Visual Acuity 6 150

[Wesley Godinez]

MostPrecision Vision eye charts carry the letter size designation in M-units. This makes it easy to calculate the visual acuity if the chart is used at any other distance than the one for which it was designed by inserting the new test distance (in meters) and the letter size (in M-units) directly into the above formula.

The MAR and the visual acuity scale are opposites. A high MAR value indicates low or poor visual acuity; a low MAR value indicates good acuity. Their relationship is also true in reverse. A patient with 20/60 (1/3) visual acuity needs 3x magnification to reach the reference standard. This can be achieved with large print that is 3x normal, with a 3x magnifier or with a 3x telescope. Since normal vision is better than 20/20, some extra magnification is desirable for comfortable and sustainable performance.

The MAR value is best known for its logarithm: logMAR. As for MAR, a higher logMAR value indicates poorer vision. Although the logMAR notation is often presented as a visual acuity notation, it actually is a notation of vision loss. Zero logMAR indicates standard vision; zero visual acuity indicates blindness.

The logMAR notation is most convenient when used with a chart where the letter sizes follow a logarithmic progression, as on the ETDRS charts. Because of this, such charts are often referred to as logMAR charts. On these charts each increase of 0.1 units on the logMAR scale indicates a one line loss on the visual acuity chart.

In the AMA Guides to the Evaluation of Permanent Impairment (5th and 6th edition) the VAS scale is used in the calculation of visual disability. A study has shown that the AMA calculations provide better ability estimates than scales that were used previously.

Visual acuity (VA) commonly refers to the clarity of vision, but technically rates an animal's ability to recognize small details with precision. Visual acuity depends on optical and neural factors. Optical factors of the eye influence the sharpness of an image on its retina. Neural factors include the health and functioning of the retina, of the neural pathways to the brain, and of the interpretative faculty of the brain.[1]

The most commonly referred-to visual acuity is distance acuity or far acuity (e.g., "20/20 vision"), which describes someone's ability to recognize small details at a far distance. This ability is compromised in people with myopia, also known as short-sightedness or near-sightedness. Another visual acuity is near acuity, which describes someone's ability to recognize small details at a near distance. This ability is compromised in people with hyperopia, also known as long-sightedness or far-sightedness.

A common optical cause of low visual acuity is refractive error (ametropia): errors in how the light is refracted in the eye. Causes of refractive errors include aberrations in the shape of the eye or the cornea, and reduced ability of the lens to focus light. When the combined refractive power of the cornea and lens is too high for the length of the eye, the retinal image will be in focus in front of the retina and out of focus on the retina, yielding myopia. A similar poorly focused retinal image happens when the combined refractive power of the cornea and lens is too low for the length of the eye except that the focused image is behind the retina, yielding hyperopia. Normal refractive power is referred to as emmetropia. Other optical causes of low visual acuity include astigmatism, in which contours of a particular orientation are blurred, and more complex corneal irregularities.

Refractive errors can mostly be corrected by optical means (such as eyeglasses, contact lenses, and refractive surgery). For example, in the case of myopia, the correction is to reduce the power of the eye's refraction by a so-called minus lens.

Neural factors that limit acuity are located in the retina, in the pathways to the brain, or in the brain. Examples of conditions affecting the retina include detached retina and macular degeneration. Examples of conditions affecting the brain include amblyopia (caused by the visual brain not having developed properly in early childhood) and by brain damage, such as from traumatic brain injury or stroke. When optical factors are corrected for, acuity can be considered a measure of neural functioning.

Visual acuity is typically measured while fixating, i.e. as a measure of central (or foveal) vision, for the reason that it is highest in the very center.[2][3] However, acuity in peripheral vision can be of equal importance in everyday life. Acuity declines towards the periphery first steeply and then more gradually, in an inverse-linear fashion (i.e. the decline follows approximately a hyperbola).[4][5] The decline is according to E2/(E2+E), where E is eccentricity in degrees visual angle, and E2 is a constant of approximately 2 degrees.[4][6][7] At 2 degrees eccentricity, for example, acuity is half the foveal value.

Visual acuity is a measure of how well small details are resolved in the very center of the visual field; it therefore does not indicate how larger patterns are recognized. Visual acuity alone thus cannot determine the overall quality of visual function.[8]

A reference value above which visual acuity is considered normal is called 6/6 vision, the USC equivalent of which is 20/20 vision: At 6 metres or 20 feet, a human eye with that performance is able to separate contours that are approximately 1.75 mm apart.[9] Vision of 6/12 corresponds to lower performance, while vision of 6/3 to better performance. Normal individuals have an acuity of 6/4 or better (depending on age and other factors).

In the expression 6/x vision, the numerator (6) is the distance in metres between the subject and the chart and the denominator (x) the distance at which a person with 6/6 acuity would discern the same optotype. Thus, 6/12 means that a person with 6/6 vision would discern the same optotype from 12 metres away (i.e. at twice the distance). This is equivalent to saying that with 6/12 vision, the person possesses half the spatial resolution and needs twice the size to discern the optotype.

A simple and efficient way to state acuity is by converting the fraction to a decimal: 6/6 then corresponds to an acuity (or a Visus) of 1.0 (see Expression below), while 6/3 corresponds to 2.0, which is often attained by well-corrected healthy young subjects with binocular vision. Stating acuity as a decimal number is the standard in European countries, as required by the European norm (EN ISO 8596, previously DIN 58220).

The precise distance at which acuity is measured is not important as long as it is sufficiently far away and the size of the optotype on the retina is the same. That size is specified as a visual angle, which is the angle, at the eye, under which the optotype appears. For 6/6 = 1.0 acuity, the size of a letter on the Snellen chart or Landolt C chart is a visual angle of 5 arc minutes (1 arc min = 1/60 of a degree), which is a 43 point font at 20 feet.[10] By the design of a typical optotype (like a Snellen E or a Landolt C), the critical gap that needs to be resolved is 1/5 this value, i.e., 1 arc min. The latter is the value used in the international definition of visual acuity:

Acuity is a measure of visual performance and does not relate to the eyeglass prescription required to correct vision. Instead, an eye exam seeks to find the prescription that will provide the best corrected visual performance achievable. The resulting acuity may be greater or less than 6/6 = 1.0. Indeed, a subject diagnosed as having 6/6 vision will often actually have higher visual acuity because, once this standard is attained, the subject is considered to have normal (in the sense of undisturbed) vision and smaller optotypes are not tested. Subjects with 6/6 vision or "better" (20/15, 20/10, etc.) may still benefit from an eyeglass correction for other problems related to the visual system, such as hyperopia, ocular injuries, or presbyopia.

Visual acuity is measured by a psychophysical procedure and as such relates the physical characteristics of a stimulus to a subject's percept and their resulting responses. Measurement can be taken by using an eye chart invented by Ferdinand Monoyer, by optical instruments, or by computerized tests[11] like the FrACT.[12]

Care must be taken that viewing conditions correspond to the standard,[13] such as correct illumination of the room and the eye chart, correct viewing distance, enough time for responding, error allowance, and so forth. In European countries, these conditions are standardized by the European norm (EN ISO 8596, previously DIN 58220).

In later editions of his book, Snellen called the letters of his charts optotypes and advocated for standardized vision tests.[15] Snellen's optotypes are not identical to the test letters used today. They were printed in an "Egyptian Paragon" font (i.e. using serifs).[16][17]

Rick Ferris et al. of the National Eye Institute chooses the LogMAR chart layout, implemented with Sloan letters, to establish a standardized method of visual acuity measurement for the Early Treatment of Diabetic Retinopathy Study (ETDRS).These charts are used in all subsequent clinical studies, and did much to familiarize the profession with the new layout and progression. Data from the ETDRS were used to select letter combinations that give each line the same average difficulty, without using all letters on each line.

Antonio Medina and Bradford Howland of the Massachusetts Institute of Technology develop a novel eye testing chart using letters that become invisible with decreasing acuity, rather than blurred as in standard charts. They demonstrate the arbitrary nature of the Snellen fraction and warn about the accuracy of visual acuity determined by using charts of different letter types, calibrated by Snellen's system.[22]

Daylight vision (i.e. photopic vision) is subserved by cone receptor cells which have high spatial density (in the central fovea) and allow high acuity of 6/6 or better. In low light (i.e., scotopic vision), cones do not have sufficient sensitivity and vision is subserved by rods. Spatial resolution is then much lower. This is due to spatial summation of rods, i.e. a number of rods merge into a bipolar cell, in turn connecting to a ganglion cell, and the resulting unit for resolution is large, and acuity small. There are no rods in the very center of the visual field (the foveola), and highest performance in low light is achieved in near peripheral vision.[4]

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