Visual acuity
Visual acuity definition
It is an ability to detect, discriminate and recognize objects in the space.
It is the spatial limit of visual discrimination.
It is the assessment of the function of fovea centralis to measure the threshold of
discrimination.
Form sense (VA) can be defined as perception of shape of the object in the outer
world. The cones play the dominant part.
Resolution power of the eye- refers to the smallest angle of separation between the
two points, which allows the formation of two discriminate images by an optical
system of the eye.
It depends on –
distance between 2 objects,
background illumination,
degree of light and dark adaptation,
connection between cones and neurons
Light Sense Form Sense Color Sense
Permit us to perceive light Permit us to perceive the Permit us to distinguish
shape of object in the between different colors
outer world as excited by light of
different wavelength
Rods are much more Cones play the dominant Function of cone
sensitive to low part.
illumination than cones
is most acute at the fovea Only occur in photopic
vision
Measurement of Visual Acuity
Minimal angle of resolution
Measured with monocular
The clinical tests for visual acuity measure the reading ability of the eye or form
sense.
The most familiar of these tests is the Snellen's chart or Landott's ring.
The targets in these test may consist of either letters( A, B, E) (Snellen's chart) or
broken circles (Landott's ring , C, U )
Each letter subtend an angle of 5' at a specific distance.
Overall size of the target subtend 5' of arc at the nodal point of the eye
the gap between the segments of each target subtends 1'of arc at the nodal point.
With Snellen's letters, the end point consists of letter recognition.
With Landott's rings, the end point consists of the orientation of the break in the
circle.
Designated by 6/6, 6/9, 6/12, 6/18, 6/24,6/36,6/60
Visual acuity= Distance between subject and chart (in meter)
Distance for that legible roll of letter that can be seen by person with normal visual
acuity
Single photoreceptor theory
One to one relationship between photoreceptor and neurone cell
Foveal cone- cone cell : midget bipolar : midget ganglion
Visual Acuity
Quantifying visual function in children is important.(b/c lead to detection of
reversible amblyopia)
Def. represents an estimate of spatial resolution ability but only a part of visual
function
Visual function :
visual acuity
Contrast sensitivity
Color vision
Visual field
Motion detection
VA is subdivided into
Detect acuity: recognize presence or absence of stimulus(Minimum visible)
Hyperacuity : ability to localize a visual target(Minimum Discriminible) relative
to another element at same target
Recognition acuity: ability to distinguish separate elements of target and identify
it as a whole as in Snellen acuity.
Optical Basic
Distance between two targets is specified by angle subtended at nodal point of the
eye
At the angle of separation, distance between 2 retinal image is 4um which is
equal to diameter of cone
Thus, 2 retinal image are separated by at least one unstimulated cone.
Anatomical Basic
Only one unstimulated cone is present between two images....points appear
discrete.
Physiological Basic
Spatial differentiation is to detect the though and light peaks of two separate
stimuli
Acuity criteria
1) Minimum visible .. determine presence or absence of a target( 1sec of arc) (vary obj
size)
2) Minimum resolvable...distinguish between more than one identifying feature in a
visible target (30sec of arc) (vary obj size on spacing bet obj components)
3) Mininum discriminable...determine relative location of two or more visible features
with respect to each other (2-10 sec of arc) (vary relative location of features)
Visual acuity definition
It is an ability to detect, discriminate and recognize objects in the space.
Form sense
It can be defined as perception of shape of the object in the outer world.
Ability to distinguish separate elements and identiy as a whole
To measure cone function
To discrimination of small detail of small object
Assessment of Visual acuity
Neonate
(1) Assessment of fixation to observe
A. fixation and follow to light, object, mother's face
Central or eccentric fixation
Steady or unsteady
Maintained or not
Fixation CSM – good VA in each eye
If fixation alternate, 2 eyes have equal VA.
(2) OKN
Eye follows alternate black and white stripes bands- rotated slowly
Infant follow the stripes which pass across field of vision until disapper, then
refixate to new stripes
If normal VA, OKN (+) when the child fixate moving targets behind examiner
(3) VEP
Are electrical responses generated in the occipital cortex by stimulating of the eye
More useful to establish presence or absence of pathology
(4) Occlusion of one eye
3-6 months visual acuity
(1) Visually detected reaching
Not imply good vision
It develops even when VA < 3/60 to assess the persistence of fixation
If vision is poor, movement are exploratory in nature
If good vision, direct movement towards target
(2) Catford drum
Use oscillating black dots on white ground
Useful in comparing the behavior between 2 eyes
(3) Forced choice Preferential Looking Test
Calm, alert infant,
two screens, matching luminance (blank, grating)
Infant prefer to fixate a pattern than homognous
Teller, Keeler, Cardiff cards
(4) Fixation test
Cover the eye with 16 prism...force to fixate
Notice fixation is
Central/ non central
Steady/ nonsteady
Maintain /not
6-18 months visual acuity
(1) hundred to thousand sweets pick up test
Ability to locate small objects
If child can locate and pick up, near vision at 33 cm. 6/24 or better
(2) Worth's static balls
(3) Worth's rolling balls
(4) Rotation Test
ability to fixation with BE
By rotation briskly through 360',
with head on examiner's palm,
face to face
When rotation stops, nystagmus is briefly for 1-2 sec, then cease (due to
suppression of post rotational nystagmus by fixation)
If VA severly impaired, nystagmus not stop
(*.* vestibule ocular response not block by visual fixation)
(5) Objection to Occlusion
If subjected, poor acuity in unoccluded eye.
(6) STYCAR
(a) (STYCAR graded ball test) Rolling ball test
Testing ball 6-3.5 mm diameter at 3m distance rolled across child FOV with both
eyes opened
Disadvantage: overestimate visual acuity
Advantage : partially assess contrast sensitivity and useful in assessment of visual
field
(b) STYCAR miniature toys
18 mths-3 years
(1)Kay single and multiple picture test
can name the pictures such as cat train or house
(2)Beale Collin's picture test
like Snellen, decrease in size
use rows of pictures gradually decreases in size
(3) STYCAR 5 letters matching test
use letters first recognized by child (V, O, X, H, T)
(5)Effok's symbols matching
Use the basic shape of square, circle, triangular
Presented single in different size on each face of a cube ranging from 6/60-6/6
3-5 years illiterate
3 years
1. Shendan-Gardiner matching test
Letters can be viewed singly using flip over cards which range from 6/60-6/6
Near vision can be tested with single letters, grouped letters or a STO
Advantage: quick, accurate Thus, method of choice
Disadvantage: overestimate of VA is amblyopic eye as it eliminate crowding
phenomenon
2. Sonsken-silver test
More accurate in amblyopia
The child has to match one letter out of a group of optotypes
4 years
1. STYCAR 7 letters matching test
Add A, U (VTOHX)
2. Linear Snellen acuity test or read a LogMAR chart ( log of minimal angle of
resolution)
4-5 years
1. E Test
Start limb directed up, down, Lt, Rt as single 4 letter on chart
Child uses a replicate E to copy the position of limb
Disadvantage: Lack of choice, difficulty in left and right orientation, 3 repetation trial
came time consumption, loss of child attendance
2. Sjogren hand test
Searching in the book for picture as same as examiner hold in hand
[Link]'s broken ring C test
The child should indicate the position of gap in each ring.
Advantage: extremely accurate
Disadvantage: difficult to perform
Literate children and adult
1. Snellen's test / Landott's C test
The targets in these test may consist of either letters( A, B, E) (Snellen's chart) or
broken circles (Landott's ring , C, U )
Use of row of letters of diminishing size
The whole letter subtend an angle of 5' at nodal point of eye at a given distance
Edge of letter subtend an angle of 1' at nodal point of eye at a given distance
The numerator indicates the viewing distance and the denominator indicate the
distance in meter for legible rows of letters which can be seen by person with
normal visual acuity.
2. LogMAR chart
More precise than Snellen test
Because regular progression in size and spacing of the letters from one line to the
next
The same no of letters on every line
If VA <6/60 with Snellen or Landott's C test, can be tested with
Counting Finger ( CF at X meter)
if he cannot recognize any symbol however close.
Hand Movement (HM at X meter)
If he cannot CF, the distance he can recognize HM
Light Projection
Can project the direction from which light enters the eye.
Light Perception
Can perceive light...absent light perception....blind
*VA test must be done for each eye separately with or without correction.
Adult Near Vision
1. Reduced Snellen Chart
2. Batson's J1-J9 If the VA and accommodation are normal, able to read J with each eye
separately at 33cm
3 Jeager's J1-J16
[Link], small print reading
Factors influencing visual acuity
Patient Factor
Target Factor and Environmental Factor
Optical System
foveal fixation
Intact receptor structure and function
Luminance
Integrity of Neural Pathway
Amblyopia ( lazy eye)
Others
I Patient Factor
Age : according to age- at birth 3/60, 1yr- 6/36 -6/60, 2yr- 6/18-6/12,3yr-6/9, 5yr-6/6
Illiteracy :reduce VA
Non reliable person : reduce VA
Defective intelligence : reduce VA
Mental disease : reduce VA
II Target Factor and Environmental Factor
Contrast : different in brightness between object and background (major factor)
e.g black letter with white background increases visual acuity
good illumination increases visual acuity
Interaction effect : VA decrease when targets are too close together.
Max at a distance of 2'-3' of arc
Exposure duration : VA decrease by decreasing exposure duration
Test distance : VA better in distance < 6m
Regibility of different letters in Snellen : easy to read for VA
Letter isolated or in a series- Isolated letters are recognized more easily
Amblyopia patient ...easy recognize to isolate letter
III Optical System
(1) Refractive errors
Uncorrected refractive error (myopia , hypermetropia, astigmatism causes decrease
visual acuity)
(2) Pupil Size
VA remains approximately constant for the pupil size 2.5mm-6mm
Pupil size >6mm.... aberration
Pupil size <2mm......diffraction
(3)Glare
VA decreases in bright situation or facing headlight at night.
(4) Pinhole effect
Can enhance the optical function of the eye and diminish the refractive error and
optical aberration
Can get Sties-Crawford effect in which retina can perceive the central ray of light
rather than peripheral rays
(5) Pressure effect
Large chalazion can press on cornea...astigmatism....decrease visual acuity
IV foveal fixation
1. Retinal Eccentricity
Only foveal fixation can give 6/6 vision.
Retinal eccentric due to squint decreases visual acuity
Primary away from fovea decreases visual acuity (10% of maximum)
2. Target Movement
Dynamic visual acuity is less than static due to the disturbance of fixation.
3. Eye Movement
Increase eye movement decreases visual acuity.
V Intact receptor structure and function
(1) state of adaptation of retina
Photopic function visual acuity is good
Scoptopic rod function: VA decreases but visual sensitivity is good.
(2) Retinal disease decrease visual acuity
VI Luminance
The greater the contrast between the object and its background, the higher the
visual acuity.
VII Integrity of Neural Pathway
Retinal disease and optic nerve disease decreases visual acuity.
VIII Amblyopia ( lazy eye)
Reduced visual acuity without organic lesion
Can occur in visual disturbance before 5 years of age
IX Others
Physical variants
testing situation
patience of examiner
Abnormal tear film , blinking decrease visual acuity
Binocular VA is better than monocular
Stiles-Crawford effect
Pencil light entering the eye from in front (centrally) are more effective than oblique entering.
It depends on
(a) Pupillary diameter
Pupil larger ....retina received more oblique way Thus, less effective
Pupil smaller....more central way Thus, more effective
(b) Cone phenomenon
Central rays...reach central retina....more cone....more effective
Thus, fall in VA correlate with fall in density of cones.
(c) Wavelength of light and use of monochromatic light
Monochromatic light...VA impair
e.g with green light..only G sensitive cones will be operate and R & B...function
Thus, under ordinary condition of measuring VA....use white light
Thus,all types of cones are operated and good VA
Classification of visual acuity according to criteria
Minimum visible Minimum resolvable Minimum
discriminable
Task Determine presence or Determine to Determine relative
absence of target distinguish between location of two or more
more than one visible features with
identifying feature in respect to each other
visible target
Question Is there a line in the Is there a C or O? Is the upper line to Rt or
field? Is the gap in C up, Lt of lower line?
Horizontal / Vertical down, left, right
Physiologic Local brightness Detection of Assignment of relative
basic difference threshold brightness difference local signs to 2 or more
between several supra threshold visual
adjoining small areas features
Method of Vary object size Vary object size or Vary relative location of
measurement spacing between features
object components
Magnitude of 1 sec of arc 30 sec of arc 2-10 sec of arc
threshold
Effect of moderate Slight (except in stere)
image
degradation