deviation

1. Vertical Deviations

2. Hyperphoria
• Hyperphoria is a latent deviation of one eye upwards
• In hypophoria the deviation is downwards and as
hypophoria of one can be regarded as hyperphoria of
the other
• The term hypophoria is not generally used and the
convention is to refer to whichever is the hyperphoric
eye.

3. RE LE
Non-dissociated state
cover
uncover
LE moves up
LE moves down
Left hyperphoria = Right hypophoria

4. RE LE
Non-dissociated state
cover
uncover
RE moves up
RE moves down
Right hyperphoria = Left hypophoria

5. Aetiology
Hyperphoria is often a secondary condition associated with
the following:
I) Horizontal heterophoria
• high degrees of comitant eso- or exophoria are often
accompanied by a small vertical component.
II) Incomitant deviations
paretic conditions involving the elevator or depressor
may begin as hyperphoria and later develop into a
squint.
Congenital incomitant deviations are often associated
with vertical deviations but symptoms are usually less
severe.

6. Aetiology
III) Poor fitting spectacles can often introduce
vertical prism and can induce a heterophoria.
Usually the Px will adapt quite quickly to the
presence of this prism and so the hyperphoria
may reduce only to reappear when the spectacles
are removed are straightened.

7. • Primary hyperphoria is seldom > 3∆
• generally considered to be due to slight
anatomical misalignments of the eyes and/or
orbits or muscle insertions.
• Vertical hyperphoria is not associated with the
convergence system in the way horizontal
heterophorias are and therefore do not tend to
differ between near and distance fixation.
• Pxs are less tolerant to vertical deviations and
decompensation can occur.
Aetiology

8. Investigation
• I) Symptoms
• these can be very marked in hyperphoria, even when
the magnitude is low.
• - frontal headache, diplopia, ocular discomfort or pain
• There can be a head tilt which helps alleviate the
symptoms of diplopia, as does the closure of one eye.
•
• II) Motility test
• should always be undertaken with close observation of
the eyes and attention to any reports by the Px of
increased regions of diplopia.
•

9. III) Refraction
Pay close attention to the binocular balancing of
the prescription.
An unbalanced correction can often be the cause
of hyperphoria.
IV) Compensation assessment
cover test, TIB test and fixation disparity useful in
the assessment of a vertical heterophoria.
Investigation

10. Management
I) REMOVAL OF THE CAUSE OF DECOMPENSATION
II) REFRACTIVE CORRECTION
in many cases proper refraction and binocular balancing will
alleviate the hyperphoria without any form of treatment
necessary.
Sometimes the TIB test will reveal a vertical misalignment
initially, but this is corrected when binocular balancing is
performed.
In cases of marked anisometropia where no correction has
previously been worn a partial correction of the more
hyperopic eye may prevent disturbance by vertical prismatic
The correction is reduced in the more hyperopic eye until the
vertical phoria is compensated when looking a little above or
below the optical centres.

11. III) ORTHOPTIC TREATMENT
Exercising the vertical fusional reserves does not seem
very useful.
IV) RELIEVING PRISMS
most primary hyperphoria can be relieved by small vertical
prisms.
The smallest prism that will level the letters in the TIB test or
the Mallet Unit may be used to prescribe the smallest prism
that alleviates the fixation disparity.
It is usual to divide the prism power between the two lenses.
Management

12. V) REFERRAL
incomitant hyperphoria of recent onset should be
referred for medical treatment.
Where there is a high degree of hyperphoria or
there is a congenital incomitancy surgical relief
may be considered.
Management

13. Dissociated Vertical Deviation
• This is a comparatively rare anomaly (also known as
Alternating Sursumduction) and can be mistaken for
hyperphoria.
• It is detected when the eyes are dissociated, the
covered eye deviates slowly upwards possibly by as
much as 25∆.
• This differs from hyperphoria in whichever eye is
covered there is an upward movement behind the
cover. When the eye is uncovered the eye moves
slowly down again to take up fixation.

14. RE LE
cover
uncover
LE moves up
LE moves down
RE LE
RE moves up
RE moves down
Dissociated Vertical Deviation