The neurology of visual acuity.

A series of patients with well defined lesions of various parts of the visual pathways was studied in an attempt to iluminate the neuropathophysiology of visual acuity. Acuity was found to remain normal in all cases with unilateral retrochiasmal lesions, including those of the optic tract. Bilateral retrochiasmal lesions involving the foveal nerve fibres on both sides impaired acuity to the same degree in both eyes. Lateral chiasmal lesions regularly produced impaired acuity in the ipsilateral eye. Midchiasmal lesions commonly led to an impairment of visual acuity in both eyes, usually asymmetrically, and roughly proportionate to the severity of the visual field defect. Compression optic neuropathy was found to reduce acuity in rough proportion to the severity of compression. It was concluded that acuity remains normal as long as either the crossing or the non-crossing neural outflow from the retinal fovea remains intact: acuity fails only when both sets of nerve fibres are compromised. A properly executed acuity test seems to be a powerful tool for detecting such conditions. The lower limit of normal acuity should never be set below 1.0 or 20/20: even this level is clearly subnormal in many subjects.