Potential Acuity Meter (PAM)

Introduction
• PAM was introduced by Minkowski in 1980.
• It is used to predict potential postoperative visual acuity in patients with media
opacities, especially cataracts.
• Works by projecting a Snellen’s visual acuity chart through clear areas of the lens
onto the retina.

Instrument Design & Optics

• Contains a halogen lamp, pinhole aperture (~0.1 mm), lenses, and mirrors.
• Projects an image of Snellen’s chart onto the retina via clear lens areas (“windows of
cataract”).
• Optotypes: Black letters on white background ranging from 20/20 to 20/400.
• Focus adjustment: from +13 D to –10 D.

Technique of Potential Acuity Meter (PAM)

1. The test is usually done after dilating the pupil so that more clear areas are available
for projection of the light.
2. The patient should wear their spectacle correction or trial lenses so that any
refractive error is corrected during the test.
3. A narrow beam of light carrying the Snellen’s chart image is directed through the
clearest part of the cataract or cornea.
4. The chart image is projected onto the retina, bypassing the cloudy lens areas.
5. The patient is asked to read the letters from the projected Snellen’s chart just like in
a normal vision test.
6. At first, the patient may see disturbing or blurred entoptic images, but as the eye
adapts, these images fade away.
7. If the retina is healthy, the patient should be able to read the letters clearly and the
examiner can judge the potential postoperative vision.
Validation
• Highly reliable in moderate cataracts.
• Predicts postoperative VA within:
o 3 lines of Snellen’s chart – 100% cases.
o 2 lines – 91% cases.
• Less reliable in:
o Cystoid macular oedema, serous macular detachment, recent retinal surgery,
macular atrophy, macular hole/cyst, dense cataract, glaucoma.

Factors Affecting Accuracy

1. Severity of cataract – more accurate in moderate than severe cataracts.
2. Type of cataract – posterior subcapsular > underestimates; nuclear & cortical easier
to bypass.
3. Preoperative VA ≤ 20/200 – both PAM and LI (Laser Interferometer) less effective.
4. Other ocular diseases – LI overestimates more than PAM in macular degeneration,
retinitis pigmentosa, etc.

Conclusions
• PAM is useful in moderate cataracts.
• In severe cataracts, PAM underestimates more than LI.
• In retinal disorders, LI overestimates more than PAM.
• Best used in combination with LI for better preoperative counseling.
 Placido Disc
Introduction
• Placido disc is a diagnostic tool used in corneal topography.
• It works on the reflection principle.
• The anterior corneal surface acts as a convex mirror.

Principle
• When concentric rings of light (from the Placido disc) fall on the cornea, the cornea
reflects them like a mirror.
• Steeper cornea → produces a smaller reflected image.
• Flatter cornea → produces a larger reflected image.
• By analyzing the size and spacing of the reflected rings, the slope and curvature of
the cornea can be calculated.

Basic Unit of Placido Disc-Based Corneal Topography System

1. Projection Device – projects concentric illuminated rings (8–32 rings).
2. Acquisition Device (CCD Video Camera) – captures the reflected ring images from
the cornea.
3. Analytical Device (Computer with software) – processes the ring reflections and
generates a topographic map of corneal curvature.

Working
1. The instrument projects concentric circular rings of light on the cornea.
2. The cornea reflects these rings, and the image is captured by a video camera.
3. The computer analyzes the reflection pattern to calculate the radius of curvature at
different corneal points.
Applications
• Measurement of corneal curvature.
• Detection of astigmatism and irregular corneal surfaces.
• Preoperative evaluation for refractive surgery (LASIK, PRK).
• Contact lens fitting.
• Early detection of corneal diseases like keratoconus.

Limitations
• Only measures the anterior surface of the cornea, not the posterior.
• Accuracy depends on proper alignment and focus.
• Errors may occur due to decentration, calibration, or artefacts.
• Central corneal regions require very high resolution for detecting small curvature
changes.
• May show errors in post-keratoplasty eyes or when artificial tears are used.
 Visual Angle
• The visual angle is the angle formed at the nodal point of the eye by the object we
are looking at.
• It depends on the size of the object and its distance from the eye.
• Larger objects or closer objects create a bigger visual angle.
• Smaller objects or farther objects create a smaller visual angle.

Visual Acuity
• Visual acuity is the measure of how well the eye can distinguish fine details and
shapes of objects at a certain distance.
• It represents the resolving power of the eye.
• Normal standard vision is 20/20 (or 6/6).
• Visual acuity testing is based on the visual angle formed by objects.
• It can be affected by:
o Retinal health (cone spacing in fovea)
o Clarity of media (cornea, lens)
o Illumination and contrast
Types of Visual Acuity
1. Minimum Detectable (Visible) Acuity
o This is the ability of the eye to detect the presence or absence of an object.
o It depends on the smallest visual angle that the eye can register at the nodal
point.
2. Minimum Separable (Resolvable) Acuity
o This is the ability of the eye to see two objects as separate rather than merged
together.
o A person with normal 20/20 vision can resolve objects that subtend a visual
angle of 1 minute of arc (60 seconds or 0.017°).
o It is mainly determined by the spacing of cones in the retina.
3. Minimum Recognizable Acuity
o This is the ability of the eye to identify or recognize a symbol, such as a letter
or picture.
o For example, reading a letter on the Snellen chart is based on minimum
recognizable acuity.
o The gold standard of this type is 20/20 (6/6) vision.
4. Minimum Discriminable Acuity (Hyperacuity)
o This is the ability of the eye to detect a very small change in alignment, size,
or orientation of objects.
o An example is Vernier acuity, where a person can detect if two lines are
slightly misaligned.
o Humans can detect misalignment as small as 2 to 5 seconds of arc, which is
finer than normal visual resolution.

Tests for Visual Acuity

1. Detection Acuity Tests
• These tests measure the ability of the eye to detect the smallest visible object or
stimulus.
• Examples:
o Boeck candy bead test
o Catford drum test
o Dot visual acuity test
o STYCAR graded balls test
2. Recognition Acuity Tests
• These tests measure the ability of the eye to recognize or identify symbols, letters,
or pictures.
• Examples:
o Snellen chart (standard test in clinics)
o Tumbling E chart
o Landolt C test
o Lea symbols chart
o HOTV test (Lippman’s HOTV)
o ETDRS chart (Early Treatment of Diabetic Retinopathy Study)
o Bailey-Lovie chart
o Sheridan letter test
o Picture charts (Beale Collin, Bailey-Hall cereal, Lighthouse test, Sjogren
hand test)

3. Resolution Acuity Tests

• These tests measure the ability of the eye to resolve two separate stimuli.
• Examples:
o Optokinetic drum (based on movement of stripes)
o Preferential looking test (like Teller acuity cards, used in infants)

So in short:
• Detection = smallest stimulus visible
• Recognition = identify or name a symbol
• Resolution = see two objects separately

Visual Acuity Testing in Different Age Groups

1. Infants (below 1 year)
• The Fixation test (CSM) checks whether the infant’s fixation is Central, Steady,
and Maintained.
• The Menace reflex is tested by moving an object suddenly toward the infant’s eyes,
and a normal response is blinking, which usually develops by 5 months of age.
 • The Brückner’s reflex test is done in a dark room with an ophthalmoscope light; the
red reflex from both eyes is compared to screen for refractive errors.
• The Optokinetic nystagmus (OKN) test is performed by moving black-and-white
striped drums or tapes in front of the eyes, and the presence of reflex eye movements
indicates the infant’s vision level.
• The Catford drum test uses rotating dots on a drum, and the smallest dot size that
induces nystagmus gives an estimate of visual acuity.
• The Preferential looking test uses the principle that infants prefer patterned stimuli
over plain ones, and tools like Teller acuity cards or Cardiff acuity cards are
commonly used.
• Lea gratings consist of striped patterns, which are used for infants and children with
developmental disabilities.
• The Visual Evoked Potential (VEP) test records electrical activity from the brain in
response to visual stimuli, and it can give an objective measure of visual acuity in
very young children.

2. Toddlers (1–2 years)

• The Boeck candy test uses small colored beads, and the child’s ability to detect and
pick them up is taken as a measure of acuity.
• The Sheridan ball test uses familiar balls, and the child’s ability to recognize and
respond to them is assessed.
• The Worth ivory-ball test uses small white balls, and the toddler’s recognition of
them gives an estimate of visual function.

3. Preschool children (2–3 years)

• The Coin test uses coins of different sizes, and the child’s ability to recognize or
differentiate them is used to measure acuity.
• The Dot visual acuity test is performed by presenting dots of different sizes, and the
smallest dot that the child can detect indicates their visual acuity.
• The Miniature toy test uses familiar small toys, and the child’s ability to recognize
and identify the toys provides an estimate of acuity.

4. Young children (3–5 years)

• The Landolt C chart presents rings with gaps, and the child has to identify the
position of the gap, which tests recognition acuity.
 • The Lea symbols chart uses simple and familiar pictures, such as an apple or a
house, which makes it easier for children to recognize symbols instead of letters.
• The HOTV test presents only the four letters H, O, T, and V, and the child is asked to
match or name the letters, making it suitable for young children who know only a few
letters.
• The Sheridan letter test uses large, simple letters that are easier for preschool
children to recognize.
• The Tumbling E chart presents the letter E in different orientations, and the child has
to point or say the direction in which the arms of the E are facing.

Why Test at 6 Meters (20 Feet)?

• Visual acuity is tested at a distance of 6 meters (20 feet) because, at this distance, the
light rays entering the eye are almost parallel.
• When light rays are parallel, the accommodation of the eye is not required.
• This ensures that the test measures the true refractive state and resolving power of
the eye, without the influence of accommodation.
• Therefore, 6 meters (or 20 feet) is considered the standard testing distance for visual
acuity.

Components of Vision
Vision has several important components that together determine the quality of eyesight:
1. Visual Acuity – It is the ability of the eye to see fine details and distinguish shapes
clearly.
2. Visual Field – It is the total area that can be seen when the eye is fixed in one
position, including both central and peripheral vision.
3. Contrast Sensitivity – It is the ability to distinguish an object from its background,
even when the contrast is low (for example, seeing a gray object against a slightly
lighter background).
4. Color Vision – It is the ability of the eye to perceive different colors based on cone
cell function in the retina.
5. Stereopsis (Binocular Single Vision) – It is the ability to perceive depth and three-
dimensional structure because of the coordination of both eyes.
 Test Chart Standards & Types
Vision
• Vision is the physiological sense of sight by which the eye perceives the form, color,
size, movement, and distance of objects.

Visual Acuity
• Visual acuity is the resolving power of the eye, or the ability to see two objects as
separate.
• It is a measure of form sense.
• It is the reciprocal of the Minimum Angle of Resolution (MAR) measured in
minutes of arc.

Visual Angle
• The visual angle is the angle subtended at the nodal point of the eye by the physical
size of the object.
• A Snellen test letter subtends a visual angle of 5 minutes of arc at the eye.
• The individual strokes or gaps in the letter subtend 1 minute of arc.

Minimum Angle of Resolution (MAR)

• MAR is the smallest separation between two points or lines that allows them to be
seen as separate.
• Two points are seen separately when they subtend a visual angle of at least 1 minute
of arc at the eye.

Test Chart Standards

1. Optotypes (symbols/letters) – should be simple, non-serif letters, usually in a grid
pattern (5×5).
2. Letter size – designed so that at 6 meters, the letter subtends 5 minutes of arc.
3. Legibility – all letters are not equally legible. Standardized sets of equally legible
letters are used (e.g., Sloan letters, British Standards).
4. Spacing – spacing between letters and lines should be evenly distributed to avoid
crowding effects.
5. Luminance – American standard: 34–51 cd/m²; British standard: 150 cd/m².
 6. Contrast – letters should have at least 84% contrast against background for reliable
testing.

Types of Test Charts

1. Printed Charts
• These are physical charts printed with black letters or symbols.
• They can be either internally illuminated or externally illuminated.
a) Internally Illuminated
• Black letters printed on a white matte background.
• Mounted inside an aluminum box (approx. 24” × 16”).
• Uniformly illuminated by two incandescent lamps (40–60 W).
• Available in English letters, other regional languages, Tumbling E, or Landolt C.
b) Externally Illuminated
• Chart is hung at a distance of 6 meters.
• Light source is projected onto the chart.
• Illumination depends on room lighting.
• Disadvantage: requires a long room and is affected by ambient light.

2. Retro-Illuminated Charts
• Letters are printed on a transparent surface.
• Illumination comes from behind the chart using lamps.
• Often constructed in long boxes, using illumination from all four sides.
• Provides more uniform lighting than external charts.
• Disadvantage: still influenced by ambient illumination and limited letter options.

3. Projection Charts
• Symbols or letters are projected onto a screen using a projector.
• Size of letters can be adjusted by changing the projection.
• Advantages:
o Reduces effect of ambient light.
o Allows multiple letter sizes and test variations.
 o Faster and more flexible compared to printed charts.

Types of Visual Acuity (based on test principle)

• Detection Acuity – ability to detect a stimulus (e.g., fixation and following light,
CSM test).
• Resolution Acuity – ability to resolve two objects separately (e.g., preferential
looking tests, grating acuity).
• Recognition Acuity – ability to recognize or name a symbol (e.g., letter charts,
symbol charts, picture matching).

CSM Test (Central, Steady, Maintained)

• The CSM test is a simple clinical method to assess fixation in infants and young
children.
• Central: The reflex seen in the eye should be centered, meaning fixation is at the
fovea.
• Steady: The fixation should be stable, and there should be no nystagmus present.
• Maintained: Fixation should be held even when the other eye is uncovered during a
cover–uncover test.
• Use: Helps in detecting strabismus, amblyopia, and in assessing fixation preference.

Preferential Looking Test

• The preferential looking test is a method of measuring minimum resolvable acuity
in infants and young children.
• It is based on the principle that infants prefer to look at patterned stimuli (like
stripes or pictures) rather than plain surfaces.
• The child is shown two targets: one with a pattern (like black and white stripes) and
one blank.
• If the child looks toward the patterned side, it indicates that the pattern is being
resolved.
• The test is recorded in cycles per centimeter (cpcm) or converted into Snellen
notation.
• It can be performed with different tools:
o Teller acuity cards (striped patterns on one side of a card).
o Cardiff cards (pictures on top or bottom of a rectangle).
 o Lea paddles (striped vs blank paddles).
• Age group: Effective in children aged 6 months to about 2.5 years.
• Range: Can record visual acuity from 6/60 to 6/6 depending on test distance.

Cardiff Visual Acuity Test

• The Cardiff Visual Acuity Test is a type of preferential looking test designed for
young children and infants.
• It uses pictures of different edge thickness (like a car, house, or fish) drawn inside a
rectangle card.
• On each card, the picture is placed either at the top or the bottom, while the other
side is left blank.
• The examiner observes the child’s eye movements or head movements to see if the
child looks at the picture side.
• The test is performed at distances of 1 meter and 0.5 meter.
• At 1 meter, the test can measure visual acuity in the range of 6/60 to 6/6.
• It is useful for testing visual acuity in toddlers and preschool children, especially
those who cannot respond to letters or symbols.
• Principle: Based on the preferential looking technique—children prefer to look at
patterned or picture stimuli rather than blank spaces.
Common Special Charts
• Landolt C – a ring with a gap; patient identifies gap direction.
• Tumbling E – patient indicates direction of letter E.
• Allen cards / Kay pictures – picture charts for children.
• Lea symbols – uses 4 simple pictures (house, apple, square, ball).
• Lotus College Symbol Chart – uses familiar symbols for Indian children.

Snellen Chart
• The Snellen chart is the most widely used test chart for measuring distance visual
acuity.
• It was designed by Herman Snellen in 1862.
• The chart consists of letters (optotypes) of different sizes, arranged in rows from
large at the top to small at the bottom.
• Each letter is constructed so that the whole letter subtends 5 minutes of arc at the
eye, and each stroke or gap in the letter subtends 1 minute of arc.
• The chart is usually placed at a distance of 6 meters (20 feet) from the patient.
• The patient is asked to read the smallest line of letters they can see clearly.
Advantages
• Simple and quick to use.
• Familiar to both patients and clinicians.
• Available in many languages and symbols (English, regional letters, Tumbling E,
Landolt C).

Disadvantages
• Unequal number of letters in each line.
• Spacing between lines and letters is not standardized.
• Progression of letter size is not uniform.
• Less accurate compared to logMAR charts.

Feature Snellen Chart logMAR Chart (Bailey–Lovie)

Year / Inventor 1862, Herman Snellen 1976, Bailey & Lovie

Logarithm of Minimum Angle of

Notation Fraction (e.g., 6/6, 6/18)
Resolution (e.g., 0.0, 0.3)

Progression of Uniform, each line decreases by

Not uniform
Letter Size 0.1 log unit

Number of Letters Constant (usually 5 letters per

Variable (few at top, many at bottom)
per Line line)

Spacing Between Equal to the width of the letters

Irregular
Letters on the same line

Spacing Between Equal to the height of letters in

Irregular
Lines the previous line

More systematic and scientific,

Ease of Use Simple, quick, widely available
but needs trained use

Accuracy / Less accurate; differences between More accurate; allows precise

Reliability lines not standardized statistical analysis

Standardized, consistent scoring,

Familiar, easy to use, available in
Advantages suitable for research and clinical
many languages and optotypes
trials

Inconsistent letter size progression,

Less familiar to patients, takes
Disadvantages uneven spacing, harder to compare
longer to administer
across patients
 Logmar Chart
Other Notations
• Decimal Notation – Snellen fraction converted to a decimal (e.g., 6/60 = 0.1).
• LogMAR – logarithm of the minimum angle of resolution; more accurate and
standardized (e.g., 6/12 = 0.30 logMAR).
• Visual Acuity Rating (VAR) – derived from logMAR (100 = normal 6/6 vision, 50 =
6/60 vision).
• Near Acuity Notations –
o N notation (New Times Roman font, e.g., N6, N8).
o Metric (M) notation – based on print size subtending 5′ of arc at 1 m.
o Jaeger chart – old system, J1 to J20, but not standardized.
o Reduced Snellen chart – Snellen chart scaled down for near use.

Near Visual Acuity

• Definition: Near visual acuity is the ability of the eye to see and resolve fine details
at a close distance, usually at the normal reading distance of 33–40 cm.
• It is tested to assess how well a person can perform near tasks such as reading,
writing, sewing, or using a mobile phone.

Test Charts for Near Visual Acuity

1. N Notation (Jaeger Notation)
o Uses printed text in different font sizes (e.g., N6, N8, N10).
 o The number (N6, N8) refers to the size of print that can be read at a normal
reading distance.
o N6 is considered equivalent to standard print size (newspaper print).
2. Reduced Snellen Chart
o A miniature version of the Snellen distance chart scaled down for near use.
o Held at 33–40 cm from the patient.
3. M Notation (Metric Notation)
o Uses the size of print that subtends 5 minutes of arc at 1 meter.
o Example: 1M print = newsprint size. If read at 40 cm, notation = 0.4/1M.
4. Jaeger Chart (Old System)
o Uses notations J1, J2, up to J20.
o Not standardized (different publishers had different print sizes).
o Rarely used now.

Procedure
• The patient is asked to read the smallest line or paragraph at a distance of 33–40 cm
using appropriate near correction (spectacles if prescribed).
• Both eyes are tested separately and then together.

Clinical Importance
• Detects presbyopia (age-related near vision difficulty).
• Useful in patients with low vision to prescribe magnifiers.
• Helps assess functional vision in daily activities.

Trial Case and Lenses

Trial Case
• A trial case is a tray containing trial lenses and accessories used to determine the
refractive error of the eye.
• Contents include:
o Trial lenses (spherical and cylindrical)
 o Pin hole disc
o Stenopic slit
o Maddox rod
o Red and green filters
o Prisms
o Cross cylinder lens
o Occluder
Trial Lenses
1. Full Aperture Lens
o Diameter: ~38 mm.
o Shape: biconvex or biconcave.
o Advantage: does not obscure the patient’s face.
o Disadvantage: heavier and thicker, larger errors possible.
2. Reduced Aperture Lens
o Small lens (20 mm) mounted in 38 mm rim.
o Types: planoconvex and planoconcave.
o For refraction: curved surface faces the eye.
o For neutralization: curved surface placed against the spectacle lens.
3. Spherical Lenses
o Positive: +0.12 D to +20.00 D.
o Negative: –0.12 D to –20.00 D.
o In small steps (0.12, 0.25, 0.50, 1.00, 2.00).
4. Cylindrical Lenses
o Positive: +0.12 D to +6.00 D.
o Negative: –0.12 D to –6.00 D.
o Steps: 0.12, 0.25, 0.50.
5. Occluder Lens
o Opaque disc used to cover one eye during testing.

Special Lenses & Accessories

 • Pinhole Disc:
o Small hole (1–2 mm).
o Allows only a pencil of light to pass.
o Helps to distinguish refractive error from pathological error.
o Pinhole of ~1.32 mm is most effective.
• Stenopic Slit:
o Rectangular slit (0.5–1 mm wide, up to 15 mm long).
o Allows a strip of light.
o Used to refine the cylindrical axis.
• Maddox Rod:
o Made of parallel cylinders.
o Produces a streak of light.
o Used to measure squint deviation.
o Available in red or white colors.
• Red and Green Filters:
o Used to disassociate the eyes.
o Helpful in tests like Worth Four Dot test.
o Detects fusion, suppression, diplopia, and squint.
• Prisms:
o Powers range from 0.5Δ to 12Δ.
o Used to measure ocular deviation.
• Cross Cylinder Lens:
o Used in subjective refraction to refine cylinder power and axis.

Trial Frames
• Frames that hold trial lenses for testing.
• Types:
1. Full Aperture Trial Frame – holds up to 5 lenses per eye; adjustable PD,
bridge height, and side length.
2. Reduced Aperture Trial Frame – lightweight, holds up to 4 lenses; easy
insertion and removal.
 3. Half-Eye Trial Frame – designed for children or small PD; available with
adjustable or fixed bridge.
4. Trial Clips – monocular frames attachable to spectacles; useful in low vision
patients.

Design Considerations for Trial Frames

• They should be lightweight and comfortable.
• They must allow accurate centering vertically and horizontally.
• They should remain stable even on an asymmetric face.