I-170 Zdrav Vestn Supl | junij 2012 | Letnik 81
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Which psychophysical colour vision test to 
use for screening in 3–9 year olds?
Kateri test za oceno barvnega vida je najprimernejši 
za otroke, stare od 3 do 9 let?
Manca Tekavčič Pompe, Branka Stirn Kranjc
Izvleček
Izhodišča: Primerjava 4 psihofizičnih testov za 
oceno barvnega vida in ocena primernosti posa-
meznega testa pri predšolskih otrocih in mlajših 
šolarjih.
Metode: V raziskavi smo ocenjevali 4 teste. Prvi 
je bil otrokom prilagojeni test Ishihara (Handaya 
Co. Ltd., Tokyo), drugi test CVTME (Colour 
vision testing made easy, T. L. Waggoner, 1994), 
tretji test Netz (WPS, 2001) in četrti test MRM 
(Mollon-Reffin Minimalist test, verzija 0.7, 1994). 
Pri prvih treh je bila otrokova naloga prepoznati 
simbole na slikah, pri četrtem testu pa je moral 
poiskati barvni krožec med 5 krožci različnih od-
tenkov sive. Sodelovalo je 37 otrok z normalnim 
barvnim vidom (19 deklic in 18 dečkov), starih 
med 3 in 9 let. Normalni barvni vid smo potrdili, 
če je otrok vsaj enega izmed 4 testov opravil brez 
napak. Pri prvih treh testih smo beležili število 
napak, pri zadnjem pa smo zabeležili najmanj 
saturirani krožec, ki ga je otrok še prepoznal. Za 
vsakega od štirih testov smo izračunali specifič-
nost za posamezno starostno skupino. Vsakega 
otroka smo tudi vprašali, kateri test mu je najbolj 
všeč.
Rezultati: 16/37 otrok je naredilo 1 ali več napak 
pri testu po Ishihari, med njimi vsi mlajši od 5 
let. Devet otrok je naredilo 1, trije so naredili 2, 
dva sta naredila 3 in dva otroka sta naredila 5 na-
pak. 8/37 otrok je naredilo 1–3 napake pri testu 
CVTME. Štirje otroci so se zmotili enkrat, trije 
dvakrat in eden trikrat. Vsi otroci so naredili vsaj 
eno napako pri testu Neitz. Najtežje prepozna-
ven je bil lik na mestu 6. Dve 3-letni deklici testa 
Neitz nista bili sposobni z zanesljivostjo izvesti. 
10/37 otrok ni opravilo testa MRM brez napake, 
večina je imela težave v modrem delu barvnega 
spektra. Najvišjo specifičnost za vse 3 starostne 
skupine sta imela testa CVTME in MRM. Večini 
otrok (28/37) je bil najbolj všeč test MRM.
Zaključki: Raziskava je pokazala, da je najpogo-
steje klinično uporabljan test po Ishihari (analfa-
betska verzija) za večino mlajših otrok prezahte-
ven in zato nezanesljiv. CVTME se je v raziskavi 
izkazal za sprejemljivejšega, predvsem za otroke, 
mlajše od 5 let. Za najmanj zahtevnega se je izka-
zal test MRM, ki je bil obenem med otroki tudi 
najbolj priljubljen.
Abstract
Background: To compare 4 psychophysical co-
lour vision tests in children and to decide which 
test is most suitable for screening in pre-school 
and early school-age period.
Methods: The first test used was a modified Ishi-
hara plates test (Handaya Co. Ltd., Tokyo). The 
second test ”Colour vision testing made easy” 
(CVTME) (T. L. Waggoner, 1994) is also based on 
pseudoisochromatic plates with child-friendly 
symbols. The third test used was the ”Neitz test 
of colour vision” (WPS, 2001) and the fourth was 
”Mollon-Reffin Minimalist test” (MRM) (version 
0.7, 1994). In the first three tests, the child had to 
tell what he or she saw in the picture, whereas in 
the fourth test the child had to pick the coloured 
button among distractors.
Thirty-seven children (19 girls and 18 boys) from 
3–9 years of age with normal colour vision (at 
least one test should be performed without er-
rors) were tested. The number of errors in each 
of the first 3 tests was registered, whereas in 
the MRM test the least saturated button distin-
guished among distractors was registered. Speci-
ficity was calculated for each test. Every child was 
also asked which was his or her favourite test.
Results: 16/37 children made one or more er-
rors in the modified Ishihara test, among them 
all children under the age of 5 years. Nine chil-
dren made 1 error, three made 2, two made 3 and 
two children made 5 errors. 8/37 children made 
Očesna klinika, 
Univerzitetni klinični 
center Ljubljana,  
1525 Ljubljana
Korespondenca/
Correspondence:
asist. dr. Manca Tekavčič 
Pompe, dr.med., očesna 
klinika Ljubljana, 
grablovičeva 46,  
1000 Ljubljana,  
tel: 01 522 1801,  
fax: 01 522 1960, e-mail: 
manca.tekavcic@kclj.si
Ključne besede:
barvni vid, otroci, 
psihofizični testi
Key words:
colour vision, children, 
psychophysical tests
Citirajte kot/Cite as:
Zdrav Vestn 2012;  
81: I-170–7
Prispelo: 18. jan. 2012, 
Sprejeto: 15. mar. 2012
Zdrav Vestn Supl | Which psychophysical colour vision test to use for screening in 3–9 year olds? I-171
TehnoLogIje/TechnoLogIeS
28/37 children chose the MRM test as their fa-
vourite.
Conclusions: The modified Ishihara colour test 
has turned out to be too difficult and therefore 
unreliable in the youngest children. For children 
under 5 years of age CVTME was more reliable 
in this study. For all ages the MRM test was the 
easiest to perform. Most children in this study 
subjectively preferred the MRM test.
Introduction
Colour vision is an important part of vi-
sual perception. Evaluation of colour vision 
falls within the basic ophthalmologic exa-
mination. Colour vision deficiency may be 
acquired or congenital. Acquired deficiency 
can result from retinal diseases, or optic ner-
ve and visual pathway pathology. Congenital 
colour vision deficiency is present in 8–12 % 
of men and 0.5 % of women and is often inhe-
rited recessively linked to chromosome X.1,2 
The most common congenital colour vision 
deficiency is deuteranomalia, followed by 
protanomalia, deuteranopia and protanopia. 
Deuteranomalia is present in approximate-
ly 5 % of people, all three types of cones are 
present, with middle-wavelength cones (M) 
being affected. Protanomalia is present in 
approximately 1 % of people, all three types 
of cones are present, with long-wavelength 
cones (L) being affected. Deuteranopia is 
present in approximately 1 % of people, with 
M cones being absent. Protanopia is present 
in approximatelyt 1 % of people, with L co-
nes being absent.3
Colour vision evaluation plays an im-
portant role in acquired deficiencies, espe-
cially in disease detection and its follow-up. 
In congenital deficiencies thorough colour 
vision evaluation is needed for vocational 
guidance and counselling.
For colour vision evaluation in daily cli-
nical practice different psychophysical tests 
are used. These tests are based on judging 
the ability of the patient to compare the same 
and to differentiate among different colo-
urs in a certain colour vision axis. The first 
group of psychophysical colour vision tests 
(screening tests) are used to detect colour vi-
sion deficiency. Among these tests, Ishihara 
pseudoisochromatic plates are most widely 
used. The second group of psychophysical 
colour vision tests (anomaloscopes, Farn-
sworth-Munsell hue 100 and D15 tests etc.) 
are used to grade the deficiency.1,4 Colour 
vision evaluation with psychophysical tests 
is subjective. However, electrophysiologi-
cal methods can be used to evaluate colour 
vision objectively. Chromatic visual evoked 
potentials5-7 and chromatic electroretino-
graphy8 are still experimental electrophysio-
logical methods which aim to evaluate sepa-
rate cone function and parvocellular visual 
pathway integrity.
Most of the psychophysical colour vision 
tests are designed for testing adults, therefo-
re reliable testing of paediatric population is 
difficult.9 Until now, Analphabetic Ishihara 
plates (Handaya Co. Ltd., Tokyo) were wide-
ly used in Slovenia to evaluate colour visi-
on in children. Daily clinical experience has 
shown that the results obtained using this 
test are not always reliable, because the test 
is often too difficult for very young children. 
One often gets false positive results, which 
means that a child’s colour vision is wron-
gly estimated as being deficient. There are, 
however, some psychophysical tests that are 
designed to test paediatric population, espe-
cially preschool children.10-12
The purpose of this study was to compa-
re four psychophysical colour vision tests by 
testing young children and to find out which 
psychophysical test is most suitable for te-
sting colour vision in this age group.
1–3 mistakes in the CVTME test. Four children 
made one mistake, three made two and one child 
made three mistakes. All tested children made 
at least one mistake in the Neitz test. All gave a 
wrong description for the figure in the 6th posi-
tion of the test. Two 3-year-old girls were not able 
to perform the test. The MRM test was not per-
formed in full by 10/37 children. Most of these 
children made errors in the tritan colour vision 
axis. The highest specificity in all 3 age groups 
was calculated for CVTME test and MRM test. 
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Figure 1: Analphabetic 
Ishihara test.
Figure 2: color Vision 
Testing Made easy test.
reening for colour vision deficiencies in 
the red-green colour vision spectrum4. 
It consists of 10 pseudoisochromatic pla-
tes with animal and flower motifs which 
have to be recognized by the child. The 
first plate is the so-called recognition 
plate, which can also be detected if one 
has colour vision deficiency. This plate is 
used to explain the test to the child. Pla-
tes that follow have to be recognized in at 
least 10 seconds, the child has to observe 
the plates perpendicularly about 75 cm 
away. Figure 1 shows 10 pseudoisochro-
matic AI test plates.
2. Color Vision Testing Made Easy (CVTME) 
is a psychophysical colour vision test 
which was designed by T. L. Waggoner 
in 1994 and is 100 % Ishihara compatible. 
The test consists of two parts. The first 
part consists of a recognition plate and 9 
testing plates with simple motifs (star, cir-
Methods
37 children (18 boys and 19 girls) aged 3 
to 9 years were included in the study. Chil-
dren were divided into three age groups. In 
the first group (3–5 year-olds), 8 children (2 
boys and 6 girls) were included. In the se-
cond group (5–7 year-olds), 13 children (6 
boys and 7 girls) were included. In the third 
group (7–9 year-olds), 16 children (10 boys 
and 6 girls) were included. Before testing, 
informed consent was signed by parents for 
each child. All children had normal colour 
vision, which was proven by their ability to 
perform at least one of the psychophysical 
tests without a single error. All children who 
were not able to perform at least one test wi-
thout error were excluded from the study.
Every child performed the following 4 
psychophysical colour vision tests:
1. Analphabetic Ishihara Test (AI): is a 
psychophysical test which is used for sc-
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Figure 3: neitz test of 
colour vision.
3. The Neitz Test of Color Vision (Neitz) is a 
psychophysical test which was designed 
in the Neitz Laboratories (WPS, 2001) 
and is 100 % Ishihara compatible. The 
test is a sheet test and is meant to test 
larger groups of children (school classes, 
for example). On every sheet of paper 
there are 9 fields with dot patterns and 
a child has to identify coloured shapes 
within grey dot patterns. Below each pat-
tern there are five response options – a 
circle, a triangle, a square, a diamond and 
nothing, the correct response has to be 
marked. With this test, colour vision de-
ficiencies in the red-green and blue-yel-
cle, square). There can be several motifs 
presented on a single plate. The second 
part comprises a recognition plate and 3 
testing plates with slightly more complex 
motifs (dog, sailing boat, house). The 
child has to recognize motifs on the pla-
tes in no more than 3 seconds, by viewing 
them perpendicularly from approxima-
tely 75 cm distance. With this test, colour 
vision deficiencies in the red-green spec-
trum can be detected. The test also allows 
a certain extent of deficiency grading (by 
using testing plates with multiple motifs, 
where one motif is recognized, whereas 
others are not).11 Figure 2 shows 10 + 4 
pseudoisochromatic CTVME plates.
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Figure 4: Mollon-Reffin 
“Minimalist” test.
Results
1. Analphabetic Ishihara Test (AI)
21/37 (57 %) children performed the test 
without a single error, they identified all 10 
plates correctly, whereas 16/37 (43 %) chil-
dren made one or more errors. 9 children 
made 1 error, 3 children made 2 errors, 2 
children made 3 errors and 2 children made 
5 errors. The two children with the highest 
error rate were from the youngest age gro-
up (3–5 years). The plates with a rabbit and 
a tortoise as the motif were found most dif-
ficult to identify correctly. Specificity of the 
AI test for each age group is demonstrated 
in Figure 5.
2. Color Vision Testing 
Made Easy (CVTME)
29/37 (78 %) children performed the test 
without a single error, they identified all 14 
plates correctly, whereas 8/37 (22 %) children 
made one or more errors. 4 children made 1 
error, 3 children made 2 errors and 1 child (a 
four year old girl) made 3 errors. Specificity 
of the CVTME test for each age group is de-
monstrated in Figure 5.
3. Neitz Test of Color Vision (Neitz)
None of the children tested were able to 
perform this test without errors, because of 
the testing field number 6, which could not 
be identified by a single child. This test was 
also too demanding for the two youngest 
girls (aged 3 years). Among 35 children who 
were able to perform the test, there were 12 
children who made at least one more error 
besides the one at the field number 6. Ac-
cording to the Neitz scoring system,12 their 
colour vision was characterized as deutera-
nomaly in 9 and protanomaly in 3. Specifi-
city of the Neitz test for each age group is 
demonstrated in Figure 5.
low spectrums can be detected.12 Figure 
3 shows the Neitz sheet test.
4. The Mollon-Reffin “Minimalist” 
test (MRM) (version 0.7, 1994) is a 
psychophysical test which was designed 
by Mollon and Reffin in 1991. The test 
consists of 5 distractors (grey chips, dif-
ferent greyness) and 1 coloured chip (red, 
green and blue chips of different satura-
tion). The child has to point the coloured 
chip among distractors and the examiner 
replaces the coloured chips with less and 
less saturated ones. The examiner’s task is 
to establish the least saturated chip that 
the child can distinguish among distrac-
tors. The procedure is repeated for pro-
tan, deutan and tritan chips. With this 
test colour vision deficiencies in the red-
-green and blue-yellow spectrums can be 
detected. The grade of colour vision de-
ficiency can also be evaluated.10 Figure 4 
shows a diagram of the MRM test.
For each of the 4 tests the number and 
type of errors made by an individual child 
was recorded. The specificity of each test was 
calculated for each age group. At the end of 
the testing each child was asked which of the 
four tests he or she subjectively preferred.
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Figure 5: The specificity 
of each of the four 
psychophysical tests for 
each age group.
Figure 6: Subjective 
preference of tests in all 
age groups.
Discussion
The study has shown that the most 
frequently used clinical psychophysical co-
lour vision test, the Analphabetic Ishihara 
test, is not reliable enough and therefore 
less useful for testing children between ages 
3 and 9. It was shown that the “Color visi-
on testing made easy” test is much easier to 
understand for small children and therefore 
more reliable. Also, the Mollon-Reffin Mini-
malist test has shown to be very valuable for 
testing children, especially because it does 
not demand any verbal cooperation.
In Slovenia, the most widely used clini-
cal pseudoisochromatic colour vision test 
is the Ishihara plates test. The same test is 
often used for testing adults and children. 
The child has to recognize numbers from 
the plates, but when he or she does not know 
the numbers yet, the child is instructed to 
trace the number with his finger. This kind 
of colour vision testing is therefore often 
unreliable especially for preschool children. 
In a previous study, in which 100 children 
from 3 to 6 years of age were tested, it was 
shown that about 4 % of them were unable 
to perform the test.13 A better solution is the 
Analphabetic Ishihara test where numbers 
are replaced by different motifs (animals, 
flowers etc.), which should be easier for chil-
dren to recognize . But the problem is that 
these motifs are often too complex and the-
refore the testing score does not always re-
present the real colour vision status. A study 
of 1800 children between the ages of 3 and 
13 years has shown that about 1–2 % of fal-
se positive results can be expected by using 
this test, in younger children far more than 
in older.14 In our study, nearly half of the 
children tested (43 %) did not identify all of 
the 10 motifs from the Analphabetic Ishiha-
ra test. Most children correctly identified the 
dog, the fish, the elephant and the butterfly. 
Most errors were recorded with the rabbit 
and the tortoise. The results of this study are 
in favour of simplifying the motifs to be ea-
sier for younger children.
The Mollon-Reffin Minimalist (MRM) 
test has shown the highest specificity among 
all four tests used in the study. This test is 
recently widely used for testing young chil-
4. Mollon-Reffin “Minimalist” 
test (MRM)
27/37 (73 %) children performed the test 
without a single error, whereas 10/37 (27 %) 
children made one or more errors. Colour 
vision deficiency was characterized as deu-
teranomaly in 2, protanomaly in 2, tritana-
nomaly in 4, combined protan- and trita-
nanomaly in 1 and combined deutan- and 
tritananomaly in 1. Specificity of the MRM 
test for each age group is demonstrated in 
Figure 5.
The specificity of each test represents the 
proportion of children with normal colour 
vision who were correctly identified as ha-
ving normal colour vision by a particular 
test. Figure 5 shows the specificity of each 
of the four psychophysical tests for each age 
group.
The results of subjective evaluation in 
which each child was asked which was his 
or her favourite test are shown in figure 6. 
The majority of children from all three age 
groups preferred the MRM test.
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all four psychophysical tests used in this stu-
dy, the authors recommend the “Color Visi-
on Testing Made Easy” test and the Mollon-
-Reffin Minimalist test. However, there are 
more potentially useful tests available, such 
as the Hardy Rand Rittlers – HRR test and 
the CU Dynamic Colour Vision test, which 
can be successfully used for testing children. 
A comparable study would be needed to 
show which test is most reliable for testing 
pre-school children.
Acknowledgements
The authors would like to thank all the 
children who participated in the study as 
well as John Mollon and Maureen Neitz who 
kindly provided the tests.
dren in Great Britain and Canada.15 The ad-
vantage of this test is its short testing time, 
because the test does not demand high co-
gnitive and motor skills. In this study the 
specificity of the MRM test was comparable 
in all three age groups, which has not been 
shown for any other test. In the 3–5 age gro-
up the specificity of the MRM test was the 
highest (87 %) compared to the other three 
tests, which also speaks in favour of using 
this test in youngest children.
The “Color Vision Testing Made Easy” 
(CVTME) test has shown the highest speci-
ficity in both groups of older children. It was 
85 % in the 5–7 age group and 94 % in the 7–9 
age group. In a previous study, 150 children 
aged 5–7 years and 40 adults with or without 
colour vision deficiency were tested with 
the CTVME test. The study has shown that 
all children tested were able to perform the 
test. Test specificity for the adult group was 
100 %, whereas test sensitivity was 90 %11
The Neitz test has shown to be too de-
manding for children included in this study. 
All children made an error at the 6th posi-
tion, whereas the two youngest girls could 
not perform the test at all. If the error at the 
position number 6 is neglected, there were 
still 40 % of children who made at least one 
more error. The Neitz test was designed for 
testing larger groups of children, especially 
in classes, therefore its sheet design, which 
was actually very popular with children. 
The target population for this test are school 
children12 and this is also the most proba-
ble reason why the results of this test are not 
that good in the present study.
Subjectively most children preferred the 
MRM test among all 4 psychophysical tests 
used in this study. The only task that has to 
be accomplished in this test is to show the 
coloured chip among five grey distractors. 
There is no need for any verbal communi-
cation from the child’s side and also motor 
skills needed are very basic, which is proba-
bly the reason why this test was the favourite 
one for all three age groups.
This study has proven our clinical ob-
servation that Analphabetic Ishihara test, 
which was the most widely used clinical test 
until now, is less reliable for testing colour 
vision in children under the age of 5. Among 
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