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Binocular Vision Assessment Tips and Flows


5 min


Binocular vision assessment

When it comes to assessing binocular vision, a systematic approach is essential. The ability of both eyes to work together harmoniously to form a single, coherent image—known as binocular vision—is essential for depth perception, spatial awareness, and general visual function.

Comprehending the complexities of binocular vision assessment can result in more precise diagnosis and customised treatment regimens. Therefore, we prepared binocular vision assessment tips and flows.

Patients and Family History

Getting relevant medical history information about the patient is crucial before beginning the binocular vision assessment procedure. Pay close attention to any history of strabismus, including onset, deviation, and whether it’s constant or intermittent. Another thing to think about is prematurity, which might affect how a child develops visually.


If the patient is able to communicate well, have a conversation with them to find out about any symptoms they might be having. Furthermore, using surveys or questionnaires might offer insightful information about their general health and eye health. 

Customized Binocular Vision Questionnaire


Subtle indications regarding the patient’s binocular vision might be found by closely examining their physical attributes. Keep an eye out for any symptoms that have been recorded, as well as any symmetry in the face, posture, and existence of epicanthus or pseudostrabismus.

Important aspects of this stage also include evaluating the symmetry of corneal reflections and monitoring motility and smooth pursuit movements.

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A number of tests are necessary for assessing binocular vision. 

The Brückner Test

The Brückner Test is a quick and effective screening tool used to detect strabismus (eye misalignment), anisometropia (unequal refractive power), media opacities (such as cataracts), abnormal pupil reactions, and fundus anomalies near the visual axis.

By observing the red reflex, practitioners can identify these issues early, leading to prompt and appropriate intervention.

Visual Acuity (VA or BCVA)

Visual acuity tests measure the sharpness of vision. Best-Corrected Visual Acuity (BCVA) is determined by having the patient read letters on a chart at a standardized distance. This test is fundamental in assessing the clarity of vision and detecting refractive errors.

Refraction: Objective and Subjective

Refraction tests determine the prescription needed for corrective lenses. Objective refraction, such as retinoscopy, involves measuring the eye’s refractive error without patient input. 

Cycloplegic retinoscopy, the gold standard, involves dilating the pupil to get an accurate measurement. 

Alternatively, Mohindra retinoscopy can be used for infants without dilation. Subjective refraction fine-tunes the prescription by asking the patient to choose between lens options.

Ocular Motility

Ocular motility tests evaluate the six positions of gaze to ensure smooth and coordinated eye movements. This is crucial for identifying muscle weaknesses or neurological issues that could affect binocular vision. Furthermore, it is also an important step of binocular vision assessment.

The Vestibulo-Ocular Reflex (VOR)

The VOR test assesses both gross visual acuity and ocular motility by checking the eyes’ ability to maintain a steady gaze during head movements. This test is useful for detecting issues with eye alignment and coordination.

Cover / Uncover Test

The cover/uncover test identifies tropias (constant eye deviations) and phorias (latent eye deviations). By covering one eye and then uncovering it, practitioners can observe any movement of the uncovered eye, indicating a misalignment. Read more about the cover tests. 

Induced Tropia Test

Using a base-down (BD) prism, the induced tropia test checks for suppression, a condition where the brain ignores input from one eye to avoid double vision. This test helps in diagnosing and managing amblyopia (lazy eye).

Motion Detection

Motion detection tests, such as monocular optokinetic nystagmus (OKN), involve observing the eyes’ response to moving stimuli. This test can help identify neurological issues affecting eye movement and coordination.

Strabismus Angle Assessment

Assessing the angle of strabismus involves tests like the alternate prism test, Krimsky test, and Hirschberg test. These tests measure the degree of eye deviation and help in planning treatment strategies.

Sensory Binocularity

Sensory binocularity tests, including the Lang, Randot, Frisby, or TNO tests, evaluate how well the eyes work together to perceive depth and three-dimensional images. These tests are essential for assessing, diagnosing, and managing binocular vision disorders.

Accommodation Testing

Accommodation testing measures the eye’s ability to focus on near objects. Tests for amplitude (near point of accommodation), accuracy (cross-cylinder tests), and facility (lens methods and accommodative rock) assess how well the eyes can adjust focus.

Signs/Symptoms of Accommodative Dysfunction

Vergence Testing

Vergence testing evaluates the eye’s ability to maintain alignment on a target. Tests measure amplitude (near point of convergence), accuracy (dissociated vergence posture), and facility (prism flippers and near-far rock). These tests help diagnose issues like convergence insufficiency or excess.

Signs/Symptoms of Non-strabismic Vergence Dysfunction

ACA Ratio

The accommodative convergence to accommodation (ACA) ratio helps determine the relationship between focusing and eye alignment. High AC/A ratios indicate vergence excess, while low ratios suggest vergence insufficiency. Normal ratios indicate balanced vergence postures.

Ocular Health Assessment and Systemic Health Screening

In addition to evaluating binocular vision, it’s extremely important to perform a thorough evaluation of systemic and ocular health. This includes inspecting the eyelids and adnexa, biomicroscopy, dilated fundus examination, and screening for systemic diseases that may impact visual function.

Recommendations and Prescription

Based on the assessment findings, recommendations may include prescription glasses or contact lenses, vision therapy (VT), surgical intervention, environmental modifications, and discussions about preventive measures and healthy habits.


Regular follow-up appointments are crucial for monitoring progress, adjusting treatment plans as needed, and addressing any concerns or changes in the patient’s condition.

Binocular Vision Assessment Tips and Flows: Download the Handout!

Enhance your practice and improve patient care with our binocular vision assessment handout!

Binocular Vision Assessment Tips and Flows


In conclusion, binocular vision assessment is a multifaceted process that requires attention to detail, a comprehensive understanding of visual function, and a patient-centered approach. 

By following structured assessment protocols and utilizing a diverse array of tests and tools, eye care professionals can effectively diagnose binocular vision disorders and provide personalized treatment plans to optimize visual outcomes.

Frequently Asked Questions

What are some key tests used in binocular vision assessment?

Key tests in binocular vision assessment include the Brückner Test, Visual Acuity tests, Refraction (both objective and subjective), Ocular Motility tests, the Vestibulo-Ocular Reflex (VOR) test, Cover/Uncover test, Induced Tropia test, Motion Detection tests, Strabismus Angle Assessment, Sensory Binocularity tests, Accommodation Testing, and Vergence Testing. Each test provides valuable information about different aspects of eye function and alignment.

How does patient and family history contribute to the assessment of binocular vision?

Patient and family history are crucial in binocular vision assessment because they provide context and background information that can influence the diagnosis and treatment plan. Information about any history of strabismus, visual development issues, and general health conditions helps practitioners understand potential underlying causes and tailor their approach to the patient’s specific circumstances.

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