Visual Acuity and Pupil Testing for the COA®: Snellen, Pinhole, and the Swinging Flashlight Test

Visual Assessment and Pupil Assessment are each 7% of IJCAHPO’s COA® content areas effective 8/1/2025. Test acuity one eye at a time and record eye, correction and the smallest line read. A pinhole helps show whether reduced acuity is refractive. For pupils, check size and reaction, then swing a light between the eyes to look for an RAPD.

Last checked Nov 2, 2026. Confirm fees and dates with the certifying body. optical.education is independent and is not affiliated with or endorsed by IJCAHPO. Disclaimer.

Exam study material, not clinical training; the simulators are practice aids, not diagnostic tools. Follow your clinic’s protocol.

Weights

Visual Assessment 7% and Pupil Assessment 7% of the COA content areas effective 8/1/2025 (checked Nov 2, 2026).

Visual acuity: distance, near and low vision

• Test one eye at a time, with the other covered.
• Test distance and near vision, with correction if the patient wears it, or as the clinic requires.
• If the patient can’t read the largest letter, step down: count fingers (CF) at a stated distance, hand motion (HM), light perception (LP), or no light perception (NLP).

Practice notation on the visual acuity simulator; it explains partial lines and abbreviations.

Pinhole

Use pinhole when acuity is reduced. A pinhole only compensates for refractive error, so improvement points to a refractive component, while no improvement suggests something else, such as disease, is limiting vision. Improvement does not rule disease out, since a refractive error and an eye disease can be present together. Record the pinhole result next to the original.

Pupils: size, reaction and the swinging flashlight test

Three things are being checked: whether the two pupils match in size, whether light makes them smaller, and, if the doctor asks for it, whether they get smaller for a near target. Light shone in one eye should make both pupils smaller: the lit eye’s response is called direct and the other eye’s is called consensual. Work in a darkened room with the patient fixing on a far target.

Finish with the swinging flashlight test. The light alternates between the eyes, a few seconds on each.

Practice on the swinging flashlight simulator.

Recording

Note whether the pupils matched and reacted normally, and whether an RAPD was seen and in which eye. Use your clinic’s format.

Practice questions

1. A patient reads the whole 20/30 line with glasses on the right eye. How do you record it?

   Show answer

   OD cc 20/30

2. Acuity is 20/60 and improves to 20/25 with pinhole. What does that suggest?

   Show answer

   A refractive cause is likely contributing. Pinhole improvement does not rule out eye disease; the doctor still evaluates the eye.

3. The patient can’t read the top letter but counts fingers at 3 feet. How is it recorded?

   Show answer

   CF 3 ft (count fingers at 3 feet)

4. When the light swings to the left eye, both pupils dilate. What is the finding?

   Show answer

   RAPD in the left eye (OS)