Public Health (1998) 112, 8184

R.I.P.H.H. 1998

Leading Article
Colour blindness
N Gordon
Huntlywood, 3 Styal Road, Wilmslow, SK9 4AE, UK
The physiology of colour vision is discussed; as is the way in which the human eye can detect various combinations of
red, green and blue. Red-green colour blindness, with X-linked inheritance, is the most common, but other types are
also considered. Methods of testing relating to the age of the child are reviewed.
The use of colours in teaching is widespread, but there is controversy over the difculties this may cause a colour
blind child. A review of the literature does not reveal much information on this, and any problems that do arise are
likely to be individual to the child, and to depend on such factors as overall intelligence, the attitude of the teacher, and
the personality of the child.
There is no doubt that it is essential to recognise colour vision defects when it comes to choosing a career, and that
tests must be done during secondary schooling, but in order to avoid some affected children being disadvantaged there
is enough evidence to support testing at school entry.
Keywords: colour vision; types colour vision decit; causes colour vision decit; vision testing; general education;
career choice

Introduction
Colour blindness is a long-established term, and although
rather misleading it will be used in this paper. Alternatives
such as impaired colour vision may well be better, but can be
considered pedantic. Red-green colour vision impairments
affect about 610% of boys, and 0.40.7% of girls.1,2 Most
assessments carried out in schools include a test for colour
vision, especially those done around the age of eleven or
twelve. Is this time well spent? Particularly, does it matter
if a girl or boy is red-green colour blind, at least till the time
comes to choose a career and to train for it?
Physiology of colour vision
Theories of colour vision explain the fact that the human
eye can detect various gradations of colours when red,
green, and blue are mixed in different combinations, at
least after the rst few weeks of life. In the retina there are
three types of receptors, or cones, which are stimulated by
the three primary colours in different combinations. For
example, orange light mainly stimulates red cones, and to a
much lesser extent green cones, whilst a blue light only
stimulates blue cones, and a yellow light red and green
cones to an equal extent. When a single group of colour
receptive cones is missing from the retina the person cannot
distinguish some colours from others. A person who lacks
red cones is called a protanope, and one who lacks green
cones is called a deuteranope. Green, yellow, orange, and
red colours are normally differentiated, one from the other,
by the red and green responsive cones. If either of these are
missing it is no longer possible to use this method to
discriminate the four colours, and it is especially difcult to
separate red from green; and those affected are said to be
red-green colour blind. Total absence of cones, or
trichromatic colour blindness, which must make the world
look much like a black and white television picture, is very
Correspondence: Dr NS Gordon.
Accepted 15 December 1997

rare. This may be an example of partial sex-linkage, as this

may possibly explain its occurrence as sex-linked in some
families, Y-linked in others, and sometimes with a
confused pattern of inheritance.3 Sacks4 gives a fascinating
account of an island community who all suffered from this
type of impaired colour vision. It is commoner to nd
reduced sensitivity to one cone type, due to alteration of
spectral absorption properties of one of the pigments or an
absence of one of the pigments. If there are only two
pigments present, the vision is said to be dichromatic. This
will lead to poor colour discrimination and distortion of
colour perception; and three types of defective colour
vision, depending on which cone system is missing; red,
green, or blue. These have been termed protanopia,
deuteranopia, and tritanopia.
There is a further group of colour vision deciencies in
which all three pigments are present but in which one gives
an altered response sensitivity curve. This is refered to as
anomalous trichromatic vision, and there are three forms
depending on which cone pigment is affected.5
Impaired colour vision, in the case of red and green
deciencies, is genetically determined by X-linked inheritance, occurring in males but transmitted through the
female. About 8% of all women are carriers.6 The defective
genes for protan and deutan deciencies occur at different
loci on the X chromosome, and are therefore non-allelic.5
The inheritance of other forms of defective colour vision is
complex,2 for example mosaicism can occur in females and
cause minimal colour deciency in heterozygotes, and
tritan deciencies may be inherited in an incomplete
autosomal dominant manner.
Tests for impaired colour vision
Screening for defective colour vision does not fulll all the
criteria for a screening test, for a start it is not a treatable
condition. However this is not the purpose of this exercise,
but a desire to prevent any adverse effects.
In screening tests the method most often used for the
older child is by Ishihara charts, a confusion of spots of

Colour vision
N Gordon

82

various colours hiding wavy lines or numbers, some of

which are read differently by unaffected children and those
with colour blindness, or cannot be read at all by the latter.
It is suggested that preferably cards using wavy lines
should be used from the age of 411 y, and those with
numbers from 12 y upwards,5 but the use of the lines does
lead to a high incidence of errors.7 However, even at school
entry many children can either read the numbers or trace
them with a nger; and this is supported by studies on
children over the age of ve, especially in girls.8 In the case
of very young children matching colours can be tried, but
this is not very reliable. It is also suggested that the Ishihara
charts may have their limitations. They carry spatial
information predominantly in the high frequencies, and
the possibility exists that in some instances the failure to
resolve such stimuli may indicate, not an absence of colour
resolution, but an inability to detect the critical features in
the test. This can be due to abnormal size of the receptive
cortical elds; so that some residual colour discrimination
is retained, especially if the stimuli are sufciently large.9
This may be a possible reason for nding that the results of
this test are sometimes equivocal. Five or more errors on
the rst thirteen plates have been identied with some
degree of inherited colour defective vision, and may
warrant referral for additional tests.10 The test should be
carried out, if possible, in natural daylight, avoiding direct
sunlight. It can therefore be concluded that the Ishihara test
is good for screening, but does not discriminate complete
and partial degrees of colour blindness with accuracy.11
As there are several different type of impaired colour
vision, more specialized tests, such as a quantitative test
using the City University triton test, may be needed. This
consists of ve plates, three of them for screening
trichromatic vision and two to distinguish severe triton
defects. Other tests are well described by Birch,2 and
should be used if there are doubts about the results of the
Ishihara test, and when decisions have to be taken on
training for a career. Then, it may well be necessary to refer
the child to an expert in this eld. The different types of
colour vision tests for children are reviewed by Hill.5
Cerebral Achromatopsia
There are columns of cells in the visual cortex which
respond specically to visual signals, and presumably are
the areas for deciphering colours. With damage to the
caudal region of the fusiform gyrus, and possibly to the
adjacent lingual gyrus, it may not be possible to name
colours or discriminate between them. This defect may be
associated with bilateral visual eld loss, and other sensory
decits such as impaired topographical memory, colour
anosmia (inability to name colours), and prosopagnosia
(failure to recognise faces).2 It may be that the extrastriate
cortical areas specializing in processing information about
wavelength are failing to act normally, and colours are not
seen. Such patients, who describe themselves as colour
blind, and when severely affected their perceptual world as
grey, can still perceive the orientation, movement, and
shape of purely chromatic borders; and chromatic contrast
sensitivity can be normal. They will, however, fail most
conventional tests for colour blindness.12 These ndings
suggest that awareness of colour is determined in a
particular part of the cortex, and not throughout.13 This
may be due to the parvocellular channel being selectively
and totally destroyed at the level of the visual cortex, so

that vision is mediated by the magnocellular channel. This

pathway arises from the large retinal ganglion cells, and
conveys black and white information rapidly to the visual
cortex via the dorsal lateral geniculate nucleus, particularly
the timing of visual events; while the parvocellular pathway
starts from smaller retinal cells and transmits colour and
accurate ne detailed point-to-point spatial information
more slowly to the cortex, also via the geniculate nucleus.6
It has been suggested that colour discrimination could also
be encoded by a neural system which responds to fast
icker.14
Such lesions are most unlikely to occur during childhood
and adolescence, but there is no harm in keeping the
possibility in mind.
The use of colours in teaching techniques
Schools are full of colour; and, especially in the case of
young children, colours (4) are used in teaching.15 If it is
not known that a child does have a defect of colour vision,
the teacher may accuse the child of carelessness, leading to
feelings of inferiority. Also, such a child has an unstable
reference in the development of his language and visual
associations as a consequence of frequent contradictory
corrections by adults of colour names.5 It is suggested that
children who are colour blind may have additional
difculties when being taught reading and mathematics,
and may be affected in a number of ways. Bacon16
investigated the extent of the possible handicap. He found
that colour differentiation was needed in many lessons;
from the use of coloured materials in the infant class; the
use of colours in teaching reading, mathematics, geography, natural history, and science in primary school, to the
teaching of chemistry, physics and biology in secondary
school. In the case of biology a study has shown that
students with defective colour perception have increased
difculties in achieving success.17 On the other hand the
evidence is conicting, and teachers commented that
observed difculties were infrequent, and that most
affected children discovered clues for differentiating
colours, other than by their hue. As might be expected
the higher the child's intelligence the easier this proved to
be. Although some have recorded an increased incidence of
decient colour vision among educationally handicapped
children,18 others showed no evidence that children with
learning difculties are any more or less likely to be colour
blind.19 Also Lampe et al20 found that school achievement
did not seem to be related to defects of colour vision.
One method for teaching children with specic disorders
of language development was devised in order to make
maximum use of the unaffected visual pathways.21 In this,
the parts of speech are differentiated by colour; nouns in
red, verbs in yellow, adjectives in green, prepositions and
conjunctions in blue, and adverbs in brown. Words can be
represented by lines of appropriate colour, and the lines
built into patterns to show what is required to describe
pictures or events. Nouns are taught initially, as whole
words, in association with objects; rst of all with an actual
object, and then with many different objects of the same
type so that the full concept of what is represented by the
particular symbol is demonstrated.
A child with impaired colour vision may well be at a
disadvantage in art classes if this condition is not
recognized, although not necessarily so. A number of well
known artists have been, or have been thought to have

Colour vision
N Gordon

been, affected in this way. These include Whistler,

Carriere, Leger, and possibly Constable and Mondrian.22,23
Also some people may choose unusual colours, but this
may not be incompatible with an aesthetically satisfactory
work;15 although the appreciation of a painting by the
viewer often depends on analysis of the colours used by the
painter.24 Mandola25 found no denite link between
defective colour vision and drawing ability.
Older affected students can also be at a disadvantage in
other subjects, such as bacteriology, botany, horticulture,
cartography, chemistry, design, and geology.5
Conclusions
The importance of the evaluation of all screening tests, is
now quite rightly emphasised. Such screening tests for
defective colour vision are usually included alongside other
vision screening tests. In a survey of 1809 eight to ten year
old children, carried out to estimate the value of repeating
colour vision tests during junior schooling, colour vision
was checked in 560 children who had abnormal visual
acuity. Colour vision defects were found in 29 boys, only 2
of whom had been previously documented.
Although satisfactory colour vision tests have been
recorded, using Ishihara charts, for most school-entry
children aged ve years, the age of 1112 y or up to 14 y
is recommended by the Joint Working Party of the British
Paediatric Association, chaired by Polnay26 as being the
most appropriate time; even if there may be little evidence
that abnormal colour vision causes learning problems.27
However if a child is found to have learning difculties
before this age the possibility of impaired colour vision
should always be checked.28 If a child is known to have
such a defect, and the method of teaching involves the
recognition of ve different colours, the teacher can easily
make the necessary adjustments to the teaching technique.29
Very occasionally colour blindness can be acquired, for
example in people who suffer from diabetes mellitus. This
can lead to problems if the urine is monitored for glucose
level by a method using colour matching. When the vision
of premature babies is tested during childhood an unusually
high incidence of colour vision defects has been found,
predominantly of the tritanopia type. This may be due to
the blue cones being destroyed by the infant receiving high
doses of light, mainly in the blue part of the visual
spectrum.30
When it comes to the selection of a career it may well be
essential to identify possible colour vision defects. For
example, anyone who is colour blind should be advised
against training for such occupations as pilots, train drivers,
navigators, electrical work, electronics, the fabric industry,
certain jobs in the armed forces, merchant navy, and the
police.31,32 Colours are increasingly used in learning
technical theory and application33 and especially so in
computer graphics,5 and it has recently been stressed that
histopathologists and medical scientic ofcers can be at a
considerable disadvantage in their work if they have
impaired colour vision.34 Full lists of careers that may be
affected by impaired colour vision can be obtained from the
Careers Advisory Service.
A Ph.D. graduate has given an interesting account of
what it is like to be colour blind.35 As a young child the
author developed his own labels for colours, and when his
teacher tried to make him learn the correct names he
became anxious and felt different from other children, and

83

this can hinder the development of self-concept. This is an

argument in favour of early testing of colour vision. He
found it important to learn to compensate for his
deciency, for example the order in which trafc lights
change. Also he found that his colour deciency made him
more sensitive to texture, shape, and form, and in his
paintings he placed particular emphasis on these qualities.
He perceived that people probably treat the colour blind as
if they had a problem, but he found that through
compensation it was perfectly possible to operate normally.
There is obviously considerable controversy over the
results of defective colour vision, particularly as the effects
of different types are so variable. When it is defective it can
cause problems, although more often than not these can be
overcome. Success will depend on such factors as the
child's intelligence, the age at which it is diagnosed, the
attitude of teachers, and the help given to the child.
Although it may not be vital to identify defective colour
vision until advice on career choice is being made, it does
seem reasonable to test at school entry, until further
research has been done; and avoid any chance of an
interference with learning, or impairing educational
success.36 The studies of Holroyd and Hall32 lead them to
conclude that, until more research had been done on
alternative methods, it was justiable to continue with
screening, hopefully more efciently done, and with better
counselling for those affected.
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Colour vision
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