Cambridge Colour Test: reproducibility in normal trichromats

Impact of blur on clinical and occupational colour vision test results

PURPOSE

To evaluate whether colour vision normal (CVN) adults pass two Fletcher-Evans (CAM) lantern tests and to investigate the impact of imposed blur on Ishihara, CAM lantern and computerised colour discrimination test (colour assessment and diagnosis test [CAD] and Cambridge colour test [CCT]) results.

METHODS

In a pilot experiment, 20 (16 CVN and 4 colour vision deficient [CVD]) participants with normal VA were tested with the CAM lantern. In the main experiment, the impact of imposed dioptric blur (up to +8.00 D) on visual acuity and the Ishihara test, CAM lantern, CAD and CCT was assessed for 15 CVN participants.

RESULTS

CVN participants can fail the CAM lantern, with specificity of 81.25% (aviation mode) and 75% (clinical mode), despite following the test requirements of participants having at least 0.18 logMAR (6/9) in the better eye. With blur, test accuracy was affected. As expected, significant detrimental effects of blur on test results were found for logMAR VA and CAM lantern (aviation) with +1.00 D or higher. Ishihara, CAD and CCT results were not detrimentally affected until +8.00 D. Yellow-blue discrimination was more affected by blur for the CAD than the CCT, which was not explained by the different colour spaces used or vectors tested.

CONCLUSION

False-positive findings on lantern colour vision tests with small apertures are likely to be increased in patients with blur due to uncorrected refractive error or ocular and visual pathway disease. Other colour vision tests with larger stimuli are more robust to blur.

An Evaluation of the Repeatability of Visual Function Following Surgical Repair of Macula-Off Rhegmatogenous Retinal Detachment

Purpose

To evaluate the reliability and reproducibility of visual function assessments for patients with macula-off rhegmatogenous retinal detachment (RRD).

Methods

This prospective study included patients with unilateral macula-off RRD of <10-day duration successfully treated with a single, uncomplicated surgery at least 1 year following repair. Visual function assessments were performed at time of enrollment and 1 month later. Testing included Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA), low-luminance visual acuity (LLVA), low-contrast visual acuity (VA) 2.5% and 5%, contrast sensitivity assessment with Mars and Gabor patches, reading speed (acuity, speed, and critical print size), color vision testing (protan, deutan, and tritan), and microperimetry. Spectral-domain ocular coherence tomography (SD-OCT) was performed. Paired t-statistics were used to compare values between visits and between the study and fellow eyes.

Results

Fourteen patients (9 male, 5 female) with a mean age of 69 years at time of surgery were evaluated. Correlation coefficients across the two visits were highest for ETDRS BCVA (0.97), tritan color vision testing (0.96), and low-contrast VA 5% (0.96), while the average t-statistic was largest for low-luminance deficit (4.2), ETDRS BCVA (4.1), and reading speed critical print size (3.7). ETDRS BCVA did not correlate with SD-OCT findings.

Conclusions

ETDRS BCVA can be considered a highly reliable and reproducible outcome measure. LLVA, protan color discrimination, contrast sensitivity, and reading speed may be useful secondary outcome measures.

Translational Relevance

This study provides guidance on the selection of visual function outcome measures for clinical trials of patients with macula-off RRD.

Cone contrast test-HD: sensitivity and specificity in red-green dichromacy and the impact of age

We report normative cone contrast sensitivity values, right-left eye agreement, and sensitivity and specificity values for the cone contrast test-HD (CCT-HD). We included 100 phakic eyes with color vision normal (CVN) and 20 dichromatic eyes (10 with protanopia and 10 with deuteranopia). The CCT-HD was used to measure L, M, and S-CCT-HD scores, and the right and left eyes were evaluated for agreement using Lin's concordance correlation coefficient (CCC) and Bland-Altman analysis to investigate the sensitivity and specificity of the CCT-HD based on diagnosis with an anomaloscope device. All cone types were in moderate agreement with the CCC (L-cone: 0.92, 95% CI, 0.86-0.95; M-cone: 0.91, 95% CI, 0.84-0.94; S-cone: 0.93, 95% CI, 0.88-0.96), whereas the Bland-Altman plots showed that the majority of cases (L-cone: 94%; M-cone: 92%; S-cone: 92%) fell within the 95% limits of agreement and showed good agreement. The m e a n±s t a n d a r d error L, M, and S-CCT-HD scores for protanopia were 0.6±1.4, 74.7±2.7, and 94.6±2.4, respectively; for deuteranopia, these were 84.0±3.4, 40.8±3.3, and 93.0±5.8, respectively; and for age-matched CVN eyes (m e a n±s t a n d a r d deviation age, 53.1±5.8 years; age range, 45-64 years), these were 98.5±3.4, 94.8±3.8, and 92.3±3.4, respectively, with significant differences between the groups except for S-CCT-HD score (Bonferroni corrected α=0.0167, p<0.0167). The sensitivity and specificity of the CCT-HD were 100% for protan and deutan in diagnosing abnormal types in those aged 20 to 64 years; however, the specificity decreased to 65% for protan and 55% for deutan in those aged >65 years. The CCT-HD is comparable to the diagnostic performance of the anomaloscope in the 20-64-year-old age group. However, the results should be interpreted cautiously in those ≥65 years, as these patients are more susceptible to acquired color vision deficiencies due to yellowing of the crystalline lens and other factors.

Do You See What I See? Diversity in Human Color Perception

In our tendency to discuss the objective properties of the external world, we may fail to notice that our subjective perceptions of those properties differ between individuals. Variability at all levels of the color vision system creates diversity in color perception, from discrimination to color matching, appearance, and subjective experience, such that each of us lives in a unique perceptual world. In this review, I discuss what is known about individual differences in color perception and its determinants, particularly considering genetically mediated variability in cone photopigments and the paradoxical effects of visual environments in both contributing to and counteracting individual differences. I make the case that, as well as being of interest in their own right and crucial for a complete account of color vision, individual differences can be used as a methodological tool in color science for the insights that they offer about the underlying mechanisms of perception. Expected final online publication date for the Annual Review of Vision Science, Volume 8 is September 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

The Effect of Cataract on Color Vision Measurement with the Low-Vision Cambridge Colour Test

Purpose

To quantify the effect of cataract on color vision as measured by the low-vision Cambridge Colour Test (lvCCT; Cambridge Research Systems) and to understand whether different types and severities of cataract have different effects on color vision.

Design

Cohort study.

Participants

Patients aged 18 to 95 undergoing routine cataract surgery at the Oxford Eye Hospital.

Methods

The lvCCT was performed to measure color sensitivity in both eyes both before and after surgery. The crystalline lens was examined and graded according to the Lens Opacities Classification System III to determine the type and severity of cataract. Measures of repeatability were performed for the data to explore test–retest bias using Bland–Altman analysis. The Wilcoxon signed-rank test was performed to assess the effect of cataract on color vision by comparing control and surgical test measurements. Three multiple linear regressions were performed to relate cataract grading or severity to color vision measurements.

Main Outcome Measures

Color discrimination along each of the protan, deutan, and tritan confusion lines.

Results

The Wilcoxon signed-rank test showed a statistically significant difference in both the protan (P = 0.024) and tritan (P = 0.020) axes on comparison of control and surgical test measurements. As severity of cataract increased, color vision sensitivity was affected more greatly, and nuclear sclerotic cataract showed the most profound effect on color vision sensitivity in the lvCCT; however, the linear regression models showed that these observations did not reach statistical significance.

Conclusions

Cataract surgery has a statistically significant effect on color vision in both the protan and tritan axes. The effects of specific subtypes of cataract and different severities could not be elucidated because of the high prevalence of patients with mixed cataract. The lvCCT color sensitivity measurements are used regularly as outcome measures in clinical gene therapy trials involving vitreoretinal surgery, and vitrectomy accelerates cataract formation. Therefore, it is important to quantify the effect of cataract on color vision measurements so that it may be taken into account when used as an outcome measure in clinical trials. We were unable to derive a precise correction factor for cataract on color vision measurements.

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.

Improvement in visual performance after nicotine gum administration in tobacco use disorder: a case report

Chronic tobacco consumption, identified as Tobacco Use Disorder (TUD), is a public health problem. We present a case report of a 37-year-old Brazilian male diagnosed with TUD at age 26, with no comorbidities, that presented visual improvements (i.e., lower thresholds and better discrimination) after nicotine gum administration. Here, we assessed contrast sensitivity and chromatic discrimination using the Metropsis and the Cambridge Colour Test, respectively. Results showed lower thresholds for both visual tasks after the use of nicotine gum. Even considering this is a single case report, our intent is to open new avenues for research involving smoking, addiction and the use of nicotine gum as a replacement tool or adjuvant tool for improvement of visual and/or cognitive processing. It is well known that nicotine gum has protective effects for some diseases, and improves some cognitive functions. However, unclear were its effects on visual processing of people with TUD.

Eye movement impairments in children with malnutrition

Malnutrition is characterised by deficient nutrient ingestion and absorption and is still one of the most important causes of morbidity and mortality in children worldwide. Our main rationale was that protein-energy malnutrition (PEM) may affect eye movement in children with malnutrition. Twenty children without PEM (mean age = 10.8; SD = 1.0 years) and 18 children with PEM (mean age = 10.9; SD = 1.2 years) were included in the present study. We applied three types of tests: one that consisted of a maze and two versions of the Spot the Seven Errors test using boats and elephants. Our results indicated that children with PEM exhibited performance deficits in the maze test (p < .001) and Spot the Seven Errors test for both boats (p < .001) and elephants (p < .001). These data suggest that nutritional impairments during the first year of life (i.e., a critical period) can directly impact eye movement. Eye tracking is a reliable technique to investigate higher-order processes, but our results should be interpreted with caution. Our findings highlight the relevance of cognitive development in malnourished children, which can negatively affect their development. Screening, assessment and rehabilitation strategies are essential in this at-risk population.

Combined influence of medication and symptom severity on visual processing in bipolar disorder

Previous studies have reported visual impairments in patients with bipolar disorder (BPD), but unclear were whether clinical variables would be associated with those disturbances. Here, we investigate the relationship between visual functioning, in terms of color discrimination, and the impact of BPD duration, mood state, and the patients' medication. Forty-five participants (25-45 years old) were recruited for this study. Color discrimination was performed using the Cambridge Colour Test. Serial multiple mediations were run to investigate the assumption of association between color discrimination and the clinical variables. Our findings showed that, compared with healthy controls, BPD patients' performance was worse for the Protan, Deutan, and Tritan vectors, revealing deterioration of color discrimination. In addition, the mediation analyses revealed a strong direct (p < .001) and moderate-to-high indirect effects (p < .01) of medication and symptom severity on color discrimination. Overall, both longer the duration of the disease and greater the symptom severity of BPD patients resulted in worse performance. It highlights the importance of examining the wider clinical context of an affective disorder to understand how it affects visual processing in this population.

Impairments of facial detection in tobacco use disorder: baseline data and impact of smoking duration

Objective:

Chronic tobacco consumption, classified as tobacco use disorder (TUD), has been associated with a variety of health problems. Investigations of face processing in TUD are hampered by lack of evidence. Here, we evaluated facial detection in TUD and assessed test-retest reliability for a facial detection task.

Methods:

Participants were instructed to detect the orientation (either left or right) of a face when it was presented with a face/non-face pair on the monitor screen, using Bayesian entropy estimation. Bland-Altman analysis and intraclass correlation coefficients were used to test the reliability of the task. The general linear model and Bayesian statistics were then used to evaluate differences between TUD (n=48) and healthy controls (n=34).

Results:

The reliability of the task was high for the 96 stimuli presentations. Slower reaction times (p < 0.001) and lower discrimination index (p < 0.001) were observed in the TUD group than for healthy controls. Mediation analysis indicated direct effects of smoking duration on reaction time (p < 0.001) and discrimination index (p < 0.001).

Conclusions:

Overall, we observed high reliability of this task and reduction of facial detection in tobacco use disorder. We conclude our findings are significant for public health initiatives and call for follow-up studies.

Heavy and light smokers have slight differences in chromatic discrimination

OBJECTIVES

The effects of smoking on color vision have been scarcely studied. To bridge such gap, this study examined if there were differences in chromatic discrimination between heavy and light smokers. Methods: The psychophysical Trivector test was used to evaluate chromatic discrimination in healthy controls (n = 36), heavy smokers (n = 29), and light smokers (n = 32). The subject's task was to identify the orientation of the Landolt C ring gap - presented and randomized in one of the four positions (e.g., up, down, right, and left). Results: The thresholds for Protan (red), Deutan (green) and Tritan (blue) were higher in heavy smokers compared to nonsmokers but not to light smokers. Conclusions: The results confirm that heavy smoking and chronic exposure to its harmful compounds affect color discrimination when compared to light smoking; and this is more pronounced in heavy smokers than light smokers. This is particularly important to understand the differences among smokers on visual and multisensory processing.

Relation between smoking and visual processing in bipolar disorder

BACKGROUND

Although some studies have shown impairments in patients with bipolar disorder (BPD) and in smokers, it is unclear how these two factors work together. Our premise was that chronic smoking affects color discrimination and this is more pronounced in BPD. Objective: Our main purpose was to investigate the influence of smoking and BPD on color discrimination. Methods: Twenty-three smokers and 23 BPD smokers patients, aged 25-45 years old, participated in this study. Color vision testing was performed using the Trivector subtest of the Cambridge Colour Test. Participants' task was to indicate the pseudoisochromatic stimulus in four directions (up, down, right, and left). Results: It was shown that the smokers had better color vision than BPD smokers for the Protan (p < .001), Deutan (p < .001), and Tritan (p < .001) (red, green, and blue, respectively) axes. Thus, the BPD smokers' group had greater difficulty distinguishing the chromaticity variations (i.e., presented diffuse color vision impairments and not specific to any axis). Conclusions: The present study highlights a possible relationship between smoking and BPD in color discrimination. This highlights the importance of understanding the diffuse effects of this relationship.

Nicotine gum enhances visual processing in healthy nonsmokers

OBJECTIVE

The main purpose of this study was to investigate the isolated effects of nicotine on visual processing, namely contrast processing.

METHODS

Thirteen participants, aged 18-40 years, were enrolled in this double blind, randomized and pilot controlled trial involving nicotine gum administration (placebo, 2-mg and 4-mg doses). The participants' instruction was to detect the location of vertical gratings (0.2; 1.0; 3.3; 5.7; 8.8; 13.2 and 15.9 cycles per degree) when it was presented either left or right on the monitor screen. A repeated multivariate analysis of variance was conducted to analyse the results for the visual processing tasks. Bayesian analyses were also carried out considering maximum robustness to avoid bias.

RESULTS

The findings that nicotine gum administration resulted in better contrast discrimination when compared to placebo gum (p < .001). More specifically, the 4-mg resulted in better visual sensitivity when compared to the 2-mg (p < .01) and the placebo (p < .001) gum. Demographic data were not related to the outcomes.

CONCLUSIONS

These data bring the need for support the findings. If proved, it is possible that nicotine, in small doses, can have a potential therapeutic use for those populations with low vision.

TRIAL REGISTRATION NUMBER

RBR-46tjy3.

Effects of Nicotine Gum Administration on Vision (ENIGMA-Vis): Study Protocol of a Double-Blind, Randomized, and Controlled Clinical Trial

Studies reported that tobacco addiction was related to visual impairments, but one unresolved issue is whether the impairments are related to the many compounds existing in the cigarettes or to the effects of nicotine. On the other hand, nicotine gum can be used as replacement therapy or as a neuroprotective agent for some diseases. The main purpose of this controlled trial is to investigate the effects of nicotine gum on vision. The ENIGMA-Vis trial aims to compare two dosages of nicotine gum (2 and 4 mg) and a placebo gum in a randomized, double-blind, placebo-controlled trial of 100 participants to be allocated into a single group assignment of repeated measures (two studies; N = 50 for each one). Eligibility criteria are healthy non-smokers not diagnosed with substance abuse and without an acute or chronic medical condition. Intervention will last three sessions for each participant with a window frame of 1 week per session. Study outcomes are (1) short-term effects of nicotine gum on contrast sensitivity; (2) short-term effects of nicotine gum on chromatic contrast discrimination; and (3) whether demographics, body mass index, or serum cotinine predicts response of visual processing. This study addresses an important gap in the effects of nicotine on vision. One of the main takeaways of this study is to understand the effects of nicotine on contrast sensitivity and chromatic contrast discrimination. This information will provide a further understanding of how nicotine interacts with early visual processes and help determine how the different components present during smoking can affect vision.

Clinical Trial Registration Number: RBR-46tjy3.