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Visual Acuity XL Doc 1.4.1 Final - iOS Apps

1. CURRENT SESSION BASE i gt Eyes Left Right Both A Corrected Yes i Notes your notes here 2012 11 07 00 29 Sloan Test uncorrected LR BoW 20 25 2012 11 07 00 29 C Test uncorrected LR 4BoW 20 20 esse ATAA Daneel unre 206 eras Sa ie N ratos A KONEN ONN amp we The bottom toolbar provides access to additional functions to calibrate the external monitor when the TV Out mode is turned on _ to establish a Bluetooth or WiFi connection between the iPad and another P i iOS device running the optional Visual Acuity Remote app x to customize the settings of the acuity testing acuity units optotype appearance chart type acuity scoring termination criterion and distance units etc s to convert between various acuity units Tii J to export the acuity data through e mail in HTML format or as a database backup file Visual Acuity XL User Guide version 1 4 June 23 2013 10 Configuring the Acuity Testing To configure the test settings tap the icon in the bottom toolbar This opens a popover window with customizable settings Acuit Units Foot Meter Decimal VAR LogMAR CPD Acuity Scoring cme G Termination Criterion Incorrect 3 Letters DECACH Meters S Viewing Distance EPE o ees Standard Acuity 20 20 Optotype Appearance Black on White AROE EF 4 Confusion Bars None Chart
2. White optotypes on black background 4BoW 4WoB C or E optotypes had 4 possible orientations 8BoW 8WoB C or E optotypes had 8 possible orientations Sent from my iPad Check out our iPhone Apps at http iphone kybervision com Visual Acuity XL User Guide version 1 4 June 23 2013 34 While you could use this feature to backup the acuity measurements we recommend using the more powerful Database Backup option instead With this option the acuity data is attached to an email as a backup file with the date time and originating device indicated in the subject line The attached file has an vaxl extension which indicates it has been created with the Visual Acuity XL app Visual Acuity XL User Guide version 1 4 June 23 2013 35 Cancel Visual Acuity XL Database Backup 2012 03 22 15 02 KyberVi To Cc Bcc From Subject Visual Acuity XL Database Backup 2012 03 22 15 02 KyberVision s iPad 2 Find below your database backup file DatabaseBac 15 02 vaxl Sent from my iPad 2 Check out our iPhone Apps at http iphone kybervision com On reception of this email on a computer you can save the attached file for archiving purpose On reception of this email on another iPad you can import the data back to Visual Acuity XL by taping the icon of the vaxl file and selecting the associated Open option ea Lot 1014 bo 4g From Details Visual Acuity XL Database Back
3. adapter supports video mirroring on iPad 2 or iPad 3 and iPhone 4S and video out only on iPad 1st generation iPhone 4 or iPod touch 4th generation Provider http store apple com Price US 29 00 The Lightning to VGA Adapter mirrors exactly what you see on the iPad screen to an external display equipped with a VGA connector TV monitor or external projector This adapter supports video mirroring on iPad 4 or iPad mini iPhone 5 and iPod touch 5th generation Provider http store apple com Price US 49 00 The Apple 30 pin Digital AV Adapter mirrors exactly what you see on the iPad 2 or iPad 3 to a HDMI compatible display TV monitor or external projector This adapter also supports video out for iPhone 4 4S and iPod touch 4th generation Provider http store apple com Price US 39 00 The Apple Lightning Digital AV Adapter mirrors exactly what you see on the iPad 4 or iPad mini to a HDMI compatible display TV monitor or external projector This adapter also supports video out for iPhone 5 and iPod touch 5th generation Visual Acuity XL User Guide version 1 4 June 23 2013 61 Provider http store apple com Price US 49 00 The Apple TV allows you to play content from your iOS devices on your TV using AirPlay The Apple TV also gives you access to the 1080p HD content including movies music and photos and more right on your widescreen TV Apple TV requires one HDMI cable sold separately Provider
4. http store apple com Price US 99 00 Visual Acuity XL User Guide version 1 4 June 23 2013 62
5. Do not try to adjust the monitor or TV settings so the iPad content completely fills the external screen through overscan for example This would affect the aspect ratio of the pixels and make the visual acuity measurements less precise Stick instead to a 4 3 aspect ratio setting if available Various warning messages may be displayed when dealing with TV Out ees Ee j TV Out Detected Connection to an external monitor i detected Do you want to turn on the TV Out mode now if the iPad is connected to an external monitor while TV Out is turned off you will be asked whether to turn it on 4MMAL AM AAAA TV Out TV Out is turned on but no external monitor found Please connect the iPad to an external monitor or turn TV Out off LT Ok if TV Out is turned on with no external monitor connected you will be asked to connect it before being able to perform a calibration or present a chart Visual Acuity XL User Guide version 1 4 June 23 2013 19 1one 001 m TV Out l TV Out is turned off Please disconnect the iPad from the external monitor if TV Out is turned off while an external monitor is connected you will be asked to disconnect it before being able to present a chart e Luminance the luminance of the bright portion of the charts can be specified in cd m only supported under iOS 5 and above otherwise it is set to If Luminanc
6. Type Multiple Lines Single Line Single Letter Mirror Mode TV Out Luminance 85 cam ee e The acuity units Foot Meter Decimal VAR LogMAR CPD Note that the standard acuity is indicated in the selected unit e g 20 20 in foot units e The optotype appearance black letters on white background or white letters on black background the number of orientations only applies to Landolt C and Tumbling E optotypes the presence and type of confusion bars none bars or frame type e The chart type multiple lines single line or single letter e The acuity scoring method simple or ETDRS Note that changing the method selection resets by default some other settings For example selecting the ETDRS method resets the chart type to Multiple Lines and the termination criterion to 3 incorrect letters e The termination criterion for the selected method 1 letter 3 letters or an entire line incorrect for the ETDRS method for example Visual Acuity XL User Guide version 1 4 June 23 2013 11 e The viewing distance and its unit metric or imperial e The mirror and TV Out modes e The luminance expressed in cd m customizable only under iOS 5 and above Acuity Units Visual Acuity XL can measure and report visual acuity in various standard units either as Snellen fractions in foot meter or decimal units as logarithmic scales in logMAR or VAR units or as resolution in cycle per degree CPD Acuit Units Stand
7. either scoring methods can be used in the remote mode Note that since a computerized acuity test has the ability to randomly generate a new chart retesting the same line with different optotypes could be a more efficient way to ensure that the subject error does not result from a false alarm thus the reliability of the simple scoring method can be easily improved by retesting the erroneous line with a new set of optotypes tap the label above the chart to generate a new random one before deciding to terminate the test Managing the Subjects es Default patient Ea The top part of the main panel is updated with the currently selected patient or group specific information whose name is always indicated in the title of the top toolbar The patient or group information includes e Some personal information gender age eye condition e mail and phone number e The eye prescription for glasses and or contact lenses e The history of acuity measurements B Patients EB 9 Default patient m John Doe e The settings for the current session tested eye correction notes Patients List Visual Acuity XL User Guide version 1 4 June 23 2013 29 The patients list is available in the left section in portrait mode and is available through a popover window in landscape mode by taping the Patients button in the top toolbar New subjects can be added by taping the button in the Patients section and entering thei
8. external display through Airplay Mirroring with an Apple TV 1 Before running Visual Acuity XL make sure that your Apple TV can mirror your iPad Connect your iPad and your Apple TV to the same Wi Fi network Double click the Home button on your iPad to display your recently used apps Swipe the recently used apps twice from left to right until you see the AirPlay icon Tap the AirPlay icon to display a list of available AirPlay devices At this stage you should see the following screen on your iPad If you don t then refer to Apple support Apple TV How to use AirPlay Mirroring to troubleshoot the problem eS aa SP Ee ay A Eg 2 Ta DS SE AirPlay LJ iPad C3 Apple TV With AirPlay Mirroring you can send everything on your iPad s display to an Apple TV wirelessly Q000 Visual Acuity XL User Guide version 1 4 June 23 2013 51 To use AirPlay Mirroring select the name of your Apple TV then toggle the ON OFF slider to ON as illustrated below AirPlay GJ iPad C3 Apple TV v Mirroring on With AirPlay Mirroring you can send everything on your iPad s display to an Apple TV wirelessly Sy 0000 At this stage the Apple TV should mirror the exact same screen on the monitor attached to it If it does not then refer again to Apple support note Apple TV How to use AirPla Mirroring to troubleshoot the problem 2 Run and setup Visual Acuity XL After launching Vi
9. it can be indicated independently of the system brightness see above and directly in term of cd m Luminance cd m EEE The iPad should be placed at a well illuminated location that does not bring reflections in iPad screen because of the very glossy nature of the iPad screen it is recommended to install an antiglare screen protector if reflections occur in the experimental environment Keep handy some cleaning cloth for the iPad and remote control screens as they can get easily covered with finger prints and smudges Landscape vs Portrait Mode The iPad can be either used in Landscape or Portrait mode the portrait mode allows the presentation of more acuity lines on the same display while the landscape mode allows the presentation of more optotypes per line for larger optotype size up to 5 Visual Acuity XL User Guide version 1 4 June 23 2013 50 Airplay Mirroring Setup Visual Acuity XL supports TV Out to display optotypes and charts on an external monitor or TV The external display can be directly connected to the iPad using one of the adapters provided by Apple referred as Video Mirroring see Apple support note iOS About Apple AV Adapter compatibility or wirelessly through an Apple TV on the same Wi Fi network referred as Airplay Mirroring see Apple support note Apple TV How to use AirPlay Mirroring Here are step by step instructions to make Visual Acuity XL display calibrated optotypes on an
10. landscape positions perfect for charging and using your iPad as a stylish photo frame No matter what position you re in you always have access to the charging port Provider http www twelvesouth com wri ii Price US 39 99 VOVT O O V The Pad Bracket is a simple system for conveniently mounting your iPad to the wall Your iPad will sit securely in both landscape and portrait orientation Provider http www claywarestore com Price US 24 95 The Wallee is a seamless wall mounting amp hard case system made specially for the iPad No unsightly brackets just a simple disk that mounts and blends seamlessly into any surface Provider http thewallee com Price US 50 00 Visual Acuity XL User Guide version 1 4 June 23 2013 59 Charging The iPad 10W USB Power Adapter lets you charge your iPad directly through an electrical outlet and the 6 foot long power cord allows you to charge it from an even greater distance ej Provider http store apple com P Price US 29 00 The PowerDock Dual lets you charge both your iPad and iPhone iPod touch from a single charging dock Provider http www griffintechnology com Price US 60 00 Connecting to External Display The Apple 30 pin VGA Adapter mirrors exactly what you see on the iPad screen to an external display equipped with a VGA connector TV monitor or external projector This Visual Acuity XL User Guide version 1 4 June 23 2013 60
11. may sometimes distort the geometry of the iPad image by chang ing its aspect ratio It is important to correct for this distortion because the pixels that compose the optotypes have to remain square This can be typically done by specifying a 4 3 ratio similar to the 1024x768 iPad resolution using the configuration menu avail able on your TV set or by adjusting the buttons e g F on the front of your moni tor so the large black square presented on the iPad screen also appears exactly square on the external display Once you have corrected for the geometry distortion tap the Achieved button The external display should then show the 2nd phase of the TV Out Calibration x TV Out Calibration Diagonal Size 40 00 cm Step 2 Measure and report the diagonal size length between the arrow tips Important properly calibrating the external display is a critical step to ensure that the optotypes are displayed at the proper size Failing to do so will make any acuity measurement inaccurate As indicated measure and report the diagonal size of the external display between the 2 arrow tips by editing the Diagonal Size textfield highlighted in red above Tap the red button in the top left corner to return to the main panel when you are done Visual Acuity XL should be now ready to show calibrated charts on the ex ternal display Make sure to carefully follow all the above instructions and setting up Visual Ac
12. single line and single letter The simple method provides an easy and fast way to measure visual acuity though less precise The simple scoring method is the one used in the manual mode the acuity score is the acuity level of the smallest line that can be read without any error The advantages of this method are its simplicity and speed However it has the main disadvantage to be prone to inaccuracy if the patient s responses are unreliable due to other factors than their limited acuity for example due to communication errors or limited recognition and interpretation skills and can lead to erroneously low estimates of visual acuity The ETDRS scoring method developed in the context of Early Treatment for Diabetic Retinopathy Study provides a simple solution to this problem and is the standard way to measure visual acuity in clinical environment the termination criterion is based on several incorrect responses on the same line typically 3 incorrect letters rather than a single one to ensure that the subject has indeed reached their acuity limit Moreover the ETDRS method takes the contribution of each failed letter into account when calculating the acuity scoring in a logMAR design with 5 letters per line and with a difference of 0 1 logMAR units between successive lines each letter contributes for 0 1 5 0 02 logMAR units Visual Acuity XL User Guide version 1 4 June 23 2013 28 Based on the selected termination criterion
13. the normal visual acuity the maximum acuity of a healthy human eye being approximately 20 16 to 20 12 The selected acuity unit in the settings is used by default in all acuity tests Note that a tool is available in the bottom bar to easily convert between the different visual acuity units see button as illustrated below Units Conversion Low Standard Best SNELLEN USA 20 400 20 20 20 10 METRIC UK 6 6 6 120 6 6 6 3 DECIMAL France ED 0 05 1 0 2 0 VAR Visual Acuity Rating 35 100 115 logMAR log10 of 1 3 0 0 0 3 Minimum Angle 00 of Resolution CPD Cycle Per Degree uaee Best Visual Acuity XL User Guide version 1 4 June 23 2013 13 Viewing Distance The viewing distance from the patient eyes to the iPad display can be expressed either in meter or foot units and can set to some preset values 40 cm 3 4 5 6 8 m or 16 in 10 13 16 20 26 ft under the chart panel or using the remote The last set value is used every time the application is launched and is displayed in the settings if not a preset value The viewing distance can be also set to any other value using the bottom slider or by taping on the distance label and entering a new value chart panel only Distance Units meters Viewing Distance 47cm 40cm 3M 4M 5M 6M 8M Near visual acuity is typically measured at a viewing distance of 40 cm or 16 while far visual acuity is measured for mu
14. Visual Acuity XL amp Visual Acuity Remote The Visual Acuity Solution for iPad User GuIDE Version 1 4 By William H A Beaudot PhD Copyright 2011 2013 KyberVision All Rights Reserved es cole Available on the App store KyberVision Consulting R amp D in Vision Sciences Contact Information 2150 Mackay Street Suite 1908 Montreal QC H3G 2M2 CANADA Phone 1 514 245 0714 Email info kybervision com Web http ios kybervision com Visual Acuity XL User Guide version 1 4 June 23 2013 DISCLAIMER The Visual Acuity XL and Visual Acuity Remote softwares are provided by KyberVision on an AS IS basis KYBERVISION MAKES NO WARRANTIES EXPRESS OR IMPLIED INCLUDING WITHOUT LIMITATION THE IMPLIED WARRANTIES OF NON INFRINGEMENT MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE REGARDING THE VISUAL ACUITY XL AND VISUAL ACUITY REMOTE SOFTWARES OR THEIR USE AND OPERATION ALONE OR IN COMBINATION WITH OTHER PRODUCTS IN NO EVENT SHALL KYBERVISION BE LIABLE FOR ANY SPECIAL DIRECT INDIRECT INCIDENTAL OR CONSEQUENTIAL DAMAGES INCLUDING BUT NOT LIMITED TO PROCUREMENT OF SUBSTITUTE GOODS OR SERVICES LOSS OF USE DATA OR PROFITS OR BUSINESS INTERRUPTION ARISING IN ANY WAY OUT OF THE USE REPRODUCTION MODIFICATION AND OR DISTRIBUTION OF THE VISUAL ACUITY XL AND VISUAL ACUITY REMOTE SOFTWARES HOWEVER CAUSED AND WHETHER UNDER THEORY OF CONTRACT TORT INCLUDING NEGLIGENCE STRICT LIABILIT
15. Y OR OTHERWISE EVEN IF KYBERVISION HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGE COPYRIGHT This manual is copyrighted with all rights reserved Under the copyright laws this manual may not be copied reproduced or translated into another language stored in a retrieval system or transmitted in any form or by any means mechanical electronic photocopying recording or otherwise in whole or in part without the prior written permission of KYBERVISION CORRECTIONS No patent liability is assumed regarding the use of the information contained herein Moreover because KYBERVISION is constantly striving to improve its high quality products the information contained in this manual is subject to change without notice Every precaution has been taken in the preparation of this manual Nevertheless KYBERVISION assumes no responsibility for errors or omissions Neither is any liability assumed for damages resulting from the use of the information contained in this publication To report any problem with this documentation or the softwares send an e mail to visualacuity kybervision com INTERPRETATION OF RESULTS This user guide does not provide guidance on the interpretation of visual acuity measurements The experimenter must ensure to have received appropriate training in such interpretation For this reason KYBERVISION cannot be held responsible for misdiagnosis of results Apple iPad iPhone iPod touch iTunes and the na
16. across the chart or validate the subject responses The test will normally self terminate based on the termination criterion selected in the iPad settings and the acuity score will be saved to the iPad database Abort the test at any time by taping the button and optionally save the current score to the iPad database Visual Acuity XL User Guide version 1 4 June 23 2013 27 Follow these steps to run a test in remote mode with the Patient role 1 Change the user role to Patient on the remote control 2 Tap the Start button to switch the iPad to the chart panel and start the measurement session 3 Use the remote to enter the patient responses 4 The test will automatically stop when the termination criterion is reached and the acuity score will be saved to the iPad database 5 Abort the test at any time by taping the button no score will be saved The test should be first initialized with the Experimenter role to establish the connection specify the optotype set or customize the session options The Patient role can then be used until the optotype set or some options need to be changed Scoring Methods The procedure for measuring visual acuity consist in presenting optotypes of decreasing size until the subject is unable to discriminate between them The scoring method is determined by the termination criterion and the same scoring method can be applied irrespective of the chart type multiple lines
17. andard optotypes specifically designed to appear equally recognizable and appropriate for testing literate and illiterate people as well as preschool children Moreover to measure visual acuity in a precise and efficient way Visual Acuity XL provides unique interactive logMAR charts that are randomly generated to prevent the subjects to memorize the test and fully exploits the potential of the iOS platform by using another device iPad iPhone or iPod touch as a remote control device for the acuity testing The Visual Acuity XL app runs exclusively on the iPad device to take advantage of it larger display and implements many features required for both research and clinical studies Getting Started To start using Visual Acuity XL tap its icon to launch it 12 15 PM The main panel shows subject specific information in the top half and optotype specific buttons in the bottom half The subjects list is shown on the left side in landscape mode only To get access to it in portrait mode tap the Patients button in the top toolbar to present the subject list in a popover window Visual Acuity XL User Guide version 1 4 June 23 2013 9 12 30 AM Patients John Doe na B PERSONAL INFORMATION i ie co NTACT LENS Near Vision p Jane Doe Age RIGHT EYE LEFT EYE SPHERICAL 1 25 2 25 Condition CYLINDRICAL 1 25 1 25 E mail john doe mail org me s Po Phone 001 ugr PRISM ua Tn
18. ard Acuity 20 20 Foot Meter Decimal VAR LogMAR CPD e Foot units are used in the US visual acuity is expressed as Snellen fractions in foot relative to 20 20 the standard definition of normal visual acuity that is the ability to resolve a spatial pattern separated by a visual angle of one minute of arc If you have a visual acuity of 20 x then if you stood 20 feet away from an object and the normal person stood x feet away you would both see the same thing If x is more than 20 feet you have worse eyesight than normal and if it is less than 20 feet you have better than normal vision e Meter units are used in UK visual acuity is expressed relative to 6 6 meters roughly equivalent to 20 20 feet e Decimal units are used in France acuity is defined as the reciprocal value of the size of the gap measured in arc minutes of the smallest Landolt C that can be reliably identified A value of 1 0 is equivalent to 20 20 Values lower than 1 0 mean worst acuity and values higher than 1 0 mean better acuity than normal e LogMAR units are used in clinical research where acuity is expressed as the logarithm of the minimum angle of resolution LogMAR scale converts the geometric sequence of a traditional chart to a linear scale It measures visual acuity loss positive values indicate vision loss while negative values denote normal or better visual acuity A value of 0 0 is equivalent to 20 20 Though this scale is rarely use
19. ch farther viewing distance close enough to optical infinity where there is no significant accommodation by the crystalline lens typically at 6 m or 20 ft away Note that without a lens correction a myopic nearsighted person generally will have better visual acuity at near than at far while a hyperopic farsighted person generally will have better acuity at far than at near Until the early to mid forties a person with 20 20 distance acuity usually also has 20 20 acuity at near However once presbyopia sets in one s uncorrected near visual acuity decreases creating the need for reading glasses or bifocals Note that because of the limited pixel resolution of their screen the use of the iPad 1 and iPad 2 is more appropriate for measuring far visual acuity at a minimum viewing distance of 1 35 meters 53 or 4ft 5 For measuring near visual acuity at a typical viewing distance of 40 cm or 16 we recommend using the new iPad with the Retina Display or our Visual Acuity app for iPhone and iPod touch preferably with a Retina Display see the Adequacy of the iPad section in the Support chapter t is important to select the most appropriate viewing distance and it is even more critical to ensure that the patient is located at the specified distance from the iPad display since the precision of the acuity measurement depends on it Visual Acuity XL User Guide version 1 4 June 23 2013 14 Measurement Protocol Visual Ac
20. cuity XL User Guide version 1 4 June 23 2013 24 Cover the eye not being evaluated starting with the worst of the two eyes if known Ask the patient to read the optotypes from left to right starting with the top line Decrease the size of the optotype until the patient is unable to read or misses some of the characters on any one line Note the last line successfully read and record the incorrect result Repeat the above procedure for the fellow eye then for both eyes together with and without corrective lenses The computerized solution provided by Visual Acuity XL for the iPad supports two ways to enter validate the patient responses e Manual mode where the experimenter interacts directly with the iPad through touch screen interactions e Remote mode where the experimenter or the patient interacts remotely with the iPad through another iOS device running the free Visual Acuity Remote app which acts as a remote control Not all protocols are supported by these 2 modes only the chart type is considered in the manual mode and the remote mode should be used instead to fully take advantage of the acuity scoring and termination criterion options Manual Mode In the manual mode the experimenter interacts directly with the iPad through touch screen interactions Follow these steps to run a test in manual mode 1 Configure your test in the settings section units optotype appearance protocol Create or sel
21. d clinically it is more frequently used in statistical calculations because it provides a more scientific equivalent for the traditional clinical statement of lines lost or lines gained which is valid only when all steps between lines are equal which is not usually the case e VAR Visual Acuity Rating units provide a more intuitive scoring the VAR scale is similar to the logMAR scale but represented as a percentage A value of 100 Visual Acuity XL User Guide version 1 4 June 23 2013 12 is equivalent to 20 20 Values lower than 100 mean worst acuity and values higher than 100 mean better acuity than normal e CPD Cycle Per Degree units express visual acuity in term of angular resolution A value of 30 cod corresponds to a resolution of 2 arc minutes per line pair i e a 1 arc minute gap in an optotype and is equivalent to 20 20 Values lower than 30 cpd mean worst acuity and values higher than 30 cpd mean better acuity than normal The upper limit is directly related to the resolving power of the cone photoreceptors in the retina center fovea and by the imperfect optics of the eye for a human eye with excellent acuity the maximum theoretical resolution is 50 CPD equivalent to 20 12 m As emphasized above it is important to note that despite being referred as the normal or standard visual acuity 20 20 and its equivalents in other units do not indicate a perfect vision but should be thought of as the lower limit of
22. decreased or increased by 0 1 0o log unit Use the slider between these two buttons to set the size of the top line to any valid value displayed in red above the chart The acuity bar on the left side indicates the acuity value for each line of py a multiple line chart This bar is updated each time the chart is changed This bar can be shown or hidden by taping on it 20 63 Set the viewing distance to one of the preset 3M 4M 5M 6M 8M distances Use the slider on its right to set the viewing distance to any value up to 8 meters 26 ft Tap the Viewing Distance label to enter a specific value The chart is then automatically scaled to maintain the acuity level The split horizontal line on the left and right sides of a multiple lines chart points to the current line the patient is asked to read When interacting directly with the touch screen the experimenter can drag up or down this line On its release the test is stopped and the experimenter is asked whether to save the acuity score associated with this line Make sure to properly configure your iPad and remote device before running a session in terms of power settings brightness and orientation see the chapter Configuring your iPad amp iPhone iPod touch Procedures The general procedures for assessing visual acuity follow these basic steps though methods may vary from practice to practice 1 Position the patient at the appropriate distance Visual A
23. e cd m es supported it is recommended to specify a minimum luminance of 85 cd m the luminance will be otherwise specified by the brightness set in the Brightness amp Wallpaper section of the Settings app see the Configuration and Adequacy sections Note that the specified luminance is only an approximation based on the light emitted by a normal iPad without a screen protector Slight variations are normal between different iPads Available Optotypes Visual Acuity XL provides the most standard optotypes to test visual acuity in literate and illiterate people as well as preschool children including the Landolt C and Tumbling E symbols considered as the reference optotypes by the nternational Council of Visual Acuity XL User Guide version 1 4 June 23 2013 20 Ophthalmology in its Visual Acuity Measurement Standard The standard optotypes have been specifically designed to appear equally recognizable contrarily to those used in the Snellen chart The available optotypes are represented as large icons in the bottom half of the main panel and are from left to right Landolt C The Landolt C optotype is a broken ring symbol that has only one element of detail the gap which varies only in its orientation This gap subtends 5 minutes of arc in the 20 20 optotype and has an opening oriented in the top bottom right or left measuring 1 minute of arc Edmund Landolt proposed the Landolt C in 1888 based on the
24. e monitor TV controls so the presented black area appear as much square as possible Ihe squareness of the display pixels is critical to ensure precise TV Out Calibration Step 1 Make any necessary adjustment using your monitor TV controls to make this black area appear as much square as possible Not achieved Achieved Important properly calibrating the external display is a critical step to ensure that the optotypes are displayed at the proper size Failing to do so will make any acuity measurement inaccurate measurements of the visual acuity Visual Acuity XL User Guide version 1 4 June 23 2013 17 e The 2nd step consists in reporting the diagonal size in the same unit as the distance unit specified in the settings TV Out Calibration Diagonal Size 43 20 cm Measure and report the screen diagonal between arrow tips Similar to the viewing distance the accuracy of the diagonal size is critical to ensure precise measurements of the visual acuity lf the TV Out mode is enabled and an external monitor gets connected to the iPad while the Visual Acuity app is running you are presented with the list of 800 x 600 1024 x 768 1280 x 1024 Visual Acuity XL User Guide version 1 4 June 23 2013 18 available resolutions for this monitor the current one is highlighted in red and asked to select a resolution compatible with the iPad display 1024 x 768 720p or better
25. e through the remote are automatically synchronized with the iPad app The user role can be changed by taping the red button to return to the previous panel Taping one of the optotypes starts a new measurement session on the iPad with the selected optotypes note that the last selected optotypes become the default optotypes used in Subject mode see Playing the Subject role below Level 20 20 Acuity 20 20 The above panel is then presented on the remote which provides the experimenter with the following controls and indications X To stop the session and return to the previous panel w ww To show and hide the controls on the iPad display oo oo To generate a new random chart with optotype size decreased or increased by 0 1 log unit To generate a new random chart with the same size To move the line indicator one line down or up in multiple lines charts If the subject failed on the indicated line e g 3 incorrect letters on the same line for the ETDRS method the Experimenter is then presented with the option to save the score or continue see below Visual Acuity XL User Guide version 1 4 June 23 2013 42 Level lt value gt lt unit gt which indicates the acuity for the current line the line pointed by the line indicator in multiple lines charts Acuity lt value gt lt unit gt which indicates the current estimate of the subject acuity These optotypes displayed above the controls i
26. e Experimenter mode iPod amp 5 28 PM Viewing Distance 10 00 ft an m A 13ft 16ft 20ft 26ft Py 5 AN Left Right Both ee Change the user role the user role Le ee 2010 KyberVision Can 10ft The optotypes set presented to the subject is specified above the Start button These optotypes are those that have been last selected by the user in the Experimenter mode see Playing the Experimenter role section If none has been specified yet then this is indicated and the Start button gets disabled as shown below iPod gt 2 29 PM Viewing Distance 26 00 ft To start the test the subject should simply tap the Start button and enter their response for each letter of the presented line from left to right The subject is presented with one of the following panels where each available optotype is represented by a large button Visual Acuity XL User Guide version 1 4 June 23 2013 44 Landolt C Tumbling E Visual Acuity XL User Guide version 1 4 June 23 2013 45 5 52 PM Cw O 0 In addition of the large optotype buttons used by the subject to indicate their response each of these panels provide the user with the following controls and indications X To abort the session and return to the previous panel Q w To show and hide the controls on the iPad display Level lt value gt lt unit gt which indicates th
27. e acuity for the current line the line pointed by the line indicator in multiple lines charts Acuity lt value gt lt unit gt which indicates the current estimate of the subject acuity lt These optotypes displayed above the controls indicate the responses already made by the subject for the current line The light grey optotypes are those that the subject failed to recognized while the darker grey ones are those the subject successfully identified The acuity estimate is updated accordingly and the next line is automatically presented if the current line is successful On test completion i e once the termination criterion has been reached the user is presented with a message indicating the final score and with the option to record it in the iPad database see the Acuity History section or to abort the test Visual Acuity XL User Guide version 1 4 June 23 2013 46 Measurement Done score 20 42 At least 1 wrong responses on the same line Save Visual Acuity XL User Guide version 1 4 June 23 2013 47 Frequently Asked Questions F A Q Q The iPad and the iOS remote control cannot connect What s wrong R Make sure you have updated both Visual Acuity XL and Visual Acuity Remote to the latest versions from the App Store Verify that either the Bluetooth or WiFi capability but not both is enabled on each device in the General section of the Settings app WiFi is inside
28. e corresponding acuity score referred here as the simple scoring method 9 Abort a test at any time by taping the button inthe top left corner of the chart panel 9 If the patient shows some difficulty to locate the line to read then the experimenter can activate a line indicator by touching on the side of the line as show below this indicator is always shown when the remote is used YF ww AF WV W Mm CON lll IAA AAA Maintain and drag the touch up or down to shift the indication bar and release the touch outside the chart area to hide the line indicator Remote Mode The remote mode requires another iOS device iPad iPhone or iPod touch and the free companion app Visual Acuity Remote that transforms this device into a remote control for the acuity testing running on the iPad You can then use this remote control to provide the patient responses or self administer the test a distance away from the iPad To learn more about the capabilities of the remote control see the Visual Acuity Remote chapter in this user guide Visual Acuity XL User Guide version 1 4 June 23 2013 26 Note that in remote mode all the controls are hidden and disabled by default because they are either unnecessary or available from the remote However they can be activated on demand Two roles are available when using the remote The experimenter role where the remote can be used to browse across the chart similarly to the manual
29. e measured for the current session so it is important to make sure it is correctly specified before running a session This information can be retrieved through inspection of the measurement details in the gt HTML TABLE FOR Current Subject acuity history Note that the tested eyes and whether they are corrected can be also customized from the remote when using it as the experimenter CUITY DA HTML Table Database Backup LC Visual Acuity XL User Guide version 1 4 June 23 2013 33 Exporting amp Importing Acuity Data The acuity history can be exported through email either as an HTML table or a database backup file When exporting as an HTML table the acuity history can be emailed either for the currently selected patient or for all patients The selected acuity data is then presented and sent as an HTML table where each session is represented as a row where each column indicated a parameter value as shown below Cancel Visual Acuity Results To Cc Bcc From Subject Visual Acuity Results Visual Acuity measurements obtained with the iPad app Visual Acuity XL App from KyberVision eee a John Doe BoW with 4 0 20 19 L YES Sloan confusion None BoW with 4 0 20 19 IL YES Sloan confusion None t Eyes codes L Measurements for the left eye R Measurements for the right eye LR Measurements for both eyes t Appearance codes BoW Black optotypes on white background WoB
30. ect the patient and customize the session tested eye correction notes in the Current Session section of the subject panel Tap one of the optotype icons to switch to the chart panel Set precisely the viewing distance using the bottom slider or using one of the preset values Visual Acuity XL User Guide version 1 4 June 23 2013 25 5 Adjust the vertical slider on the right to select a range of letter sizes that can be easily seen by the patient for a multiple lines chart this would be a range for which the subject can easily identify all letters in the first line but fails for the last one This step can be skipped by starting with the default initial acuity level 20 200 6 Ask the patient to read the optotypes from left to right starting with the top line 7 Ifthe subject can correctly identify all letters on that line then ask the subject to read the next smaller line and so on until the subject fails at least once If the last line is reached without error then press the button to generate a new chart with smaller letters and repeat this step until the subject fails at least once If the subject fails on the first line press the button to generate a new chart with larger letters and repeat this step 8 Once an error occurs tap and release the smallest line the patient can successfully read i e whose letters were all correctly identified the acuity estimate is then displayed above the chart to save th
31. enter through the touch screen interactions and the measurement determined by the line taped by the experimenter which should correspond to the smallest line the patient can fully read Miscellaneous Options Mirror Mode OFF Mirror Mode the mirror mode involves the use of a mirror to increase the viewing distance which would be otherwise limited by the depth of your testing room In this mode the presented optotypes are mirror inverted so they appear normally presented to the patient when viewing through the mirror e Itis important to note that the specified distance should be the virtual viewing distance between the patient and the display that is twice the physical distance between the patient and the mirror TV Out Mode the TV Out mode implies the use of an external monitor instead of the iPad display to present the charts to the patient This may be necessary when the iPad display is too small relative to the available viewing distance for example when using the mirror mode as described above TV Out is supported by all iPad devices by using either e Video Mirroring where your iPad is directly connected to a TV monitor projector or LCD display through the Apple VGA or Digital AV Adapter see Apple support note iOS About Apple AV Adapter compatibility e AirPlay Mirroring where your iPad is connected wirelessly to an Apple TV on the same Wi Fi network see Apple support note Apple TV How to use AirP
32. fact that not all of Snellen s optotypes were equally recognizable In its Visual Acuity Measurement Standard the International Council of Ophthalmology considers the Landolt C the purest research standard and requires all other research approaches to be calibrated against the Landolt C It is the recommended reference optotype for testing visual acuity and the preferred visual acuity measurement symbol for laboratory experiments but gained only limited acceptance in clinical use Tumbling E The Tumbling E optotype follows the same design principles as the Landolt C but uses a stylized letter E instead Charts based on this single optotype in various orientations were created by Hugh Taylor in 1976 to test visual acuity of Australian Aborigines The use of the Tumbling E has become standard for testing of illiterates and populations not familiar with the Roman alphabet or too young to read letters since like for the Landolt C they simply need to indicate the orientation of the symbols Note however that this optotype contains 3 times more information about its orientation than the Landolt C Sloan optotypes The Sloan optotype set consists in 10 letters C D H K N O R S V and Z specifically designed by Louise Sloan in 1959 in order to avoid the problem that not all letters are equally recognizable in the Snellen chart The Sloan chart were also specifically designed to follow a geometric progression of letter sizes form
33. ications set to OFF e Brightness amp Wallpaper section Auto Brightness set to OFF Brightness level set to an appropriate level see below e General section WiFi disabled in the Network option if using Bluetooth remote mode Bluetooth set to OFF if using WiFi remote mode Location Services set to OFF Auto Lock set to NEVER Lightning Conditions amp Brightness Visual acuity testing should be conducted under standardized lighting conditions The test light level recommended by the National Academy of Sciences and by the American National Standards Institute for ETDRS is a minimum luminance of 85 cd m2 This level corresponds to about 25 of the maximum brightness level provided by the iPad Visual Acuity XL User Guide version 1 4 June 23 2013 49 display measured maximum brightness is about 375 to 400 cd m This testing brightness can be specified either e by moving the slider in the Brightness amp Wallpaper section of the Settings app to about 3 cm from the left extremity should provide about 85 cd m2 If unsure about the correct brightness simply max out the iPad brightness to ensure optimal viewing conditions Settings Brightness amp Wallpaper z Brightness amp Wallpaper E Picture Frame N General ate si ee o I Auto Brightness C OFF e or when running the app under iOS 5 or above using the Luminance option available from the settings popover window
34. ility to resolve details at near and far distance It usually involves reading letters or looking at symbols of different sizes optotypes on a wall chart similar to the famous Snellen chart found in most physician offices and developed by Dutch ophthalmologist Herman Snellen in 1862 Visual Acuity XL for iPad is KyberVision s mobile solution for vision care specialists it brings computerized versions of the gold standard acuity testing on this popular mobile platform in the clinical environment and it provides fast efficient and reliable assessment of visual acuity for literate and illiterate people as well as preschool children Moreover Visual Acuity XL promotes the use of the logMAR chart design recommended by the National Eye Institute NEI and the nternational Council of Ophthalmology ICO to address design flaws in the Snellen chart Visual Acuity XL for iPad has many useful features for the clinical environment e Interactive LogMAR charts in landscape and portrait modes e Randomized design to prevent subjects to memorize the test e Near and far visual acuity testing e Keep track of visual acuity history subject patient information and prescription Exporting of acuity data through email in HTML format e Database backup and import with overwrite append and merge capabilities e Units conversion tool Information about common eye conditions you can share with your patient subject e Free remote control app Visual Acuit
35. ing the basis of the logMAR design HOTV optotypes The HOVT optotype set consists in only 4 letters H O T and V which are more appropriate for testing visual acuity in preschool children under 5 6 years old These optotypes are also assumed to be equally recognizable and maximally distinguishable A child should be first taught the four symbols and then tested against the HOTV chart Kid optotypes Visual Acuity XL User Guide version 1 4 June 23 2013 21 The Kid optotype set consists in outlines of 6 figures apple house circle square heart and star It is adapted from the LEA Symbol and Patti Pics charts used to measure visual acuity in preschool children too young to perform the HOTV test The Kid chart follows the same logMAR design as the other charts Numbers optotypes The Number optotype set consists in 8 digits 2 3 4 5 6 7 8 9 found in the Feinbloom Number Chart designed by Dr William Feinbloom in 1935 to test people with low vision The Numbers chart follows the same logMAR design as the other charts Cyrillic optotypes The Cyrillic optotype set consists in the 7 Cyrillic letters LU B M H K bl N found in the Golovin Sivtsev table developed by Soviet ophthalmologists S Golovin and D A Sivtsev in 1923 It is still used in some post Soviet states The Cyrillic chart follows the same logMAR design as the other charts Snellen optotypes The Snellen optotype set uses
36. l Acuity XL User Guide version 1 4 June 23 2013 55 Devices iPad 1 amp 2 iPad 3 amp 4 Comparison Retina Display Minimum distance 26 5 67 cm 22 55 cm 13 33 cm for 20 20 Minimum distance 53 135 cm 43 110 cm 26 5 67 cm for 20 10 60 cpd Best acuity at reading distance 20 32 to 20 37 20 30 to 20 26 20 18 to 20 16 14 16 36 41 cm Best acuity 20 13 20 11 20 7 at 39 1m Pros amp Cons The iPad screen is a very high quality LCD display with a high brightness and a high contrast ratio well suited for acuity testing Pixel density for the iPad 1 and 2 132 ppi is adequate for measuring far visual acuity 20 10 measurable at a distance of 53 and pixel density for the new iPad Retina Display 264 ppi is adequate for measuring near visual acuity 20 10 measurable at a distance of 25 However when following a logMar design the main limitation is its resolution size limited to 9 x 6 deg at the minimum distance of 53 and 4 x 3 deg at a distance of 10 ft for a 9 7 iPad a maximum of 4 letters can be presented on the same line at a 20 200 acuity level at the minimum distance and only 1 letter at 10 ft This is even more limited for the iPad mini due to its smaller 7 9 size Another potential problem is the screen glossiness glossy screens are more susceptible to glare reflecting light from windows and light bulbs Moreover they tend to show fingerprints and smudges more readily especially
37. lay Mirroring or an Airplay enabled Macintosh or PC computer using for example the 3rd party AirServer software Note that AirPlay Mirroring to Apple TV 2nd and 3rd generation is limited to the 720p resolution 1280 x 720 For help about Airplay Mirroring through an Apple TV see the following Apple article Troubleshooting AirPlay and AirPlay Mirroring For step by step instructions see the Airplay Mirroring Setup section in the Support chapter Visual Acuity XL User Guide version 1 4 June 23 2013 16 Although the charts are presented on the external monitor they are also presented on the iPad but at a scale that is not related to the viewing distance between the patient and the external monitor Obviously the patient should only look at the external monitor It is important to note that when using TV Out it is mandatory to perform a calibration of the external monitor by ensuring that the pixels have a square aspect ratio and by measuring the diagonal size of the chart area This is a critical step to ensure that the optotypes are displayed with the correct size Failing to properly calibrate the external display will make any acuity measurement inaccurate The calibration panel is available from the button in the bottom toolbar greyed out if the TV Out option is turned off or is automatically displayed when connecting an external monitor e Inthe 1st step you are asked to make any necessary adjustment using th
38. lyopia The surround can be either bars or a frame and applies on the single letter whole line or entire chart depending on the chart type with a spacing corresponding to half the size of a single optotype Tap the icon corresponding to the desired optotypes to switch to the chart panel and start the testing Measuring Visual Acuity x Tap here to randomize the chart wy Acuity 20 20 VSGSHRH LSC ee H KO 2 N 20 32 V D R a NKONV 22 Te S K O CD sng NOS CS malts VZKZN Zone RNORC ES AR Viewing Distance 10 00 ft Chart Panel After starting the acuity test you are presented with the chart panel that displays optotypes to be discriminated by the patients similar to the one shown below Visual Acuity XL User Guide version 1 4 June 23 2013 23 Note that the largest optotypes in the initial chart always correspond to an acuity of 20 200 1 logMar unit and depending on the default viewing distance a single optotype may be shown due to the limited size of the iPad display and the logMAR design that constrains the spacing between optotypes on the same line and the interline spacing Several controls are available on the chart panel except for the Snellen chart The label above the chart to generate a whole new chart each time one taps it x Stop the session and return to the previous panel no data is saved w Hide the controls on the iPad display Generate a new chart with optotype size
39. mended to quit and relaunch both apps Tap the Done button in the above panel Visual Acuity XL User Guide version 1 4 June 23 2013 40 or quitting the VARemote app to stop the connection the iPad will automatically detect the disconnection Note that since Visual Acuity XL supports multitasking under iOS 4 2 it is necessary to remove it from the list of background apps to actually quit it as illustrated below VisualAcuity XL Playing the Experimenter role In this mode the Experimenter can manually browse through the chart lines presented on the iPad screen have access to the acuity level and the currently presented optotypes and validate the subject responses The acuity score is automatically updated and is made available to the Experimenter who can decide to save or discard it This mode is also useful for fast screening iPod gt 10 30 AM sjes _ a VE a Viewing Distance 10 00 ft r ri Saai C Tumbling E Corrected Not Corrected Change the user role wes y S When selecting the Experimenter role the user is presented with the above panel that provides control for the test settings viewing distance tap the viewing distance button 2011 SV Visual Acuity XL User Guide version 1 4 June 23 2013 41 to specify a value more precisely than the slider does tested eye s whether the subject s vision is corrected and the available optotype sets The changes mad
40. mes of Apple products referenced herein are trademarks of Apple Inc registered in the U S and other countries App Store is a service mark of Apple Inc All other brand and product names are trademarks of their respective holders Any omission of such trademarks from any product is regretted and is not intended as an infringement on such trademarks Visual Acuity XL User Guide version 1 4 June 23 2013 2 symbols Used This manual uses the following symbols to indicate special information Symbol Description Oe Indicates tips that help you better use this app Indicates important information pertaining to visual acuity Terminology This user guide uses the terms Experimenter or User to refer to the person operating the iPad device and Patient or Subject to refer to the person undergoing the test and who may also use the remote control to provide his responses The Remote Control refers to another iOS device iPad iPhone or iPod touch running the Visual Acuity Remote app available for free on the App Stores Documentation This user manual is also available as an iBooks textbook for iPad created with iBooks Author Visual Acuity XL User Guide version 1 4 June 23 2013 3 Table Of Contents Overview Visual Acuity XL Getting Started Configuring the Acuity Testing e Acuity Units Viewing Distance Measurement Protocol Miscellaneous Options Available Optotypes Landolt C Tumbling E Sloan o
41. mode described above or to validate the subject responses and follow the specified protocol i e the correct responses are available to the experimenter on the remote device With this role the test is user terminated or self terminating The patient role where the remote is only used to indicate the patient responses using touchable icons representing the possible choices With this mode the test is self terminating following the specified protocol the test continues until the patient cannot reliably indicate the letter orientation or identify the letter and stops automatically once the termination criterion is reached Follow these steps to run a test in remote mode with the Experimenter role 1 Configure your test in the settings section units optotype appearance protocol Create or select the patient and customize the session tested eye correction notes in the Current Session section of the subject panel tested eye and correction can also be set through the remote Tap the button on both iPad and remote control to establish a Bluetooth or WiFi connection between the 2 devices Select the Experimenter role on the remote control Using the remote set the tested eye and whether it is corrected if not already done from the iPad in step 2 Set the viewing distance as well Select the optotype set to switch the iPad to the chart panel and start the measurement session Use the remote to browse
42. motely control the Visual Acuity XL app that runs on the iPad Although the use of this app is optional it provides a convenient access to the acuity test settings without having to physically access the iPad display It also allows subject s responses to be entered while standing a distance away from the iPad or during self administration of the test Either the subject or the experimenter can use it Getting Started a on Apps aha o FieldOfView ee VisualAcuity VARemote Tap the VARemote icon on your other iOS device to start the remote app and follow these steps when using the remote see also the Remote Mode section in the Visual Acuity XL chapter 1 Establish a Bluetooth or WiFi connection between the device and the iPad 2 Selecting the user role experimenter or patient 3 Start a test 4 Run the test until it ends and save the score to the iPad or abort the test 5 Go to the step 2 to change the test or step 3 to start a new test Visual Acuity XL User Guide version 1 4 June 23 2013 38 iPod 4 58 PM Visual Acuity Remote 4 Version 1 1 fa R Make sure to run Visual Acui on your iPad or Visual Acuity on your Mac and tap the button to establish a Wi Fi or Bluetooth connection 2 KyberVision tae Consulting R amp D in Vision Sciences www kybervision com S aig 2011 KyberVision Establishing a connection between the remote control and the iPad Here a
43. ndicate O the ones that the subject should recognize i e those on the current line Based on the subject response the experimenter should tap each letter that is wrongly identified which is then shown in light grey The acuity estimate is updated accordingly The Experimenter is presented with the option to save the score or continue after the subject fails a line if saved the score is recorded in the iPad database see the Acuity History section If not saved the test simply continues with the possibility to change the response for the last line Save Score Score 20 23 At least 1 wrong responses on the same line No If the test is interrupted by taping on the Stop button the user is asked whether to also save the current score or to abort only If saved the score is recorded in the iPad data base Playing the Subject role The Subject mode should be used when the subject is allowed to directly enter their responses using the remote control device Nevertheless the Subject mode can also be used by the experimenter if the subject is unable to use the remote device or if the experimenter prefers to use this mode to enter the subject s responses himself However contrary to the Experimenter mode the user cannot modify the test Visual Acuity XL User Guide version 1 4 June 23 2013 43 configuration in the Subject mode these settings are shown but are locked i e to modify them you need to return to th
44. of the American Academy of Optometry Boston October 2011 JM Black RJ Jacobs G Phillips L Chen E Tan A Tran B Thompson 2013 An assessment of the iPad as a testing platform for distance visual acuity in adults BMJ Open Link Visual Acuity XL User Guide version 1 4 June 23 2013 48 Configuring your iPad amp iPhone iPod touch Both the iPad and remote control need to be properly configured before running any visual acuity test Here are a few important recommendations to follow before carrying out a test to ensure a smooth process Power Adapter vs Battery lf the iPad and remote control are not plugged to an electrical outlet or a computer system while running the acuity testing make sure that their batteries are fully charged beforehand the battery level is indicated in the top right hand corner While the iPad provides up to 10 hours of battery life the use of the Bluetooth connection can significantly reduce this time Keep handy the USB cable for charging through an electrical outlet or a computer system or an iPad 10W USB Power Adapter that lets you charge your iPad directly through an electrical outlet A 6 foot long power cord is available to allow you to charge it from an even greater distance Settings Make sure that there is no system setting on both devices that interfere with the testing process Open the Settings app and verify the following settings in the e Notifications section Notif
45. ption information can be entered either using the numerical keyboard by SPHERICAL CYLINDER AXIS PRISM BASE CYL IAXIS ADD Visual Acuity XL User Guide version 1 4 June 23 2013 31 EYE PLEFT EYE buttons For an eyeglass prescription ACUITY HISTORY Foot units 2010 11 30 15 36 Sloan Test corrected L BoW 20 19 2010 11 30 15 03 Sloan Test corrected L BOW 20 19 h A For a contact lens prescription Session DetailS Date 2012 02 05 20 54 DELETE Acuity 20 20 Method Sloan Chart Tested Eyes Both Protocol Manual Corrected No Criterion 3 letters Viewing Distance 10 0 ft Notes Luminance 85 cd m Appearance Black on White your notes here Confusion Bars None Nb Optotypes 10 Acuity History Each new acuity measurement is added to the acuity history The history can be expanded or collapsed by taping the or sign in the table header Tap any entry in this table to inspect the detail of the measurement Tap the Delete button in the session details to delete this entry Session Information Visual Acuity XL User Guide version 1 4 June 23 2013 32 oS CURRENT SESSION ti ee Eyes Left Right E Corrected o Ye Se Notes Sd Information for the current session consists of e The tested eye s e Whether the eye s is corrected e Any other information that would be useful to note This information is recorded along with the acuity scor
46. ptotypes HOTV optotypes Kid optotypes Numbers optotypes Cyrillic optotypes Snellen optotypes Optotype settings Measuring Visual Acuity Chart Panel Procedures Manual Mode Remote Mode Visual Acuity XL User Guide version 1 4 June 23 2013 11 12 14 15 16 20 21 21 21 21 21 22 22 22 22 23 23 24 25 26 Scoring Methods Managing the Subjects Patients List Personal Information Eye Prescription e Acuity History Exporting amp Importing Acuity Data Visual Acuity Remote Getting Started Establishing a connection between the remote control and the iPad Playing the Experimenter role Playing the Subject role Frequently Asked Questions F A Q Configuring your iPad amp iPhone iPod touch Power Adapter vs Battery Settings Lightning Conditions amp Brightness Landscape vs Portrait Mode Airplay Mirroring Setup Adequacy of the iPad for Visual Acuity Testing iPad Display Specifications Specifications for visual acuity testing Pros amp Cons Useful Accessories Visual Acuity XL User Guide version 1 4 June 23 2013 28 29 29 30 30 32 34 38 38 41 43 48 49 49 49 49 50 51 55 55 55 56 57 Game Pad Stylus Protection Stand amp Wall Mounting Charging Connecting to External Display Visual Acuity XL User Guide version 1 4 June 23 2013 57 57 58 59 60 60 Overview Visual acuity is the most important test used to evaluate eyesight It measures the eye s ab
47. r name Tap the Edit button to remove rename or reorder a patient Then tap the PERSONAL INFORMATION Gender Male Female Age 33 Condition None E mail john doe mail org Phone 001 234 5678 Vs UU Done button to validate these changes Note that the list is displayed in alphabetical order by default and a search field is also included If you are not interested to keep a list of patients you may simply add a group name instead Personal Information The personal information consists of e The patient gender e The patient age e The patient eye condition Several common conditions are available e The patient email and phone number All this information is mandatory The personal information is locked by default To unlock them tap the locker icon Eye Prescription If Known the eye prescription can be entered for either glasses or contact lenses For eyeglass prescription both distance and near vision prescriptions can be provided The prescription format includes all standard parameters found in the prescription provided by an eyewear prescriber such as an optometrist or ophthalmologist Visual Acuity XL User Guide version 1 4 June 23 2013 30 Nis INIA DA GLASS CONTACT LENS m E Lao lt RIGHT EYE LEFT EYE ais e B eT e CYLINDER AXIS PRISM 12 12 ADD POWER BASE gt Loo A PUPILLARY DISTANCE so E L s S 7 _ The prescri
48. re the steps to follow to establish a working connection between the iOS device and the iPad 1 Make sure that both have Bluetooth enabled or are connected to the same WiFi network to create a local WiFi network see the FAQ 2 Tap the large green button on the iOS device and select the iPad option CONNECTING TO The iOS device will start looking for the iPad running the Visual Acuity XL app Visual Acuity XL User Guide version 1 4 June 23 2013 39 Connect to iPad Waiting Cancel Connection 3 Launch the Visual Acuity XL app on the iPad if it does not run yet and tap the connection button in the bottom toolbar to activate the remote capability The 2 devices should then automatically connect after a few seconds 4 On successful connection the following panel appears on the remote control screen and asks what role the user wants to play Tap the button that corresponds to the intended user role experimenter or patient iPod 3 55 PM gt Select the user role _ _ wv _ _ Subject Patient 4 ee x E TANN T ee 2011 KyberVision If establishing a connection takes too long simply cancel the connecting process on both devices and repeat the process Establishing a Bluetooth connection can be slow on the first attempt however the subsequent connections should be much faster If for some reasons the communication between the devices stops working it is recom
49. sual Acuity XL should automatically detect the presence of an external display and ask you whether to turn TV Out on as illustrated below None ail firstne s g aTa a ataa i da TV Out Detected CUR Connection to an external monitor detected Do you want to turn on the TV Out mode now Visual Acuity XL User Guide version 1 4 June 23 2013 52 Tap YES to turn on the TV Out mode As illustrated below Visual Acuity XL should then display a list of compatible resolutions If your monitor and your Apple TV are properly configured this list should include the optimal resolution 1280 x 720 CYLI E mail firstname lastname m a _ i on Phone 001 000 0000 SELECT A COMPATIBLE RESOLUTION 1024 x 768 1280 x 720 720p or above 1280 x 720 Notes your notes here 2013 Sloan 2013 Select the 1280 x 720 resolution and Visual Acuity XL should then switch to the TV Out Calibration panel phase 1 as illustrated below TV Out Calibration Step 1 Make any necessary adjustment using your monitor TV controls to make this black area appear as much square as possible Not achieved Achieved Important properly calibrating the external display is a critical step to ensure that the optotypes are displayed at the proper size Failing to do so will make any acuity measurement inaccurate Visual Acuity XL User Guide version 1 4 June 23 2013 53 The external display
50. the Network option Once enabled the WiFi or the Bluetooth indicators is shown in the top left and top right corners of the status bar respectively Q cannot use my iOS device as a remote control because there is no WiFi network to connect to Is there a solution R If no WiFi network is available then use Bluetooth to connect the remote control to your iPad You could also create your own WiFi local network using a recent Macintosh computer which can either share its wired internet connection through WiFi see the Internet Sharing option in Sharing System Preferences or create its own local Ad Hoc Wireless network see the Create Network option in the Airport menu A Both of these solutions would allow the WiFi connection of the 2 iOS devices on your own local WiFi network For more information check the following links Turn your Mac into a WiFi hotspot using OS X s internet sharin How to Set Up an Ad Hoc Wireless Network Q Has this Visual Acuity solution been validated by independent vision care professionals R Several research laboratories around the world are currently evaluating this solution compared to other chart based or computer based solutions Find below references to some of these works We will add more when made publicly available Jacobs Robert Black Joanna Tran An Chen Lu Geraint Phillips Thompson Ben University of Auckland An iPad for an eye test 89th Annual Meeting
51. the 9 letters C D E F L O P T Z found in the original Snellen chart However it is adapted to the same logMAR design as the other charts i e follows a geometric progression of letter sizes and proportional spacing between letters t is important to select the most appropriate optotype set based on the patient abilities The Landolt C and Tumbling E optotypes only require the patients to indicate their orientations while all other optotypes need to be identified Using the Optotype Appearance ROEE S a o Confusion Bars com it OC remote control may greatly facilitate the acquisition of the patient s responses Optotype settings The optotypes presentation can be customized in the settings section Visual Acuity XL User Guide version 1 4 June 23 2013 22 e Appearance the optotypes can be displayed either as black letters on white background or white letters on black background If there is no counter indication acuity testing should be performed preferentially with black letters on white background e Orientations Landolt C and Tumbling E optotypes have always their orientation randomized among 4 C amp E or 8 directions C only The use of 8 orientations for the Landolt C can improve the reliability of the acuity measurement e Confusion Bars the optotypes can be surrounded to investigate the crowding effect interaction between target in its surround which is particularly important in Amb
52. uity XL to use Airplay Mirroring should be a smooth process If you wonder why this setup looks so complicated then remember that measuring visual acuity requires optotypes at a given acuity level to be presented with the right size at the specified vision distance De termining precisely the resolution and physical size of the external display is a critical step to achieve this Visual Acuity XL User Guide version 1 4 June 23 2013 54 Adequacy of the iPad for Visual Acuity Testing iPad Display Specifications e Technology e Aspect ratio e Glossy screen iPad 1 amp iPad 2 Resolution Diagonal Pixel density Min Luminance Max luminance Max contrast ratio LED backlit IPS LCD 4 3 1024 x 768 9 7 24 6 cm 132 ppi 5 2 ppm 0 5 cd m 375 cd m 50 1 new iPad 3 amp 4 with Retina Display Resolution Diagonal Pixel density Min Luminance Max luminance Max contrast ratio iPad mini Resolution Diagonal Pixel density Min Luminance Max luminance Max contrast ratio 2048 x 1536 9 7 24 6 cm 264 ppi 10 4 ppm 0 45 cd m 300 360 cd m 670 770 1 1024 x 768 7 9 20 cm 163 ppi 6 4 ppm 0 5 cd m 390 cd m 780 1 Specifications for visual acuity testing e Recommended minimum luminance 85 cd m see the Luminance and Configuring your devices sections e The table below provides some comparison between the different iPad devices Visua
53. uity XL offers several protocols based on a combination of chart types acuity scoring and termination criterion Are available 3 types of charts Chart Type a Multiple Lines Single Line Single Letter e Multiple lines multiple lines of optotypes are presented according to the logMAR design which specifies the spacing between optotypes and between lines typically the size of a single optotype e Single line a single line of optotypes is presented with up to 5 optotypes with a spacing corresponding to the size of a single optotype e Single letters a single optotype is presented in the center of the display 2 acuity scoring methods Acuity Scoring e Simple the easy and fast way to measure visual acuity though less precise e ETDRS the standard way to measure visual acuity in clinical environment 3 termination criteria based on incorrectness Termination Criterion e 1 letter the test stops after 1 incorrect letter e 3 letters the test stops after 3 incorrect letters on the same line this is the default termination criterion for the ETDRS scoring Visual Acuity XL User Guide version 1 4 June 23 2013 15 e 1 line the test stops after a whole incorrect line The protocol defined in the settings is only followed when running a session through the remote mode The protocol is otherwise considered as manual as the progress across the chart is under the control of the experim
54. up 2012 03 22 15 02 KyberVision s iPad 2 22 March 2012 3 08 PM Find below your database backup file A Open in VisualAcuity XL 3 6 KB Sent from my iPad 2 Check out our iPhone Apps at http iphone kybervision com When opening an vaxl file the Visual Acuity XL app will launch and ask what to do with the data contained in the imported file The available options are Visual Acuity XL User Guide version 1 4 June 23 2013 36 WHAT TO DO WITH IMPORTED JA A sry LI rAw Overwrite to replace the current data with the imported one beware that the previous data will be lost so be carefull Append to add the imported data to the current one beware that patients with the same name may then appear in the patients list and may require that you manually clean this list Merge to complete the current data with the imported one patients with same name gender and age year and month are merged so missing data like condition and contact information will be filled in and the respective acuity history be ap pended to the previous one if differing in the assessment date and time Visual Acuity XL User Guide version 1 4 June 23 2013 37 Visual Acuity Remote The Visual Acuity Remote app runs on iPad iPhone or iPod touch with Bluetooth or WiFi capabilities note that Bluetooth was not supported on the first generation iPhone and iPod touch and it is used to re
55. when they are off On the contrary matte screens tend to handle glare better due to a polarized coating over the glass that diffuses ambient light A side effect of the matte finish is a slight blurring reduced contrast and a narrower viewing angle Visual Acuity XL User Guide version 1 4 June 23 2013 56 Useful Accessories You may find the following accessories very useful to carry out the acuity testing using the iPad and the remote control Note that we do not endorse any of these products similar products may be available from different manufacturers at different prices Make sure to get accessories that fit your devices e g many accessories are not compatible between iPads because of differences in display size or connector Game Pad The Gamer Action for iPhone 3G and 3GS and iPod touch 2G and 3G provides a rubber grip texture that gives more comfort and control of the iPhone and iPod touch running the Visual Acuity Remote app Note This accessory is currently not compatible with iPhone 4 4S 5 and iPod touch 4 5G though you may find some cases that would make your device fit into this accessory e g the dermaSHOT Silicone Case from Incipio for the iPod touch 4G provides the same form factor than the iPhone 3G Provider http Wwww boxwave com Price US 24 95 Stylus The mini Capacitive Stylus for iPhone iPod touch and iPad works on all capacitive touch screens and is perfect to prevent finger smudges left on
56. y Remote for iPad iPhone or iPod touch iBooks and PDF documentation available online Many options are also available to customize acuity testing e Simple or ETDRS acuity scoring e Charts composed either of single letter single line or multiple lines e Standard optotypes Landolt C Tumbling E Sloan HOTV Kid Numbers Cyrillic Snellen e Standard acuity units foot meter decimal VAR logMAR cpd e Black letter on white background or reverse e Confusion bars e 4or 8 orientations for Landolt C optotype e Distance units and viewing distance up to 8 meters 26 feet e Mirror and TV Out modes e Custom luminance levels Note that some of these features require the use of a particular device or a specific version of iOS The table below summarizes these requirements Visual Acuity XL User Guide version 1 4 June 23 2013 7 iOS Device Far Visual Near Visual TV Out Custom Lu Acuity Acuity minance e o new iPad 3 amp 4 Retina Display Visual Acuity XL User Guide version 1 4 June 23 2013 8 Visual Acuity XL The most reliable acuity tests used today follow the logMAR design recommended by the National Eye Institute NEI and the International Council of Ophthalmology ICO to address design flaws in the 150 year old Snellen chart the charts provided by Visual Acuity XL follow this logMAR design by implementing a geometric progression of letter sizes and proportional spacing between letters with st
57. your device display or for cold days when you don t want to remove your gloves It is also conveniently designed to attach to your device via the 3 5mm headset jack Visual Acuity XL User Guide version 1 4 June 23 2013 57 Provider http www boxwave com Price US 19 95 Protection The ClearTouch Antiglare screen protector provides in addition of scratches protection the perfect blend of antiglare and optical clarity with maximum screen readability under sunlight and various outdoor lighting conditions This screen protector is particularly useful to minimize the reflections due to the glossy nature of the iPad display Provider http Awww boxwave com Price US 24 95 One of the numerous skin cases available for the iPad The QuadGrip FlexiSkin for the Apple iPad is an ultra low profile skin case designed for complete usability Precision constructed with antistatic material the QuadGrip FlexiSkin skin case provides reliable protection from unwanted dust and accidental bumps and adds extra grip ergonomically Provider http www boxwave com Price US 22 95 ff Visual Acuity XL User Guide version 1 4 June 23 2013 58 Stand amp Wall Mounting The BookArc tabletop stand for iPad provides a choice of four different positions In work mode iPad sits at an angle in both portrait and landscape positions and provides access to the home button In storage mode iPad sits upright in both portrait and

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