This document discusses various tests and classifications for eye alignment. There are four main types of alignment tests: cover tests, corneal reflex tests, dissimilar image tests, and dissimilar target tests. The cover test is the most commonly used test and can accurately measure deviations. Eye alignment is also assessed in secondary positions including near fixation, cardinal positions, and midline positions. Abnormalities in secondary positions may indicate conditions like convergence insufficiency. Classification of eye alignment includes categories like orthophoria, heterophoria, and heterotropia as well as patterns like A or V patterns.

1. 1
Copyright Information goes here Company Proprietary and Confidential
Alignement
Tukezban Huseynova, MD
Specialist in Strabismus and Refractive Cornea,
Briz-L Eye Clinic, Baku, Azerbaijan
Tukezban@gmail.com

2. 2
Copyright Information goes here Company Proprietary and Confidential
Primary Position

3. 3
Copyright Information goes here Company Proprietary and Confidential
Classification
• Orthophoria: The eyes are perfectly aligned, and no deviation
occurs, even when the fusion reflex is disrupted.
• Heterophoria and Heterotropia: Misalignment
compensated for by the fusion reflex keeps the deviation in heterophoria
latent. Manifest misalignment is heterotropia.
- Horizontal
- Vertical
- Torsional

4. 4
Copyright Information goes here Company Proprietary and Confidential
Determination
There are four basic types of alignment tests which
determine the alignement in a whole.
• The various cover tests
• The corneal reflex tests,
• The dissimilar image tests
• The dissimilar target tests.

5. 5
Copyright Information goes here Company Proprietary and Confidential
Determination
Cover Test
• Which depend on the fixation reflex
• Advantages of cover testing include:
- a high degree of interobserver repeatability,
- easy quantification using prisms, and
- the ability to accurately measure the angle of deviation in
all fields of gaze.

6. 6
Copyright Information goes here Company Proprietary and Confidential
Determination
Cover Test

7. 7
Copyright Information goes here Company Proprietary and Confidential
Determination
Cover Test
• Cover–uncover test

8. 8
Copyright Information goes here Company Proprietary and Confidential
Determination
Cover Test
• Alternate cover test.

9. 9
Copyright Information goes here Company Proprietary and Confidential
Determination
Corneal Reflex Test
• Studying the reflection of an examining light provides information
regarding the alignment of the eyes in patients who cannot
cooperate sufficiently to perform the alternate cover test or who lack
fixation ability due to amblyopia.
• There are two kind of tests according to corneal reflex of the eyes:
-- Hirshberg test
-- Krimsky test

10. 10
Copyright Information goes here Company Proprietary and Confidential
Determination
Corneal Reflex Test
• Hirschberg corneal
reflex test
• Krimsky test

11. 11
Copyright Information goes here Company Proprietary and Confidential
Determination
Corneal Reflex Test

12. 12
Copyright Information goes here Company Proprietary and Confidential
Determination
Corneal Reflex Test
• Krimsky corneal reflex test. A. Congenital esotropic
infant. B. Measuring esotropic angle.

13. 13
Copyright Information goes here Company Proprietary and Confidential
Determination
Dissimilar images test
• The same fixation target, which is simultaneously
presented to each eye, is converted into dissimilar
images on the right and the left retina for the
purpose of making fusion difficult or impossible.

14. 14
Copyright Information goes here Company Proprietary and Confidential
Determination
Dissimilar images test
• Maddox Wing
Maddox Wing dissociates the eyes for near fixation (1/3m) and measures
heterophoria. Measurements are made as follows:
-The horizontal deviation is measured by asking the patient to which
number the white arrow points.
-The vertical deviation is measured by asking the patient which number
the the red arrow interests.
-The amount of cyclophoria is determined by asking the patient to move
the red arrow so that it is parallel with the horizontal row of numbers.

15. 15
Copyright Information goes here Company Proprietary and Confidential
Determination
Dissimilar images test
• Maddox Wing
IncycloExcyclo
Left Hypertrophy
XF EF
Right Hypertrophy

16. 16
Copyright Information goes here Company Proprietary and Confidential
Determination
Dissimilar images test
• Maddox rod
Maddox rod consists of a series of fused cylindrical red glass rod which
convert the light into a red streak.

17. 17
Copyright Information goes here Company Proprietary and Confidential
Determination
Dissimilar images test
• Maddox rod

18. 18
Copyright Information goes here Company Proprietary and Confidential
Determination
Dissimilar images test
• Maddox rod
Normal
Xt
Et

19. 19
Copyright Information goes here Company Proprietary and Confidential
Secondary Positions

20. 20
Copyright Information goes here Company Proprietary and Confidential
• The three secondary positions are
near fixation, cardinal positions,
and midline position.

21. 21
Copyright Information goes here Company Proprietary and Confidential
Near fixation
• The purpose of investigating near fixation is
to study the effect that the convergence
associated with accommodation (synkinetic
near reflex) has on the alignment of the eyes.

22. 22
Copyright Information goes here Company Proprietary and Confidential
Near fixation
Determination
• The near point usually chosen to study the near alignment is 0.33
meter from the eyes.
• The test must be conducted so that the accommodation is
stimulated.
• The only satisfactory tests for the near position are the cover test
(cover–uncover, alternate cover, and simultaneous prism and cover).
• To stimulate accommodation, +3.00 lenses are inserted before each
eye, simulating a test performed at 0.33 meter.

23. 23
Copyright Information goes here Company Proprietary and Confidential
Near fixation
Classification
The classifications of near fixation are as follows.
Normal. The distant (primary position) and near position alignment
are comparable.
Abnormal. The distant and near position alignment are not
comparable:
- Convergence excess: greater esodeviation at near than at distance
- Convergence insufficiency: greater exodeviation at near than at
distance
- Divergence excess: greater exodeviation at distance than at near
- Divergence insufficiency: greater esodeviation at distance than at
near

24. 24
Copyright Information goes here Company Proprietary and Confidential
Cardinal Positions
Classification
Normal. The horizontal and the vertical plane alignment are
orthophoric in all six cardinal positions.
Abnormal. There is a horizontal and/or a vertical plane
misalignment in one or all of the six cardinal positions.
Concomitant. The deviation is identical in all positions.
Horizontal
Esodeviation
Exodeviation
Vertical
Right hyperdeviation
Left hyperdeviation

25. 25
Copyright Information goes here Company Proprietary and Confidential
Cardinal Positions
Classification
Abnormal. There is a horizontal and/or a vertical plane
misalignment in one or all of the six cardinal positions.
Nonconcomitant. The deviation varies in different gaze
positions.
Horizontal
Esodeviation
Exodeviation
Vertical
Right hyperdeviation
Left hyperdeviation

26. 26
Copyright Information goes here Company Proprietary and Confidential
Cardinal Positions

27. 27
Copyright Information goes here Company Proprietary and Confidential
Cardinal Positions
• The purpose of studying these six positions
is to compare the prime mover of the one
eye for each of these positions with the
comparable prime mover of the other eye.
(Only the horizontal and vertical planes are
tested; the torsional plane is disregarded).

28. 28
Copyright Information goes here Company Proprietary and Confidential
Midline Positions
• Both horizontal and
vertical plane deviations
are studied in the up and
down midline positions.

29. 29
Copyright Information goes here Company Proprietary and Confidential
Midline Positions
Classification
The classifications of midline positions are as follows:
Normal. The horizontal and the vertical plane alignment are
orthophoric in both straight upgaze and downgaze.
Abnormal. A horizontal and/or a vertical plane misalignment is
present in the upgaze position and/or the downgaze position.
Horizontal
A pattern
V pattern

30. 30
Copyright Information goes here Company Proprietary and Confidential
Midline Positions
Classification
Abnormal. A horizontal and/or a vertical plane misalignment is
present in the upgaze position and/or the downgaze position.
Vertical
• Double elevator palsy
• Fibrosis of a vertical rectus muscle
• Myopathy due to thyroid disease
• Adherence syndrome
- Following fracture of orbital floor
- Following surgery of extraocular muscles
- Brown syndrome
(All these diseases will be presented in detail in the future presentations)

31. 31
Copyright Information goes here Company Proprietary and Confidential
Thank You