The Cover-Uncover Test

Introduction Procedure LXT demo Exophoria demo

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 coveruncover 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 coveruncover 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.