A reassessment and comparison of the Landolt C and tumbling E charts in managing amblyopia

Current criteria for amblyopia do not account for difference in visual acuity charts. This prospective observational study analyzed 100 children younger than 10 years treated at a tertiary referral center. Visual acuity was separately tested in each eye using Landolt C and tumbling E charts in a random order. For each chart, receiver operating characteristic curve analysis was performed to determine the best cutoff for visual acuity score. Main outcome measures included the difference in visual acuity scores between the two charts, the feasibility of repeated testing of visual acuity in each eye, and amblyopia cutoff values for each chart. Mean logMAR visual acuity scores obtained by tumbling E chart were significantly better than those obtained by Landolt C chart. For amblyopia, the best cutoff values were <  + 0.14 (20/27 Snellen equivalent) for tumbling E chart and <  + 0.24 (20/35 Snellen equivalent) for Landolt C chart. For children under 10 years old, visual acuity scores for tumbling E chart were significantly better than those for Landolt C chart. We suggest that amblyopia management in children should account for age and the type of visual acuity chart used.