Threshold visual acuity testing of preschool children using the crowded HOTV and Lea Symbols acuity tests

Purpose: To compare the testability and threshold acuity levels for very young children on the crowded HOTV logMAR distance visual acuity test presented on the BVAT apparatus and the Lea Symbols logMAR distance visual acuity chart. Methods: Subjects were 87 Head Start children from age 3 to 3.5 years. Testing consisted of binocular pretraining at near using a lap card as needed, binocular pretraining at 3 m, and threshold testing for each eye. The testing procedure, adapted from the Amblyopia Treatment Study, presented optotypes until the child was unable to correctly name or match three of three or three of four optotypes of a given size. Threshold acuity was the smallest size for which at least three optotypes were correctly identified. Results. Both near and distance pretraining were completed by 71% of children for HOW and by 75% for Lea Symbols (P = .39). The distribution of threshold acuities differed between the two tests. For the 69 eyes of 53 children who were successfully tested with both optotypes, results from the crowded HOW acuity test were on average 0.25 logMar (2.5 lines) better than those from the Lea Symbols acuity test (P < .001). Conclusions. The proportion of children between 3 and 3.5 years of age whose monocular visual acuity could be assessed was high and was similar for the two charts tested. Crowded HOW acuity results were better on average than results using Lea symbols. The different formats of the two tests may explain the observed differences in threshold acuity level.