Awareness People with a colour deficiency often lack awareness of its extent and effect.
34 A few react
by denial.35 In the study by Cole and Steward,29 5% of dichromats and 25% of anomalous trichomats
were not aware of their deficiency. Students at art school can be unaware of it even when severe.36 In
one study, lack of awareness of the acquired form was shown by all 34 diabetics37 with retinopathy;
and, of eight people who made more than two-step errors on home testing of urine, none were aware
of any difficulty. The tritan deficiency that occurs with ageing tends to go unnoticed owing to adaptive
processes occurring slowly over time.38 The lack of awareness must in part be because of the effective
use of cues, often unconsciously, to guess the colour of the object observed. For example, brightness
can be a cue to red, the texture of a lawn to green, and the shape of a banana to yellow. In addition, it
has been observed that individuals with a congenital deficiency learn from childhood to keep quiet
about it39 and so are deprived of the opportunity of fully understanding its implications. To understand
these implications takes a sustained effort,40 and few attempt this. The difficulty of gaining awareness
that colours are not being perceived can be shown by asking individuals with normal colour vision about
their colour vision at night. Many do not realise that in dim light (scotopic conditions) they see only in
black, grey, and white, except when viewing direct sources of light.6 Experiments have shown how
strong the tendency is of even those with normal colour vision to rely on assumptions about the colour
of an object.9 They can match, for example, the image of a brown lemon as yellow; and the poorer the
colour information given, the stronger this tendency is. This helps to explain how those with a CVD can
make assured but incorrect judgements of colour. 470 British Journal of General Practice, June 1999 J A
B Spalding Review article Table 1. Classification and prevalence (in Caucasians) of congenital
deficiencies.7 Type Name Prevalence (%) Hue discrimination Male Female Dichromat Protanopes (‘red’
deficiency) 1 0.01 Severely impaired (two cone photopigments only) Deuteranopes (‘green’ deficiency) 1
0.01 Trichromat Protanomalous (‘red’ deficiency) 1 0.03 Continuous range (three cone photopigments,
from severe to mild15 one abnormal) Deuteranomalous (‘green’ deficiency) 5 0.53 The suffix,
anomalous, denotes the possession of an abnormal photopigment. Protan and deutan are terms
denoting both dichromats and trichromats. Tritan (‘blue’) prevalence = dichromats: 1 in 10 000;
trichromats: unknown. Monochromats are extremely rare. British Journal of General Practice, June 1999
471 J A B Spalding Review article Prevalence of CVD in the medical profession and allied occupations
Table 2 gives the results of all known studies that include prevalence figures for doctors, dentists, and
medical and dental students when reliable methods of testing for CVD have been used. Two large
studies,1,2 not included in the table, give prevalence for all students, medical and non-medical,
attending Queen’s University of Belfast for two periods of five years (1949–1954 and 1954–1959). CVD
testing was part of the health assessment for all entrants. The prevalence of CVD was 6.9% for 1966 men
and 5.5% for 2405 men. The Ishihara test was used but with ‘no special illumination’. If tungsten lighting
was used, it could account, by missing some of the deutans, for the low figures. All prevalence figures
came close to, or a little above, the average 8% for men with inherited CVD in the general population,
except for ophthalmologists45 who had a prevalence of 6.7%, which suggests some self-selecting out for
this specialty
