Original Article

Prevalence of Color Vision Deficiency and its Correlation

with Amblyopia and Refractive Errors among Primary
School Children
Zhale Rajavi1,2, MD; Hamideh Sabbaghi3,4, MS; Ahmad Shojaei Baghini4, MD; Mehdi Yaseri3,5, PhD
Koroush Sheibani4, MD; Ghazal Norouzi6, MD
1
Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2
Department of Ophthalmology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3
Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4
Basir Eye Safety Research Center, Basir Eye Clinic, Tehran, Iran
5
Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, Tehran, Iran
6
School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract
Purpose: To determine the prevalence of color vision deficiency (CVD) and its correlation with amblyopia
and refractive errors among primary school children.
Methods: In this population‑based cross‑sectional study, 2160 children were selected from 36 primary
schools; 60 students were from each school  (10 students in each grade), with equal sex distribution.
A  complete eye examination including refraction using a photorefractometer, determination of visual
acuity (VA) and color vision using a Yang vision tester, and evaluation of ocular media opacity using a
direct ophthalmoscope was performed. Children who could not answer at least 4 plates of the Ishihara
color test were considered as color vision deficient subjects. Amblyopia was determined if pinhole VA was
worse than 0.3 LogMAR (equal to 20/40).
Results: The prevalence of CVD was 2.2% (95% CI: 1.5% to 3%) which was higher in male subjects (37 [3.5%]
boys vs. 11 [1.0%] girls, P < 0.001). Mean VA was lower among students with CVD as compared to normal
color vision children (P = 0.035) and amblyopia was observed in 8.3% (95% CI: 0.2% to 16.4%) of patients
with CVD versus 2.1% (95% CI: 1.5% to 2.08%) of children with normal color vision perception (P = 0.005).
A statistically significant correlation between lower VA and CVD was observed (P = 0.023).
Conclusion: Although CVD was correlated with lower VA and amblyopia, there was no relationship
between CVD and the type of amblyopia, refractive error, anisometropia or strabismus.

Keywords: Amblyopia; Color Vision Deficiency; Refractive Error; Visual Acuity

J Ophthalmic Vis Res 2015; 10 (2): 130-138.

Correspondence to: INTRODUCTION

Hamideh Sabbaghi, MS. Ophthalmic Research Center,
Shahid Beheshti University of Medical Sciences, No. 23, The prevalence of inherited red‑green color vision
Paidarfard St., Boostan 9 St., Pasdaran Ave., deficiency  (CVD) has been reported to be 8% and
Tehran 16666, Iran. 0.4% in male and female individuals among European
E‑mail: sabbaghi_h@yahoo.com Caucasian populations[1‑5] and 4% to 6.5% among male
Received: 23-02-2014 Accepted: 17-11-2014
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How to cite this article: Rajavi Z, Sabbaghi H, Baghini AS, Yaseri M,

DOI: Sheibani K, Norouzi G. Prevalence of color vision deficiency and its
10.4103/2008-322X.163778 correlation with amblyopia and refractive errors among primary school
children. J Ophthalmic Vis Res 2015;10:130-8.

130 © 2015 Journal of Ophthalmic and Vision Research | Published by Wolters Kluwer - Medknow
 Color Vision Deficiency and Amblyopia; Rajavi et al
subjects of Chinese origin.[5‑11] In Saudi Arabia, the rate of
CVD in female individuals has been 0.35%.[12] A marked
difference between male and female ratios has usually
been testified.[5]
Although decreased vision is the prominent sign of
amblyopia,[13] there are certain associated microscopic
anatomical and structural abnormalities in the retina,[14,15]
lateral geniculate body (LGB)[15,16] and in area V1 of the
visual cortex.[15,17,18] Deficiency in other visual functions
including contrast sensitivity, binocularity, the crowding
phenomenon and visual evoked potential may be
observed along with amblyopia.[19]
Patients affected with disorders such as optic
neuropathies, macular diseases, media opacities and
amblyopia show a higher prevalence of CVD; among
these, amblyopic children demonstrate the lowest
prevalence of CVD.[20] Color perception arises from
signals generated by three cone photoreceptors with
different spectral sensitivity functions. Signals from
the retina which pass through the LGB are eventually
transmitted to the cerebral cortex.[21] Transmission of
color and motion information predominantly occurs by
two major parallel pathways to the brain, where visual
signals are reintegrated in the visual cortex. Retinal cells
in the parvocellular pathway are responsible for fine
and chromatic stimuli, while cells of the magnocellular
pathway are responsible for moving and achromatic
stimuli.[22] Some studies have revealed that monocular
visual deprivation affects the size of parvocellular and
magnocellular cells in the LGB which is more significant
with long‑term involvement of the eye,[22,23] and may
affect color vision. The color spectrum is perceived by
different color wavelength sensitive cones which also
have an effect on control of accommodation and refractive
error (RE),[24] therefore problems with color perception
may impact accommodation and refractive errors.
In the present study, we aimed to determine the
prevalence of CVD and its correlation with amblyopia
and refractive errors among primary school children in
Tehran, Iran.
METHODS
In this population‑based cross‑sectional study, out of a total
of 1781 primary schools in Tehran, 36 schools (including
an equal number of public and private schools) were
selected by random cluster sampling from different
regions (North, South, West, East and Center) of Tehran,
the capital city of Iran, from October 2013 to January
2014. There are six elementary levels in primary schools
in Iran and in all selected schools, 10 students from each
elementary grade were randomly selected for this study.
The children were aged from 7 to 12 and the number of
male and female subjects was equal.
A total of 2160 children were selected from 36
primary schools. These included 60 students from each
Journal of Ophthalmic and Vision Research 2015; Vol. 10, No. 2
school (10 students in each grade). Available data from
2150 children was used in the final analysis; incomplete
data from 10 other children was discarded due to different
reasons. Patients with mental retardation, ocular diseases
or anomalies and disorders of fixation were excluded.
The study was approved by the Ethics Committee
of the Ophthalmic Research Center, Shahid Beheshti
University of Medical Sciences, Tehran, Iran and Basir
Eye Safety Research Center and adhered to the tenets of
the Declaration of Helsinki. Formal written consent was
obtained from the students’ parents prior to the study.
The participants were interviewed by school health
instructors and a questionnaire concerning past health
history and demographic status of the subjects was filled,
then a complete eye examination including VA and color
vision assessment, refractive error measurement, ocular
deviation determination, anterior and posterior segments
evaluation and red reflex observation was performed.
Visual Acuity and Color Vision Testing
We used the Yang vision tester (SIFI Diagnostic S.P.A‑Via
Castellana, 70/e‑31100 Trevise, Italy) with constant
luminance of 120 cd/m2 for VA examination using its
Snellen E‑chart with 5 letters on each line to include
the effect of the crowding phenomenon. In addition,
Ishihara color test on the Yang vision tester was used
for CVD screening.
The examination was performed at 2 meters distance
in day light. The Ishihara test consists of 16 plates and
we asked children to read the colored number at the
middle of each plate monocularly. If the child was able to
read 13 plates or more correctly, the child was considered
as normal color vision, otherwise she/he was considered
to be color vision deficient. The order of presentation of
the plates was changed from one eye to the other eye to
prevent cheating.
If the child had glasses, VA and color vision were
assessed with his/her own correction. The eye was
suspected to be amblyopic if VA was 20/40 or less, then
the measurement was repeated by a 2 mm pinhole and
amblyopia was confirmed if VA did not improve to better
than 20/40 with the pinhole. VA was classified according
to pinhole VA into 20/20‑20/30, 20/40‑20/100, and less
than 20/100.
Refractive Errors
The refractive status of all children was measured using
a photorefractometer (PlusoptiX SO4 GmbH, Nürnberg,
Germany) with no cycloplegia by a trained technician;
this device has a reported sensitivity of 63%‑94% and
specificity of 62%‑99%.[25] Photorefraction was repeated
three times for each subject and the average result was
used for statistical analysis. The measurement range of the
photorefraction device is from −7.00 diopter (D) of myopia
to +5.00 D of hyperopia, therefore cases with refractive
131
 Color Vision Deficiency and Amblyopia; Rajavi et al

errors out of this range were considered to have “high”
refractive errors. Anisometropia was defined as spherical
equivalent (SE) difference of at least one diopter between
the fellow eyes. Myopia, hyperopia and astigmatism were
considered as SE ≤−0.50 D, SE ≥+2.00 D and cylindrical
power of 0.75 D or more, respectively.
Ocular Deviation
Ocular deviation was checked using the alternate cover
test if VA was more than 20/200 and the Krimsky method
in subjects with VA less than 20/200. The deviation was
measured for near (33 cm) and far (6 m). In order to reveal
any extraocular muscle dysfunction, the extraocular
muscles were evaluated in nine different gazes.
Ocular Structure
We assessed the ocular media by examining the red
reflex using a direct ophthalmoscope  (HEINE BETA®
200; Herrsching, Germany). If the size of central lens
opacity was more than 3 mm, the child was suspected of
having cataract. The macula and optic nerve head were
examined by direct ophthalmoscopy to exclude children
with retinal lesions.
Statistical Analysis
To present data, we used mean values, standard
deviation, median, range, frequency and percentage
data. To evaluate the association of different factors with
CVD, we used logistic regression analysis and odds ratio
with 95% confidence intervals. The multilevel method
was used to consider the intra‑cluster correlation of
observations. All statistical analyses were performed by
SPSS software (version 21.0, IBM Co., Chicago, IL, USA).
P values less than 0.05 were considered as statistically
significant.
RESULTS
A total of 2150 children aged 7‑12  (mean, 9.4  ±  1.7)
years were studied. Details of baseline demographics
and ocular findings are presented in Table  1. CVD
was detected in 48 children indicating a prevalence of
2.2% (95% CI: 1.5% to 3%). The prevalence of CVD in
male subjects was significantly higher as compared to
female students [3.5 vs. 1.0%, P < 0.001, Table 1].
Mean and median pinhole VA were lower in children
with CVD as compared to subjects with normal color
vision  [P  =  0.035, Figure  1]. There was a significant
difference between children with CVD and normal color
vision subjects in terms of amblyopia; the prevalence
of which was 8.3%  (CI: 0.2‑16.4%) in children with
CVD versus 2.1%  (CI: 1.5‑2.08%) in those without
CVD  [P  =  0.005, Tables  1 and 2]. However, there was

Table 1. Demographic and ocular characteristics of children with normal and deficient color vision
Factors Total Color vision deficiency OR 95% CI of OR P*
No Yes Lower Upper
Age (year)
Mean±SD 9.4±1.7 9.4±1.8 9.4±1.6 0.99 0.89 1.13 0.986
Median (range) 9 (6-14) 9 (6-13) 9 (7-14)
Sex (%)
Male 1061 (49.3) 1024 (48.7) 37 (77.1) 3.86 2.28 6.52 <0.001
Female 1089 (50.7) 1078 (51.3) 11 (22.9) 1
Visual acuity
Mean±SD 0.17±0.13 0.17±0.12 0.31±0.29 1.43† 1.07 1.91 0.035
Median (range) 0.1 (0.1-1) 0.1 (0.1-1) 0.18 (0.1-0.9)
Amblyopia (%)
Yes 49 (2.3) 45 (2.1) 4 (8.3) 4.14 1.53 11.21 0.005
No 2101 (97.7) 2057 (97.9) 44 (91.7) 1
Refractive error (%)
Yes 1104 (25.9) 1074 (25.8) 30 (31.9) 1.02 0.99 1.05 0.185
No 3155 (74.1) 3091 (74.2) 64 (68.1) 1
Anisometropia (SE
difference ≥1.00 D) (%)
Yes 85 (4.0) 82 (3.9) 3 (4.3) 1.05 0.26 4.22 0.942
No 2042 (96.0) 1998 (96.0) 44 (95.7) 1
Strabismus (%)
Yes 49 (2.3) 46 (2.2) 3 (6.3) 3.01 0.81 11.27 0.101
No 2101 (97.7) 4178 (99.4) 94 (97.9) 1
*Based on multilevel analysis; †Calculated for each line of decreased visual acuity. SD, standard deviation; OR, odds ratio; CI, confidence interval;
SE, spherical equivalent; diff, difference; D, diopter; P, probability

132 Journal of Ophthalmic and Vision Research 2015; Vol. 10, No. 2
 Color Vision Deficiency and Amblyopia; Rajavi et al
Figure 1. Mean visual acuity (LogMAR) in children with and
without color vision deficiency. VA, visual acuity; logMAR,
logarithm of the minimum angle of resolution
Figure 3. Comperhensive view of the examined population
based on amblyopia and color vision deficiency. CVD, color
vision deficiency.
no significant correlation between CVD and refractive
errors, anisometropia, or strabismus [Table 1].
The prevalence of CVD among different VA categories
is presented in Figure  2. The increased positive line
slope indicates more reduction of VA; however this
association should be considered with caution due to
small sample size (3 children with CVD among 5 children
with significant reduction of VA). Figure  3 presents a
comprehensive view of the normal (no amblyopia and
no CVD) examined children and those with amblyopia,
CVD or combination thereof in the studied population.
Out of 48 children with CVD, 77.1% were male, 16.6%
had hyperopia >+2.00 D, 25% had astigmatism >0.75 D,
Journal of Ophthalmic and Vision Research 2015; Vol. 10, No. 2
Figure 2. The percent of color vision deficiency in different
categories of visual acuity. VA, visual acuity
6.3% had exotropia, 8.3% had amblyopia and 4 subjects
showed coexisting CVD and amblyopia. The deficiency
in color perception occurred in children with VA of
0.3 LogMAR or less. The majority of children were
high hyperopic  (spherical equivalent ≥+4.00 D) and
astigmatic  (>1.00 D), half of the cases were exotropic
and one had anisometropia  [Table  2]. Clinical data of
the 49 amblyopic children are presented in Table  3.
A  comparable proportion of male  (51.02%) and
female (48.97%) children were amblyopic. There were
more cases with high refractive errors among amblyopic
children and most strabismic amblyopic children had
esotropia (8 out of 13 cases, 61.54%). The total sum in
some columns in Tables 2 and 3 are not equal to actual
numbers of studied students, as photorefraction was not
possible in certain children with high refractive errors
due to the limited range of the device (−7.00 to +5.00 D),
pupillary abnormalities, media opacities or strabismus.
Table  4 compares basic characteristics among
amblyopic children, those with CVD, and subjects with
coexisting amblyopia and CVD, versus normal (no CVD
and no amblyopia) children. Although mean VA among
children with no CVD and no amblyopia was lower than
color vision deficient children, the standard deviation
was wider among children with CVD and there was no
statistically significant difference. Mean age of amblyopic
children were significantly lower than normal (no CVD
and no amblyopia) children (P = 0.033).
DISCUSSION
In the current study, in order to improve diagnostic
accuracy, the Yang vision tester and PlusoptiX SO4
photorefractometer were applied. The former test can
be calibrated for desired distances ranging from 30 cm
to 9 m and testing conditions are adjusted automatically;
133
 Color Vision Deficiency and Amblyopia; Rajavi et al

Table 2. Basic characteristics of 48 children with color vision deficiency

Number Age Sex VA Amblyopia Refraction (D) Anisometropia Strabismus Mixed†
(year) (%) (LogMAR) (SE difference
OD OS OD OS ≥ 1.00 D)

Sphere Cylinder Axis Sphere Cylinder Axis

1 8.0 Girl 0.9 0.9 Yes 4.25 −2.75 180 4.00 −2.00 1 No XT No
2 8.0 Boy 0.4 0.3 Yes 4.50 −1.75 8 H.H* - - Yes No No
3 9.0 Boy 0.3 0.2 Yes 4.25 −3.25 8 3.75 −3.00 179 No No No
4 9.0 Girl 0.1 0.1 No 1.00 −0.50 9 0.50 −0.25 7 No No No
5 11.0 Boy 0.1 0.1 No 1.50 −0.50 15 2.00 −0.25 10 No No No
6 11.0 Boy 0.0 0.1 No 0.00 −0.25 165 −0.75 −0.25 39 No No No
7 9.0 Girl 0.4 0.0 Yes 0.00 −1.00 0 0.00 −3.75 0 No XT No
8 12.0 Boy 0.1 0.0 No 0.25 −0.50 94 −0.25 0.00 0 No No No
9 8.0 Boy 0.0 0.0 No 0.50 0.00 0 1.00 0.00 0 No No No
10 10.0 Girl 0.0 0.0 No 2.50 −0.25 123 2.75 −0.25 35 No No No
11 10.0 Boy 0.0 0.0 No 1.00 −0.25 18 1.25 0.00 0 No No No
12 8.0 Boy 0.0 0.0 No 0.75 −0.50 178 1.75 −0.50 1 Yes No No
13 10.0 Boy 0.0 0.0 No 1.50 −0.75 84 1.25 −0.75 94 No No No
14 14.0 Boy 0.0 0.0 No 0.50 −0.75 178 1.00 −1.25 176 No No No
15 7.0 Boy 0.0 0.0 No 0.50 −0.25 65 0.75 0.00 0 No No No
16 10.0 Boy 0.0 0.0 No 0.50 −0.50 10 0.75 −0.50 7 No No No
17 11.0 Girl 0.0 0.0 No 1.75 −0.75 13 2.25 −1.00 17 No No No
18 10.0 Boy 0.0 0.0 No 1.00 −0.50 87 1.00 −0.25 100 No No No
19 12.0 Boy 0.0 0.0 No 0.25 −0.50 115 0.50 −0.50 54 No No No
20 8.0 Boy 0.0 0.0 No 1.00 −0.25 20 0.75 −0.25 169 No No No
21 10.0 Boy 0.0 0.0 No −1.25 −2.00 175 −0.75 −2.75 2 No No No
22 12.0 Girl 0.0 0.0 No 4.50 −1.50 2 4.75 −0.75 165 No No No
23 7.0 Boy 0.0 0.0 No 1.00 −0.50 135 1.25 −0.50 73 No No No
24 9.0 Boy 0.0 0.0 No 1.00 −0.50 93 0.75 −0.25 53 No No No
25 8.0 Boy 0.0 0.0 No 0.25 −0.50 92 0.50 −0.25 95 No No No
26 9.0 Boy 0.0 0.0 No 1.25 −0.50 178 1.25 0.00 0 No No No
27 8.0 Boy 0.0 0.0 No 0.00 −0.25 53 −0.25 −1.25 177 No No No
28 9.0 Boy 0.0 0.0 No 1.75 −1.25 26 1.25 −0.75 7 No No No
29 11.0 Boy 0.0 0.0 No 0.50 −0.25 103 0.50 −0.50 81 No No No
30 12.0 Boy 0.0 0.0 No 0.25 −0.25 128 0.75 0.00 0 No No No
31 9.0 Girl 0.0 0.0 No 1.00 −0.25 175 0.75 −0.50 3 No No No
32 9.0 Boy 0.0 0.0 No 1.50 −0.50 82 1.00 −0.50 133 No No No
33 7.0 Boy 0.0 0.0 No 1.50 −0.50 131 0.75 −0.25 71 No No No
34 8.0 Boy 0.0 0.0 No 1.75 −0.75 107 1.00 −0.25 69 No No No
35 9.0 Girl 0.0 0.0 No 0.50 −0.25 116 0.50 −0.25 65 No No No
36 10.0 Girl 0.0 0.0 No 1.00 −1.00 10 1.25 −1.25 173 No No No
37 11.0 Girl 0.0 0.0 No 0.25 −0.25 108 0.50 −0.50 43 No No No
38 8.0 Boy 0.0 0.0 No 1.25 −0.75 87 1.00 −0.50 115 No No No
39 10.0 Boy 0.0 0.0 No 0.25 −0.25 169 0.25 0.00 0 No No No
40 9.0 Boy 0.0 0.0 No 1.75 −0.50 1 1.25 −0.25 25 No No No
41 10.0 Boy 0.0 0.0 No 0.50 0.00 0 0.50 0.00 0 No No No
42 9.0 Girl 0.0 0.0 No - - - 1.25 −1.00 179 - No No
43 12.0 Boy 0.0 0.0 No 0.00 −0.50 116 0.75 −0.25 30 No No No
44 9.0 Boy 0.0 0.0 No 1.00 −0.50 165 1.00 −0.75 20 No No No
45 9.0 Boy 0.0 0.0 No 1.00 −0.25 105 0.75 −0.25 7 No No No
46 7.0 Boy 0.0 0.0 No 1.50 −0.25 148 2.50 −0.25 70 Yes No No
47 8.0 Boy 0.0 0.0 No 0.50 −0.25 38 0.50 −0.25 160 No XT No
48 9.0 Boy 0.0 0.0 No 0.00 −0.25 64 0.00 0.00 0 No No No
Mean 9.4 Male: 0.05 0.04 8.3% 1.08 −0.63 - 1.04 −0.60 - 6.25% 6.3% 0%
77.08%
SD 1.6 0.16 0.14 1.20 0.65 1.08 0.79
*H.H, high hyperopia which was out of range of photorefractometer; †Mixed, Combination of anisometropia and strabismus. VA, visual acuity; OD, oculus dexter;
OS, oculus sinister; LogMAR, logarithm of the minimum angle of resolution; SE, spherical equivalent; diff, difference; M, male; SD, standard deviation; D, diopter;
No, number; y, year

134 Journal of Ophthalmic and Vision Research 2015; Vol. 10, No. 2
 Color Vision Deficiency and Amblyopia; Rajavi et al

Table 3. Basic characteristics of 49 amblyopic children

Number Age Sex VA CVD Refraction (D) Anisometropia Strabismus Mixed†
(year) (LogMAR) (SE difference
OD OS OD OS ≥1.00 D)
Sphere Cylinder Axis Sphere Cylinder Axis
1 7.0 Boy 0.5 0.6 No 0.00 −3.00 0 0.00 −2.75 0 No ET No
2 11.0 Girl 0.0 0.3 No 1.75 −1.25 179 1.75 −0.75 13 No No No
3 9.0 Girl 0.3 0.2 No −2.75 −0.25 97 −2.75 −0.50 70 No XT No
4 11.0 Girl 0.3 0.0 No 2.00 0.00 0 3.50 −0.50 125 Yes No No
5 12.0 Girl 0.3 0.3 No −0.25 −0.75 95 0.00 −0.75 82 No No No
6 11.0 Boy 0.7 0.7 No - - - - - - - No No
7 8.0 Boy 0.3 0.0 No 2.75 −3.50 12 0.75 −0.75 171 No No No
8 9.0 Boy 0.3 0.2 Yes 4.25 −3.25 8 3.75 −3.00 179 No No No
9 7.0 Girl 0.1 0.3 No 2.25 −0.75 169 0.00 −4.00 0 No No No
10 7.0 Girl 0.3 0.3 No 1.25 −3.50 9 0.50 −2.75 178 No No No
11 8.0 Girl 0.2 0.3 No 2.50 −2.25 7 3.50 −3.00 179 No ET No
12 11.0 Boy 0.3 0.2 No - - - - - - - No No
13 10.0 Girl 0.3 0.0 No 0.00 −2.25 0 0.00 −2.00 0 No ET No
14 8.0 Boy 0.3 0.0 No 1.50 −0.25 105 0.75 0.00 0 No ET No
15 7.0 Girl 0.2 0.4 No 2.00 −0.50 158 3.00 −0.50 6 Yes No No
16 7.0 Girl 0.3 0.0 No 3.75 −2.25 5 1.25 −0.75 169 Yes No No
17 9.0 Girl 0.3 0.2 No 1.00 −2.75 7 0.75 −1.50 174 No No No
18 7.0 Girl 0.4 0.4 No 0.00 −4.25 0 0.00 −3.00 0 No No No
19 12.0 Girl 0.0 1.0 No −0.25 −0.50 77 4.75 −2.00 128 Yes XT Yes
20 8.0 Boy 0.3 0.0 No - - - - - - - No No
21 12.0 Boy 0.3 0.2 No 0.25 −1.00 178 0.25 −0.50 9 No ET No
22 7.0 Girl 0.3 0.1 No 3.75 −3.75 0 0.00 −3.50 0 No XT No
23 7.0 Girl 0.5 0.7 No −3.25 −2.75 175 0.00 −4.00 0 Yes No No
24 9.0 Girl 0.4 0.0 Yes 0.00 −1.00 0 0.00 −3.75 0 No XT No
25 9.0 Girl 0.6 0.0 No 3.00 −0.50 175 2.75 −1.50 167 No No No
26 8.0 Girl 0.9 0.9 Yes 4.25 −2.75 180 4.00 −2.00 1 No XT No
27 9.0 Girl 0.3 0.3 No 0.50 −5.00 2 0.25 −5.00 2 No No No
28 12.0 Boy 0.1 0.3 No 0.75 −0.50 77 1.75 −1.50 153 No No No
29 12.0 Girl 0.0 0.5 No 0.25 −0.25 118 0.75 −0.25 40 No ET No
30 8.0 Boy 0.0 0.3 No 1.00 0.00 0 - - - - No No
31 9.0 Boy 0.3 0.3 No 4.25 −2.75 8 3.00 −2.50 175 Yes No No
32 7.0 Girl 0.2 0.3 No 0.25 −4.75 2 0.25 −4.50 171 No No No
33 7.0 Boy 0.3 0.1 No 1.75 −3.75 7 1.50 −3.25 165 No No No
34 8.0 Boy 0.4 0.3 Yes 4.50 −1.75 8 H.H* - - Yes No No
35 9.0 Boy 0.3 0.1 No 0.00 −0.50 0 0.00 −0.50 0 No No No
36 10.0 Boy 0.3 0.2 No −2.00 −0.25 177 −2.50 −0.50 9 No No No
37 8.0 Girl 0.4 0.5 No 5.00 −3.25 2 3.25 −2.75 179 Yes No No
38 7.0 Boy 0.3 0.3 No 1.75 −2.75 10 2.00 −2.50 173 No No No
39 8.0 Boy 0.2 1.0 No - - - - - - - No No
40 8.0 Girl 0.3 0.3 No - - - - - - - No No
41 12.0 Girl 0.9 0.0 No 0.25 −0.25 108 0.25 −0.25 63 No ET No
42 8.0 Boy 0.3 0.1 No 1.00 −4.75 3 0.75 −2.25 176 Yes No No
43 10.0 Boy 0.3 0.1 No 4.50 −1.00 1 2.75 −1.75 1 Yes ET Yes
44 7.0 Boy 0.3 0.3 No 3.25 −2.00 179 4.25 −2.25 78 No No No
45 8.0 Boy 0.0 0.3 No 1.50 −0.50 18 3.50 −0.75 154 Yes No No
46 12.0 Boy 0.4 0.0 No 0.50 −4.25 10 0.50 −0.50 2 Yes No No
47 7.0 Boy 0.3 0.3 No 2.00 −1.25 179 3.50 −1.50 3 Yes No No
48 11.0 Boy 0.3 0.2 No 3.50 −3.25 13 3.25 −4.25 74 No No No
Mean 8.0 Boy 0.3 0.3 No 2.00 −1.25 179 3.50 −1.50 3 Yes No No
SD 8.9 Male: 0.31 0.28 8.2% 1.35 −1.78 - 1.24 −1.67 - 28.6% 26.5% 4.1%
51.02%
1.8 0.19 0.25 1.86 1.55 1.72 1.43
*H.H: high hyperopia which was out of range of photorefractometer; †Mixed: Combination of anisometropia and strabismus. VA, visual acuity;
OD, right eye; OS, left eye; LogMAR, logarithm of minimum angle of resolution; CVD, color vision deficiency; SE, spherical equivalent; diff, difference;
M, male; F, female; SD, standard deviation; D, diopter; No, number; y, year

Journal of Ophthalmic and Vision Research 2015; Vol. 10, No. 2 135
 Color Vision Deficiency and Amblyopia; Rajavi et al

thus, accurate color vision testing is possible at different

Mixed‡**

VA, visual acuity; LogMAR, logarithm of minimum angle of resolution; OD, right eye; OS, left eye; SE, spherical equivalent; diff, difference; CVD, color vision deficiency; M, male; F, female;
Bonferroni method, ‡Based on logistic regression: adjusted for multiple comparison by Bonferroni method, §Based on GEE analysis, adjusted for multiple comparison by Bonferroni method.
2 (4.4)

6 (0.3)
distances. Its luminance can also be set from 80 to

0.031
0.001
0.031
0.001
0 (0)

0 (0)

D, diopter; y, year; PNC, correlation between normal (No CVD & No amblyopia) and CVD children; PNA, correlation between normal (No CVD & No amblyopia) children and amblyopic
*Both: Combination of color vision deficiency and amblyopia, **Mixed: Combination of anisometropia and strabismus, †Based on analysis of variance: adjusted for multiple comparison by
(%)
320 candela  (cd)/m2 and the commonly used value
is 120  cd/m2 which is constant for all measurements.
Therefore, we tested color perception in all children
Strabismus‡

11 (24.4)
under standard conditions of our system with more

35 (1.7)

<0.001
1 (2.3)

2 (50)

0.001
0.801

0.053
(%)

stability as compared with the conventional Ishihara test.

children; PNB, correlation between normal (No CVD & No amblyopia) children and those with coexisting of both; PCA, correlation between CVD and amblyopic children
The Ishihara test was also applied in our study as it
is commonly used to screen for red‑green CVD and can
be learned easily and performed rapidly in children.
Anisometropia‡
(SE difference
≥1.00 D) (%)

It contains of ten characters differing in size  (thinnest

14 (28.6)
3 (6.25)

70 (3.4)

<0.001

<0.001
<0.001
1 (25)

0.705
portions being under 0.5 cm), parallel to VA results.[26]
We performed photorefraction with no cycloplegia
according to manufacturer recommendations, since
induced peripheral aberrations due to a dilated pupil
makes measurement of astigmatism more difficult and
−1.67±1.43

−0.52±0.59
−0.6±0.79
Cylinder

−2.9±0.9

there is a possibility of off‑axis refraction. In addition,

-
-
-
-

photorefraction was performed at a longer working

distance (1 m or more) as compared to other refractive
OS

error measurement tools such as a retinoscope or

1.04±1.08
1.24±1.72

0.83±0.79
Sphere

autorefractometer, therefore accommodation might be

3.9±0.2
Refraction (D)§

more relaxed.
-
-
-
-

In our study, 48 out of 2150 children had CVD [Table 1].

The male to female ratio was 3.5 with higher prevalence
−0.63±0.65
−1.78±1.55

−0.49±0.58
Cylinder

in male subjects which is consistent with other

−2.2±1

>0.99

>0.99
0.999

0.997

studies.[5,12] CVD is usually inherited by an X‑linked

recessive pattern[5] and studies on European Caucasians
OD

have revealed that CVD is approximately 20 times more

1.35±1.86

0.83±0.82

prevalent among male as compared to female subjects.[1‑5]

1.08±1.2
Sphere

4.3±0.1

0.999
0.998
0.999
0.999

The difference in male to female ratio in our population,

Table 4. Comparison of all the basic characteristics among examined children

as compared to European studies, may be the lower age

or a different genetic basis for CVD in our population.
0.04±0.14
0.28±0.25

0.12±0.04

We observed that all four patients with combined

0.5±0.4
OS

CVD and amblyopia had a VA of 20/40 or less [Table 2]

-
-
-
-

which is comparable to the study by Bradley et  al[27]

VA§

reporting that all patients with combined CVD and

0.05±0.16
0.31±0.19

0.12±0.04

amblyopia had VA of less than 20/50. We also found a

0.5±0.3

<0.001

<0.001
0.579

0.006
OD

statistically significant correlation between CVD and

VA which means CVD was more prevalent in children
with lower VA [Figures 1 and 2] as von Noorden[28] and
female (male %)

1001/1056 (48.7)

other researchers have stated.[20,27,29] These findings are

23/22 (51.1)
35/9 (79.5)
Sex‡ male/

consistent with studies showing that color perception

2/2 (50)

<0.001
0.003

0.745
0.957

is affected when VA decreases to less than 20/50.[2]

Furthermore, it has been reported that color vision
loss occurs more frequently when the VA is less than
20/400[20] or 20/200.[29]
McCulley et  al [26] reported that the Ishihara test
9.4±1.6
8.9±1.8
8.5±0.6
9.5±1.7
(year)

0.993
0.993
0.033
0.992
Age†

was the color test most dependent on good VA and it

was not affected up to VA of 0.72 LogMAR  (20/106).
In our study, 6 of 8 eyes  (75%) with VA worse than
and no amblyopia)
Normal (no CVD

0.7 LogMAR did not show CVD which is not consistent

with this assumption. It seems that determination of VA
Amblyopia

as an accuracy criterion for the Ishihara test should be

considered with caution [Table 2].
Both**

PNA
CVD

PNC
PCA

Although there was no difference between normal and

PNB

color vision deficient children considering strabismus

136 Journal of Ophthalmic and Vision Research 2015; Vol. 10, No. 2
 Color Vision Deficiency and Amblyopia; Rajavi et al
and refractive errors, amblyopia was significantly more
common among children with CVD [P = 0.005, Table 1].
Qian et al[30] found a lower incidence of myopia among
children with abnormal color perception as compared to
normal (no CVD and no amblyopia) children while in the
present study, there was no difference between normal
color vision and CVD children in terms of myopia.
Ocular deviation especially exotropia was seen in
50% of children with coexisting amblyopia and CVD
whereas 25% of them showed anisometropia [Table 2].
Bradley et  al[27] also observed strabismus in 66% of
children with coexisting amblyopia and CVD with
no difference among certain deviation types but the
majority had unsteady foveal or eccentric fixation.
Koçak‑Altintas et  al[19] found no relationship between
CVD and any types of amblyopia such as anisometropia
or strabismus which is comparable to our results.
Bradley et al[27] reported that most amblyopic children
with CVD were hyperopic (sphere ≥+2.50 D). In the present
study, 4 children had both amblyopia and CVD, and 5 out of
6 amblyopic eyes had hyperopia more than + 4.00 D which
is comparable to Bradley’s findings [Table 2].
One of the limitations of the current study is that
examined children were screened only for red‑green CVD
since the Ishihara test is not able to detect blue‑yellow
deficiency. Children who were diagnosed with CVD were
not retested using another color vision test with more
sensitivity to validate our observations. Moreover, lack of
cycloplegic refraction and determination of best corrected
VA among all children was another limitation of our study.
In summary, although CVD was correlated with
amblyopia and decreased vision, there was no
relationship between CVD and the type of amblyopia,
refractive error, anisometropia and ocular deviation.
Exotropia and hyperopia were the most common form
of ocular deviation and refractive error among children
with coexisting CVD and amblyopia.
Acknowledgments
This study was supported by the Ophthalmic Research
Center, Shahid Beheshti University of Medical Sciences
and Basir Eye Safety Research Center.
The authors would like to thank all the children
and their families who participated in this study, as
well as Shadi Akbarian, Masoumeh Kalantarion, Simin
Kalantarion, Bahar Kheiri, Shirin Mohebi and Bahar
Safdari for their efforts in coordinating the fieldwork
and their assistance in data collection.
Financial Support and Sponsorship
Nil.
Conflicts of Interest
There are no conflicts of interest.
Journal of Ophthalmic and Vision Research 2015; Vol. 10, No. 2
REFERENCES
1. Waaler GH. Über die Erblichkeitsverhältnisse der verschiedenen
Arten von angeborener Rotgrünblindheit. Acta Ophthalmol
1927;5:309‑345.
2. Feig  K, Ropers  HH. On the incidence of unilateral and
bilateral colour blindness in heterozygous females. Hum Genet
1978;41:313‑323.
3. Kherumian R, Pickford RW. Hérédité et fréquence des Anomalies
Congénitales du Sens Chromatique: (dyschromatopsies). Paris:
Vigot Frères. 1959. p. 63‑67.
4. Crone  RA. Incidence of known and unknown colour vision
defects. A study of 6526 secondary school pupils in Amsterdam.
Ophthalmologica 1968;155:37‑55.
5. Birch J. Worldwide prevalence of red‑green color deficiency. J Opt
Soc Am A Opt Image Sci Vis 2012;29:313‑320.
6. Sato  S. Statistical observations on congenital abnormalities in
colour vision in Japan. Acta Soc Ophthalmol Jpn 1935;38:2227‑2230.
7. Chan  E, Mao  WS. Colour‑blindness among the Chinese. Br J
Ophthalmol 1950;34:744‑745.
8. Yang C, Chiang JC, Feng PH, Yang NH. Color‑blindness among
the Chinese. Chin Med J 1958;76:283‑284.
9. Iinuma  I, Handa  Y. A  consideration of the racial incidence
of congenital dyschromats in males and females. Mod Probl
Ophthalmol 1976;17:151‑157.
10. Kilborn LG, Beh YT. The incidence of color‑blindness among the
Chinese. Science 1934;79:34.
11. Kim  HB, Lee  SY, Choe  JK, Lee  JH, Ahn  BH. The incidence of
congenital color deficiency among Koreans. J  Korean Med Sci
1989;4:117‑120.
12. Alabdelmoneam M. Prevalence of congenital color vision defects
in Saudi females of Arab origin. Optometry 2011;82:543‑548.
13. Harrad R, Sengpiel F, Blakemore C. Physiology of suppression
in strabismic amblyopia. Br J Ophthalmol 1996;80:373‑377.
14. Williams  C, Papakostopoulos  D. Electro‑oculographic
abnormalities in amblyopia. Br J Ophthalmol 1995;79:218‑224.
15. Holmes JM, Clarke MP. Amblyopia. Lancet 2006;367:1343‑1351.
16. von Noorden GK, Crawford ML. The lateral geniculate nucleus
in human strabismic amblyopia. Invest Ophthalmol Vis Sci
1992;33:2729‑2732.
17. Kiorpes L, McKee SP. Neural mechanisms underlying amblyopia.
Curr Opin Neurobiol 1999;9:480‑486.
18. Davis  AR, Sloper  JJ, Neveu  MM, Hogg  CR, Morgan  MJ,
Holder GE. Electrophysiological and psychophysical differences
between early‑  and late‑onset strabismic amblyopia. Invest
Ophthalmol Vis Sci 2003;44:610‑617.
19. Koçak‑Altintas AG, Satana B, Koçak I, Duman S. Visual acuity and
color vision deficiency in amblyopia. Eur J Ophthalmol 2000;10:77‑81.
20. Almog Y, Nemet A. The correlation between visual acuity and
color vision as an indicator of the cause of visual loss. Am J
Ophthalmol 2010;149:1000‑1004.
21. Komatsu  H. Mechanisms of central color vision. Curr Opin
Neurobiol 1998;8:503‑508.
22. Davis  AR, Sloper  JJ, Neveu  MM, Hogg  CR, Morgan  MJ,
Holder  GE. Differential changes in color and motion‑onset
visual evoked potentials from both eyes in early‑  and
late‑onset strabismic amblyopia. Invest Ophthalmol Vis Sci
2008;49:4418‑4426.
23. Lunghi C, Burr DC, Morrone MC. Long‑term effects of monocular
deprivation revealed with binocular rivalry gratings modulated
in luminance and in color. J Vis 2013;13:1-15.
24. Rucker  FJ, Kruger  PB. Cone contributions to signals for
accommodation and the relationship to refractive error. Vision
Res 2006;46:3079‑89.
25. Schimitzek T, Haase W. Efficiency of a video‑autorefractometer
137
 Color Vision Deficiency and Amblyopia; Rajavi et al
used as a screening device for amblyogenic factors. Graefes Arch
Clin Exp Ophthalmol 2002;240:710‑716.
26. McCulley  TJ, Golnik  KC, Lam  BL, Feuer  WJ. The effect of
decreased visual acuity on clinical color vision testing. Am J
Ophthalmol 2006;141:194‑196.
27. Bradley A, Dahlman C, Switkes E, De Valois K. A comparison
of color and luminance discrimination in amblyopia. Invest
Ophthalmol Vis Sci 1986;27:1404‑1409.
138
28. von Noorden  GK. Binocular Vision and Ocular Motility:
Examination of Patient‑III Sensory Signs Symptoms and
Adaptation in Strabismus. St. Louis: Mosby Co.; 1990. p. 219‑231.
29. François J, Verriest  G. Color discrimination in strabismic
amblyopia. Doc Ophthalmol 1967;23:318‑331.
30. Qian YS, Chu RY, He JC, Sun XH, Zhou XT, Zhao NQ, et al. Incidence
of myopia in high school students with and without red‑green color
vision deficiency. Invest Ophthalmol Vis Sci 2009;50:1598‑1605.
Journal of Ophthalmic and Vision Research 2015; Vol. 10, No. 2