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AueRtcnrvJounnru-or Opronsrny & PHvsror,ocrcAt,

Optrcs Volume53,No. ll, November19?6


Copyright@ 1976AmericanAcademyof Optometrv Printedin U.S.A.

New Design Principlesfor Visual


Acuity tetter Charts*
Ian L. Baileyt and qlan E. Lovie$
NationalVisionResearch
Instituteof Australia,Melboltrne,Australia
AuenlceN Jounnrl or Omonsxny & Pnvsrol,octclI, Optrcs Volume53,No. ll. November19?6
Copyright @ 1976American Academyof Optometry hinted dnU.S.A.

New Design Principlesfor Visual


Acuity Letter Charts*
fan L. Baileyt and qlan E. Lovieg
Natiorwl VisionResearchInstitute of Austrolia,Melbourrrc,Australia

ABSTRA T chart designs, but the only 2 propooalsto have


This paper introduce$ new principles for {he gained wide acceptanceare the following.
design and use of letter charts for the Letter sizes on a chart should follow a geo-
tnecrsuretnentof uisual acuity. It is aduocated metric progression (i.e., advance in uniform
ttnt the test task should be essentially the satne steps on a logarithmic scale).This proposalhas
at each size leuel on the chort, Such been advocated by authorities ranging from
standardization of the test task requires the use Grcenr in 1867to Sloan'in more recent times.
of letters of equal legibility, the same rurmber of The logarithmic progression principle has been
letters on eoch row, and uniform between-letter accepted by the International Council of
ard between-rou) spacing. It is also aduocated Ophthalmology Committee on optotypest and
that, combined with the test tash by Germany in ite new German Standard. for
stondardization, there should be a logarithmic the measurement of visual acuity. Both bodies
prcgressionof letter size. Chorts incorporoting use the original recommendation of Green,t that
tlwse design features haue been mode. These the multiplier or ratio of the geometricprogres-
clurts facilitate the use of rwnstandord testing sion should be lh,/10 (this is equal to 1.2589or
distanceswhich ntght be used when tlwre is low 0.1 log unit).
uisual acuity, when exami,nation room layout Letters used in a chart should be of equal
preuents testing at the standard distance, or legibility; this principle hae been generally
wlwn it is necessaryto ualidate uisual acuity accepted and is optimally achieved only in
$coresctr detect malingering. AdjustirW the those charts which uce Landolt C, illiterate E,
uisual acuity score according to the chosen or similar targets. Some authors'.7.t have in-
testing distance is simplificd by the use of vestigated the relative legibilities of letters hav-
logarithmic scaling. ing particular styles or designs. From their re-
sults, they have recommended sets of almost
equally legible letters for use in visual acuity
The method of measuring visual acuity with charts. For acuity charts it is commonly ac-
letter charts is so familiar and so easy to cepted that the letter height should equal 5
administer that it appears secure from chal- stroke widths; however, there is no consensus
lenge by alternative methods. Despite the ex- on whether the letters should be constructed on
tensive use of letter chart visual acuity mea- a 5 x 4 or a 5 x 5 framework, nor is there agree-
surementsfor socio-legal,clinical, and scientific ment on whether the letters should have serifs.
purposes,there remain a number of deficiencies
in the design of currently available charts. DEFICIENCIES IN CURRENT CHART
Bennettr has reviewed the development of DESIGNS
letter charts since Snellent first introduced his The basic principle of measuring visual acu-
optotypes in 1862. Since the time of Snellen, ity with letter test charts is that the smallest
numerous suggestions have been made for letters which can just be read satisfactorily
improving the psychophysicalrationale of letter provide the index of visual acuity. It should
therefore follow that, apart from size, each
'Read before the Southern Regional Congress, visual acuity level on a test chart ehould present
Melbourne, Australia, May 1975. an essentially equivalent task. However, cur-
f Optometrist, M.S., Fellow, American Academyof rently available charts fail in this respect. The
Optometry. common practice is to use a single or 2-letter
f Optometrist, M.S. candidate. task for low acuity levels and I or l0letters in a
740
Nouember,lg76 New Visual Acuity Chari-Bciiei't 6nf, Louie 741
row for higher acuity levels. Furthermore, the essentially the same at each level so that the
spacingsbetween adjacent letters and between angular size of the letters remains the only
adjacent rows rarely have any systematic or parameter which determines the visual acuity
logical relationship to letter size. It is well score; and (b) the letter size progressionis in
knowne.rothat personswith amblyopia or other uniform stepson a logarithmic scaleso that the
disorders of central vision can frequently read scaling factor is constant throughout the chart
single letters more easily than a row of letters and will remain unaltered when nonstandard
and that letters at the beginningand/or end of a viewing distances are used.
row can often be discerned more readily than
more central letters. Flom et al.rr have shown IVEW CHANT DESIGN
that for persons with normal vision or We have produced letter charts designed to
amblyopia the presenceof nearby contours can satisfy both of these principles.An exampleof
considerablyreduce the legibility of individual these charts is shown in Fig. 1. It has the
lelters. Current visual acuity charts appeal to following design features.
includc no allowance for these eft'ects; chart Legibility. The letters are of almost equal
designersseem to have selectedthe number of legibility. We choseto use the seriesof ten 5 x 4
lettcrs pt:r row und spacing arrangcmentsfirr non-serifedletters which were adopted in 1968
irrclevant aesthetic reasonssuch as having the by the British Standards Institution. rz
rows of letters of equal length. Number of letters. Each row has the same
In the clinical measurementof visual acuity number of letters. We chose to use 5 letters per
with letter charts it is not uncommon to use ro\^r.
nonstandard testing dietances.This procedure Letter spacing. The between-letterspacingis
becomesnecessarywhen the visual acuity of the equal to 1 letter-width (i.e., equal to 4 stroke
examinee is not sufficient to permit reading of widths).
the largest letters on the chart at the standard Row spaung. The between-row spacing is
distance; the viewing distance is then reduced. equal to the height of the letters in the smaller
Nonstandard viewing distances are also used row (this is almost exactly equal to the width of
when the luyout of the examination nxrm does the letters in the larger row).
not readily lend itself to viewing the chart from Size progression. The progression of letter
the standard distance. sizesfollows a geometric progressionwhoseratio
Despitc severalrecommendationsto the con- or multiplier is equal to 10r,40 (0.1 log unit or
trary, many currently used charts have very 1.z'8e).
irrcgular progressionsof letter size. With such Range of sizes. This chart is designed for a
charts, a change in viewing distance can intro- standard testing distance of 6 m; at this dis-
duce very significant changesin the scalebeing tance the largeet letters have stroke widths
used, and this may significantly affect the score subtending 10 minutes of arc, and the smallest
obtained. For example, consider a common letters have stroke widths subtending 0.5 min-
chart having letter sizesof 60, 30,24,18,15,9, 6, utcs of arc. The visual acuity range measurable
and 4.5 m (200, 100,80, @, 50, 40, 30, 20, and 15 from this standard distance, therefore, is 6/60 to
ft). A visual acuity scoreof 6/60 (20/2ffi')will be 6/3 br 20/2W to 20110).There are 14 rows of
obtained when the subject reads the ttl60 (20/ letters.
200) letters but fails ro read the 6/30 (201100) Scale notation. The rows of the chart are
letters. If the same subject were to be tested at labeled with visual acuity ratings that relate to
:l m ( l0 ft), it might be expectedthat the acuity the standard viewing distance of 6 m. On one
score would be 3/30 (10/100).However, all that side of the chart, the visual acuity ratings are
is requircdin ordcr to be cunsistentwith tho 6 m given as the logarithm of the minimum angleof
(20 f't) scoresis that the acuity be worse than resolution (logMAR), which is the logarithm to
3/15 ( 10/50)and at least as goodas 3/30 ( 10/100). the base10ofthe angular subtenseofthe stroke
Because<ll the change in scale which has oc- widths at 6 m. This scale exactly indicates the
curred with the change in viewing distance, sizesof letters on the chart. On the other side of
there are 3 scoreswhich could be obtained by the chart, the visual acuity ratings are
this subject. They are 3/30, 3/24, and 3/18 (10/ expressedin the traditional Snellen notation;
100, 10/80,and 10/60). for convenience,some of the denominators of
Many of the disadvantagesof currently avail- the Snellen "fractions" have been rounded.
able letter charts can be overcome,and addi- In Fig. 1, it can be seen that the 3 smallest
tional advantages can be derived from having a rows have not been labeled for size. Continuing
test chart design in which: (a) the test task is the labeling to this level would have meant
742 AM J OPTOM & PHYSIOL OYTICS V o L 5 3 ,N o .1 I

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Ftc. l. New visual acuity letter chart.

either crowding of the labels or making the sary to test visual acuity at nonstandard dis-
labels applying to those 3 rows smaller. It tances.
should, however,tle <lbviousthat continuingthe In order to maintain equivalenceto the stand-
chart to beyond the 616 (20/201 logically ard testing situation, the nonstandard viewing
requires the next 3 rows to have visual acuity distance should be chosen from a geometric
ratings of 6.418,6/3.8,and 6/3 (20/L6, 20/L2.5, progression which is based on the standard
and 20/10)on the Snellenscale,and .0.1, 0.2, distanceand which has the same multiplier or
and -0.3 on the logarithmic scale. ratio as the progressionof letter sizes.For this
Chart slze. The chart is approximately 80 cm chart, with its progression of letter sizes in
high and 75'cm wide. These charts have been 0.1-log unit steps, the sequenceof optional
lrrinted on matte white cards, and some have testing distances follows the progression in
been printed on translucent white plastic meters:6, 4.8,3.8,3.0,2.4,1.9,1.5,etc. (in feet:
sheets. 20, 16, 12.5,10,8, 6.3,5, etc.). It shouldbe noted
Fig. 1 showsthe Snellennotation scalebased that this sequenceis a factor of 10different from
on u testing distance of 6 m. I'or clinicians the letter size sequence(60, 48, 38, etc., or 200,
whose usual practice is to use the decimal 160,125,etc.) which is labeled on the chart and
notation or the Snellen notation in feet, the can thus serve as a remi4der to the clinician.
chart labeling can be converted according to When the testing distdnce is reduced from 6
Table 1. Where decimal notation is used, it is m (20 ft) to 4.8 m (16 ft), which is four-fifths of
advisableto have additional labeling so that the the standard distance, there is a 25% (almost
visual acuity ratings are given in both decimal exactly 0.1 log unit) increasein the angular size
and Snellen form. of all letters on the chart. This createsa l-row
shift so that the examineewill be able to read I
NONSTANDARD TESTING DISTAhICES additional row on the chart. Similarly, moving
Becausethe chart has essentially equivalent in a further step of four-fifths to 3.8 m (12.5ft)
test tasks and a logarithmic size progression,it allows reading of 2 rows of letters more than
has special advantageswhen it becomesneces- would have been read at the standard distance;
Nouember, 1976 New Visual Acuity Chart-Bailey snd Louie 743
Tenue l. Conversionof the IogMAR and &m Snellen the chart (6/6, 6n.5, etc., or 20/20,20/25,etc.).
notations, shown on the new chart, to 20-ft Snellen To provide a further example, a visual acuity
and decimal notations score of 2.41ffi $/?ffi') will be equivalent to
Snellen
6/150 (or 20/500).
Snellen
IogMAR (6 m) (20 fr ) Decimal

LOGARITHMIC SCAI.E
1.0 6/ffi 20/2M 0.10
0.9 6/48 20/rffi 0.r25 The adjustment of visual acuity scores to
0.8 6/38 20/126 0.16 account for the nonstandard viewing distance is
0.7 6/30 20/rN 0.20 very much simplified by working with the
0.6 6/24 20/N 0.25 logMAR scale.For each0.1-logunit reduction of
0.5 6/r9 20/63 0.32 viewing distance there is an 0.1-logunit increase
0.4 6/r5 20/3{J 0.40 in the angular subtense of all letters on the
0.3 6/12 n/40 0.50 chart. Consequently, it becomes necessaryto
o.2 6/e.5 20/32 0.63 adjust each of the logMAR ratings for rows of
0 .1 6n.5 20/25 0.80 the chart by 0.1. For erample, when viewing
0.0 6/6 20/20 1.00 from a distance of 2.4 m (8 ft), a correction
-0.r 6/4.8 n/rc L.25 factor of 0.4 log units must be added to each of
-o.2 6/3.8 20/12.5 r.60 the logMAR ratings as labeled on the chart; the
-0.3 6/3 wrc 2.00 row of letters labeled logMAR = 0.0 now
acquires a logMAR rating of 0.4, 0.1 becomes
at 3 m (10 ft), it is 3 extra rows; at 2.4 m (8 ft), 0.5, and so on, up to the largest row whose
it is 4 rows; at 1.9 m (6.3 ft), it is 5 rows;at 1.5 labeledlogMAR rating of 1.0is adjustedto 1.4.
m (5 lt), it is 6 rows; aL 1.2m (4 lt), it is 7 rows; When a logMAR rating of visual acuity of
and so on. grcater than 1.0 is obtained, it is dealt with by
Some clinicians prefer to denote visual acuity recalling that 1.0 log unit is equivalent to a
as the Snellen acuity scores expected at the factor of 10 times, and 2.0log units is equivalent
standard distance rather than Snellen "frac- to a factor of 100 times. As an example: a
tions" which have nonstandard "numerator€." subject reading the row labeled logMAR - 0.9
It is a relatively simple matter to make the when the chart is at a distance of 2.4 m
conversionfrom a nonstandard Snellen "frac- (correction factor 0.4 log units) will obtain a
tion" to the equivalent Snellen score for the visual acuity scoreof logMAR = 1.3; by refer-
standard distance. Consider an examineewho, ring to the standard labeling of rows on the
when tested at 2.4 m (8 ft), can read the row chart, it is seenthat logMAF[ = 0.3 is equivalent
labeled 6119(20/63);his visual acuity would be to Snellen 6/f2 (Snellen20/40or decimal 0.5);
recordedas2.4/19(8/63).The examiner is aware logMAR = 1.3 represents an acuity which is
that the testing distance is 4 incremental steps worseby a factor of 10times and so is equivalent
closerthan standard and that the examineewill to Snellen 6/L20 (20/400or 0.05).
therefore be able to read letters which are 4 When using the logMAR scale and reduced
incremental steps smaller t,han those which working distancesin this manner, it is particu-
would have beenread at the standarddistance. larly easy to convert back t<l the more familiar
Accordingly, the examiner counts up 4 steps Snellenor decimal notation. There is no needto
larger than the threshold row of letters and refer to tables, sinceall the relevant information
determinesthat, in this example,the equivalent is given by the scalelabeling on the chart. Some
acuity score for the standard distance is 6/48 examplesare presentedin Table 2.
(20/160).
When applying this method to measurevisual DISCUSSION
acuities which are less than 6/60 (201200),the
'l'he letter chart described here introduces
examiner rnust be aware that |,he sequenceol
visual acuity scores that are less than 6/60 new design principles. The most basic principle
(n/zCo) follow the pattern 6fi6,6/95, 6/120, is that the visual acuity task for all letter sizes
6/150, etc. (201250,20/ 320,20/ 400,20/ 600,etc.). should be practically the same and should
Again, it is not necessaryto commit this pro- remain so when nonstandard viewing distances
gressionto memory because,apart from being are used. Consequently,the only chart design
different by a factor 10, it follows the same parameter likely to influence the measured
sequenceas the visual acuity scoreslabeled on visual acuity score is letter size.
744 AM J OYTOM & PHYSIOL Of|TICS V ol .53,N o. 1I
Treta 2. Examples strowing application of a logarithmic distance "correction factor" arrd,conversion of the
conected logMAR score to Snellen or decimal notation
The "correction factor" f(rr a particular l,estingdistance indicates [he magnitude (in logarithmic units) of the
change in angular size resulting from the change from the standard test distance. When an eraminee reade to
hie threshold level on the chart, note is made of the logMAR label applied to the row of letterg which can just be
read. To this "chart score" ie added the "correction factor." The sum of the chart scoreand correction factor
is
the corrected VA Hcoroexprossodus the logaril,hm of the minimum angle of recolution. Using procedures
described in the text, the corrected IogMAR score can easily be converted to Snellen or decimal notation.

Cuue Cuse Cuce Cuse Case Case


ABCDEF
Viewing distance
Meters 4.8 2.4 1.5 0.95 0.38 7.5
Feet 168 D 3.2 1.25 26
CorroctioulucLor 0.1 0.4 0.6 0.8 r.2 -0.r
Chart score-logMAR 0.4 0.9 0.8 1.0 1.0 0.0
Corrected VA score-logMAR 0.5 1.3 1.4 1.8 2.2 -0.1
Equivalent Snellen
Metric 6/19 6/120 6/150 6/380 6/950 6/4.8
Feet 20/63 20/400 n/500 nllzffi n/320/J_ 20/16
Decimal 0.32 0.05 0.04 0.016 0.0063 t.25

An advantagewhich derives from this princi- ensure adeqtrate focus; it might also become
ple is realized when a penpn attempting to read necessary to pay special attention to the ef-
a nowof near-threshold letters is not able to read fects of obliquity of viewing.
all letters correctly. In such situations, examin-
ers generally record such partial success by ACKNOWLEDGMENTS
recording a score such as 6/30 + | or 6/15 - 2. This work u)oa supported by the Natiorwl
Unlike the situation with existing charts (with Health and Medical Research Council of Aus-
different numbers and legibility of lettens on a trulb Gront 72/4719 owarded to lan L. fuilet
row), the addition of such a suffix to a visual ard by the Assocbtion for the Blind, Mel-
acuity score on the new chart carries the same b ourne, Austrulia Resq,r ch S cho larship ow arde d
meaning in terms of qualifying the visual score to Jon E. Louie.
at each level of the chart. With 5 letters in all
rows there is no need to use a suffix outside the REFERENCES
range -2 to +2. 1. Bennett A. G., Ophthalmic test types, Br. J.
The other major priniciple is that there Physiol. Opt., 22: 238-271,1965.
should be a logarithmic size progression in 2. Snellen, H., Letterproeven tot Bepaling der
conjunction with the standardizing of the test Gezigtsscherpte(P.W. van der Weijer, Utrecht,
task. It is only when these 2 features are 1862),cited in Bennett, A.G., Ophthalmic test
combined that it becomespossible to utilize a types, tsr. J. Phyriol. Opt., 22: 238-271,1965.
3. Green, J., Notes on the clinical determination of
wide variety of testing distanceswith the assur-
the acutcneesof vision including the construction
ance that valid and consistentacuity scoreswill and graduation of optotypes, Tlanb. Am.
be obtained. Reducing the testing distance is Ophthalmol. Soc., 10: 644-654,1905.
particularly useful in casesof low vision, where 4. Sloan, L. L., New charts for the measurement of
this new chart permits reliable grading of visual visual acuity at far and near distances, Am. J.
acuity in fine stepson scalesthat are continuous Ophthalmol., 48: 807-813,1959.
and consistent with the scaling that is used to 5. Ogle K. N., On the problem of an international
measurebetter visual acuities. Flexibility in the nomenclature for designating visual acuity, Am.
.J. Ophthalmol., 36: 909-921,1953.
choice of viewing distance provides a means of
6. Deutche Normen, Sehscharfebestimmung,DIN
validating scoresof visual acuity, and this can
ffi 2n Bl 1,3, Beuth-Vertrieb, Berlin, 19?4.
be useful in detecting nralingerert. In some 7. Coates, W. R., Visual acuity and test letters,
cases of unusually poor acuity, very small Ttans. Inst. Ophthalmic Opticians, lll, lggb,
testing distances becomenecessary,ind it may cited in Bennett, A. G., Ophthalmic test types,
be appropriate to introduce convex lenses to Br. J. Physiol. Opt., 22:238-2?1, 1965.
Nwember,Ino NcutVbwI Aeuity Chst ,Eailey arlldLoub 745
E. Woodruff,E W., Vi.ualacuityend therrlcctionof man, Vburl rrdutbn rrd mtour intrnction, J.
tat lcttsn h SomeRsscntAdvrnco in ODhthrl- Opt. tloc. Am.,68: 1026-l(82,1968.
mic Opticr. london, Hatton Prclrb l9{?, citcd in f2. Britirh gtanderd, Tod chrrtr fc detaruining
Brnnett" A. G., Ophthrlmic tolt typca Br. J. dirtrnc virud rcuity. B$l {!ll,l: 190E.Iandon,
Pbpiol. Ogt., %2:238-Zl1,1966. Bdtid St dtdr In$ihtion" 1968.
9. Burian, H. M., Patlrophyriologic b!!is of
amblyopie and itr trcltmont, Am. J. Ophthal-
mol.,8ll: 1-12,lS. ATI1UOB'8 N}DBE88:
f0. YourUron,R M., Anonrly invinralecuitytrtins Iut L. tuW
in children, Br. J. Ophtbrlmol., 50: 16E-U0, Sclroofof Optonpny
rfl6. Wril,elaity 4 Cdifntu
ll. Flom, M. C., F. W, Wcymouth,and D. Kehno- Mtchi, Calilarin Ufn

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