Measurement of visual acuity,

Refractive errors, Visual

handicap
BY CO Bekibele
 Visual acuity measurement
• Definition: this is a measure of the visual perceptive
ability of the eye.
• The visual acuity (VA) is dependant on (1). The
focusing (dioptric) mechanism of the eye (2).the
retinal status as well as (3). The optic nerve and (4).
Central nervous system mechanisms.
• A defect in any of these 4 can therefore affect the
value of VA.
• The VA is measured by the smallest obj which can be
clearly seen at a certain distance (usually 6 meters or
20 feet by convention).
 Visual acuity measurement
• For 2 separate points to be distinguished by the retina, it is
necessary that 2 individual cones be stimulated while the area
b/w them remains un-stimulated.
• Histologically, the average diameter of a cone in the macular
region is 0.004mm ( it also repr the smallest distance b/w 2
cones).
• A normal eye should therefore be able to appreciate a retina
image of 0.004mm.
• The further away an object is from the eye the smaller the
image formed on the retina b/cos the perceived size of an obj
is a function of both the size and the distance away from the
eye.
• The visual angle combines these 2 in estimating the VA.
 Visual acuity measurement
• The visual angle is formed by 2 lines drawn from the
extremeties of an obj thru the nodal points of the
eye.
• To produce an image of 0.004mm, the obj must
substend a visual angle of 1 minute of an arc( ie the
size of one normal cone).
• The principle inco operated into Snellen tests types
for VA measurement : size of the letters in the chart
is such that their edges substend a visual angle of 1
minute of an arc when they are a certain specific
distance away.
 Visual acuity measurement
• Largest (1st line) test size is such that 1 min visual angle is
formed at 60 meters by a normal person, the second at
36meters, 3rd 24m, 4th 18m, 5th 12m, 6th 9m, 7th at 6m, 8th at
5m.
• Thus if a pt is placed at 6m he should be able to easily read
down the line to the minimum letters.
• Results expressed in a fraction, numerator-pts distance away
from chart and denominator the smallest line seen at this
distance.
• Thus a normal vision at 6m=6/6, but if only able to read what
normal person can see at 24m=6/24; at 36m=6/36; at
60m=6/60; if not able to see from 6m, reduce test distance to
3m, 1m, CF, hand movement, and light perception.
 Visual acuity measurement
• Requirements for VA measurement:
• Even illumination of the chart reqd
• VA of each eye is done separately
• Corrective specs for each eye should be worn
• Pin-hole test of each eye differentiates b/w refr error
and ocular pathology
• Carefully instruct the patient
• Test types include: Snellens, E-chart, Landolt’s C,
(adults) pictorial, Sheridan Gardners, Worth’s ivory
ball test, principle of preferential looking with
optokinetic disc(for children).
 Refractive errors
• Refraction is bringing rays of light to a focus.
• Emmetropia is the refractive state of the eye in which parallel
rays of light are focused on the retina with the eyes in a
relaxed state(ie with out accomodative effort) . In this state
the 2nd principal focus fall on the retina.
• Refractive error is failure to focus rays of light on the retina
with the eyes at rest.
• Accomodation is the ability of the eye to increase its dioptric
(converging) power so that near obj are seen clearly.
• In myopia, the second principal focus lies in front of the
retina, thus parallel rays of light are focused in front of the
retina, obj thus appear blurred and enlarged.
 Refractive errors
• This may occur when the globe is abnormally long or
the dioptric power of the eye too high. These pts can
see near but can’t see far clearly.
• In hypermetropia, the 2nd principal focus lies behind
the retina, parallel rays of light from obj at infinity
are therefore focused behind the retina, they appear
blurred and small. Causes include unusually small
/short eyes or inadequate refr power of the eye.
These pts have to strain (ammomodate) to see far
and near leading to symptoms of eye strain such as
eye pain and headache.
 Refractive errors
• In astigmatism, the refractive power of the eye varies in
different meridians. The image formed is thus blurred, indistinct
and may be clearer in some meridian than the other. Thus H
may be seen as I I, or R may be confused for E and K etc.
• Anisometropia is when the refraction of the 2 eyes are different
eg severe hypermetropia or myopia in one eye relative to the
other eye.
• It may result in amblyopia in the worse eye.
• Presbyopia is loss of accomodation with age. There is gradual
loss of power of accomodation with age. The infant is capable
of 14D of accomaodation but this drops gradually to about 4D
at age 45yrs. There is thus increasing diff seeing near obj after
age 40-45years.
 Refractive errors
• Aniseikonia: A situation where the size and shapes of the
images in the 2 eyes are unequal.
• May occur as a result of difference in refraction b/w the 2
eyes(anisometropia) and is determined by the differences in
magnification effectivity of the correcting lenses worn.
• In un-ocular aphakia differences are as high as 30% and are
intolerable-diplopia.
• The eyes can tolerate differences up to 5% in normal
situations(dioptric diff upto 2.5D).
• Treatment is the correction of the disparity in the size of
retinal images with iseikonic lenses(cause magnification
without appreciable refractive power introduction).
 Refractive errors
• Diagnosis of refractive errors
• Pin hole test- PH theoretically allows only one ray of
light from each point of an obj to pass through the
principal axis to the retina, thus a clear image is
formed regardless of the refr state of the eye. Helps
to confirm that reduced VA is due to refr error and
not ocular pathology or neurological dx.
• Refraction: a practice carried out to identify the
refractive state of the eye and reqd power of lens to
correct the underlying refr error.
 Refractive errors
• Correction of refractive errors
• The purpose of the correcting lens is to deviate parallel rays of light so
that they focus on the retina.
• For hypermetropia, converging lens is used to focus parallel rays of light
on the retina rather than behind it.
• For myopia, a correcting concave lens(diverging) is used to diverge parallel
rays of light so that they focus on the retina rather than in front.
• For astigmatism, the 2 principal meridians with different refractive power
are identified and the difference is neutralized with the aid of a cylindrical
lens having effective power in only one meridian.
• For presbyopia, the convergent lens of power equal to the weakness in
accomodation is used to bring near obj so that they focus on on the retina
instead of behind it.
 Visual handicap
• Def: reduction of VA/field of vision such that a person is
unable to adequately carry out his normal daily activities.
• Normal range of vision is 6/5-6/18.
• Categories of vision
• Category best VA Minimum VA
• 1 <6/18 6/60
• 2 <6/60 3/60 (CF at 3m)
• 3 <3/60 1/60 (CF at 1m)
• 4 <1/60 LP
• 5 No light perception
 Visual handicap
• Considering visual field: if CVF <10 degrees, but >5
around fixation=category 3. If CVF <5 degrees, then
pt is in category 4.
• Interpretation:
• Category 0 ie VA > 6/18=normal vision.
• ,, 1, VA <6/18-6/60 (visual impairment)
• ,, 2 ,VA <6/60-3/60 (severe visual
impairment)
• ,, 3-5, VA<3/60-NLP( blind)