Effects of Contrast Sensitivity

on Colour Vision Testing

Anvesh Annadanam a, Jiawei Zhaoa, Jiangxia Wangb, and Allen O. Eghrari
 Introduction

Colour to assess severity of

CV loss by acquired
vision (CV) or genetic disease
processes or drug
testing toxicities.

Methods and apparatues:

Pseudoisochromatic plates Disc arrangement tests

The Ishihara and Hardy-Rand-Rittler FarnsworthMunsell 100 and Farnsworth

(HRR) tests D-15 (D15) hue discrimination tests.
Pseudoisochromatic Plates
1917 The full Ishihara colour test
• A quick assessment of congenital X-linked protan-deutan colour blindness
• uses numbers arranged as colour dots of varying size, hue, and saturation.

1955 The HRR test

• Requires the identification of coloured shapes on a grey dotted background.
• Scored based on the number of symbols correctly identified,
• Currently used as an initial analysis of patients’ CV loss due to congenital defects,
retinal diseases, or acquired colour deficiencies.

Inexpensive, durable, and readily available for use in

the offices of eye care professionals.
Disc Arrangement Tests

Using caps of different hues then the patient sort them into a
particular spectrum or group.
Developed for occupational colour discrimination and can
detect CV loss across all three axes.
Numbers and shapes do not need to be discriminated  less
reliant on visual acuity (VA).

More sensitive
to detect early
Time-consuming
visual
dysfunction
Contrast Sensitivity (CS)

Measures an individual’s ability to discern an object’s lightness or

darkness in comparison with its background.

One may have high VA but poor contrast discrimination, which

may affect activities of daily life such as motion detection and
pattern recognition.

Changes in CS can occur in patients with dry eye syndrome,

retinal diseases, macular disorders, and glaucoma, among others
CV tests have been explored in relation to
low vision, colour blindness, and cone
dystrophies

The effect of contrast vision loss on test results

has not been extensively studied.

In this study, we used a computer model for

CS loss to determine its effect on CV testing
scores for the Ishihara and HRR tests when
compared with the gold standard colour
vision D15 test.
 Materials and Methods
A prospective clinical investigation

Recruited from the Exclusion: Patients with

Wilmer Eye Institute and
School of Medicine at
the Johns Hopkins
Hospital.
Age between 18 and 75
ocular pathology, including
those that affect colour or
contrast vision, or binocular
best-corrected visual acuity
(VA) worse than 20/30.

Underwent best-corrected
logMAR VA assessment,
Farnsworth D-15 CV and Pelli-
Robson CS testing, and
computer image
discrimination testing
 VA Measurement of distance VA with corrective lenses
(if worn) was using computerized logMAR VA charts

CV
Starting at the 20/30 line, testing proceeded
sequentially to the line on which greater than or
equal to half of the letters were properly read, for
Computer
each eye separately, and then both eyes together
 Using the Farnsworth D-15 (D15) test, consists of 15 colour
discs comprising the entire colour spectrum.

VAVA Under simulated natural daylight conditions, subjects were

asked to arrange the discs in order according to the
colour.
CVCV
Each correctly placed disc received 1 point.

Computer
Computer
Subjects who did not place all discs in the correct order
were ineligible for the study
 Subjects were shown 212 images on a computer
monitor (Dell P2314H) at a distance of 42 inches
with luminance in the range of 0 to 4 candelas/m2
VAVA

The images fell into five categories:

CVCV
• 23 images of HRR pseudoisochromatic plates
• 17 of Ishihara pseudoisochromatic plates
Computer
Computer • 10 of D15 discs
• 2 of PelliRobson (PR) CS charts
• 1 of ETDRS VA chart.
 • An unadjusted
• Three contrast adjusted were made using ImageJ
Total was four software
variants of each
• High: 1.80 log units (1.6% contrast loss)
image:
• Medium: 1.50 log units (3.2% contrast loss)
• Low: 1.05 log units (8.9% contrast loss)

• The discs were arranged in a clockwise manner with the pilot disc on the left side.
• Pictures were taken of the discs arranged in the proper order as well of those in
D15 test an incorrect order, i.e., some discs were switched around.

• Participants were asked to read as many letters as they could, and the faintest
triplet for which at least two of three letters were correctly identified indicated the
PR charts log contrast sensitivity score of the tested eyes.

• VA was determined by the lowest line on which at least half of the letters were
ETDRS read.
chart
Ishihara HRR D15
plates plates discs
2 points: for correctly
2 points: for correctly identifying the shape and
identifying single-digit or quadrant for both one- 1 point: if the subject was
double-digit plates. shape and two-shape successfully able to
plates. determine if the disc
order was correct or
incorrect
1 point: for correctly
1 point: if only one digit
identifying only one
was identified on a two-
shape in the two-shape
digit plate
plates.

0 points: if numbers were 0 points: otherwise

0 points: for incorrect
not identified on both
shape identification on
one-digit and two-digit
either plate type.
plates.
Statistics

 All analyses were performed using Stata Statistical Software,

release 14.1 (StataCorp LP, College Station, TX, USA).
 The Wilcoxon signed-rank test was used to assess differences
between task scores, comparing each of the three CV tests
at each of the three contrast levels.
 Differences within a particular CV test were also assessed for
each contrast level compared with baseline scores.
 Statistical significance was adjusted using the Bonferroni
method to account for multiple comparisons, indicated in
each table.
 Results

Demographic data of subjects

Characteristic Subjects •A total of 13 participants were tested and

two were excluded for had baseline
Mean age in years (SD) 28.6 (14.7) Ishihara scores that were less than 70% of
Sex, n (%) the total possible score.
Male 9 (81.2)
Female 2 (18.2) •Median visual acuity in each eye was
20/20. Mean Pelli-Robson score was 1.95 at
Race, n (%) baseline.
White 3 (27.3)
Asian 6 (54.5)
Middle Eastern 2 (18.2)
 Results
Median scores (range) for colour vision tests

Test Baseline High Medium Low

Ishihara (max 34) 34 (33-34) 34 (31-34) 34 (32-34) 31 (15-34)
HRR (max 46) 45 (42-26) 44 (42-26) 41 (30-44) 27 (12-33)
D15(max 10) 10 (10-10) 10 (9-10) 10 (8-10) 7 (6-9)

•Mean PR scores for baseline, high, medium, and low contrast were
1.95, 1.82, 1.49, and 1.04, respectively (p = 0.004 for all).
 Results
p values of comparison between contrast p values of comparison between colour
settings for each colour vision test vision tests for each contrast setting

Settings Ishihara HRR D15 Tests High Medium Low

Baseline-High 0.8343 0.0471 0.0833 Ishihara-HRR 0.4707 0.0033* 0.0033*
Baseline-Medium 0.8342 0.0032* 0.084 Ishihara-D15 0.3225 0.4610 0.1305
Baseline-Low 0.0074* 0.0033* 0.0028* HRR-D15 1.00 0.0044* 0.0087*
High-Medium 0.9583 0.0032* 0.9464
*Statistically significant with
High-Low 0.0048* 0.0033* 0.003* a p value of < 0.017
Medium-Low 0.0067* 0.0033* 0.0029*

*Statistically significant with a p value of < 0.008

Results

•Percentage difference in accuracy

based on contrast level.

•At low and medium contrast levels,

accuracy decreased significantly in
HRR compared to Ishihara or D15
testing.
 Discussion
Contrast sensitivity (CS)  important visual parameter that determines ability to
distinguish between brighter and dimmer areas of an image.
• PR chart that contains letter arranged in triplets of decreasing contrast =
simpler method.

In this study:
• CS loss had the most significant impact on HRR scores, support previous
research:
• Zhao et al (2015): positive correlation between HRR and PR CS scores in
optic neuropathy patients.
• HRR showed a larger decrease in scores (medium and low contrast settings)
• HRR scores = not accurate reflection of CV in patients with CS loss.
• D15 (gold standard) also showed a score decrease between baseline and
lowest contrast
• Contrast decrease may resemble the effects of fogging on reducing visual
acuity & affects the results of CV tests.
 Discussion
Pseudoisochromatic plates require an observer to identify shapes (HRR) or
numbers (Ishihara) arranged as coloured dots of varying size, hue, and
saturation against a similarly styled background.
• Variances in spectral sensitivity  differences in luminous reflectances
between figure and background  colour perception altered.

CS is decreased in ocular pathologies with increasing age, including macular

degeneration, retinal diseases, and dry eye.
Optic neuropathies rely on abnormal pseudoisochromatic plate testing for
clinical suspicion.
• Aroichane et al (1996): HRR testing is more likely than Ishihara to detect CV
deficit in patients with non-glaucomatous optic neuropathy.
• Our finding: HRR is impacted by CS loss may explain its advantage over
Ishihara, for detecting reduced CS in patients with optic neuropathy.
 Discussion
Limitations in this study:
• Small study population
• The use of Farnsworth D-15 as standard CV test instead of Farnsworth-
Munsell 100 (more sensitive in detecting acquired CV deficiency, but has a
higher rate of false positives for CV loss).
• Use a computer model for CS loss.
• Future studies in patients with ocular pathology that decreases CS
without effects on CV, will allow a direct examination of the CL loss
impact on the results of pseudoisochromatic plates.
Conclusion

HRR scores may be

significantly affected by CS
loss.

Clinicians should be cautious

when interpreting results from
HRR tests, especially in
patients with disorders that
affect CS
CRITICAL APPRAISAL
TITLE
Not more than 12 words, can illustrate the journal
Too long / short ?
content generally

Illustrate the observed variables ? Yes

Non standard Abbreviation? No

Anvesh Annadanam, Jiawei Zhao, Jiangxia Wang,

Allen O. Eghrari. Wilmer Eye Institute, John Hopkins
Any corresponding author and email ? University School of Medicine, 600 N. Wolfe Street,
Baltimore, MD 21287, USA.
(e-mail: allen@jhmi.edu)
CRITICAL APPRAISAL
ABSTRACT
Consists of 4 parts: background, No, only consist 3 parts: method, result, and
method, result, and conclusion? conclusion

Any keywords ? Yes

Do the abstract is wholly appropriate ? Yes

AIM & BENEFIT OF THE RESEARCH

Does the aim explained ? Yes

Does the benefit explained ? No

CRITICAL APPRAISAL
METHODS
Is there any research design ? Yes, it is explained

Population & samples Yes, it is explained

Inclusion-Exclusion Criteria Yes, it is explained

It is not explained
Sampling & Sample size formulation

Did the subject selection is appropriate? Yes, it is appropriate.

Is there any bias ? The study population was small.

Treatment Yes, it is explained

CRITICAL APPRAISAL
METHODS
Did the measurement blind ? NO
Is there any bias on procedure, means, and
NO
subject obedience ?
Is there any explanation about independent &
Yes, it is explained
dependent variables ?

Is there any operational definition ? Yes

Is there any ethical clearance consent ? Yes

Data analysis ? Yes

CRITICAL APPRAISAL
RESULTS
Any Drop out ? None

Is there any subject characteristic

Yes
table ?
Is there any aim for the results? Yes

What is the main result of the Hardy-Rand-Rittler (HRR) test may no be an accurate reflection
research ? of colour vision in patients with contrast sensitivity loss.

DISCUSSION
Did the result suits the theory ? Yes
Is there any comparison with another
Yes, there are some similarities and differences
research ?
CRITICAL APPRAISAL
CONCLUSION
Could it be applied in chosen
sample, reachable and target Yes, but it needs further studies
population ?

Could this research be applied for

Applicable
patients ?
 SECTION 1: INTERNAL VALIDITY
The spectrum of patients is representative
of the patients who will receive the test in
practice.
Selection criteria are clearly described.
The gold standard is likely to classify the
condition correctly.
The period between gold standard and
index test is short enough to be
reasonably sure that the target condition
did not change between the two tests.
Poorly addressed.
This study analyses how CS loss affect CV testing. But,
patient with ocular pathology, including those that
affect colour or contrast vision were excluded.
Well covered.
Inclusion criteria: Between the ages of 18 and 75
Exclusion criteria: ocular pathology, that affect colour
or contrast vision; binocular best-corrected visual
acuity worse than 20/30
Adequately covered.
The D15 test, which was used as gold standard CV
test, also showed a score decrease between the
baseline and lowest contrast setting, but still better
than HRR test.
Not reported.
It was not reported in the study.
The gold standard was independent of the index test Well covered.
(i.e. the index test did not form part of the gold The index test (HRR and Ishihara) did not
standard). form part of the gold standard (D15).

The execution of the index test was described in
sufficient detail to permit replication of the test.
The execution of the gold standard was described in
sufficient detail to permit replication of the test
Index test results were interpreted without knowledge
of the results of the reference standard. (BLINDING)
Well covered.
The examination procedure of Ishihara
and HRR were well described with the
detail of process and equipment.
Well covered.
The examination procedure of ID15 was
well described with the detail of process
and equipment.
Not applicable.
There was no reference standard.

Reference standard results were interpreted without Not applicable

knowledge of the results of the index test. (BLINDING) There was no reference standard.
 Not reported.
Uninterpretable or intermediate test
Uninterpretable or intermediate test results was not
results are reported.
reported.
Well covered.
An explanation is provided for Two participants were excluded for had baseline
withdrawals from the study. Ishihara scores that were less than 70% of the total
possible score.
Section 2: OVERALL ASSESSMENT OF THE STUDY

How reliable are the conclusions of this ++

study? Code ++, +, or –

Were the same clinical data available

when test results were interpreted as
Yes
would be available when the test is
used in practice?
 Section 3: DESCRIPTION OF THE STUDY
11 subjects.
How many patients are included in this study?
Inclusion: Between the ages of 18 and 75
Please indicate number of patients included,
Exclusion: ocular pathology, that affect
with inclusion/exclusion criteria used to select
colour or contrast vision; binocular best-
them.
corrected visual acuity worse than 20/30
What is the prevalence (proportion of people 9 patients (81.2%) presented with
with the disease being tested for) in the
corrective lenses.
population from which patients were selected?
What are the main characteristics of the 9 patients (81.2%) were male, 6 (54.5%)
patient population? were Asian. The mean age was 28.6 years

What test is being evaluated in this study? Ishihara, HRR, D15

What is the gold standard with which the test D15 was used as gold standard.
And each test was compared with its
being evaluated is compared?
baseline.
What is the estimated sensitivity of the test being
Not applicable
evaluated? (state 95% CI)
What is the estimated specificity of the test being
Not applicable
evaluated? (state 95% CI)
What is the positive predictive value of the test
Not applicable
being evaluated?

What is the negative predictive value of the test

Not applicable
being evaluated?
What are the likelihood ratios for the test being
Not applicable
evaluated?
Wilmer Biostatistics Core Grant EY01765
How was this study funded?
and NIH L30 EY024746.

Are there any specific issues raised by this study? No

Thank You