Assessment of Binocular Vision 153
system, and in children with significant birth com-
plications (e.g. forceps delivery). It is, therefore,
recommended that the following questions be
posed to the parent/carer during the case history
examination:
■ Was the child a full-term baby or were they
born prematurely?
■ What was the birth weight? (less than 2500
gr or 5.5 pounds is a significant risk factor
for strabismus, in particular esotropia;
Mohney et al. 1998).
■ Were there significant complications at the
child’s birth?
■ Is the child’s current and past general health
good?
■ Since birth, has the child been investigated or
received treatment for any medical condition?
5.2 RELEVANT INFORMATION
FROM ASSESSMENTS
OF OTHER SYSTEMS
5.2.1 Binocular visual acuity
In cases where the acuities in the right and left eyes
are similar or identical, it is usual to find that binocu-
lar visual acuity (VA) is typically between half
a line and a line better than monocular acuity
(Pardhan & Elliott 1991). Of course, it is not possible
to find this improvement if monocular VA equals
the ‘bottom line’ of the Snellen chart you are using.
When using a non-truncated chart, a binocular VA
that is equal to or worse than the monocular VA can
indicate a binocular vision problem. A poor patient
reaction to the restoration of binocular vision after
an occluder has been removed following monocu-
lar subjective refraction can also indicate a binocu-
lar vision problem.
5.2.2 Retinoscopy and subjective
refraction
1. Fluctuations in retinoscopy: Fluctuations in
spherical power during retinoscopy indicate
changes in accommodation. These could be
due to variable fixation, but also possible
latent hyperopia or pseudomyopia that
should be investigated using assessments of
accommodation (sections 5.17 to 5.19) and/or
cycloplegic refraction (section 4.20).
2. Differences between retinoscopy and
subjective refraction: A retinoscopy result that
is significantly (⬎1.50 D) more positive than
the subjective result could indicate latent
hyperopia or pseudomyopia that should be
investigated using assessments of
accommodation (sections 5.17 to 5.19) and/or
cycloplegic refraction (section 4.20).
3. Fluctuations in subjective refraction:
Fluctuations in spherical power during
subjective refraction could suggest poor
control of accommodation. These could be
due to the use of monocular refraction
and/or poor technique, but may need to be
investigated using assessments of
accommodation (sections 5.17 to 5.19) and/or
cycloplegic refraction (section 4.20).
5.2.3 Systemic and ocular health
assessment
Information provided by the patient about sys-
temic or ocular disease, previous or current, may
explain signs or symptoms that are of a binocular
vision nature. For example, diabetes or thyroid dis-
ease can lead to binocular vision problems. Similarly,
particular signs or symptoms may prompt the prac-
titioner to ask again about systemic health and/or
to seek explanation within the eye. For example, a
newly acquired divergent heterotropia (section 5.4)
and ptosis may be observed in a palsy of the third
cranial nerve and is suggestive of diabetes. Finally,
cortical cataract and occasionally posterior subcap-
sular cataract can generate diplopia that is monocu-
lar in origin (i.e. it persists even when one eye is
covered).
5.3 CLASSIFICATION OF
HETEROPHORIA
Binocular vision requires that the eyes move together
so that the visual axes intersect at the object of regard.
154 Clinical Procedures in Primary Eye Care
The eyes are held in alignment by a combination of
the sensory and motor fusion mechanisms. If sens-
ory fusion is prevented (for example, by occluding
one eye as during the cover test), only the motor
fusion mechanism is operational and a misalignment
of the visual axes will occur in many patients. This
misalignment is sometimes referred to as a latent
deviation but is more commonly known as a het-
erophoria. Video clips of the cover test being used to
assess a variety of heterophorias are provided on
the website .
5.3.1 Direction
ORTHOPHORIA is present if the visual axes remain
correctly aligned when sensory fusion is prevented.
Heterophorias can be defined in terms of the direc-
tion of the misalignment when sensory fusion is
prevented:
■ ESOPHORIA: Convergence of the visual axes
■ EXOPHORIA: Divergence of the visual axes
■ HYPERPHORIA: One visual axis higher than
the other
■ HYPOPHORIA: One visual axis lower than
the other.
Classification of vertical heterophorias is rather arti-
ficial in the sense that if the right visual axis is higher
than the left this may be classified as a right hyper-
phoria or, alternatively, as a left hypophoria. In prac-
tice, it is usual to classify vertical heterophorias in
terms of which eye is the hyperphoric eye; thus ver-
tical heterophorias are normally described as either
right hyperphoria or left hyperphoria in order to
indicate the higher visual axis.
A relative rotation of the vertical poles of the
cornea is called a cyclophoria, which can be further
categorised into:
■ EXCYCLOPHORIA: Outward rotation of the
upper poles
■ INCYCLOPHORIA: Inward rotation of the
upper poles.
Cyclophorias are seldom investigated in primary
eye care examinations. If a cyclophoria is present it
is likely that it will be accompanied by other types
of heterophoria (e.g. vertical heterophoria) and in
most cases it will be possible to explain its presence
by considering the actions of the elevating and
depressing extraocular muscles of the eye (von Noor-
den 2002; e.g. the intorting actions of the superior
oblique muscles and extorting actions of the infer-
ior oblique muscles). Given the rarity with which
cyclophorias alone are diagnosed in primary eye care
and the fact that no treatment exists, cyclophorias
will not be discussed further.
5.3.2 Magnitude and stability
Most patients have a small amount of heterophoria,
especially at near. The magnitude of heterophoria
is estimated or measured in prism dioptres (Δ). At
distance, between 2Δ of esophoria and 4Δ of exopho-
ria is considered normal. At near, between 3Δ and
6Δ of exophoria is considered normal. The tendency
for the eyes to exhibit a small amount of exophoria
at near is referred to as physiological exophoria. The
tolerance to vertical misalignments is less than hori-
zontal with greater than 0.5Δ vertical heterophoria
considered abnormal. While heterophoria over the
course of a lifetime remains fairly constant (although
physiological exophoria shows a small increase
with age; Freier & Pickwell 1983), the ability of the
patient to cope with their heterophoria can be influ-
enced by stress on the visual system (e.g. excessive
workload), by fatigue or by the patient’s general
health.
5.3.3 Comparing heterophoria at
distance and at near
Heterophoria is usually evaluated with distance
(6 m or 20 ft) and near (40 cm or 16”) viewing
because the amount of heterophoria exhibited at
the two distances is often quite different. This is
because of the accommodation/convergence rela-
tionship. When a near target is viewed the eyes
converge as well as accommodate. Depending upon
the amount of convergence that accompanies each
dioptre of accommodation (the magnitude of the
AC/A ratio, section 5.11), the heterophoria at near
may be very different from that which exists at dis-
tance. The following names are used to describe the
possible conditions that may be present when a large
difference exists between the distance and near het-
erophoria and where the patient is experiencing

symptoms that are consistent with the presence of a
binocular vision problem:
■ CONVERGENCE INSUFFICIENCY:
Exophoria much larger at near than at
distance. The definition indicates that
exophoria must be much larger because of
physiological exophoria at near (section
5.3.2).
■ CONVERGENCE EXCESS: Esophoria larger
at near than at distance.
■ DIVERGENCE INSUFFICIENCY: Esophoria
larger at distance than at near.
■ DIVERGENCE EXCESS: Exophoria larger at
distance than at near.
Patients with convergence insufficiency or conver-
gence excess will obviously experience their symp-
toms during near viewing whereas patients with
divergence insufficiency or divergence excess will
report symptoms during distance viewing.
5.3.4 Compensated versus
decompensated heterophorias
The majority of patients will exhibit a heterophoria
under some conditions and most heterophorias
will not cause symptoms.
■ COMPENSATED HETEROPHORIA: A
heterophoria that does not cause symptoms
(or suppression).
■ DECOMPENSATED HETEROPHORIA: A
heterophoria thought to be responsible for
the patient’s symptoms or for generating
suppression.
It is important to stress that it is not simply the case
that large heterophorias will be decompensated
whereas small heterophorias will be compensated.
The best example of this is the case of vertical het-
erophorias where even small tendencies towards
vertical misalignment (e.g. 0.5Δ) can give rise to
symptoms whereas much larger horizontal het-
erophorias frequently exist without leading to symp-
toms or suppression. In order to deduce whether a
particular heterophoria is compensated or decom-
pensated it is necessary to consider factors in add-
ition to the magnitude of the heterophoria. For
Assessment of Binocular Vision 155
example, the quality of the recovery movement on
cover test (section 5.5) or the amount of fusional
reserves that oppose the heterophoria (section 5.12)
will also help to evaluate if the patient’s symp-
toms or suppression stem from the presence of the
heterophoria.
5.4 CLASSIFICATION OF
COMITANT HETEROTROPIA
(SQUINT OR STRABISMUS)
Binocular vision requires that the eyes move together
so that the visual axes intersect at the object of
regard and the eyes are held in alignment by a com-
bination of the sensory and motor fusion mechan-
isms. If the fusion reflex fails to develop or is unable
to function normally, a manifest misalignment of
the eyes or heterotropia (tropia, strabismus, squint)
will result. In a comitant heterotropia the angle of
deviation is constant in all directions of gaze
although it may differ depending upon whether
the patient is viewing a near or distant target. There
are considerable variations in the type of comitant
heterotropia observed in clinical practice (Stidwell
1997) and consequently comitant heterotropia
requires a more detailed classification than het-
erophoria. In addition to the direction and magni-
tude (in Δ) of the deviation, information is also
required regarding its frequency, laterality, age of
onset, influence of accommodation and cosmesis
(Table 5.1). A comitant heterotropia is detected using
the cover test (section 5.5). It should be differenti-
ated from an incomitant heterotropia (section 5.24)
in which the angle of deviation varies with direc-
tion of gaze and is usually caused by the malfunc-
tioning of one of the six extraocular muscles. An
incomitant heterotropia is detected using the motil-
ity test (section 5.25). Video clips of the cover test
being used to assess a variety of heterotropias are
provided on the website .
5.4.1 Age of onset
Congenital strabismus is used to describe devi-
ations that are present at birth or develop during
the first 6 months (von Noorden 2002). The term
‘acquired strabismus’ may be applied to deviations
that arise after this age.