Acuity Measurement

Basic Visual Fields

 Introduction
• A lot to fit in, apologies
• Morning
– Acuity
– Visual Fields Testing
• Afternoon
– Understanding Spectacle Prescriptions
– Little About Low Vision Assessment
 Distance Vision/Visual Acuity
• Measures maximal spatial resolution
• Tells us what people can see in the distance!
• Core Measurement
• Easy to take,
• but many ways to do it...
– 6/60
– 20/200
– 1.00logMAR
– 0.1
• Snellen
• Decimal notation
• logMAR
 Snellen
• In 1862 Dr Herman Snelling introduced a chart made
of letters on a 5 x5 grid
• “Normal vision” is defined as being able to resolve a
letter of 5 minutes of arc at 6m distance.
• Common usage
 Snellen
• Snellen is represented by a fraction
• E.g. 6/6 6/24
• The top number tells us the testing distance
• The Bottom number tells us how much bigger (or
further away)the letter was than the standard letter
• Arithmetic Scale
– So the 6/12 letter is twice as big as the 6/6
– The 6/18 is half the size of the 6/36
– 3/60 is equivalent of 6/120
 Snellen Around the World
• Americans still use feet and inches
• Therefore 6m becomes 20ft
• 6/6 becomes 20/20

• Europeans commonly use a

decimal notation.
• They simply convert the Snellen
fraction into a decimal
– 6/6 = 1.0
– 6/12 = 0.5
– 6/60 = 0.1
 Snellen
Pros Cons
• Quick • Aimed at fully sighted people
• Used a lot • Large Gaps at lower acuity
• Reasonably well understood bands
• Often what people quote even • Too few letters at the top of
if they have measured acuity the chart
in a different way • Depressing for low vision
patients
• Uneven Crowding
• Not reproducible?
• How do I measure 6/48
• What if acuity is less than
6/60?
 logMAR and ETDRS Chart
logMAR is what I use!
Chart is logarithmic

Needs some mental arithmetic

Or a calculator!
 logMAR and ETDRS Chart
How does it work?
Test at 4m

Every line has a value.

Top line is 1.00

Every line lower the value

DECREASES by 0.1. Second row 0.9
Third row 0.8

If get every letter right you score

the value for the line.
 logMAR and ETDRS Chart
For every letter you get wrong you
add 0.02 to the value of the line

e.g. if you read 2 letters wrong on

the 0.90 line your logMAR value is

0.90 + 0.02 + 0.02 = 0.94logMAR

If you cannot read the chart at 4m

you test at half the distance and
add 0.30 to your score
 logMAR
Pro Con
• Linear Progression • Needs more knowledge
• Even Gaps • People often don’t understand
• Even Crowding your result
• Greater range of acuity levels • Takes longer
• Better subjective measurement
• Harder with kids?
• Can calculate per letter
• Much more accurate for determining
low vision
• Better for seeing if your interventions
have worked
• Patients feel happy they can read
something
• Letters even legibility
 Idiot’s Guide?

Poor Acuity Good Acuity

Snellen 6/60 6/6
Decimal 0.1 1.0
logMAR 1.00logMAR 0.00logMAR

Low Value High Value

Snellen GOOD BAD
Decimal BAD GOOD
logMAR GOOD BAD
 Does Acuity Tell Us Everything?
• VA tells us a very specific piece of information
and does not give the whole picture
• Other Measurements We Should Be Aware of
when assessing Visual Function
– CSF
– Visual Fields
– Accommodation
– Colour vision
– Reading speed/acuity
 Contrast Sensitivity Function Loss
• CSF measures how well you see when contrast
falls.
• Optic Nerve lesion or lens opacity often leaves
CSF reduced.
• Causes
– Difficulty reading packaging
– Problems seeing kerbs
– Problems seeing gradients
 Contrast Sensitivity Function Loss
• Various Ways of Measuring Contrast Sensitivity
 CSF what can you do?
• CHANGE THE CONTRAST
– Use Higher Contrast
– Contrasting Backgrounds
– Paint Stair Edges
– Bold Pens
– Electronic enhancement
• Improve Lighting
• Magnification Not Helpful
Visual Fields
 Introduction
• What are visual fields
• Methods of Field Testing
• Fields and low vision assessments
• What Does it Mean to the Patient
• Action Points
• Conclusions
 Normal Visual Fields
• The field of vision is defined as the area that is
perceived simultaneously by a fixating eye. The limits
of the normal field of vision are 60° into the superior
field, 75° into the inferior field, 110° temporally, and
60° nasally.

• Harry Moss Traquair (1875-1954) "an island of vision

or hill of vision surrounded by a sea of blindness".
Hill of Vision
 Testing Visual Fields
• Visual Fields assess the height and extent of the hill of vision

• Different Methods
– Static
– Kinetic

• Formal
– Goldmann
– Humphrey
– Henson

• Informal
– Amsler
– Confrontation
– Observation
 Static Testing
• Size and location of the test target remain constant.
 The shape of the island is defined by repeating a threshold

measurement at various locations in the field of vision

 Retinal sensitivity at a specific location is determined by

varying the brightness of the test target.

• Either
– Full Threshold (accurate/slower)
– Supra Threshold (screening/quicker)
Static Testing- full threshold

JODY R. PILTZ-SEYMOUR, ONECA HEATH-PHILLIP and STEPHEN M. DRANCE

 Results from Static Perimetry
• Full Threshold
Static Testing- Supra threshold
 Results from Static Perimetry
• Supra Threshold
 Kinetic Fields
• Stimulus moved from a non-seeing area of the visual
field to a seeing area along a set meridian.
• Repeated along other meridians, usually spaced
every 15°.
• In kinetic perimetry, one attempts to find locations in
the visual field of equal retinal sensitivity.
• Lines joining points of equal sensitivity called isopter.
• Change luminance and the size of the target is
changed to plot other isopters.
Results From Kinetic Perimetry
 Differences
• In kinetic perimetry, the island of vision is
approached horizontally. Isopters can be considered
the contour lines on the hill of vision
• Static approached vertically
• Static automated more easily
• Kinetic better with poorer acuity?
 Informal Fields Testing
• Confrontation Testing

• Amsler Grid

• Observation
Scottish Sensory Centre
 Pros and Cons
Pros Cons

Easy Easy to get it wrong

Simple Too Simple

Can be done at school Not quantifiable

 Fields and Low Vision
• I use the Esterman test
– 120 targets
– Wide test arc (160 degrees horizontally)
– Targets are bright
– Test is done binocularly
– Static Test
– Pt. watches fixation light
– Pt .press button when light seen

• Gives a real world view of the pattern of greatest loss

Plot example
 Symptoms of Field loss
• Assumption
– “Black in centre of vision”
– “Just turn your head more”

• Reality
– Simulation specs are poor
– Fields Loss often not well self reported
– Hard to Judge where field loss starts and finishes
 FIELD LOSS
• You “don’t know what
you can’t see”
• Sim Specs are not real
Life

• Action
– Counselling (orientation awareness)
– Mobility Training
 Loss of Fields : Symptoms and Case Study

• 82 year old man

• Stroke 2 years ago.
• Seen hospital “nothing could be done”
• Stroke has given dad a problem with his left eye.
• Son noticed dad very withdrawn since moving to
a new residential home.
• Staff saying he is only interested in the television
and ignores people.
Field Plot
Field Plot
 Field Loss
• Field loss causes the problems we suspect.
– Tripping
– Falling over
– Fear
– Isolation

• But not necessarily the symptoms we expect