Lecture 12, 13 - Prescribing Magnification Flashcards
Steps for prescribing LVA’s for distance tasks:
• Measure BVA
• Think about TA:
- TV ~ 6/18
- Street signs < 6/12
• Calculate magnification, Try predict M, Modify from there
• Decrease viewing distance
• Lva (Monoc/Binoc?)
- VA < expected: Focusing? Baseline VA/M calculation correct? Scotoma? Cosmesis?
- VA as expected: Trial LVA, Give instructions + check up
Factors affecting baseline VA:
• Illumination
- Rod monochromatic: better acuity in dim illumination
- Retinitis pigmentosa
- Media opacities
• Visual field status
- Peripheral field loss may result in inability to see larger targets but good response to see smaller ones
- Central scotoma may require eccentric viewing, isolation of optotypes (crowding)
• Measurement techniques
- Patient & practitioner motivation is important
- Different acuity charts may give different VAs, depending on:
* Contrast, (e.g. projector, computer vs printed charts)
* Crowding (number of optotypes and lines etc)
* Testing distance
Contrast sensitivity and contrast reserve:
• Ability to read fluently or scan a visual scene quickly depends on contrast reserve
• CR is the ratio between Px contrast threshold (min cont) and targets contrast (e,g book or TV)
- Optimum contrast reserves are 20:1 while min req for reading is 10:1
• Testing a Px’s CS will help defide if light enhancement (>6%) or contrast enhancement (>4%) would be beneficial
Field loss and scotomas with ARMD:
• Scotoma, which are extremely common in ARMD, reduce VA but also affect the accuracy and efficiency of eye movements. Poor eye movement control reduces the ability to scan a visual scene quickly and affects reading speed and reading comprehension
Calculation for distance magnification:
• Snellen notation : M= TA/BVA
I.e BVA = 6/60, TA = 6/12
(6/12)/(6/60)= 5x
• Logmar : M = (1.25)^Number of steps
- Each step = 0.1log unit
Options available for improving distance vision:
- Spectacle lenses
- Contact lenses
- Coatings & tints
- Telescopes
- Multiple pinhole lenses
What steps are done after magnification need has been established?
• Focus LVA yourself for appropriate distance
• Ask patient to locate and read chart
• Show them how to optimise focus
• Note handling ability, reaction to FoV and cosmesis
Management strategies for near vision:
• Same for near as for distance.
- Calculate Magnification
- Try predict M/modify
- Chose LVA for task
- Trial
• “Divide by 3 Rule”
- Distance Va = 6/X near VA should be : (X/3) at 25cm (eg 18/3= N6)
Reasons for not using the “Divide by 3 rule”
There are good reasons for not using only distance VA:
While this may sometimes work there are good reasons for NOT using distance acuity to determine near magnification needs:
- Accommodation at near
- Pupillary constriction at near
- Lighting at near maybe different
- Myopia at near (retinal image size greater without Rx)
- Corneal or lens opacities
• It is always more accurate to use near acuity chart then calculate mag using this at 25cm
Examples of near vision notations:
• Point System - N point
Example:
N6 (‘near vision standard test 6 point) at
33cm
• Sloan M-notation
Example:
0.8M
• Keeler A chart (LogMAR chart)
Example:
A2 (5’ * 1.25 = 6.25 armin at 25 cm)
• logMAR near charts
Example:
0.5 logMAR
Near VA testing procedure:
As with distance VA, assess near VA:
• monocularly and binocularly
- fogging or occlusion required?
- different levels of illumination affect VA?
-difference between letter VA and text VA?
• Well designed near chart combines long + short words which are unrelated
- If this proves too difficult can use words that are related but have constant crowding
• Always record near vision with best N Rx, with LVA’s. Record chart type, viewing distance, eccentric viewing position and illumination
Determining near target acuity
• Estimated : Newspaper print is N8, While books N10
• Otherwise can measure letter sixe snd convert into N point or Logmar
• “Rule 144”: Count number of letters/spaces in 1 inch of text, Divide into 144 for N point
How is magnification calculated for Near VA: (N point notation)
• When TA/BVA have been determined:
- M = BVA/TA
Example:
BVA = N32 @ 25cm
Required for newsprint = N8
M = N32/N8=4x
The equivalent viewing distance:
• The viewing distance between Without LVA (i.e 25cm) and with LVA will decrease in proportion to magnification
- i.e 4x mag = 6.25cm Equivalent viewing distance
• This is the same as the focal length of the magnifier
Magnifier calculation for Log MAR:
• Magnification = 1.25^Number of steps
Example: BVA = logMAR 1.2; TA= logMaR 0.6 = 6lines
So Mag = 1.25^6=4x
Reading Rate (RR) Depends on:
• Type & difficulty of text
- Newspaper 400-600 wpm
- Stories 300-400 wpm
- Textbooks 240-300 wpm
• Age & education
• Visual acuity /Print size
• Viewing conditions
Fluent reading: 100-150 wpm
Spot reading (price labels, phone numbers): 40wpm
Acuity reserve:
• Acuity reserve is the ratio of print size that the patient can read fluently, compared to the threshold print size that the patient can just resolve (text VA):
• For Fluent reading, the print size must be above threshold level
Example:
Px can just see N6 but reads N12 print fluently. AR = 12/6 = 2:1
Calculating magnification based on AR and RR?
- Magnification requirement based on an assumed ‘fixed’ acuity reserve
- Magnification requirement and acuity reserve are calculated individually
- Magnification can be calculated
- Magnification requirement based on an assumed ‘fixed’ acuity reserve
- Magnification requirement and acuity reserve are calculated individually
• When RR insufficient
1. Va assessment: Establish threshold acuity at known distance
2. RR assessment: C habitual near Rx, a text reading chart. The Px reads sentences out aloud + time taken to record. RR is calculated:
- RR (wpm) = (Correct characters - errors made) x 60 / Reading time (s) x 6
- CPS can then be established
- Magnification can be calculated
• Required EVD = TA/CPS x Current Viewing distance
When are monocular aids chosen instead of binocular aids:
• Very close working distance → too high a convergence demand
• Limited aperture of high-powered lenses
• Limited convergence of binocular telescopes
Types of aids to consider for improving near vision:
• Hand held magnifiers
• Stand magnifiers
• Spec-mounted magnifiers
• Telescopes/ Telemicroscopes
• EVES
If near magnifier doesn’t produce expected VA, what do you check?
- focused correctly
- positioned correctly
- baseline VA measurement is correct
- lighting is adequate
If no magnification achives require VA what may the Px have?
• Central scotoma
• Poor contrast sensitivity
Other reading tests:
Some Px may not enjoy reading even if good speed and suf mag + good acuity has been achieved. Therefore other tests can be used:
• Low vision reading comprehension test: Based on Close procedure (identifies comprehension problems)
• Pepper visual ills for reading test : Word length increases and spaces decrease towards bottom of chart
Px Instructions and follow up:
• Important to instruct px which aid and which eye to use to make sure they understand working distance
• Px dont know how to clean magnifier + change bulbs/battery
• Follow up shld be 2-6 weeks
Questions asked during follow up
• Have you been able to use the aid?
• How long/often?
• What for?
- Is it suitable for the intended use?
- Have requirements/priorities changed or been added?
• What spectacles did you use?
• “Show me what you have been doing?”
• Are there any problems using it?
- May need a different aid?
- Extra training/instruction?
- Non-optical aids? Lighting?
Main types of Lv Aids and their Rx to be used:
• Telescope: Distance
• Hand held magnifier: Distance (sometimes near)
• Stand magnifier: (Near)
• Spec mounted plus lens magnifier: Distance if clip on; otherwise take Rx into account
