Measuring Resolution in the Contrast Domain: The Small Letter Contrast Test

Background Recent evidence suggests that small letter contrast sensitivity (CS) is more sensitive than visual acuity (VA) to defocus, luminance, binocular enhancement, and visual differences among pilot trainees. It would be valuable to make this test available for general use. We developed a hard copy (letter chart) version called the Small Letter Contrast Test (SLCT) and evaluated its sensitivity and reliability in comparison to standard vision tests. Methods The SLCT has 14 lines of letters with 10 letters per line. The letters are of constant size (20/25 or 4/5 at 4 m), but vary in contrast by line in 0.1 log steps (0.01 log units per letter). Normal room illumination is used. The SLCT was evaluated in 16 subjects under various conditions (spherical and astigmatic blur, low luminance, 2 eyes vs. 1 eye) to determine test sensitivity and reliability, and in patients with clinical conditions. Scores were compared to those obtained with standard tests of VA (Bailey-Lovie) and CS (Pelli-Robson). Results SLCT scores were similar to previous measures, and retest reliability was one line. The SLCT was more sensitive than VA to spherical and astigmatic blur, low luminance, and vision with two eyes vs. one eye. Greater sensitivity of the SLCT endured despite correction for variability. The SLCT was more sensitive than standard tests to visual loss from early cataract, keratoconus, corneal infiltrates, edema, and amblyopia. Conclusions The SLCT is a sensitive, adjunctive test, which complements existing measures of VA. It can reveal subtle visual deficits that may be undetected by standard clinical techniques. The SLCT should prove useful for monitoring vision in refractive surgery, corneal and macular edema, optic neuritis, and for selection and evaluation of candidates for occupations requiring unique visual abilities like aviation.