9/7/2017

EVALUATING VISUAL Course Objectives:

ACUITY
You will be able to…
• Explain what visual acuity is & how it is
measured
• Determine when the pinhole test should
be performed and how to do it
• Properly record the visual acuity of a
patient

Lecturer: M. Patrick COLEMAN, ABOC, COT

Introduction & Overview The Physiology of Visual Acuity

• The physiology of visual acuity QUESTION:
On which patients should you measure
• Measuring visual acuity Visual Acuity (VA)?
– Distance
– Near
• Pinhole Testing
– When to do it
– How to do it
• Recording visual acuity
• Summary and conclusion

The Physiology of Visual Acuity (cont.) The Physiology of Visual Acuity (cont.)
What is Visual Acuity?
Visual acuity is a measure of the resolving • The most common test targets
power of the visual system; it measures your of a visual acuity chart are the
ability to receive, transmit, and interpret Snellen letters.
visual images.
• The Snellen letters have a
specific construction (height &
width)
• They are designed to measure
visual acuity in a repeatable &
consistent manner via a
Snellen Test Chart.

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The Physiology of Visual Acuity (cont.) The Physiology of Visual Acuity (cont.)
How many DEGREES are in a CIRCLE? How many “MINUTES” are in a DEGREE?

The Physiology of Visual Acuity (cont.) The Physiology of Visual Acuity (cont.)
The 20/20 letter “subtends” 5 minutes of arc @ 20 ft The “arc” that the 20/20 letter “subtends” remains
5 minutes “wide” …no matter the DISTANCE!
As you get farther away, the letter grows LARGER
but @ that distance, it is still “subtending” 5 min of
arc, stimulating the SAME AMOUNT OF AREA
ON THE RETINA as when it was 20 feet away…

The image stimulates a SMALL area of CONES in the

MACULAR area of the retina. If pt can separate out
EACH MINUTE of difference, they have 20/20 vision!

Measuring Visual Acuity: Distance & Near Measuring Visual Acuity: Distance & Near (cont.)
• Visual Acuity tells us the visual status of pt:
WHERE SHOULD
– Nearsighted? Farsighted? Astigmatic?
YOU BE LOOKING
– Amblyopic?
WHEN CHECKING
– Presbyopic? a Visual Acuity
– Signs of heterotropia? (VA)?
– Has a cataract progressed since last visit?
– Is there corneal damage, foreign matter
in the aqeuous or vitreous, or even
retinal damage?
– Visual acuity is essential to an eye exam!
You must measure it correctly!

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Measuring Visual Acuity: Distance & Near (cont.) Measuring Visual Acuity: Distance & Near (cont.)
Some “rules” for checking visual acuity: Which type
• Vision is tested monocularly (one eye at a time) OCCLUDER
– Do right eye first (unless reason not to…) do you use?
• Patient wears appropriate Rx for test distance
– Driving glasses on for DVA
– Reading glasses on for NVA
– Does Pt wear MF or PAL? Wear for DVA & NVA!
– Sometimes we test VA without the Rx. How do
we indicate that?
– Put “sc” for testing WITHOUT CORRECTION
– Put “cc” to indicate tested WITH CORRECTION.
– If the doc wants you to test patients both ways, do
WITHOUT first

Measuring Visual Acuity: Distance & Near (cont.) Measuring Visual Acuity: Distance & Near (cont.)
Charts for kids & illiterate folks:
“Rules” for checking visual acuity:
• Children? Test “good” eye first!
• WHY? Children frustrate easily!
• Use an eye chart appropriate for the
child’s ability
• An object chart for a 2 to 4 year old.
• A Tumbling E or Landolt C chart for a 5
or 6 year old
• Save the Snellen letter or number Object Tumbling Landolt
chart for kids 7 and older Chart “E” chart “C” chart

Measuring Visual Acuity: Distance & Near (cont.) Measuring Visual Acuity: DISTANCE
QUIZ TIME! • Before you check DISTANT
visual acuity, make sure your
letter size(s) are correct!
• Q: Squinting - Is this a problem?
• RULE? 20/200 “E” = 4.4mm
• Q: You notice the patient trying to turn for every foot of test distance
their head or move the occluder to see Chair-screen 20/200 “E” height
w/the “covered” eye. What’s the deal?! distance
20' 88 mm
• Q: The patient keeps trying to move the
NVA card farther away or closer to them. 15' 66 mm
Is that okay?
10' 44 mm

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Measuring Visual Acuity: DISTANCE (cont.) Measuring Visual Acuity: DISTANCE (cont.)
Once the patient is “occluded”…
EXAMPLE #1:
• Expose lines 20/20 through 20/40 (or
• Patient gets three letters correct on the
whatever ‘block’ of test letters your projector 20/30 line, which contains six letters.
uses) to put the 20/20 line on the bottom
• They get credit for seeing 20/30
• Ask patient to read the smallest line possible, – Ask them to try the next smaller line (20/25).
without squinting • If the patient couldn’t see any of the
• If patient unable to read largest line shown, letters on the 20/25 line, you would record
adjust the chart to give them even bigger the patient’s visual acuity as: 20/30–3
letters (or objects) • The “30” indicates the patient read at least
50% of the 20/30 line; the “ – 3” indicates
• Give the patient credit for any line in which patient missed three letters
they get 50% or more of the letters correct

Measuring Visual Acuity: DISTANCE (cont.) Measuring Visual Acuity: DISTANCE (cont.)

EXAMPLE #2: QUESTION:

• Pt reads all the letters on the 20/40 line What if the patient can’t
• They get two letters correct on the 20/30 see the biggest letter
line (which has 6 letters.) of your eye chart
• Record the VA as: 20/40+2 from 20 feet away?
– The “40” indicates the patient read at (…usually the 20/400
least 50% of the 20/40 line “E” is our biggest
– The “+2” tells us the patient was able to letter)
read two of the letters on the 20/30 line

Measuring Visual Acuity: DISTANCE (cont.) Measuring Visual Acuity: DISTANCE (cont.)
Pt can’t see biggest letter of eye chart?
ANSWER: Turn on the lights; grab a printed QUESTION:
out 20/400 “E” (you do have one in each eye
lane, don’t you?) & walk toward the patient You got THREE (3)
until they can see it FEET from the patient
• Note the distance @ which Pt saw the & they still couldn’t see
printed 20/400 “E”; record that for their VA. the printed “20/400 E”
For EXAMPLE: you were carrying
• Pt was able to see the 20/400 “E” when you toward them…NOW
were five feet from them. WHAT?
• Record their vision as: 20/400 @ 5 feet

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Measuring Visual Acuity: DISTANCE (cont.) Measuring Visual Acuity: DISTANCE (cont.)
Pt can’t see the 20/400 “E” from 3 ft away?
QUESTION:
ANSWER: Time for “Count Fingers” (CF) test!
What if the Patient could NOT “Count Fingers”
With room lights still ON… 6 inches away…
• Start 3 ft away; hold up a few fingers & see if Pt NOW WHAT?!
can tell you how many you are showing
• Can’t see them? Move closer (2 ft away)
• Still nothing? Get 1 ft away
• Nothing yet? Try 6 inches from pt’s eye
• Let’s say the patient responded with the correct
number of fingers @ 6 inches
• Record the results as: CF @ 6 inches

Measuring Visual Acuity: DISTANCE (cont.) Measuring Visual Acuity: DISTANCE (cont.)
Couldn’t “Count Fingers” 6 inches away?
ANSWER: Move on to Hand Motion (HM) test! QUESTION:
How do you do it?
Patient could NOT
• From one foot (1ft) away, move your hand (or detect “Hand
don’t move your hand) in front of the pt’s eye &
see if they can tell when your hand is moving
Motion (HM) @
and when it stops. 1 ft”?
– Go slow enough you don’t create a “breeze”
on the pt’s face!
NOW WHAT?!
– If they can tell what your hand is doing, record:
HM @ 1 foot

Measuring Visual Acuity: DISTANCE (cont.) Measuring Visual Acuity: DISTANCE (cont.)
Pt couldn’t detect “Hand Motion (HM) @ 1 ft”?
QUESTION:
ANSWER: Do the Light Localization (LL) test!
How? Turn the room lights OFF Pt could NOT
• Shine a penlight towards the pt’s eye & see if they detect where
can tell you where the light is coming from. light was
• Try different locations & see if they can identify coming from
WHERE the light is coming from (i.e., “straight during Light
ahead”; “temporally”; “nasally”; or “from above”)
Localization
– Obviously, the untested eye needs to be
thoroughly covered so it can’t see ANYTHING!
test?
• If the pt can tell you where the light is shining from, NOW WHAT?!
you will record “LL” for light localization.

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Measuring Visual Acuity: DISTANCE (cont.) Measuring Visual Acuity: NEAR

Pt couldn’t detect DIRECTION during Light • Near VA is usually measured
Localization test? w/a Jaeger Acuity Card or a
“reduced” Snellen Acuity
ANSWER: Do the Light Perception (LP) test! Card - see example ---------
How do you do it? Lights still OFF… • The proper distance for NVA
testing will be printed on the
• If pt couldn’t tell which direction the light was near point card.
coming from but COULD tell that there was a • It is usually 14” or 16”, but
light shining in their eye, you would record the don’t assume! Check first.
results as “LP” (for Light Perception.) • No matter the test distance,
the vision will still be recorded
• If pt can’t tell whether you had a light
as 20/“X”
shining in their eye or not, you would record
– Not 14/14 vision or 16/16
“NLP”, which stands for No Light Perception. vision; but rather 20/20

Measuring Visual Acuity: NEAR (cont.) Measuring Visual Acuity: NEAR (cont.)
RULES for Near Visual Acuity (NVA): RULES for Near Visual Acuity (NVA):
• Done in normal room lighting • NVA is done same as distance testing: “Read the
smallest line you can without squinting”
•Test distance = determined by the card! • Did they get the 20/20 line? Awesome!
(TIP: cut a piece of string the correct length & • If not, go to bigger lines & work them down
attach it to the card.) • When pt can’t get more the 50% of the characters
• If the pt wears a NVO, a MF (PAL), or a pair of in a line, stop, & record the VA for the last line they
glasses that they wear all the time (habitual Rx), DID get 50% or more correct.
use them for NVA testing • Switch to the other eye; repeat the procedure.
• If the patient only wears glasses for driving or NOTE: If patient wears a MF or PAL, make sure that
they are looking through the lowest segment of the
distance vision, remove them for NVA testing
glasses for the near test! They can even lift the
• Test MONOCULARLY (one eye at a time) glasses up a bit if it will help.

Pinhole Testing: When to do it & How to do it Pinhole Testing: When to do it & How to do it (cont.)
• The pinhole (PH) test is done when a patient’s Q: What does the “pinhole test” tell the doctor?
best visual acuity (BVA) is found to be 20/40 or
worse at distance & near in one eye A: If a pt’s decreased visual acuity (VA) can be improved
with corrective lenses (glasses or CLs)…or not!
Example #1: patient’s VA in the OD was 20/70 in
the distance & 20/80 at near • If the pt sees BETTER when looking through the
pinholes, they will probably see better w/the correct
– The “pinhole test” SHOULD be performed for Rx in front of that eye
that eye
• Put another way, if pt only has an ametropia
Example #2: patient’s VA in the OS was found to (refractive error) the vision should improve w/the
be 20/100 in the distance & 20/30 at near pinhole.
– The “pinhole test” would not need to be • Q: What if vision did NOT improve when looking
performed! Near VA was better than 20/40 through the pinhole?
• You must measure a pt’s distant & near VA to A: More than likely, corrective lenses won’t help either
determine if you need to do the pinhole test • “No improvement” (NI) when looking through the
• The “pinhole test” is only done in the DISTANCE pinholes can indicate amblyopia, or an eye disease,
(not up close!) or some other disorder

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Pinhole Testing: When to do it & How to do it (cont.) Recording Visual Acuity

• Pinholes go in front of eye being ‘tested’; the other eye
is occluded • VA results are recorded by indicating the:
• Start with DVA line they read earlier; they must be – Tested distance (i.e., DVA or NVA)
able to see that line before you continue!
– Eye tested (i.e., OD or OS)
– If Pt read 20/70 line before, they should be able to
read that line though the pinholes, too! – Whether test was done w/corrective
• Can’t read the line? Pt needs to move the PHs around lenses (cc) or w/o corrective lenses (sc)
a little until they CAN see the line! – What was the measured acuity, using
• Once pt can see through the pinholes, start showing Snellen notation (i.e., 20/20, 20/50,
smaller lines until pt can’t read anymore. If pt got down 20/400, etc.)
to 20/30, record as “PH 20 / 30” – Include pinhole (PH) test results, if
• If pt doesn’t see any better? Record “PH = NI” (NI performed.
means “no improvement”)

Recording Visual Acuity (cont.) Summary and Conclusion

Example #1: • The physiology of visual
DVA sc NVA cc acuity
OD 20/30–1 PH 20/— OD 20/20 • Measuring visual acuity
OS 20/80+1 PH 20/25+2 OS 20/40 – Distance
----------------------------------------------------------------- – Near
• Pinhole Testing
Example #2:
DVA cc NVA cc – When to do it
OD 20/200–2 PH 20/50+2 OD 20/100 – How to do it
OS 20/400@15 ft PH 20/NI OS 20/200 • Recording visual acuity
• Summary and conclusion