Tests for malingering in ophthalmology

Unexplained Progressive Visual Field Loss in the Presence of Normal Retinotopic Maps

Lesions of primary visual cortex or its primary inputs typically result in retinotopically localized scotomas. Here we present an individual with unexplained visual field loss and deficits in visual perception in the absence of structural damage to the early visual pathway or lesions in visual cortex. The subject, monocular from an early age, underwent repeated perimetry tests over 8 years demonstrating severe anopia of the lower hemifield, and a clockwise progression of the loss through her upper left visual field. Her visual impairment was evident in a number of standardized tests and psychophysics, especially in tasks assessing spatial integration using illusory contours. However, her intellectual ability was intact and her performance in some other tasks assessing color vision or object detection in scenes was normal. We employed functional magnetic resonance imaging (fMRI), electroretinography and visually evoked potentials. Surprisingly, in contrast to the participant's severe anopia, we found no evidence of abnormal function of her early visual pathways. Specifically, we performed retinotopic mapping using population receptive field (pRF) analysis to map the functional organization of visual cortex in the anopic participant and three control participants on two occasions three and a half years apart. Despite the behavioral visual field loss, her retinotopic maps and pRF parameters in visual areas V1-V3 were qualitatively normal. Further behavioral experiments confirmed that this discrepancy was not trivially explained by the difference between stimuli used for retinotopic mapping and perimetry. Structural T1 scans were normal at both time points, and volumetric analysis of white and gray matter tissue on the segmented T1 volumes did not reveal any abnormalities or deterioration over time. Our findings suggest that normal functional organization of early visual cortex without evident structural damage to the early visual pathway as disclosed by the techniques employed in this study does not necessarily guarantee conscious perception across the visual field.

A method for identifying color vision deficiency malingering

PURPOSE

To propose a new test to identify color vision deficiency malingering.

METHODS

An online survey was distributed to 130 truly color vision deficient participants and 160 participants willing to simulate color vision deficiency. The survey contained three sets of six color-adjusted versions of the standard Ishihara color plates each, as well as one set of six control plates. The plates that best discriminated both participant groups were selected for a "balanced" test emphasizing both sensitivity and specificity. A "specific" test that prioritized high specificity was also created by selecting from these plates. Statistical measures of the test (sensitivity, specificity, and Youden index) were assessed at each possible cut-off threshold, and a receiver operating characteristic (ROC) function with its area under the curve (AUC) charted.

RESULTS

The redshift plate set was identified as having the highest difference of means between groups (-58%, CI: -64 to -52%), as well as the widest gap between group modes. Statistical measures of the "balanced" test show an optimal cut-off of at least two incorrectly identified plates to suggest malingering (Youden index: 0.773, sensitivity: 83.3%, specificity: 94.0%, AUC of ROC 0.918). The "specific" test was able to identify color vision deficiency simulators with a specificity of 100% when using a cut-off of at least two incorrectly identified plates (Youden index 0.599, sensitivity 59.9%, specificity 100%, AUC of ROC 0.881).

CONCLUSIONS

Our proposed test for identifying color vision deficiency malingering demonstrates a high degree of reliability with AUCs of 0.918 and 0.881 for the "balanced" and "specific" tests, respectively. A cut-off threshold of at least two missed plates on the "specific" test was able to identify color vision deficiency simulators with 100% specificity.