Colour discrimination thresholds in Parkinson's disease: results obtained with a rapid computer-controlled colour vision test

Altered Outer Retinal Structure, Electrophysiology and Visual Perception in Parkinson's Disease

BACKGROUND

Visual biomarkers of Parkinson's disease (PD) are attractive as the retina is an outpouching of the brain. Although inner retinal neurodegeneration in PD is well-established this has overlap with other neurodegenerative diseases and thus outer retinal (photoreceptor) measures warrant further investigation.

OBJECTIVE

To examine in a cross-sectional study whether clinically implementable measures targeting outer retinal function and structure can differentiate PD from healthy ageing and whether these are sensitive to intraday levodopa (L-DOPA) dosing.

METHODS

Centre-surround perceptual contrast suppression, macular visual field sensitivity, colour discrimination, light-adapted electroretinography and optical coherence tomography (OCT) were tested in PD participants (n = 16) and controls (n = 21). Electroretinography and OCT were conducted before and after midday L-DOPA in PD participants, or repeated after ∼2 hours in controls.

RESULTS

PD participants had decreased center-surround contrast suppression (p < 0.01), reduced macular visual field sensitivity (p < 0.05), color vision impairment (p < 0.01) photoreceptor dysfunction (a-wave, p < 0.01) and photoreceptor neurodegeneration (outer nuclear layer thinning, p < 0.05), relative to controls. Effect size comparison between inner and outer retinal parameters showed that photoreceptor metrics were similarly robust in differentiating the PD group from age-matched controls as inner retinal changes. Electroretinography and OCT were unaffected by L-DOPA treatment or time.

CONCLUSIONS

We show that outer retinal outcomes of photoreceptoral dysfunction (decreased cone function and impaired color vision) and degeneration (i.e., outer nuclear layer thinning) were equivalent to inner retinal metrics at differentiating PD from healthy age-matched adults. These findings suggest outer retinal metrics may serve as useful biomarkers for PD.

Starburst amacrine cells, involved in visual motion perception, loose their synaptic input from dopaminergic amacrine cells and degenerate in Parkinson's disease patients

BACKGROUND

The main clinical symptoms characteristic of Parkinson's disease (PD) are bradykinesia, tremor, and other motor deficits. However, non-motor symptoms, such as visual disturbances, can be identified at early stages of the disease. One of these symptoms is the impairment of visual motion perception. Hence, we sought to determine if the starburst amacrine cells, which are the main cellular type involved in motion direction selectivity, are degenerated in PD and if the dopaminergic system is related to this degeneration.

METHODS

Human eyes from control (n = 10) and PD (n = 9) donors were available for this study. Using immunohistochemistry and confocal microscopy, we quantified starburst amacrine cell density (choline acetyltransferase [ChAT]-positive cells) and the relationship between these cells and dopaminergic amacrine cells (tyrosine hydroxylase-positive cells and vesicular monoamine transporter-2-positive presynapses) in cross-sections and wholemount retinas.

RESULTS

First, we found two different ChAT amacrine populations in the human retina that presented different ChAT immunoreactivity intensity and different expression of calcium-binding proteins. Both populations are affected in PD and their density is reduced compared to controls. Also, we report, for the first time, synaptic contacts between dopaminergic amacrine cells and ChAT-positive cells in the human retina. We found that, in PD retinas, there is a reduction of the dopaminergic synaptic contacts into ChAT cells.

CONCLUSIONS

Taken together, this work indicates degeneration of starburst amacrine cells in PD related to dopaminergic degeneration and that dopaminergic amacrine cells could modulate the function of starburst amacrine cells. Since motion perception circuitries are affected in PD, their assessment using visual tests could provide new insights into the diagnosis of PD.

Chromatic discrimination measures in mature observers depend on the response window

Our past anecdotal evidence prompted that a longer response window (RW) in the Trivector test (Cambridge Colour Test) improved mature observers’ estimates of chromatic discrimination. Here, we systematically explored whether RW variation affects chromatic discrimination thresholds measured by the length of Protan, Deutan and Tritan vectors. We employed the Trivector test with three RWs: 3 s, 5 s, and 8 s. Data of 30 healthy normal trichromats were stratified as age groups: ‘young’ (20–29 years), ‘middle-aged’ (31–48 years), and ‘mature’ (57–64 years). We found that for the ‘young’ and ‘middle-aged’, the thresholds were comparable at all tested RWs. However, the RW effect was apparent for the ‘mature’ observers: their Protan and Tritan thresholds decreased at 8-s RW compared to 3-s RW; moreover, their Tritan threshold decreased at 5-s RW compared to 3-s RW. Elevated discrimination thresholds at shorter RWs imply that for accurate performance, older observers require longer stimulus exposure and are indicative of ageing effects manifested by an increase in critical processing duration. Acknowledging low numbers in our ‘middle-aged’ and ‘mature’ samples, we consider our study as pilot. Nonetheless, our findings encourage us to advocate a RW extension in the Trivector protocol for testing mature observers, to ensure veridical measures of their chromatic discrimination by disentangling these from other ageing effects—slowing down of both motor responses and visual processing.

Multimodal brain and retinal imaging of dopaminergic degeneration in Parkinson disease

Parkinson disease (PD) is a progressive disorder characterized by dopaminergic neurodegeneration in the brain. The development of parkinsonism is preceded by a long prodromal phase, and >50% of dopaminergic neurons can be lost from the substantia nigra by the time of the initial diagnosis. Therefore, validation of in vivo imaging biomarkers for early diagnosis and monitoring of disease progression is essential for future therapeutic developments. PET and single-photon emission CT targeting the presynaptic terminals of dopaminergic neurons can be used for early diagnosis by detecting axonal degeneration in the striatum. However, these techniques poorly differentiate atypical parkinsonian syndromes from PD, and their availability is limited in clinical settings. Advanced MRI in which pathological changes in the substantia nigra are visualized with diffusion, iron-sensitive susceptibility and neuromelanin-sensitive sequences potentially represents a more accessible imaging tool. Although these techniques can visualize the classic degenerative changes in PD, they might be insufficient for phenotyping or prognostication of heterogeneous aspects of PD resulting from extranigral pathologies. The retina is an emerging imaging target owing to its pathological involvement early in PD, which correlates with brain pathology. Retinal optical coherence tomography (OCT) is a non-invasive technique to visualize structural changes in the retina. Progressive parafoveal thinning and fovea avascular zone remodelling, as revealed by OCT, provide potential biomarkers for early diagnosis and prognostication in PD. As we discuss in this Review, multimodal imaging of the substantia nigra and retina is a promising tool to aid diagnosis and management of PD.

An Eye on Movement Disorders

Eye disorders spanning a range of ocular tissue are common in patients with movement disorders. Highlighting these ocular manifestations will benefit patients and may even aid in diagnosis. In this educational review we outline the anatomy and function of the ocular tissues with a focus on the tissues most affected in movement disorders. We review the movement disorders associated with ocular pathology and where possible explore the underlying cellular basis thought to be driving the pathology and provide a brief overview of ophthalmic investigations available to the neurologist. This review does not cover intracranial primary visual pathways, higher visual function, or the ocular motor system.

Cambridge Colour Test: reproducibility in normal trichromats

This study evaluated reproducibility of the Trivector subtest of the Cambridge Colour Test. Data for normal trichromats were obtained in Brazil ($ N = 111 $N=111) at T0, six months (T1), and 12 months later (T2), and in the United Kingdom (${ N}={79}$N=79), with the test directly followed by a retest. Coefficients of repeatability-Bland-Altman indices-for Protan, Deutan, and Tritan vectors were similar for both datasets. Intraclass correlation coefficients (ICCs)-measures of reliability-were low or moderate for these relatively homogeneous datasets; for a heterogeneous dataset, comprising color-normal and abnormal observers, ICCs were 0.80-0.98, indicating the high discriminative accuracy of the Trivector subtest.

New players in basal ganglia dysfunction in Parkinson's disease

The classical model of the basal ganglia (BG) circuit has been recently revised with the identification of other structures that play an increasing relevant role especially in the pathophysiology of Parkinson's disease (PD). Numerous studies have supported the spreading of the alpha-synuclein pathology to several areas beyond the BG and likely even before their involvement. With the aim of better understanding PD pathophysiology and finding new targets for treatment, the spinal cord, the pedunculopontine nucleus, the substantia nigra pars reticulata, the retina, the superior colliculus, the cerebellum, the nucleus parabrachialis and the Meynert's nucleus have been investigated both in animal and human studies. In this chapter, we describe the main anatomical and functional connections between the above structures and the BG, the relationship between their pathology and PD features, and the rational of applying neuromodulation treatment to improve motor and non-motor symptoms in PD. Some of these new players in the BG circuits might also have a potential intriguing role as early biomarkers of PD.

REM sleep behaviour disorder: an early window for prevention in neurodegeneration?

This scientific commentary refers to ‘Risk and predictors of dementia and parkinsonism in idiopathic REM sleep behaviour disorder: a multicentre study’ by Postuma et al. (doi:10.1093/brain/awz030).

Visual impairments in tobacco use disorder

Prior studies found small effects of chronic smoking on spatial and color vision, but they were inconclusive. This study tries to: (1) replicate and extend these previous findings, and (2) rule in that this relationship is pronounced by tobacco addiction. Data were recorded in 71 healthy controls (M = 33.5 years; SD = 5.4 years) and 63 individuals with tobacco addiction (M = 34.7 years; SD = 4.8 years). Visual processing was assessed in the forms of contrast sensitivity for linear sine-wave gratings (spatial frequencies ranging between 0.2 and 16 cycles per degree) and color discrimination (using the Ellipse and Trivector subtests). The groups were matched for age, gender and level of education. The group with heavy smokers had reduced sensitivity for all spatial frequencies (p < .001), and impairments in color discrimination for both Trivector (all p-values < .001 for Protan, Deutan and Tritan) and Ellipse (all p-values < .001). This study consistently replicates and extended previous findings, and showed that visual processing can be strongly associated with tobacco addiction. These results indicate that excessive use of cigarettes, or chronic exposure to their compounds, affects visual discrimination, supporting the existence of overall deficits in visual processing in tobacco addiction.

High-Order Visual Processing, Visual Symptoms, and Visual Hallucinations: A Possible Symptomatic Progression of Parkinson's Disease

Objective: To determine whether Parkinson disease (PD) patients with (VH) have different clinical characteristics and gray-matter volume than those with visual misperceptions (VM) or other visual symptoms (OvS). Background: The spectrum of visual complaints in PD is broad and complex. Methods: We conducted a retrospective chart review of 525 PD patients to identify the frequency of visual symptoms and the association with clinical and radiological features. Brain volumetric MRI data was analyzed using multivariate logistic regression to differentiate cases with and without visual symptoms. Results: Among 525 PD cases, visual complaints were documented in 177 (33.7%). Among these, 83 (46.9%) had VH, 31 (17.5%) had VM, and 63 (35.6%) had OvS (diplopia, blurry vision, photophobia, dry eyes, and eye pain or soreness). When compared to OvS, patients with VH had significantly higher age, duration of disease, rate of REM sleep behavior disorder, and cognitive impairment. Visual hallucinations patients had decreased age-adjusted volumetric averages in 28/30 gray-matter regions when compared to PD without visual symptoms and 30/30 gray-matter regions when compared to VM patients. Conclusions: Visual symptoms in PD may represent a spectrum from OvS to VM to VH, with progression of the latter associated with older age, duration of disease, presence of REM sleep behavior disorder, cognitive impairment, and decreased gray-matter volume.

Psychophysical Measurements of Luminance Contrast Sensitivity and Color Discrimination with Transparent and Blue-Light Filter Intraocular Lenses

Introduction

The purpose of this study was to measure luminance contrast sensitivity and color vision thresholdfs in normal subjects using a blue light filter lens and transparent intraocular lens material.

Methods

Monocular luminance grating contrast sensitivity was measured with Psycho for Windows (version 2.36; Cambridge Research Systems) at 3.0, 6.0, 12.0, 20.0, and 30.0 cycles per degree of visual angle (cpd) in 15 normal subjects (eight female), with a mean age of 21.6 years (SD = 3.8 years). Chromatic discrimination was assessed with the Cambridge colour test (CCT) along the protan, deutan, and tritan color confusion axes. Both tests were performed in a darkened room under two situations: with a transparent lens and with blue light filter lens. Subjective impressions were taken by subjects regarding their visual experience under both conditions.

Results

No difference was found between the luminance contrast sensitivity measured with transparent and blue light filter. However, 13/15 (87%) of the subjects reported more comfortable vision with the blue filter. In the color vision test, tritan thresholds were significantly higher for the blue filter compared with the transparent filter (p = 0.003). For protan and deutan thresholds no differences were found.

Conclusion

Blue-yellow color vision is impaired with the blue light filter, and no impairment occurs with the transparent filter. No significant differences in thresholds were found in the luminance contrast sensitivity comparing the blue light and transparent filters. The impact of short wavelength light filtering on intrinsically photosensitive retinal ganglion cells is also discussed.

Visual dysfunction in Parkinson's disease

Patients with Parkinson's disease have a number of specific visual disturbances. These include changes in colour vision and contrast sensitivity and difficulties with complex visual tasks such as mental rotation and emotion recognition. We review changes in visual function at each stage of visual processing from retinal deficits, including contrast sensitivity and colour vision deficits to higher cortical processing impairments such as object and motion processing and neglect. We consider changes in visual function in patients with common Parkinson's disease-associated genetic mutations including GBA and LRRK2 . We discuss the association between visual deficits and clinical features of Parkinson's disease such as rapid eye movement sleep behavioural disorder and the postural instability and gait disorder phenotype. We review the link between abnormal visual function and visual hallucinations, considering current models for mechanisms of visual hallucinations. Finally, we discuss the role of visuo-perceptual testing as a biomarker of disease and predictor of dementia in Parkinson's disease.

Color Discrimination Is Affected by Modulation of Luminance Noise in Pseudoisochromatic Stimuli

Pseudoisochromatic stimuli have been widely used to evaluate color discrimination and to identify color vision deficits. Luminance noise is one of the stimulus parameters used to ensure that subject's response is due to their ability to discriminate target stimulus from the background based solely on the hue between the colors that compose such stimuli. We studied the influence of contrast modulation of the stimulus luminance noise on threshold and reaction time color discrimination. We evaluated color discrimination thresholds using the Cambridge Color Test (CCT) at six different stimulus mean luminances. Each mean luminance condition was tested using two protocols: constant absolute difference between maximum and minimum luminance of the luminance noise (constant delta protocol, CDP), and constant contrast modulation of the luminance noise (constant contrast protocol, CCP). MacAdam ellipses were fitted to the color discrimination thresholds in the CIE 1976 color space to quantify the color discrimination ellipses at threshold level. The same CDP and CCP protocols were applied in the experiment measuring RTs at three levels of stimulus mean luminance. The color threshold measurements show that for the CDP, ellipse areas decreased as a function of the mean luminance and they were significantly larger at the two lowest mean luminances, 10 cd/m² and 13 cd/m², compared to the highest one, 25 cd/m². For the CCP, the ellipses areas also decreased as a function of the mean luminance, but there was no significant difference between ellipses areas estimated at six stimulus mean luminances. The exponent of the decrease of ellipse areas as a function of stimulus mean luminance was steeper in the CDP than CCP. Further, reaction time increased linearly with the reciprocal of the length of the chromatic vectors varying along the four chromatic half-axes. It decreased as a function of stimulus mean luminance in the CDP but not in the CCP. The findings indicated that visual performance using pseudoisochromatic stimuli was dependent on the Weber's contrast of the luminance noise. Low Weber's contrast in the luminance noise is suggested to have a reduced effect on chromatic information and, hence, facilitate desegregation of the hue-defined target from the background.

Psychophysical Evaluation of Congenital Colour Vision Deficiency: Discrimination between Protans and Deutans Using Mollon-Reffin's Ellipses and the Farnsworth-Munsell 100-Hue Test

We have used the Farnsworth-Munsell 100-hue (FM 100) test and Mollon-Reffin (MR) test to evaluate the colour vision of 93 subjects, 30.4 ± 9.7 years old, who had red-green congenital colour vision deficiencies. All subjects lived in Belém (State of Pará, Brazil) and were selected by the State of Pará Traffic Department. Selection criteria comprised the absence of visual dysfunctions other than Daltonism and no history of systemic diseases that could impair the visual system performance. Results from colour vision deficient were compared with those from 127 normal trichromats, 29.3 ± 10.3 years old. For the MR test, measurements were taken around five points of the CIE 1976 colour space, along 20 directions irradiating from each point, in order to determine with high-resolution the corresponding colour discrimination ellipses (MacAdam ellipses). Three parameters were used to compare results obtained from different subjects: diameter of circle with same ellipse area, ratio between ellipse’s long and short axes, and ellipse long axis angle. For the FM 100 test, the parameters were: logarithm of the total number of mistakes and positions of mistakes in the FM diagram. Data were also simultaneously analysed in two or three dimensions as well as by using multidimensional cluster analysis. For the MR test, Mollon-Reffin Ellipse #3 (u’ = 0.225, v’ = 0.415) discriminated more efficiently than the other four ellipses between protans and deutans once it provided larger angular difference in the colour space between protan and deutan confusion lines. The MR test was more sensitive than the FM 100 test. It separated individuals by dysfunctional groups with greater precision, provided a more sophisticated quantitative analysis, and its use is appropriate for a more refined evaluation of different phenotypes of red-green colour vision deficiencies.

Discrimination thresholds of normal and anomalous trichromats: Model of senescent changes in ocular media density on the Cambridge Colour Test

Age-related changes in chromatic discrimination along dichromatic confusion lines were measured with the Cambridge Colour Test (CCT). One hundred and sixty-two individuals (16 to 88 years old) with normal Rayleigh matches were the major focus of this paper. An additional 32 anomalous trichromats classified by their Rayleigh matches were also tested. All subjects were screened to rule out abnormalities of the anterior and posterior segments. Thresholds on all three chromatic vectors measured with the CCT showed age-related increases. Protan and deutan vector thresholds increased linearly with age while the tritan vector threshold was described with a bilinear model. Analysis and modeling demonstrated that the nominal vectors of the CCT are shifted by senescent changes in ocular media density, and a method for correcting the CCT vectors is demonstrated. A correction for these shifts indicates that classification among individuals of different ages is unaffected. New vector thresholds for elderly observers and for all age groups are suggested based on calculated tolerance limits.

Variation of color discrimination across the life span

The present study, an extension of Paramei [J. Opt. Soc. Am. A, 29, A290, 2012], provides normative data on chromatic discrimination, using the Cambridge Colour Test, for normal trichromats aged 10-88 years. Findings are in accord with a two-phase variation across the life span: chromatic sensitivity improves in adolescence, reaches a maximum around 30 years, and then undergoes a gradual decrease. Indicative parameters are Protan (P), Deutan (D), and Tritan (T) vector lengths and major axes and axis ratios of Ellipses. Trivector data are modeled as non-monotonic combinations of power functions, with goodness-of-fits R(P)2=0.23, R(D)2=0.23, and R(T)2=0.45. For advancing age, sensitivity decline in all chromatic systems was confirmed, though with a marked acceleration after 60 years (reflected by the power function exponent >1) and more pronounced for the tritan system.

Color discrimination deficits in Parkinson's disease are related to cognitive impairment and white-matter alterations

Color discrimination deficit is a common nonmotor manifestation of Parkinson's disease (PD). However, the pathophysiology of this dysfunction remains poorly understood. Although retinal structure changes found in PD have been suggested to cause color discrimination deficits, the impact of cognitive impairment and cortical alterations remains to be determined. We investigated the contribution of cognitive impairment to color discrimination deficits in PD and correlated them with cortical anomalies. Sixty-six PD patients without dementia and 20 healthy controls performed the Farnsworth-Munsell 100 hue test and underwent a comprehensive neuropsychological assessment for mild cognitive impairment diagnosis. In a subgroup of 26 PD patients, we also used high-definition neuroanatomical magnetic resonance imaging for cortical thickness and diffusion tensor analysis. PD patients with mild cognitive impairment performed poorly on the Farnsworth-Munsell 100 hue test compared with PD patients without mild cognitive impairment and controls. In PD patients, performance on the Farnsworth-Munsell 100 hue test was correlated with measures of visuospatial abilities and executive functions. Neuroimaging analysis revealed higher mean and radial diffusivity values in right posterior white-matter structures that correlated with poor performance on the Farnsworth-Munsell 100 hue test. No cortical thickness correlation reached significance. This study showed that cognitive impairment makes a major contribution to the color discrimination deficits reported in PD. Thus, performance on the Farnsworth-Munsell 100 hue test may reflect cognitive impairment more than color discrimination deficits in PD. Poor performance on the Farnsworth-Munsell 100 hue test was also associated with white-matter alterations in right posterior brain regions.

Color discrimination across four life decades assessed by the Cambridge Colour Test

Color discrimination was estimated using the Cambridge Colour Test (CCT) in 160 normal trichromats of four life decades, 20-59 years of age. For each age cohort, medians and tolerance limits of the CCT parameters are tabulated. Compared across the age cohorts (Kruskal-Wallis test), the Trivector test showed increases in the three vectors, Protan, Deutan, and Tritan, with advancing age; the Ellipses test revealed significant elongation of the major axes of all three ellipses but no changes in either the axis ratio or the angle of the ellipse major axis. Multiple comparisons (Mann-Whitney test) between the cohorts of four age decades (20+,…,50+) revealed initial benign deterioration of color discrimination in the 40+ decade, as an incremental loss of discrimination along the Deutan axis (Trivector test), and in the 50+ decade, as an elongation of the major axes of all three ellipses (Ellipses test).

Métodos utilizados na avaliação psicofísica da visão de cores humana

A cor é um atributo perceptual que nos permite identificar e localizar padrões ambientais de mesmo brilho e constitui uma dimensão adicional na identificação de objetos, além da detecção de inúmeros outros atributos dos objetos em sua relação com a cena visual, como luminância, contraste, forma, movimento, textura, profundidade. Decorre daí a sua importância fundamental nas atividades desempenhadas pelos animais e pelos seres humanos em sua interação com o ambiente. A psicofísica visual preocupa-se com o estudo quantitativo da relação entre eventos físicos de estimulação sensorial e a resposta comportamental resultante desta estimulação, fornecendo dessa maneira meios de avaliar aspectos da visão humana, como a visão de cores. Este artigo tem o objetivo de mostrar diversas técnicas eficientes na avaliação da visão cromática humana através de métodos psicofísicos adaptativos.

Color vision impairment in type 2 diabetes assessed by the D-15d test and the Cambridge Colour Test

Color vision impairment emerges at early stages of diabetes mellitus type 2 (DM2) and may precede diabetic retinopathy or the appearance of vascular alterations in the retina. The aim of the present study was to compare the evaluation of the color vision with two different tests - the Lanthony desaturated D-15d test (a traditional color arrangement test), and the Cambridge Colour Test (CCT) (a computerized color discrimination test) - in patients diagnosed with DM2 without clinical signs of diabetic retinopathy (DR), and in sex- and age-matched control groups. Both color tests revealed statistically significant differences between the controls and the worst eyes of the DM2 patients. In addition, the degree of color vision impairment diagnosed by both tests correlated with the disease duration. The D-15d outcomes indicated solely tritan losses. In comparison, CCT outcomes revealed diffuse losses in color discrimination: 13.3% for best eyes and 29% for worst eyes. In addition, elevation of tritan thresholds in the DM2 patients, as detected by the Trivector subtest of the CCT, was found to correlate with the level of glycated hemoglobin. Outcomes of both tests confirm that subclinical losses of color vision are present in DM2 patients at an early stage of the disease, prior to signs of retinopathy. Considering the advantages of the CCT test compared to the D-15d test, further studies should attempt to verify and/or improve the efficiency of the CCT test.

Thresholds for color discrimination in English and Korean speakers

Categorical perception (CP) is said to occur when a continuum of equally spaced physical changes is perceived as unequally spaced as a function of category membership (Harnad, S. (Ed.) (1987). Psychophysical and cognitive aspects of categorical perception: A critical overview. Cambridge: Cambridge University Press). A common suggestion is that CP for color arises because perception is qualitatively distorted when we learn to categorize a dimension. Contrary to this view, we here report that English speakers show no evidence of lowered discrimination thresholds at the boundaries between blue and green categories even though CP is found at these boundaries in a supra-threshold task. Furthermore, there is no evidence of different discrimination thresholds between individuals from two language groups (English and Korean) who use different color terminology in the blue-green region and have different supra-threshold boundaries. Our participants' just noticeable difference (JND) thresholds suggest that they retain a smooth continuum of perceptual space that is not warped by stretching at category boundaries or by within-category compression. At least for the domain of color, categorical perception appears to be a categorical, but not a perceptual phenomenon.

The retina in Parkinson's disease

As a more complete picture of the clinical phenotype of Parkinson's disease emerges, non-motor symptoms have become increasingly studied. Prominent among these non-motor phenomena are mood disturbance, cognitive decline and dementia, sleep disorders, hyposmia and autonomic failure. In addition, visual symptoms are common, ranging from complaints of dry eyes and reading difficulties, through to perceptual disturbances (feelings of presence and passage) and complex visual hallucinations. Such visual symptoms are a considerable cause of morbidity in Parkinson's disease and, with respect to visual hallucinations, are an important predictor of cognitive decline as well as institutional care and mortality. Evidence exists of visual dysfunction at several levels of the visual pathway in Parkinson's disease. This includes psychophysical, electrophysiological and morphological evidence of disruption of retinal structure and function, in addition to disorders of 'higher' (cortical) visual processing. In this review, we will draw together work from animal and human studies in an attempt to provide an insight into how Parkinson's disease affects the retina and how these changes might contribute to the visual symptoms experienced by patients.

'Gamma' band oscillatory response to chromatic stimuli in volunteers and patients with idiopathic Parkinson's disease

The signal structure of the responses to equiluminant chromatic and achromatic (contrast) stimuli was studied in normal volunteers and patients with mild to moderate idiopathic Parkinson's disease. Visual stimuli were full-field (14 x 16 deg) achromatic or equiluminant (red-green or blue-yellow) sinusoidal gratings at 2c/deg and 90% contrast presented in onset-offset mode. The signal was processed offline by DFT and factor analysis was performed in the frequency domain. The conventional VEPs to chromatic onset stimuli showed a monophasic negative wave, while the response to offset stimuli was comparable in shape to the on-/offset achromatic responses; latencies were longer and amplitudes higher than those of responses to contrast stimulation. In patients, latencies were longer than in controls after achromatic and (to a lesser extent) red-green stimulations, but not after blue-yellow stimulation; amplitudes were comparable in all stimulus conditions. In healthy subjects, two non-overlapping factors accounted for the approximately 2-30.0 Hz and approximately 25.0-50.0 Hz signal components (representative of the low-frequency VEP and gamma oscillatory responses, respectively); the frequency of the approximately 25.0-50.0 Hz factor was lower after color than after contrast stimulation. The same factor structure was identified in patients, but the peak frequency of the factor on gamma activity was higher than in controls and did not vary with color-opponent stimulation. These observations indicate that stimulus-related gamma activity originates in cortex irrespective of the activated (magno-, parvo-, or konio-cellular) visual pathway, consistent with the suggested role in the phase coding of neuronal activities. Some dopaminergic modulation of gamma activity is conceivable.

A computer-controlled color vision test for children based on the Cambridge Colour Test

The present study aimed at providing conditions for the assessment of color discrimination in children using a modified version of the Cambridge Colour Test (CCT, Cambridge Research Systems Ltd., Rochester, UK). Since the task of indicating the gap of the Landolt C used in that test proved counterintuitive and/or difficult for young children to understand, we changed the target stimulus to a patch of color approximately the size of the Landolt C gap (about 7 degrees of visual angle at 50 cm from the monitor). The modifications were performed for the CCT Trivector test which measures color discrimination for the protan, deutan and tritan confusion lines. Experiment 1 sought to evaluate the correspondence between the CCT and the child-friendly adaptation with adult subjects (n = 29) with normal color vision. Results showed good agreement between the two test versions. Experiment 2 tested the child-friendly software with children 2 to 7 years old (n = 25) using operant training techniques for establishing and maintaining the subjects' performance. Color discrimination thresholds were progressively lower as age increased within the age range tested (2 to 30 years old), and the data--including those obtained for children--fell within the range of thresholds previously obtained for adults with the CCT. The protan and deutan thresholds were consistently lower than tritan thresholds, a pattern repeatedly observed in adults tested with the CCT. The results demonstrate that the test is fit for assessment of color discrimination in young children and may be a useful tool for the establishment of color vision thresholds during development.

Irreversible color vision losses in patients with chronic mercury vapor intoxication

This longitudinal study addresses the reversibility of color vision losses in subjects who had been occupationally exposed to mercury vapor. Color discrimination was assessed in 20 Hg-exposed patients (mean age = 42.4 ± 6.5 years; 6 females and 14 males) with exposure to Hg vapor during 10.5 ± 5.3 years and away from the work place (relative to 2002) for 6.8 ± 4.2 years. During the Hg exposure or up to one year after ceasing it, mean urinary Hg concentration was 47 ± 35.4 μg/g creatinine. There was no information on Hg urinary concentration at the time of the first tests, in 2002 (Ventura et al., 2005), but at the time of the follow-up tests, in 2005, this value was 1.4 ± 1.4 μg/g creatinine for patients compared with 0.5 ± 0.5 μg/g creatinine for controls (different group from the one in Ventura et al. (2005)). Color vision was monocularly assessed using the Cambridge Colour Test (CCT). Hg-exposed patients had significantly worse color discrimination (p < 0.02) than controls, as evaluated by the size of MacAdam's color discrimination ellipses and color discrimination thresholds along protan, deutan, and tritan confusion axes. There were no significant differences between the results of the study in Ventura et al. (2005) and in the present follow-up measurements, in 2005, except for worsening of the tritan thresholds in the best eye in 2005. Both chromatic systems, blue-yellow and red-green, were affected in the first evaluation (Ventura et al., 2005) and remained impaired in the follow-up testing, in 2005. These findings indicate that following a long-term occupational exposure to Hg vapor, even several years away from the source of intoxication, color vision impairment remains irreversible.

Chromatic discrimination losses in multiple sclerosis patients with and without optic neuritis using the Cambridge Colour Test

We assessed chromatic discrimination in multiple sclerosis (MS) patients both with (ON) and without (no ON) a history of optic neuritis using the Cambridge color test (CCT). Our goal was to determine the magnitude and chromatic axes of any color vision losses in both patient groups, and to evaluate age-related changes in chromatic discrimination in both patient groups compared to normals. Using the CCT, we measured chromatic discrimination along the protan, deutan and tritan axes in 35 patients with MS (17 ON eyes) and 74 age matched controls. Color thresholds for both patient groups were significantly higher than controls' along the protan and tritan axes (p < 0.001). In addition, the ON and no-ON groups differed significantly along all three-color axes (p < 0.001). MS patients presented a progressive color discrimination impairment with age (along the deutan and tritan axes) that was almost two times faster than controls, even in the absence of ON. These findings suggest that demyelinating diseases reduce sensitivity to color vision in both red-green and blue-yellow axes, implying impairment in both parvocellular and koniocellular visual pathways. The CCT is a useful tool to help characterize vision losses in MS, and the relationship between these losses and degree of optic nerve involvement.

The possible role of retinal dopaminergic system in visual performance

It is a well-known fact that the retina is one of the tissues in the body, which is richest in dopamine (DA), yet the role of this system in various visual functions remains unclear. We have identified 13 types of DA retinal pathologies, and 15 visual functions. The pathologies were arranged in this review on a net grid, where one axis was "age" (i.e., from infancy to old age) and the other axis the level of retinal DA (i.e., from DA deficiency to DA excess, from Parkinson disorder to Schizophrenia). The available data on visual dysfunction(s) is critically presented for each of the DA pathologies. Special effort was made to evaluate whether the site of DA malfunction in the different DA pathologies and visual function is at retinal level or in higher brain centers. The mapping of DA and visual pathologies demonstrate the pivot role of retinal DA in mediating visual functions and also indicate the "missing links" in our understanding of the mechanisms underlying these relationships.

Red-green color vision impairment in Duchenne muscular dystrophy

The present study evaluated the color vision of 44 patients with Duchenne muscular dystrophy (DMD) (mean age 14.8 years; SD 4.9) who were submitted to a battery of four different color tests: Cambridge Colour Test (CCT), Neitz Anomaloscope, Ishihara, and American Optical Hardy-Rand-Rittler (AO H-R-R). Patients were divided into two groups according to the region of deletion in the dystrophin gene: upstream of exon 30 (n=12) and downstream of exon 30 (n=32). The control group was composed of 70 age-matched healthy male subjects with no ophthalmological complaints. Of the patients with DMD, 47% (21/44) had a red-green color vision defect in the CCT, confirmed by the Neitz Anomaloscope with statistical agreement (P<.001). The Ishihara and the AO H-R-R had a lower capacity to detect color defects--5% and 7%, respectively, with no statistical similarity between the results of these two tests nor between CCT and Anomaloscope results (P>.05). Of the patients with deletion downstream of exon 30, 66% had a red-green color defect. No color defect was found in the patients with deletion upstream of exon 30. A negative correlation between the color thresholds and age was found for the controls and patients with DMD, suggesting a nonprogressive color defect. The percentage (66%) of patients with a red-green defect was significantly higher than the expected <10% for the normal male population (P<.001). In contrast, patients with DMD with deletion upstream of exon 30 had normal color vision. This color defect might be partially explained by a retina impairment related to dystrophin isoform Dp260.

Independent patterns of damage within magno-, parvo- and koniocellular pathways in Parkinson's disease

Sensory deficits have been documented in Parkinson's disease, in particular within the visual domain. However, ageing factors related to the brain and to neural and non-neural ocular structures could explain some of the previously reported results, in particular the claimed impairment within the koniocellular pathway. This study addressed visual impairment attributable to the magno- (luminance), parvo- (red-green) and koniocellular (blue-yellow) pathways in a population of Parkinson's disease patients. To avoid potentially confounding factors, all subjects underwent a full neurophthalmological assessment which led to exclusion of subjects with increased intraocular pressure, diabetes even in the absence of retinopathy, and ocular abnormalities (from a total of 72 patients' eyes, 12 were excluded). Both parvo- and koniocellular pathways were studied by means of contrast sensitivity (CS) measurements along protan, tritan and deutan axes and also by fitting chromatic discrimination ellipses using eight measured contrast axes. Magnocellular function was assessed, using stimuli that induce a frequency doubling illusion, in 17 locations in the fovea and periphery. Achromatic (luminance modulation) thresholds were significantly higher in Parkinson's disease both in foveal and peripheral locations. A significant impairment was observed along protan and deutan axes, but only marginally along the tritan axis. These results were corroborated by a significant elongation of chromatic discrimination ellipses in our Parkinson's disease group. Correlation analysis showed that achromatic and chromatic CS measures were independent, which implies that multiple visual pathways are affected independently in Parkinson's disease. Magnocellular impairment was significantly correlated with age and disease stage, in contrast to the measured chromatic deficits. We conclude that in Parkinson's disease, independent damage occurs in the early magno- and parvocellular pathways. Furthermore, traditional koniocellular probing strategies in Parkinson's disease may be confounded by ageing factors, which may reconcile the previously reported controversial findings concerning chromatic impairment in Parkinson's disease.

Colour vision and contrast sensitivity losses of mercury intoxicated industry workers in Brazil

We evaluated vision loss in workers from fluorescent lamp industries (n=39) who had retired due to intoxication with mercury vapour and had been away from the work situation for several years (mean=6.32 years). An age-matched control group was submitted to the same tests for comparison. The luminance contrast sensitivity (CSF) was measured psychophysically and with the sweep visual evoked potential (sVEP) method. Chromatic red-green and blue-yellow CSFs were measured psychophysically. Colour discrimination was assessed with the Farnsworth-Munsell 100-hue test, Lanthony D-15d test and Cambridge Colour Vision Test. Patient data showed significantly lower scores in all colour tests compared to controls (p<.001). The behavioural luminance CSF of the patients was lower than that of controls (p<.001 at all frequencies tested). This result was confirmed by the electrophysiologically measured sweep VEP luminance CSF except at the highest frequencies-a difference that might be related to stimulus differences in the two situations. Chromatic CSFs were also statistically significantly lower for the patients than for the controls, for both chromatic equiluminant stimuli: red-green (p<.005) and blue-yellow (p<.04 for all frequencies, except 2 cycles per degree (cpd), the highest spatial frequency tested) spatial gratings. We conclude that exposure to elemental mercury vapour is associated with profound and lasting losses in achromatic and chromatic visual functions, affecting the magno-, parvo- and koniocellular visual pathways.

Multifocal and full-field electroretinogram changes associated with color-vision loss in mercury vapor exposure

We evaluated the color vision of mercury-contaminated patients and investigated possible retinal origins of losses using electroretinography. Participants were retired workers from a fluorescent lamp industry diagnosed with mercury contamination (n= 43) and age-matched controls (n= 21). Color discrimination was assessed with the Cambridge Colour Test (CCT). Retinal function was evaluated by using the ISCEV protocol for full-field electroretinography (full-field ERG), as well as by means of multifocal electroretinography (mfERG). Color-vision losses assessed by the CCT consisted of higher color-discrimination thresholds along the protan, deutan, and tritan axes and significantly larger discrimination ellipses in mercury-exposed patients compared to controls. Full-field ERG amplitudes from patients were smaller than those of the controls for the scotopic responseb-wave, maximum response, sum of oscillatory potentials (OPs), 30-Hz flicker response, and light-adapted cone response. OP amplitudes measured in patients were smaller than those of controls for O2 and O3. Multifocal ERGs recorded from ten randomly selected patients showed smaller N1–P1 amplitudes and longer latencies throughout the 25-deg central field. Full-field ERGs showed that scotopic, photopic, peripheral, and midperipheral retinal functions were affected, and the mfERGs indicated that central retinal function was also significantly depressed. To our knowledge, this is the first demonstration of retinal involvement in visual losses caused by mercury toxicity.

Visual dysfunction, neurodegenerative diseases, and aging

The four most common sight-threatening conditions in older adults in North America are cataract, ARM, glaucoma, and diabetic retinopathy. Even in their moderate stages, these conditions cause visual sensory impairments and reductions in health-related quality of life, including difficulties in daily tasks and psychosocial problems. Many older adults are free from these conditions, yet still experience a variety of visual perceptual problems resulting from aging-related changes in the optics of the eye and degeneration of the visual neural pathways. These problems consist of impairments in visual acuity, contrast sensitivity, color discrimination, temporal sensitivity, motion perception, peripheral visual field sensitivity, and visual processing speed. PD causes a progressive loss of dopaminergic cells predominantly in the retina and possibly in other areas of the visual system. This retinal dopamine deficiency produces selective spatial-temporal abnormalities in retinal ganglion cell function, probably arising from altered receptive field organization in the PD retina. The cortical degeneration characteristics of AD, including neurofibrillary tangles and neuritic plaques, also are present in the visual cortical areas, especially in the visual association areas. The most prominent electrophysiologic change in AD is a delay in the P2 component of the flash VEP. Deficits in higher-order visual abilities typically are compromised in AD, including problems with visual attention, perceiving structure from motion, visual memory, visual learning, reading, and object and face perception. There have been reports of a visual variant of AD in which these types of visual problems are the initial and most prominent signs of the disease. Visual sensory impairments (e.g., contrast sensitivity or achromatopsia) also have been reported but are believed more reflective of cortical disturbances than of AD-associated optic neuropathy.

Motor impairment influences Farnsworth-Munsell 100 Hue test error scores in Parkinson's disease patients

Farnsworth-Munsell 100 Hue test (FMT) error scores and peg insertion abilities significantly differ between Parkinson's disease (PD) patients and controls. Both tasks ask for performance of voluntary movements. The objective of this study was to demonstrate a relation between FMT error scores and peg insertion outcomes. We successively performed both tasks in 28 previously untreated PD patients. The FMT error score was significantly (p=0.016) lower in patients with better peg insertion outcome. A significant (Spearman R=0.47, p=0.012) correlation between peg insertion results and the FMT error scores appeared. Motor impairment influences FMT error scores in PD patients.

Animal colour vision--behavioural tests and physiological concepts

Over a century ago workers such as J. Lubbock and K. von Frisch developed behavioural criteria for establishing that non-human animals see colour. Many animals in most phyla have since then been shown to have colour vision. Colour is used for specific behaviours, such as phototaxis and object recognition, while other behaviours such as motion detection are colour blind. Having established the existence of colour vision, research focussed on the question of how many spectral types of photoreceptors are involved. Recently, data on photoreceptor spectral sensitivities have been combined with behavioural experiments and physiological models to study systematically the next logical question: 'what neural interactions underlie colour vision?' This review gives an overview of the methods used to study animal colour vision, and discusses how quantitative modelling can suggest how photoreceptor signals are combined and compared to allow for the discrimination of biologically relevant stimuli.

Progress of visual dysfunction in Parkinson's disease

Studies on progression of Parkinson's disease (PD) mainly focus on the nigrostriatal dopaminergic decline, but not on the visual system. We determined progression of (i) disturbed color vision, assessed with the Farnsworth-Munsell 100 Hue test (FMT) and (ii) intensity of PD in 18 patients. Significant differences occurred between (i) initial FMT error scores and follow-up results 3 years later (P=0.002) and analogously (ii) scored intensity of PD (P=0.002). A relation between computed differences of FMT error scores and rated activities of daily living appeared. Deterioration of color vision progresses in PD.

Decreased color discrimination and contrast sensitivity in Parkinson's disease

Patients with Parkinson's disease (PD) often complain of blurred vision or even of distinctive visual disturbances like hallucinations and illusions. Recent studies have emphasized the potential influence of primary visual deficits of color and contrast discrimination. To study primary visual function, we studied color discrimination (CD) and contrast sensitivity (CS) during 'on' medication in PD patients and compared them to non-PD subjects. Twenty one PD patients were compared to 30 age-matched controls using CD tested by the D-15 Lanthony test (D15) and the Farnsworth-Munsell 100 Hue test (FM) and CS tested by the Pelli-Robson (PL) and the Vis-Tech tables (VT). We excluded subjects with a visual acuity </=0.6 Snellen fraction or known ophthalmological diseases. PD patients showed greater impairment on all visual tests than controls. This difference was significant for the FM test (P<0.001), the spatial frequencies 12 and 18 cpd (cycles per degree) of the VT test (P<0.05) and both the monocular and binocular PR tests (P<0.05). Most tests for CS and CD showed statistical independency. CS deficits, but not CD deficits, correlated with age in both patients and controls. This study documents major and independent impairment of both color and contrast discrimination in PD patients. Further studies should elucidate possible clinical implications and correlations, such as the frequency of falls or visual hallucinations.