#415 Validation of a Tablet-based Waggoner Computerized Color Vision Test CAPT Matt Rings, MC(FS), USN Dr. Terrace Waggoner, OD LCDR Kyle Dohm Ophthalmology Dept Naval Aerospace Medical Institute Pensacola, FL 88th Annual Scientific Meeting Aerospace Medical Association

Disclosure Information 88th Annual Scientific Meeting CAPT Matthew Rings, Medical Corps, US Navy CAPT Rings has no financial relationships to disclose. Dr. Waggoner has a financial interest in the Waggoner Computerized Color Vision Test (“ColorDx”). Dr. Waggoner had no involvement in data analysis, conclusions, recommendations or AsMA presentation preparation. I will not discuss off-label use or investigational use in my presentation Disclaimer: The presentation are my opinions alone, and does not necessarily reflect the policies of the Department of Defense, or the Department of the Navy.

Learning Objectives Learn the passing grade for computerized color vision testing for Naval aviation. Be able to compare the tablet version of a computerized color vision test to the PC-based version. Explain why the Farnsworth Lantern is a poor screening tool for detecting color vision deficiency.

Overview History of Computerized Color Testing USAF, USN standards Tablet Advantages & Disadvantages Tablet Types and Testing for Suitability Surface Pro 3 Tablet and Waggoner CCVT Methodology Results Conclusions

History of Color Vision Tests in Naval Aviation: Pseudoisochromatic plates (Red/Green). Primary R/G color test in Naval Aviation Passing score 12 or better of 14 test plates Failures use Farnsworth Lantern as backup. Farnsworth Lantern (identify red, green or white lights) – designed 1940’s to pass mild R/G color vision deficient sailors for duty, “Color Safe” Occasionally passes more moderately severe CVD Eliminated for new accessions JAN 2017

USN Allowed Computerized Tests: Waggoner Computerized Color Vision Test (WCCVT) Binocular testing Calibration not critical / infrequent schedule Laptop, desktop or tablet format (Surface Pro 3) Rabin Cone Contrast Test (RCCT) USN & USAF aviation accepted Critical calibration required weekly Netbook format and tablet format available (Surface Pro 3) Colour Assessment & Diagnosis (CAD) UK civil aviation standard Expensive, large desktop format, research tool

Tablet Test Format Tablet Benefits: Single power plug Battery powered (Portable) Touch screen Microsoft Windows tablets: USB calibration Tablet Cons: Impossible to calibrate Android and Apple tablets Small  Easily stolen Portable  fragile, dropping & breaking

Tablet Selection Process Android Tablets (Lenovo, Asus, Samsung Pro S) Wide range of saturation and color inaccuracies, many color “modes” No calibration possible (no USB port for colorimeter) Apple iPad Air 2 Accurate factory color Wide color gamut, good gamma, good white-point iTunes account required, Navy does not support Apple iOS Windows Surface Pro 3  Chosen for research Accurate factory color profile – wide color gamut, good gamma, good white point USB ports for calibration, if desired / required Windows software supported by Navy

Methodology Purpose: Compare Uncalibrated Tablet vs. Calibrated PC version IRB-approved: Naval Hospital Portsmouth 300 active duty aviation personnel: 277 male, 33 female Nagel Anomaloscope, Pseudoisochromatic plates, FALANT Waggoner Computerized Color Vision Test (WCCVT, “ColorDx”) PC: Spyder 4 Elite Calibrated LCD Monitor Surface Pro 3: Windows sRGB color profile – no external calibration Randomized ‘normal’ population selection (PIP passing score) All CVD personnel offered to participate (PIP failures) Randomized PC vice Tablet testing order

PC Monitor vs. Surface Pro 3 Tablet PC laptop with Samsung IPS 19” TFT monitor Spyder 4 Elite Colorimeter Calibration (94% sRGB) 85 cd/m2 (avg) 6698K white point (avg) Gamma 2.2 DeltaE (50% grey) 1.40, avg all colors 1.80 Microsoft Surface Pro 3 Tablet – 12” IPS monitor NO CALIBRATION sRGB IEC 61966-2.1 Windows color profile (98% sRGB) 50% brightness setting, 83 cd/m2(avg) 6764K white point (avg), DeltaE white 2.13 DeltaE 50% grey: 1.60, avg all colors 1.79

Diagnosis of R/G CVD by Test

Computerized R/G CVD Grading Scores PC R/G Normal 256 254 PC MILD DEUTAN 21 17 TABLET MILD RED GREEN 2 MOD DEUTAN 9 15 SEV DEUTAN 10 8 Total Deutan 40 42 MILD PROTAN 1 MOD PROTAN SEV PROTAN Total Protan 4 Total R/G CVD 44 46   Total 300 Two Tritan CVD scores not summed with R/G defects

Pass/Fail USN Aviation Standard

21-25 Normal R/G 0-20 Abnormal R/G Pearson Correlation = 0.964 Sig (1-tail) = .000

Significance (1-tail) p < .001 Constant error p < .395 32 32 Pearson Correlation = 0.861 Significance (1-tail) p < .001 Constant error p < .395 Pearson Correlation = 0.946 Significance (1-tail) p < .001 Constant Error p < .470 32 17-32 Mild 4-16 Moderate 0-3 Severe

10-12 Normal 6-9 Mild 3-5 Mod 0-4 Severe

Findings regarding WCCVT testing Uncalibrated Surface Pro 3 Tablet and calibrated PC have similar high sensitivity (98%-100%) for detecting red/green CVD as compared to Nagel Anomaloscope Uncalibrated Tablet screening scores correlate highly to calibrated PC screening scores (0.96, p<0.001) Uncalibrated Tablet protan & deutan scores are highly correlated to PC protan & deutan scores (0.86 & 0.95, p<0.001) Uncalibrated Tablet tended toward grading CVD more severely than calibrated PC version, with slightly higher screening failure rate using USN aviation standards, but trend not statistically significant. Not enough Tritanomalous data to make statistically significant regression comparison for PC vs Tablet scores

Conclusions regarding WCCVT testing Surface Pro 3 Tablet results sufficiently similar to the PC version to be used for screening aviation personnel for color vision defects Tritan defects may be detected, but require further evaluation to determine cause and possibility of acquired CVD Although calibration not required in a research setting, calibration may still be required for clinical use since tampering of video settings is possible by technicians (brightness, color profiles, display color sliders) Navy Policy: requirement to perform testing and calibration as recommended by the manufacturer

matthew.c.rings.mil@mail.mil

Bibliography: Assessment of Color Vision Screening Tests for U.S. Navy Special Duty Occupations Supplement 2, Reddix M, Gao H, Kirkendall C, 2014 CAA Paper 2009/04 Minimum Colour Vision Requirements for Professional Flight Crew Assessing the Severity of Color Vision Loss with Implications for Aviation and Other Occupational Environments, Rodriguez-Carmon m. O’Neill-Bib M., Barbur JL, Aviation, Space and Environmental Medicine, Vol 83(1), 2012 Procedures for Testing Color Vision: Report of Working Group 41, Committee on Vision, National Research Council, 1981 Assessment of Color Vision Screening Tests for U.S. Navy Special Duty Occupations, Reddix M., Kirkendall C., Gao H., NAMRU-Dayton, AsmA 85th Annual Scientific Meeting, 2014 Variability in Normal and Defective Colour Vision: Consequences for Occupational Environments, Barbur JL, Rodriguez-Carmona M., City University London, 2012. Rapid Quantification of Color Vision: The Cone Contrast Test, Rabin J, Gooch J, Ivan D, Investigative Ophthalmology and Visual Science, Vol 52(2), Feb 2011 The Cone Contrast Test: Normative Scores for Binocular Testing, Vu LK, USAF School of Aerospace Medicine, AsMA 84th Annual Scientific Meeting, 2013 Sloan, LL, Comparison of Tests for Red-Green Color Deficiency, Aviation Medicine, Dec 1948

Additional Bibliograpy and Resources: 1) Paulson, H. (1966). NSMC, Report 466 : The performance of the Farnsworth Lantern at the Naval Submarine Research Laboratory and the Field from 1955 to 1965. U.S. Naval Submarine Medical Center, Groton, CT. 2) Rings, Picken, NAMI research; CCVT validation study vs. PIP vs. FALANT vs. Nagel. (2013). 3) DeHart, Fundamentals of Aerospace Medicine, 3rd Edition, p. 373. 4) NATO WG-24, Operational Colour Vision in the Modern Aviation Environment 5) Cole, B.L., & Maddocks, J.D. (2008). Color vision testing by Farnsworth lantern and ability to identify approach-path signal colors. Aviation, Space, & Environmental Medicine, 79(6), 585-90. 6) Zentner, A.B., (1987), A Proposal for a Diagnostic Colour Vision Standard for Civil Airmen 7) Cole, B.L., (1985), Do protanomals have difficulty seeing red lights? Proc. 20thSession CIE. 1, E 0411-3 Paris. 8) Dille, J.R., 1975 Accident Experience of Civilian Pilots with Static Physical Defects, FAA, AsMA, Feb, 1978 9) Dille, J.R., 1976 Accident Experience of Civilian Pilots with Static Physical Defects, FAA, AsMA, Feb, 1980 10) SUSNFS Newsletters, Oct 1984, Oct 1987, Jan 1986 11) Ivan, D.J., Yates, J.T., (1994) In Search of the Abominable Coneman, Clinical Sciences Division, Brooks AFB 12) Sloan, LL, Comparison of Tests for Red-Green Color Deficiency, Aviation Medicine, Dec 1948 13) US Navy Color Vision Standards Revisited NSMRL Report 98-01 http://www.displaymate.com/Surface_Pro_ShootOut_1.htm “Surface Pro 3 Technical Evaluation”