HETEROPHORIA

University of Gondar
Department of Optometry
By Nebiyat Feleke

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 Unit Outline:

• Binocular vision anomalies

• Definitions of Heterophoria
• Classification of phoria
• Measurement of heterophoria
• Investigation
• Treatment of phoria

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 Learning objectives

By the end of this session ,the student will be able to:

Define Heterophoria
Describe the clinical methods of classifying phoria

Identify & explain the different measurement

techniques

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 Introduction
Binocular vision anomalies : broadly classified
1. Anomalies in which there is binocular vision but
maintained due to considerable amount of
stress on the visual system.
a) Fusional vergence dysfunction
b) Accommodation anomalies
c) Fixation disparity
d) Heterophoria
2. Anomalies in which binocular vision is absent
=> e.g. strabismus
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 Definition of heterophoria

• The relative misalignment of the visual axis when

fusional convergence is blocked.
• The change in relative position of the eyes
observed when the possibility of binocular fusion
is removed.

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• The tendency for eyes to drift is a normal
binocular condition, but there are tolerances.
• Measured in prism dioptres 7∆ = 4°
• Everyone has phoria if look closely enough –
mostly well controlled – compensated.
• 5-10% of phorias which do arise problems
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• in a completely dark environment, then the visual
system has no feedback that can be used to
control ocular alignment.
• The eyes are free to deviate, in most cases they
deviate.
• the eyes move to their resting position
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 • Vergence is influenced by several factors,

including an awareness of the distance of the

object (proximal vergence),

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 • Cross linking with the accommodative system
(accommodative vergence) and the fine tuning of
ocular alignment during the fusion of each
monocular image into a single percept (fusional
vergence).
 When an eye is covered, for example during a
cover test, there is no fusional vergence and the
eye behind the cover is likely to revert towards the
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resting position 9
 Schematic illustration of resting position of
vergence system, divergence, and convergence

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 Classification

• Heterophoria can be classified clinically by :

The direction of deviation

Fixation distance
compensation
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 1. Direction of deviation

A.EXOPHORIA

• Eyes tend to drift out when possibility of fusional convergence

is removed.

i.e. when eyes are covered, they drift out.

• Recovery movement is easier to see as it is faster.

• should be symmetrical recovery movement in amplitude,

speed and direction:
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 Direction of deviation …

b.Esophoria
• Eyes tend to drift in when possibility of
fusional convergence is removed. i.e. when
eyes are covered, they drift in

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 Esophoria

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 Exophoria

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 c. Hyperphoria

Visual axes vertically misaligned when the eyes are dissociated

Presume to be incomitant. Usually related to muscle
weaknesses. Suspicious.
Rarely occur in isolation. If due to mechanical factors, likely to
also have a horizontal phoria and cyclophoria.
R hyperphoria = RE will go up under the cover, LE will go down

L hyperphoria = LE will go up under the cover, RE will go down

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 d. Cyclophoria
The eye rotate about the visual axis when dissociated
Not normally on its own – also with horizontal and vertical phoria.
If prescribe large cyl out of axis – can induce cyclophoria.
Inferior and superior oblique muscles cause this.
Obloquies cause torsion = rotation
What can be done? If sufficiently decompensated = surgery?
Incyclophoria - top of primary vertical meridian rotates nasally
Excyclophoria - top of primary vertical meridian rotates temporally

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 Less common vertical phorias

• Kataphoria – a tendency of the visual axes of

both eyes to deviate below the horizontal

plane , in the absence of a stimulus to fusion.

( Very rare)
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 Dissociated vertical divergence

• Abbreviated as DVD

• on dissociation of either eye ,the eye behind the

cover deviates upward but reverts to its fixating
position when dissociation ceases
The condition can occur either as an isolated phenomena
or be associated with strabismus or latent squint

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 Fixation distance
 Esophoria

Divergence weakness =distance ESOPs greater than for

near vision
Convergence excess= higher degree of esophoria for near
vision than for distance
Basic esophoria – the degree of phoria does not differ
significantly with the fixation distance
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 Fixation distance

Exophoria
Convergence weakness = higher degree of exop
for near vision than for distance
Divergence excess – higher degree of deviation
for distance vision than for near vision
Basic exop= almost same at distance and near
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 Compensation
Third method of classifying phoria and clinically the most
important classification is as either compensated or
decompensated
In most cases it is not harmful and causes no symptoms.

In this situation it is described as “compensated”

abnormal stresses on the binocular vision which results in

symptoms and the hetrophoria is described as being

“decompensated”
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 Factors affecting compensation
a. Stress on the visual system

I. excessive use of vision under adverse conditions

- work held to close to the eyes for long period of time

- poor illumination or contrast

- tasks which dissociate acomm .and convergence

II. Accommodative anomalies

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 Factors cont’d

iii. Refractive error

iV. Low fusional reserves
b.Stress on the well-being of the patient
- poor general health
- worry and anxiety
- old age
- emotional problems
- adverse drug effects
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 Comitancy

a. Comitant Phoria – the angle of deviation

remains the same for every position of gaze –
with constant fixation distance.

Due to functional problem above midbrain –

not a serious systemic condition or diseases
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 Comitancy ////

b. Incomitant phoria – the angle of deviation

changes for different positions of gaze and
depending on which eye is fixating

Caused by disease process i.e. damage to

nerve or muscles
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