Worth Four Dot

Purpose: Worth four dot test assesses the client´s flat fusion ability at distance and near. The hand-held test in front of you is also used to detect a small unilateral central scotoma. The test is indicated when stereopsis is below 40 seconds of arc. It is also used in the differential diagnosis of unilateral decreased visual acuity. The traditional test is performed on a paper form. The client reports what colour the circle is. In the application, client simply taps on a coloured circle at the top of the screen and their dominant eye is displayed on the screen. Equipment and set-up: Put a red glass filter in front of the client´s right eye and the green filter in front of the left eye over the correction for the distance. The test is held at 40 cm. Show the client this test and ask them how many light spots they see. Interpreting the results:
  • If the client recognises four dots, they have normal flat fusion
  • If the client reports that they see two red dots, they are using only the right eye, therefore they are suppressing their left eye.
  • If the client reports that they see three green dots, they are using only their left eye, therefore they are suppressing their right eye.
  • If the client sees 5 dots, ask where the green ones are located. Based on the response, we can determine the relationship of the visual axes of the two eyes:
    • If the red dots are to the right of the green ones, the client has an ESO deviation.
    • If the red dots are to the left of the green dots, the client has an EXO deviation
    • If the red dots are above the green dots, the client has a RIGHT HYPODEVIATION (or left hyperdeviation)
    • If the red dots are below the green dots, the client has a right RIGHT HYPERDEVIATION (or left hypodeviation).
Testing for a central scotoma: – Hold this test at 40 cm – Ask the patient to continue fixating four dots and to report if the number of dots drops to either 3 or 2 at any time – Slowly start to move the test away from the patient – Stop when the patient reports a change in number of dots and estimate the distance at which it occurs – If the patient sees all four dots at 3 metres the test stops and you can record “no suppression to 3 metres” Determine which eye is suppressing then ask a patient to cover the eye that is not suppressing and to report whether or not the suppressed dots reappear. If the dots reapper, the patient has a suppression scotoma that only occurs in binocular vision. If the dots do not reappear, the patient has a unilateral scotoma.
Worth Four Dot
The mechanics of Worth 4-dot testing are described in Chapter 4. Only patients who are using both eyes together can appreciate all 4 lights being projected (see Chapter 4, Fig 4-10). If the right eye is suppressed, as often occurs if that eye is deviated, the patient will report seeing 3 green lights because the white light appears green. If the left eye is suppressed, the patient will report seeing 2 red lights because the white light appears red. If alternate eyes are suppressed, the patient may see 2 red and 3 green lights alternating. Patients with diplopia may report seeing 5 lights simultaneously. The Worth Four Light Test, also known as the Worth’s Four Dot test or abbreviation W4LT, is one simple clinical test mainly used for assessing a patient’s degree of binocular vision. We could say that W4LT is one of the simpler methods for investigating fusion, suppression, and anomalous retinal correspondence (ARC). This test can be performed in two methods (ways). One method is to have a fixed target at a distance from the subject, which may either be contained in an illuminated box or projected on a screen. This is referred to as the distant Worth dot test (6 meter) . The other method is a near Worth dot test (at 33 cm), which consists of a flashlight easily advanced or receded from the subject to alter the projection angle of the target image on the retinas. At both testing distances (distance and near) the patient is always required to wear red-green goggles (with one red lens over one eye, usually the right, and one green lens over the left). Illuminated box or flashlight (depending weather test is performed at distance or near) is composed of 4 lights, which are arranged in a diamond formation. One red light is always at the top, two green lights at either side (left and right) and one white light is always at the bottom. The patient views the target through anaglyphic testing glasses that consist of a red filter in front of one eye and a green filter in front of the other. Viewed through the red filter, the green dots are invisible; viewed through the green filter, the red dot is invisible. The white dot is seen as red when viewed through the red filter and as green when viewed through the green filter.

Contents

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Interpretation of Worth Four Light test

Before the doctor starts to perform interpretation of worth four light test, it is very important not to forget to ask the patient, usually child a series of questions. These questions are essential and very important to every clinician:
  1. How many lights are you seeing?
  2. What color are they?
  3. Where are they located?
  4. Are all the lights in line? Or are some higher than the others?
  5. Do all the lights show up at one time, or are they flashing on and off?
Clinician is also advised to note the distance at which the test is conducted and whether or not the patient wore their own refractive correction. The subject should be tested with the optimal optical correction on (spectacles or contact lenses) behind the anaglyphic filters. It is also very important, when there is a difficulty in communication between clinician and patient (adult) or when working with a small children, to ask patient / child to draw what they are seeing. This simplifies a lot and helps clinician in interpretation the result from the drawing.

There are a number of possible results demonstrated by a W4LT

The patient sees all four dots :
  • Normal binocular response with no manifest deviation (NRC with no heterotropia)
  • Harmonious ARC with manifest squint.
The patient sees five dots:
  • uncrossed diplopia with esotropia, red dots appear to the right
  • crossed diplopia with exotropia, red dots appear to the left of the green dots.
The patients sees three green dots, suppression of the right eye The patient sees two red dots, suppresion of the left eye

Additional Resources

References

  1. Worth C. Squint: Its causes, pathology and treatment. Philadelphia: Blakiston, 1908
  2. Noorden GK von. Binocular vision and ocular motility: theory and managment of strabismus, 5th Ed. St Louis: Mosby, 1996.
  3. Duane’s Clinical Ophthalmology. New York: Lippincott Williams & Wilkins, 2005.
In the Worth 4-dot test, a red glass is worn in front of 1 eye and a green glass in front of the other (Fig 4-10). The eye behind the red glass can see red light but not green light because the red glass blocks this wavelength. Similarly, the eye behind the green glass can see green light but not red light. A polarized Worth 4-dot test is available; it is administered and interpreted much like the traditional test except that polarized glasses are worn rather than red and green ones. As with the red-glass test, the Worth 4-dot test can produce a diplopic response in nonsuppression heterotropic NRC and either a diplopic or a fusion response in ARC, depending on the depth of the ARC adaptation. As mentioned earlier, this test must be performed in conjunction with cover testing. When testing a patient for monofixation syndrome (see the section Monofixation Syndrome later in this chapter), the Worth 4-dot test can be used to demonstrate both the presence of peripheral fusion and the absence of bifixation. The standard Worth 4-dot flashlight projects onto a central retinal area of 1° or less when viewed at 10 ft, well within the 1°–4° scotoma characteristic of monofixation syndrome. Therefore, patients with monofixation syndrome will report 2 or 3 lights when viewing at 10 ft, depending on their ocular fixation preference. As the Worth 4-dot flashlight is brought closer to the patient, the dots begin to project onto peripheral retina outside the central monofixation scotoma until a fusion response (4 lights) is obtained. This usually occurs between 2 and 3 ft.
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