Clinical use of the American Optical Company (Hardy, Rand and Rittler) pseudoisochromatic plates for red-green colour deficiency

The efficiency of the American Optical Company (Hardy, Rand and Rittler) (HRR) plates for screening, grading and classifying red-green colour deficiency was examined for 401 mate colour deficient subjects previously identified and diagnosed with the Nagel anomaloscope. There were 83 protanopes, 30 protanomalous trichromats, 96 deuteranopes and 192 deuteranomalous trichromats. Screening sensitivity was found to be 100% for dichromats and 96.4% for anomalous trichromats based on one screening error (35 subjects, including 7 dichromats, were identified by a single error). Thirty subjects (13.5%) made errors on screening plates only and were identified as having minimal colour deficiency. The HRR grading system did not distinguish dichromats and anomalous trichromats; 54% of dichromats were graded as having moderate rather than severe colour deficiency. Protan/deutan classification was correct for 95% of subjects who failed grading plates. HRR grades for anomalous trichromats were compared with the anomaloscope matching range and with pass or fail of the D15 test. The results show that only two rather than four grading categories can be distinguished by the HRR plates and that both the D15 and the HRR plates are needed in a vocational test battery to establish the severity of colour deficiency.     

Statistical demonstration of minor colour vision abnormalities

Analysis of the results from 94 male and 94 female young normal trichromats on the 100 hue test and the Nagel and Pickford-Nicolson anomaloscopes shows that colour deviant and/or colour weak subjects can be distinguished from the wholly normal bulk by considering the normality of certain test result distributions as well as by considering the combinations between test results considered abnormal. The stated minor abnormalities of colour vision are frequent and their types are those described by Pickford and by Lakowski (never' colour asthenopia). They are recognised by means of the anomaloscopes and not by means of the 100 hue test.     

Computer analysis of Farnsworth-Munsell 100-hue test

Color vision abnormalities indicated by the Farnsworth-Munsell 100-hue Color Vision Tests (FM-100) were analyzed by computer to better characterize and group congenital and acquired color vision disorders and to help establish statistically significant diagnostic criteria.Standard evaluation of the FM-100 is by axis and error score calculations. A method has been established for computer-averaging many tests from patients with the same color abnormalities determined by history, standard FM-100 and Nagel anomaloscope. The computer calculated an average error score and standard deviation for each of the 85 color caps. Every time a new patient was evaluated for color vision abnormality, his score was compared with averaged tests with common diagnoses, by calculating distance scores. The averaged test with the lowest distance score consistently tended to coincide with the diagnosis.An analysis of 130 FM-100 color tests found technician-calculated error scores to be incorrect, although usually minor, in 40% of the tests. The computer-calculated axes agreed well with the technician's estimates. The distance scores predicted the diagnosis accurately 89% of the time. Many errors were due to the small number of protanopes averaged and inability to distinguish trichromats from dichromats.     

Chromaticity co‐ordinates of Ishihara plates reveal that hidden digit plates can be read by S‐cones

Background: The Ishihara pseudoisochromatic plates constitute one of the most commonly used screening tools for red‐green colour vision deficiencies. Even though hidden digit plates are supposed to be read only by those who are colour vision defective, studies report that some normal trichromats can indeed read these plates. By measuring the chromaticity co‐ordinates of the dots used in Ishihara plates, the purpose of this study was to clarify the mechanism that enables normal trichromats and colour vision defectives to read the plates, particularly hidden digit plates. Methods: Spectrophotometric measurements were made for a 24‐plate version of the Ishihara pseudoisochromatic plates and chromaticity co‐ordinates of the dots were expressed in the MacLeod‐Boynton diagram. Results: As theoretically expected, reading of Ishihara plates by normal trichromats was mediated by the dot chromaticity differences along the L/(L + M) axis. On the other hand, reading by colour vision defective observers was made possible mainly by the dot chromaticity differences along the S/(L + M) axis. This would also explain why some normal trichromats can read hidden digit plates, the plates that are supposed to be read only by colour vision defective observers. Conclusion: Normal trichromats read Ishihara plates using their chromatic discrimination ability along the L/(L + M) axis. Red‐green colour vision defective observers rely on S‐cones in reading the plates. Some normal trichromats can read the hidden digit plates because they can extract S‐cone differences efficiently despite the distraction from the L/(L + M) axis.     

The use of colour difference vectors in diagnosing congenital colour vision deficiencies with the Farnsworth—Munsell 100-hue test

Colour difference vector analysis provides useful and meaningful information in scoring the Farnsworth-Munsell (FM) 100-hue test. However, the FM 100-hue test is limited in its ability to diagnose type and severity of congenital colour vision defect. Type classification for all subjects is incorrect in 21% of cases, and for deuteranomals the misclassification rate is 38%. Visual inspection of the plots yields a similar misclassification rate and classification of plots with few errors (under 180) is generally less reliable. The FM 100-hue test has a limited ability to separate dichromats from anomalous trichromats. A test protocol based on joint D15 and FM 100-hue tests should pass 36% of anomalous trichromats and 26% of all colour defectives yet fail all dichromatic observers. We conclude that administering the FM 100-hue test is of less value than a combination of D15 panels (Standard D15 and L'Anthony's desaturated D15) in the clinical diagnosis of congenital colour defective observers. Our results for the FM 100-hue panel are similar to those reported previously by other investigators.     

Errors reading the Ishihara pseudoisochromatic plates made by observers with normal colour vision

Background: Ishihara pseudoisochromatic plates are one of the best screening tools for red‐green colour vision deficiencies. Although a majority of persons with normal colour vision read all plates correctly, a significant proportion makes mistakes. The purpose of this study was to obtain results for normal trichromats reading the Ishihara plates and analyse the misreading responses to seek clinical implications. Methods: A sample of 249 (161 female) was tested with the Ishihara pseudoisochromatic plates. The number and nature of errors were recorded and typical errors, those that observers with abnormal colour vision were expected to make, were distinguished from other kinds of error. Results: Out of 249 normal trichromats, 111 individuals (45 per cent) misread at least one plate. Females made up to six total errors and males up to five total errors. When only typical errors were counted, all the normal trichromats made two or fewer errors. There was no significant gender difference for either total or typical errors. Conclusion: It is suggested that clinicians count only typical errors when administering the Ishihara test. Using a criterion of no more than two typical errors for a diagnosis of normal colour vision could improve the specificity and sensitivity of the test.     

Survey of the accuracy of new pseudoisochromatic plates

The accuracy of three new pseudoisochrometic tests for detecting red–green colour deficiency was assessed. These were the Ishihara plates, the Ishihara test for 'unlettered persons' and Ohkuma's lest cards. We examined 500 subjects; 471 normal trichromats and 29 colour-deficient people, Results obtained for the 1989 edition of the Ishiliara places were compared with the 9th edition and the most efficient plates identified. Although normal trichromats may be expected to make several interpretive misreadings, the Ishihara plates were found to be superior to the 9th edition and to the Ohkuma test (1986) for colour vision screening. The new symbol designs of the Ishihara plates for 'unlettered persons' (1990) were found to be very effective for colour vision screening, and a further study with young children is proposed. The 38 plate I9S9 edition of the Ishihara les; is recommended for use in clinical practice. The designs included in the concise 24 plate edition and the new abbreviated 14 plate edition are not selected from the point of view of accuracy and more reliable results are obtained if the full lest is given or if the practitioner shows only the most efficient designs.     

Identification of red–green colour deficiency: sensitivity of the Ishihara and American Optical Company (Hard,Rand and Rittler) pseudo‐isochromatic plates to identify slight anomalous trichromatism

Screening sensitivity, based on a specific number of errors, of the Ishihara plates and of the American Optical Company (Hardy, Rand and Rittler) plates (HRR plates) was determined by reviewing data obtained for 486 male anomalous trichromats identified and classified with the Nagel anomaloscope. Data were obtained for the 16 screening plates, with Transformation and Vanishing numeral designs, of the 38 plate Ishihara test, and for the four red–green screening plates (with six Vanishing designs) of the HRR test. Sensitivity of the Ishihara plates was found to be 97.7% on 4 errors and 98.4% on 3 errors. Only anomalous trichromats with slight deficiency, according to the anomaloscope matching range, made 8 errors or fewer. One screening error, a single missed figure, is normally allowed as a pass on the HRR test and 3 errors is often recommended as the fail criterion to eliminate false positive results. Twenty‐three subjects made no error on the HRR screening plates and 12 subjects made a single error (35 anomalous trichromats). Screening sensitivity was therefore 92.8% using 2 errors as the fail criterion. Screening sensitivity was reduced to 87% when 3 errors was the fail criterion, and some deuteranomalous trichromats with moderate deficiency, according to the anomaloscope matching range, were not identified. Individuals who make a maximum of 2 errors on the HRR test, or on the Richmond HRR 4th Edition, should be re‐examined with the Ishihara plates to determine their colour vision status. The present review confirms that the Ishihara test is a very sensitive screening test and identifies people with slight anomalous trichromatism. The HRR test is unsatisfactory for screening and should not be chosen solely for this purpose.     

Validation of the Holmes - Wright lanterns for testing colour vision

The recently introduced Holmes - Wright Type A and Type B lanterns and the Farnsworth lantern were administered to 100 observers with normal colour vision and 100 observers with defective colour vision. With the fail criteria adopted, all normals passed the Holmes - Wright Type A lantern and with one exception all normals passed the Farnsworth lantern. However, 8% of normals failed the more difficult Holmes - Wright Type B lantern. It is noted that the normals who fail this lantern test appear to do so not because of poor colour discrimination but because the coloured stimuli presented by the lantern have a point brilliance close to the average chromatic threshold. About one-third of the colour vision defective group passed the Farnsworth lantern and between 14 and 17% passed the Holmes - Wright Type A lantern depending on the test procedure used. Only two mild deuteranomals in the sample of 100 colour abnormal observers succeeded in passing the Holmes - Wright Type B lantern. Dichromats and severe anomalous trichromats fail all three lanterns so that those who pass are all mild anomalous trichromats. A significant proportion of protanomals pass the Farnsworth lantern and some protanomals pass the Holmes - Wright Type A lantern despite their reduced sensitivity to red light and correspondingly reduced signal range for red signals.     

Technical Note: The effect of refractive blur on colour vision evaluated using the Cambridge Colour Test, the Ishihara Pseudoisochromatic Plates and the Farnsworth Munsell 100 Hue Test

The results of a prospective study examining the effect of refractive blur on colour vision performance in normal subjects measured with three different colour vision tests are reported. The Farnsworth Munsell 100 Hue (FM100) and Cambridge Colour Test (CCT) results were significantly affected at +6 D of spherical refractive blur, whereas those from the Ishihara Pseudoisochromatic Plate (IPP) test were not. In a clinical setting, correction of refractive error up to 3 D for colour vision testing with these tests may not be required. Poor colour vision should not be attributed solely to refractive causes of poor visual acuity (Snellen equivalent: >6/36). Fastest test times were achieved using IPP, followed by CCT.     

Pre-age related maculopathy and the desaturated D-15 colour vision test

The Desaturated D-15 colour vision test was used to investigate the colour discrimination of aged normal subjects, subjects with age-related maculopathy RM), and subjects designated as pre-age related maculopathy (pre-ARM). subjects classified as pre-ARM had normal visual acuity but showed ophthalmoscopically visible pigmentary disturbance at the macula. There were significant losses of colour vision in the pre-ARM subjects and the ARM subjects compared to the aged normals on the Desaturated D-15 colour vision test. This decrement in colour discrimination was predominantly a blue-yellow (tritan) hue confusion. The results indicate that functional changes are occurring in subjects with pigmentary disturbance at the macula before ARM can be diagnosed by conventional clinical criteria.     

Performance of colour-deficient people on the Holmes-Wright lantern (type A): consistency of occupational colour vision standards in aviation.

INTRODUCTION: The Holmes-Wright lantern type A (H-W A) is an occupational colour vision test used by the UK Civil Aviation Authority (CAA) and approved by Joint Aviation Requirements (JAR) to select aircrew. Pass, to obtain a CAA Class 1 Aviation medical certificate, can be achieved at three stages of the examination. The Commission Internationale d'Eclairage (CIE) recommends that the Falant pass criteria are used with all approved lanterns. A pass to obtain CIE Colour Vision Standard 2 can be achieved at two stages of the examination. This study examines the consistency of these pass criteria. METHODS: One hundred and twenty-five men with red-green colour deficiency were examined. All subjects completed three runs of the nine colour pairs shown on the H-W A at high brightness, in photopic and scotopic viewing. RESULTS: Ten of 78 deuteranomalous trichromats examined passed to obtain a CAA Class 1 Aviation medical certificate at the first stage of the examination but only two of these subjects were successful at all three stages. Seventeen deuteranomalous trichromats passed to obtain CIE Colour Vision Standard 2 in photopic viewing and 20 subjects (one protanope and 19 deuteranomalous trichromats) passed in scotopic viewing. Only 50% of subjects who passed at the first stage of the examination were also successful at the second stage in either viewing condition. Ten deuteranomalous trichromats passed to obtain CIE Colour Vision Standard 2 in both photopic and scotopic viewing. Forty-three per cent of subjects made red-green errors and 79% made red-white errors at some stage of the examination. CONCLUSIONS: The staged pass criteria used by the CAA and the CIE lack internal consistency when applied to the H-W A. Colour-deficient people who pass to a standard at the first stage of the examination are unlikely to be successful if the examination is continued. The staged pass criteria do not identify individuals with superior colour discrimination ability and it is difficult to justify selection of personnel for high risk occupations in aviation on this basis.     

Colour vision defects in asymptomatic carriers of the Leber's hereditary optic neuropathy (LHON) mtDNA 11778 mutation from a large Brazilian LHON pedigree: a case-control study

AIMS: To determine if asymptomatic carriers from a previously identified large pedigree of the Leber's hereditary optic neuropathy (LHON) 11778 mtDNA mutation have colour vision deficits. METHODS: As part of a comprehensive analysis of over 200 members of a large Brazilian LHON pedigree spanning seven generations, colour vision tests were obtained from 91 members. Colour vision was tested one eye at a time using the Farnsworth-Munsell 100 (FM-100) hue colour vision test. The test was administered under uniform conditions, taking into account: ambient light levels, daylight colour temperature of 6700 kelvin, and neutral uniform background. Tests were scored using the FM-100 MS-Excel computer scoring program. Defects were determined and categorised as tritan, deutan, or protan. Categorisation of each dyschromatopsia was based on review of demonstrated axis computer generated plots and age adjusted error scores which coincided with Verriest 95% confidence intervals. Only the axis with the greatest magnitude error score was used to classify the defect. 55 of the 91 test subjects were LHON mtDNA 11778 J haplotype mutation carriers, proved by mtDNA analysis. The remaining 36 subjects were age matched non-blood relatives (off pedigree), who served as controls. RESULTS: 27 of 55 carriers (49.10%) were shown to have colour vision defects in one or both eyes. 13 of the 27 (48%) abnormal tests in the carrier group were tritan defects and the remaining 14 (52%) were deutan defects. Nine of the 27 (33%) abnormals in the carrier group were identified as having bilateral defects. Six of these were deutan, and the remaining three were tritan dyschromatopsias. Only six of the 36 (16.66%) age matched controls were found to have any type of dyschromatopsia. Five (83.3%) of these were deutan defects. The remaining one was a tritan defect. The difference between the two groups using a chi(2) test with one degree of freedom was statistically significant with a p value less that 0.001. CONCLUSIONS: Until now, LHON has always been characterised by a sudden, devastating vision loss. Asymptomatic carriers, those without vision loss, were considered unaffected by the disease. It now appears that asymptomatic carriers of the LHON mutation are affected by colour vision defects and may manifest other subtle, yet chronic, changes.     

The C-100:a new dichotomiser of colour vision defectives

This paper evaluates a new instrument (C-100) which employs flicker photometry or silent substitution to determine the type of colour vision defect (protan or deutan). Specifically, this study addresses the unit's capacity to: 1. detect colour vision defects; 2. differentiate protans from deutans; and 3. produce reliable measurements under different viewing conditions. We find that an average of five readings enables protans to be clearly separated from deutans in all cases (p < 0.0001), but that the distinction between these groups and normals is less clear. Dichromats are not distinguished from anomalous trichromats, so the instrument cannot be used as an index of severity. The results are shown to be robust to most of the test conditions likely to be encountered during normal clinical use. A clinical protocol is suggested that utilises the C-100 for classification of colour defective observers. It is concluded that normal, and some anomalous, trichromat settings are performed using flicker photometry, whereas dichromatic observers appear to utilise silent substitution.     

Search for coloured objects in natural surroundings by people with abnormal colour vision

Background: People with abnormal colour vision often report difficulty seeing coloured berries and flowers in foliage, which suggests they will have a diminished capacity for visual search when target objects are marked out by colour. There is very little experimental evidence of the effect of abnormal colour vision on visual search and none relating to search for objects in natural foliage. Method: We showed 79 subjects with abnormal colour vision (seven protanopes, 10 deuteranopes, 16 protanomals and 46 deuteranomals) and 20 subjects with normal colour vision photographs of natural scenes and asked them to locate clumps of red berries, to trace the length of a red string on grass and to name the season depicted in a photograph taken in the Autumn and the same scene photographed in the Summer. Colour vision was assessed using the Ishihara, the Medmont C100, the Farnsworth D15, the Richmond HRR and the Nagel anomaloscope. Results: All the subjects with abnormal colour vision located fewer clumps of red berries than those with normal colour vision. The subjects who failed the Farnsworth D15 performed significantly worse than those who passed but the distribution of scores in the two groups overlaps. The majority of subjects with abnormal colour vision could not trace the full length of the string: only 38 per cent of anomalous trichromats who passed the Farnsworth D15 test and three per cent of those who failed it were able to trace the full length of the string. Fifty‐five per cent of those classed as having a mild deficiency by the HRR test could trace the whole string. Most dichromats were unable to identify the Autumn season and those who did may have been assisted by guessing. Most (94 per cent) of those who passed the Farnsworth D15 test and all those classified as having a ‘mild’ deficiency by the HRR test could identify the season. Conclusions: All people with abnormal colour vision, even those with a very mild deficiency, have some degree of impairment of their ability to see coloured objects in natural surroundings. A pass at the Farnsworth D15 test or a ‘mild’ classification with the Richmond HRR test identifies those likely to have the least problems with visual search and identification tasks. The results have practical implications for the selection of personnel in occupations that involve visual search in natural terrain.     

Effect of Illumination on Colour Vision Testing with Farnsworth-Munsell 100 Hue Test: Customized Colour Vision Booth versus Room Illumination

Purpose

To evaluate a customized, portable Farnsworth-Munsell 100 (FM 100) hue viewing booth for compliance with colour vision testing standards and to compare it with room illumination in subjects with normal colour vision (trichromats), subjects with acquired colour vision defects (secondary to diabetes mellitus), and subjects with congenital colour vision defects (dichromats).

Methods

Discrete wavelengths of the tube in the customized booth were measured using a spectrometer using the normal incident method and were compared with the spectral distribution of sunlight. Forty-eight subjects were recruited for the study and were divided into 3 groups: Group 1, Normal Trichromats (30 eyes); Group 2, Congenital Colour Vision Defects (16 eyes); and Group 3, Diabetes Mellitus (20 eyes). The FM 100 hue test performance was compared using two illumination conditions, booth illumination and room illumination.

Results

Total error scores of the classical method in Group 2 as mean±SD for room and booth illumination was 243.05±85.96 and 149.85±54.50 respectively (p=0.0001). Group 2 demonstrated lesser correlation (r=0.50, 0.55), lesser reliability (Cronbach''s alpha, 0.625, 0.662) and greater variability (Bland & Altman value, 10.5) in total error scores for the classical method and the moment of inertia method between the two illumination conditions when compared to the other two groups.

Conclusions

The customized booth demonstrated illumination meeting CIE standards. The total error scores were overestimated by the classical and moment of inertia methods in all groups for room illumination compared with booth illumination, however overestimation was more significant in the diabetes group.     

Using clinical tests of colour vision to predict the ability of colour vision deficient patients to name surface colours

PURPOSE: To determine the predictive power of commonly used tests for abnormal colour vision to identify patients who can or cannot name surface colours without error. METHODS: The colour vision of 99 subjects with colour vision deficiency (CVD) was assessed using the Ishihara, the Richmond HRR (2002), the Farnsworth D15, the Medmont C100 and the Nagel anomaloscope. They named 10 surface colours (red, orange, brown, yellow, green, blue, purple, white, grey and black), which were presented in two shapes (lines and dots) and three sizes. The surface colours were also named by an age-matched group of 20 subjects with normal colour vision. The performance of the clinical tests to predict the CVD subjects who made no colour naming errors and those who made errors is expressed in terms of the predictive value of a pass P((P)) and the predictive value of a fail P((F)). RESULTS: The P((P)) values of the tests were between 0.59 and 0.70 and P((F)) values were between 0.77 and 1.00. CONCLUSIONS: A 'mild' classification with the Richmond HRR test, especially if no more than two errors are made on the HRR diagnostic plates, identifies patients with abnormal colour vision who are able to name surface colour codes without error or only the occasional error. A pass of the Farnsworth D15 test identifies patients who will make no or few (up to 6%) errors with a 10 colour code, but who will be able to name the colours of a seven colour code that does not include orange, brown and purple. If protans are excluded, the predictive value for a pass P((P)) for the Farnsworth D15 is improved from 0.59 to 0.70. The anomaloscope is not an especially good predictor of those who can recognise surface colour codes. However, an anomaloscope range >35 units identifies those who have difficulty in recognising surface colour codes, as does a fail at the Farnsworth D15 test.     

Are ethnic differences in the F‐M 100 scores related to macular pigmentation?

Background: It is known that the macular pigment can significantly affect colour matching and other aspects of colour vision tests. The difference in macular pigmentation between Asians and Caucasians may lead to different colour discrimination. Methods: This study compared chromatic discrimination between Asians and Caucasians using the Farnsworth‐Munsell 100 Hue test. Fifty Asians who were ethnically Chinese and 50 Caucasians served as subjects, ranging in age from 30 to 59 years. Results: The partial blue‐yellow square root error score of the Asian subjects was signifi‐cantiy higher than diat of the Caucasian subjects (p = 0.022) and die difference appeared to increase with age. Discussion: There was a difference in die F‐M 100 scores between the two groups. The difference was confined in die blue‐yellow region, producing a tritan‐like bias for the Asian group in die test.     

New color vision tests to evaluate faulty color recognition

PURPOSE: To develop and assess new color vision tests to be used in evaluating faulty color recognition. METHODS: We developed new color vision tests to evaluate faulty color recognition. The two types of color vision tests, designed to assess faulty color recognition in color vision deficiencies, are based on principles that are different from those of the conventional color vision tests. In the first test plate, the subject is asked to choose either a red, green, or gray line from among 10 lines that are randomly colored red, green, gray, yellow, or blue. The score is the difference between the number of correct answers and the number of incorrect answers. In the second test plate, the subject is asked to identify a total of 10 red azalea blossoms, which are dispersed among numerous green leaves. Seventy-five persons with congenital color deficiencies and 20 subjects with normal color vision were examined using these new test plates. RESULTS: The scores differed significantly between dichromats and anomalous trichromats, and between anomalous trichromats and subjects with normal color vision. CONCLUSIONS: The new tests are easy to use, sensitive, and have good reproducibility for use in discriminating subjects with color vision anomalies. These tests reveal the faulty color recognition that occurs unconsciously in persons with color deficiencies, and are useful in judging the quantification of color vision required in their daily life and occupations.     

The Farnsworth-Munsell 100 hue test in the first episode of demyelinating optic neuritis.

The Farnsworth-Munsell 100 hue test (F-M 100) was used to examine 30 patients with their first episode of unilateral demyelinating optic neuritis (DON) at presentation, after 6 weeks and after 6 months. Twelve patients satisfactorily completed the test with the affected eye at presentation. This number had increased to 23 by 6 weeks and to 27 by 6 months. No patient with a visual acuity of LogMAR 0.86 (Snellen equivalent approx 6/43) or worse, could complete the test. The mean total error score of affected eyes showed significant improvement at each subsequent examination but was always worse than the non-affected eyes. There was a significant correlation between total error scores and visual acuities of affected eyes at presentation and after 6 months. Fourteen patients recovered a visual acuity of LogMAR 0.0 (Snellen equivalent 6/6) or better but the total error scores of the affected eyes were significantly worse than the non-affected eyes (p = 0.017), indicating that defective colour vision is an indicator of a previous episode of DON despite the recovery of normal visual acuity. DON is reported to produce a red-green (Type II) axis of colour defect but individual F-M 100 polar diagrams were usually generally abnormal and did not show any predominance of recognisable axis of colour defect at any examination. Group averaging of the F-M 100 data from such a well-defined group of patients with acute DON revealed a significant bipolar abnormality in the tritan (blue-yellow) axis at presentation which was not demonstrated at the subsequent examinations or at any examination of the non-affected eyes.