Module 5: Ocular Motility - Cover Tests

http://www.eyetec.net/ce/M5START.htm

OVERVIEW
   
Estimated study time:  3/4 hour.
Target Audience:  This module covers basic concepts and is appropriate for assistant and  technician level
personnel. 
 
Pre-requisites:  A basic knowledge of extraocular muscle actions.
Date of original release:  February 2000
 
   
  Section 1: The Cover Test 
   
Description of content:  This section discusses how the Cover Test is used to detect a tropia.  The procedure
is reviewed step-by-step.  Animated examples are included.  The difference between a tropia and a phoria is
discussed,  and types of deviations are reviewed.
  Instructional  objectives:  Upon completion of  this section,  the student should be able to: 
 Explain the difference between a tropia and a phoria
 Describe the Cover Test procedure
 Identify types of deviations revealed by the Cover Test
   
  Section 2: The Uncover Test
   
Description of content:  This section discusses how the Uncover Test is used to detect a phoria.  The
procedure is reviewed  step-by-step.  An animated demonstration is included.
Instructional objectives:  Upon completion of this section,  the student should be able to: 
 
 Explain how the Uncover Test works to reveal a phoria
 Describe the Uncover Test procedure
 Identify types of deviations revealed by the Uncover Test
   
  Section 3: The Cover-Uncover Test
   
Description of content:  This section discusses how the Cover Test and the Uncover Test are combined into
one procedure; the Cover-Uncover Test.  The procedure is reviewed step-by-step,  and animated examples are
given.
  Instructional objectives:  Upon  completion of this section,  the student should be able to: 
 Explain the functions of the steps involved in the Cover-Uncover Test
 Describe the Cover-Uncover Test procedure
 Identify types of deviations revealed by the Cover-Uncover Test
   
  Section 4: The Alternate Cover Test
   
Description of content:  This section discusses the difference between the Cover-Uncover Test and the
Alternate Cover Test.  Advantages and disadvantages of the Alternate Cover test are explained.  The procedure
is reviewed step-by-step,  and an animated demonstration is given.
  Instructional objectives:  Upon  completion of this section,  the student should be able to: 
 Explain the difference between the Cover-Uncover Test and the Alternate Cover Test
 Describe the Alternate Cover Test procedure
 Identify types of deviations revealed by the Alternate Cover Test
   
Section 1: The Cover Test
     
  Introduction

This module uses animations extensively to demonstrate important concepts.  The material is best
viewed online in a browser window.  Viewing the material on a printed page may not give sufficient
information for a good understanding of the material.

The cover test is a simple procedure, using only the occluder, that is used to detect the presence of
an eye muscle imbalance known as a tropia.

Ortho

A patient who does not demonstrate a deviation of eye alignment is termed "ortho" or "orthophoric".

Tropia

A tropia is an eye turn or deviation that the patient has no, or very little,  control over. The patient is
unable to keep the eye straight with the power of fusion. Even though there is such a thing as an
intermittent tropia, a tropia is a manifest deviation, meaning it is evident upon inspection and is not
hidden.

Phoria

A phoria is a muscle imblance that is hidden by fusion.  The eyes remain straight as long as fusion is
present.  The phoric deviation only becomes evident when fusion is disrupted.

Identifying deviations by direction and by deviating eye

While the fellow eye fixes on a visual target,  the tropic eye deviates either toward the nose
(esotropia),  temporally (exotropia),  superiorly (hypertropia),  inferiorly (hypotropia),  or a
combination of a horizontal and a vertical deviation.
The deviation is further identified by the eye that is deviating.  Possibilities are:

right esotropia (RET)

right exotropia (RXT)
right hypertropia (RHT)
right hypotropia 
 
left esotropia (LET)
left exotropia (LXT)
left hypertropia (LHT)
left hypotropia
 
alternating esotropia (ALT ET)
alternating exotropia (ALT XT)
 
A hypotropia is a bit confusing because they may be labeled as a hypertropia of the other eye.  For
example,  a left hypotropia may be labeled as a right hypertropia,  even though the left eye is
deviating and the right eye is fixing.  To avoid confusion only use the RHT to indicate a right eye
that is deviating upward.  If the left eye is deviating downward you can simply write out "left
hypotropia".
 
An alternating tropia occurs when a patient always has a deviating eye, but can and does fixate
with either eye.  For example,  the patient may be fixing with the right eye and the left eye may be
deviating outward (XT).  A moment later the patient may switch fixation to the left eye and the right
eye will move to an outward deviation.  
 
A combination left exotropia and left hypertropia might  be labeled:
LXT with LHT. 

Procedure

When performing the cover test,  our job as technicians is to answer the question: Is there a tropia
present? Yes or no. If the answer is yes, we should identify (name) the tropia.  The Uncover Test
(Sections 2 and 3) and the Alternate Cover Test (Section 4) will be used to detect a phoria.

 Have the patient view a distant target (the test is also performed at near).
 While you observe the right eye, use the occluder to cover the left eye.  One of two things
will happen:

1)  If the right eye does not move and remains fixed on the visual target, then the right eye is not
tropic.

2)  If the right eye is observed to move in order to take up fixation,  then the eye is tropic and the
tropia is identified according to the direction the eye moved from,  and which eye it is that moved.

Look at the two demonstrations below.  In the top demo a right esotropia (RET) is demonstrated.  

The patient is viewing a distant target.  It is obvious in this example that the left eye is fixing on the
target and the right eye is turning in.  Small angle tropias are not this obvious.  As the demo starts,
 an occluder moves over the left eye,  forcing the right eye to search for the target.  The right eye
moves to take up fixation.  The right eye is moving outward from an inward position, so the
deviation is termed a right esotropia.

ESOTROPIA DEMO

The demo below illustrates a right exotropia (RXT) revealed by the cover test.

EXOTROPIA DEMO

We have checked the right eye with the cover test.  Now we complete the cover test examination by
testing the left eye.

 Remove the occluder from the left eye and allow the patient's gaze to stabilize on the
target.
 Now cover the right eye with the occluder while you observe what happens to the left eye. 
As discussed above,  the left eye will either remain straight, or it will move from a deviated
position to take up fixation.

Exceptional situations

It is possible that an obviously tropic eye will not move to take up fixation.  This typically occurs
when the vision is poor in the deviating eye.  The eye cannot see the fixation target,  so it doesn't
pick up fixation.  In these cases the tropia is usually so obvious that a cover test is not needed.

A confusing situation for beginners is the patient with an alternating tropia.  This patient may
fixate first with the right eye and a moment later shift fixation to the left eye, and may do so back-
and-forth.  As fixation is shifting,  the fellow eye moves to a deviated position.  You may not even
need an occluder for this patient.  The trick is to recognize that the patient is shifting fixation from
one eye to the other and to observe which way the deviating eye is moving.
 
Section 2: The Uncover Test
     
  Introduction

When a phoria is present it means that there is a muscle imbalance,  but the eyes are kept in the
aligned position by the power of fusion.  The goal of the testing procedure is to disrupt fusion (cover)
and observe which direction the covered eye moves to take up fixation when double vision occurs
(uncover).

Procedure

Let’s look at what happens in the procedure step-by-step. We have already determined by the Cover
Test that no tropia is present (see Module 5, Section 1).

Both eyes appear to be fixing (or straight) when not covered.

The patient is instructed to look at the distant target. We cover the left eye  and leave it covered for
about 10 seconds. We have disrupted fusion.

In the Cover Test we were interested in what was happening with the uncovered eye. This time we are
interested in what is happening with the covered eye.  By way of illustration let’s say that the left eye,
which is covered and is not fixing,  now drifts to it’s resting position,  which happens to be outward.

We now uncover the left eye.

At this moment (which indeed may be a very short moment) the right eye is fixing but the left eye is
not fixing and has drifted outward.  At this moment the patient has.......you guessed it, double vision.
This is an emergency bell to the brain that some realignment needs to be done.

An electro-mechanical process now goes into effect which realigns the eyes,  restores binocular
fixation, and regains single vision. The physiological action that you will observe is that the left eye
will move from it’s outward position in an inward direction to again take up fixation.
Identification

How do we name or describe what we have observed? It is anexophoria. The left eye has moved
from it’s outward (exo) position in an inward direction to take up fixation. If the eye had moved from
an inward (eso) resting position in an outward direction to take up fixation it would be an esophoria,
as pictured below.

If the eye had moved from an upward (hyper) resting position to take up fixation it would be a left
hyperphoria.

If the eye had moved from a downward (hypo) resting position it would be a right hyperphoria.
Even though it seems logical to refer to it as aleft hypophoria this condition is usually identified by
the eye that is most upward.

Please note that nothing has been mentioned about a left or right esophoria, or a left or right
exophoria. That is because this further identification is unnecessary when referring to a horizontal
phoria.  If there is a left exophoria present then there is automatically a right exophoria present. A
phoria describes the resting, non-fixating relationship between the two eyes. The terms left or right
exotropia are used because left or right describes which eye is deviating when both eyes are not
covered.  In the case of a phoria,  both eyes fixate (do not deviate) when the eyes are not covered.

Demonstration

The right eye is covered and uncovered first,  and then the left eye, to demonstrate the presence of
an esophoria.  When covering,  be sure to pause long enough with the eye covered to allow the
covered eye time to drift to it's resting position.

UNCOVER DEMO
Section 3: The Cover-Uncover Test   
     
  Introduction

It is useful for the beginner to think of the Cover-Uncover Test as two separate tests: The Cover
Test and the Uncover Test.  The Cover Test, which tests for the presence of a tropia,  was presented
in Section 1.  The Uncover Test,  which tests for the presence of a phoria,  was presented in Section
2.  In clinical practice the two tests are performed together as the Cover-Uncover Test.  Let's go
through the procedure step-by-step.

Procedure

Our patient is instructed to view  a distance or near fixation  target.

We then cover the left eye while simultaneously watching the right eye for any movement.  This is
the "Cover" part of the test.  If the right eye does not move,  and it appears to be fixing,  then there
is no tropia of the right eye. 

If the right eye does move to pick up fixation,  then we identify the deviation by the direction from
which it moved to pick up fixation.  For example,  if it moved from a temporal position inward to
take up fixation, then it is a right exotropia (RXT).  If we detect a tropia,  then we don't have to pay
attention to the "Uncover" part of the test because we have already identified the deviation.

If no tropia is detected,  then we proceed with Uncover Testing.  After leaving the occluder in place
for several moments, we then remove the occluder from the left eye while watching the left eye as
the occluder is removed.

If there is no movement of the left eye,  we can usually assume that there is no phoria.  Movement
of the left eye indicates the presence of a phoria,   which is identified according the position from
which the eye moved.  For example,  if the eye moved from an inward, or nasal position, it would
be  termed an esophoria.  A phoria is confirmed  by observing  the same type of movement after the
right eye is uncovered.
We now allow the patient a few moments to regain stable fixation with the eyes not covered.

We proceed with testing by covering the right eye while observing the left eye (Cover Test) for any
movement which would  indicate the presence of a tropia in the left eye.

If a tropia is not detected in the left eye,  then we observe the right eye as it is being uncovered. 
Any movement of the right eye to take up fixation would indicate the presence of a phoria.

LXT example

Illustrated below is a demonstration of a left exotropia revealed by cover-uncover testing.  Read an

explanation of the procedure under the illustration.

LXT DEMO
COVER-UNCOVER TESTING

1)  We cover the left eye and observe the right eye.  If a tropia exists in the right eye,  the eye will
move from the deviated position to take up fixation (assuming the eye has good enough vision). 
The right eye does not move and appears to be fixing,  so we conclude there is not a tropia involving
the right eye.

2)  Our attention now shifts to the left eye as we uncover the left eye.  If a phoria exists,  the left eye
will shift to take up fixation again as the cover is removed.  The left does not shift to take up
fixation as the cover is removed,  so we assume that a phoria does not exist in the left eye.

3)  We now cover the right eye and observe the left eye for any movement, which would indicate
the presence of a tropia.  We observe that the left eye moves inward from a temporal position to
take up fixation,  indicating the presence of a left exotropia (LXT).

 4)  As the cover is removed from right eye we observe the right eye return to fixation and the left
eye move back to exotropia.  If there was an alternating exotropia,  the right eye would stay in the
exo position with the left eye fixating.

Exophoria example

Illustrated below is a demonstration of an exophoria revealed by cover-uncover testing.  Read an

explanation of the procedure under the illustration.

EXOPHORIA DEMO
COVER-UNCOVER TESTING

1)  The left eye is covered as we observe the right eye for any movement to take up fixation,  which
would indicate the presence of a tropia.  There is no movement of the right eye and it appears to be
fixing on the target.

2)  We now shift our attention to the left eye as it is being uncovered.  Any movement to take up
fixation would indicate the presence of a phoria.  We observe the left eye move inward from a
temporal position to take up fixation.  This would indicate an exophoria.

3)  We proceed to cover the right eye and observe the left eye for confirmation that it is an
exophoria that we are observing.  The left eye does not move and appears to be fixing on the target, 
confirming that a tropia does not exist. 

4)  If an exophoria does exist,  we would expect that the left eye would also exhibit movement
inward from an outward position as we uncover the eye.  We observe that this is the case.
Section 4: The Alternate Cover (Cross-Cover) Test  
     
  Introduction

The Alternate Cover Test can be used to quickly tell whether a patient is ortho or if the patient has a
deviation.  It is particularly useful in uncovering phorias because the technique does not allow the
patient to establish binocular fixation.  It is not always easy for the beginner to differentiate between
a phoria and a tropia with the alternate cover test.  The cover test can be used for confirmation.

What is the difference between the Cover-Uncover Test and the Alternate Cover Test?

The Cover-Uncover test allows the patient to establish binocular fixation if  possible.  Of course,  if
there is binocular fixation,  then there is no tropia.  The cover test is used to detect binocular fixation
and rule out a tropia.

The uncover part of the test is used to disrupt fusion (binocular fixation) and hopefully reveal a
phoria.  The problem is that once fusion is established a covered eye will not always immediately
drift off to its resting position when fusion is disrupted.  Sometimes you have to leave the cover in
place for an extended period of time until the eye "relaxes" into the phoric position.

This problem is solved by using the Alternate Cover (cross-cover) Test.  Instead of allowing the
eyes to be simultaneously uncovered for a period of time as with the cover-uncover test,  in the
alternate cover test the cover is moved from one eye to the other,  preventing fusion.  As a result, 
the eyes move to their "resting" positions relative to one another and the appearance of movement is
accentuated during the test.

Procedure

1)  Either eye can be covered with an occluder  to start the test.

Pause for a while with the cover in place over the eye to allow time for the eye to "drift".

2) Quickly move the cover to the other eye.

Pause again to allow the uncovered eye time to pick up fixation.

3) Quickly move the cover back to the other eye.

Pause again to allow the uncovered eye time to pick up fixation.

Repeat the procedure in a swinging fashion,  observing the eye that is being uncovered.

Any movement of  the eyes to pick up fixation indicates that the patient has a muscle imbalance.  As
discussed in the previous sections,  the direction of movement indicates the type of deviation (eso,
exo, or hyper).

Final step:  After you have been able to observe any eye movement present,  the final step is to
remove the cover, allowing binocular fixation to re-establish,  if possible.  This step helps you to tell
the difference between a phoria and a tropia.  The following discussion only applies if you have
observed eye movement during the alternate cover test.  If both eyes remained fixed on the target
during the alternate cover test,  then the patient was ortho.

If the eye being uncovered moves to take up fixation and the fellow eye remains fixing,  then you
have been observing a phoria.  If the eye being uncovered does not move to take up fixation (it
remains in the deviated position),  or if the fellow eye moves to a deviated position,  then you have
been observing a tropia.  The topia is further identified by which eye it is that is deviating (right,
left, or alternating).  Confirmation can be made by performing the cover test.

Example:  Esophoria as revealed by the alternate cover test.

We begin by covering either eye.  Allow a few moments for the eye under the cover to "drift".

Now move the cover back and forth between the two eyes.  Do not allow the patient to gain
binocular fixation.  Repeat the process as necessary to observe any movement present.  You may
need to pause in the covered position to allow the uncovered eye to pick up fixation.  Move your
 mouse over the illustration below to activate the demonstration. 

We observe that each eye is moving outward from a nasal position,  indicating the presence of an
eso deviation.  We do not know yet if it is a phoria or a tropia.

In the final step (4) we remove the cover and observe any movement of each eye.  Move your
mouse over the illustration to activate the demonstration.  If you want to repeat the demo,  move
your mouse off the illustration,  then move it back over the illustration.

We observe that when the cover is removed,  the left eye moves from a nasal position to pick up
fixation.  The right eye remains stationary,  fixed on the target.  Since both eyes gain fixation,  this
would indicate that an esophoria is present.