THE COVER TEST

AUTHOR
Pirindhavellie Govender: University of KwaZulu Natal (UKZN) Durban, South Africa

PEER REVIEWER
Bina Patel: New England College of Optometry, United States

THIS CHAPTER WILL INCLUDE A REVIEW OF:

 Features of ocular deviation
 Cover test assessment of ocular deviation
 Von Graeffe assessment of ocular deviation
 Maddox rod assessment of ocular deviation

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FEATURES OF OCULAR DEVIATION

The cover test is used to determine whether there is any tendency of the eyes to deviate from
well co-ordinated behaviour. If a deviation is detected, the cover test will show a deviation if it is
latent (heterophoria - tendency to turn under certain conditions) or manifest (heterotropia -
permanent turn). The cover test can also be used to estimate or measure the direction and size
of the deviation, and give some indication whether it is compensated or not.
Every patient’s deviation must be described in terms of its frequency, direction, magnitude,
laterality and comitancy.
 Frequency: may be either constant or intermittent.
 Direction: may be horizontal, vertical or rotatory (cyclo). In addition, no deviation of the
line of sight is termed othortropia / orthophoria. Horizontal deviations are either inward
(nasal) deviation from the line of sight (known as an eso deviation) or outward (temporal)
deviation of the line of sight (known as an exo deviation). A vertical upward deviation of
the line of sight of one eye is referred to as a hyper deviation while a vertical downward
deviation of the line of sight and is referred to as a hypo deviation of the eye (Figure 7.1).
When there is a deviation of the eye around the antero-posterior axis of the eye, then the
eye is said to have a cyclo or torsional deviation. An excyclodeviation is characterised by
a temporal rotation of the superior aspect of the globe while an incyclodeviation is
characterised by a nasal rotation.
 Magnitude: According to Daum in Eskridge et al (1991), “the magnitude of the deviation is
the angular measurement of the difference in direction of the lines of sight of the eyes for a
specific fixation distance and direction of gaze”. The magnitude of a deviation is specified
in prism dioptre () units.
BACKGROUND  Laterality: is usually only specified when the deviation is constant. A constant strabismus
INFORMATION may be either unilateral or alternating. If the deviation is unilateral, then it implies that the
deviation is constantly in only one eye, for example right constant exotropia. If the patient
uses either eye to fixate, then the deviation is referred to as an alternating deviation and
the deviating eye cannot be specified due to its alternation. This type of deviation would
simply be documented as an alternating tropia.
 Comitancy: refers to the magnitude of the deviation when the eye changes to various
directions of gaze. If a deviation is comitant or concomitant then it implies that the
magnitude of the deviation remains the same irrespective of the direction of gaze of the
patient. If it is incomitant or inconcomitant then it implies that the magnitude of the deviation
changes when the eye shifts its gaze from one direction to another.

Figure 7.1: Diagrammatic representation of tropias

The use of the information gathered from establishing the binocularity of the patient has several
implications:
 The clinician may chose to perform further testing of the oculomotor system.
BINOCULAR  There may have to be modifications in the typical refraction routine. Additional specific
IMPLICATIONS tests may need to be performed. For example, a patient who has a tropia is considered
monocular and therefore cannot undergo binocular balancing tests.
 The binocular status may suggest the presence of eyestrain, headaches, decreased
performance, Amblyopia or reduced stereopsis.

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COVER TEST ASSESSMENT OF OCULAR DEVIATION

The cover test can be divided into two categories, viz. objective and subjective.

The objective cover test is sometimes termed the “cover-uncover” test. It is probably one of the
most important of all of the tests to determine the oculo-motor balance of a patient. It may be
carried out at distance and near. It can also be carried out on patients wearing no correction or
wearing a habitual prescription. If the patient has a habitual prescription then the cover test
should be conducted with the prescription on at all times when tested. According to Benjamin in
Borish’s Clinical Refraction (2006), the unilateral cover test confirms the presence of a tropia or
phoria and defines its directions.

There are two types of cover tests:

1. Unilateral cover test (cover-uncover test)
2. Alternate cover test

1. UNILATERAL COVER TEST (COVER-UNCOVER TEST)

The unilateral cover test is performed by placing an occluder in front of one eye and
then observing the movement, if any, in the fellow eye. This test is used to detect the
presence of a tropia / heterotropia / strabismus. A tropia is a deviation of the eye that is
visible by simply looking at the patient. In Figure 7.2, when observing the position of the
patient’s eyes, one can see that the right eye is turned inward. This eye is the deviating
eye while the other eye is the fixating (dominant) eye. One would therefore classify this
deviation as an esotropia.

OBJECTIVE
COVER TEST

Figure 7.2: Schematic of unilateral cover test

2. ALTERNATE COVER TEST

The alternate cover test is performed by alternating the occluder from one eye to the
other while the patient fixates a target and observing the movement, if any, in the eye
that has just been uncovered (Figure 7.3).

Figure 7.3: Schematic of unilateral cover test showing an esophoria.

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COVER TEST ASSESSMENT OF OCULAR DEVIATION (cont.)

AIM
The cover test is an objective method of evaluating the presence, direction and magnitude of a
strabismus (tropia) or phoria.

EQUIPMENT
 VA chart
 Occluder
 Near point target
 Overhead lamp (only if required)

SET-UP
 Patient wears the habitual Rx for the distance being tested, i.e. either distance Rx or near
Rx as in the case of presbyopes.
 Choose a single letter as a target, on a line above the patient’s best VA in the worse eye,
(preferably a letter at the edge of a line to avoid distractions). Either you or the patient can
hold the target (whichever makes you comfortable) at 40 cm to stimulate accommodation.
If the habitual working distance is not 40 cm, then the chart for near cover test must be
held at the patient’s habitual working distance.
 If the patient’s VA is 6/18 (20/60) or less, then the target must be a spot of light, however,
if the patient’s VA is better, then a spot of light is not a preferred target since it will not
stimulate an under corrected hyperope’s accommodation.
 The room must be well illuminated for eye movement observation. A lamp placed directly
above patient may be used if needed.
PERFORMING THE
COVER TEST  The examiner must be positioned so that observation of the eyes is possible without
interfering with the patient's view of the target.

PROCEDURE: UNILATERAL / COVER-UNCOVER

1. Start off with both eyes open, and initially hold the occluder at the patient’s nose
(Figure 7.4A). To test the left eye, cover the patient's right eye, observe the left eye for
movement as soon as the right eye is covered (Figure 7.4B). Remove the occluder and
wait for 2 seconds before covering the right eye again, thereby allowing both eyes to
fixate the target. This step is performed to confirm the presence of a slight deviation in
the left eye which may not have been imperceptible the first time the right eye was
covered.
2. To test the right eye, start with both eyes open (Figure 7.4C) and cover the patient's left
eye (Figure 7.4D). Observe the right eye as soon as the left eye is covered. Remove
the occluder and wait for 2 seconds before repeating (Figure 7.4).

Figure 7.4: Unilateral cover test to diagnosing a left exotropia

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COVER TEST ASSESSMENT OF OCULAR DEVIATION (cont.)

PROCEDURE: UNILATERAL / COVER-UNCOVER (cont.)

3. If no movement is observed then there's no tropia, in which case the patient is said to
have an ORTHOTROPIA (however, do not discount the presence of a microtropia –
this will be discussed further in the Orthoptics course).
4. If there is an outward movement, then it implies that the eye was occupying an inward
position and therefore the patient is said to have an ESOTROPIA.
5. If there is an inward movement, then it implies that the eye was occupying an outward
position. Therefore the patient is said to have an EXOTROPIA (Figure 7.4 illustrates the
findings in a patient with a left exotropia).
6. If there is an upward movement, then it implies that the eye was in the downward
position. Therefore the patient is said to have a HYPOTROPIA.
7. If there is an downward movement, then it implies that the eye was in the upward
position and therefore the patient is said to have a HYPERTROPIA.

RECORDING
 Orthotropia: (no horizontal or vertical deviations)
 Exotropia = XOT or XT
 Esotropia = SOT or ET
 Hypotropia = hypotropia
 Hypertropia = hypertropia

INTERPRETATION OF FINDINGS
An alternating strabismus
 If upon covering the left eye, the right eye makes a movement to take up fixation and
PERFORMING THE versional movement is made by both eyes.
COVER TEST  If upon removing the cover the right eye remains fixating, there will be no versional eye
(cont.) movement.
 When the cover is placed over the right eye, the left moves to take up fixation, similarly
there will be a versional movement of both eyes. Upon removing the cover from the right
eye, the left eye remains fixating and there is no versional movement of the eyes, this
confirms the presence of an alternating strabismus.
 In this case the deviating eye cannot be specified as with a unilateral strabismus.

PROCEDURE: ALTERNATING COVER TEST

 Start off with both eyes open (Figure 7.5A).
 Place the occluder over one and then move the occluder over the patient’s other eye so
that at no time both eyes are allowed to fixate the target together (Figures 7.5B and 7.5C).
 Upon moving the occluder to the fellow eye, the examiner will observe an inward
movement of the eye that has just been uncovered.

Figure 7.5: Alternate cover test diagnosing exophoria (observe position of eye under occluder)

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COVER TEST ASSESSMENT OF OCULAR DEVIATION (cont.)

 If no movement observed then there's no phoria, in which case the patient is said to have
ORTHOPHORIA.
 If there is an outward movement, then it implies that the eye was occupying an inward
position. Therefore the patient is said to have an ESOPHORIA.
 If there is an inward movement, then it implies that the eye was occupying an outward
position. Therefore the patient is said to have an EXOPHORIA.
 If there is an upward movement, then it implies that the eye was in the downward position.
Therefore the patient is said to have a HYPOPHORIA.
 If there is a downward movement, then it implies that the eye was in the upward position.
Therefore the patient is said to have a HYPERPHORIA.

RECORDING
 Orthophoria: (no horizontal or vertical deviations)
 Exophoria = XOP or XP
 Esophoria = SOP or EP
PERFORMING THE  Hypophoria = hypophoria
COVER TEST
 Hyperphoria = hyperphoria
(cont.)

The practitioner can, through clinical experience, estimate the deviation or measure the
deviation using prisms. This will be further explained in your binocular vision / orthoptics
module. If you determine a measurement, then it should be recorded. For example, you
measure a constant XOT of 4 prism dioptres in the right eye, then this result is recorded as:
4RXOT

EXPECTED VALUES
Distance phoria: 1 XOP ± 1
Near: 3 XOP ± 3

Note: Patients with binocular vision anomalies may present with diplopia, abnormal head
posture, reports of eyestrain / asthenopia and various other complaints based on the type of
deviation that exists and its magnitude, frequency, etc. All of these factors will be explored
further in the binocular vision module.

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COVER TEST ASSESSMENT OF OCULAR DEVIATION (cont.)

SUBJECTIVE COVER TEST

The subjective cover test was introduced by Duane in 1925. He called it the parallax test. This
test is performed to assess a phoria. It is sometimes referred to as the Phi phenomenon and
describes the patient’s perception that the target object is moving during the cover test. In a
case of esophoria, the apparent movement of the target is in the opposite direction to the
movement of the cover, while in exophoria it is perceived in the same direction as the
movement of the cover. Similarly, in R hyperphoria, the object appears to move downwards and
upwards in a L hyperphoria when the cover is moved from the right to the left. It must be noted
that the subjective direction of movement is in the same direction as that of refixation.

PERFORMING THE
COVER TEST
(cont.)

Figure 7.6: Ray diagram showing the subjective cover test for an esotrope.

In Figure 7.6, a case of esophoria with the right eye being covered and then the cover is moved
to the left eye. The image in the right will initially fall on the nasal retina (B’R) and the image will
be projected temporally (i.e. to the right of the eye: B’R).

Therefore the individual will perceive the fixation object apparently jumping to the right (B’R).
Consequently the right eye will rotate rapidly to return the image to the fovea (M’R). Therefore in
a case of esophoria, the apparent movement of the target is in the opposite direction to the
movement of the cover, while in exophoria it is perceived in the same direction as the
movement of the cover. Similarly, in R hyperphoria, the object appears to move downwards and
upwards in a L hyperphoria when the cover is moved from the right to the left. It must be noted
that the subjective direction of movement is in the same direction as that of refixation.

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OTHER METHODS TO DETERMINE THE PRESENCE OF A DEVIATION

AND ITS MAGNITUDE
The Von Graefe method measures the phoria subjectively. It uses dissociating prisms and
measuring prisms. It has the same prerequisites as that of the objective determination of the
deviation. The target still has to be one of detail that would stabilise accommodation and
provide good target alignment. It is performed at distance and near and can be performed
with or without an Rx.

PURPOSE
The von Graefe phoria test is a subjective method of evaluating the presence, direction and
magnitude of a phoria at distance or near.

EQUIPMENT
 Phoropter with Risley prisms (Figure 7.7).
 VA chart at distance.
 Near VA chart with an isolated letter or line of 20/30 size.

VON GRAEFE
ASSESSMENT OF
OCULAR DEVIATION

12 BI 6 BU
Measuring prisms Dissociating prisms
Figure 7.7: Detailed view of Risley prism orientation when conducting Von Graefe technique.

PROCEDURE
1. Place phoropter with the patient’s distance Rx before the patient. Ensure that the
pupillary distance is appropriate for the testing distance, i.e. distance PD for distance
Von Graefe and near PD for near Von Graefe. If conducting the near Von Graefe test, a
near point card must be attached to the phoropter at 40 cm.
2. When conducting the distance test, an isolated letter one line above the best acuity at
distance must be provided as the target. This target may differ slightly based on the
equipment available for testing. For example, if it is not possible to isolate a single letter,
the practitioner may have to use a vertical column of letters.
3. The practitioner instructs the patient to close their eye’s while the Risley prisms are set at
12BI RE and 6BU LE (some texts mention that the practitioner may use 10BI RE and
6BU LE) as in Figure 7.7.
4. The practitioner then has the patient open both eyes. The patient is asked to report how
many targets he can observe and where they are located relative to each other. The
practitioner should verify that the patient indeed sees two images by occluding one eye
and asking the patient to verify how many targets he now sees. The two images seen
by the patient are positioned such that one image is up to the right and the other one
down and to the left (Figure 7.8).

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OTHER METHODS TO DETERMINE THE PRESENCE OF A DEVIATION

AND ITS MAGNITUDE (cont.)

PROCEDURE (cont.)
5. If the patient reports seeing only one of the targets, the practitioner must occlude one eye
and assist the patient in locating the targets out in space. Alternatively, the practitioner
can alter the position of the dissociating prisms before the eyes from the BU to the BD
position or the practitioner may increase the amount of measuring prism.

Figure 7.8: Resulting images viewed when using the dissociating and measuring prism

MEASURING THE HORIZONTAL PHORIA

1. When measuring the horizontal phoria, the 12BI represents the measuring prism
while the 6BU represents the dissociating prism.
2. The patient’s fixation is directed to the lower target and he is instructed to keep it clear
(Figure 7.8).
3. While the patient is observing the lower target, the 12BI measuring Risley prism
before the RE is reduced at a rate of about 2 per second until the patient reports that
VON GRAEFE the targets are aligned vertically one above another or sometimes describe to the
ASSESSMENT OF patient as “buttons on a shirt” (Figure 7.9).
OCULAR DEVIATION 4. The practitioner must record the amount and direction of prism to achieve alignment
(cont.) of the targets.
5. To confirm the final result, the practitioner may overshoot the point of alignment and
move the prism back in the direction toward the value that was originally obtained for
alignment. If there is a difference in the amount of prism that produces alignment of
the targets between the original and rechecked values, then the practitioner may take
the average of the two measurements, however, it is advised that if the two values
differ by more than 3, the practitioner should repeat the measurement.

1.5 BI 6 BU
Measuring prisms Dissociating prisms
Figure 7.9: Scenario of position of Risley prisms when conducting Von Graefe technique
when measuring the horizontal deviation (end point)

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OTHER METHODS TO DETERMINE THE PRESENCE OF A DEVIATION

AND ITS MAGNITUDE (cont.)
Measurement outcomes
 If on alignment, the 12BI has been reduced to zero  no horizontal phoria
 If remaining prism is BI  Patient has XOP
 If remaining prism is BO  Patient has SOP

e.g. in the case above (Figure 7.9), the final result is 1.5 BI. This result indicates that the
patient has an XOP of 1.5 in magnitude.

Implications of findings: It is important to note that a patient may not always end up with a
result of zero. The eyes have a tolerance to overcome a small amount of latent deviation of
the eyes, however, if the magnitude of the deviation lies outside of the tolerance or the patient
is unable to compensate for the deviation with their inherent fusional ability, it is likely that the
patient will have symptoms of asthenopia and double vision. A management plan which may
include active vision therapy or a prism prescription is crucial in these patients.

MEASURING THE VERTICAL PHORIA

1. When measuring the vertical phoria, the 12BI is the dissociating prism and 6BU is
the measuring prism.
2. The 6BU is reduced before the LE until the two images appear one next to the other,
also described to a patient as “headlights on a car” or “side by side”. In this case it
implies that the 6BU is the measuring prism and 12BI is the dissociating prism.
(Figure 7.10).
3. The practitioner must record the amount and direction of prism to achieve alignment
of the targets.
VON GRAEFE
ASSESSMENT OF
OCULAR DEVIATION
(cont.)

12 BI 3 BU
Dissociating prisms Measuring prisms
Figure 7.10: Scenario of position of Risley prisms when conducting Von Graefe technique
when measuring the vertical deviation and the resultant position of the targets

MEASUREMENT OUTCOMES
 If on alignment, the 6BU has been reduced to zero  no vertical phoria
 If aligning prism is BU  Left hypophoria or Right hyperphoria
 If aligning prism is BD  left hyperphoria or Right hypophoria

e.g. In the case above (Figure 7.10), the practitioner is left with a measurement of 3∆ BU
which indicates that the patient has either a Left hypophoria or Right hyperphoria.

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OTHER METHODS TO DETERMINE THE PRESENCE OF A DEVIATION

AND ITS MAGNITUDE (cont.)

EXPECTED VALUES
(Scheiman and Wick, 2008)

Distance Near
Horizontal / lateral phoria: Horizontal / lateral phoria:
 
Children and young adults: 1 XOP ± 1 Children and young adults: 3 XOP ± 3
 
For Presbyopes: 1 SOP ± 1 For Presbyopes: 8 XOP ± 3
Vertical phoria: no deviation Vertical phoria: no deviation

The Maddox rod test is a method of detecting and measuring a tropia or phoria subjectively.
The Maddox Rod is a trial lens composed of a series of powerful planoconvex cylinders in red
or white plastic. Dissociation with this lens is produced by the distortion of a spot of light into a
line target. When the rod is orientated with the cylinders in the horizontal direction, it produces
a line target that is vertical. When orientated vertically, it produces a line target that is
horizontal.

EQUIPMENT
 Phoropter or
MADDOX ROD  Loose Maddox Rod (it may be a clear lens or red lens) (Figure 7.11) with trial frame and
ASSESSMENT OF loose prisms
OCULAR DEVIATION
(cont.)  Penlight torch or transilluminator.

Figure 7.11: Maddox rod

PROCEDURE
1. The patient is seated comfortably and wearing their best distance refractive correction.
2. The test may be performed at distance or near.
3. The Px fixates a spot of light from penlight or transilluminator. Ideally, this is not the best
target for accommodative stabilisation.
4. The room lights should be dimmed to allow a better view of the streak produced by the
Maddox rod (red lens in this example).

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OTHER METHODS TO DETERMINE THE PRESENCE OF A DEVIATION

AND ITS MAGNITUDE (cont.)
MEASURING THE HORIZONTAL PHORIA
1. Place the Maddox Rod before one eye (usually the deviating eye) with the cylinder
axis orientated horizontally. This produces a streak that is vertical in orientation.
2. The other eye remains fixated on a spot of light.
3. The eyes are now dissociated with one eye seeing the streak of light and the other
seeing the spot of light. If the patient is unable to see both the streak and the spot of
light then suppression is indicated and the test cannot be performed.
The perception of the direction of the images in the Maddox rod test is based on
retinal projection as depicted in Figure 7.13. For example, an object that is perceived
in the temporal visual field is traced back to the nasal retina in the eye. Therefore, a
patient who experiences crossed diplopia indicates the presence of an exophoria
(Figure 7.12A) while uncrossed diplopia is indicative of esophoria (Figure 7.12C).
Coincidence of the streak and spot of light depicts a case of orthophoria
(Figure 7.12B).

MADDOX ROD
ASSESSMENT OF Figure 7.12: Ray diagrams showing principles of crossed and uncrossed diplopia in
OCULAR DEVIATION (A) exophoria; (B) orthophoria and (C) esophoria.
(cont.)
4. If the patient is able to perceive both targets, then he is asked to report if the spot of
light appears to the right, left or on top of the streak (Figure 7.13).

Measurement outcomes (Maddox rod before RE)

Figure 7.13: Patient’s perceptions of the targets in cases of

(a) exophoria; (b) orthophoria and (c) esophoria

MEASURING THE VERTICAL PHORIA

1. The Maddox Rod is placed before one eye (usually the deviating eye) with the cylinder
axis orientated vertically. It will then produce a streak that is horizontal in orientation.
2. The other eye remains fixated on the spot of light.
3. The eyes are now dissociated with one eye seeing the streak of light and the other
seeing the spot of light.
4. The patient is asked to report if the spot of light appears to the above, below or on top of
the streak (Figure 7.14).

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OTHER METHODS TO DETERMINE THE PRESENCE OF A DEVIATION

AND ITS MAGNITUDE (cont.)
Measurement outcomes (Maddox rod before RE)

MADDOX ROD
ASSESSMENT OF
OCULAR DEVIATION
(cont.)

Figure 7.14: Patient’s perceptions of the targets when measuring the vertical deviation

POINT TO NOTE
The Maddox rod test is not able to differentiate existence of a tropia or phoria. The practitioner
must deduce this from the cover test or from the patient’s subjective complaints of diplopia.
The Maddox wing test was introduced in 1912. It is a convenient hand held quick and efficient
test for near phoria using the Maddox wing instrument (Figure 7.15).
 The scales are mounted at a fixed viewing distance of 33 cms. This is generally much
closer than the standard working distance for most patients and the findings are
therefore questionable.
 A septum on the instrument divides the visual field into two sections, thereby allowing
the right eye to see only the white and red arrows, whilst the left eye sees only the
horizontal and vertical rows of figures.
 The horizontal deviations are indicated by the white arrow pointing to the white figures.
 The vertical deviation is indicated by the red arrow pointing to the red figures.
 Cyclophoria is assessed by sliding the arrow which overlaps the edge of the chart until it
appears parallel with the white line above. Incyclophoria is indicated when the arrow
points above the zero while excyclophoria is indicated when the arrow points below the
zero.

MADDOX WING
ASSESSMENT OF
OCULAR DEVIATION

Figure 7.15: Maddox wing

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NOTES

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