Journal of Ophthalmic Medical Technology

www.JOMTonline.com

HowweshouldreallybedoingandinterpretingtheIshihara
MichaelN.Wiggins,MD

Onatypicalclinicalday,I(ormytechnologist)willevaluateapatientonhydroxychloroquine
(Plaquenil)orwithacolorvisioncomplaint.So,IreachfortheIshiharabook;havethepatientputon
theirglassesandcoveroneeye.AsIslowlyturnthepages,thepatientcallsoutthenumbers.Everyone
seemstobeabletoeasilygetthe1stplate(anumber12).WhenIgettoplate#8(anumber2),Itellthe
patienttojustskiptheplatebesideit,becausetherereallyisntanythingonit.Thenextplatehasa
16andtheadjacentplatehasasquigglylineforilliterateornonverbalpatients,somypatientshould
justskipthisone,too.Mostpatientscanseethenext2plates(numbers35and96)andthelastplateis
anothersquigglyline,sothatdoesntseemtobeworthdoing.AsIrecordmyresults,Inotethenumber
correctover11foreacheyeseparately(i.e.8/11and6/11).Idontrecorditas8/14fortherighteye
and6/14forthelefteye,sinceIskipped3plates.ThenIlookbackatpreviousnotesandseeifthis
matchespreviousIshiharatestingorifachangehasoccurred.

Iwouldguessthatthisscenariomightsoundfamiliartomanyinourfield.Butisthis
abbreviatedIshiharaacceptable?Canthetestrevealmorethanjustacomparisontotheprevious
numberofcorrectplates?Whatisthepurposeofplate#9(theonenexttothenumber2)?

History
TheIshiharaisactuallyentitled,IshiharasTestsforColourDeficiency.1ItwascreatedbyDr.Shinobu
Ishihara(18791963),whowasaProfessorEmeritusattheUniversityofTokyoinJapan.2
Itwasdesignedtodetectcongenitalcolordeficiencies,whicharecommonlyredgreendefects.1The
conciseversionoftheIshiharacontains14plates.3

Backgroundinformationyoushouldknow4
Eachconeintheretinahasonetypeofpigment:red,blueorgreen.Theconesnotonlytellwhichcolor
isbeingseen,butalsothebrightnessorintensityofonecolorcomparedtoanother,specifically,redto
greenandbluetoyellow.Aredgreendeficientpersonhasdifficultytellingredfromgreen.Thiscanbe
fromanabsenceofredpigment(Protan),oritcouldbefromanabsenceofgreenpigment(Deutan).
Redgreencolordeficiencyiscommoninmen(58%ofmen,only0.5%ofwomen)becauseitis
commonlyaproblemontheXchromosome(Xlinked)andunlikewomen;mendonothaveaspareX
chromosome.


Redgreencolordeficiency

A.Protanopialossordefectiveredpigment

B.Deuteranopialossordefectivegreenpigment
Blueyellowcolordeficiency

A.Tritanopia

Blueyellowdeficiency(Tritan)isveryrarelycongenital,andusuallyindicatesanacquireddisease.Itis
seenequallyinmenandwomen.4Ingeneral,acquireddiseasesoftheopticnervecausearedgreen
problem,whileacquireddiseasesoftheretinacauseblueyellowproblems.However,acquireddiseases
oftheeyedontalwaysfollowthisrule.5

ItisimportanttounderstandthattheIshiharawasnotdesignedtodetectblueyellowdefects.1Itwas
designedtodetectcongenitalredgreencolordeficiency.Therefore,ifyoutestforanacquireddisease
oftheretina(suchashydroxychloroquinetoxicity),theIshiharamayormaynotdetectit.Analternative
colorvisiontestthatincludesblueyellowtestingshouldbeconsidered(theHardyRandRittlerplates,
forexample).

Howtointerpretresults1

Scoringoccursonthefirst11plates
10/11isconsiderednormal
7/11orlessisabnormal
Thosescoring8or9/11needfurthertestingtoknow
(FarnsworthPanelD15orFarnsworthMunsell100huetest,forexample)

Whatdotheplatesmean?1

Plates211aretestingforcolordefects
Plate1isforexplainingthetesttothepatient.Everyone(withveryrareexception)shouldseeplate1.
Inplates25,redgreendeficientpatientsmayseedifferentnumbers.Theyshouldnotseedifferent
numbersonplates610,withtheexceptionofplate#9.Plate#9isspecial.Normalcolorvisiondoesnot
allowyoutoseeit,butaredgreendeficientpersoncanseea2.

Plates1214areforthosewithredgreendeficiencies
These3plateshelptodifferentiatebetweenprotanopiaanddeuteranopia.Patientswithprotanopia
cannotseethefirstdigitonplates12and13ortheredlineonplate14,whilethosewithdeuteranopia
cannotseetheseconddigitonplates12and13orthepurplelineonplate14.

TAKEHOMEPOINTS
TheIshiharadetectsRedGreendefects,notBlueYellow
MostcongenitaldefectsareRedGreen
PatientswithRedGreendefectscanseeplate#9
Ifthepatientscores10outofthefirst11plates,theyarenormalandyoumaystopthetest
AcquiredretinaldiseasescouldbemissedbytheIshihara

IencourageyoutopickupyourIshihara,brushoffthedustoftheaccompanyinginsertandlookatthe
tableonthelastpage.

References
1.IshiharasTestsforColourDeficiency,Conciseedition.KaneharaTradingINC.,Tokyo,Japan.2006.
2.ShinobuIshihara,FromWikipedia,thefreeencyclopedia
http://en.wikipedia.org/wiki/Shinobu_Ishihara.Accessed12709.
3.MeasuringColourVisionDefects,http://www.geocities.com/HotSprings/8018/Measure.html.
Accessed12709.
4.ColorVisionandTestsofcolorvision,RetinaandVitreous,AmericanAcademyofOphthalmologyBasic
andClinicalScienceCourse,section12,20072008,p.43and195.
5.Martin,TandCorbettJ.Neuroophthalmology;therequisitesinOphthalmology.Krachmer,Jeditor;
Mosby,StLouis;2000;p22.