Validation of printed and computerised crowded Kay picture logMAR tests against gold standard ETDRS acuity test chart measurements in adult and amblyopic paediatric subjects

Eye (Lond). 2012 Apr;26(4):593-600. doi: 10.1038/eye.2011.333. Epub 2011 Dec 23.


Aims: The impression exists that picture acuity scores may overestimate function when subjects are switched to letter charts. This has not been systematically investigated. The aims of this study were to validate both printed crowded Kay picture (pCKP) and computerised CKP (cCKP) logMAR test acuity measurements against gold standard ETDRS letter chart scores.

Methods: A total of 30 adult subjects with various ophthalmic disease and 40 amblyopic children underwent test and re-test visual acuity measurements using the ETDRS chart, the pCKP logMAR test, and the cCKP acuity scores taken, using the COMPlog visual acuity measurement system. Bland and Altman methods were employed.

Results: Computerised and printed Kay picture acuity scores agreed well. Both Kay picture test measurements were systematically biased when compared with ETDRS chart measurements. No significant proportional bias was found. The test retest variability (TRV) of all three tests was found to be similar between ± 0.14 and 0.16 logMAR in both groups.

Conclusions: All three tests were similarly replicable and computerised Kay pictures appear to be a valid alternative to hard copy Kay pictures. Kay picture acuity measurements were systematically biased when compared with the gold standard ETDRS. Measurement error means that differences of up to 0.16 logMAR may be observed in clinically stable patients when re-measured using the same technique. A combination of TRV and systematic bias can however lead to differences of up to 0.40 logMAR in stable amblyopic patients when switched from CKPs to ETDRS chart acuity measurements.

Publication types

  • Validation Study

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Algorithms
  • Amblyopia / diagnosis*
  • Amblyopia / physiopathology
  • Diagnosis, Computer-Assisted / instrumentation
  • Diagnosis, Computer-Assisted / methods*
  • Diagnosis, Computer-Assisted / standards
  • Female
  • Humans
  • Male
  • Middle Aged
  • Reference Standards
  • Reproducibility of Results
  • Vision Tests / instrumentation
  • Vision Tests / methods*
  • Vision Tests / standards
  • Visual Acuity / physiology