Chromatic vision and structural assessment in primary congenital glaucoma

Primary congenital glaucoma is a rare disease that occurs in early birth and can lead to low vision. Evaluating affected children is challenging and there is a lack of studies regarding color vision in pediatric glaucoma patients. This cross-sectional study included 21 eyes of 13 children with primary congenital glaucoma who were assessed using the Farnsworth D-15 test to evaluate color vision discrimination and by spectral domain optical coherence tomography to measure retinal fiber layer thickness. Age, visual acuity, cup-to-disc ratio and spherical equivalent data were also collected. Global and sectional circumpapillary and macular retinal fiber layer thicknesses were measured and compared based on color vision test performance. Four eyes (19%) failed the color vision test with diffuse dyschromatopsia patterns. Only age showed statistical significance in color vision test performance. Global and sectional circumpapillary and macular retinal fiber layer thicknesses were similar between the color test outcomes dyschromatopsia and normal. While the color vision test could play a role in assessing children with primary congenital glaucoma, further studies are needed to correlate it with damage to retinal fiber layer thickness.

Comparison of Two Printed Pseudoisochromatic Tests for Color Vision Assessment

SIGNIFICANCE

The Waggoner PIP24 is a pseudoisochromatic test with a pattern similar to the Ishihara test. This study determined that the W-PIP24 can be used clinically to yield screening results (or sensitivity and specificity) comparable with the Ishihara.

PURPOSE

This study aimed to determine whether the W-PIP24 is equivalent to the Ishihara 38 edition pseudoisochromatic test in detecting red-green color vision defects. Also, the performance of each plate of the W-PIP24 in detecting the color vision defects relative to the Ishihara test was determined.

METHODS

Sixty-three individuals with congenital red-green color vision defects and 57 with normal trichromacy were recruited. Participants were tested with both the Ishihara and W-PIP24. The first-order agreement coefficients were calculated for the Ishihara and W-PIP24. The results were also analyzed using specificity, sensitivity, efficiency, and predictive pass and fail values.

RESULTS

The agreement between the W-PIP24 and Ishihara test using the recommended criterion of using all plates was perfect. The sensitivity, specificity, predictive pass, and predictive fail were 1.00 (95% confidence interval, 0.94 to 1.00).

CONCLUSIONS

This study showed that the W-PIP24 using a failure criterion of three or more errors on screening plates 1 to 15 is equivalent to the Ishihara test while screening for red-green color vision deficiency using a failure criterion of three or more errors on screening plates 1 to 17 of the Ishihara 38 edition.

Color Vision Deficiency Among Doctors: Can We Make Useful Adaptations to the Color Codes Used in the Clinical Environment?

ABSTRACT

Color vision deficiency (formerly known as color blindness) is common as a congenital and as an acquired condition. Some professions, most famously commercial aviation, require their members to demonstrate normal color vision. In the United States and United Kingdom, no restriction is placed on the ability of the color-deficient doctor to practice medicine, although there is evidence that certain clinical discriminations are harder for such doctors. Generally ignored has been the difficulty and the potential for error that arises from the use of color codes in clinical equipment. In this review, we introduce the basic concepts of color deficiency, summarize evidence for the challenges it poses to the doctor, examine global variation in policy, show the potential for confusion among clinical color codes, and suggest how the current situation could be improved to enhance both patient safety and the well-being of the color-deficient doctor.

The description of physical signs of illness in photographs by physicians with abnormal colour vision

BACKGROUND

Physicians with congenital colour vision deficiency (CCVD) have reported difficulties recognising certain physical signs of illness, for example, jaundice, red rashes and pallor, and interpreting coloured charts, diagrams and slide projections. However, there has been little study of the effects of CCVD on the performance of medical practitioners.

AIM

The aim of this study was to look for evidence of the effect of CCVD on the ability of physicians to recognise and describe physical signs of illness that have colour as either the main or an important feature.

METHOD

Twenty-three general practitioners with CCVD were shown 11 colour photographs depicting colour signs of illness and were asked to describe the signs they saw and rate their confidence in making their descriptions. Their responses were compared to those of 23 age-matched general practitioners with normal colour vision.

RESULT

General practitioners with CCVD compared to those with normal colour vision had less ability and confidence in detecting physical signs in the photographs and naming the colours.

CONCLUSIONS

The results of this study support other evidence that physicians with CCVD have difficulties detecting some colour signs of illness and naming the colours. Because of the use of photographs the extent of the problem in clinical practice is unknown but medical practitioners with CCVD should be aware of the possibility of failing to detect or correctly assess physical signs that are characterised by colour.

The effect of abnormal colour vision on the ability to identify and outline coloured clinical signs and to count stained bacilli in sputum

AIM

To determine if medical practitioners with congenital colour vision deficiencies (CCVD) are less able to identify and delineate the extent of coloured abnormal signs than those with normal colour vision.

METHOD

Twenty-two medical practitioners with CCVD and 17 with normal colour vision, matched for age and gender, were shown 10 photographs. They were asked to identify and outline the extent of the clinical sign in eight that were of vomit or stool (six of these showing fresh blood), one of a skin rash and for one to mark the position of bacilli in sputum stained by the Ziehl-Neelsen method.

RESULTS

There were statistically significant differences between the CCVD practitioners and those with normal colour vision in their ability to outline abnormalities in five of the six photographs that showed fresh blood, in the photograph of a rash and in marking the position of bacilli in the photograph of a stained slide.

CONCLUSION

Medical practitioners with CCVD are handicapped in their evaluation of the presence and extent of coloured clinical signs. Medical schools should ensure that students with CCVD are aware of their deficiency and know its severity, so they can take special care in clinical practice.

Interocular Symmetry of Foveal Cone Topography in Congenital Achromatopsia

Purpose: To determine the interocular symmetry of foveal cone topography in achromatopsia (ACHM) using non-confocal split-detection adaptive optics scanning light ophthalmoscopy (AOSLO). Methods: Split-detector AOSLO images of the foveal cone mosaic were acquired from both eyes of 26 subjects (mean age 24.3 years; range 8-44 years, 14 females) with genetically confirmed CNGA3- or CNGB3-associated ACHM. Cones were identified within a manually delineated rod-free zone. Peak cone density (PCD) was determined using an 80 × 80 μm sampling window within the rod-free zone. The mean and standard deviation (SD) of inter-cell distance (ICD) were calculated to derive the coefficient of variation (CV). Cone density difference maps were generated to compare cone topography between eyes. Results: PCD (mean ± SD) was 17,530 ± 9,614 cones/mm2 and 17,638 ± 9,753 cones/mm2 for right and left eyes, respectively (p = .677, Wilcoxon test). The mean (± SD) for ICD was 9.05 ± 2.55 µm and 9.24 ± 2.55 µm for right and left eyes, respectively (p = .410, paired t-test). The mean (± SD) for CV of ICD was 0.16 ± 0.03 µm and 0.16 ± 0.04 µm for right and left eyes, respectively (p = .562, paired t-test). Cone density maps demonstrated that cone topography of the ACHM fovea is non-uniform with local variations in cone density between eyes. Conclusions: These results demonstrate the interocular symmetry of the foveal cone mosaic (both density and packing) in ACHM. As cone topography can differ between eyes of a subject, PCD does not completely describe the foveal cone mosaic in ACHM. Nonetheless, these findings are of value in longitudinal monitoring of patients during treatment trials and further suggest that both eyes of a given subject may have similar therapeutic potential and non-study eye can be used as a control.

Behavioural and emotional issues among primary school pupils with congenital colour vision deficiency in the Federal Territory of Kuala Lumpur, Malaysia: A case-control study

Background: Congenital colour vision deficiency (CCVD) is an untreatable disorder which has lifelong consequences. Increasing use of colours in schools has raised concern for pupils with CCVD. This case-control study was conducted to compare behavioural and emotional issues among age, gender and class-matched pupils with CCVD and normal colour vision (NCV). Methods: A total of 1732 pupils from 10 primary schools in the Federal Territory of Kuala Lumpur were screened, of which 46 pupils (45 males and 1 female) had CCVD. Mothers of male pupils with CCVD (n=44) and NCV (n=44) who gave consent were recruited to complete a self-administered parent report form, Child Behaviour Checklist for Ages 4-18 (CBCL/ 4-18) used to access behavioural and emotional problems. The CBCL/ 4-18 has three broad groupings: Internalising, Externalising and Total Behaviour Problems. Internalising Problems combines the Withdrawn, Somatic Complaints and Anxiety/ Depression sub constructs, while Externalising Problems combines the Delinquent and Aggressive Behaviour sub constructs. Results: Results from CBCL/ 4-18 showed that all pupils from both groups had scores within the normal range for all constructs. However, results from the statistical analysis for comparison, Mann-Whitney U test, showed that pupils with CCVD scored significantly higher for Externalising Problems (U=697.50, p=0.02) and Total Behaviour Problems (U=647.00, p= 0.01). Significantly higher scores were observed in Withdrawn (U=714.00, p=0.02), Thought Problems (U=438.50, p<0.001) and Aggressive Behaviour (U=738.00, p=0.04). Odds ratios, 95% CI, showed significant relative risk for high Total Behaviour Problem (OR:2.39 ,CI:1.0-5.7), Externalising Problems (OR:2.32, CI:1.0-5.5), Withdrawn (OR:2.67, CI:1.1-6.5), Thought Problems (OR:9.64, CI:3.6-26.1) and Aggressive Behaviour (OR:10.26, CI:3.4-31.0) scores among pupils with CCVD. Conclusion: Higher scores among CCVD pupils indicates that they present more behavioural and emotional problems compared to NCV pupils. Therefore, school vision screenings in Malaysia should also include colour vision to assist in the early clinical management of CCVD children.

Causes and consequences of inherited cone disorders

Hereditary cone disorders (CDs) are characterized by defects of the cone photoreceptors or retinal pigment epithelium underlying the macula, and include achromatopsia (ACHM), cone dystrophy (COD), cone-rod dystrophy (CRD), color vision impairment, Stargardt disease (STGD) and other maculopathies. Forty-two genes have been implicated in non-syndromic inherited CDs. Mutations in the 5 genes implicated in ACHM explain ∼93% of the cases. On the contrary, only 21% of CRDs (17 genes) and 25% of CODs (8 genes) have been elucidated. The fact that the large majority of COD and CRD-associated genes are yet to be discovered hints towards the existence of unknown cone-specific or cone-sensitive processes. The ACHM-associated genes encode proteins that fulfill crucial roles in the cone phototransduction cascade, which is the most frequently compromised (10 genes) process in CDs. Another 7 CD-associated proteins are required for transport processes towards or through the connecting cilium. The remaining CD-associated proteins are involved in cell membrane morphogenesis and maintenance, synaptic transduction, and the retinoid cycle. Further novel genes are likely to be identified in the near future by combining large-scale DNA sequencing and transcriptomics technologies. For 31 of 42 CD-associated genes, mammalian models are available, 14 of which have successfully been used for gene augmentation studies. However, gene augmentation for CDs should ideally be developed in large mammalian models with cone-rich areas, which are currently available for only 11 CD genes. Future research will aim to elucidate the remaining causative genes, identify the molecular mechanisms of CD, and develop novel therapies aimed at preventing vision loss in individuals with CD in the future.

[A case of rod monochromasia]

A case of rare genetic disease rod monochromasia which is often called total congenital cone dysfunction (syn. congenital cone dystrophy, congenital achromatopsia) is presented. Symptoms and signs of the disease are described in details and methods for improvement of patient's condition are indicated.

Prevalence of congenital color vision defects in Saudi females of Arab origin

BACKGROUND

Inherited color vision deficiencies (CVD) vary in prevalence by population and by sex. The most common CVD is X chromosome-linked anomalous trichromacy. Prevalence varies significantly by sex and race. The frequency of color vision defects in Saudi females has not been studied previously. This study surveyed the prevalence of congenital color vision defects in Saudi females of Arab origin.

METHODS

Seven thousand four hundred sixty-seven female subjects (N = 7,467) from the Kingdom of Saudi Arabia were screened using both Ishihara pseudoisochromatic plates and the Farnsworth Dichotomous test (D-15). CVD subjects were tested further with the Farnsworth-Munsell 100 Hue test.

RESULTS

Of 7,467 female subjects tested, 26 subjects were found to have defective color vision, for a prevalence of 0.35%. Sixteen subjects had a deutan defect, and 10 had a protan defect. Arab females have significantly lower prevalence of CVD when compared with published data from females of other races. Analysis of the 5 regions of Saudi Arabia showed no significant difference between the regions.

CONCLUSION

Prevalence of CVD among Saudi females of Arab origin is 0.35% and is among the lowest of all published data.

[Comparative follow-up study of unselected male population with congenital defective color vision from inland and Mediterranean areas of Croatia]

AIM

The aim of this ten-year study (from the end of 1998 to the end of 2008) was to assess the prevalence of congenital dyschromatopsia in unselected healthy male population aged 15-45 from two Croatian regions, i.e. inland and Mediterranean parts of Croatia. Results collected in these two regions were compared and respective conclusions drawn. The results primarily referred to the prevalence of color vision disturbances and their differences according to the main color groups (dichromacy and anomalous trichromacy) and subgroups (protanopia, deuteranopia, protanomaly, deuteranomaly, and others). To our knowledge, no such a long-term study in a large population sample has been carried out in southeast Europe to date.

METHODS

Color vision was examined after complete ophthalmologic examination in all subjects presenting for examination required for amateur driver license. Color vision examination was performed by use of pseudoisochromatic Ishihara tables, Nagel II anomaloscope and Panel D-15 color test at industrial medicine offices and ophthalmology departments in the two regions. There were 12,974 and 9,974 subjects in inland and Mediterranean Croatia, respectively.

RESULTS

The results confirmed the hypothesis and clinical perception of a lower prevalence of color vision disturbances in southern parts, i.e. in Mediterranean Croatia (8.50%) as compared with inland Croatia (8.90%). The rate of dichromacy was higher in Mediterranean Croatia (2.40%), while the rate of anomalous trichromacy was greater in inland Croatia (6.93%).

CONCLUSION

The results of this study provide better insight in the status of color vision disturbances and possible differences between the relatively close areas of north (inland) and south (Mediterranean) Croatia.

Adaptive optics retinal imaging: emerging clinical applications

The human retina is a uniquely accessible tissue. Tools like scanning laser ophthalmoscopy and spectral domain-optical coherence tomography provide clinicians with remarkably clear pictures of the living retina. Although the anterior optics of the eye permit such non-invasive visualization of the retina and associated pathology, the same optics induce significant aberrations that obviate cellular-resolution imaging in most cases. Adaptive optics (AO) imaging systems use active optical elements to compensate for aberrations in the optical path between the object and the camera. When applied to the human eye, AO allows direct visualization of individual rod and cone photoreceptor cells, retinal pigment epithelium cells, and white blood cells. AO imaging has changed the way vision scientists and ophthalmologists see the retina, helping to clarify our understanding of retinal structure, function, and the etiology of various retinal pathologies. Here, we review some of the advances that were made possible with AO imaging of the human retina and discuss applications and future prospects for clinical imaging.

Color vison deficiency among medical students: an unnoticed problem

Color vision deficiency, most of the time remains an unnoticed problem; although it is not very rare. The faculty of appreciation of color is essential for our smooth daily activities. Unfortunately, even many doctors do not know the severity of their color vision deficiency and tend to assume it as slight, and a few, as in the general population, do not know about their disability. Some common difficulties reported by medical practitioners and medical students were in recognizing- widespread body color changes (pallor, cyanosis, jaundice, rashes, erythema of skin), colorful charts, slides, test-strips for blood and urine, body products: blood or bile in urine, faeces, sputum, vomit, microscopy, mouth and throat conditions, impressions presented in the Ishihara chart, titration end-points, tissue identification (surgery) etc. The present study was undertaken to evaluate the presence of congenital color vision deficiencies among the medical students. The study was carried out among the 1st and 2nd year medical students of Nepal Medical College and Teaching Hospital (n= 120) with the help of Ishihara chart, that was shown to all participants. They were asked to read the impressions in the color chart. The impression perceived by a person with normal color vision was different from the impression perceived by a person with color vision deficiency. It was noted that, among the study population (n=120) 5.83% of the volunteers were color weak. Amongst the color-deficient volunteers, 57.0% were protanopic while 43.0% were deuteranopic. Medical students must be made aware of their congenital color vision deficiency and its effects on their work. Screening will enable the student and later the doctor to become aware of limitations in their powers of observation and devise ways of overcoming them; the patient will be protected from harm and litigation may be avoided when doctors have adapted their practice to their deficiency. Medical students and physicians must be screened for color vision deficiency and advised about it so they can take special care in clinical practice.

Congenital Color Blindness in Young Turkish Men

We investigated a healthy population of men from different regions of Turkey for the presence of congenital red-green color blindness. Using Ishihara pseudoisochromatic plates, 941 healthy men from the Turkish army were tested for congenital red-green color blindness. The prevalence of red-green color blindness was 7.33 +/- 0.98% (5.10% protans and 2.23% deutans). These ratios were higher than other reported samples from Mediterranean Europe. Higher percentages of color blindness were found in regions with a lower education level and more consanguineous marriages.

Testing of colour vision for vocational purposes

All red-green defects of colour vision can be effectively screened with a combination of two pseudo- isochromatic tests. Severe (major) colour vision defects regarded as a serious handicap in all occupations needing colour naming ability can be quickly detected with the Panel D-15 dichotomous test. Only a trained ophthalmologist can make the detailed estimation of the type and degree of the colour vision defect with the aid of the anomaloscope and the Farnsworth-Munsell 100-hue test. In the diagnosis of a congenital colour vision defect the exclusion of an eye disease with a consecutive acquired colour vision defect is important.

[Comparison of congenital color vision deficiencies prevalence between Han and Uygur high-school students]

OBJECTIVE

A population-based study was conducted to compare the prevalence of congenital color vision deficiencies (CVD) in high-school students of Uygur and Han nationalities in Xinjiang Uygur autonomous region.

METHODS

Students from 7 high schools were examined with pseudoisochromatic color plates and further with Farnsworth Munsell 100 test. The chi-square test was applied to compare categorical variables, and the independent-samples t test was used to compare the measure data.

RESULTS

In the study population of 3764 Uygur students, 88 students had CVD, including 69 males and 19 females. 48 of 2055 Han students were diagnosed with CVD, including 46 males and 2 females. No significant difference existed in the prevalence of CVD in boys between two nationalities. The prevalence of CVD in Uygur girls was higher than that in Han girls.

CONCLUSIONS

No significant difference was found in the prevalence of CVD in boys between two nationalities. The prevalence of CVD in Uygur girls was higher than that in Han girls.

Retinal nerve fiber layer thickness in congenital color vision deficiency

PURPOSE

To evaluate the thickness of the retinal nerve fiber layer (RNFL) in subjects with congenital red-green color vision deficiency (CVD).

METHODS

This study included 20 healthy subjects with congenital red-green CVD and 22 healthy subjects with normal color vision. After Ishihara test and examinations visual field by automated perimetry, all individuals underwent scanning laser polarimetry to measure the thickness of the RNFL.

RESULTS

All scanning laser polarimetry parameters related to RNFL thickness were found to be similar in subjects with congenital CVD and normal color vision (p>0.05).

CONCLUSIONS

This is the first report suggesting normal thickness of the RNFL in subjects with congenital red-green CVD.

A New Color Vision Test to Differentiate Congenital and Acquired Color Vision Defects

PURPOSE

To investigate the efficacy of a novel computer-controlled color test for the differentiation of congenital and acquired color vision deficiency.

DESIGN

Observational cross-sectional study.

PARTICIPANTS

Thirty-one patients with congenital color vision deficiency and 134 patients with acquired color vision deficiency with a Snellen visual acuity better than 20/30 underwent an ophthalmologic examination including the Ishihara color test, Hardy-Rand-Rittler test, Nagel anomaloscopy, and the Seohan computerized hue test between June, 2003, and January, 2004.

METHODS

To investigate the type of color vision defect, a graph of the Seohan computerized hue test was divided into 4 quadrants and error scores in each quadrant were summated. The ratio between the sums of error scores of quadrants I and III (Q1+Q3) and those of quadrants II and IV (Q2+Q4) was calculated.

MAIN OUTCOME MEASURES

Error scores and ratio in quadrant analysis of the Seohan computerized hue test.

RESULTS

The Seohan computerized hue test showed that the sum of Q2+Q4 was significantly higher than the sum of Q1+Q3 in congenital color vision deficiency (P<0.01, paired t test) and that the sum of Q2+Q4 was significantly lower than the sum of Q1+Q3 in acquired color vision deficiency (P<0.01, paired t test). In terms of discriminating congenital and acquired color vision deficiency, the ratio in quadrant analysis had 93.3% sensitivity and 98.5% specificity with a reference value of 1.5 by the Seohan computerized hue test (95% confidence interval).

CONCLUSIONS

The quadrant analysis and ratio of (Q2+Q4)/(Q1+Q3) using the Seohan computerized hue test effectively differentiated congenital and acquired color vision deficiency.

Optical coherence tomography of the macula in congenital achromatopsia

PURPOSE

It is known that symptoms of congenital achromatopsia are caused by the lack of functioning cones, but there are very few published data on histologic changes in the retina in these cases. This study was conducted to examine in vivo the anatomic structure of the retina of patients with achromatopsia.

METHODS

Fifteen eyes of eight patients with congenital achromatopsia and 18 eyes of nine control subjects were examined by optical coherence tomography. Radial 6-mm scans were taken of the macula. The thickness of the neuroretina was measured both automatically and manually. Measurements were taken at the foveola and at distances of 1.5 and 3 mm. Total macular volume and the retinal thickness in the nine ETDRS regions were also calculated.

RESULTS

In patients with achromatopsia, statistically significant reductions were found in total macular volume and in the thickness of the central retina. Remarkable differences were found between the results obtained from different methods of measuring retinal thickness. Automated methods underestimated retinal thickness compared with manual measurements.

CONCLUSIONS

The structure of the macula in achromats differs from that in normal subjects. A possible reason for the structural alteration is the qualitative and/or quantitative disorder of the cone photoreceptors, as the morphologic change is most expressed in the foveola. The automated methods are not always suitable for measuring retinal thickness in the foveola. The structural changes seen in the central retina of the patients could provide useful information for future gene therapy.

AcrySof Natural SN60AT versus AcrySof SA60AT intraocular lens in patients with color vision defects

PURPOSE

To determine whether implantation of the AcrySof Natural intraocular lens (IOL) worsened the severity of existing color deficit in congenital partial red-green color deficient individuals (CPRG).

METHODS

A prospective controlled randomized double-masked analysis of 30 consecutive patients with CPRG defect and bilateral cataracts received a Natural IOL (test group) in 1 eye and a single-piece AcrySof IOL (control group) in the other eye. Patients were tested unilaterally to detect CPRG defect using Ishihara pseudoisochromatic plates and the Farnsworth D-15 test. Plates 1 to 21 measured the Ishihara error score; plates 22 to 25 indicated severity of defect based on clarity of both numerals as partial mild/moderate (both visible), partial severe defect (only 1 visible). The D-15 test is based on number of diametrical crossings on the circular diagram; severity is graded as mild (1 crossing), moderate (2 crossings), or severe (>2 crossings). Tests were performed before and after IOL implantation at 1, 3, and 6 months. At mean follow-up of 6.13 months +/- 1.2 (SD), analysis of variance test judged the difference in error scores and cross tabulation represented change in number of diametrical crossings.

RESULTS

The mean age was 62.3 +/- 8.5 years. All patients were men. Before IOL implantation, all patients had moderate CPRG defect on both tests. The Ishihara error score in the test and control groups did not reveal statistically significant differences (P = .505 and P = .119, respectively). With D-15, none of the patients in the test or control group showed >2 crossings.

CONCLUSION

The implantation of AcrySof Natural IOL did not worsen the preexisting severity of color defect in CPRG individuals.

Impact of congenital colour vision defects on occupation

AIMS

To investigate whether there is an association between congenital colour vision defects (CVD) and occupational choice and employment history, in order to inform the debate about the value of universal childhood screening for these disorders.

METHODS

Participants were 6422 males and 6112 females from the 1958 British birth cohort, followed from birth to 33 years, whose colour vision was assessed (Ishihara test) at 11 years.

RESULTS

A total of 431 males (6.7%) had CVD. Men with CVD had pursued some careers for which normal colour vision is currently regarded as essential; for example, eight men (3.1%) with CVD were in the police, armed forces, or fire-fighting service at 33 years compared to 141 men (3.8%) with normal colour vision. They were, however, under-represented compared to those with normal colour vision, in other occupations; for example, no men with CVD were employed in electrical and electronic engineering at 33 years compared to 15 men (0.4%) with normal colour vision.

CONCLUSIONS

The findings of this study suggest there is little to be gained by continuing with existing school screening programmes for CVD, whose primary purpose is to advise affected children against certain careers. Other ways of informing young people about potential occupational difficulties and pathways for referral for specialist assessment are likely to be more useful.

Blue cone monochromatism: a phenotype and genotype assessment with evidence of progressive loss of cone function in older individuals

AIM

To perform a detailed clinical and psychophysical assessment of the members of three British families affected with blue cone monochromatism (BCM), and to determine the molecular basis of disease in these families.

METHODS

Affected and unaffected members of three families with BCM were examined clinically and underwent electrophysiological and detailed psychophysical testing. Blood samples were taken for DNA extraction. The strategy for molecular analysis was to amplify the coding regions of the long wavelength-sensitive (L) and middle wavelength-sensitive (M) cone opsin genes and the upstream locus control region by polymerase chain reaction, and to examine these fragments for mutations by direct sequencing.

RESULTS

We have confirmed the reported finding of protan-like D-15 arrangements of patients with BCM. In addition, we have demonstrated that the Mollon-Reffin (MR) Minimal test is a useful colour-discrimination test to aid in the diagnosis of BCM. Affected males were shown to fail the protan and deutan axes, but retained good discrimination on the tritan axis of the MR test, a compelling evidence for residual colour vision in BCM. This residual tritan discrimination was also readily detected with HRR plates. In two families, psychophysical testing demonstrated evidence for progression of disease. In two pedigrees, BCM could be linked to unequal crossovers within the opsin gene array that resulted in a single 5'-L/M-3' hybrid gene, with an inactivating Cys203Arg mutation. The causative mutations were not identified in the third family.

CONCLUSIONS

The MR test is a useful method of detecting BCM across a wide range of age groups; residual tritan colour discrimination is clearly demonstrated and allows BCM to be distinguished from rod monochromatism. BCM is usually classified as a stationary cone dysfunction syndrome; however, two of our families show evidence of progression. This is the first report of progression associated with a genotype consisting of a single 5'-L/M-3' hybrid gene carrying an inactivating mutation. We have confirmed that the Cys203Arg inactivating mutation is a common sequence change in blue cone monochromats.

Clinical heterogeneity between two Japanese siblings with congenital achromatopsia

Congenital achromatopsia is a stationary retinal disorder with autosomal recessive inheritance. It is characterized by significant attenuation of cone-photoreceptor function. Symptoms include photophobia, nystagmus, and poor visual acuity from birth. Unlike in cone or cone-rod dystrophies, the retinal fundus usually appears normal. Here we describe two siblings with congenital achromatopsia, who exhibit different ophthalmic phenotypes. History was taken, and ophthalmic examinations were performed in a 7-year-old girl and her 5-year-old brother, who were referred to our department because of poor visual acuity. Two of their grandparents were brother and sister, suggesting an autosomal recessive transmission in inheritance. They have been followed for more than 13 years since the initial evaluation. Symptoms, visual acuity, and kinetic visual field were very similar to each other, consistent with findings of typical congenital achromatopsia. However, color-vision tests suggested that the brother had residual color discrimination, but the sister did not. The siblings had different full-field electroretinographic and spectral-sensitivity findings: residual cone functions were detected in only the brother, in agreement with his residual color vision. They also had different findings of retinal fundi and ocular refractions: the sister had bilaterally atrophic-appearing macular lesions and myopic errors. In contrast, the brother remains hyperopia and has exhibited no specific retinal findings until age 18 years. The causes why both complete and incomplete achromats occur in the siblings are uncertain but might be caused by modifying effects of sex-related genes or by environmental factors influencing certain gene regulations in cone photoreceptors.

Color vision testing

The science of color vision testing has evolved since its inception in the late 1700s. Since then, the rudimentary technique of comparing color names has been replaced by more sophisticated methods. Commonly used tests in clinical practice today include isochromatic plates, arrangement tests, anomaloscopes, and lantern tests. Each category has unique attributes that make it suitable for a particular clinical situation. The clinician should be aware of the requirements for administering and grading each test type. Factors such as the quality of the illuminant and the size of the field of view are important elements in setting up a proper color vision laboratory. Currently, no treatment exists for congenital color vision defects. However, studies show that diagnosis of these defects early in life may help children adjust better to tasks at school and may help adults understand their limitations at work. Acquired color vision defects are often used as markers of ocular pathology in the clinical setting. Different color vision tests are appropriate for diagnosing the different categories of defects. Sometimes, a battery of tests may be appropriate. This paper is a review of the current knowledge in the field of color vision testing.

[Molecular genetic findings in patients with congenital cone dysfunction. Mutations in the CNGA3, CNGB3, or GNAT2 genes]

PURPOSE

This study compares clinical and molecular genetic findings in patients with congenital cone dysfunction.

METHODS

In this study 28 patients underwent a basic ophthalmologic examination. Except for a 1-year-old boy, color vision, perimetry, and full-field ERG (ISCEV standard) were evaluated in all patients. Blood samples were taken for molecular genetic analysis of the CNGA3, CNGB3, or GNAT2 genes.

RESULTS

Two patient groups could be distinguished: patients without and with residual cone function in the ERG. In 14 of 17 patients without cone function, mutations in one of the three genes were detected, and except for one patient mutations in both alleles could be determined. In these patients, visual acuity was reduced to 20/400 and color discrimination was absent. In 2 of 11 patients with residual cone function, mutations in one allele of the CNGB3 gene were detected. It is of interest that 6 of 16 patients with mutations perceived their disease as progressive; in three of them we could determine a progression. Only in 4 of 16 patients was the ocular fundus normal. The other patients with mutations presented with central pigment irregularities, attenuated vessels, or pale optic disk.

CONCLUSION

In patients with congenital cone dysfunction without cone function in the ERG, an analysis of the CNGA3, CNGB3, or GNAT2 gene is advisable. In contrast, patients with residual cone function did not show clear association with mutations in one of the three genes. In patients with mutations, retinal alterations and nystagmus are frequent. In contrast to the designation of these disorders as stationary, in some patients with mutations in the CNGA3 and CNGB3 gene slow progression was observed.

[Congenital achromatopsia: electroretinogram in early diagnosis]

PURPOSE

Achromatopsia is a hereditary disease responsible for congenital low vision. Patients present with nystagmus, abnormal visual behavior or photophobia. Only the electroretinogram (ERG) can confirm the diagnosis in infants.

PATIENTS AND METHODS

Thirty children referred for nystagmus or low vision were included in this retrospective study. A complete ophthalmological examination, an ERG and when possible a color vision test (Ishihara, Farnsworth 15 Hue test) was done. A Ganzfeld ERG was performed in accordance with ISCEV standards in patients more than 6 years of age. In younger patients, a simplified method using electroluminescent diode stimulation was used and a comparative ERG in accordance with ISCEV standards was performed when the patients were old enough.

RESULTS

The ERG response was identical in children and adults. It confirmed the diagnosis of achromatopsia: the scotopic components obtained in dark adapted conditions were normal, (scotopic a-wave, b2 wave). The photopic components, recorded in light-adapted conditions, in order to inhibit the scotopic response (photopic wave, b1 wave), were not recordable. The color vision tests confirmed color blindness; however, in some patients color denomination was correct.

CONCLUSION

The simplified ERG procedures performed in our series were reliable in detecting achromatopsia. However, it may not be sufficient to discriminate complete from incomplete achromatopsia.

[Quantitative criteria for the evaluation of congenital chromatic vision disorders]

The minimum angular size of a color stimulus required for its discrimination has been ascertained to be a quantitative criterion for evaluating the form and degree of congenital chromatic visual diseases. Unlike individuals with normal color perception who distinguish all basic and intermediate colors despite their saturation, anomalous trichromats discriminate more saturated colors with larger angular sizes of stimuli than those with normal color perception. Mild and moderate anomalous trichromats do not discriminate lowly saturated colors or for this they require the angular sizes tens of times greater those for normal trichromats. Persons with severe chromatic visual diseases (Type A) do not distinguish moderately saturated colors either. On recognizing the color of test objects, anomalous trichomats make the most mistakes in perceiving the green and yellow colors, the fewest mistakes in perceiving the red color. The minimum angular sizes required to distinguish colors, the percent of errors in their discrimination, and the range of vision of safety signs depend on the form and degree of congenital chromatic diseases. This makes it necessary to apply a differential approach to providing jobs that require rapid and accurate color discrimination in persons with the protanomalous forms of chromatic pathology.

Repeatability of the C-100 colour vision test

BACKGROUND

The C-100 colour vision test has been shown to have a high validity for diagnosing the type of red-green colour vision defect, however, there is little information on the repeatability of the test. This study examines the repeatability of the C-100 in classifying the colour vision defect as either protan or deutan.

METHODS

The C-100 was administered on two occasions to 58 subjects with congenital red-green colour vision defects. The sessions were separated by a minimum period of 10 days.

RESULTS

The repeatability of the C-100 was high with a kappa coefficient of agreement for diagnosis of 0.96. The few discrepancies were misclassifying protans as deutans.

CONCLUSION

The C-100 is a highly repeatable test in terms of separating protans from deutans. However, if a discrepancy occurs, it is more likely to be a protan misclassified as a deutan rather than vice versa.

Analysis of L-cone/M-cone visual pigment gene arrays in females by long-range PCR

The L-cone/M-cone visual pigment gene arrays were analyzed in a group of 63 Japanese females consisting of 7 applicants for examination of their carrier status, 14 color-deficient females, 6 obligate carriers with no genotypic data available for affected father or sons, and 36 color-normals. The first and the downstream genes, the entire region from the promoter to exon 6, were each amplified very efficiently by the long-range PCR to give products of 15.8 and 14.4 kb, respectively. The products were gel-purified and used as the template in the second PCR for exon 5. The region from intron 4 of the last genes, to the nearest neighbor gene, TEX28, was also efficiently amplified by the long-range PCR and the gel-purified products (27.5 kb) were used as the template in the second PCR for exon 5. The status of the 7 applicants was thought to be 3 non-carriers, 2 protan carriers and 2 deutan carriers. All of the 14 color-deficient females had unusual arrays in which an M gene was present as the first gene, an L gene(s) was present downstream, or a single L gene constituted both of the two arrays. One protanopic subject, A348, had an L gene as one of the first genes. The 6 obligate carriers also had unusual arrays with the exception of the mother of the A187, a male subject with pigment color defect. In the 36 color-normal individuals, 4 had downstream L genes. The long-range PCR method is useful for analysis of the L/M visual pigment genes.

Frequency of congenital dyschromatopsias in male population of the Split-Dalmatian County in Croatia

A population of 9974 healthy male subjects (aged 15-45 years) was screened for congenital dyschromatopsia. The study group consisted of subjects applying for a driving license in the Split-Dalmatian County between 1996 and 1999. The aim was to establish colour vision deficiency (dichromats) and borderline deficiencies (anomalous trichromats) in candidates through complete ophthalmologic examination including the Ishihara pseudoisocromatic plates, anomaloscope Nagel II, and Hue Lanthony colour test. The frequency of congenital dyschromatopsias was 8.48%. This frequency includes 2.39% dichromats (1.49% protanops and 0.90% deuteranopes) and 6.09% anomalous trichromats (1.27% protanomals, 4.20% deuteranomals, 0.21% extreme protanomals and 0.41% extreme deuteranomals). It is important to recognise and classify dyschromatopsias according to type and severity in order to avoid misinterpretation of results and consequent unjustified limitations imposed on anomalous trichromats in the selection of a profession.

Novel missense mutations in red/green opsin genes in congenital color-vision deficiencies

The DNAs from 217 Japanese males with congenital red/green color-vision deficiencies were analyzed. Twenty-three subjects had the normal genotype of a single red gene, followed by a green gene. Four of the 23 were from the 69 protan subject group and 19 of the 23 were from the 148 deutan subject group. Three of the 23 subjects had missense mutations. The mutation Asn94Lys (AAC-->AAA) occurred in the single green gene of a deutan subject (A155). The Arg330Gln (CGA-->CAA) mutation was detected in both green genes of another deutan subject (A164). The Gly338Glu (GGG-->GAG) mutation occurred in the single red gene of a protan subject (A89). Both normal and mutant opsins were expressed in cultured COS-7 cells and visual pigments were regenerated with 11-cis-retinal. The normal red and green opsins showed absorbance spectra with lambda(max) of 560 and 530 nm, respectively, but the three mutant opsins had altered spectra. The mutations in Asn94Lys and Gly338Glu resulted in no absorbance and the Arg330Gln mutation gave a low absorbance spectrum with a lambda(max) of 530 nm. Therefore these three mutant opsins are likely to be affected in the folding process, resulting in a loss of function as a visual pigment.

Effects of maternal occupational exposure to organic solvents on offspring visual functioning: a prospective controlled study

BACKGROUND

Previous studies in adults and animals with high level exposure to organic solvents suggested impairments in visual functioning. The objective of this pilot study was to examine the effects of maternal occupational exposure to organic solvents during pregnancy on offspring color vision and visual acuity, the development of which may be especially vulnerable to organic solvent exposure.

METHODS

We conducted a prospective cohort study of 32 offspring of women who were exposed occupationally to organic solvents during pregnancy compared with 27 nonexposed children. Monocular and binocular color vision and visual acuity were assessed using the Minimalist Test and the Cardiff Cards, respectively. Children with known hereditary color vision loss were excluded.

RESULTS

Solvent-exposed children had significantly higher error scores on red-green and blue-yellow color discrimination, as well as poorer visual acuity compared with the control group. Exposure index (an estimated measure of exposure intensity) was not significantly related to color discrimination or visual acuity score. Despite excluding all children with a known family history of color vision loss, clinical red-green color vision loss was found among 3 of the 32 exposed children compared with none of the matched controls.

CONCLUSIONS

These preliminary findings suggest that occupational exposure to organic solvents during pregnancy is associated with an increased risk of color vision and visual acuity impairment in offspring. The importance of routine visual function screening in risk assessment after prenatal exposure to chemicals warrants further attention.

Detection of female carriers of congenital color-vision deficiencies by visual pigment gene analysis

PURPOSE

Congenital color-vision deficiencies are frequent among males, 4.7-8.0%, suggesting that female carriers are present at a frequency of 9-15%. The purpose of this study was to determine whether carriers could be detected by analysis of the visual pigment genes.

METHODS

DNA from 29 males with congenital color-vision deficiencies, from their mothers, and from 117 randomly-selected females was analyzed. The most upstream genes, the downstream genes, and the most downstream genes in the red/green pigment gene arrays were amplified separately by PCR. Exon 5 of each gene was analyzed by single-strand conformation polymorphisms (SSCP).

RESULTS

Analysis of the visual pigment genes suggests that one of the 29 mothers examined is a female protan and two others are carriers of both protan and deutan defects. The remaining 26 mothers were confirmed to be carriers of congenital color-vision deficiencies. Unusual patterns were observed in 15 (13%) of the randomly-selected females; among them, 5 appeared to be protan carriers and at least 4 to be deutan carriers.

CONCLUSIONS

Female carriers of congenital color-vision deficiencies can be detected by analysis of the visual pigment genes. Since the proportion of females showing unusual patterns was slightly higher than expected, some must be false-positives and require more detailed examination.

The luminance fall in anomaloscope examination: clinical examples

PURPOSE

The evaluation of the anomaloscope slope quotient in patients with acquired colour vision deficiency.

METHODS

Two patients with Stargardt's disease in combination with protanomaly and deuteranomaly, respectively, were selected and also 3 patients with a presumed dominant optic atrophy of the protan type. The anomaloscope examination was performed according to the Linksz procedure. The luminance fall was calculated as the slope quotient SQ:Y units luminance fall per X units width of the matching range.

RESULTS

The SQ of the 2 Stargardt patients was steeper than the SQ of congenital colour vision defectives, especially at the red end of the anomaloscope green-red mixture scale, indicating pathologic scotopization superimposed on the congenital deficiency. In optic atrophy of the protan type the SQ was flatter than in congenital deficiency, indicating that this deficiency has nothing to do with congenital protan deficiency.

CONCLUSION

Calculation of the slope quotient SQ is helpful for the diagnosis of acquired colour vision deficiency, especially when the subject also has a congenital colour vision deficiency or is supposed to have such a deficiency.

[The clinical application of different brightness and different saturation D-15 tests]

PURPOSE

To compare the clinical application of different brightness and different saturation D-15 tests.

METHODS

Eighteen normal subjects (30 eyes), 19 cases (38 eyes) of congenital color vision defects and 36 cases (59 eyes) of eye diseases were tested with Panel D-15 test, Hann's double D-15 test, middle and low saturation CAS-PI (Psychological Institute, Chinese Academy of Sciences) D-15 tests.

RESULTS

A few of the normal eyes made minor errors in the low saturation D-15 tests. All of the protanopes and deuteranopes could be detected correctly. Protanomalias and deuteranomalias showed normal arrange or some type of abnormal arranges in all of the 5 sets of D-15 tests. In sick eyes, the abnormal rates were the highest in the low saturation D-15 tests and the lowest in Panel D-15 test.

CONCLUSION

The five sets of different brightness and different saturation D-15 tests had similar efficiencies of detecting congenital color vision defects. The abnormal rates of CAS-PI(4/5)D-15 tests and the CAS-PI(2/5)D-15 tests were similar to those of Panel D-15 test and Hann's Double D-15 test. Both tests can be used in the clinical setting.

Anomaloscope examination: scotopization (the luminance fall)

PURPOSE

The evaluation of a criterion for the detection of pathologic scotopization in routine anomaloscope examination.

METHODS

Fifty congenital protan subjects, 50 congenital deutan subjects, 30 autosomal recessive congenital achromats, and 25 (44 eyes) acquired type I red-green defective subjects were selected. The anomaloscope examination was according to the Linksz procedure. The luminance fall was calculated as the slope quotient SQ: Y units luminance fall per X units width of the matching range.

RESULTS

The mean SQ was -0.01 for congenital deutan subjects, -0.40 for congenital protan subjects and -1.30 for congenital achromats. There was no overlap between the three groups. Pathologic scotopization was found in 98% of the eyes presenting with an acquired type I colour vision defect.

CONCLUSION

Calculation of the slope quotient SQ is helpful for the detection of pathologic scotopization in acquired colour vision deficiency.

[Analysis of fusion points in hybrid genes and gene deletion for congenital red-green color vision defects]

OBJECTIVE

To investigate gene deletion and the fusion points of hybrid genes in congenital red-green color vision defects.

METHODS

Genomic DNA was collected from 11 protans, 19 deutans and 5 normal controls. Promoter and exons 2-5 of the red and green pigment genes in these subjects were analyzed by using PCR-Heteroduplex-SSCP analysis. The origin and component of each individual gene were determined by comparison with the patterns of known sequence of the red and green visual pigment genes.

RESULTS

Fourteen out of the 30 patients with red-green color vision defects were found to have hybrid gene. The fusion points of the hybrid gene were located in exon 1-intron 1(4 cases), introns 2-3(5 cases) and intron 4 (5 cases).

CONCLUSION

The fusion point of a hybrid gene may occur in exon 1-intron 1 and intron 4 as well as in introns 2-3(including exon 3).

Medical students and congenital colour vision deficiency: unnoticed problems and the case for screening

The results are given of a questionnaire study to determine the range of difficulties that doctors notice in their work due to congenital colour vision deficiency (CCVD). The study is primarily qualitative. A questionnaire was sent to 40 self-selected doctors, 35 of whom were general practitioners (GPs). All were administered a number of colour vision tests to assess the type and severity of their deficiency. Many difficulties and some ways of overcoming them were reported. Those with a mild deficiency reported fewer difficulties and this relationship was significant. Twenty-three of the doctors also reported difficulties as medical students and their answers are given verbatim. The results are discussed in relation to other studies and data on colour vision. The reasons for and against screening medical students for this deficiency are considered and it is concluded that there is a strong case for screening.

Selective color constancy deficits after circumscribed unilateral brain lesions

The color of an object, when part of a complex scene, is determined not only by its spectral reflectance but also by the colors of all other objects in the scene (von Helmholtz, 1886; Ives, 1912; Land, 1959). By taking global color information into account, the visual system is able to maintain constancy of the color appearance of the object, despite large variations in the light incident on the retina arising from changes in the spectral content of the illuminating light (Hurlbert, 1998; Maloney, 1999). The neural basis of this color constancy is, however, poorly understood. Although there seems to be a prominent role for retinal, cone-specific adaptation mechanisms (von Kries, 1902; Pöppel, 1986; Foster and Nascimento, 1994), the contribution of cortical mechanisms to color constancy is still unclear (Land et al., 1983; D'Zmura and Lennie, 1986). We examined the color perception of 27 patients with defined unilateral lesions mainly located in the parieto-temporo-occipital and fronto-parieto-temporal cortex. With a battery of clinical and specially designed color vision tests we tried to detect and differentiate between possible deficits in central color processing. Our results show that color constancy can be selectively impaired after circumscribed unilateral lesions in parieto-temporal cortex of the left or right hemisphere. Five of 27 patients exhibited significant deficits in a color constancy task, but all of the 5 performed well in color discrimination or higher-level visual tasks, such as the association of colors with familiar objects. These results indicate that the computations underlying color constancy are mediated by specialized cortical circuitry, which is independent of the neural substrate for color discrimination and for assigning colors to objects.

Prevalence of congenital colour blindness among Inuit in East Greenland

PURPOSE

To establish whether congenital colour blindness among males is still rare in Inuit (Eskimos) as indicated previously in 1893 and 1930, especially in East Greenland, as demonstrated by Erik Skeller in 1950.

METHODS

The study was comprised mainly of school children. 540 Inuit in East Greenland were compared to 545 controls in East Greenland and Denmark examined by three sets of pseudoisochromatic plates (Ishihara 1932, original plate used by Skeller), Ishihara (1994), and standard P.P. 2 part Igaku-Shoin (1994).

RESULTS

Only 1.0% of male Inuit (3/290) are colour blind, a significantly lower incidence than the 8.7% among Danish males in Denmark (15/173). The prevalence was the same in the three control groups, Danes in East Greenland, immigrants and Danes in Denmark. Deuteranopia is the most common type. Females showed the same low prevalence in all four groups.

MAJOR CONCLUSIONS

Colour blindness is still remarkably low among Inuit in East Greenland as compared with the present three control groups.

Prevalence of congenital red-green color vision defects in Arab boys from Riyadh, Saudi Arabia

The prevalence of congenital red-green color vision defects (CVDS) is both racial and gender dependent. Red-green color vision defects (CVDS) have been screened for among Arab boys from Riyadh, Saudi Arabia, by using both the Ishihara plates and the D 15 test. The results indicate a prevalence of 2.93%. Deutan defect was present in 1.95% of the subjects, protan defect in 0.49% and unclassified color defect in 0.49%. This result confirms the previously reported low prevalence of congenital red-green CVDS among adult Arab males from the central region of Saudi Arabia.

Clinical vision characteristics of the congenital achromatopsias. I. Visual acuity, refractive error, and binocular status

Visual acuity, refractive error, and binocular status were determined in 43 autosomal recessive (AR) and 15 X-linked (XL) congenital achromats. The achromats were classified by color matching and spectral sensitivity data. Large interindividual variation in refractive error and visual acuity was present within each achromat group (complete AR, incomplete AR, and XL). However, the number of individuals with significant interocular acuity differences is very small. Most XLs are myopic; ARs show a wide range of refractive error from high myopia to high hyperopia. Acuity of the AR and XL groups was very similar. With-the-rule astigmatism of large amount is very common in achromats, particularly ARs. There is a close association between strabismus and interocular acuity differences in the ARs, with the fixating eye having better than average acuity. The large overlap of acuity and refractive error of XL and AR achromats suggests that these measures are less useful for differential diagnosis than generally indicated by the clinical literature.