# Visual acuity

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

## Overview

Visual acuity (VA) is acuteness or clearness of vision, especially form vision, which is dependent on the sharpness of the retinal focus within the eye and the sensitivity of the interpretative faculty of the brain.[1]

VA is a quantitative measure of the ability to identify black symbols on a white background at a standardized distance as the size of the symbols is varied. It is the most common clinical measurement of visual function. In the term "20/20 vision" the numerator refers to the distance in feet from which a person can reliably distinguish a pair of objects. The denominator is the distance from which a person with standard VA would be able to distinguish them--the distance at which their separation angle is 1 arc minute. The metric equivalent is 6/6 vision. Twenty feet is essentially infinity from an optical perspective (the difference in optical power required to focus at 20 feet versus infinity is only 0.164 diopters). For that reason, 20/20 vision can be considered nominal performance for human distance vision; 20/40 vision can be considered half that acuity for distance vision and 20/10 vision would be twice normal acuity. The 20/x number does not directly relate to the eyeglass prescription required to correct vision; rather an eye exam seeks to find the prescription that will provide 20/20 vision.

## History

Year Event
1843 German ophthalmologist Heinrich Kuechler wrote a treatise advocating the need for standardized vision tests and developed a set of three charts.[2][3]
1854 Eduard von Jaeger published a set of reading samples to document functional vision. He published samples in German, French, English and other languages. He used fonts that were available in the State Printing House in Vienna in 1854 and labeled them with the numbers from that printing house catalogue.
1861 Franciscus Donders coined the term visual acuity to describe the “sharpness of vision” and defined it as the ratio between a subject's VA and a standard VA.
1862 Hermann Snellen published his famous letter chart. His most significant decision was not to use existing typefaces but to design special targets, which he called optotypes. This was crucial because it was a physical standard measure to reproduce the chart. Snellen defined “standard vision” as the ability to recognize one of his optotypes when it subtended 5 minutes of arc, thus the optotype can only be recognized if the person viewing it can discriminate a spatial pattern separated by a visual angle of 1 minute of arc. Since Snellen's days, few major improvements in visual acuity measurement have been made.
1875 Snellen changed from using feet to meters (from 20/20 to 6/6 respectively). Today, the 20-foot distance prevails in the United States and 6 meters prevails in Britain. Also in 1875 Monoye proposed to replace the fractional Snellen notation with its decimal equivalent (e.g., 20/40 = 0.5, 6/12 = 0.5, 5/10 = 0.5). Decimal notation makes it simple to compare visual acuity values, regardless of the original measurement distance.
1888 Edmund Landolt proposed the Landolt C, a symbol that has only one element of detail and varies only in its orientation. The broken ring symbol is made with a "C" like figure in a 5 x 5 grid that, in the 20/20 optotype, subtends 5 minutes of arc and has an opening (oriented in the top, bottom, right or left) measuring 1 minute of arc. This proposal was based in the fact that not all of Snellen's optotypes were equally recognizable. This chart is actually the preferred visual acuity measurement symbol for laboratory experiments but gained only limited acceptance in clinical use.
1923 Soviet ophthalmologists Sergei Golovin and D. A. Sivtsev developed the table for testing visual acuity,[4] that was used in the USSR until 1991 and as of 2007 is still used in some post-Soviet states. It consisted of two parts, ten rows each, both parts with visual acuity values incrementing by 0.1 from row to row, i.e. representing the range 0.1-1.0. The left part contained Cyrillic letters Ш, Б, М, Н, К, Ы, И in a definite order, with width of each character equal to its height, and the size of a first row character being 70mm, in the second row it was 35mm, and in the last row - 7mm.[5] Right part of the table contained Landolt C symbols. The distance was set to be 5 meters.[6] This table is called Golovin-Sivtsev Table (Russian: Таблица Головина-Сивцева).[7]
1959 Louise Sloan designed a new optotype set of 10 letters, all to be shown in each and every line tested, in order to avoid the problem that not all letters are equally recognizable. The larger letter sizes thus required more than one physical line. Louise Sloan also proposed a new letter size notation using the SI system stating that standard acuity (1.0, 20/20) represents the ability to recognize a standard letter size (1 M-bunit) at a standard distance (1 meter).
1976
• Ian Bailey and Jan Lovie published a new chart featuring a new layout with five letters on each row and spacing between letters and rows equal to the letter size. This layout was created to standardize the crowding effect and the number of errors that could be made on each line, so letter size became the only variable between the acuity levels measured. These charts have the shape of an inverted triangle and are much wider at the top than traditional charts. Like Sloan's chart, they followed a geometric progression of letter sizes.
• Lea Hyvärinen created a chart, the Lea chart, using outlines of figures (an apple, a house, a circle and a square) to measure visual acuity in preschool children.
• Hugh Taylor used these design principles for an illiterate Tumbling E Chart used to study the visual acuity of Australian Aborigines and it's actually used to screen visual acuity on illiterate people.

## Physiology of visual acuity

To resolve detail, the eye's optical system has to project a focused image on the fovea, a region inside the macula having the highest density of cone photoreceptors (the only kind of photoreceptors existing on the fovea), thus having the highest resolution and best color vision. Acuity and color vision, despite being done by the same cells, are different physiologic functions that don't interrelate except by position. Acuity and color vision can be affected independently.

Light travels from the fixation object to the fovea through an imaginary path called the visual axis. The eye's tissues and structures that are in the visual axis (and also the tissues adjacent to it) affect the quality of the image. These structures are: tear film, cornea, anterior chamber, pupil, lens, vitreous, and finally the retina. The posterior part of the retina, called the retinal pigment epithelium (RPE) is responsible for, among many other things, absorbing light that crosses the retina so it cannot bounce to other parts of the retina. (However in many vertebrates, such as cats, where high visual acuity is not a priority, there is a reflecting tapetum layer that gives the photoreceptors a "second chance" to absorb the light, thus improving the ability to see in the dark. This is what causes an animal's eyes to seemingly glow in the dark when a light is shone on them.) The RPE also has a vital function of recycling the chemicals used by the rods and cones in photon detection. If the RPE is damaged and does not clean up this "shed" blindness can result.

As in a photographic lens, visual acuity is affected by the size of the pupil. Optical aberrations of the eye that decrease visual acuity are at a maximum when the pupil is largest (about 8 mm), which occurs in low-light conditions. When the pupil is small (1–2 mm), image sharpness may be limited by diffraction of light by the pupil (see Diffraction limit). Between these extremes is the pupil diameter that is generally best for visual acuity in normal, healthy eyes; this tends to be around 3 or 4 mm.

If the optics of the eye were otherwise perfect, theoretically acuity would be limited by pupil diffraction which would be a diffraction-limited acuity of 0.4 minutes of arc (minarc) or 20/8 acuity. The smallest cone cells in the fovea have sizes corresponding to 0.4 minarc of the visual field, which also places a lower limit on acuity. The optimal acuity of 0.4 minarc or 20/8 can be demonstrated using a laser interferometer that bypasses any defects in the eye's optics and projects a pattern of dark and light bands directly on the retina. Laser interferometers are now used routinely in patients with optical problems, such as cataracts, to assess the health of the retina before subjecting them to surgery.

The visual cortex is the part of the cerebral cortex in the posterior (occipital) part of the brain responsible for processing visual stimuli. The central 10° of field (approximately the extension of the macula) is represented by at least 60% of the visual cortex. Many of these neurons are believed to be involved directly in visual acuity processing.

Proper development of normal visual acuity depends on an animal having normal visual input when it is very young. Any visual deprivation, that is, anything intefering with such input over a prolonged period, such as a cataract, severe eye turn or strabismus, or covering or patching the eye during medical treatment, will usually result in a severe and permanent decrease in visual acuity in the affected eye if not treated early in life. The decreased acuity is reflected in various abnormalities in cell properties in the visual cortex. These changes include a marked decrease in the number of cells connected to the affected eye as well as few cells connected to both eyes, resulting in a loss of binocular vision and depth perception, or stereopsis. The period of time over which an animal is highly sensitive to such visual deprivation is referred to as the critical period.

The eye is connected to the visual cortex by the optic nerve coming out of the back of the eye. The two optic nerves come together behind the eyes at the optic chiasm, where about half of the fibers from each eye cross over to the opposite side and join fibers from other eye representing the corresponding visual field, the combined nerve fibers from both eyes forming the optic tract. This ultimately forms the physiological basis of binocular vision. The tracts project to a relay station in the midbrain called the lateral geniculate nucleus and then to the visual cortex along a collection of nerve fibers called the optic radiations.

Any pathological process in the visual system, even in older humans beyond the critical period, will often cause decreases in visual acuity. Thus measuring visual acuity is a simple test in accessing the health of the eyes, the visual brain, or pathway to the brain. Any relatively sudden decrease in visual acuity is always a cause for concern. Common causes of decreases in visual acuity are cataracts and scarred corneas, which affect the optical path, diseases that affect the retina, such as macular degeneration and diabetes, diseases affecting the optic pathway to the brain such as tumors and multiple sclerosis, and diseases affecting the visual cortex such as tumors and strokes.

## Visual acuity expression

Visual acuity scales
Foot Metre Decimal LogMAR
20/200 6/60 0.10 1.00
20/160 6/48 0.13 0.90
20/120 6/36 0.17 0.78
20/100 6/30 0.20 0.70
20/80 6/24 0.25 0.60
20/60 6/18 0.33 0.48
20/50 6/15 0.40 0.40
20/40 6/12 0.50 0.30
20/30 6/9 0.63 0.18
20/25 6/7.5 0.80 0.10
20/20 6/6 1.00 0.00
20/16 6/4.8 1.25 -0.10
20/12 6/3.6 1.67 -0.22
20/10 6/3 2.00 -0.30

Visual acuity is often measured according to the size of letters viewed on a Snellen chart or the size of other symbols, such as Landolt Cs or Tumbling E.

In some countries, acuity is expressed as a vulgar fraction, and in some as a decimal number.

Using the foot as a unit of measurement, (fractional) visual acuity is expressed relative to 20/20. Otherwise, using the metre, visual acuity is expressed relative to 6/6. For all intents and purposes, 6/6 vision is equivalent to 20/20. In the decimal system, the acuity is defined as the reciprocal value of the size of the gap (measured in arc minutes) of the smallest Landolt C that can be reliably identified. A value of 1.0 is equal to 20/20.

LogMAR is another commonly used scale which is expressed as the logarithm of the minimum angle of resolution. LogMAR scale converts the geometric sequence of a traditional chart to a linear scale. It measures visual acuity loss; positive values indicate vision loss, while negative values denote normal or better visual acuity. This scale is rarely used clinically; it is more frequently used in statistical calculations because it provides a more scientific equivalent for the traditional clinical statement of “lines lost” or “lines gained”, which is valid only when all steps between lines are equal, which is not usually the case.

A visual acuity of 20/20 is frequently described as meaning that a person can see detail from 20 feet away the same as a person with normal eyesight would see from 20 feet. If a person has a visual acuity of 20/40, he is said to see detail from 20 feet away the same as a person with normal eyesight would see it from 40 feet away. It is possible to have vision superior to 20/20: the maximum acuity of the human eye without visual aids (such as binoculars) is generally thought to be around 20/10 (6/3) however, recent test subjects have exceeded 20/8 vision. Recent developments in optometry have resulted in corrective lenses conferring upon the wearer a vision of up to 20/10. Some birds, such as hawks, are believed to have an acuity of around 20/2; in this respect, their vision is much better than human eyesight.

When visual acuity is below the largest optotype on the chart, either the chart is moved closer to the patient or the patient is moved closer to the chart until the patient can read it. Once the patient is able to read the chart, the letter size and test distance are noted. If the patient is unable to read the chart at any distance, he or she is tested as follows:

Name Abbreviation Definition
Counting Fingers CF Ability to count fingers at a given distance.
Hand Motion HM Ability to distinguish a hand if it is moving or not in front of the patient's face.
Light Perception LP Ability to distinguish if the eye can perceive any light.
No Light Perception NLP Inability to see any light. Total blindness.

Many humans have one eye that has superior visual acuity over the other. If a person cannot achieve a visual acuity of 20/200 (6/60) or above in the better eye, even with the best possible glasses, then that person is considered legally blind in the United States. A person with a visual field narrower than 20 degrees also meets the definition of legally blind.

A person's visual acuity is registered documenting the following: whether the test was for distant or near vision, the eye(s) evaluated and whether corrective lenses (i.e. spectacles or contact lenses) were used:

• Distance from the chart
• D (distant) for the evaluation done at 20 feet (or 6 meters).
• N (near) for the evaluation done at 15.7 inches (or 40 cm).
• Eye evaluated
• OD (Latin oculus dexter) for the right eye.
• OS (Latin oculus sinister) for the left eye.
• OU (Latin oculi uterque) for both eyes.
• Usage of spectacles during the test
• cc (Latin cum correctore) with correctors.
• sc: (Latin sine correctore) without correctors.
• Pinhole
• PH abbreviation is used followed by the visual acuity measured with it.

So, distant visual acuity of 20/60 and 20/25 with pinhole in the right eye will be:
DscOD 20/60 PH 20/25

Distant visual acuity of count fingers and 20/50 with pinhole in the left eye will be:
DscOS CF PH 20/50

Near visual acuity of 20/25 with pinhole remaining at 20/25 in both eyes with spectacles will be:
NccOU 20/25 PH 20/25

"Dynamic visual acuity" defines the ability of the eye to visually discern fine detail in a moving object.

## Measurement

Visual acuity is typically measured monocularly rather than binocularly with the aid of an optotype chart for distant vision, an optotype chart for near vision, and an occluder to cover the eye not being tested. The examiner may also occlude an eye by sliding a tissue behind the patient's eyeglasses, or instructing the patient to use his or her hand. This latter method is typically avoided in professional settings as it may inadvertently allow the patient to peek through his or her fingers, or press the eye and alter the measurement when that eye is evaluated.

1. Place the chart at 20 feet (or 6 meters) and illuminate to 480 lux at that distance.
2. If the patient uses glasses, then the test is performed using them.
3. Place the occluder in front of the eye that is not being evaluated. The first evaluated eye is the one that is believed to see less or the one the patient says that is seeing less.
4. Start first with the big optotypes and proceed to the smaller ones. The patient has to identify every one on the line being presented and communicate it to the physician.
5. If the measurement is reduced (below 20/20) then the test using a pinhole should be done and register the visual acuity using the pinhole. Both measures should be registered, with and without using pinhole.
6. Change the occluder to the other eye and proceed again from the 4th step.
7. After both eyes have been evaluated in distant visual acuity, proceed to evaluate near visual acuity placing a modifid snellen chart for near vision (such as the Rosembaum chart) at 15.7 inches (or 40 centimeters). Then repeat the test from the 2nd step.

In some cases, binocular visual acuity will be measured, because usually binocular visual acuity is slightly better than monocular visual acuity.

## Measurement considerations

Visual acuity measurement involves more than being able to see the optotypes. The patient should be cooperative, understand the optotypes, be able to communicate with the physician, and many more factors. If any of these factors is missing, then the measurement will not represent the patient's real visual acuity.

Visual acuity is a subjective test meaning that if the patient is unwilling or unable to cooperate, the test cannot be done. A patient being sleepy, intoxicated, or having any disease that can alter the patient's consciousness or his mental status can make the measured visual acuity worse than it actually is.

Illiterate patients who cannot read letters and/or numbers will be registered as having very low visual acuity if this is not known. Some of the patients will not tell the physician that they don't know the optotypes unless asked directly about it. Brain damage can result in a patient not being able to recognize printed letters, or being unable to spell them.

A motor inability can make a person respond incorrectly to the optotype shown and negatively affect the visual acuity measurement.

Variables such as pupil size, background adaptation luminance, duration of presentation, type of optotype used, interaction effects from adjacent visual contours (or “crowding") can all affect visual acuity measurement.

### Visual acuity testing in children

The newborn’s visual acuity is approximately 20/400, developing to 20/20 by two years. [8]

The measurement of visual acuity in infants, pre-verbal children and special populations (for instance, handicapped individuals) is not always possible with a letter chart. For these populations, specialised testing is necessary. As a basic examination step, one must check whether visual stimuli can be fixed, centered and followed.

More formal testing using preferential looking techniques use Teller acuity cards (presented by a technician from behind a window in the wall) to check if the child is more visually attentive to a random presentation of vertical or horizontal bars on one side compared with blank page on the other side - the bars become progressively finer or closer together, and the endpoint is noted when the child in its adult carer's lap equally prefers the two sides.

Another popular technique is electro-physiologic testing using visual evoked potentials (VEP), which can be used to estimate visual acuity in doubtful cases and expected severe vision loss cases like Leber's congenital amaurosis.

VEP testing of acuity is somewhat similar to preferential looking in using a series of black and white stripes or checkerboard patterns (which produce larger responses than stripes). However, behaviorial responses are not required. Instead brain waves created by the presentation of the patterns are recorded. The patterns become finer and finer until the evoked brain wave just disappears, which is considered to be the endpoint measure of visual acuity. In adults and older, verbal children capable of paying attention and following instructions, the endpoint provided by the VEP corresponds very well to the perceptual endpoint determined by asking the subject when they can no longer see the pattern. There is an assumption that this correspondence also applies to much younger children and infants, though this doesn't necessarily have to be the case. Studies do show the evoked brain waves, as well as derived acuities, are very adult-like by one year of age.

For reasons not totally understood, until a child is several years old, visual acuities from behavioral preferential looking techniques typically lag behind those determined using the VEP, a direct physiological measure of early visual processing in the brain. Possibly it takes longer for more complex behavioral and attentional responses, involving brain areas not directly involved in processing vision, to mature. Thus the visual brain may detect the presence of a finer pattern (reflected in the evoked brain wave), but the "behavioral brain" of a small child may not find it salient enough to pay special attention to.

A simple but less-used technique is checking oculomotor responses with an optokinetic nystagmus drum, where the subject is placed inside the drum and surrounded by rotating black and white stripes. This creates an involuntary flicking or nystagumus of the eyes as they attempt to track the moving stripes. There is a good correspondence between the optikinetic and usual eye-chart acuities in adults. A potentially serious problem with this technique is that the process is reflexive and mediated in the low-level brain stem, not in the visual cortex. Thus someone can have a normal optokinetic response and yet be cortically blind with no conscious visual sensation.

## "Normal" vision

Visual acuity depends upon how accurately light is focused on the retina (mostly the macular region), the integrity of the eye's neural elements, and the interpretative faculty of the brain. [9] "Normal" visual acuity is frequently considered to be what was defined by Snellen as the ability to recognize an optotype when it subtended 5 minutes of arc, that is Snellen's chart 20/20 feet, 6/6 meter, 1.00 decimal or 0.0 logMAR. In humans, the maximum acuity of a healthy, emmetropic eye (and even ametropic eyes with correctors) is approximately 20/16 to 20/12, so it is inaccurate to refer to 20/20 visual acuity as "perfect" vision. 20/20 is the visual acuity needed to discriminate two points separated by 1 arc minute -- about 1/16 of an inch at 20 feet. This is because a 20/20 letter, E for example, has three limbs and two spaces in between them, giving 5 different detailed areas. The ability to resolve this therefore requires 1/5 of the letter's total arc, which in this case would be 1 minute. The significance of the 20/20 standard can best be thought of as the lower limit of normal or as a screening cutoff. When used as a screening test subjects that reach this level need no further investigation, even though the average visual acuity of healthy eyes is 20/16 to 20/12.

Some people may suffer from other visual problems, such as color blindness, reduced contrast, or inability to track fast-moving objects and still have normal visual acuity. Thus, normal visual acuity does not mean normal vision. The reason visual acuity is very widely used is that it is a test that corresponds very well with the normal daily activities a person can handle, and evaluate their impairment to do them.

## Other measures of visual acuity

Normally visual acuity refers to the ability to resolve two separated points or lines, but there are other measures of the ability of the visual system to discern spatial differences.

Vernier acuity measures the ability to align two line segments. Humans can do this with remarkable accuracy. Under optimal conditions of good illumination, high contrast, and long line segments, the limit to vernier acuity is about 8 arc seconds or 0.13 arc minutes, compared to about 0.6 arc minutes (20/12) for normal visual acuity or the 0.4 arc minute diameter of a foveal cone. Because the limit of vernier acuity is well below that imposed on regular visual acuity by the "retinal grain" or size of the foveal cones, it is thought to be a process of the visual cortex rather than the retina. Supporting this idea, vernier acuity seems to correspond very closely (and may have the same underlying mechanism) enabling one to discern very slight differences in the orientations of two lines, where orientation is known to be processed in the visual cortex.

The smallest detectable visual angle produced by a single fine dark line against a uniformally illuminated background is also much less than foveal cone size or regular visual acuity. In this case, under optimal conditions, the limit is about 0.5 arc seconds, or only about 2% of the diameter of a foveal cone. This produces a contrast of about 1% with the illumination of surrounding cones. The mechanism of detection is the ability to detect such small differences in contrast or illumination, and does not depend on the angular width of the bar, which cannot be discerned. Thus as the line gets finer, it appears to get fainter but not thinner.

Stereoscopic acuity is the ability to detect tiny differences in depth with the two eyes. For more complex targets, stereoacuity is similar to normal monocular visual acuity, or around 0.6-1.0 arc minutes, but for much simpler targets, such as vertical rods, may be as low as only 2 arc seconds. Although stereoacuity normally corresponds very well with monocular acuity, it may be very poor or even absent even with normal monocular acuities. Such individuals typically have abnormal visual development when they are very young, such as an alternating strabismus or eye turn, where both eyes rarely or never point in the same direction and therefore do not function together.

## References

1. Cline D; Hofstetter HW; Griffin JR. Dictionary of Visual Science. 4th ed. Butterworth-Heinemann, Boston 1997. ISBN 0-7506-9895-0
2. Herman Snellen (www.whonamedit.com)
3. http://www.ski.org/Colenbrander/Images/Measuring_Vis_Duane01.pdf
4. (Russian) Refraction and acuity
5. (Russian) Some information on Golovin-Sivtsev Table - that website as a whole doesn't seem to be reliable, but it seems to present reliable information on Golovin-Sivtsev Table dimensions
6. (Russian) Medical Encyclopedia