Telemedicine testing of visual acuity, color vision, stereopsis and brightness-sense is now possible!  Introducing the iOS DiagnosticGame app which integrates technology of two essential Patents: (1) Binary Choice (US patent 9,089,257) that simplifies test response selection to YES or NO and (2) Amblyometer® (US PATENT 9,560,960) that provides automated simultaneous comparison of rivalrous binocular stimuli for testing relative brightness. 

 

Visual acuity, color vision and stereopsis are customary tests and broadly applied, however, brightness-sense testing is neither customary nor broadly applied.  For over 44 years scholars have recognized the great utility of the brightness-sense for detecting elusive asymmetric eye diseases such as glaucoma and amblyopia, it is now time to apply brightness-sense evaluations on the iPad or iPhone.  The DiagnosticGame app is the newest and best tool to uncover and monitor optic nerve diseases and childhood amblyopia.  According to Steven S. Kane, MD, PhD of Columbia University, “The children were familiar with the iPad and regarded the experience as a game, approaching it with enthusiasm and remembering a pleasant experience.”

 

The chronology of brightness-sense testing:

 

  1. 1976:  J S Glaser in Eye reported deficits in apparent brightness perception in optic nerve disease.  

  2. 1980:  M A Mainster and J P Dieckert in Am J Ophthalmol. described a quantitative method of measuring color brightness in optic nerve and macular diseases.  

  3. 1985:  A A Sadun and S Lessell reported the value of the brightness-sense in optic nerve disease in Arch Ophthalmol.  They sequentially tested the brightness-sense in right and left eyes and concluded “Impairment of brightness-sense was a consistent finding among patients with optic neuropathies and, in some cases, brightness testing appeared to be more sensitive than other techniques in establishing the presence of disease.”  

  4. 1990:  S L Tech, et al. reported in BJO that brightness disparity between the two eyes was significantly different in 86% of 28 glaucoma patients, “Moreover, there was a significant relationship between the interocular differences in brightness-sense and the difference in the degree of visual field loss between the two eyes”.

  5. 1994:  E MacMillan, et al. reported in Arch Ophthalmol. a new simultaneous interocular brightness-sense test that was given to 91 normal observers and concluded, “ The test is quick and simple to complete and appears to offer considerable scope for the assessment of visual function when differences in the functional integrity of the optic nerves of the right and left eyes are suspected.”

  6. 1994:  D Cummins, et al. reported in Arch Ophthalmol. that the test reported in #5 (E MacMillan, et al.) can also be used to test patients with ocular hypertension and glaucoma.  They found: (1) 36.8% of 19 patients with ocular hypertension exhibited brightness perception asymmetry outside the normal limits for age-matched controls and (2) all 20 patients with established POAG had results outside the normal limits for a test sensitivity of 100%.  Three control observers had abnormal results, giving a test specificity of 95%.  

  7. 1999:  T S Hofeldt and A J Hofeldt reported in BJO that color rivalry suppression was positively correlated (p<0.0001) with the interocular difference in logMAR acuity and negatively correlated (p=0.019) with stereoacuity in 14 non-pediatric patients with amblyopia. 

  8. 2016:  R Gise and S A Kane at ARVO reported using automated simultaneous comparison of rivalrous binocular stimuli for measuring the relative brightness-sense in 16 normal and 16 amblyopic children aged 3 to 7 years.  Tests were administered on an iPad utilizing the staircase algorithm program of the Amblyometer®, part of the DiagnosticGame app.  All 16 Amblyopes with greater than 1-line disparity on the Snellen Eye Chart were detected and there were no false positives for children without Amblyopia, sensitivity of 100%.  Comparison of test to retest scores, found testing was highly consistent (r=0.99, p <0.00001). The depth of amblyopic defect and lines of acuity disparity were also highly correlated. (r=0.85, p<0.0001).:

  9. 2018: S A Kane reported at the American Academy of Pediatrics 2018 his results of testing 286 school children from 3 to 7 years of age using the Amblyometer® of the DiagnosticGame® app.  There were 284 true negatives and 2 true positives (100% sensitivity), 0 false negatives and 0 false positives.  

In conclusion, the children were familiar with the iPad and regarded the experience as a game, approaching it with enthusiasm and remembering a pleasant experience. The normally sighted children were identified by a balanced brightness-sense. The children with amblyopia were identified by rivalrous brightness disparity with high sensitivity and specificity.  Brightness rivalry may be the most sensitive and specific method to detect amblyopia.

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