Problems with traditional visual acuity charts!

 The clinical measurement of visual acuity has been made traditionally with a
“Snellen chart” of optotypes, usually letters, presented at a standard
distance (commonly 6 meters or 20 feet)
 When the visual acuity is so poor that the largest optotypes cannot be named,
generally the clinician brings the chart closer to the patient, but rarely closer
than 1 meter
 If the largest optotype cannot be read at the close distance, testing visual
acuity with optotypes is abandoned and the usual practice is for the clinician
to next ask the patient to count the fingers on a hand held at a close distance
 If the fingers cannot be counted, the next step is to determine whether the
patient can identify when the clinician’s hand is moving. The procedures for
the “Count Fingers” (CF), and “Hand Motion” (HM) vision tests are not
standardized

 There is no “standard” closest distance for viewing the “Snellen Chart.” The
Berkeley Rudimentary Vision Test was designed to provide a rational system
for quantifying very poor levels of visual acuity (i.e., spatial vision) with
methods that are simple and easy to apply in any clinical environment
 Bailey and Lovie (1976) introduced a set of principles for chart design that
ensure that the visual task remains the same at each size level. This means
that size remains the only significant variable from one size level to the next

 At each size level there must be the same number of optotypes,the spacing
between optotypes and between rows are proportional to the size of the
optotypes and the progression of size must follow a constant ratio.
 Visual acuity scores in terms of logMAR the common logarithm of the Minimum
Angle of Resolution (MAR).
 Landolt rings, Tumbling E’s, and most sets of letters that are used as
optotypes are constructed so that the width of the stroke and the spacing
between strokes is one-fifth of the letter height.
 The MAR is commonly taken to be the angular size of one fifth of the height of
the optotype and it is specified in minutes of arc. When the size progression
proceeds in 0.10 log unit steps (ratio = 1.26x) and there are 5 optotypes per
row, then each letter can be assigned a value of 0.02 log units.
 ETDRS chart chose the family of 10 Sloan letters as its optotype and 4 meters
as its standard testing distance.
 The Sloan letters are C, D, H, K, N, O, R, S, V, and Z drawn to specific
dimensions
 The ETDRS chart has rows of 5 letters, the spacing of letters within a row is
equal to one letter height, the spacing between one row and the next is equal
to the height of the letters in the smaller row, and the size progression ratio
is equal to 0.1log unit (= 1.26x)
 The layout is center justified.
 There are 14 different sizes ranging from the largest size of 40 M-units (58.2 mm) at
the top of the chart down to the smallest size of 2.0 M-units (2.9 mm). At the
recommended viewing distance of 4 meters, the visual acuity range is from logMAR
1.00 to 0.30 (20/200 to 20/10, 6/60 to 6/3, 4/40 to 4/2, 0.1 to 2.0)
 (The M-unit is the letter height that corresponds to a visual angle of 5 min of arc
at a distance of 1 meter. An advantage of the M-unit notation is that is equal to
the distance in meters at which a letter is seen under 5 min of arc (analogous to
a decimal acuity of 1.0, or Snellen 20/20)
 The ETDRS chart has become the “gold standard.” The recommended protocol
provides for shortening the viewing distance to 1 meter when the largest row cannot
be read at 4 meters
 At close viewing distances, positioning large charts is difficult, and the
process can be claustrophobic and intimidating to the patient
 At extremely large angular sizes, head movements or even changes in body
posture can be required to shift attention from one end of the row to the
other, or from one part of a target letter to another
 Several automated computer based tests have been developed for the
purpose of measuring acuity in patients with very low vision. Freiburg Visual
Acuity and Contrast Test (FrACT)
The Berkeley Rudimentary Vision Test
 BRVT test could quickly provide reasonably precise measures of vision, and
which could easily be used by non-technical support personnel in almost any
setting without requiring power or technological display systems

 The test should be an attractive and more quantitative alternative to the

 to systematically simplify the visual task and to use very close viewing distances
when the visual resolution abilities become very poor.
 Within the BRVT, there is a three level hierarchy of task complexity
 Recognition of a single isolated optotype is a less complex visual task than
reading across rows of letters on an ETDRS or similar chart
 The Single Tumbling E (STE)was chosen as the single optotype for the BRVT
because it is easy to administer regardless of the patient’s language or
literacy skills.
 For the recognition of a STE, localization of visual attention is required and
the patient needs to identify both the orientation of the 3-bar grating
component of the E as well as the location of the cross bar
 The second step in the BRVT sequence of task simplification is to measure GA.
Recognition of grating orientation is a simpler visual task than recognizing the
orientation of a STE
 For the grating task, fixation control and localization of the point of attention
are relatively unimportant
 The patient simply has to recognize that, somewhere within the display field,
there is a periodic pattern with a discernible orientation
 The third level of task complexity in the BRVT battery is a test of basic
spatial vision function.
 It tests whether the patient can detect and localize large white fields and
also determines whether the patient can tell whether a large display field is
black or white

 The Berkeley Rudimentary Vision Test consists of three card pairs. Each card-
pair has two 25-cm square cards hinged together so that there are four panel
faces for each of the three card pairs
 The STE card pair is used for measuring visual acuity with single optotypes
 Each STE card-pair has 4 STEs whose sizes in M-units are 100 M, 63 M, 40 M
and 25 M. (in millimeters-145mm, 92 mm, 58 mm, and 36 mm)
 The visual task is to identify the direction to which the legs of the E are
pointing: up, down, right, or left
 The STE cards are hinged so that when the 100 M and 25 M E’s are on the
outside faces, the intermediate 63 M and 40 M E’s are on the inside faces.
 For these STE targets, the visual acuity demand, the MAR, is determined by
the stroke widths (or the spacing between parallel strokes) in arc-minutes
 For a viewing distance of 100 cm, the visual acuity demands for these 4
optotypes are, in logMAR terms, logMAR = 2.00, 1.80, 1.60, and 1.40
(equivalent to 20/2000, 20/1250, 20/800, and 20/500)
 For a viewing distance of 25 cm, the angular sizes increase by 0.6 log units
to become logMAR = 2.60, 2.40, 2.20, and 2.00 (equivalent to 20/8000, 20/
5000, 20/3200, and 20/2000)
 The GA card-pair has 4 square-wave gratings of different spatial frequencies,
and the gratings fill the area of the 25-cm square panels
 The widths of the black and white stripes on the 4 different grafting's are
60, 38, 24, and 15 mm
 For a viewing distance of 25 cm, the visual acuity values of the four grating
targets are logMAR = 2.90, 2.70, 2.50 and 2.30 (equivalent to 20/16,000,
20/10,000, 20/6,300, and 20/4,000)
 The M-unit values given to the gratings are the distances in meters at
which the stripe widths subtend 1 min of arc, and for these 4 gratings these
are 200 M,125 M, 80 M, and 50 M.
 For a 25 cm viewing distance, the 25 cm square test cards subtend an angle of
53°
 The patient’s task is to identify whether the stripes are oriented
horizontally or vertically
 The GA cards are hinged so that when the 200 M and 50 M gratings are on the
outside faces, the intermediate 125 M and 80 M gratings are on the inside
 There is a test of spatial localization called White Field Projection (WFP).
Two card faces are used for this test
 One card is black with a white quadrant the other card is divided into a
black half and a white half
 The visual task is to identify the location of the large white area. When
presented at 25 cm, the quad-field subtends 26° × 26° and the hemi-field
area is 26° × 53°
 The other test of basic vision function is called Black White Discrimination
(BWD). One of the two card faces is all black, the other all white
 The patient’s task is to tell whether the card being presented is black or
white
 With the cards at 25 cm from the eye, the black and white fields of the BWD
test subtend 53° × 53°
 The Basic Vision card-pair is hinged so that when the quad-field and hemi-
field panels for the WFP test are on the outside, the black and white panels
for the BWD test are on the inside
BRVT Testing Sequence
 The testing sequence with the BRVT is simple and intuitive
 Testing with the BRVT standard protocol begins with the STE card-pair at a
viewing distance of 100 cm. The smallest STE (25M) is presented first
 If the orientation of the 25 M STE can be readily recognized at 100 cm, then it
is likely that visual acuity will be measurable with an ETDRS chart or similar
at 100 cm, given that the largest optotype size on the ETDRS chart (40 M) is
larger than the 25 M STE
 If the 25 M STE cannot be recognized at 100 cm, then the 100 M STE is
presented at 100 cm
 If the 100 M STE can be recognized at 100 cm, then the visual acuity
measurement can be completed at 100 cm with the STE card-pair
 If the 100 M STE cannot be recognized at 100 cm, the visual acuity for STEs is
less than logMAR = 2.0 (equivalent to 20/2000), then the viewing distance
should be reduced to 25 cm
 Because the cards are 25 cm square, it is convenient to use the card itself as
a measuring stick to check that the eye-to-card distance is 25 cm
 If the 100 M STE can be recognized at 25 cm, the visual acuity for STEs is at
least logMAR = 2.60, (equivalent to 20/8,000), and the visual acuity
determination can be completed with STEs
 100 M STEs cannot be recognized at 25 cm, then testing with STEs is
abandoned, and the GA card-pair is used next
 The GA test begins with the largest grating (200 M) being presented at 25 cm
 If the grating orientation can be recognized then the GA is at least logMAR =
2.90 (equivalent to 20/16,000), and GA can be measured using the finer
grating targets
 If the orientation of coarsest grating target (200 M) cannot be recognized at
25 cm, then visual acuity measurement is abandoned, and then the Basic
Vision tests card-pair is used.
 The Basic Vision Tests are presented at a viewing distance of 25 cm.
 For the WFP test, the quad-field card and the hemi-field card should each be
shown at least once in each of the 4 card orientations
 If the location of the white quad-field or hemi-field cannot be reliably
identified, then the BWD test is administered
 If the patient is unable to discriminate black from white with the BWD test,
then a test of “Light Perception” is conducted using a penlight shone at the
eye from a close distance.
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wide-angle-vs-expanded-field-telescopes/