Visual Assessment CH18

Question 1

Which of the following is the standard test done on virtually every patient at every
visit?
a) pupil evaluation
b) slit-lamp exam
c) visual acuity
d) tonometry

Answer 1

c) Visual acuity evaluation is the most basic of tests in any eye care office.

Question 2

The standard testing distance of 20 feet is used to test visual acuity because:
a) this is the distance at which the letters subtend 5 minutes of arc
b) this is the length of most eye exam rooms
c) this relaxes accommodation
d) this stimulates accommodation

Answer 2

c) Accommodation is stimulated, in part, by diverging light rays (ie, light rays leave an
object and spread outward as they travel; the closer an object is, the more sharply the light
diverges before reaching the eye and accommodation is stimulated). We do not wish the patient to accommodate during distance testing. Light rays are nearly parallel at 20 feet, so this was selected as a practical testing distance.

Question 3

The figures on an eye chart or acuity card—whether letters, numbers, symbols, or
pictures—are known as:
a) Snellens
b) optotypes
c) points
d) Allens

Answer 3

b) Visual acuity testing figures are called optotypes.

Question 4

The top number (numerator) of the notation “20/20” means:
a) the size of the optotypes
b) the vision of a “normal” eye
c) the test distance
d) the patient’s acuity

Answer 4

c) The upper number (numerator) of the standard “20/20” fraction stands for the test distance.

Question 5

The bottom number (denominator) of the notation “20/20” means:
a) the normal eye can recognize optotypes of this size from 2 feet away
b) the normal eye can recognize optotypes of this size from 20 feet away
c) an acuity quotient of 1%
d) the testing distance is 1 foot

Answer 5

b) The test distance is the standard 20 feet (the numerator). The denominator (bottom number) is the distance at which someone with normal vision can correctly recognize optotypes of this size. Thus, 20/20 denotes an eye that can see “normally,” or what the normal eye should see from 20 feet away.

Question 6

A visual acuity of 20/20 or better (corrected or uncorrected) indicates all of the follow-
ing except:

a) the media are clear
b) the optic nerve is functioning properly
c) the fovea is being used for fixation
d) the rod cells are functioning normally

Answer 6

d) Visual acuity tests the cone cells, not the rods.

Question 7

A person with 20/80 vision:
a) sees at 80 feet what the normal eye can see at 20 feet
b) sees at 20 feet what the normal eye can see at 80 feet
c) can see better than 20/20
d) has a refractive error

Answer 7

b) The person with 20/80 vision sees at 20 feet (the test distance, numerator) what a person with normal vision can see from 80 feet away (the denominator). Thus, the patient with 20/80 vision has to be 60 feet closer to the optotype than someone with normal vision, before he or she can correctly identify it. The patient may have a refractive error, but sub-normal vision can have many causes.

Question 8

The patient’s acuity is noted to be 10/40. This indicates:
a) a test distance that is one-fourth of normal
b) a test distance of 40 feet
c) a test distance of 20 feet
d) a test distance of 10 feet

Answer 8

d) The numerator (top number) always refers to test distance; thus, 10/40 indicates a test
distance of 10 feet.

Question 9

A visual acuity of 20/15 means that:
a) the patient was 15 feet away from the chart
b) the patient missed five of the optotypes
c) the patient could not see 20/20 optotypes
d) the patient’s vision is better than 20/20

Answer 9

d) A visual acuity of 20/15 means that the patient sees at 20 feet what the normal eye sees at 15. Thus, the normal/average eye has to get 5 feet closer before it can correctly identify the optotypes. Having vision better than 20/20 is sometimes called “super vision.”

Question 10

A vision of 15/20 is tested how far from the target?
a) 0.5 feet
b) 10 feet
c) 15 feet
d) 20 feet

Answer 10

c) The numerator indicates the test distance; thus, the patient was 15 feet from the target or chart.

Question 11

The patient’s acuity is noted to be 5/200. Convert this to a standard “20/X” acuity
notation.
a) 20/40
b) 20/400
c) 20/800
d) 20/1000

Answer 11

c) Remember how to change a fraction: If you multiply (or divide) both the numerator and
denominator by the same number, you keep the correct ratio, and the fractions are equal.
The conversion looks like this: 5/200 = 20/X
You can see that if you multiply the first numerator (5) by 4, you will get the desired
20 numerator. Thus, you must also multiply the denominator (200) by 4. This means that
X equals 800 and the answer is 20/800.

Question 12

The illumination in the examination room during the distant acuity test:
a) should be no less than half of the chart’s illumination
b) should be no less than one-fifth of the chart’s illumination
c) should be increased
d) should be turned off

Answer 12

b) The illumination in the room should be no less than one-fifth of the illumination on the
chart.

Question 13

Which of the following is an inadequate occluder?
a) near vision card
b) 3 × 5 index card
c) eye patch
d) patient’s hand

Answer 13

d) The only adequate occluder is opaque with no openings for peeking. A patient using his
or her hand might peek between fingers.

Question 14

A patient should be told not to squint during the acuity test because:
a) squinting will give a falsely low acuity
b) squinting will give a falsely high acuity
c) squinting will make the pupil enlarge
d) squinting will make the pupil smaller

Answer 14

b) Squinting acts like a pinhole and, thus, may improve the vision. In visual acuity testing,
we want the measurement to reflect the patient’s usual vision, so no squinting allowed!

Question 15

Which of the following acuity tests is appropriate for an illiterate patient?
a) Snellen letters, numbers, and pictures
b) Snellen letters, Sheridan Gardner test, and numbers
c) Snellen letters, E game, and numbers
d) E game, Landolt C, and sometimes numbers

Answer 15

d) An illiterate patient might be tested with the E game or Landolt C. Many illiterate
patients can recognize numbers. (Of course, pictures might be used, too, but did not appear in a proper answer combination. Be sure to read all items in an answer.) The “functionally literate” can usually recognize letters, but this situation was not identified in the question.

Question 16

All of the following could cause falsely low distance acuity readings except:
a) a fingerprint on the projector bulb
b) smudges on the chart, mirrors, or slides
c) an old projector bulb
d) a laminated acuity chart closer than 20 feet

Answer 16

d) If the testing distance is closer than 20 feet, the letters seem larger, and the patient’s acuity would be falsely high. (A laminated chart was specified because projector-and-mirror systems can be calibrated to account for different testing distances.)

Question 17

The standard acuity chart or projector can produce a falsely high sense of the
patient’s usable vision because:
a) it is low contrast
b) it is high contrast
c) it does not have any contrast
d) it is more accurate than a potential acuity meter reading

Answer 17

b) Because the standard acuity chart has high contrast (absolute black on stark white), the
measured acuity might be falsely higher than the patient’s actual visual ability.

Question 18

The standard Snellen chart may not be adequate for evaluating how a patient really
sees because:
a) it is not as accurate as a visual field test
b) it does not measure macular function
c) the “real world” is a mixture of shadows and contrast
d) it is easy to memorize

Answer 18

c) The standard Snellen chart employs black letters on a bright white background. In other
words, it has high contrast. How much of our world is of such high contrast? Most of what
we see are shades and shadows. Therefore, the Snellen chart may give an exaggerated sense of the patient’s acuity. Low-contrast situations—which are difficult even for a person with normal contrast sensitivity—may be virtually debilitating to a person with low-contrast sensitivity. Cataracts are notable among ocular disorders that can cause this problem.

Question 19

For Questions 19 and 20, use the following eye chart:
EGNUS 20/50
FPEDZ 20/40
OFLTZ 20/30
APEOF 20/25
EVOTZ 20/20

The patient reads “EGNUS” then “PPFOS.” Vision is recorded as:
a) 20/50 + 1
b) 20/40 – 4
c) 20/50
d) 20/40 + 1

Answer 19

a) The patient read the entire 20/50 line correctly, but got only one letter correct on the 20/40 line: 20/50 + 1.

Question 20

For Questions 19 and 20, use the following eye chart:
EGNUS 20/50
FPEDZ 20/40
OFLTZ 20/30
APEOF 20/25
EVOTZ 20/20

The patient reads “FPEDZ, OPLFZ, ADPSP.” Vision is recorded as:
a) 20/40 + 3 + 1
b) 20/25 – 4 – 1
c) 20/30 – 2 + 1
d) 20/30 – 2

Answer 20

c) The patient read the 20/40 line correctly, missed two on the 20/30, and got one right on the 20/25 line: 20/30 – 2 + 1.

Question 21

If the patient cannot read the Snellen 20/400 line until he is 10 feet from it, vision is
recorded as:
a) 20/10
b) 10/400
c) 2/40
d) 10/200

Answer 21

b) If the patient recognizes the letter from 10 feet away, the numerator should be 10, hence
10/400.

Question 22

A new patient’s records have the following: VA cc 20/40 OD, 20/20 OS. Which of the
following is true?
a) The patient’s vision was checked without glasses.
b) The patient’s vision was checked with glasses.
c) The patient’s vision was checked with both eyes together.
d) The patient’s vision was checked with a pinhole.

Answer 22

b) The notation “cc” means with correction.

Question 23

In the same patient as above, which of the following is true?
a) The vision in the patient’s right eye is 20/20.
b) The vision in the patient’s left eye is 20/40.
c) The vision in the patient’s left eye is 20/20.
d) The patient’s cumulative vision is 20/60.

Answer 23

c) The abbreviation OD refers to the right eye, and OS refers to the left eye. Thus, the
patient sees 20/40 in the right eye and 20/20 in the left.

Question 24

If the patient is unable to read the Snellen 20/400 line:
a) vision does not need to be evaluated further
b) a refractometric measurement should be done
c) vision can only be checked with a Snellen chart
d) decrease testing distance until he or she can recognize the 20/400 figure

Answer 24

d) If the patient cannot recognize the 20/400 figure, one option (and the only option offered here as an answer) is to have him or her walk up to the letter until it is recognized. Remember, however, this necessitates changing the numerator to reflect the true test distance.

Question 25

If a patient is unable to read the largest letters on the chart, another option is to:
a) have him or her count fingers at increasing distances
b) switch to an illiterate chart
c) refrain from further vision testing
d) have him or her move further back from the chart

Answer 25

a) Instead of having the patient walk closer to the chart, you could do a count fingers test,
moving further away each time until the patient can no longer count fingers accurately.

Question 26

If a patient is unable to count fingers at 6 inches, the next option is to:
a) record “blind” on the patient’s record
b) do a glare test
c) do a contrast sensitivity test
d) see if he or she can detect hand movement

Answer 26

d) A patient who cannot count fingers at 6 inches is not necessarily blind, nor can he or she see well enough to do a glare or contrast. Find out if he or she can detect hand motion.

Question 27

The hand motion test:
a) should be done by increasing the testing distance after each accurate response
b) should be done by moving the hand 3 inches in front of the patient’s face
c) can be done at any distance from the patient because the distance is irrelevant
d) should be done with both eyes opened

Answer 27

a) If the patient can detect hand motion, move further away until he or she can no longer detect motion. This distance is recorded (eg, hand motion 3.5 feet OD). Each eye is tested separately.

Question 28

Under what circumstances would you use a penlight (or muscle light) to evaluate a
patient’s vision?
a) When he or she has failed to read the Snellen chart.
b) When he or she has failed to count fingers.
c) When he or she has failed to see hand motion.
d) When he or she has failed the glare test.

Answer 28

c) If the patient cannot detect hand motion, the next step is to see if he or she can detect the presence of light.

Question 29

The difference between light perception and light projection is:
a) light perception is the ability to locate the light; light projection is the ability to see the
light
b) light perception vision is better than light projection
c) light perception is the ability to see light; light projection is the ability to locate the light
d) light perception can be done with children; light projection is done in adults

Answer 29

c) Light perception means the patient can perceive the presence of light. In light projection, the patient can detect from which direction the light projects, which is considered a higher level of vision than light perception alone.

Question 30

If the patient is unable to see or locate the light, his or her vision is recorded as:
a) no light perception (NLP)
b) legally blind
c) malingering
d) subnormal

Answer 30

a) Absence of the ability to detect the presence of light is recorded as NLP.

Question 31

When checking a patient’s near vision, it is important to:
a) have the patient wear his or her usual reading glasses
b) have the patient use a pinhole instead of any usual reading glasses
c) remove contact lenses, if worn
d) check both eyes together rather than one at a time

Answer 31

a) A patient should wear his or her habitual reading correction for the near vision test. (Your physician might want a corrected and uncorrected near vision measurement, but that is not offered as an answer here. You have to work with the answers listed.)

Question 32

The patient should be told to hold the near card:
a) at whatever distance gives the best vision
b) at 14 to 16 inches
c) at 1 meter
d) in his or her lap

Answer 32

b) The near card is designed to be held at 14 to 16 inches. (Note: During refractometry, the
near card can be placed at the patient’s preferred distance.)

Question 33

Each of the following represents normal near vision except:
a) 14/14
b) J2
c) N5
d) L1

Answer 33

d) Answers a through c are all normal near-vision acuities. There is no such designation as “L1.”

Question 34

Vision with both eyes together:
a) is never checked
b) is usually slightly better than each eye tested alone
c) is usually slightly worse than each eye tested alone
d) should be checked without correction

Answer 34

b) Vision with both eyes is usually better than with either eye alone. (Of course, there are
exceptions. The word “usually” is your clue here.)

Question 35

If the patient consistently misses the letters on the right side of the chart:
a) this is unimportant
b) he or she should be pressure patched immediately
c) a visual field defect may be present
d) he or she is obviously malingering

Answer 35

c) A visual field defect might cause the patient to be unable to see a portion of the chart.
The patient’s consistency is the clue in this case. While he or she might be malingering, the assumption is that there is a problem until proven otherwise.

Question 36

Your patient informs you that, because you checked her vision at last week’s appoint-
ment, she does not need it checked today. You should:

a) honor her wishes and skip the test
b) explain why vision needs to be checked at every visit
c) write “patient is uncooperative” in the chart
d) tell your physician

Answer 36

b) Taking visual acuity in the ophthalmic/optometric office is like checking blood pressure in the general practitioner’s office. It is done every time, providing a long-term record of the patient’s visual function. Explain this to the patient, and she will most likely cooperate.

Question 37

Visual acuity in a patient with posterior subcapsular cataracts will usually worsen
when tested:
a) in bright light
b) in dim light
c) at near as opposed to distance
d) after being dilated, in dim light

Answer 37

a) A posterior subcapsular cataract can cause visual acuity to plummet in bright light
because the constricted pupil forces the patient to try to look directly through the opacity.

Question 38

It is appropriate to include notes with the visual acuity measurement to indicate:
a) the patient’s attention during the test
b) accuracy of occlusion
c) illumination of the chart
d) illumination of the room

Answer 38

a) It is proper to make noteworthy records of your observations of the patient during testing. This could include the patient’s apparent motivation, attention, or mental capacity. Occlusion must always be accurate, and illumination should be standard with every patient.

Question 39

It is appropriate to include notes with the visual acuity measurement to indicate:
a) the use of contact lenses or low-vision aids
b) how wide open the patient’s eyes were during the test
c) the pupil width during the test indicating accommodation
d) eye redness that might affect the vision

Answer 39

a) It is important to make thorough, accurate notes regarding any correction the patient uses during the visual acuity test.

Question 40

In an ocular emergency, visual acuity should be checked:
a) only after instilling numbing drops
b) only if the patient complains of vision loss
c) in every case
d) on a case-by-case basis

Answer 40

d) While checking vision is the general rule, there might be some cases where the injury is
so severe that visual acuity is temporarily not so important.

Question 41

A malingerer is:
a) a patient who cannot read
b) a patient who cannot verbalize
c) a patient who intentionally and falsely claims to have poor vision
d) a patient who has poor vision due to hysteria

Answer 41

c) A malingerer falsifies his or her responses, generally for some type of gain.

Question 42

The “crowding phenomenon” affects the visual acuity of patients with:
a) astigmatism
b) strabismus
c) amblyopia
d) ametropia

Answer 42

c) A person with amblyopia may have better acuity if optotypes are presented singly. Thus,
a row of optotypes (“crowded”) gives a more accurate acuity.

Question 43

Because of the “crowding phenomenon,” it is best to check visual acuity:
a) in a room with no other people present
b) with both eyes open
c) using isolated figures
d) using a row of figures

Answer 43

d) See answer 42.

ANSWER 42: A person with amblyopia may have better acuity if optotypes are presented singly. Thus, a row of optotypes (“crowded”) gives a more accurate acuity.

Question 44

In checking visual acuity of children, the most important information is:
a) whether or not the vision is 20/40 or better
b) the patient’s vision with both eyes opened
c) any difference between the acuity of the two eyes
d) whether or not the vision in each eye is 20/20

Answer 44

c) It is most crucial to find amblyopia at as early an age as possible, while it is still correctable. So, finding a difference between the two eyes is more important than the actual vision. (An exception might be the child with low vision, but that was not offered as a response.)

Question 45

The presence of vision in an infant may be tested by:
a) noting the child’s reaction to his or her mother
b) noting the child’s reaction if his or her mother leaves the room
c) seeing if the child’s eyes follow a moving light
d) seeing if the child’s eyes follow a squeaking toy

Answer 45

c) If an infant’s eyes locate and follow an object, vision is considered present and noted as “fix and follow.” A squeaking toy will not work because it makes noise. A blind infant will still respond both to the mother and her absence.

Question 46

Which of the following notations means that a 6-month-old infant’s vision is probably
normal?
a) Allen card vision of 10/10
b) fixates on a bright light in dark room
c) searching movements, OU
d) central, steady, and maintained

Answer 46

d) An infant with normal vision will move his or her eye (assuming one is occluded for the
test) to look at an object pretty much straight-on. This is the central component, in that the
child is using central vision, and not looking to the side of the object. The infant should also
look at the object steadily, without searching movements. Fixation should be maintained
even when the other eye is suddenly unoccluded. These components, when present, are abbreviated as CSM. (Note: The Allen cards are inappropriate for a nonverbal infant. In addition, visual tests on infants are usually done in normal lighting.)

Question 47

All of the following are true regarding the preferential looking test (using Teller or
similar visual acuity cards) except:
a) it may be used for any nonverbal patient, infant or otherwise
b) the patient will automatically look at the card with the stripes
c) there is a tendency to underestimate vision with this test
d) the stripes are graded for finer and finer acuity

Answer 47

c) The cards used in the preferential looking test are divided in half; one half is a gray
square, and the other is black with stripes. The cards vary in stripe frequency (ie, the stripes get closer and closer together). The test can be used on any nonverbal patient, checking each eye alone and both eyes together. The card is presented to the patient as the examiner observes through a hole in the card’s center. The patient will automatically look at the striped side of the card, if acuity is intact. The finer the stripes that the patient responds to, the better the acuity. However, overestimation of acuity (not underestimation) can occur, especially where amblyopia is present.

Question 48

A 3-month-old may be tested for amblyopia by which of the following methods?
a) Worth 4 dot testing
b) rating central, steady, and maintained
c) preferential looking technique
d) stereo testing

Answer 48

c) Of the tests listed, only the preferential looking technique can be used to diagnose
amblyopia in an infant. While the preferential looking technique does not give an actual
acuity level, it can identify a difference in acuity between the two eyes, which strongly
indicates amblyopia. Rating an infant’s vision as central, steady, and maintained is not useful in this case; even an eye with poor vision can maintain steady, central looking.

Question 49

A 6-month-old baby continues to look at you happily if you cover her right eye. If you
cover her left eye, she becomes distracted and tries to move away from the cover. This
may indicate:
a) vision is equal in both eyes
b) vision is better in the right eye
c) vision is weaker in the right eye
d) vision is weaker in the left eye

Answer 49

c) The child will not want her only good eye covered, and she loses concentration when you cover the left eye. She will not care if you cover the weak right eye.

Question 50

In the patient above, an appropriate notation of her vision would be:
a) prefers OD
b) prefers OS
c) covers OS easier
d) vision steady and maintained

Answer 50

b) The child prefers to use her good, left eye.

Question 51

When checking vision in young children, it is important to:
a) move quickly, because they get bored and tired
b) move slowly, because they take longer to understand
c) move slowly, so they are not tempted to malinger
d) stop if the child seems tired

Answer 51

a) Speed is the name of the game when working with kids, who tire and bore easily.

Question 52

Which of the following are the earliest and easiest letters recognized by children?
a) HTOV
b) ABC
c) XYZ
d) EGK

Answer 52

a) Children most often learn and recognize the letters HTOV first.

Question 53

When teaching a child the E game for the first time, it is best to:
a) send an E card home and let the parents practice with the child
b) practice with the child for 20 minutes prior to the real test
c) disregard the first acuity taken
d) tell the child how important it is that he or she do well

Answer 53

a) Let the parents work on the E game at home. A 20-minute practice session will wear the child out before the test is ever done! Answer d puts pressure on the child. Disregarding the first acuity will not work—how do you know when the acuity is accurate?

Question 54

Clinically, amblyopia is diagnosed when the:
a) best-corrected vision of each eye differs by two or more acuity lines
b) best-corrected vision of each eye differs by four or more acuity lines
c) uncorrected vision of each eye differs by four or more acuity lines
d) patient cannot appreciate binocular/stereoscopic vision

Answer 54

a) If the eyes are best-corrected and there is a difference of two or more acuity lines in the
vision of the eyes, the diagnosis is amblyopia. An amblyopic patient will do more poorly
on or fail the stereo test, but so will other patients with other eye problems.

Question 55

Which of the following is appropriate when testing a preschooler for amblyopia?
a) single Allen cards
b) isolated projected figures
c) a full line of figures
d) single Es

Answer 55

c) An amblyopic eye can identify figures more easily if they are isolated than if they are
presented in a group. This is called the crowding phenomenon. An accurate assessment of vision on an amblyopic eye can be obtained only by using a row of age-appropriate optotypes.

Question 56

It is best to check an amblyopic eye first, because:
a) the child will object to having the strong eye covered
b) the child will object to having the amblyopic eye covered
c) the child might memorize the chart if the strong eye is tested first
d) it is important to learn if the stronger eye has been occluded

Answer 56

c) While we usually check the right eye first, a patient with amblyopia in the left eye should
be checked left eye first. If you check vision in the stronger eye first, the child might
memorize the optotypes and try to fake you out. Then everyone loses, especially if you have been using patching therapy. He or she may certainly object to having the strong eye covered, but this is no reason to check it first.

Question 57

A disadvantage to the Allen cards is:
a) most children do not recognize the pictures
b) the testing distance must be standardized
c) it is difficult to record
d) it presents single pictures instead of a row of figures

Answer 57

d) Single pictures, as with the Allen cards, may give a falsely high acuity if the patient has
amblyopia (see answer 55).

ANSWER 55: An amblyopic eye can identify figures more easily if they are isolated than if they are presented in a group. This is called the crowding phenomenon. An accurate assessment of vision on an amblyopic eye can be obtained only by using a row of age-appropriate optotypes.

Question 58

When testing the vision of a child with the Allen cards, a difference in the testing dis-
tance of how many feet between the eyes is considered significant?
a) 1 foot
b) 2 feet
c) 3.5 feet
d) 5 feet

Answer 58

d) In Allen card testing, a difference between the two eyes of 5 feet or more is considered
a positive finding for amblyopia.

Question 59

A child should be told what regarding the visual acuity test?
a) “This test will show me how smart you are.”
b) “If you fail the test, you will get to wear glasses.”
c) “The letters will get too small to read, but do the best you can.”
d) “You will have to spend the day here at the office until you cooperate.”

Answer 59

c) Answers a, b, and d are intimidating. Untutored, most kids assume you are trying to find out how smart they are. Let them know ahead of time that nobody sees all the letters. This takes some of the pressure off.

Question 60

If a child struggles with identifying the letters, you should:
a) have the child count your fingers
b) try numbers, rings, pictures, or Es
c) skip the vision test
d) encourage the child to try harder

Answer 60

b) A child may “know” the alphabet (as in be able to sing the “ABC” song), but not be able
to identify letters. Try Es, rings, pictures, or numbers.

Question 61

When checking visual acuity on a preschool child, it is important to:
a) be sure he or she can consistently identify the pictures
b) be sure he or she can have both eyes uncovered
c) use your hand as an occluder
d) check vision at 10 feet instead of 20

Answer 61

a) If the child does not know what the pictures are, how can you test vision? It does not matter if the child calls the horse “doggie,” as long as he or she does it every time. Each eye is tested separately at 20 feet using an opaque occluder.

Question 62

When a small child becomes uncooperative during the exam, it is best to:
a) have the parent leave the room
b) have the parent scold the child
c) push on with the exam to get it done quickly
d) change gears by chatting for a moment

Answer 62

d) If a small child’s patience wears thin during the exam, give him or her a short break. You
might distract him or her with a toy or ask fun questions. (What is your favorite food? Do
you have a cat at home?) Having the parent leave will probably make the child more anxious. Scolding is not indicated unless the child is being downright naughty.

Question 63

When a child responds incorrectly to a test item, the assistant should:
a) tell the child he or she is doing a good job
b) tell the child he or she is not trying hard enough
c) scold the child
d) have the parent scold the child

Answer 63

a) Scolding and shaming are not good ideas. While you would not tell the child that his or
her answer is correct, you can still praise him or her for answering at all.

Question 64

The potential acuity meter (PAM) is commonly used to evaluate macular function in
the presence of:
a) glaucoma
b) retinal disorders
c) optic nerve disease
d) media opacities

Answer 64

d) The PAM transmits a tiny, bright eye chart to the back of the eye, bypassing media
opacities. Its most common use is in evaluating macular function in the presence of cataracts (especially very dense ones where the physician has a hard time viewing the macula directly).

Question 65

Before performing a PAM test, it is important to:
a) set the eye piece
b) enter the patient’s refractive error
c) calibrate the unit
d) have the patient wear his or her best correction

Answer 65

b) There is a knob on the side of the unit where you must dial in the spherical equivalent of the patient’s refractive error.

Question 66

Your patient has cataracts. The surgeon may want a PAM measurement on him or her
if the patient also has:
a) macular degeneration
b) glaucoma
c) dry eye
d) high astigmatism

Answer 66

a) The PAM will help the surgeon know whether the patient’s postoperative vision will be improved enough to make the surgery worthwhile.

Question 67

Which of the following might warrant a PAM test?
a) preoperative posterior capsulotomy
b) preoperative refractive surgery
c) preoperative laser trabeculectomy
d) preoperative laser iridotomy

Answer 67

a) The posterior capsulotomy is treatment for a cloudy lens capsule following cataract surgery. It is a media opacity and thus might warrant a PAM reading prior to the procedure.

Question 68

All of the following are true regarding a PAM test except:
a) the patient should be dilated
b) ask the patient, “Do you see anything?”
c) do not check the pupils just prior to testing
d) position the patient firmly in the chinrest

Answer 68

d) The chinrest is actually moved out of the way so the patient can talk without disrupting
fixation.

Question 69

The target in a PAM is a(n):
a) Amsler chart
b) eye chart
c) set of mires
d) grid pattern

Answer 69

b) The target in a PAM is an eye chart that is projected directly onto the retina, bypassing
moderate opacities in the ocular media.

Question 70

Your patient sees 20/200 without correction in the right eye. You have performed
refractometry and have improved this to 20/40. Which of the following tests could help
you know whether or not this is the best acuity possible?
a) duochrome
b) pinhole
c) PAM
d) contrast sensitivity

Answer 70

b) The pinhole will compensate only for refractive error, not pathology. The refractometric measurement should correct the patient to at least the pinhole vision.

Question 71

Which of the following is not true regarding the pinhole?
a) If vision improves with the pinhole, a refractive error is present.
b) It compensates for media opacities.
c) It can be used if a patient has forgotten his or her glasses.
d) It increases contrast.

Answer 71

b) The pinhole does not improve poor vision caused by opacities in the ocular media.

Question 72

An intelligent, literate patient sees 20/400 without correction, 20/200 with the pinhole,
and 20/200 with correction. The most reasonable assumption is:
a) he or she needs a change of glasses
b) he or she is malingering
c) he or she is uncooperative
d) he or she has some type of ocular pathology

Answer 72

d) The patient sees no better with correction than with the pinhole, so changing the glasses will not help. The residual poor acuity would be due to pathology.

Question 73

A patient is found to have 20/80 without correction, then to have 20/25 with a pinhole.
This would be written as:
a) VA cc 20/80, PH 20/25
b) VA sc 20/80, PH 20/25
c) VA sc 20/25, PH 20/80
d) VA sc 20/80, PH 20/80

Answer 73

b) The notation “sc” means without correction; PH means the pinhole was used.