetropic or

ametropic, the measure of visual acuity is taken.
The minimum visible is, in reality, the determination of brightness or of
minimum visible contrast of the object. Minimum visible is the ability to
determine whether an object is present or not in a field of stimuli
visuals. Ex: Point of light in a dark field.
Visual acuity is measured from the moment it is used as
criterion, the minimum separable, that is, it is the visual angle necessary for
two separate beams can be discriminated. Minimum separable acuity is
the detection and recognition of the object.
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2.3.1 Measurement of Visual Acuity

The assessment of visual acuity depends on the size of the visual angle.
which is formed by the two lines drawn from the ends of the object to the
retina, passing through the nodal point of the eye, therefore, the visual angle is the angle

formed by the object, at the nodal point of the eye which is the point through which the

rays pass out suffer deviation to it is approximately 17.20mm ahead

from the retina.

The visual angle, which allows distinguishing numbers and letters in terms
practical, is equal to the separable minimum.

Logo, to produce an image of minimum size, the object must

to have a minimum visual angle of 1' of arc.
Considering that the human eye can perceive two points as
different if they were separated by an angle of 1 arc minute and
Since this is the resolution limit of the human eye, this means that two
points located 6 meters away will only be identified as
distinct points if they are separated by a distance of, in the
minimum, 1.74mm and the referred points must have at least this diameter.
The further away the object is from the eye, the smaller it will be.
image formed on the retina, therefore, the size of the image depends not only on the

size of the object as well as the distance between the object and the eye.
The average diameter of a cone in the macular region is 0.004mm.
the visual system cannot detect a point when its image
becomes smaller than the diameter of a cone. For two objects to be
separate views require that two cones be stimulated, leaving
among them, one that receives a lower stimulus, which allows signing the
presence of two sources of stimulus.
Thus, to produce a minimum size image of
0.004mm, the object must subtend a visual angle of 1' of arc.
Visual acuity is determined by the smallest retinal image whose
shape can be perceived and is measured by the smallest object that can be
clearly seen from a certain distance.
In order to discriminate the shape of an object, its various parts
they must be differentiated and if two separate points must be distinguished
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through the retina, it will probably be necessary for two individual cones to be
stimulated while among them is not stimulated, therefore, for two
objects can be discriminated separately, the necessary angle will be
3’ of arc.

2.4 Snellen Optometric Scale

The optometric scale is one of the methods used for the verification of
visual acuity.
It is characterized by a whiteboard on which figures are arranged,
letters or hieroglyphs of various diameters and black color, called optotypes,
differentiated according to the scale.

Your organization is in descending order. The optotypes of equal

sizes are presented on the same horizontal line.
The optotype is the main factor for differentiating the scales, because,
they use the same angle of view and its exponent in the identification of
visual acuity.

2.4.1 Snellen Notation

The most common Visual Acuity unit is the Snellen notation, which
define normal adult acuity as 20/20.
Valores de Acuidade Visual esperados conforme a idade
First quarter 20/600 to 20/400
Second quarter 20/200 to 20/150
A year 20/100 to 20/80
Two years 20/50 to 20/40
Three years 20/30
Four to five years 20/20

The Snellen notation 20/20 means that the patient can see lines
in black letters on a white background at a distance of 20 feet (6 meters) ahead
when the field of each line of the lyric is 1 minute of arc on the retina. A
The notation 20/40 corresponds to 2 arc minutes.

2.5 Evaluation Distance

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Visual acuity for distance is measured with the optotypes positioned at 20.
ft (1ft=30.5cm) or 20 feet (6 meters), as at this distance the accommodation of
crystalline is of very low power.

2.5.1 Notation Table in Different Systems

Notation in feet Notation in meters Decimal notation

20/10 6/3 2.0
20/15 June 4th 1.3
20/20 6/6 1.0
20/30 6/9 0.66
20/40 6/12 0.5
20/50 6/15 0.4
20/70 June 21 0.28
20/100 6/30 0.2
20/200 6/60 0,1

2.6 Optotype Table

An optotype chart is constructed for visual acuity equal to 20/20,

having the thickness of the letter strokes equal to the value of the white width that

The black lines are separated and should be used at a distance of 6.10 meters.
so that they can be seen by the examined at an angle of 1' arc.
The tables can be composed of letters, numbers, or figures always.
based on a visual angle of 5' of arc, built to be used at
20 feet.
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2.7 Types of Visual Acuity

2.7.1 According to the lighting

The cones are located in the central region of the retina and are associated
with daytime vision, color, and the perception of fine details, while
the rods are located at the periphery of the retina and are associated with vision
nighttime.
It can also be defined in terms of light levels.
intermediaries, the mesopic vision.
I. Photopic - Daylight. Vision ensured by cones, for high levels.
of brightness.
II. Scotopic - Night light. Visual perception for low levels of
brightness only allowing to roughly distinguish the shape of objects.
Secured by the rods.
III. Mesopic – Twilight. Type of vision intermediate between photopic and
scotopic. Used when the lighting is neither nighttime nor daytime
of the sun. In this situation, both cones and rods come into
action.
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2.7.2 According to the type of optotype used

AC Morphoscopic
Visual acuity determined with a group of optotypes in line
it is based on the minimum separable. There are several characters in each of the lines

and each line characters of different sizes

AC Angular
Visual acuity determined by the observation of an isolated optotype
is based on the minimum visible. It is the one we take with picture cards or
individual letters of different sizes.

2.7.3 According to the view of one or both eyes

When the retina is stimulated by an object located in space,

different retinal sensory elements are stimulated resulting in a
direction of visual space.
This visual direction has no absolute value, but depends on the direction.
visual of the fovea, which is the area of highest visual acuity of the retina.

The object is called a fixation point and the line that connects the object with
the retina is the visual axis. When this visual axis meets the fovea, it is called
main direction line.
AV Binocular: AV is taken with both eyes with the objective that the
The main lines of direction of each eye intersect at the fixation point.
AV Monocular: the AV is taken in each eye separately with the aim
that only a main direction line reaches the fixation point.
By conventional norm, one starts with the right eye, with the left eye being
excluded.

2.7.4 According to the correction

Without correction (SC): The patient's AV is taken without him using

any type of correction (glasses, contact lenses, etc.)
With correction (CC): If the patient is ametropic, visual acuity is taken by ...

use of correction.
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According to the distance of the optotype

Distance vision (DV): 6 meters.

Near vision (VP): 33cm to 40cm.

2.8 Lighting and Contrast

In general, the greater the lighting, the greater the visual acuity.
it is possible to identify smaller optotypes, thus, the lighting must
be in the photopic range.
The greater the contrast, the more sharply the stimulus will be perceived.

2.8.1 Type of illumination of the optotype

As a rule, the illumination of the optotypes should be between 12 and 20 candles.

(130 – 215 lux).

I – Front light
Optotypes that receive illumination from the outside.

II – Back light
Optotypes that receive illumination from lights installed inside them.

2.9 Types of Optotypes

2.9.1. Snellen Optotype and Directional

Table built with the letter E in different directions and senses. It can
be angular or morphoscopic and is mainly used for illiterates and
children from two years old.
Snellen charts can also be constructed with letters from
alphabet or numbers. It can be morphoscopic or angular and in this case it is
mainly used in adults or literate children.
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Snellen Chart and Snellen Table

I - Landolt Ring Optotype

Table constructed with a visual angle of 5' where the ring failure or the
The "mouth" of letter C is oriented in 4 positions. The examined indicates with a
hand movement where each ring is broken. It is used to measure the
AV morphoscopic or angular in illiterate adults and children.

Figure - Landolt Ring

II – Broken Wheel Test
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Based on the Landolt test. The figure of two is shown to the child.
cars and she must say which ones have flat tires. Measures the sharpness
angular in children from three to five years old. Applied at 50cm.

Figure – Broken Wheel Test

III - Sheridan-Gardiner Test

It consists of using symmetrical letters (H, V, T, O, A, U, X) where the

examined as recognized by the shape and design, indicating an identical letter
on a card. It can be angular or morphoscopic and is usually applied to
from three years old.

Figure - Sheridan-Gardiner Test

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V – Test NYLH – New York Light House

This visual acuity test consists of three main figures

(house, apple, and umbrella), with scales from 20/200 to 20/10. It is requested to
child who matches the figure shown with one of the ones they have in
hand. Used in children aged three to six years and can be angular or
Morphoscopic. It applies at a distance of three meters.

Figure – NYLH Test

V - Allen Optotypes

Table built from the visual angle of 5' of arc. It is about a

conventional test with pediatric figures to measure visual acuity
morphoscopic or angular.
Easily recognizable figures are used (phone, cake, hand, car,
horse). It can be used for children from 5 years old and for illiterate individuals.
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Figure – Allen's Optotypes

VI – Preferred Look With Rackets

This type of visual acuity uses two ping pong paddles.

a ping pong, one with black and white stripes and the other completely gray.
Two rackets are presented in front of the child, and it is observed which one of them

two she prefers to look. As the child follows the racket

that contains the tracks, the rackets are being exchanged and are being decreased.
thicknesses of the bands so that the differentiation of the rackets becomes difficult.
When the child no longer follows the racket with the stripes and fixes it
only in the gray racket, the amount of visual acuity will be that of the racket
presented earlier. This test is applied to children over
six months old and the distance of 30cm.

Figure – Preferred gaze

VII - Jaeger Table

Table that uses letters and phrases to measure visual acuity in vision
up close. It does not have the technical rigor of the distant vision chart. It is used to

a distance of 33cm to 40cm.

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Figure – Jaeger Table

VIII - Rosenbaum Table

This type of table is also used for visual acuity assessment.

in close view and uses numbers and letters and directional.

Figure - Rosenbaum Table

IX – Pin Hole (Pinhole Camera)

The pinhole will limit the incidence of light in the eye, allowing
only the entry of light at the most sensitive point of the eye, the fovea, soon its

the purpose is to increase the depth of focus. The examined with error
refractive immediately improves visual acuity and thus serves as
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assistance in distinguishing between low visual acuity due to refractive error or

for intraocular pathology. The PH should only be used if the best acuity
patient's vision of 20/40 or worse.

Figure – Pin Hole

3.0 Protocol for Visual Acuity Assessment

3.0.1 Table selection

The table uncle is chosen based on age and education.

3.0.2 Distant visual acuity (SC)

Visual acuity is measured at distance vision, without correction and

monocularly, starting with the right eye and then the left eye. If the visual acuity

For less than or equal to 20/40, P.H. is used.

3.0.3 Distance visual acuity (CC)

Visual acuity is taken at distance vision, with correction (if applicable)

of an ametropic examined person) and monocularly, first the right eye and then
left eye.

3.0.4 Near visual acuity (SC)

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Visual acuity is measured for near vision, without correction and

monocularly, first right eye and then left eye.

3.0.5 Near visual acuity (CC)

The AV is taken in VP and with correction (if applicable for an examined individual)

ametropic) and monocularly, first OD and then OS.

3.1 How to Measure Visual Acuity

3.1.1 Vision from afar (first SC and then CC)

It starts with the OD, followed by the OE and then by AO.

Take AV at 6.1m: 20/200 at 20/15 and note it down.
If the patient does not reach even AV @0/200, one must move to
the next steps one by one and record the AV progress he achieves.
The optotype is approaching 3m (make conversion)
The optotype approaches 1.5m (conversion to be made)
CD (count fingers) at 1m
Hand movement at 1m
Perception and projection of light at 1m

Light perception at 40cm

NPL (no light perception): amaurosis

3.1.2 Conversion

When the examinee does not reach VA 20/200 at 6.1m, they should be brought closer to the

table to 3m and make the conversion of the denominators through a rule of

three simple.

3.1.3 Close-up view (first SC and then CC)

It starts with the right eye, followed by the left eye and then by the visual acuity.
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The AV is taken with the table close (33cm to 40cm).

Ask the patient to read line J1.
If you can't read the J!, move on to the J2 and so on.
Note the line that the patient can read. This is the visual acuity for near.

3.2 Visual Screening Sheet

The screening form will include the test date, full name and a
brief description of the examined data. All data found in the
AV taking must be recorded on a visual screening form.
All fields of the screening form must be filled out.
It should also be noted on the screening form which optotype is being used.
used in the test, as well as the type of optotype.
A correct evaluation and notation on the triage form are fundamental.
for the final work of the professional who will assess whether there is a need to
that the examined individual be referred to a specialized professional.

3.2.1 Abbreviated terms on the screening form

VA: visual acuity

SC: without correction

CC: with correction

VL: vision from afar
VP: close vision
PH: pin hole or pinhole
OD: right eye
left eye
AO: both eyes
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BIBLIOGRAPHIC REFERENCES

ALVES, Aderbal de Albuquerque. Refração. 4ed. Rio de Janeiro, Editora

Medical Culture, 2005.

ELDER, Duke. Refração Prática. 10 ed. Rio de Janeiro, Editora Rio Med, 1997.

GROSVENOR, Theodore. Primary Care Optometry. (pp 105 – 110).

Masson Publisher.

MIRANDA, A. Vision - From Ocular Refraction to Lens Calculation. Editions

Intelligent. São Paulo, 2004.

PONSA, Edgardo. Clinical Assessment of Accommodation and Binocular Vision.

REINECKE, Robert D.; HERM Robert J.. Refraction - A programmed text.

Rio Med Publishing. Rio de Janeiro, 1996.

SILVA, Noé Marinho. Practice in Preventive Optometry. Princess Graphic.

Lages, 2000.