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Determining the Variability Associated with Visual Acuity and Refractive Error Measurements: A Systematic Review.

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Summary

Measurement variability for distance visual acuity (VA) and refractive error (RE) in adults is high, exceeding recommended limits. New studies are needed, but provisional limits of ±0.20 logMAR for VA and ±0.70 D for RE are suggested.

Keywords:
Limits of agreementMeasurement variabilityRefractive errorVision scienceVisual acuity

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Area of Science:

  • Ophthalmology and Optometry
  • Clinical Measurement Science

Background:

  • Accurate measurement of distance visual acuity (VA) and refractive error (RE) is crucial for effective eye care.
  • A scientific consensus on acceptable measurement variability for VA and RE is currently lacking.
  • Existing literature suggests variability limits of ±0.15 logarithm of the minimum angle of resolution (logMAR) for VA and ±0.5 diopters (D) for RE.

Purpose of the Study:

  • To systematically evaluate the measurement variability of distance visual acuity (VA) and refractive error (RE) in adult populations.
  • To compare current measurement variability against established or suggested clinical limits.

Main Methods:

  • A systematic review adhering to PRISMA guidelines, registered on PROSPERO (ID CRD42024554663).
  • Searches conducted across Medline, PubMed, and Embase databases.
  • Risk of bias assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool; Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) used for certainty of evidence.

Main Results:

  • Included 12 studies for VA and 6 for RE; 33% demonstrated low risk of bias in key domains.
  • In 69% of subgroups, limits of agreement (LoA) exceeded suggested variability ranges (VA: ±0.15 logMAR, RE: ±0.5 D).
  • Overall summarized mean LoA was ±0.20 logMAR for VA and ±0.70 D for RE, with very low certainty of evidence.

Conclusions:

  • Distance VA and RE measurements exhibit high variability in adults, surpassing suggested clinical limits.
  • Current evidence is insufficient to support proposed variability limits, often stemming from methodologically weak studies.
  • Propose provisional reference limits of ±0.20 logMAR for VA and ±0.70 D for RE, pending more rigorous research.