VISUAL ACUITY AND REFRACTIVE ERROR EVALUATIONS

VA TESTS
Infants and toddlers
1. Effective communication skills
2. Objective tests
3. Behavioural responses:
a. OKN
b. Stycar balls
c. Binocular fixation patterns
d. VEP
e. VOR
Young children
1. Forced preferential looking (TAC)
2. Broken wheel
3. HOTV
4. LEA symbols
OKN
Definition
Movement

Reflex
optokineti
c in
neonates
Mature
Optokineti
c
VA

Response to motion of large visual field

Alternating slow phase eye movements with fast phase (saccadic
like) eye movements
VOR works with OKN to stabilize eye position against head rotation
Slow phase:
Occurs in same direction as field motion
Almost same velocity as field (should be slow or moderate)
Stabilizes image of field at retina, allowing for clear view of field
Fast phase:
Occurs opposite to direction of field motion
Allows for resetting of eye position so that additional slow phases
can occur
Follows responses to large, moving, patterned fields
More easily evoked in neonates than pursuit responses to small
isolated target
May be due to size of target and immaturity of fovea
Responds to target motion in any direction or orientation
Slow following movements interrupted 2/3x per second by saccadic
refixation in opposite direction
Caution equating + OKN with good vision
Paediatric OKN drum (with animals) is highly effective in gaining
infants attention, but has no correlation with Snellen acuity
Standard OKN drum has theoretical Snellen equivalent based on
distance at which it is held, but renders acuity demand no greater
than gross index of resolution

BV

VEP
Def
Process

Target

Reference
points

Uses

Initially used to determine VA in infants but have been introduced to

evaluate development of binocularity
In px with binocular anomalies, asymmetric OK response exhibited
Childhood strab; monocular cataract/amblyopia
Slow phase has higher velocity in response to nasalward and
downward than to temporal and upward field motion
Asymmetry occurs for monocular stimulation of either preferred
or non preferred eye and is believed to result from deficit of
cortical binocularity
In absence of binocularity, temporal asynchrony between two
eyes inputs results in subcortical suppression of motion signals in
temporal and upward direction
In infants, reflex is fairly robust whether motion is to left or right
Reduced CS affects gain of slow phase response
OKN response becomes symmetric after 3-6 months
Persistence of abnormal reflex after this suggests problem in visual
development

Electrical signal generated in occipital region of cortex in response to

visual stimulation
Elicited at designated time after representation of stimulus
Recoded with EEG-type electrodes and gold cup disks which are
adhered to scalp with electro-conductive gel and gauze
Small region of scalp is cleaned and electro-conductive gel is used to
attach electrode (placed 1cm above inion)
Assesses foveal projections to visual cortex and can be affected by
sharpness of retinal image focus
Largest VEP response indicates best objective refraction and is result
of sharpest retinal image
Cells respond to complex patterns of light thus checkerboard stimuli
works great
Size of checkerboard can be changed to determine smallest size that
can be seen
Oz = active electrode placed 10% from inion
o> most important placement for VEP measurement
Fz = reference electrode placed 30% from nasion to inion
Cz = ground electrode placed halfway between nasion and inion
Electrodes normally placed according to international EEG guidelines
Due to placement of recording electrodes over occipital cortex,
underlying cortical anatomy and cortical magnification > VEP
primarily assesses foveal projections to visual cortex
Localizing important components of visual function
Predicting development of vision in premature or small for
gestational age infants with generalized delays in motor
development
Amplitude of major positive component of VEP decreases as contrast
or angular subtense of visual stimulus is decreased

Flash VEP

VA

Normal
visual
developmen
t

1.

2.

Clinical
applications

1.
2.
3.
4.

Useful to examine whether there is any cortical reaction to

illumination of retina, especially in px who are:
a. Unable to cooperate (refraction and fixation problems minimized)
b. Poor px compliance
c. Babies and infants
d. Coma or reduced level of consciousness
Amplitude of transient VEP measured for series of grating patterns
Grating patterns defined ito spatial frequency or number of cycles
(light and dark bar) of grating per degree of visual angle
Conversion of grating angle (measure in cycles/degree) to snellen
notation:
Grating with 30 cycles/degree = 1 min of arc of visual angle
(20/20 VA)
Maturation of VEP waveform:
Maturational changes during first 6 months of life
With age, VEP waveform becomes more complex, amplitude
increases and latency of main positive component decreases
Assessment of visual function in infancy
VA
VEP measurement of VA development indicates much more
rapid growth than behavioural methods with FPL
CS
with sweep VEP for low spatial frequency, grating targets
developed rapidly between birth and 10-12 weeks
Stere
Stereoscopically evoked potentials recorded at age
o
10-91 weeks > onset of cortical binocularity precedes
stereopsis
Infants have functional BV cortex by 3 months
CV
Infants at 2 weeks have functional medium- and longwavelength sensitive cones and postreceptical
circuits which relay information to visual cortex
Infants at 5 weeks have functional short wavelength
sensitive cones
Behavioural measurements of colour discrimination
indicate development of CV occurs later
Determination of refractive error
VEP in amblyopia: CS
VEP in amblyopia: VA
VEP in clinical populations:
Px with visual impairment and multiple disabilities
Albinism
Cortical blindness
Delayed visual maturation

Preferential Looking