Optometry in Practice Vol 5 (2004) 5370

Visual Acuity
AJ Jackson1 PhD MCOptom and IL Bailey2 OD MS FCOptom FAAO
Department of Ophthalmology, Royal Group of Hospitals, Belfast and 2School of Optometry, University of Berkeley, CA, USA Accepted for publication 14 January 2004
1

Almost 150 years after Herman Snellen (Snellen 1862, 1864), the renowned ophthalmologist from the University of Utrecht, published his table of optotypes for assessing the visual status of the eye, we continue to utilise optotype test charts as the mainstay of our clinical evaluation of vision. Although the term visual acuity is almost synonymous with the assessment of central visual status, using optotypes, it is however more specific and refers to the ability of the visual system to resolve spatial detail. It is a measure of the angular size of detail that is just resolvable by the observer and its limitations are imposed by a combination of optical and neural factors.

Relative Brightness

1.22/p 1.64/p 2.23/p

Distance

Optical Limitations
When the emmetropic eye is in optimal focus, the image of a point object, formed at the macula, is not a perfect point, but a blur circle surrounded by a series of faint concentric rings (Figure 1). This is a diffraction phenomenon, which was first satisfactorily explained by the Astronomer Royal Sir George Airy, in 1835, and applies to all aperture-limited optical systems (Airy 1834, cited in Jenkins & White 1976). The central circle is known as the Airy disc, and its peak intensity is 57 times

2.67/p

Figure 1 Diagrammatic illustration of the diffraction phenomenon described by Sir George Airy in 1835. The graph illustrates the relative brightness and position of surrounding rings in relation to the central disc (Table 1) (courtesy of Mr C Wolsey).

Table 1. Relative intensities and sizes of the light distribution in the Airy disc and surrounding rings for the image of a point source Relative intensity (Lmax) Airy disc First dark ring First bright ring Second dark ring Second bright ring 1 0 1/57 0 1/240 Relative intensity (Ltotal) 1 0 1/12 0 1/30 Radius of ring (radians) 1.22 /p 1.64 /p 2.23 /p 2.67 /p

Lmax, relative brightness of surrounding rings at their brightest point, in comparison to the central point in the Airy disc which has been allocated an arbitrary value of 1; Ltotal, relative brightness of each ring in total compared to the brightness of the central disc.

Address for correspondence: Prof AJ Jackson, Low Vision Clinic, Department of Ophthalmology, Royal Group of Hospitals, Belfast BT12 6BA

2004 The College of Optometrists

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brighter than that of the first surrounding ring. The angular size, or radius, of each of the surrounding dark and light rings is a function of the wavelength of the incident light () and the pupil diameter (p). In the case of the first dark ring the diameter, expressed in radians, is 1.22 /p, where and p are normally expressed in millimetres. The diameter of the first bright ring is 1.64 /p radians. In converting the measurement from radians to degrees and subsequently to minutes of arc, one needs to multiply the figure by 57.29 and thereafter by 60 (Table 1). If the eye were perfectly focused and free of aberrations, the only optical factor limiting the resolution of the eye would be diffraction. Applying the Rayleigh criterion, the amount of overlap between adjacent blur circles, to render resolution impossible, would be half the diameter of the blur circle. At this point, the centre of one blur circle would be aligned with the edge of its neighbour. An eye with a pupil diameter of 4.6mm would thus have a minimal angle of resolution (MAR) of 0.5min of arc whereas an eye with a pupil diameter half that size (2.3mm), would have an MAR of 1min of arc (Bailey 1998). The relationship between pupil size and image quality is, however, more complex because superimposed on diffractive blur are degradations in image quality due to optical aberrations. These optical aberrations result from the shape, alignment and positioning of the various optical surfaces within the eye and variations in the refractive indices and the chromatic dispersion of the optical media. When the eye views a point source, it receives a cone of diverging rays and the diameter of the incident cone is limited by pupil size. Because of aberrations, the cone of rays that converge to form the image on the retina has an apex that is imperfectly defined. Ideally all rays would converge as a cone to a single point, and with the eye in focus, the image point at the apex of the image cone would be on the retina. In reality, for light of a given wavelength, rays from different parts of the pupil deviate from the ideal cone pattern, so the image on the retina is a patch rather than a point. The light distribution across the patch is called the point spread function and the distribution is not necessarily symmetrical. In general, rays from the more peripheral parts of the pupil are more aberrated. Retinal cones are, however, directionally sensitive, being less sensitive to rays that fall upon them obliquely (Stiles & Crawford 1933). The StilesCrawford effect thus reduces the impact of the aberrational effects associated with rays from more peripheral parts of the pupil. If the object is a fine line, the cross-sectional distribution of light in the image has a bell shape. This is called the line spread function. This profile differs from the point spread function in that it is narrower and it does not have the noticeable rings or fringes.

For light of different wavelengths, there will be a longitudinal difference in the position of best focus. Shortwavelength light will have its best focus about 0.5mm anterior to the best focus for long-wavelength light. This represents about 1.5D of longitudinal chromatic aberration. The light spread in the retinal image depends on pupil size. Light spread due to diffraction increases as the pupil becomes smaller. On the other hand, light spread due to monochromatic and chromatic optical aberrations is reduced as the pupil becomes smaller. The optimal pupil size required to balance these effects best is approximately 2.5mm (Westheimer 1964).

Neural Limitations
A significant neural limitation on visual resolution is imposed by the anatomical structure of the retinal photoreceptor layer. In the foveal region, cones are packed closely together and cones are known to have an average diameter of about 2m. It might be expected that, in order for images of two-point objects to be resolved, they should fall on two individual cones separated by a cone which is not stimulated. The two-point images should thus be separated by a distance of 4m. Assuming the nodal point of the eye is 16.67mm from the retina, then the neural limit to resolution becomes 0.82min of arc. Other neural limitations of the system may also be imposed by the various complex interconnections and interactions between neurones within the retina and visual pathways.

Defining Resolution
Resolution can be defined as minimum detectable, minimum separable or minimum recognisable.

Minimum detectable resolution

Minimum detectable (or minimum distinguishable) resolution is the minimum angular size of a spot or the minimum angular width of a line necessary for it to be detected against its background. In the case of a spot, when the diameter of the image formed on the retina becomes smaller than the surface area of a single photoreceptor, detection remains possible as long as the visual system can recognise that adjacent photoreceptors, one receiving the stimulus and one not, have responded differently. Threshold detection is achievable when the spot is large enough or has sufficient contrast to create a detectable elevation or reduction in illumination on the photoreceptor, in comparison to its neighbour. Under photopic conditions, the differential contrast threshold

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remains a constant ratio, at approximately 1%, irrespective of overall field luminance. This phenomenon forms the basis of Webers law (Weber 1834). As lighting levels drop, the threshold contrast ratio between target spot and its surround must increase by up to 20 times in order to enable target detection to take place. Detectability will also vary as a function of target size, wavelength and the distribution of luminance within the visual field. The minimal dimension of a high-contrast point object required for detection is reported to be between 10 and 35 seconds of arc, whereas for a highcontrast line target, the width only needs to be 410 seconds of arc (Duke-Elder 1937).

Minimum separable resolution

Minimum separable resolution is a measure of the minimum separation between adjacent spots or lines required for the observer to identify the objects as separate. This form of resolution is usually assessed using grating targets, the dimensions of which may be expressed in cycles per degree (cpd). In a grating with a spatial frequency of 30 cpd, the width of each dark stripe and each bright stripe will be 1 min of arc. The limit of an eyes ability to resolve a high-contrast grating, and distinguish it from a uniform field of the same average luminance, is a measure of its threshold spatial frequency for minimum separable resolution. An eye that can just resolve a 30-cpd grating can be said to have a MAR of 1 min of arc. In measuring resolution with grating targets, there may be spurious resolution, in which the presence of a grating can be recognised, even though the perception of the number of stripes in the grating is erroneous. This can be seen most easily in resolution tests that use sets of three line gratings that have different spatial frequencies (Figure 2).

Figure 2 Resolution and spurious resolution An illustration of the light distribution within a three-line target when the spacing is close to the resolution limit. The figure depicts the light distribution on the retina viewing an object that consists of three fine white lines. Due to diffraction and aberrations, each individual fine line creates an image with a bell-shaped light profile, and each of these light distributions is called a line spread function (LSF). Diffraction and aberrations affect the width and shape of the LSF. Bottom: the light distribution of the retinal image when there is only marginal overlap of the adjacent LSF. The observer should easily be able to tell there are three lines present. Middle: the lines have been brought closer together (spatial frequency has been increased) so there is substantial overlap between the three LSFs. In the total light distribution of the image, there are three peaks corresponding to the positions of the three lines in the object. There is only a relatively small difference between the retinal illuminance at the three peaks and the two troughs. If this difference (contrast) is sufficient, the observer will perceive a low-contrast grating pattern from the three lines. As the lines are brought a little closer together, the difference between the retinal illuminance at the peaks and troughs will be further reduced. Top: the lines are even closer together. The overlap between adjacent LSFs is more substantial. Now, summation between the sloping sides of adjacent LSFs gives rise to peaks in the total light distribution. Here, the sum of the three LSFs gives two peaks with an intervening trough. The observer may perceive a striped pattern of low contrast, but it will appear that there are only two lines present . This is called spurious resolution. The observer can tell the object has a grating structure, but has an erroneous perception of the number of component lines.

Hyperacuities
To this point we have described visual acuity as a measure of the ability of the eye to detect spatial separation between details, and that the magnitude of visual acuity is closely related to the angle between adjacent retinal receptors. There are, however, some tasks in which information about location is pooled across many receptors, allowing spatial discriminations that are finer than the minimal separable resolution by a factor of about 10-fold. The term hyperacuity is used to describe these ultrafine spatial discriminations. Vernier acuity and stereoacuity are the two best known of the hyperacuities. When assessing Vernier acuity, the task is to judge whether two line segments are in line with each other. When assessing stereoacuity, the task is to judge whether one line segment is closer or further away than another in

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three-dimensional space. Thresholds for these hyperacuity tasks are commonly in the order of 5 seconds of arc. Other hyperacuity tasks include recognising that a line is curved rather than straight, discriminating deviations from vertical or horizontal, discerning deviations from parallelism, detecting a bump in a line and judging equality of lengths in a bisection task.

Serif E 5 5

Landolt ring

Minimum recognisable resolution

Minimum recognisable (or minimum legible) is the term given to the measurement of acuity using optotype symbols. Whereas grating acuity is often used to determine optical performance under laboratory conditions, most clinical tests of visual resolution utilise symbols or optotypes as targets (Figure 3). The optotypes chosen may, however, be simple or complex. Landolt rings, which represent the simplest of targets, were adopted in 1909 by the XI International Ophthalmological Congress as the standard test object (Landolt 1899, Woodruff 1947). Each ring is constructed so that its external diameter is five times greater than its stroke width, which in turn, is equal in size to the gap in the ring. Most vision tests using Landolt rings simply require the observer to identify the location of the gap which may be in one of four positions to the right, left, up or down. Sometimes obliquely oriented gaps (45, 135, 225 and 315) are included, giving a choice of eight gap orientations. When testing with Landolt rings, the patient need not be familiar with any particular alphabet. The test is therefore well-suited for testing persons who are illiterate or who cannot name letters that might otherwise be used as the optotype. For research purposes, Landolt rings may be the preferred optotype because the resolution task is essentially the same for each of the alternative gap positions. When using a combination of letters as optotypes, the observers task and decisionmaking strategies might be quite different from one letter to another. Tumbling E (or illiterate E) charts have been constructed using an E optotype with four alternative orientations. Typically, the E is constructed on a 5 5 grid with each of the three parallel limbs being one grid-unit wide. As for the Landolt ring test, the observers task is to identify the orientation of each optotype by indicating if the legs of the E point right, left, up or down. Forcedchoice methodology is often used in the assessment of threshold acuity using tumbling Es or Landolt rings, especially when used for research purposes. More traditional visual acuity tests utilise charts with sets of alphanumeric symbols as optotypes, as this makes the process of testing simpler and quicker. Individual letter, or number, optotypes are usually constructed using either a

Sans serif H 5 5

Sans serif E 5 4

Figure 3 An illustration of the font styles and grid structure of serif and sans serif letters, the Landolt ring and tumbling E. 5 4 grid, in which stroke width measures one-fifth of the grid height, or a 5 5 grid. Snellens original charts used letters the stroke width of which were equal to one-fifth of the letter height. Although most letters were constructed using a 5 5 grid, some 5 6 letters were used (Snellen 1862, 1864). His letters had serifs, which are short lines added to the ends of the limbs of the letters. Since Snellen, there have been numerous variations in the design of the letters and the chart layout. Bennett (1965) reviewed the history of visual acuity chart design at about the time the British Standards Institute chose to adopt a set of 10 letters based on a 5 4 grid format as the standard optotypes for clinical testing of visual acuity (BSI 4274-1 1968). The UK standards have recently been updated in such a manner as to introduce log MAR notations and several other features consistent with log MAR testing strategies (BSI 4274-1 2003).

Optotype Test Chart Design

Since the time of Snellen, the practice of expressing central visual status using measurements obtained from optotype charts has been confounded by the proliferation of charts utilising different design features. The

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assessment of visual acuity using optotype targets has become almost synonymous with clarity of vision (Figure 4). Bennett (1965) in his extensive review on ophthalmic test types classified the three principal problems associated with standardisation as: 1. Selection and style of symbols 2. Progression of sizes of symbols 3. The notation used for expressing acuity

Symbol selection
Not all letters are of equal legibility and legibility will differ according to font style. Snellens charts (1862) used Egyptian paragon styled serif letters, each of which had prominent ornamental cross-strokes at the end of each limb. Green (1868, 1905), who favoured simpler font styles, initially used a sans serif Gothic design and excluded letters with oblique lines (Z, N, S etc). Hartridge and Owen, who compared the legibility of Snellen and Green style letters, recommended that acuity should be assessed using a series of nine letters (D F H N P T U X Z) selected from the Green series (Hartridge & Owen 1922). By 1872, Greens thoughts on the matter had changed in favour of a modified serif design as sans serif letters had been criticised as being unfinished in appearance (Green 1872). Dennett (1885) adjusted individual letter sizes in an attempt to compensate for relative legibility whereas others, including Cowan (1928) and Monoyer (1875), emphasised the importance of individually selecting font styles and linear dimensions (ie 5 5, 5 4 or 5 3) on a letter-by-letter basis. As suggestions concerning letter shape and size proliferated, reverse contrast was proposed as a method of compensating for legibility differences (Walker 1942). Much of the original work on relative legibility was undertaken by Woodruff (1947) and Coates (1935) who accumulated considerable normative data on legibility. The effect of font style on relative legibility has been reviewed by Borish (1970). Bennett (1965) illustrated how different letter design styles could affect legibility, serif letters in particular, introducing characteristic identification errors. In his comprehensive review on the subject, he outlined the rationale used by various test chart designers for selecting letters of various styles. British Standard BS4274-1, which was published in 1968, recommends 10 (5 4) sans serif letters giving legibility ratings ranging from 0.92 (R) to 1.10 (Z) (D E F H N P R U V Z) (BSI 4274-1 1968). The most recent version incorporates log MAR notation, recommends a 5 5 letter grid format, a modification to row progression, and introduces the letters C and K to the recommended range from which letters should be selected (BSI 4274-1 2003). In the USA Sloan, who pioneered much of the work on standardisation, selected a sans serif style (Sloan 1951, Sloan et al. 1952). Her preference was for 10 letters in a 5 5 grid style (S O C D K V R H N Z) (Sloan 1959). Her legibility ratings ranged from 0.90 (O) to 1.10 (Z). Regrettably, many currently available charts, though using sans serif letters, do not consider legibility ratings. Legibility is also affected by contour interaction, a term coined by Flom to describe the effect of neighbouring contours on the discriminability of detail (Flom et al. 1963). Flom distinguishes between contour interaction,

Figure 4 In popular perception the test letter chart quickly became synonymous with the sight test, as demonstrated by the cartoonist Sidney Strube (18911956) in this newspaper drawing from 1938. The Prime Minister, Neville Chamberlain, is portrayed as an ophthalmic optician whose sum total of equipment consists of an electrically illuminated screen chart, a simple drop-cell trial frame and case of trial lenses. The inability of the governing MPs (portrayed as the British lion in a school cap) to read the smallest lettering is intended as a symbol for their failure to focus on what supporters of Appeasement felt to be a more important issue in a country still recovering from the effects of the great economic slump. Mother, in the form of Winston Churchill, dressed somewhat ridiculously as Britannia, sits in on the test in a position of splendid isolation across the room. All may not be as it seems, however. As Strube was a fanatical anti-Nazi and favourite of Churchill it is possible that the artists intention is to illustrate the priority of the more easily seen letters (courtesy of Mr Neil Handley MA AMA, Curator British Optical Association Museum, College of Optometrists, London). The Daily Express The original sketch for this cartoon, in which Chamberlain is described as an oculist, is in the collection of the BOA Museum at the College of Optometrists.

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which affects resolution of detail, and crowding, which affects assignment of attention. Both affect performance in recognising optotypes on a visual acuity chart. Bailey studied the effects of spacing between letters and between rows for different optotypes. Using British Standard letters, he found that a twofold increase in letter spacing changed the visual acuity score by 0.03 log units (Bailey 1988). Spacing was noted to have more of an effect when assessing acuity with Landolt rings than when using Sloan-styled letters (Raasch & Bailey 1984). Bailey recommends letter and row spacings should equal letter width.

Increments on visual acuity scales

Geometric Reciprocal Arithmetic Conventional 6/6 6/60

Row progression
Superimposed on the debate surrounding letter style has been an equally vociferous debate about chart design and row progression ratios. Both geometrical and arithmetical progressions, using a variety of progression rates, have been utilised over time. Snellen chose for his original chart seven rows of letters which subtended 5min of arc at distances of 6, 9, 12, 15, 21, 30 and 60m. The 1911 edition of his chart changed the size progression to 6, 8, 12, 18, 24, 36 and 60-m letters. The six smaller rows approximate a geometric or logarithmic progression with a multiplier of 1.4 (1.4 = 2 = 100.15 = 0.15 log unit). Using this factor, letter size doubles every second row (6, 8.5, 12, 17, 24, 34). Figure 5 illustrates the consequences of using three different size progression sequences. One has a geometric (logarithmic) progression with a constant multiplier ratio of 100.1 (6/6, 6/7.5, 6/9.5, 6/12 ...), the second uses a simple arithmetic progression in height (6/6, 6/12, 6/18, 6/24 ...) and the third uses equal steps of the reciprocal of size with 0.1 increments on the decimal scale. The sequence on the decimal scale is 1.0, 0.9, 0.8, 0.7 ... with the corresponding Snellen sizes being (6/6, 6/6.7, 6/7.5, 6/8.6, 6/10 ...): the figure is scaled so that the increments are equal on the geometric scale. Three steps correspond to a twofold change in size over the entire range. With the arithmetic scaling sequence, three steps cover a four-times change in size at the small end, and a 1.43 times change in size at the large end. For the reciprocal progression, three steps at the small end represent a 1.43 change in size, whereas at the larger end of the scale, three steps cover a four times change in size. Also shown on this figure is the conventional size series commonly used in the UK (6/4, 6/5, 6/6, 6/7.5, 6/9, 6/12, 6/18, 6/24, 6/36 and 6/60). This series uses optotypes tightly spaced at the smaller sizes and more sparsely spaced at the larger sizes. Westheimer (1979) took advantage of the eyes natural decline of visual acuity away from the fovea to show that the probability of seeing function, a graph showing

Figure 5 This figure shows the distribution of increments on the visual acuity charts and their dependence on the mathematical system by which the size increments are determined. The diamonds illustrate increments that follow a geometric or logarithmic size progression. There is a constant ratio between the sizes in adjacent rows. It is now widely accepted that this system is the most appropriate for visual acuity scaling. It is the basis for the log MAR and visual acuity rating scales. Here, there are 10 steps between 6/6 and 6/60. The open circles show the increments on a scale that follows the reciprocal of visual angle. This is the basis of the decimal visual acuity scale. The increments are relatively compacted at the small size and sparsely spaced at the larger size. Here there are nine steps between 6/6 and 6/60. The sequence is 1.0, 0.9, 0.8, 0.7, etc (6/6, 6/6.66, 6/7.5, 6/8.57, 6/10, 6/12, 6/15, 6/30, 6/60). The open squares show the scale for an arithmetic progression. This scale has equal steps in terms of minimum angle of resolution (1, 2, 3, 4, 5, etc in minutes of arc) or in terms of the Snellen fraction denominator (6/6, 6/12, 6/18, 6/24, 6/30, 6/36, 6/42, 6/48, 6/54, 6/60). The increments are quite sparse at the smaller sizes and compacted at the larger size. Here, there are nine steps between 6/6 and 6/60. The filled triangles illustrate the conventional scale most widely used in the UK. The increments are most densely packed at the smaller sizes and more sparsely spread at the larger size. There are nine steps between 6/6 and 6/60, the sequence being (6/6, 6/7.5, 6/9, 6/12, 6/18, 6/24, 6/36, 6/60).

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percentage correct recognition as a function of size, was essentially the same for all levels of acuity, provided that visual acuity was plotted on a logarithmic scale. There is a broad acceptance that logarithmic (constant-ratio) scaling should be used for visual acuity measurement, and the most popular scaling ratio is now 0.1 log units (100.1, 3 1.2589 or approximately 2). This progression, which was proposed by Green (1905) and endorsed by the American Committee on Optics and Visual Physiology (Ogle 1953; Spaeth et al. 1955), has had more recent advocates in Keeler (1956), Sloan (1951) and Bailey & Lovie (1976). On this scale, 10 steps represent a 10-fold change, three a twofold change, and one step represents a change of about 5/4. This sequence, based on a 6m reference, is 6, 7.5, 9.5, 12, 15, 19, 24, 30, 38, 48 and 60. For 20ft, the sequence is 20, 25, 32, 40, 50, 63, 80, 100, 125, 160, 200.

patients, with ample accommodative reserves, attention may need to be paid to the potential for defocus induced by proximal accommodation if the chart is at a close distance.

Acuity designation
Whereas visual acuity is an expression of the angular size of the smallest detail just resolvable by the eye, there are several alternative ways of specifying the value clinically. The Snellen fraction expresses the angular size of the optotype as a fraction, specifying the test distance d as the numerator and the distance at which the just-resolvable letters should be positioned in order to subtend an angle of 5min of arc as the denominator D (visual acuity = d / D) (Figure 6). A benefit of expressing visual acuity in this way is that the clinician records the testing distance, a factor that can be important in paediatric eye care and lowvision work. At a viewing distance of 6m, a patient with a best corrected visual acuity of 6/24 will just be able to read the 24m letter, which subtends 5min of arc at a distance of 24m. In the USA, test distances are expressed in feet, whereas in most European and Commonwealth countries, a metric notation is used (6/6 = 20/20, 6/60 = 20/200, etc). On the European continent, following the notation used by Monoyer (1875), the Snellen fraction is usually reduced to a decimal notation. An acuity of 6/6 thus becomes 1.0, whereas a visual acuity of 6/60 becomes 0.1 in the decimal notation. With the decimal notation, information on test distance is lost. Further, and more importantly, visual acuity scores in decimal notation can become confused with acuity scores expressed as log MAR. Those familiar with the task of checking European and

Test distance
The original Snellen chart was designed for use at a testing distance of 20 Parisian feet (6.5m). (One Parisian inch is equivalent to 1.0658 English inches.) By 1875, new editions of the Snellen chart were calibrated in metric units and were produced for use at 6m. Charts for use at 5m testing distances were, however, soon to become available. Both Landolt and Monoyer advocated the use of the 5m test distance (Landolt 1899, Monoyer 1875). The XI International Ophthalmologic Congress in 1901 ratified a recommended working distance of 5m (cited in Bennett 1965). Historically, the UK has stayed with a 6m standard test distance, whereas in the USA the 20ft standard has been adopted. Given that clinical rooms are rarely 6m long, test distances are often achieved using indirect charts viewed in a mirror. The US Committee on Vision of the National Academy of Science/National Research Council recommended that 4m be the standard test distance (NAS-NRC 1980). Current British standards state that the testing distance should not be less than 4m (BSI 4274-1 2003). In low-vision work, the concept of a variable working distance is widely used and charts may be presented at various distances, sometimes as close as 50cm from the eye. At close distances, attention may need to be paid to the accommodation demand induced by reducing the working distance. The dioptric depth of field of the eye provides a tolerance to small errors of focus. It is generally assumed that the refractive correction should be no more than +0.25D from the optical correction that would be optimal for the viewing distance that is being used. For low-vision patients with poor visual acuity, wider dioptric tolerances are often allowed. When testing younger

Eye with 6/6 E

6m

Angle = 5 min of arc = 1/12 degree

E
12m

E
18m

Eye with 6/18

E
6m

12m

E
18m

Figure 6 The Snellen fraction (e.g. 6/6, 6/12, 6/18, etc.), of which the first number (numerator) indicates the test distance in metres and the second number (denominator) indicates the height of the letter. The height of the letter is indicated by the distance at which a letter of that height will subtend a specific angle, namely, 5min of arc = 1/12 degree.

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North American reference articles for comparable studies will be familiar with the problems which can arise. Alternative notations have been proposed by various authorities over the years. Blaskoviscs (1924) proposed the oxyoptre, which was the reciprocal of the visual angle (in degrees) of the smallest recognisable target. Javal (1900) proposed that letter height should be used, whereas Swaine (1925), who coined the term visual badness, suggested that the Snellen fraction should be inverted.

Minimum angle of resolution

MAR is used to express, usually in minutes of arc, the angular size of the critical detail within a just-resolvable optotype. It is usually assumed that the critical detail is one-fifth of the letter height. Thus, an individual with a best corrected visual acuity of 6/6 can resolve critical detail, represented by a letter limb width of 1min of arc. If the best corrected acuity were 6/60, the minimal limb width resolvable would be 10min of arc. The MAR is, in fact, the reciprocal of the decimal acuity value. The log MAR designation was introduced in 1976 with the BaileyLovie chart (Bailey & Lovie 1976). It expresses the visual acuity as the common logarithm of the MAR. On this scale, the 6/6 acuity (MAR = 1) becomes 0 on a log MAR chart (log10 (1.0) = 0). A 6/60 acuity (MAR 10) becomes log10 (10.0) = 1.0 (Table 2). Using charts with five letters per row and a 0.1 log unit progression of size, a Table 2. Comparison of different visual acuity designations.
Snellen fraction
(metres)

value of 0.02 log MAR units can be assigned to each letter read correctly. Other forms of acuity expression have also been advocated. Bailey (1988) suggested the use of a visual acuity rating (VAR), derived from log MAR acuity values (VAR = 100 50 log MAR). Using this system 6/6 equates to VAR = 100, 6/60 becomes VAR = 50 and 6/600 becomes VAR = 0. There is one VAR point per letter on a BaileyLovie or Early Treatment of Diabetic Retinopathy Study (ETDRS) chart. Another designation system, visual efficiency (VE), rarely used in the UK, was proposed by Snell and Sterling in 1926 in an attempt to quantify visual loss for medicolegal purposes (Snell & Sterling 1926). They proposed the efficiency formula VE = 0.2 (MAR1)/9. An individual with normal (20/20) vision would be allocated a VE rating of 100%, while an individual with a best corrected visual acuity of 20/200 would have a VE rating of 20%. This method, which has been reviewed by Hofstetter (1950), was adopted by the American Medical Association in 1955 (Spaeth et al. 1955). Somewhat similar ratings for field loss and motility restrictions were subsequently developed and a permanent impairment index was introduced in 1984 (American Medical Association 1984). In many circles, within the UK at least, it has become commonplace to record visual acuities of less than 6/60 as CF, HM, PL or NPL. CF stands for count fingers and indicates that the patient can recognise the number of fingers held up by the clinician. This is an unnecessarily

Snellen fraction
(feet)

Decimal notation

Minimum angle of resolution (MAR)

Log MAR

Visual acuity rating (VAR)

Visual efficiency %

Conventional Snellen Chart

Keeler A chart

Snellen fraction
(metres (4m))

Snellen fraction
(feet)

In the conventional Snellen and Keeler A series columns, brackets around the acuity values indicate that the size is only a moderately close equivalent to the values in the other seven columns. For the Keeler A series, exact Snellen fraction equivalents are shown in parentheses.

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crude way of estimating visual acuity. Finger widths will vary from one clinician to another, separations between fingers will differ from one presentation to the next and the luminance and complexity of the background will affect the visibility of the fingers, so the visual task is not well-controlled. Working distances are often not recorded by those who choose to express visual status in terms of counting fingers. For patients whose visual acuity is less than 6/60, appropriate measures of visual acuity may be made by holding a visual acuity chart at a close distance. If a 60m letter cannot be read at a distance of, say, 50cm or even closer, then attempts at obtaining a meaningful score of visual resolution may be abandoned. Hand movements (HM) is not a measurement of visual acuity, but rather a more basic and coarse classification of visual function. It should be reserved for those cases where the patient is unable to see any chart optotypes at any distance. With this level of vision, the observer can only detect shadows or large objects moving across the visual field. Perception of light (PL) indicates an ability of the eye to detect a light source which may be a ceiling light, or an ophthalmoscope bulb held close to the eye. Such a classification of vision should be reserved for eyes incapable of detecting hand movements. It can be useful to ask if the direction of the light source can be identified, as an ability to judge the direction of major light sources can be functionally valuable when it comes to orientation awareness. The NPL (no perception of light) classification of vision refers to total blindness. Clinicians are often required to provide visual acuity measurements in order to determine an individuals eligibility for benefits, for privileges or for occupational assessment purposes. It can be useful to have information on hand on the World Health Organization classification of central visual status (World Health Organization 1979) and local definitions that are relevant to occupational standards (Association of Optometrists 2002), driving (Taylor 1995) and visual impairment registration (Bunce et al. 1998, Evans 1995).

Modern Test Chart Characteristics Logarithmic progressions

The first of the modern logarithmically based test charts was introduced to UK-based practitioners in 1956 by Charles Keeler. The Keeler charts were referred to as A series charts and were marketed as particularly useful for those involved in low-vision practice (Keeler 1956). The chart layout was generally similar to that of a conventional Snellen chart. At the larger sizes, the sans serif letters had

stroke widths that were only one-seventh of the letter height. An important feature was that size progression was logarithmic. Successive sets of letters, moving up the chart, were larger, by a factor of 1.25, than their predecessors. On the original chart, there were eight A1 (6/6) letters and only one A20 (6/416) letter. In the USA, Sloan developed a visual acuity chart using her family of 10 5 5 sans serif letters and a logarithmic size progression with a multiplier ratio = 1.2589 = 1010 = 100.1 (Sloan 1959). An important advance in the measurement of visual acuity came with the development and introduction of the BaileyLovie design principles which were applied to new distance and near vision charts in the 1970s (Bailey & Lovie 1976). The design principles cause the visual acuity task to be standardised at each size level. Other features that combined with the logarithmic size progression to standardise the task are: (1) the same number of optotypes in each row; (2) spacings between optotypes and between rows are proportional to the size of the optotypes; and (3) the mix of optotypes has approximately the same level of difficulty. This means size is the only significant chart variable from one size level to the next. Their design uses a geometrical progression of size and they chose a factor of 1.2589 (= 100.1) as their multiplier ratio. Bailey and Lovie introduced the term log MAR as a measure of visual acuity used in conjunction with a visual acuity chart. On their log MAR scale, there are 10 steps between 6/60 and 6/6, with the size progression being 60, 48, 38, 30, 24, 19, 15, 12, 9.5, 7.5, 6. On the charts, the log MAR values are in increments of 0.1 log units: 6/60 = 1.0 log MAR, 6/48 = 0.9 log MAR, 6/38 = 0.8 log MAR, and so forth (Table 2). Every third line on the chart sees a doubling, for larger letters, or a halving, for smaller letters, of letter size, so doubling or halving causes a change in the log MAR value by 0.3. Each line differs in size from the rows immediately above or below by a factor of 1.2589 (0.1 log units). On currently available charts, there is a 20-fold range of size with 14 rows of letters which, assuming a 6m viewing distance, provide a size range from log MAR 0.8 (6/38 equivalent) to log MAR 0.5 (6/1.9 equivalent). On the BaileyLovie charts, there are five letters per row, with the letters selected from the group of 10 recommended in the 1968 British Standards (BSI 4274-1 1968). The spacing between adjacent letters is equal to one letter width, and the separation between rows is equal to the width of the letters in the larger row. The combination of letters on each line is selected to ensure about equal average difficulty from row to row. Visual acuity measurements recorded using BaileyLovie charts can be determined using either row-by-row scoring or letter-by-letter scoring. Common clinical practice is to record the acuity as the smallest line on which the patient is able to identify either 50% of 80% of letters correctly.

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This methodology is, however, too coarse to identify small or moderate changes in acuity. A small change in the number of letters read, even by one letter, can easily cause the acuity score to change by one row. A change in visual acuity score cannot be taken to be real or significant unless the change is by two rows or more (Bailey et al. 1991). The row-by-row scores can be refined by applying the plus or minus notations, commonly used when expressing Snellen fraction measurements of acuity (6/6 2). Giving credit for every letter read improves sensitivity substantially (Figure 7). The BaileyLovie design principles allow each letter to be given the same value in log MAR or VAR units. Every extra letter read changes the log MAR score by 0.02 and the VAR score by 1. This facilitates scoring visual acuity letter-by-letter. With the five-letters-per-row chart, each letter can be assigned a value of 0.02 log MAR units (VAR = 1), with the result that each additional letter read on a subsequent line changes the log MAR score by 0.02 and the VAR by +1. The patient who reads all letters on every row down to the 0.20 log MAR line (VAR = 90 = 20/32) and one letter on the 0.1 log MAR line would thus be allocated a log MAR score of 0.18 (VAR = 91). Another patient who reads all letters on every row down to the 0.20 log MAR row, four out of five on the 0.10 row and three out of five on the 0.00 row scores, using individual letter scoring, a log MAR score of 0.06 (0.20 0.08 0.06 = 0.06). In VAR units the equivalent score is 97 (90 + 4 + 3 = 97). When giving credit for every letter read using a

BaileyLovie chart, a difference of five letters can usually be taken as being significant. That is, there is a 95% confidence that two visual acuity scores will be no more than four letters different from each other when there has been no change in vision. Thus a change of five letters can be taken as being a real or significant change. Confidence limits may be broader for some patient groups in whom acuity measurements are less consistent (Bailey et al. 1991). The term log MAR chart is often used to describe charts that follow the BaileyLovie design principles (Figure 8). The most widely used log MAR chart is the ETDRS chart designed for the Early Treatment of Diabetic Retinopathy Study by Ferris et al. (1982). These charts, of which there are three, use a combination of the 10 Sloan 5 5 letters rather than the 5 4 British standard letters and they were designed for use at 4m following the recommendations of the Committee on Vision of the National Academy of Sciences National Research Council in the USA (NAS-NRC 1980). The use of standardised illumination is encouraged and both direct and retro illumination cabinets have been designed for use with ETDRS charts (Ferris & Sperduto 1982). Strong and Woo produced the Waterloo chart, which uses a logarithmic progression, with letters in columns becoming progressively smaller from left to right. They also added contour bars at the end of each row and

Frequency

By row By letter

Test / retest discrepancy (letters)

one row = five letters = 0.1 log unit

Figure 7 Distribution of testretest discrepancies expected when scoring visual acuity, recorded for normally sighted subjects, on a BaileyLovie log MAR chart using letterbyletter and rowbyrow scoring criteria. The 95% confidence limit for change using letterbyletter scoring is 5 letters. For row by row scoring it is 2 rows.

Figure 8 A selection of currently available log MAR charts: a highcontrast BaileyLovie chart, a lowcontrast BaileyLovie letter chart, an ETDRS chart, Glasgow Acuity cards and Kay Crowded Symbol Cards.

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column, thus ensuring that contour interaction affected all letters equally (Strong & Woo 1985). Log MAR principles have also been applied to the development of distance visual acuity charts utilising Chinese characters (Woo & Lo 1980). Similar principles have been applied to both optotype and picture symbol acuity charts developed for the assessment of vision in young children (Hyvarinen et al. 1980, Jayatunga et al. 1995). McGraw and Winn developed the Glasgow acuity card log MAR-based system, which incorporates contour interaction bars, for assessing vision in preschool children (McGraw & Winn 1993). Recent studies indicate that visual acuity results recorded using Kay picture, crowded symbol and crowded letter log MAR-based tests, on children with amblyopia, are comparable (Jones et al. 2003).

Test Chart Luminance

The sensitivity of the visual system is such that it is capable of responding to illuminated targets over a very wide range of intensities. The normal healthy eye can operate over a very wide range (78 log units) of luminance, encompassing both scotopic and photophobic vision. Visual acuity does vary with changes in chart luminance. The British Standard recommendations are that internally illuminated charts should have a minimum background luminance of 120 candela per square metre (cd/m2), with newly installed charts having a minimum background luminance of 150 cd/m2 in order to allow for ageing of the system (BSI 4274-1 1968). Externally illuminated charts should have a minimum illuminance of 480lux, although new installations should measure 600lux. Recommendations in the most recent British Standards remain unchanged, although guidance on background illumination has been withdrawn (BSI 4274-1 2003). The recommended lighting levels, for the externally illuminated (8071345lux) and internally illuminated (343cd/m2) charts advocated by Ferris, are higher than those recommended in British Standards (Ferris & Sperduto 1982). Sheedy and colleagues have reported that, when chart luminance is within the moderate photopic range (40600cd/m2), doubling the chart luminance only alters the visual acuity score by a little less than 0.02 log units (Sheedy et al. 1984). They recommended that chart luminances be in the range 80320cd/m2. Within any given clinical environment, it has been recommended that chart luminance should be kept constant with a tolerance of 15% (Bailey 1998) and that variance across a chart should not exceed 20% (BSI 4274-1 2003).

Other Test Chart Design Features

Historically, acuity charts were produced as printed panels designed for use with direct illumination. Most were printed on card and, as a result, were susceptible to discoloration and ageing. Charts printed on plastic panels were more durable and could, in addition, be wiped down with a damp cloth, thus rendering them grime- and dirtfree. Given the lack of availability of 6m testing facilities, many visual acuity charts are printed in reverse format so they can be viewed via a mirror in rooms 34m in length. In an attempt to introduce standardisation of testing conditions, internally illuminated acuity testing equipment was produced, the most commonly used in British hospitals being the rotating Snellen drum. Even with these units, charts are subject to ageing and care needs to be taken in the selection of background bulb intensity. Log MAR charts are now also available as internally illuminated units with interchangeable panels to allow variation in the letter sequencing. An alternative to the panel chart is the projector chart. Typically their display area is relatively small in angular size and this limits the length of the rows and the number of print sizes that can be presented at the same time. The angular size of the projected letters will be independent of viewing distance provided the projection screen is equidistant from both the projector and the patient. In short rooms, mirrors may be used to increase the optical path length from projector to screen and from screen to patient. The magnification of the projector may be varied, allowing precise calibration of the angular size of the letters for a given eye-to-patient distance.

Testing Protocols
Many of the important principles and practices associated with acuity testing have been outlined by Johnston (1991). Irrespective of the type of chart used, or the test distance selected, it is important to record both monocular and binocular acuities. Good clinical practice is to commence the assessment of visual functions by recording habitual visual acuities with the patient wearing his or her own distance spectacles or contact lenses. Adapting the practice of recording data for the right eye (Rt/OD) first, whilst ensuring total occlusion of the left eye, minimises the risk of erroneously recording laterally transposed data on the record card. Thereafter left-eye data (Lt/OS) should be recorded using, if possible, a separate acuity chart. This can be readily achieved using a Snellen rotating drum system, hand-held charts or alternatively by utilising different charts from the

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BaileyLovie or ETDRS sets. Generally, binocular acuities (Binoc/OU) will be equal to or marginally better than best monocular acuity. Sometimes, such as in the case of congenital nystagmus, the difference may become as great as 0.3 log MAR units. It is often useful to record unaided acuities (Rt/Lt and Binoc), or visions, as they are often called in the UK, in order to ascertain the extent to which the refractive correction improves visual status. In cases where an occupational report is requested, it is not uncommon for employers to request information on both habitual and unaided visual acuities as well as best corrected acuities. Best corrected visual acuities, recorded monocularly and thereafter binocularly, should be recorded after full refraction. Pinhole acuities (PH) are measures of visual acuity through a 11.5mm pinhole. Pinhole acuities should be determined when the best corrected visual acuity is less than expected or where there is reason to suspect that visual impairment is predominantly the result of medial irregularity as, for example, in keratoconus or cortical cataract. To ensure that a given patients threshold lies within the range of the chart, all letters should be read at the largest size and no letters should be legible at the smallest size. If a patient correctly reads half or more of the letters in one row, he or she should be encouraged to attempt to read any letters in the following row. In clinical research protocols, it is common practice to have all patients read from the top of the chart, even for patients with excellent visual acuity. This practice can be laborious when using log MAR charts where, for normally sighted subjects, the threshold size will commonly be at the 12th or 13th row on the chart. In the interest of time, patients may be encouraged to start reading three rows above the expected threshold. Using log MAR charts, care has to be taken to encourage patients with macular defects, and those with neurological impairment, as the visual task can be difficult and exhausting. Isolating letters, or sets of letters can be useful and flip charts such as the SonksenSilver charts may be useful in such circumstances (Sonksen & Silver 1988). For more expeditious testing, Rosser et al. designed charts with an abbreviated size range, different letter designs and fewer letters per row (Rosser et al. 2001). An alternative approach advocated by Camparini and colleagues is to estimate the threshold region by having the patient read only the first letter in each row of ETDRS charts until mistakes are made (Camparini et al. 2001). In both cases, quicker testing is achieved with modest reductions in reliability and validity. There is a popular belief that 20/20 vision (6/6 or log MAR = 0.0) represents normal vision. Elliott and co-workers have shown that the average best corrected visual acuity in those under the age of 50, who show no signs of ocular

pathology, is about 6/4.8. Even in those over the age of 75 years, provided the eyes are free of disease, the average visual acuity is marginally better than 6/6 (Elliott et al. 1995). For clinicians to monitor changes in ocular health and visual status, visual acuity measurements should be made with appropriate test charts, viewed under controlled conditions, and credit should be given to every additional letter read correctly. The significance of this statement is borne out by the publication of two British Medical Journal papers on the subject in the mid-1990s (McGraw et al. 1995, Pandit 1994). McGraw et al. concluded that doctors must be extremely cautious when assigning clinical importance to changes in acuity of two lines or less because of the inherent variability of the Snellen chart, whereas Pandit stressed the practical importance of standardising working distances and illumination conditions when assessing visual acuity using Snellen charts in general practice.

The Impact of Glare

Light scatter from lenticular or corneal media haze produces veiling luminance over the retina. This reduces the contrast of the retinal image which produces glare disability. Substantial visual disability and glare discomfort may be encountered in certain lighting conditions, such as when facing oncoming headlights when driving at night, or when driving towards the setting sun. In the consulting room, lighting conditions are rarely sufficient to induce significant glare disability or discomfort. Sometimes, vision may, however, be reduced when reading material printed on glossy paper, illuminated by an inappropriately positioned luminaire. A clinical simulation of distance vision under glare can be achieved by using the brightness acuity tester. This device allows acuity to be assessed, viewing through a 12mm diameter peephole in a 60mm hemispherical lightdiffusing bowl which can be set at three different levels of glare intensity. Neumann et al. (1988) found the brightness acuity tester to be an accurate predictor of outdoor high-contrast acuity in cataractous patients. Glare has an even more dramatic impact on visibility when the test targets are of low contrast (Elliott & Bullimore 1993).

Contrast and Acuity Charts

Although a review of contrast sensitivity is outside the scope of this paper, it should be acknowledged that fundamental to vision is the eyes ability to differentiate

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luminance differences within an image formed on the retina. The difference in luminance (L) that can just be detected is proportional to the luminance of the background on which the increment is displayed. This is expressed as Webers law (L/L = constant), where L is the overall background or prevailing luminance (Tunnacliffe 1994). The threshold contrast ratio (or Fechner constant) is about 0.020.03 over the full range of photophobic luminance (11000 cd/m2). Under scotopic conditions, the Fechner constant rises exponentially to 0.7 and the eye becomes less good at detecting differences in luminance levels within a target. When quantifying the contrast inherent in a conventional black-on-white chart, it is common practice to express contrast (C) as C = L/L or C = (Lmax Lmin)/Lmax. The British Standard recommendations are that conventional acuity charts should have a contrast factor of 0.9 (90%), which is close to the theoretical maximum with printed charts (BSI 4274-1 1968). Sloan suggested that the lowest acceptable contrast ratio for the assessment of conventional high-contrast acuity was 0.84 (84%) (Sloan 1951). In recent years, increased understanding about the impact of ocular and visual pathway pathology on contrast sensitivity function has resulted in the development of low-contrast acuity charts. Regan letter charts, which are visual acuity charts with eight letters on each of five lines, are available at 96%, 7% and 4% contrast levels. They are designed for use at 3m and are scored on a letter-by-letter basis (Regan 1988). Also available is the reduced-contrast BaileyLovie visual acuity chart, which is identical to the high-contrast chart in design, except that the letters are printed at an 18% contrast level (Bailey 1982). The Regan and BaileyLovie low-contrast visual acuity charts are used to determine the smallest letters that can be read at two or more different contrast levels. Less well-known are the low luminance charts (Smith-Kettlewell Institute Low Luminance or SKILL charts) designed by HaegerstromPortnoy et al. (1997). These charts utilise black letters on a dark-grey background and they have been shown to be sensitive at detecting retinal and optic nerve disease. A significantly different test is the PelliRobson lowcontrast letter chart which measures contrast threshold, not visual acuity. This chart consists of Sloan letters of equal size (49mm) but of progressively decreasing contrast. Letters are grouped in 16 sets of three, each set decreasing in contrast by 0.15 log units. Those at the top left-hand corner of the chart have 89% contrast whilst those at the bottom right have 0.5% contrast (Pelli et al. 1988). This chart provides a contrast threshold measurement at a single letter size.

Electronic Display Technology and Clinical Measurement of Visual Acuity

Computer-controlled displays offer some important advantages for clinical measurement of visual acuity and related functions. For visual acuity charts, optotype sequences may be varied, so memorisation becomes less of a problem, especially when it is necessary to take repeated measurements. Patients responses can be recorded online and presentation protocols may be modified to enhance efficiency of testing, reliability of results and storage of data. Systematic variations may easily be made in stimulus variables such as luminance, contrast, spacing arrangements, optotype sizes, exposure time, and so forth. Until recently it had been difficult to obtain high luminances on electronic screens. Pixel structure imposes some limitations in that, for reasonable shape fidelity, letters need to be about 10 pixels or more in height, and the need for more pixels may be more pronounced for Landolt ring and tumbling E targets with their more regular structures. The smallest letters on the chart should be just beyond resolution for normally sighted subjects. Pixellation still imposes important limitations. If the smallest letters on the chart are 10 pixels high, a row of five 5 5 letters would need to be 110 pixels long, allowing for one-letter spacing between letters, and similar spacing at either end of the row. It would be 88 pixels for 5 4 optotypes. For a chart covering a 20-fold size range (6/60 to 6/3), the length of the largest row would thus need to be 2200 or 1760 pixels. With the separation between rows being equal to the height of the letters, the height of the chart would need to be at least 187 times the height of the smallest letters for a 20-fold range of sizes. Thus, for a 6/60 to 6/3 size range, a display screen would need to have in the order of 2000 pixels in both directions. The pixellation constraints are not so restrictive in the vertical dimension because vertical scrolling could be used to limit the display to a size range of immediate relevance. For letters to be 10 pixels high and to represent a 6/3 visual acuity angle the pixels need to subtend 15 seconds of arc at the eye. This means the pixel size would need to be 0.22mm for a 3-m viewing distance, or 0.44mm for 6m. The screen width or height would thus need to be 45 or 90cm. Current display screen technology is very close to being able to accommodate the high resolution and large area required for a log MAR acuity chart with a size range extending from 6/60 to 6/3. A particularly interesting development is the BV-1000 automated subjective refractive system, which has recently come to the market in the UK. The system utilises single Landolt Cs oriented

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randomly in one of four directions. The optotype sizes follow a logarithmic sequence and presenting visual acuity levels range from 6/60 (log MAR =1.0) to 6/3.8 (log MAR = 0.2). The single optotype presentation means the results are not directly comparable to results from optotypes in log MAR chart format (Dave 2003).

access to controlling target characteristics, luminances and layouts will enable clinicians to make more thoughtful systematic evaluations of the visual capabilities of their patients.

References Acknowledgements
The authors wish to offer particular thanks to Miss E Elliman, Mrs J Martin and Ms S OConnor, whose assistance in preparing the manuscript was invaluable.
American Medical Association (1984) Evaluation of permanent visual impairment. In: AMA Council on Scientific Affairs (eds) Guides to the Evaluation of Permanent Impairment. AMA Physicians Desk Reference for Ophthalmology, 2nd edn, pp. 14151. Chicago Association of Optometrists (2002) AOP Members Handbook 2002. Section C Vision Standards. London: Association of Optometrists Bailey IL (1982) Simplifying contrast sensitivity testing. Am J Optom Physiol Opt 59 (suppl.),12 Bailey IL (1988) Measurement of visual acuity towards standardisation. In: Vision Science Symposium: A Tribute to Gordon G Heath, pp. 21730. Bloomington: Indiana University Bailey IL, Bullimore MA, Raasch TW, Taylor HR (1991) Clinical grading and the effects of scaling. Invest Ophthalmol Vis Sci 32, 42232 Bailey IL (1998) Visual acuity. In: Benjamin WJ, Borish IM, Lampert R (eds) Borishs Clinical Refraction, ch. 10. Philadelphia: WB Saunders Bailey IL, Lovie JE (1976) New design principles for visual acuity letter charts. Am J Optom Physiol Opt 53 (11), 7405 Bennett AG (1965) Ophthalmic test types. Br J Physiol Opt 22, 23871 Blaskoviscs L (1924) The new unit of visual acuity and its practical use. Arch Ophthalmol 53, 47685 Borish IM (1970) Clinical Refraction, Visual acuity, 3rd edn, pp. 345422. Chicago, IL: Professional Press BSI 42741 (1968) Visual Acuity Test Types Pt 1: Specification for Test Charts for Clinically Determining Distance Visual Acuity. London: British Standard Institute BSI 42741 (2003) Visual Acuity Types Pt 1: Test Charts for Clinical Determination of Distance Visual Acuity: Specifications. London: British Standards Institute Bunce C, Evans J, Fraser S, Wormald R (1998) BD8 certification of visually impaired people. Br J Ophthalmol 82 (1), 7276 Camparini M, Cassinari P, Ferrigno L, Macaluso C (2001) ETDRS fast: implementing psychophysical adaptive methods to standardise visual acuity measurement with ETDRS charts. Invest Ophthalmol Vis Sci 42 (6), 122631 Coates WR (1935) Visual acuity test letters. Trans Inst Ophthalm Opticians III, 138 Cowan A (1928) Test cards for the determination of visual acuity: a review. Arch Ophthalmol NY 57, 28392 Dave T (2003) Topcon BV 1000 automated subjective refraction system. Optom Today April 4th 16 Dennett WS (1885) Test type. Trans Am Ophthalmol Soc 4, 1339 Duke-Elder SW (1937) The subjective examination of the eye. In: Duke-Elder SW (ed.) Textbook of Ophthalmology, vol. II, ch. 29. London: Henry Kimpton Elliott DB, Bullimore MA (1993) Assessing the reliability, discriminative ability and validity of disability glare tests. Invest Ophthalmol Vis Sci 34 (1), 10819 Elliott DB, Yang KCH, Whitaker D (1995) Visual acuity changes throughout adulthood in normal healthy eyes: seeing beyond 6/6. Optom Vis Sci 72 (3), 18691

Conclusion
Visual acuity, measured with letter charts, is likely to remain the principal test of central visual function used by clinicians. Advances in medical and optical technology will inevitably lead to eye care practitioners being more interested in accurately measuring small changes in vision. Practitioners will need better measurements to assess the outcome of sophisticated refractive surgery or the benefits achievable through using new designs of ophthalmic appliance. Decisions about treatments, access to funds to pay for treatment, or eligibility for certain benefits and privileges, will increasingly depend more on clinical data, and tightly specified criteria, and less on a clinicians declaration of opinion. The clinical community is slowly moving towards improving visual acuity measurement. There is an increased awareness that chart design affects visual acuity scores. There is also a growing acceptance of the need to standardize significant chart design features such as the choice of optotype, the number of letters at each size, the layout and spacing arrangements of the charts, and the sequence of the size progression. Scoring visual acuity in fine steps, giving additional credit for each additional letter read, should become the rule rather than the exception as clinicians become more interested in getting more precise and reliable measures of vision. As with the assessment of visual fields, progress in visual acuity measurement, by real-world clinicians, is likely to be gradual until such times as computer-based technology becomes adequate and affordable. It will not be long. When computer-based acuity measurement is made easy, and incorporated into examination routines, clinicians will embrace visual acuity tests with randomly generated letter sequences, efficient automated procedures to establish threshold, and automatic registering of precise visual acuity scores with measures of reliability. Ready

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Evans J (1995) Causes of Blindness and Partial Sight in England and Wales 19901991. Studies on Medical Population Subjects No. 57. London: HMSO Ferris FL, Sperduto RD (1982) Standardised illumination for visual acuity testing in clinical research. Am J Ophthalmol 94, 978 Ferris FL, Kassoff A, Bresnick GH, Bailey IL (1982) New visual acuity charts for clinical research. Am J Ophthalmol 94, 916 Flom MC, Weymouth FW, Kahneman K (1963) Visual resolution and contour interaction. J Opt Soc Am 53 (9), 102632 Green J (1868) On a new series of test letters for determining acuteness of vision. Trans Am Ophthalmol Soc 1 (3), 6871 Green J (1872) Some Improvements in Test Letters. London: IVth International Ophthalmology Congress Green J (1905) Notes on the clinical determination of the acuteness of vision, including the construction and gradation of opto-types and on systems of notation. Trans Am Ophthalmol Soc 10 (3), 644654 Haegerstrom-Portnoy G, Brabyn J, Schneck M, Jampolsky A (1997) The SKILL card: an acuity test of reduced luminance and contrast. Invest Ophthalmol Vis Sci 38 (1), 20718 Hartridge H, Owen HB (1922) Test types. Br J Ophthalmol 6, 543549 Hofstetter HW (1950) The AMA method of appraisal of visual efficiency. Am J Optom Arch Am Acad Optom 27 (2), 5563 Hyvarinen L, Nasanen R, Laurinen P (1980) New visual acuity test for pre-school children. Acta Ophthalmol 58, 50711 Javal E (1900) Rforme de la notation de lacuit visuelle. Ann Oculist 124, 1559 Jayatunga R, Sonksen PM, Bhibe A, Wade A (1995) Measures of acuity in primary school children and their ability to detect minor errors in vision. Dev Med Child Neurol 37, 515 Jenkins FA, White HE (1976) Fundamentals of Optics, 4th edn, p. 329. Kogakusha: McGrawHill Johnston AW (1991) Making sense of the M, N and log MAR systems of specifying visual acuity. Probl Optom (Lippincott) 3 (3), 394407 Jones D, Westall C, Averbeck K, Abdolell M (2003) Visual acuity assessment: a comparison of two tests for measuring childrens vision. Ophthalmol Physiol Opt 23 (6), 5416 Keeler CH (1956) Visual aids for the partially sighted. Trans Ophthalmol Soc UK 76, 60514 Landolt E (1899) Nouveaux opto-types pour la dtermination de lacuit visuelle. Arch Ophthalmol Paris 19, 465471 McGraw PV, Winn B (1993) Glasgow acuity cards: a new test for the measurement of letter acuity in children. Ophthalmol Physiol Opt 13 (4), 4003 McGraw P, Winn B, Whitaker D (1995) Reliability of the Snellen chart. BMJ 310, 14812 Monoyer M (1875) Echelle typographique dcimale pour msurer lacuit de la vue. CR Hebd Sance Acad Sci Paris 80, 11378 NASNRC (National Academy of Science: National Research Council Vision Committee on Vision) (1980) Recommended standard procedures for the clinical measurement and specification of visual acuity (report 39). Adv Ophthalmol 41, 10348 Neumann AC, McCarty GR, Locke J, Cobb B (1988) Glare disability devices for cataract: a consumers guide. J Cataract Refract Surg 14, 21216 Ogle KN (1953) On the problem of an international nomenclature for designating visual acuity. Am J Ophthalmol 36, 90921 Pandit JC (1994). Testing acuity of vision in general practice: reaching recommended standards. BMJ 309, 1408 Pelli DG, Robson JG, Wilkins AJ (1988) The design of a new letter chart for measuring contrast sensitivity. Clin Vision Sci 2 (3), 187200

Raasch T, Bailey I (1984) Choice of optotype and spacing affect visual acuity scores. Invest Ophthalmol Vis Sci 25 (suppl. 86), 145 Regan D (1988) Low contrast letter charts and sinewave grating tests in ophthalmological and neurological disorders. Clin Vision Sci 2, 23550 Rosser DA, Laidlaw DAH, Murdoch IE (2001) The development of a reduced log MAR visual acuity chart for use in routine clinical practice. Br J Ophthalmol 85, 4326 Sheedy JE, Bailey IL, Raasch TW (1984) Visual acuity and chart luminance. Am J Optom Physiol Opt 61 (9), 595600 Sloan LL (1951). Measurement of visual acuity. AMA Arch Ophthalmol 45, 70425 Sloan LL (1959) New test charts for the measurement of visual acuity at far and near distances. Am J Ophthalmol 48 (6), 80713 Sloan LL, Rowland WM, Altman A (1952) Comparison of three types of test target for the measurement of visual acuity. Q Rev Ophthalmol 8, 416 Snell AC, Sterling S (1926) An experimental investigation to determine the percentage relation between macular acuity of vision and macular perception. In: Menasha G (ed.) Contributions to Ophthalmic Science, pp. 5262. Banta Snellen H (1862) Letterproeven tot Bepaling der Gezigtsscherpte. Utrecht: PW Vander Weijer Snellen H (1864) Test Types for the Determination of the Acuteness of Vision. Official War Office edition (2nd edn). Utrecht: PW Vander Weijer Sonksen PM, Silver J (1988) The Sonksen Silver Acuity System. Test System and Instruction Manual. Windsor: Keeler Spaeth EB, Fralick FB, Hughes WF, Scheie HG (1955) American Medical Association council on industrial health: special report, estimation of loss of visual efficiency. Arch Ophthalmol 54, 4628 Stiles WS, Crawford BH (1933) The luminous efficiency of rays entering the eye pupil at different points. Proc R Soc (Lond) Biol 112, 42850 Strong G, Woo GC (1985) A distance visual acuity chart incorporating some new design features. Arch Ophthalmol 103, 446 Swaine W (1925) The relation of visual acuity and accommodation to ametropia. Trans Opt Soc 927 Taylor JF (ed.) (1995) Medical Aspects of Fitness to Drive. London: Medical Commission on Accident Preventions Tunnacliffe A (1994) Visual acuity updated: 4. Br J Optom Dispens 2 (12), 4558 Walker JPS (1942) Test type. Br J Ophthalmol 26, 556559 Weber EH (1834) De Pulsu, Resorptione, Auditu et Tactu Annotationes Anatomicae et Physiologicae. Leipzig: CF Koehler Westheimer G (1964) Pupil size and visual resolution. Vis Res 4, 3945 Westheimer G (1979) Scaling of visual acuity measurement. Arch Ophthalmol 97, 32730 Woo G, Lo P (1980) A Chinese word acuity chart with new design principles. Singapore Med J 21, 68992 Woodruff EW (1947) Visual acuity and the selection of test letters. In: Some Recent Advances in Ophthalmic Optics, pp. 5970. London: Hatton Press World Health Organization (1979) Guidelines for Programmes for the Prevention of Blindness. Geneva: World Health Organization

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Multiple Choice Questions

This paper is reference C5333b. Four College credits are available. Please use the inserted answer sheet. Copies can be obtained from Optometry in Practice Administration, PO Box 6, Skelmersdale, Lancashire WN8 9FW. There is only one correct answer for each question.

1. (a) (b) (c) (d) (e) 2.

The diffraction pattern of the image of a point source of light Has a Gaussian profile. Consists of a series of concentric circles. Has a central disk surround by rings. Is independent of wavelength. Is independent of pupil size. Monochromatic light from a point object, focused by the optics of the eye, forms a patch of light on the retina. The light distribution across the patch is referred to as the Ramsden disk. Petzval surface. Interval of Sturm. Contrast sensitivity function Point spread function. In a system free of aberrations or defocus, visual resolution Is poorer with smaller pupils. Is better with smaller pupils. Is independent of the wavelength of light. Is better when the point spread function is larger. Is better if the areas of the foveal cones are larger. Under photopic conditions, the differential contrast threshold remains a constant ratio of approximately 80% 20% 15% 1% 0.1% For a 3-bar target, spurious resolution Causes vertical lines to appear horizontal. Causes noticeable colored fringes. Causes a doubling of the spatial frequency. Causes the 3 lines to appear to be 2. Causes the 3 lines to appear to be 4.

7. (a) (b) (c)

Regarding optotypes for visual acuity measurement British Standard letters are all 5x4 letters with serifs. Sloan letters are all 5x5 letters without serifs. Keeler chart letters all have stroke widths that are 20% of the letter height.

(d) Landolts Rings were developed before Snellens Letters. (e) Snellens original letter set were all 5x5 letters. 8. (a) (b) (c) (d) (e) The term Oxyoptre as suggested by Blaskovics is a measure of Retinal image blur in diopters. Optical defocus. The reciprocal of the visual angle in degrees. Spatial frequency. Longitudinal chromatic aberration in diopters.

(a) (b) (c) (d) (e) 3. (a) (b) (c) (d) (e) 4. (a) (b) (c) (d) (e) 5. (a) (b) (c) (d) (e)

9. Regarding the designation of visual acuity (a) The Snellen fraction is a measure of letter height. (b) The MAR is the angle that the letter (or optotype) height subtends at the eye. (c) If a chart follows the Bailey-Lovie format, each letter has a value of 0.02 logMAR units. (d) LogMAR notation can only be used if there is the same number of letters on each row. (e) In decimal notation, 2.0 is equivalent to 6/12. 10. Which of the following is NOT true about charts that follow the Bailey Lovie principles (a) The progression of size should follow a constant ratio. (b) There should be the same number of letters (or optotypes) per row. (c) The letters (or optotypes) chosen for each row should be balanced for difficulty. (d) Between-row spacing should be proportional to letter height. (e) Between-letter spacing should be proportionally greater when letter sizes are smaller. 11. Comparing the merits of row-by-row and letter-byletter scoring methods (a) If using letter-by-letter scoring, you are more likely to get exactly the same score for test and retest. (b) If using row-by-row scoring, you are less likely to have 1 row difference between test and retest. (c) If using row-by-row scoring, you are less likely to have 2 rows difference between test and retest. (d) If using letter-by-letter scoring, you ignore errors made at sizes larger than the smallest row on which more than 50% of the letters were read correctly. (e) If using letter-by-letter scoring, you are substantially more able to identify changes in visual acuity.

6. Hyperacuities (a) Occur only for sinusoidal grating targets. (b) Occur only under binocular viewing and bi-foveal fixation. (c) Occur because of vertical orthophoria. (d) Occur because of pooling information from the two eyes. (e) Occur because of pooling of spatial information across receptors.

Questions for this paper are continued on inside back cover

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