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Optometric prescribing in decompensated heterophoria.

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Optometry in Practice Vol 9 (2008) 63–78

Optometric Prescribing for Decompensated

Heterophoria
Bruce J. W. Evans1,2 BSc PhD FCOptom DipCLP DipOrth FAAO FBCLA
1
Institute of Optometry, London
2
Department of Optometry and Visual Science, City University, London
Date of acceptance 29 April 2008

Abstract
Decompensated heterophoria is usually detected by the presence of certain symptoms, including asthenopia, blurring, and
sometimes doubling. These symptoms are non-specific in that they can be caused by other eye problems. The differential
diagnosis of decompensated heterophoria therefore relies on clinical tests and the most useful of these are reviewed.

The first stage in the management of decompensated heterophoria is to determine the reason for decompensation.
Sometimes, a change to the working environment or a correction of the refractive error is all that is needed to eliminate
the symptoms. Many cases of decompensated heterophoria can be treated with eye exercises and this is often the treatment
of choice, particularly for exophoric deviations. Decompensated heterophoria can also be corrected using prisms or by
refractive modification. In refractive modification negative lenses are prescribed for exophoria and positive lenses for near
esophoria. This approach can be useful in pre-presbyopes, even if emmetropic. Methods of prescribing spherical and
prismatic lenses to correct decompensated heterophoria are reviewed.

The literature suggests that the Mallett Fixation Disparity Test is a useful instrument for detecting and prescribing for
decompensated heterophoria at near. This method should not be used in isolation, but when used in conjunction with other
test results it can be a valuable clinical tool. Indeed, it is argued that testing for binocular vision anomalies should not take
place in isolation, but should be considered within the context of a full eye examination.

Introduction The factors that can cause a heterophoria to

Heterotropia (strabismus) occurs when the two eyes are
not directed towards the fixation point and this affects
about 3% of the population (Adler 2001). Although most
people do not have a heterotropia, they will still exhibit a
tendency for the eyes to misalign when they are
dissociated, such as when one eye is covered. This
tendency is defined as a heterophoria (Millodot 2000).
Since heterophoria is ubiquitous it would clearly be
inappropriate to argue that heterophoria very commonly
needs treatment. But heterophoria signifies that a person
is having to apply fusional vergence to overcome the
dissociated deviation and in some cases this effort can be
too much and results in symptoms. Rarely, a patient who
has trouble compensating for a heterophoria may avoid
decompensate are summarised in Figure 1. Essentially,
there are three factors that can cause a heterophoria to
decompensate. First, if the heterophoria is very large (eg
an esophoria in a child resulting from high latent
hypermetropia) then the heterophoria may just be too
much for the motor and sensory fusion to cope. Working
at an abnormally close working distance could also cause
the heterophoria to increase to an intolerable degree.
Second, the motor fusion (fusional reserves) may be
inadequate. For example, a person who has a near exophoria
Heterophoria
Motor fusion Sensory fusion
▲
▲

symptoms by developing foveal suppression (Tang & Evans

2007). Even though these cases may not have symptoms, ▲
they can still require treatment because there is a risk of
the heterophoria deteriorating to heterotropia if it is not Compensated or
treated or corrected. A heterophoria that gives rise to Decompensated
symptoms or suppression is defined as decompensated (or
uncompensated) heterophoria (Millodot 2000). Figure 1. A simple model of binocular vision. (Reproduced with
permission from Evans (2007).)
Address for correspondence:
Bruce Evans, Institute of Optometry, 56–62 Newington Causeway, London SE1 6DS, UK (bruce.evans@virgin.net).

63
© 2008 The College of Optometrists
BJW Evans
may become ill and as his or her general health
deteriorates the fusional reserves may weaken to the point
when they can no longer comfortably overcome the
heterophoria. Third, there may be a problem that
interferes with sensory fusion. Some examples of factors
that can impair sensory fusion are working in dim
environments, cataracts, visual field loss and uncorrected
refractive error. If a patient develops a decompensated
heterophoria then enquiries about the patient’s general
health and working environment and a consideration of
Figure 1 will often help the practitioner to determine the
cause of the problem.
It is important to note that some of these factors that can
cause a heterophoria to decompensate can be an indicator
of pathology. For example, a sudden large change in a
heterophoria that cannot be explained by any change in
working environment could be a sign of an incomitant or
comitant deviation resulting from a lesion in the central
nervous system. Similarly, a deterioration in sensory fusion
could result from visual field loss in glaucoma. These
scenarios are unlikely, so it is certainly not appropriate to
refer every case of decompensated heterophoria to the
hospital eye service. However, these points are a reminder
that an assessment of binocular (orthoptic) function is
best carried out as part of a full eye examination.
From a clinical point of view, optometrists will only need to
intervene if a heterophoria is decompensated. Significant
foveal suppression is rare (Tang & Evans 2007) so
decompensated heterophoria is almost synonymous with
symptomatic heterophoria. The symptoms of decompensated
heterophoria are listed in Table 1. Recent research suggests
that asthenopia that results from binocular vision anomalies
is more likely to be characterised by headache and aching
eyes whereas sore eyes are more likely to be attributable to
dry-eye problems (Sheedy et al. 2003).
The symptoms in Table 1 are non-specific: they could all
result from causes other than decompensated
heterophoria. Hence, there is a need for an eye care
practitioner to carry out clinical tests to reach a diagnosis.
These clinical tests will now be described.
Diagnostic Tests for Decompensated
Heterophoria
Cover test recovery
In young or uncooperative patients there is a need for an
objective test to assess whether the heterophoria is
compensated and an evaluation of cover test recovery is
the only widely available objective clinical test for
64
compensation. A system for grading observations of cover
test recovery, called the Institute of Optometry Cover Test
Analysis (IOCTA), has been suggested (Table 2) and the
test–retest and interobserver repeatability of this system
are currently being researched at the Institute of
Optometry.
A system of recording cover test results has also been
suggested (Evans 2005). For example, a near cover test of
4⌬ exophoria on the cover–uncover test which increased to
8⌬ exophoria on the alternating cover test and
demonstrated slow recovery, but did not break down to
heterotropia, would be recorded as follows:
4⌬ XOP ➝ 8⌬ XOP Grade 3
It is better to provide an estimated value for the size of the
deviation (e.g. 4⌬) rather than a vague statement (e.g.
‘small’) and a simple method of estimating the amplitude
is described in the literature (Evans 2005, 2007). It should
be noted that, although XOP is an abbreviation for
exophoria in the UK (Millodot 2000), in North America a
common abbreviation for exophoria at distance is X, with
X’ representing exophoria at near.
Table 1. Symptoms of decompensated heterophoria.
Number Type of symptom Symptom
1 Blurred vision
2 Visual Double vision
3 Distorted vision
4 Difficulty with stereopsis
5 Binocular Monocular comfort
6 Difficulty changing focus
7 Headache
8 Asthenopic Aching eyes
9 Sore eyes
10 Referred General irritation
(Reproduced with permission from Evans (2005).)
Table 2. A grading system that can be used to gauge cover test
recovery in heterophoria.
Grade Description
1 Rapid and smooth
2 Slightly slow/jerky
3 Definitely slow/jerky but not breaking down
Slow/jerky and breaks down with repeat covering, or only
4
recovers after a blink
5 Breaks down readily after 1–3 covers
(Reproduced with permission from Evans (2005).)

Fixation disparity and aligning prism
(associated heterophoria)
If a patient has a large heterophoria then it might be thought
that this will greatly increase the risk of it being
decompensated. This is certainly true for hyperphoria,
because the vertical fusional reserves are modest. A
significant degree of esophoria is also quite likely to be
decompensated, and in a child patient this would make the
practitioner suspicious of latent hypermetropia so that a
cycloplegic refraction is usually indicated. But in cases of
exophoria, the size of the heterophoria is a poor indicator
of the likelihood that the patient will be able to
compensate for the deviation (Jenkins et al. 1989, Yekta &
Pickwell 1986, Yekta et al. 1989). This is probably because
the magnitude of the heterophoria is determined under
dissociated conditions, which bear little relationship to
the situation under everyday conditions, when the
monocular percepts are fused rather than dissociated.
About 50 years ago, this led many workers to study the
performance of the vergence system when the eyes are
fused, or associated (Lyons 1966, Mallett 1964, Ogle et al.,
1949). This resulted in the development at the Institute of
Optometry of the Mallett Fixation Disparity Unit (Figure
2), which has revolutionised the diagnosis and
management of decompensated heterophoria in the UK.
One survey indicates that this equipment is regularly used
by about 85% of UK optometrists (Karania & Evans 2006).
It should be stressed that the Mallett Unit does not
measure fixation disparity. It is used to detect the
presence of a fixation disparity and then to investigate the
minimum prism or sphere that eliminates the fixation
disparity. To describe these variables, the terms ‘aligning
prism’ and ‘aligning sphere’ have recently replaced the older term
‘associated heterophoria’, which was an oxymoron (Evans 2007).
Great care was taken in designing the Mallett Unit to
ensure that the fixation disparity test resembles everyday
viewing conditions (Mallett 1988). The test has both a
central ‘fusion lock’ (the OXO text) and peripheral fusion
detail (the text around the test). Only the coloured (green, for
the near unit) strips (Nonius markers) are seen monocularly,
and these are presented against a black background so as to
minimise the risk of retinal rivalry. Room illumination is
increased during the test to counteract the effect of the
polarising visors, and Mallett even recommended that the
test should not be carried out through a phoropter
(refractor head) because the reduced field of view may
interfere with natural viewing conditions (Mallett 1988).
Although not all of these claims of Mallett have been
investigated experimentally, there is evidence demonstrating
that an adequate illumination level is important (Pickwell
65
Optometric Prescribing for Decompensated Heterophoria
et al. 1987b, 1987c). Recent research also highlights the
importance of test instructions (Karania & Evans 2006).
This research shows that patients should be asked not just
whether the green strips are aligned, but whether one or
both of them ever moves. If it does, then prisms should be
introduced, initially in 0.5⌬ steps, to bring the strips into
stable alignment. The aligning prism will be much smaller
than the dissociated heterophoria, because the eyes are
associated. It is argued that the aligning prism represents
the extent of the uncompensated part of the imbalance
(Mallett 1988). The patient should fixate the X.
Several studies have shown that patients with a fixation
disparity on the near Mallett Unit are likely to have
symptoms (Karania & Evans 2006, Pickwell et al. 1991,
Yekta & Pickwell 1986, Yekta et al. 1989). The best studies
of the relationship with symptoms have produced receiver
operator curves and have demonstrated that for pre-
presbyopes a horizontal aligning prism of 1⌬ or more is
likely to be associated with symptoms and for presbyopes
an aligning prism of 2⌬ or more is likely to be associated
with symptoms (Jenkins et al. 1989, Yekta et al. 1989). In
these studies, the sensitivity and specificity of the Mallett
Fixation Disparity Test for detecting symptomatic
heterophoria in pre-presbyopes can be calculated as 75%
and 78% respectively. Although impressive, these figures
also highlight the fact that the test is not infallible. It is
therefore useful for clinicians to have other methods of
diagnosing decompensated heterophoria in their armoury
and these are discussed below.
Figure 2. The Mallett Fixation Disparity Test. Available from IOO
Sales Ltd; www.ioosales.co.uk.
Most research with the Mallett Unit has concentrated on
near vision, because this is where most decompensated
heterophoria occurs. Interestingly, the few studies that
have investigated the performance of the test for distance
decompensated heterophoria have found that it does not
BJW Evans
work as well as for near vision (Karania & Evans 2006,
Pickwell et al. 1991). It is not clear why this is, but it may
be explained by the relative scarcity of symptomatic
heterophoria at distance (Pickwell et al. 1991). It may also
be related to the different nature of decompensated
exophoria for distance fixation (divergence excess), which
tends to be well compensated one moment and then
suddenly to break down into an exotropia with suppression
(Evans 2007).
Fixation disparity tests are not without their critics.
Several workers have shown that the subjective fixation
disparity, detected as the offset of the Nonius markers, is
different to objective fixation disparity, detected by
measuring eye position (Jaschinski et al. 1999, Kertesz &
Lee 1987, Kommerell et al. 2000). The difference between
objective and subjective fixation disparity is minimised by
using a foveal fusion lock, as on the Mallett Unit
(Brautaset & Jennings 2006). The design details of
fixation disparity tests strongly influence the results
obtained (Dowley 1989), and this point is returned to
below.
Sheard’s criterion
Sheard’s criterion is often stated as specifying that the
fusional reserve that opposes the heterophoria should be
at least twice the heterophoria (Griffin & Grisham 2002).
In fact, Sheard quoted several criteria (Sheard 1930), but
it seems that it is the ‘twice the phoria’ rule which has
persisted. Sheard stressed that this should be to the blur
point in fusional reserve measurement, or if there is no
blur point then the break point. For example, if a patient
has 8⌬ of exophoria at near on cover testing then during
convergent fusional reserve testing (with base-out prisms),
he or she should not report blurring or diplopia until the
prism exceeds 16⌬.
There are problems with Sheard’s criterion. The size of
heterophoria varies depending on which dissociation test
is used (Casillas & Rosenfield 2006, Mallett 1966, Rainey
et al. 1998) and fusional reserves are also highly dependent
on the test conditions (Fowler et al. 1988, Stein et al.
1988). Experimental evidence suggests that Sheard’s
criterion is of some value, particularly for exophoria at
near (Sheedy & Saladin 1977, 1978). It is therefore useful
to measure the fusional reserves when decompensated
heterophoria is suspected, and a prism bar is the most
common method (Evans 2007) (Figure 3).
Percival’s criterion
Percival’s criterion predates Sheard’s and is limited in that
it does not take account of the heterophoria. Percival’s
criterion can be summarised as specifying that the
66
convergent and divergent fusional reserves (to blur point)
should not be disproportionate (Percival 1928). In
practice, the criterion is met if the lesser fusional reserve
is at least half of the greater. Percival emphasised the
likelihood of esophoria being associated with symptoms
(Percival 1928) and it is therefore fitting that later
research found Percival’s method to be of some value in
near esophoric cases (Sheedy & Saladin 1978).
Other methods
There are many other methods of determining whether to
prescribe or treat a heterophoria, and most of these are
discussed in the section on prescribing, below. Research
indicates that prism (vergence) adaptation is abnormal in
patients with decompensated heterophoria (Brautaset &
Jennings 2005, North & Henson 1981) and prism
adaptation may improve following eye exercises (North &
Henson 1992). However, an early study indicated that
prism adaptation may have limited value as a clinical test
(Pickwell & Kurtz 1986).
Vergence facility is a test that is not widely used in the UK
but which appears to be useful in detecting patients with
symptomatic heterophoria (Gall & Wick 2003). It was noted
in the introduction that decompensated heterophoria can be
associated with foveal suppression. The Mallett Foveal
Suppression Test is a useful tool for detecting this (Mallett
1988). A recent study provided norms for this test, showing
that statistically significant foveal suppression occurs when
a patient can read approximately one line further in the
test monocularly compared to under fused dichoptic conditions,
which is when foveal suppression will occur (Tang & Evans 2007).
Diagnostic occlusion (a trial period of occlusion) has also
been suggested as a method of detecting subtle cases of
symptomatic hyperphoria (Surdacki & Wick 1991). A
Figure 3. Fusional reserves can be measured with a prism bar.
The fusional reserve that opposes the heterophoria is measured first
(convergent, using base-out prisms, for exophoria), to blur point
(if present), break point, and then the prism is reduced until the
recovery of single vision.
 Optometric Prescribing for Decompensated Heterophoria

concern is that this might cause the binocular vision to

3. Is the cover test recovery rapid and smooth?
break down, although one study suggests that this is not
Yes or No If no, score +2 (+1 if borderline)
likely (Neikter 1994). Nonetheless, it would still be a
sensible precaution for patients undertaking this to be 4. Is the Mallett horiz aligning prism:
monitored closely. <1⌬ for patients under 40, or <2⌬ for patients over 40?
Yes or No If no, score +2
As noted elsewhere in this review, decompensated
heterophoria is likely to be associated with reduced 5. Is the Mallett aligning prism stable (Nonius strips
stereoacuity and a slight reduction in binocular visual stationary with any required prism)?
acuity. Although the differences that these tests detect Yes or No If no, score +1
are slight and not of great diagnostic use, they do help to
give the clinician the complete picture. 6. Using the polarised letters binocular status test,
is any foveal suppression < one line?

Combining methods Yes or No If no, score +2

Add up score so far and enter in right-hand column if score:

The literature reviewed above indicates that no single test <4 diagnose normal
is 100% effective at diagnosing decompensated >5 treat
4–5 continue down table adding to score so far
heterophoria. The situation is analogous to diagnosing
glaucoma, although it is somewhat easier in decompensated
heterophoria because of the likely presence of symptoms. 7. Sheard’s criterion:
Optometrists deal with the difficulties of diagnosing (a) measure the dissociated phoria (e.g., Maddox wing,
glaucoma by combining tests (eg discs, fields and prism cover test); record size & stability
(b) measure the fusional reserve opposing the heterophoria
pressures). This approach will also greatly increase their (i.e., convergent, or base out, in exophoria). Record as
diagnostic accuracy for decompensated heterophoria. An blur/break/recovery in Δ.
Is the blur point, or if no blur point the break point,
algorithm has been developed that is based on this [in (b)] at least twice the phoria [in (a)]?
principle (Evans 1997, 2007) and is reproduced in Table
Yes or No If no, score +2
3. Although this approach awaits experimental validation,
it is useful as an example of how symptoms and clinical 8. Percival’s criterion: measure the other fusional reserve
tests results can be combined. and compare the two blur points.
Is the smaller blur point more than half the larger
blur point?
Table 3. Scoring system for diagnosing decompensated heterophoria Yes or No If no, score +1
and binocular instability at near. This scoring algorithm is most
appropriate for horizontal heterophoria: for vertical heterophoria, if 9. When you measured the dissociated heterophoria,
aligning prism of 0.5⌬ or more is detected then, after checking trial was the result stable, or unstable (varying over a
frame alignment, measure the vertical dissociated phoria. If this is range of ±2⌬ or more) (e.g., during Maddox wing test,
more than the aligning prism and there are symptoms, then diagnose if the horiz phoria was 4Δ XOP and the arrow was
decompensated heterophoria but still complete the worksheet for any moving from 2 to 6, then the result is unstable)
horizontal phoria that may be present. Stable or Unstable If unstable, score +1

10. Using the fusional reserve measurements, add the

1. Does the patient have one or more of the symptoms of
decompensated heterophoria?
(Headache, aching eyes, diplopia, blurred vision, distortions,
reduced stereopsis, monocular comfort, sore eyes, general
irritation.)
If so, score +3 (+2 or +1 if borderline)
2. Is the patient orthophoric on cover testing?
Yes or No If no, score +1
score
divergent break point to the convergent break point.
Is the total (=fusional amplitude) at least 20⌬?
Yes or No If no, score +1
Add up total score (from both sections of table) and enter in
right hand column. If total score: <6 then diagnose
compensated heterophoria, if >5 diagnose decompensated
heterophoria or binocular instability.

(Reproduced with permission from Evans (2007).)

67
BJW Evans
Overview of the Management of
Decompensated Heterophoria
Introduction
The title of this review requires it to concentrate on
prescribing for decompensated heterophoria, but other
methods of dealing with decompensated heterophoria
should also be mentioned. In particular, many cases of
decompensated heterophoria can be treated successfully
using eye exercises. These are particularly suitable for
decompensated exophoria, with or without convergence
insufficiency, but can also be used for some cases of esophoria
(once latent hypermetropia has been excluded). Methods are
covered in detail in the optometric literature (Evans 2007).
It is very rare for decompensated heterophorias to require
surgery and these will be the very large deviations. But it
is important for cases that are not amenable or responsive
to treatment or correction by the community optometrist
to be referred for a second opinion. This may be from
another community optometrist specialising in binocular
vision anomalies or in a hospital eye unit.
The decision about how to manage decompensated
heterophoria usually depends on the type of heterophoria
and patient factors. The management of decompensated
heterophoria will now be considered in turn for different
types of heterophoria.
Hyperphoria and cyclophoria
If hyperphoria and/or cyclophoria is present then the
patient requires a very careful examination to search for
an incomitant deviation, particularly a superior oblique
palsy (Evans 2007). Hyperphoria is unusual and if a
hyperphoria changes significantly then this requires
referral. Community optometrists are more likely to
encounter long-standing cases which are often helped by a
small vertical prism, typically prescribed using the Mallett
Fixation Disparity Test (see below). Indeed, a previous
review concluded that ‘There seems to be unanimous
opinion that the vertical associated phoria is the best way
to prescribe vertical prism’ (Goss 1995).
It has been argued that decompensated cyclophoria is an
underdiagnosed condition (Wick & Ryan 1982). Cyclo-
deviations can be detected with the double Maddox rod
test (Evans 2007) and are more likely to be symptomatic
if there is a tipping of the Nonius markers on the Mallett
Fixation Disparity Test (Mallett 1988). The condition is
difficult to treat, but a binocular refraction of astigmatism
and correction of any hyperphoria may be helpful
(Rabbetts 1998).
68
Several authors have noted that the correction of small
vertical deviations often improves fusion (London & Wick
1987) and makes a previously decompensated horizontal
deviation compensated (Mallett 1988, Sheard 1923).
Esophoria
The first stage of managing decompensated esophoria in
children is usually a cycloplegic refraction and if
significant hypermetropia is found, then spectacles or
contact lenses are indicated. There is some debate over
whether the full cycloplegic findings should or should not
be prescribed. The present author’s view is that the only
dogma that should be followed is to beware of dogmatic
views! Two contrasting examples will be given to illustrate
the dangers of both the ‘always give full cyclo plus’ and the
‘always avoid full cyclo plus’ viewpoints.
In the first example, a parent brings a 4-year-old child to
the optometrist because she notices an eye turning
inwards every day when the child is tired. Pre-cycloplegic
cover testing reveals a significant (20⌬) esophoria at
distance and near, which breaks down on repeated
covering to an esotropia. Pre-cycloplegic retinoscopy
reveals +1.50DS each eye and cycloplegic retinoscopy
reveals +2.00DS. It is clear that if there is any chance of
controlling the eso-deviation and preventing a constant
esotropia from developing then the full cycloplegic plus
will need to be prescribed. Of course, other tests and
regular monitoring by the community optometrist will be
required.
In the second example, an 8-year-old attends for a routine
eye examination, with no reports from the parents of a
strabismus and no visual symptoms but occasional
headaches after school. Unaided acuities are normal in
each eye at distance and near and cover testing reveals a
small (4⌬) esophoria at distance and near with good
recovery; but causing an eso-fixation disparity (1⌬ base-
out aligning prism) on the Mallett Unit at distance and
near. Pre-cycloplegic retinoscopy reveals +1.50DS each
eye and excellent accommodation, but cycloplegic
retinoscopy reveals +4.00DS. If the full +4.00DS was
prescribed then this could cause a symptomatic exophoria
(this could be checked with post-cycloplegic testing) and
would be likely to cause the child difficulty in distance
vision. The author has seen cases like this where the full
plus has been prescribed by another practitioner and the
child either looks over the glasses or abandons them. A
more sensible approach by practitioners would be to
investigate, before cycloplegia, the effect of plus lenses
using the Mallett Fixation Disparity Test and cover testing
at distance and near. The minimum plus to eliminate the
fixation disparity is likely to help the headaches. Again,

other tests (eg accommodative lag) would be necessary
(Evans 2007), but the point of this example is that full
cycloplegic plus is not always necessary or desirable.
There is also a debate over whether it is possible to wean
hypermetropic children with an eso-deviation out of
spectacles by gradually reducing the plus correction
(Hutcheson et al. 2003, Lambert & Lynn 2006, Mulvihill et
al. 2000, Rutstein & Marsh-Tootle 1998, Somer et al.
2006). After the pre-school years, it is unlikely that there
will be a very large change in hypermetropia, so children
with significant hypermetropia should not be led to believe
that they will be able to manage for long periods of time
without spectacles (Rutstein & Marsh-Tootle 1998).
Even in cases where there is no hypermetropia, if there is
a decompensated esophoria at near then plus lenses,
typically in the form of bifocals, are a valuable treatment
option. In myopic children with near esophoria, bifocals
seem to reduce the rate of progression of myopia (Goss
1994), although the effect is modest (Fulk et al. 2000).
Bifocals for children should be fitted with the segment
position high, typically at the lower edge of the pupil, and
varifocals are an option (Evans 2007).
If older adults become esophoric then this should arouse
different concerns because the cause could be a lateral
rectus palsy which might have a vascular aetiology in an
older patient (Santiago & Rosenbaum 1999). Although
most cases spontaneously recover, the risk of underlying
pathology (King et al. 1995) means that all cases should be
referred promptly.
Exophoria
Most cases of decompensated heterophoria encountered
in optometric practice will be near exophoria. This is
sometimes associated with the onset of myopia and then a
refractive correction is the appropriate management. In
some cases the cause of decompensation can be attributed
to a change in the working environment (as discussed
above) and the role of the optometrist is to give advice
about changes to the working environment. Changes in
illumination, working distance, or the position of a
computer monitor can all cause problems in certain
people (Jaschinski 1997, Jaschinski et al. 1998,
Jaschinski-Kruza 1993, Pickwell et al. 1987a, 1987c, Yekta
et al. 1987).
Decompensated exophoria, particularly at near, often
responds to treatment with eye exercises, and these can be
effective at any age (Aziz et al. 2006, Evans 2000),
although they may be harder for older patients (Winn et al.
1994). If a patient is motivated to do eye exercises then
these will usually be the treatment of choice (Evans 2007).
69
Optometric Prescribing for Decompensated Heterophoria
Some patients lack the time or motivation for eye
exercises and in these cases refractive modification or
prisms are often helpful.
Refractive modification involves ‘over-minussing’, and this
is a valuable approach which seems to be underused in
optometric practice. If, for example, an emmetropic pre-
presbyopic patient is prescribed minus lenses then the
patient will accommodate, which will induce
accommodative convergence, which will reduce the exo-
deviation. The efficacy of this approach is well established
(Caltrider & Jampolsky 1983, Rowe et al. 2008, Rutstein et
al. 1989, San et al. 2001) and it does not induce
significant changes in refractive error (Rutstein et al.
1989). Success is limited by the degree of over-minus that
is required, available accommodation and AC/A ratio
(Evans 2007). The methods for prescribing are described
in the next section.
In cases that are not amenable to eye exercises or
refractive modification then base-in prisms can be useful.
For example, base-in prisms can help older patients with
decompensated exophoria or children with combined
accommodative insufficiency and convergence
insufficiency (who will need the prisms to be combined
with plus lenses). Methods of prescribing will now be
described.
Methods of Prescribing for Decompensated
Heterophoria
Mallett Fixation Disparity Test
It was noted above that the aligning prism obtained with
the Mallett Unit is believed to represent the extent of the
uncompensated part of the imbalance (Mallett 1988). It
therefore follows that prescribing the aligning prism or
sphere will make a decompensated heterophoria become
compensated, and this is usually the case. There has been
one small randomised controlled trial demonstrating the
efficacy of prisms prescribed with the Mallett Unit (Payne
et al. 1974).
Most studies of decompensated heterophoria have
concentrated on symptoms, since these are the factor to
which eye care practitioners understandably attach
greatest importance (O’Leary & Evans 2003). But visual
performance is also important to patients and a
randomised controlled trial showed that prisms prescribed
with the Mallett Near Vision Unit significantly improve
rate of reading when they are 2⌬ or more (O’Leary &
Evans 2003). This supports previous work showing a small
improvement in binocular visual acuity with the Mallett
aligning prism (Jenkins et al. 1994a, 1994b, 1995).
BJW Evans
The clinical method with the Mallett Unit is
straightforward. The practitioner should ask the patient
whether one or both of the Nonius markers (coloured
lines) ever moves, rather than just asking if they are
aligned (Karania & Evans 2006). If there is movement or
misalignment, then prisms or spheres (see above) are
added to determine the minimum power that eliminates
the fixation disparity. It is important that the test
simulates everyday viewing conditions as closely as
possible (Mallett 1988). The room lighting should be
turned up to counteract the effect of the polarised visors,
the patient should be in ‘free space’ (no phoropter and
ideally no trial frame that greatly restricts viewing), and
hand-held (not rotary) prisms should be introduced
gradually in initially 0.5⌬ steps with the patient reading
text between prisms so that he or she adapts fully. The
patient should be encouraged to look at the X of the OXO.
Although patients who need an aligning prism to eliminate
a fixation disparity on the Mallett Unit are more likely to
have symptoms, this does not mean that they all require
correction. In some studies the questionnaires used to
detect symptoms have been quite sensitive, for example
asking if patients have sore or tired eyes if they read for a
long time (Karania & Evans 2006). Some patients may
answer yes to this question, but if they hardly ever read for
a long time then it may not be appropriate to recommend
an intervention solely on the basis of this symptom. The
decision about whether to prescribe or treat a
decompensated heterophoria can only be made on an
individual basis, taking account of all of the test results,
the symptoms, and the patient’s visual habits and
requirements. The data in Figure 4 indicate that patients
who require higher degrees of aligning prism are likely to
have more severe symptoms, which will help the
practitioner to provide appropriate advice.
An advantage of the Mallett Fixation Disparity Test is that
it is as easy to determine the aligning sphere as it is to
determine the aligning prism. When refractive modification
is used, for example minus lenses to correct decompensated
exophoria, it is usual to try to reduce the prescription over
time. Typically, the child is monitored every 3 or 6 months
and the prescription is reduced each time if the proposed
new prescription does not result in a fixation disparity or
poor cover test recovery (Evans 2007). Spectacles for this
purpose have been described as ‘exercise glasses’ and it is
advisable to annotate the prescription to this effect, so
that if the patient consults a different practitioner in the
future then the purpose of the glasses is apparent.
When spectacles are prescribed to correct a
decompensated heterophoria using the Mallett Unit it is
rare for patients to return needing a stronger correction
for their heterophoria. If this occurs it should raise the
70
index of suspicion for pathology being present. It is
interesting that the required prism does not usually
increase since, if a patient with a compensated
heterophoria looks through a prism for a few minutes,
then typically heterophoria increases by the amount of the
prism. This is called prism (or vergence) adaptation
(Henson & North 1980). Patients with abnormal binocular
vision do not exhibit normal prism adaptation (North &
Henson 1981) and this is probably a part of the
explanation for them developing a binocular vision
anomaly. A desirable consequence of this is that prisms or
spheres will usually be effective at correcting their
problems.
As noted above, methods based on fixation disparity,
including the Mallett Unit, are not without their critics.
But there is quite convincing evidence of the relationship
between the Mallett Fixation Disparity Test result and
symptoms (Jenkins et al. 1989, Karania & Evans 2006,
Pickwell et al. 1991, Yekta et al. 1989). A significant
Mallett aligning prism also improves binocular visual
acuity (Jenkins et al. 1994a, 1994b, 1995) and speed of
reading (O’Leary & Evans 2006). Furthermore, fixation
disparity has been shown to be associated with reduced
stereoacuity (Cole & Boisvert 1974, Ukwade et al. 2003) and
an abnormal visual evoked potential (Suter et al. 1993).
However, although the Mallett test usually works well for
near vision, it is not infallible, and the result should be
checked with other methods, as indicated below.
Decompensated heterophoria for distance vision is rare,
but prescribing in these cases can be challenging. These
cases are particularly likely to require a multi-method
approach, including the techniques described below.
Figure 4. Graph showing the relationship between the severity of
symptoms and the degree of horizontal aligning prism (prism
diopters) at near. The error bars represent the standard error of the
mean (SEM). The number of participants (N; shown above the
scale for the horizontal axis) is small for higher degrees of aligning
prism and this may explain why the SEM increases. (Reproduced
with permission from Karania & Evans (2006).)

Sheard’s criterion
Sheard’s criterion, described above, can be used to
prescribe prisms as well as to diagnose decompensated
heterophoria. The notion is that a prism is required that
will just cause the patient to pass Sheard’s criterion: to
reduce the heterophoria to less than half the opposing
fusional reserve. It should be remembered that the prism
will also increase the fusional reserve. So, if patients have
an exophoria of 8⌬ and convergent reserves of 10⌬ then
they would need a prism of 2⌬ base-in. This prism should
decrease the exophoria to 6⌬ and increase the convergent
reserves to 12⌬, so Sheard’s criterion would just be met.
The randomised controlled trial of the prism prescribed
with the Mallett Unit, although supportive of the Mallett
Unit, found that ‘Based on our results, one would not
expect to find a significant preference for prism prescribed
according to Sheard’s criterion’ (Payne et al. 1974). An
earlier small randomised controlled trial found the prism
prescribed using Sheard’s criterion to be of limited
success (Worrell et al. 1971) and a recent larger
randomised controlled trial found prism prescribed in this
way to be ineffective (Scheiman et al. 2005).
Percival’s criterion
Rather like with Sheard’s criterion, patients who fail
Percival’s criterion (described above) could be prescribed
a prism of a magnitude that would cause them to pass
Percival’s criterion (Griffin & Grisham 2002). The author
knows of no experimental validation of this method of
prescribing and a PubMed search revealed no relevant
publications. Since Percival’s approach does not take
account of the heterophoria, it seems limited and will not
be described further.
Other methods
One approach that has been fairly popular in North
America is to compare the patient’s results with ‘norms’ or
‘expecteds’, the most commonly used of which are
‘Morgan’s expected criteria’ (Griffin & Grisham 2002).
The idea is that a prism or sphere is prescribed that will
reduce the heterophoria to make it within the normal
range. The difficulty with this approach is that not all
people are ‘normal’, or indeed should necessarily be made
‘normal’. Nor should it be expected that to make a
person’s clinical results lie within the normal range will
necessarily make symptoms resolve.
71
Optometric Prescribing for Decompensated Heterophoria
Griffin & Grisham also described a ‘clinical wisdom
criterion’, the origin of which they described as obscure. A
patient with a symptomatic exophoria is prescribed a
prism of one-third of the angle of deviation and those with
esophoria or hyperphoria are given the sphere or prism
that fully corrects the deviation (Griffin & Grisham 2002).
The present author has found no experimental validation
of either of these approaches.
For those of a mathematical disposition, a fuller
understanding of these criteria and of individual cases can
be obtained by graphical methods. Although these are
time-consuming, they do help interested clinicians to gain
a deeper understanding and are described in detail in an
informative book by Goss (1995).
Another graphical approach is to plot the fixation disparity
curve. This is a graph of the aligning prism versus fixation
disparity and the resulting fixation disparity curve can be
described as one of four types (Ogle et al. 1949). However,
fixation disparity curves have been shown to be unreliable
(Wildsoet & Cameron 1985) and they may be especially so
in patients with binocular stress (Cooper et al. 1981). With
most binocular vision tests, differences in the design of
tests mean that different instruments produce different
results and this is true of fixation disparity curves (Goss &
Patel 1995, Ngan et al. 2005). In particular, changes in the
design of the fusional lock change the fixation disparity
curve in symptomatic patients (Saladin & Carr 1983). One
of the few studies to measure the fixation disparity curve
with the Mallett Unit found that it was not useful for
predicting symptoms, but the aligning prism was (Yekta et
al. 1989). This study measured the fixation disparity by
modifying the Mallett Unit so that the angular
misalignment of the Nonius markers could be determined.
The degree of fixation disparity was a useful predictor of
symptoms, but was no better than the aligning prism,
supporting the conventional use of this instrument (Yekta
et al. 1989).
The instruments that are used most often to measure the
actual fixation disparity and to determine the fixation
disparity curve are instruments like the Sheedy
Disparometer, which do not have a central fusion lock
(Sheedy & Saladin 1975). The advantage of such a design
is that the minimal separation between the Nonius
markers facilitates the measurement of the fixation
disparity, but they have the disadvantage of not simulating
natural viewing conditions. The foveal area of the visual
field has the greatest cortical representation and one
might therefore expect that a foveal fusion lock is
essential for a binocular vision test that aims to determine
the situation under normal viewing conditions.
Experimental evidence supports this hypothesis. Fixation
BJW Evans
disparity measurements are smaller and more precise
when there is a central and peripheral fusion lock (Ukwade
2000) and a central fusion lock stabilises the Nonius
markers (Wildsoet & Cameron 1985).
In northern continental Europe the Zeiss Polatest method
is sometimes used for prescribing prisms (Cagnolati
1991). This approach involves a battery of tests, including
fixation disparity tests. Several of these tests lack the
detailed foveal fusion lock of the Mallett Unit and this may
be why the Polatest approach has been criticised for
overprescribing prisms (Lang 1994).
Recently, a German group has suggested a new method of
prescribing prisms (Otto et al. 2008). This method is
simply to have the patient adjust a rotary prism to find the
‘prism that appears most comfortable’. The authors called
this the ‘comfortable prism’, although they have not
demonstrated that the prism would improve comfort in
everyday life. They argue that the prism is chosen ‘under
natural viewing conditions’, although their experimental
conditions involve a fixed head position, restricted field of
view in one eye (through a rotary prism), dim illumination
and the subject constantly adjusting a rotary prism. Not
surprisingly, the prism that the subject selected was
different to the dissociated heterophoria or aligning
prism. This method indicated that nearly all the
participants required a prism, which raises doubts over the
clinical value of this approach. However, the method of
measuring the aligning prism in this study, which
attempted to simulate but did not use a Mallett Unit, also
revealed an unusually high proportion of cases with an
aligning prism of atypically high values. Indeed, the
aligning prism appeared to be of a similar magnitude to
the dissociated heterophoria, which is contrary to the
literature (Goss 1995, Yekta et al. 1989). The researchers
did not enquire whether the participants had asthenopia,
but since they were not selected for this it seems unlikely
that there would be a high proportion of symptomatic
patients, making the results even more surprising.
72
Conclusions
Only a small proportion of patients with heterophoria
suffer decompensation and require an intervention. In
many cases modification to the working environment or
appropriate correction of the refractive error is all that is
required and eye exercises are an effective intervention for
others. A few cases require correction with refractive
modification or prisms and in the UK the Mallett Fixation
Disparity Test has become a very popular method of
prescribing for these cases. It is reassuring that the
Mallett instrument, unlike some other methods, only
indicates that a correction is required for a small
proportion of cases of heterophoria who are usually
symptomatic and the prescriptions that result are usually
small (Jenkins et al. 1989). Since these prisms seem to be
effective at alleviating symptoms (Payne et al. 1974) and
improving visual performance (Jenkins et al. 1994a,
1994b, 1995, O’Leary & Evans 2006) this suggests that
the instrument identifies an effective prism. Although
longitudinal trials are not available, clinical experience
suggests that the prism strength does not need to be
subsequently increased in most cases. Indeed, when
spherical refractive modification is used in children it is
normal to try to reduce the prescription over time (Evans
2007).
The diagnosis of decompensated heterophoria should only
take place once a full eye examination has been
completed, including relevant orthoptic tests. The Mallett
Fixation Disparity Test is one of the most useful of these
orthoptic tests, but should be used in conjunction with
other tests. For example, it is useful to measure the
fusional reserves to determine the adequacy of the
vergence reserve that opposes the heterophoria. Cover
testing and motility testing are essential in any
investigation of binocular vision anomalies.
It is becoming increasingly common for community
optometrists to specialise, and the College of
Optometrists Diploma in Orthoptics was the first
postgraduate specialist qualification in orthoptics in the
UK. The syllabus was modernised in 2000 and can be
obtained from the College of Optometrists. The diploma is
gained in two stages, or Certificates. The first of these
includes optometric prescribing for decompensated
heterophoria. Guides on how to prepare for the various
sections can be obtained from the author.

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 Optometric Prescribing for Decompensated Heterophoria

Multiple Choice Questions

This paper is reference C-9040. Three credits are available. Please use the inserted answer sheet. Copies can be obtained from Optometry
in Practice Administration, PO Box 6, Skelmersdale, Lanchashire WN8 9FW. There is only one correct answer for each question.

1. Which one of the following is not a factor which 6. In a pre-presbyope, what is the minimum aligning
could cause a heterophoria to decompensate? prism with the near Mallett Unit that would indicate
(a) Starting to work in dim illumination a significant likelihood of a symptomatic horizontal
(b) Low fusional reserves following illness heterophoria?
(c) Cataract (a) 0.5⌬
(d) High fusional reserve opposing the heterophoria (b) 1⌬
(c) 2⌬
2. Which one of the following is least likely to be a (d) 4⌬
symptom of decompensated heterophoria?
(a) Nausea 7. Which of the following is the most typical example of
(b) Headache Sheard’s criterion?
(c) Blurring (a) A patient with 8⌬ exophoria should have a convergent
(d) Aching eyes fusional reserve of at least 8⌬
(b) A patient with 8⌬ exophoria should have a convergent
3. Using the Institute of Optometry Cover Test Analysis fusional reserve of at least 16⌬
(IOCTA) method of grading cover test recovery, (c) A patient with 8⌬ exophoria should have a divergent
which one of the following represents Grade 3 fusional reserve of at least 8⌬
recovery? (d) A patient with 8⌬ exophoria should have a divergent
(a) Slow/jerky and breaks down with repeat covering, or fusional reserve of at least 16⌬
only recovers after a blink
(b) Definitely slow/jerky but not breaking down 8. Which of the following statements about hyperphoria
(c) Slightly slow/jerky is not true?
(d) Breaks down readily after 1–3 covers (a) It can be a sign of incomitancy
(b) Long-standing cases are often helped by small
4. Which of the following best describes the aligning vertical prisms
prism? (c) A significant change in the magnitude of the
(a) The maximum vernier misalignment of the Nonius hyperphoria would be grounds for referral
markers in a fixation disparity test (d) Correction of a hyperphoria is unlikely to help a
(b) The maximum prism to eliminate the fixation horizontally decompensated heterophoria
disparity
(c) The minimum vernier misalignment of the Nonius 9. Which of the following statements is most strongly
markers in a fixation disparity test supported in the paper?
(d) The minimum prism to eliminate the fixation (a) In any child with esophoria, always give maximum
disparity cycloplegic plus
(b) In any child with esophoria, cycloplegic refraction is
5. Which of the following statements about the Mallett not usually indicated
Fixation Disparity Test is not true? (c) In any child with esophoria, always suspect
(a) Room lighting should be increased to counteract the hypermetropia
effect of the polarised filters (d) In any child with esophoria, prescribe base-out prisms
(b) The person should be directed to look directly at one
of the Nonius strips
(c) The practitioner should avoid using a phoropter
(refractor head)
(d) The OXO text is a central fusion lock

77
 BJW Evans

10. Which of the following is least likely to be an 14. With which one of the following is fixation disparity
effective intervention for decompensated exophoria least likely to be associated?
at near? (a) Reduced stereoacuity
(a) Exercises to increase the convergent fusional (b) Reduced binocular visual acuity
reserves (c) Reduced speed of reading
(b) Over-minus lenses (d) Complete third-nerve palsy
(c) Base-in prisms
(d) Varifocals 15. Which of the following statements is true?
(a) Convergent fusional reserves are always measured
11. Which of the following statements about prescribing before divergent reserves
with the Mallett Fixation Disparity Test is most (b) Convergent fusional reserves are measured with
accurate? base-out prisms
(a) The test is more useful for near vision problems than (c) The blur point is measured after the recovery point
for distance vision anomalies (d) The blur point can always be measured
(b) If an aligning prism is found, then this should always
be prescribed
(c) If a fixation disparity is found, then this should
always be prescribed
(d) The test eliminates the need for other binocular
vision tests

12. Which of the following is not a method of

determining the prism power that would help in a
case of decompensated heterophoria?
(a) Sheard’s criterion
(b) Zeiss Polatest
(c) Sheedy Disparometer
(d) Double Maddox rod test

13. Which of the following is not true about fixation

disparity curves?
(a) They are usually measured on instruments that do
not have a foveal fusion lock
(b) They are a plot of the fusional reserves versus the
fixation disparity
(c) There are four main types
(d) They cannot be readily measured with the Mallett
Unit

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