COVER TEST

Cover / uncover test looks for manifest deviations Alternate cover test looks for latent deviations BUT lots of other information can also be gained from the cover test. Before performing a cover test: Observe the patient Note any AHP / CHP Note any obvious squint, nystagmus, ptosis, unequal pupils or any other obvious ocular abnormality

General points for all cover tests: Always start with a light, then go on to use an accommodative target Test at 1/3m and 6m (and if the distance deviation is a lot larger than for near then test in far distance as well) Make sure the patient has plenty of time to fix with each eye Test with and without glasses at all distances Test with and without AHP at all distances

Cover / uncover test The patient is asked to fix on a target and the occluder is introduced over one eye Look at the uncovered eye Note any movement to take up fixation (telling you that the eye had a manifest deviation) Note the size, direction and speed of movement Note any nystagmus Repeat with the other eye

Alternate Cover Test The patient is asked to fix on a target and one eye is covered with the occluder. The occluder is then switched to the other eye, making sure that one eye is kept occluded at all times, i.e. the patient is not allowed to fuse and have binocular vision. This is repeated several times to fully dissociate the two eyes. The movement of the occluder can be fairly quick but be sure to hold the occluder in front of each eye for long enough for the patient to re-fix properly. It is better to keep the occluder in place too long than to go too fast. Look at the covered eye as the occluder is removed Note any movement, its direction and size Note whether the deviation increases with dissociation When the occluder is removed completely at the end, watch for a recovery movement as the patient restores binocular vision. Note the sped of recovery, and confirm that binocular vision has been restored with a cover / uncover test

Recording results: Record the test distance: 1/3m, 6m or far distance With or without glasses Size of deviation e.g. slight, moderate, marked etc Type of deviation e.g. eso / exo, hyper / hypo, phoria / tropia Effect of dissociation For phorias always note speed of recovery e.g. rapid, good, delayed, poor, and whether diplopia is noted prior to recovery For tropias note the affected eye Note speed of fixation movement e.g. good or poor Note if any diplopia is appreciated Note if fixation of the manifest eye is maintained after cover test i.e. alternation Note any nystagmus and type e.g. latent, manifest, horizontal, vertical, rotary, pendular or jerky

PRISM COVER TEST

To measure the size of a manifest or latent deviation The patient is first fully dissociated using the alternate cover test Once dissociated, and still always keeping one eye occluded, a prism bar is introduced over one eye. This should be base inward for exo deviations and base out for eso deviations. (The apex of the prism should point in the direction that the eye deviates. The same applies when using vertical prism bars) Continue to do an alternate cover test, gradually increasing the strength of the prism, with should decrease the movement of the eye. Eventually the deviation will be seen to reverse. This means it is overcorrected. Reduce the prism to find the highest strength prism before reversal. This gives the size of the deviation The prism cover test should be performed at all distances as with the cover test. It is usually done with any refractive correction, but can be repeated without if necessary. It can be done with and without any AHP. It can also be adapted if necessary to measure the manifest component of a deviation that increases on dissociation