REVIEW

Visual Acuity and Contrast Sensitivity Testing for Sports Vision

Aaron B. Zimmerman, O.D., M.S., Kimberly L. Lust, B.S., and Mark A. Bullimore, M.C.Optom., Ph.D.

Abstract: The building blocks of effective sports vision are visual acuity and
of test targets—whether briefly presented or moving—is
contrast sensitivity. Proper measurement of these spatial vision attributes is
discussed along with the potential for enhancement using tinted
necessary for repeatability in the clinic or in the laboratory. The most lenses and vision training.
repeatable method of testing visual acuity is with logMAR charts— either the Visual acuity and contrast sensitivity are two aspects of spatial
Bailey–Lovie chart or the Early Treatment Diabetic Retinopathy Study chart. vision assessed in clinical and research settings. Visual acuity is a
The Pelli–Robson and the Mars are the most repeatable contrast sensitivity measure of an individual’s ability to resolve fine detail, that is, what
tests. Athletes may or may not demonstrate superior visual acuity and contrast is the smallest black-on-white letter that a subject can identify.
sensitivity compared with age-matched nonathlete populations, and the optical Contrast sensitivity is the individual’s ability to detect low-contrast
quality of their eyes may be similar. Dynamic visual acuity in athletes and their objects of various sizes. In the laboratory, contrast sensitivity—the
performance are typically superior to those of nonathletes. How these reciprocal of threshold contrast—is measured for sine wave gratings
differences relate to on-field performance is not known. Other changes to the
for a range of spatial frequencies, specified in cycles/degree. Low
visual system because of refractive surgery or contact lens wear may increase
spatial frequencies correspond to broad stripes, whereas high spatial
higher order aberrations and reduce low-contrast visual acuity. The ability to
improve already-normal visual acuity is unclear although contrast sensitivity
frequencies correspond to narrow stripes. The CSF has an inverted U
can improve with fast-paced video games. Tinted contact lenses help reduce shape with the peak contrast sensitivity at approximately 4
discomfort glare and speed up adaptation but do not have an appreciable effect cycles/degree meaning that the human visual system is relatively less
on visual acuity and contrast sensitivity. Conclusion: The use of valid and sensitive to high and low spatial frequencies (Fig. 2). 1 The highest
repeatable visual acuity and contrast sensitivity tests is essential for measuring spatial frequency that can be detected at 100% contrast corresponds to
the differences in visual perfor-mance among athletes and nonathletes. The the subject’s visual acuity. Thus, contrast sensitivity and visual acuity
development of a standardized dynamic visual acuity test is needed as are well- are related, although the former is a more complete description of
controlled scientific studies to evaluate the benefits of sports vision training
visual performance.
An individual’s visual acuity is physiologically limited
Key Words: Visual acuity—Contrast sensitivity—Vision of athletes— optically, retinally, and cortically. The optical limitations of the
Vision training—Dynamic visual acuity. eye are because of pupil size and aberrations induced by the
cornea and the lens. The normal pupil size for young adults is
(Eye & Contact Lens 2011;37: 153–159) typically approximately 5.3 mm, whereas that of a 60-year-old is
3.2 mm.2 A larger pupil can make the aberrations of the eye
manifest, whereas a smaller pupil can degrade the image through

T he ‘‘Sports Vision 2010—A New Paradigm’’ meeting took

place in early 2010 with multiple professions being represented,
diffraction. Spherical aberration is present in normal eyes and
increases as the pupil dilates.3
Orthokeratology is a specialty contact lens fit utilized to
including ophthalmology, optometry, and athletic trainers. A theme of reversibly reduce a patient’s myopia. Cone density at the center of
the meeting was the Vision Pyramid (Fig. 1) consisting of various
visual system characteristics and their integration to achieve the the fovea is approximately 200,000 cones/mm2 with cone spacing
ultimate goal of on-field performance enhancement. At the base of being 2.5 mm. Each photoreceptor subtends approximately 28
the pyramid lies visual acuity and contrast sensitivity, which are the arcsec, and this allows for just a little greater than 60
fundamentals of visual performance. This article will discuss the
science of visual acuity and the contrast sensitivity function (CSF), cycles/degree or slightly better than 20/10 Snellen visual acuity. 4
their limitations, how to properly test these variables, the effect of This limitation is commonly referred to as the Nyquist limit. 5
refractive correction, and whether or not training is beneficial.
Furthermore, the potential for the inclusion of dynamic presentation Recent advancements with adaptive optics, particularly scanning
laser ophthalmoscopy, have confirmed that the photoreceptor
density in vivo correlates well with the Curcio et al. data from
harvested retinas.4,6,7 The visual pathway advances to the
From the College of Optometry, The Ohio State University, Columbus, ganglion cells, then the lateral geniculate nucleus, and ends at the
OH. visual cortex. The upstream structures do not currently have any
The authors have no funding or conflicts of interest to disclose. Address known properties capable of enhancing the spatial visual acuity.
correspondence and reprint requests to Aaron B. Zimmerman
O.D., M.S., College of Optometry, The Ohio State University, 338 West
10th Avenue, Columbus, OH 43210; e-mail: azimmerman@optometry. logMAR Visual Acuity Charts
osu.edu
Accepted December 23, 2010. There are numerous methods used to test visual acuity. The most
common method used is recognition acuity or resolving an optotype
DOI: 10.1097/ICL.0b013e31820d12f4
in which the patient is familiar with the target. The most repeatable
and standardized method of measuring visual acuity is through the

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A. B. Zimmerman et al. Eye & Contact Lens Volume 37, Number 3, May 2011

repeatability of the measurement and allows more precise

specification of visual acuity.10 Clinicians often give patients
credit for a partial line read, and the by-letter scoring approach
formalizes this notion. Visual acuity testing can be made more
rigorous by forcing the patients to guess letters even if they say
they cannot read them.
Contrast Sensitivity Charts
Several researchers have advocated the use of letters to assess
contrast sensitivity. Letters have the advantage of being familiar to
patients, and their forced-choice properties means that the patients do
not merely have to state whether or not they can see a grating or
choose between a limited number of orientations with a relatively
high chance of guessing correctly. Pelli et al. 11 were among the first
FIG. 1. The vision pyramid. Reprinted with permission from to assert that the CSF could be adequately described by two points on
Kirschen DG, Laby DM. The role of sports vision in eye care today. the function: visual acuity corresponding to the high spatial cut-off
Eye Contact Lens 2011;37;127-130. Copyright 2011 Contact Lens and contrast sensitivity for large letters corresponding to the height of
Association of Ophthalmologists, Inc.
the CSF (Fig. 2).To facilitate rapid assessment, Pelli et al. introduced
the Pelli–Robson Chart, which consists of 5-cm-high letters of
use of logMAR charts. Two types of logMAR are commonly used:
decreasing contrast. The Pelli–Robson chart has 16 triplets of Sloan
the Bailey–Lovie chart8 and the Early Treatment Diabetic letters with decreasing contrast. Each triplet is 0.15 log units lower in
Retinopathy Study (ETDRS) chart,9 and these have become standard contrast than its predecessor, and repeatability can be further
in all federally funded clinical studies and many under the auspices of improved by assigning each letter a value of 0.05 log units. 12 Each
the United States Food and Drug Administration. Both charts use 10
letter subtends 2.8L at a test distance of 1 m.
letters chosen to have similar legibility. The Bailey–Lovie chart uses
the letters D, E, F, H, N, P, R U, V, Z, which are 5:4 height to width. Elliott and Bulllimore13 demonstrated that contrast sensitivity
The ETDRS chart uses Sloan letters C, D, H, K, N, O, R, S, V, Z, could be measured with greater repeatability with letter-based
which are 5:5 in height to width. charts, including the Pelli–Robson Chart, than with charts
Each line on the logMAR charts contains five letters of equal containing gratings. In the 20 years since the introduction of the
Pelli–Robson Chart, a few similar tests have been introduced. The
size, separated by equal distance. The spacing between lines is the
Mars Letter Contrast Sensitivity Test is a smaller more portable
same height as the preceding letter height, such as the spacing
between the 20/25 and 20/32 lines is the height of the 20/25 line. derivative of the Pelli–Robson chart. 14 These charts are 23 3 35.5
The chart also consists of a uniform line size reduction of 1.25 or cm, whereas the Pelli–Robson chart is 63 3 86 cm. The Mars test
0.1 log units. Because five letters are on each line, each individual consists of eight rows of six letters, but each letter is lower in
letter is assigned a value of 0.02. Instead of giving credit for an contrast by 0.04 log units than the previous. Dougherty et al. 15
entire line, this test allows for visual acuity to be measured and found that the Pelli–Robson and Mars charts demonstrated similar
specified on a letter-by-letter basis. This both improves the repeatability and showed good agreement. The Mars test may be
more practical in the sports vision setting because it is much more
portable and durable.

Dynamic Visual Acuity Tests

Many sports challenge the participant to localize and track a
fast moving object such as a baseball, a tennis ball, or a hockey
puck. This raises the question of whether vision tests that
incorporate moving targets could be developed and used .
Currently, there is no widely accepted or standardized method to
assess dynamic visual acuity. Dynamic visual acuity has been
tested with targets moving laterally on a screen, on a rotating disc,
or using projected letters imaged by rotating mirrors, with either
letters or numbers as stimuli. For the laterally moving targets
variations in stimulus duration, luminance, target size, contrast,
and eccentricity have all been tested. 16–19 It is well established
that as the target velocity increases, an individual’s visual acuity
will decrease.16,18,19 It is also clear that stimulus duration has an
effect on dynamic visual acuity. 18 It has also been shown that
dynamic visual acuity can be improved with training. 17
Clinicians have been interested in studying dynamic visual acuity
hypothesizing that it is related to athletic performance. According to
Rouse et al.,20 it would be more advantageous for an athlete to
discriminate rather than just detect a target, for example, the laces on
FIG. 2. The contrast sensitivity function. a baseball. Ludvigh and Miller performed many studies

154 Eye & Contact Lens Volume 37, Number 3, May

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 Eye & Contact Lens Volume 37, Number 3, May 2011 Visual Acuity and Contrast Sensitivity

regarding aviation, and their study indicates that pilots with better
dynamic visual acuity make fewer errors. Rouse et al. 20 compared the
dynamic visual acuity of members of the California State University
at Fullerton baseball team with that of optometry students from the
Southern California College of Optometry. The subjects had to
identify the orientation 20/25 Landolt Cs projected for 400 msec at
varying velocities. They found that the baseball players could, on
average, identify the orientation at significantly higher velocities.
Other researchers have used briefly presented targets to
evaluate vision. This is particularly useful when assessing a
patient whose vision may be fluctuating because of variations in
tear film or movement of a contact lens. 21,22 Indeed differences in
performance can be identified that are not apparent for static
targets. Other researchers have made objective dynamic FIG. 3. The distribution of visual acuity among Major League Baseball
evaluations of ocular image quality using aberrometry and players. Reprinted with permission from Laby DM, Rosenbaum AL,
demonstrated the importance of the tear film. 23,24 Kirschen DG, et al. The visual function of professional baseball players.
Am J Ophthalmol 1996;122:476–485.
The final class of dynamic vision tests is kinetic visual acuity
where the target is moved toward the subject. 25 This approach is
analogous to gradually or rapidly increasing the size of a letter Laby et al. also measured contrast sensitivity in their cohort of
until a subject can identify it, and thus, results will be influenced baseball players and found superior values when compared with
by both visual acuity and reaction time. unpublished normal values at higher spatial frequencies. On some of
In summary, the assessment of vision for dynamic, moving the tests, the players could identify the lowest contrast stimuli, but
targets seems to be a potentially fruitful avenue of investigation given the design of the tests, the probability of guessing correctly is
and development. Many test variables can be manipulated high. Hoffman et al.28 found higher contrast sensitivity in college
including letter size, target velocity, contrast, and exposure baseball players compared with in an optometry student control group
duration, and the challenge is to standardize these into a using the Arden Plates. Unfortunately, this test is criteria dependent
repeatable, valid test that can then be used to discriminate among (‘‘tell me when you see it’’) and may be further confounded by the
groups of subjects or to assess the benefits of a vision-training reaction times of the subjects. Although contrast sensitivity may be
regimen. Incorporating the principles of existing static clinical higher among elite athletes, these previous reports are worthy of
tests such as logMAR charts or using Landolt Cs would seem further investigation using a concurrent control group and well-
desirable. For example, Bailey– Lovie or ETDRS charts use designed tests.
letters of relatively equal resolution difficulty and follow a One potential explanation for higher visual performance among
uniform (logarithmic) size progression. 8,9 It would also be athletes is lower ocular aberrations. To this end, Kirschen et al.
possible to develop a low contrast or a variable contrast chart.

How Does Athletes’ Vision Compare With That of

the Normal Population?
The largest study to date evaluating the performance of the visual
system in athletes was performed by Laby et al. 26 in the 1990s.
During Baseball spring training from 1992 to 1995, these
investigators performed thorough vision screeners evaluating static
visual acuity, contrast sensitivity, and distance and near stereoacuity
(including random dot) on players from the Los Angeles Dodgers.
Nearly 80% of the Major League Baseball (MLB) players were
found to demonstrate static visual acuity of 20/15 (20.125 logMAR)
or better. Only 1.3% of the players showed visual acuity of 20/30
(+0.20 logMAR) or worse (Fig. 3). Some players even approached
20/9 (20.35 logMAR). These values are impressive when compared
with our historical benchmark of 20/20, but most young normal
subjects demonstrate visual acuity that is better than 20/20. The oft-
cited work of Elliott et al. 27 reports a mean visual acuity of –0.13
logMAR in 18- to 24-year-olds and –0.16 logMAR in 25- to 29-year-
olds. Inspection of their data (Fig. 4) suggests that approximately
60% of their subjects between 20 and 35 years old demonstrate visual FIG. 4. The distribution of visual acuity among eyes of 223 normal
acuity of 20/15 or better and approximately 20% demonstrate 20/12.5 healthy subjects ranging from 18 to 80 years of age. The best
or better. In other words, the visual acuity of the Laby et al. baseball linear and bilinear fits are shown. Reprinted with permission from
Reprinted with permission from Elliott DB, Yang KC, Whitaker D.
players may be superior to those of a normal population, but only by a Visual acuity changes throughout adulthood in normal, healthy
letter or two. eyes: Seeing beyond 6/6. Optom Vis Sci 1995;72:186–191.

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 A. B. Zimmerman et al. Eye & Contact Lens Volume 37, Number 3, May 2011

assessed higher order aberrations in professional baseball players

and compared them with published controls. 29,30 The only
significant difference between these two populations was for
trefoil, but the 0.0147-mm difference corresponds to a 0.031-D
equivalent spherical difference for a 4-mm pupil and was thus
judged to be clinically irrelevant. This finding is consistent with
that of Villegas et al. 3 who found that lower levels of ocular
aberrations did not explain the supernormal visual acuity
observed in some subjects.
In summary, high levels of visual performance may exist
among elite athletes, but future research should recruit concurrent
control groups and test them under identical conditions using
appropriately designed methodology. Differences in performance
are unlikely to be because of ocular aberrations, and thus, their
correction in a normal population may not lead to measurable
improvements in vision.

Refractive Modification
According to the International Society of Refractive Surgery U.S.
2009 Trend Survey, laser in situ keratomileusis (LASIK) continues to
be the most common form of refractive surgery, and many high- FIG. 5. The relation between basketball free throw shooting and
profile athletes have undergone the procedure. 31,32 It is unclear visual acuity. Reprinted with permission from Applegate RA,
whether LASIK results in an improvement or detriment of on-field Applegate RA. Set shot shooting performance and visual acuity in
basketball. Optom Vis Sci 1992;69:765–768.
performance, for example, in baseball players. 33 It is has been shown
that best-corrected high contrast visual acuity is unaffected by
LASIK; however, low-contrast visual acuity is reduced for toward them by either a bowling (pitching) machine or a live bowler
individuals with greater than 26 D of preoperative myopia and those at two different velocities, medium and fast. Each batsman was
who have undergone LASIK with astigmatic keratectomy. 34 Marcos blurred using soft contact lenses allowing for four conditions: plano,
et al.35 found that higher order aberrations increased significantly +1.00, +2.00, and +3.00 D with the players’ habitual correction used
after LASIK, with higher preoperative levels of myopia for the plano condition. These conditions yielded visual acuities of
demonstrating a larger increase in aberrations. A recent study has approximately 20/15, 20/40, 20/60, and 20/160. Although, one would
shown that with wavefront-guided LASIK spherical aberration does suspect that blur would have a significant effect on hitting
not change significantly for myopia up to 27 D.36 performance, their results suggest that there is no decrease in
Orthokeratology has been used since 1989 to reversibly reduce a performance until the +3.00-D condition (Fig. 6). 40 This effect was
patient’s myopia. Similarly to LASIK flattening, the central corneal found not only with a predictable and repeatable pitching machine but
surface leads to more spherical aberration and reduced low-contrast also with nonpredictable human bowlers (pitchers).
visual acuity.37 In both of these refractive procedures, the practitioner Blur may not cause a significant reduction in athletic
and patient should be aware of the potential reductions in visual performance in a sport with fast moving targets, because of the
performance, particularly under nighttime conditions when the pupil dorsal vision pathway. Because the magnocellular pathway has
will be larger. For individuals pursuing LASIK surgery, the amount
of refractive error being corrected needs to be considered, and
wavefront-guided procedures are preferred. Orthokeratology is
reversible with discontinuation of lens wear and thus may be
considered in younger athletes.
There are some circumstances where refractive error has little
effect on sports performance. Applegate and Applegate 38 studied the
effects of induced refractive error on free throw shooting. Grade
school and high-school basketball players were blurred using trial
lenses and shot 25 free throws for each condition. Figure 5 shows that
the percentage of free throws made goes down immediately if the
subject is blurred to 20/40. This decrease in shooting percentage was
not statistically significant, although a 10% improvement in free
throw shooting over an entire season may be meaningful. As blur was
increased, the shooting percentage stayed nearly identical. Thus,
uncorrected refractive error for a static, repeatable motion such as
free throw shooting may not be critical.
Mann et al.39,40 have recently evaluated the impact of blur on the FIG. 6. The effect of blur on cricket shot quality. Reprinted with
permission from Mann DL, Ho NY, De Souza NJ, et al. Is optimal
more visually demanding and high velocity game of cricket. Male
vision required for the successful execution of an interceptive task?
batsmen were instructed to hit cricket balls that were projected Hum Mov Sci 2007;26:343–356.

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 Eye & Contact Lens Volume 37, Number 3, May 2011 Visual Acuity and Contrast Sensitivity

large receptive fields and is relatively insensitive to high spatial Yellow-tinted contact lenses block out shorter wavelength
frequencies, it can be surmised that low levels of blur will not light, particularly blue light. Benefits may thus accrue because of
dramatically decrease performance. reduction in the longitudinal chromatic aberration of the eye or
reduction in intraocular light scatter. Although the effect of
Training Visual Acuity yellow-tinted lenses on visual acuity and contrast sensitivity is
It is well established that vision training including occlusion and equivocal, there may still be a role based on subjective
other forms of penalization is an effective treatment for amblyopia, preference, and specific tints for specific sports may be
particularly in the younger patient. 41 More controversial is the use of appropriate. Former MLB player Mark McGwire used yellow
vision therapy to improve uncorrected visual acuity in myopia. tinted lenses toward the end of his career and claimed that these
Multiple techniques have been attempted with some claiming lenses allowed for crisper vision and a reduction in glare. 51
reduction in the degree of myopia. 42,43 Trachtman’s and Randle’s
work, although independent, used devices to measure accommo- Therapy
dative accuracy, which fed into a tone generator to give feedback to
Recent studies have suggested that contrast sensitivity may be
the subject regarding their accommodative status. Trachtman’s goal
was to treat functional myopia, which was defined as less than 2 D of enhanced in normally sighted subjects. 52 The investigators
myopia. He found that he could treat between 0.25 and 0.75 D of compared contrast sensitivity of individuals who commonly play
myopia. Randle’s studies demonstrated that subjects could voluntarily video games and nonvideo game players. The video game players
control their accommodative systems and subjects could extend their showed higher contrast sensitivity at mid and high spatial
far point. Unfortunately, neither researcher evaluated pre and frequencies. In a confirmatory experiment, a sample of nonvideo
postcycloplegic refraction to determine whether refractive status truly game players were assigned to two groups: one group played
changed. Balliet et al.44 tried to train visual acuity by having subjects action video games (Call of Duty 2 by Infinity Ward, Encino,
view oblique square wave gratings whose optical distance was varied.
CA), and the control group played a nonaction game (The Sims 2
Improvements in visual acuity were found and attributed to changes by Electronic Arts, Redwood City, CA). Only those exposed to
in the tear lens, although refractive status was unchanged. the action video game demonstrated a significant improvement in
contrast sensitiv-ity. The investigators suggest that because of
cortical plasticity, contrast sensitivity can be improved.
Gilmartin45 summarized myopia-reduction therapy in a 1991
New techniques may offer benefits in the area of sports vision. For
review article and concluded that there is no experimental evidence to
example, recent reports suggest improvements in contrast sensitivity
indicate that training visual acuity through biofeedback is effective.
in older amblyopic subjects, a population that historically has not
He was careful not to dismiss the theory of biofeedback treating
myopia but emphasized the need for objective data. The American been offered therapy.53 The investigators trained amblyopes, aged 9
Academy of Ophthalmology dismisses any current treat-ment for to 55 years, using sine-wave patches, with and without flanking high-
reducing myopia and believes that the only risk associated with this contrast patches.54 The investigators found that by reconstructing
therapy is financial.46 http://www.eyecareamerica.org/ those elements that were not acquired during development, visual
eyecare/treatment/alternative-therapies/visual-training.cfm. acuity and contrast detection could be improved. Because 100%
contrast stimuli are rare in the natural world, showing good contrast
Contrast Sensitivity Enhancement sensitivity may be more important than superior visual acuity for
overall visual performance. Superior contrast sensitivity comes from
Devices demonstrating healthy and optimally corrected eyes; however, new
Tinted spectacle lenses have long been used in some sports studies are showing that the visual components responsible for
including shooting and archery. Subjective improvements in vision perceiving contrast may have plasticity. The question of whether
are common although not accompanied by objective improvements in training contrast sensitivity helps improve on-field performance will
contrast sensitivity.47 The Nike Maxsight contact lenses (Bausch need to be addressed.
+ Lomb, Rochester, NY) were introduced in 2005 and were
designed to improve on-field performance. These lenses have since Concluding Comments
been discontinued; however, studies have been published regarding To date, there have been limited controlled studies evaluating
the effect these lenses had on visual performance. sports vision therapy. Wood and Abernethy 55 evaluated 30
Early reports suggested no improvements in visual acuity or subjects placed in three groups: a vision therapy group, a placebo,
contrast sensitivity with Nike Maxsight contact lenses. 48 Sub- and a control group. The exercises used in the vision-training
sequently, Porisch49 compared contrast sensitivity with Nike Max- group were common vision therapy techniques used in clinical
sight contact lenses and with clear lenses of collegiate and practice. Their results showed that the vision training did not have
professional athletes by comparing performance either. A significant any effect. They later performed an additional study with four
difference was found only at 3 and 18 cycles/degree, corresponding to groups. The first group was administered a sports vision–specific
1 to 2 letters on the Pelli–Robson chart. Subjects also reported a battery of therapy, the second group was administered a different
decrease in glare. This is consistent with subjective responses from vision therapy regimen, the third group was a placebo, and the
the Erickson et al.50 study in which visual performance and comfort fourth was a control. Again, there was no difference with
of clear and tinted lenses were compared in bright lighting conditions. performance. Specifically, static visual acuity and dynamic visual
Erickson et al. found that dark-adapted subjects were able to visually acuity did not improve.
adapt faster to bright light conditions with the tinted lenses, and they The most fundamental aspects of sports vision are contrast
also found that subjects noticed significantly less glare with tinted sensitivity and visual acuity. Visual acuity is tested on a daily basis,
lenses as compared with clear lenses. and in most circumstances, treating refractive error is the easiest

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 A. B. Zimmerman et al. Eye & Contact Lens Volume 37, Number 3, May 2011

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