Examination of Visual Acuity
– Neurologic Examination > Cranial Nerve Examination > Chapter 12
– Examination of Visual Acuity
during the neurologic examination is to determine how well the optic
nerves are functioning.
examination if the patient has any visual symptoms or if the patient is
thought to have a condition that can ultimately affect vision. In the
absence of these situations, it is not imperative to check visual
acuity in all patients as part of a routine neurologic examination.
the eye (anterior compartment and posterior compartment, including the
retina) and the optic nerve. Lesions posterior to the optic chiasm
affect visual fields (see Chapter 13, Visual Field Examination) but do not cause abnormal visual acuity within the intact fields.
In a brightly lit room, have the patient
hold the visual acuity card in one hand, while using the other hand to
keep one eye closed. If the patient needs visual correction for
reading, have the patient use this.
Have the patient hold the card
approximately 14 in. away. (Holding the card at a specific, exact,
distance is not imperative from the standpoint of the neurologic
examination. Have the patient hold the card at a reasonably comfortable
distance, which usually ends up being approximately 14 in. away anyway.)
Point to the 20/20 line on the card and
ask the patient to read the numbers. If the patient is unable to read
the 20/20 line, point to the next higher line until the patient is able
to read most of the numbers correctly. Report this line as the visual
Repeat with the other eye.
most patients with normal optic nerve function should have close to
20/20 vision in each eye.
Visual acuity can be affected by
dysfunction of the eye or the optic nerve. The finding of abnormal
visual acuity despite appropriate refractive correction suggests optic
nerve dysfunction, because most patients with normal optic nerve
function can be corrected with the appropriate lenses to nearly 20/20
for reading. Other ophthalmologic (e.g., retinal) causes of diminished
visual acuity may need to be excluded through ophthalmologic
Patients sometimes need coaxing to read the smallest line that represents their true acuity.
It often helps to shine a bright light on
the card to improve brightness and contrast, allowing demonstration of
the best visual acuity.
If the patient normally uses reading
glasses but does not have them available, the patient’s near vision can
be tested through a pinhole. A pinhole acts like a lens that corrects
the refractive error for near vision of most patients (who have normal
optic nerve function) to close to 20/20, albeit within a small field of
vision. A pinhole can be created on the spot by taking a small piece of
cardboard and making a hole in it with a safety pin. The patient should
be asked to hold this up to each eye and to read the card through the
hole. Try this on yourself (especially if you need correction for
reading) and see how well it works.