Briici<ner Test

ANDREA CIBIS TONGUE,* GERHARD W. CIBISt

Abstract: Bruckner, in 1962, published a paper in German describing

a "trans-illumination" test extremely useful in the diagnosis of small
angle deviations and amblyopia in young uncooperative children. A
bright coaxial light source, such as a direct ophthalmoscope, is used.
Both eyes of the patient are simultaneously illuminated from approxi-
mately one meter distance. First, the position of the corneal light reflex,
(Hirschberg test), along with brightness difference of the fundus reflex
as seen in the pupil through the ophthalmoscope, is evaluated. When
strabismus is present, the fixing eye has a darker reflex than the de-
viated eye. The second step evaluates pupil size, pupil reaction, and
fixation movement of the eyes on "successive" illumination of one eye
at a time. This is useful in detecting amblyopia. [Key words: ambly-
opia, Bruckner test, fundus reflex, Hirschberg test, strabismus.] Oph-
thai mology 88: 1041 -1044, 1981

Small-angle strabismus and amblyopia detection
in infants and uncooperative children is particu-
larly difficult. Without visual acuity values, prism
measurements, cover-uncover tests and sensory
evaluation, the diagnosis of strabismus and ambly-
opia is reduced to assessment of the position of the
corneal light reflex relative to the pupil (Hirsch-
berg test), and fixation pattern assessment for the
diagnosis of amblyopia. Bruckner, reporting in the
German and French literature,I-3 has added to this
armamentarium a more extensive light reflex test
which we have found extremely valuable in clinical
practice. Since this test is little known to English-
speaking ophthalmologists, it is the purpose ofthis
paper to describe the test and give examples of its
clinical usefulness.
PROCEDURES
The patient is seated in the mother's lap while
examining room lights are turned low enough to
From the Elks Children's Eye Clinic, University of Oregon Health
Science Center,' Portland and the Children's Mercy Hospital and
Department of Ophthalmology, University of Missouri at Kansas
City·t
Presented in part at the Third Annual Pediatric Ophthalmological
Symposium, San Francisco, April 4-6, 1977.
Supported by the Paul A. and Lisa M. Cibis Trust.
Reprint requests to Dr. Andrea Tongue, 470 SW Sixth Street, Lake
Oswego, OR 97201.
eliminate anything of interest in the room except
for the examiner's light source, but not so low as
to frighten the child. The test should be performed
before the pupils are dilated with drops, since sub-
tle differences in the brightness of the red reflex
are difficult to detect when the pupil is widely di-
lated.
The examiner sits 80 to 100 cm (arm's length)
in front of the patient and shines the beam of a
direct ophthalmoscope onto the patient's eyes. The
light beam must be wide enough to illuminate both
eyes simultaneously. The examiner looks through
the ophthalmoscope and adjusts the lens dial to
compensate for the working distance and his own
refractive error until the corneal light reflex and the
fundus reflex within the pupil (red reflex) are in
focus. The position of the corneal reflex in each
eye relative to the pupil is assessed. This is the
Hirschberg test. Attention is then directed to the
fundus reflex (red reflex) in the patient's pupils.
When the patient is orthotropic, the color, and es-
pecially brightness, of the fundus reflex is equal in
the two eyes (Fig lA). Strabismus, anisometropia,
anisocoria, posterior pole abnormalities and media
opacities cause a difference in brightness of the
fundus reflex from the two eyes (Figs 2A, 2B,
3A, 4, 5).
When strabismus is present, the fundus reflex of
the fixing eye is darker while that of the non-fixing
eye is a brighter, lighter, red-yellow or white color
(Figs lB, 2A, 2B, 4, 5). The difference in brightness

0161-6420/8111000/10411$00.70 © American Academy of Ophthalmology 1041

 OPHTHALMOLOGY . OCTOBER 1981 • VOLUME 88 • NUMBER 10
is more important than the difference in color. Fur-
thermore, the pupil of the deviated eye appears
larger than the pupil of the fixing eye. This is an
illusion. Pupil diameter measurements are equal.
Differences in brightness of the red reflex may
also be produced by anisometropia, anisocoria,
media opacities and posterior pole lesions. In the
latter, the nature of the retinal abnormality deter-
mines which of the two eyes has the brighter re-
flex . In anisocoria, the reflex usually appears
brighter in the eye with the larger pupil. In aniso-
metropia, the reflex from the more ametropic eye is
usually brighter. However, in uncorrected high an-
isometropia, the reflex may actually be darker in
the ametropic one.
Dilatation of the pupils may eliminate the bright-
ness difference between the two eyes (Figs 3A,
3B). For this reason, the use of mydriatics or cyclo-
plegics should be avoided before the examination.
A sufficiently strong coaxial light source is im-
portant in evaluating the fundus reflex as de-
scribed. Halogen ophthalmoscopes, cord-powered
giantscopes or pantoscopes are ideal, as is the fun-
dus camera used for the clinical photos in this pub-
lication. Battery-powered ophthalmoscopes tend
to be too weak. The color of the fundus reflex is in
part dependent on the type of light source used.
However, color is not as important as symmetry or
asymmetry of brightness of the reflex! Of utmost
importance also is the patient's fixation on the light
source .
Monitoring fixation is not difficult. When not
fixing on the light, both pupils are dilated and there
is no difference in the color of the fundus reflex.
The corneal light reflex in both eyes is away from
the expected angle kappa position, and asymmetric
in the two eyes. When taking up fixation, both
pupils rapidly constrict due to the accommodation
convergence pupillary reaction, and the corneal
light reflex in the fixing eye (or eyes) assumes the
proper position. The fundus red reflex in the fixing
eye (or eyes), becomes darker than when the pa-
tient was not fixing . If strabismus is present, the
fixing eye is darker than the deviated eye. Identi-
fying the fixing eye is useful in rapid alternators or
patients with nystagmus where the Hirschberg test
alone may not identify the type of deviation.
The first step of the test as described by Bruckner
consists of evaluation of the corneal reflexes and
the color and brightness of the fundus reflex as
seen in the pupils with simultaneous illumination
of both eyes. A further step the "successive illu-
mination test" of Bruckner consists of evaluation
of the fundus reflex, pupillary action, and fixation
movement with illumination of each eye sepa-
rately. This is the test for amblyopia. This can be
done by covering the fixing eye of the patient. If a
child does not allow this, it can be done by narrow-
ing the light beam and shining it over one eye at a
time.
1042
Initially, as illumination is switched from both
eyes to the eye with the brighter fundus reflex,
slight pupillary dilation will be observed. Subse-
quently two things may occur. If the patient's fix-
ation switches to foveal fixation with this eye, the
pupil will constrict the fundus reflex will become
darker. In this case, amblyopia is unlikely. If am-
blyopia is present, fixation usually does not change ,
.the pupil will not constrict, and the fundus reflex
n~mains unchanged or brighter than that of the op-
posite eye while it was fixing. The patient may also
exhibit a wavering unsteadiness of fixation with
that eye. The monocular illumination step is thus
a fixation pattern assessment with the added advan-
tage of monitoring pupillary behavior and fundus
reflex brightness changes . Furthermore, the cor-
neal reflex (Hirschberg test), is easier to judge
against the red fundus reflex than against a dark
pupil that occurs with non-coaxial illumination
(muscle light).
RESULTS
Fig 2 shows the fundus reflex in the pupils of an
alternating esotrope fixing first with the right (Fig
2A) and then with the left (Fig 2B) eye. The pupil
of the fixing eye appears darker and smaller; that
of the deviating eye, brighter and larger. This true
brightness , but illusory size difference, is present
even in small cosmetically inapparent horizontal or
vertical deviations . The brightness differences in
microtropia are not always as striking as illustrated
(Fig 5). However, increasing experiences with the
test facilitate detection of even minor differences
in the fundus reflex. Bruckner states that he was
able to detect strabismus of as little as one and one
half degrees. This is our experience as well.
Bruckner's test has been of particular help in
postoperative evaluation of patients with strabis-
mus who appear to be orthotropic or in whom the
Hirschberg test may indicate the presence of a small
deviation. In uncooperative children, it may be dif-
ficult to tell which eye is fixing. Simultaneous
evaluation of the fundus reflex quickly establishes
the fixing eye as the darker eye.
Individual (successive) illumination of the eye
with the brighter reflex is then useful to determine
whether amblyopia is present. If the pupil does not
constrict, and the eye fails to pick up proper fixa-
tion and the light reflex remains unchanged, the
eye is amblyopic. Frequently, the pupil of the am-
blyopic eye will oscillate back and forth with un-
steady fixation on the target light while the red
fundus reflex remains brighter than that of the
sound eye when it was fixing. In mild degrees of
amblyopia, the amblyopic eye may pick up fixa-
tion, as the pupil tends to constrict more slowly
and sluggishly than in the better eye.
In patients with congenital nystagmus, the cover-
 TONGUE AND CISIS • SROCKNER TEST

Fig lA. First row left, equally bright fundus reflex in each pupil of an ametropic patient with Duane's syndrome, orthotropic on slight left
gaze. Fig. lB. First row right, same patient in primary gaze demonstrating brighter right fundus reflex and definite esotropia. Dark red
reflex identifies left eye as fixing. Fig. 2A. Second row left. abnormal, unequally bright fundus reflex in patient with large-angle
alternating esotropia. The fundus reflex in the pupil of the fixing right eye is duller and less bright than that of the strabismic left eye. Fig
2B. Second row right, same patient as in Fig 2A, left eye fixing. Fig 3A. Third row left. asymmetric fundus reflex in acquired amblyopia
and microtropia secondary to recurrent herpetic keratitis, left eye. Fig 3B. Third row right. same patient as in Fig 3A after pupillary
dilatation. Fundus reflex now appears equally bright Fig 4. Fourth row left, cosmetically unapparent micro strabismus with hypoplastic
optic nerve, and moderate amblyopia, left eye. Fundus reflex of the non-fixing eye is brighter than that of the fixing right eye. Fig 5.
Fourth row right, postoperative small-angle strabismus in a patient uncooperative for visual acuity or cover test assessment. The dark
fundus reflex identifies the left eye as fixing. The strabismic right eye has the brighter fundus reflex.

1043
 OPHTHALMOLOGY. OCTOBER 1981 • VOLUME 88 • NUMBER 10
uncover test may be difficult to interpret. The red
reflex test is enormously helpful in evaluating these
patients since many of them are strabismic and
have monocular fixation. The red reflex test accu-
rately identifies the strabismic and fixing eye.
Performance of Bruckner's test in different po-
sitions of gaze is helpful in identifying areas of
orthotropia in young patients with incomitant stra-
bismus. This is particularly useful in infants with
Duane's syndrome who may have binocularity in
one direction of gaze even though cosmetically
they appear to be constantly strabismic. Typical of
these patients is the fact that relatively small changes
in direction of gaze away from the area of apparent
fusion, produces large and sudden deviations (Figs.
lA, 1B).
Bruckner's test has been helpful in detecting de-
viations as small as three prism diopters, and acu-
ity differences of as little as one line on the Snellen
chart. Anisometropic microtropia is particularly
noticeable because of the cumulative effect of the
ocular deviation and anisometropia on the bright-
ness difference of the red reflex.
CONTROLLED STUDY
In order to quantitate our clinical impression as
to the usefulness of this test in detecting ambly-
opia, a controlled study was carried out by one of
us (GWC). The Bruckner test was performed on
219 verbal patients ranging in age from three to
seven years. The examiner predicted orthotropia
and amblyopia prior to acuity determination by an-
other person.
Of 100 consecutive patients predicted to be nor-
mal (ie, negative Bruckner test, equal visual acu-
ity) all were normal with equal acuity. Of 119 con-
secutive patients with a positive Bruckner test, 66
were predicted to have equal visual acuity (non-
amblyopic) and did. None was predicted to have
amblyopia and did not.
Of 53 amblyopes with one Snellen line differ-
ence or greater, 34 (64%) were correctly predicted
to have amblyopia, 19 were missed. If a two Snel-
len line or greater difference was used as the cri-
terion for amblyopia then only 2 (17%) were missed.
The Bruckner test correctly diagnosed an ambly-
opia of three Snellen line difference or greater in
92 % of the cases.
COMMENTS
Using the coaxial illumination of an ophthalmo-
scope, Smith4 and later Maddox 5 observed that the
corneal reflex is more readily seen against the
bright background of the pupillary light reflex than
against a dark pupil as exists when non coaxial
illumination is used. Worth6 was the first to recog-
1044
nize that the pupil of the deviating eye appeared
larger and the fundus reflex brighter than that of
the fixing eye. Bruckner rediscovered these prin-
ciples and augmented their clinical usefulness by
observation of pupillary behavior.
The slight pupillary dilatation occurring on
switching illumination from both eyes to one eye
only is the normal response to halving of the total
amount of light reaching the pupillary system. The
rapid reconstriction of the pupil of a non-am-
blyopic eye is presumably the normal near fixation,
accommodation response. The sluggishness of this
response or its absence in the presence of ambly-
opia is explicable by the poorer fixation and ac-
commodation present in amblyopia. 6 This is not an
afferent pupil defect test!
Explanation of the difference in color brightness
of the pupillary light reflex with strabismus is more
complicated. Bruckner attributes it to the differ-
ences in fundus pigmentation in the macula and
peripheral fundus. 1 - 3 Loss of the brightness differ-
ence on pupillary dilatation would tend to support
this contention. The presence of a brightness dif-
ference in anisometropia and its elimination or crea-
tion with lenses suggests that the degree of diver-
gence or convergence of the incident and reflected
light alters its brightness just as it does in retinos-
copy. The entire phenomenon is most easily seen
in infants, less so in older children, and with dif-
ficulty in adults. Age-related differences in fundus
reflectivity, lens structure, or pupil size relative to
that of the globe appear to playa role. Suffice it to
say that the observations of Bruckner have been
both correct, and in our experience, very useful
adjuncts to the clinical evaluation for strabismus
and amblyopia of the small and uncooperative child.
Bruckner's name for this test translates as "pu-
pillary transillumination." We find this term both
confusing and limiting and prefer to name the test
after its originator. The test has been particularly
useful in detection of residual and small-angle de-
viations after surgery or spectacle correction.
REFERENCES
1. Bruckner R. Exakte Strabismusdiagnostik bei 1/2-3 jahrigen
Kindern mit einem einfachen Verfahren, dem "Durchleuch-
tungstest." Ophthalmologica 1962; 144:184-98.
2. Bruckner R. Praktische Ubungen mit dem Durchleuchtung-
stest zur Fruhdiagnose des Strabismus. Ophthalmologica
1965; 149:497-503.
3. Bruckner R. Clinical methods for the detection of functional
amblyopia in childhood prior to the knowledge of optotypes.
J Fr Orthopt 1974; 6:47-63.
4. Smith P. On the corneal reflex of the ophthalmoscope as a
test of fixation and deviation. Ophthalmic Rev 1892; 11 :37-42.
5. Maddox E. Cited by Bruckner.
6.. Worth C. Cited by Bruckner.