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Trichromatic Enhanced Dynamic Color Screening on the PDI Check Nintendo 3DS Game

Introduction Classification of color deficiency has required substantial time and expense with the static Farnsworth-Munsell and Innova Rabin tests. Therefore, dynamic color tests were developed for the Nintendo 3DS. Methods Fifteen color deficient patients and 17 age-matched normals performed Rabin color test in addition to PDI Check dynamic color games resembling Farnsworth-Munsell presentation (version 0.2.8) and 3-color iso-luminance gray (version 0.2.13). Results Tests of red, green and blue cone-deficient with the v0.2.8 had sensitivity/specificity/PPV of 92%/86%/92% protanopes, 78%/90%/88% deutanopes and 87%/50%/93% tritanopes. Version 0.2.13 had sens/spec/PPV of 78%/83%/78% red-cone, 100%/85%/80% green cone and 67%/78%/33% blue cone. Corresponding IntraClass Correlation (ICC) utilizing v0.2.8 were red-cone 0.22 (−0.02–0.60), green-cone 0.34 (−0.10–0.67) and blue-cone 0.38 (0.12–0.75). ICC for v0.2.13 was higher with protanope 0.62 (−0.07–0.87), deuteranope 0.64 (−0.09–0.88) and tritanope 0.31 (−0.07–0.70). The PDI Check color game took 65 seconds compared to 197 seconds for Innova Rabin. Conclusion The PDI Check color game quickly identifies patients with inherited color deficiencies.


Introduction
Accurate characterization of color defects is important in the diagnosis and management of inherited and acquired retinal and neuro-ophthalmic conditions. Adult and pre-literate matching cards are often used clinically, however more complex tests are required for detailed diagnosis and quantification of color deficiency. 1 Many tests are expensive and require significant time, understanding 2 and cooperation. Smartphone presentation can substitute for flip-book Ishihara color plates. 3 Utilizing the autostereoscopic barrier screen of the Nintendo 3DS XL console, near vision screening testing games have been developed. 4 Near monocular visual acuity, stereopsis and color vision can be screened in normal military staff and also in remote, non-English speaking villagers. 5 PDI Check correlates well with conventional near vision tests and helps identify ocular suppression both through stereo deficiency, but also with autostereoscopically presented, rivalry near optotypes. 6 Champion shotgun shooters demonstrated extraordinary red-cone and blue cone detection with PDI Check compared to age-matched normal subjects. 7 We undertook this study to analyze two types of dynamic, quick trichromatic separated color tests on the PDI Check and then compare them with industry standard, static, calibrated, computer delivered Innova Rabin system. 1,8

Methods
This study has IRB approval through Pacific University [109-17; 1098158-5]. It complies with the Declarations of Helsinki and the Health Insurance Portability and Accountability Act. Patients and/or their guardians provided written informed consent. De-identified data can be found: http://www.abcd-vision.org/references/Color% 20PDI%20Rabin.pdf.
Color deficient individuals were identified through Ishihara testing during eye examinations. Normal subjects were recruited from clinical and research staff. Each performed Innova Rabin's Cone Contrast color test 8 following standard procedure monocularly with the non-tested eye patched.
PDI Check has two different dynamic color testing games; two different dynamic color tests were programmed for the Nintendo 3DS XL. One ("FM," version 0.2.8) presents four forced choice identical discs on the upper screen starting at the cone confusion regions of an FM 100 test, then one random quadrant gradually deviates around the spectrum for the subject to identify by clicking the lower screen. The second type of test ("gray disc," version 0.2.13) starts with four iso-luminance gray discs against a neutral gray background. Then the pixels directed at one eye, in one random quadrant transform into a gradually intensifying teal, pink or a purple color for the subject to select as soon as the difference is perceived. Some subjects performed comparison of both PDI Check color versions. The Nintendo 3DS console automatically adjusts background screen luminance to an aesthetically pleasing viewing level. The PDI Check game on Nintendo 3DS and the Innova Rabin tests were viewed from 30 cm.
Given a mean of 95 and standard deviation of 10, the sample size to detect a difference of 15 given alpha 0.05 and Power 0.80 is 7.

Results
Fifteen color deficient individuals were identified through Ishihara testing during comprehensive eye examinations. Ages ranged from 7 to 50 years. According to Innova Rabin scores, the hue was predominantly red deficient in 6, green deficient in 8 and blue deficient in one. Thirteen of the fifteen color deficient were males. Seventeen normal individuals aged 11 to 60 served as controls of which 7 were males.
The time to perform patched Innova Rabin on both eyes averaged 197 seconds (range 162 to 260 seconds) while time to complete un-patched, monocular PDI Check dynamic gray-game for both eyes averaged 65 seconds (range 40-120 seconds).
The test re-Test reliability for version 0.2.8 color was 54 ±7 for red, 60±6 for green and 63±7 for blue; essentially the deviation was 10% of the mean. In comparison, PDI stereo can perform with 3% deviation compared to the mean.

Discussion
After gradual recruitment from a pediatric eye clinic, patients with inherited color deficiency and age-matched normal DovePress subjects had compared digital trichromatic evaluation on the same day. Each had industry-and US Military standard INNOVA Rabin computerized, timed static color quantification with non-tested eye patched compared to non-patched, dynamic, autostereoscopic monocular presentation on a portable, Nintendo 3DS XL game console. There was a good correlation and the dynamic presentation was quicker. Speed was not the issue when multiple digital color tests were compared in 68 color defective individuals without colornormal controls. 9 Insufficient time can be an issue with the D15 type color tests. 10 A limitation of this study was relatively small sample size. It is not simple to collect large numbers of color deficient individuals due to the relative rarity of the condition. 5 We did not yet include patients with acquired color defects. We defined color cone deficiency by Innova Rabin method that may not exactly represent FM 100 or anomaloscope. Not all our subjects were able to complete both PDI Check versions on the different test phases, but an advantage of our study was head-to-head comparison of two digital tests one the same day with identical lighting. The scores for normal color in PDI Check under-estimated Innova Rabin values therefore further mathematical modeling is underway. PDI Check continues to refine the output and presentation of the game to better provide useful clinical data. The autostereoscopic screen on the Nintendo 3DS XL allows monocular rapid screening for color defects in addition to monocular near dynamic acuity and stereopsis.

Conclusion
PDI Check in a quick, dynamic, forced-choice monocular presentation was able to quickly discriminate color deficient from normal vision individuals.

Funding
There is no funding to report.

Disclosure
Robert Arnold, Kyle Smith, Aaron Molina and Alex Damarjian are board members of PDI Check. Robert Arnold and Alex Damarjian have patent pending on autostereoscopic vision screening. Robert Arnold is also President of Glacier Medical Software and is coordinator of the Alaska Blind Child Discovery which has received discounted vision screen technology from several vendors. Robert Arnold reports nonfinancial support from PDI Check, during the conduct of the study; non-financial support from and being a board member of Glacier Medical Software, non-