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Updated: Jun 18, 2025
Using an Automated Hirschberg Test App to Evaluate Ocular Alignment
Published on: March 24, 2020
To compare horizontal strabismus deviation as assessed from photographs with that in the strabismus clinic using the
Aparna Bose1, Abadan Khan Amitava, Yogesh Gupta
1Institute of Ophthalmology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India.
Purpose:
To compare the deviation in cases of horizontal strabismus as assessed from photographs with the measurements as obtained in the strabismus clinic.
Methods:
After obtaining informed consent, we recruited subjects with manifest horizontal strabismus. We took a frontal flash photograph from a distance of 50 cm using smart-phone-based cameras with the flash light vertically aligned with the lens. After projecting the photograph on a laptop and using a vernier caliper, we measured the horizontal corneal diameter of the non-strabismic eye and the decentration of reflex in the strabismic eye taking limbus as the reference point. We converted these values to degrees by using a conversion factor of 7.5°/mm and further to prism diopters (PD) by the standard mathematical formula 100*tanθ.
Results:
We included 74 subjects aged between 5 and 40 years with manifest horizontal deviation from 20 to 85 PD. We found a statistically significant correlation of 82.6% (P value < 0.001) between the clinic and photographic measurements. Agreement analysis suggested that the photographic measurements measured on average 7 PD less (95% confidence interval: 4.6 to 9.2) than clinical measurements along all values of misalignment, although the difference between the two methods decreased as the quantum of deviation increased. Linear regression revealed an r2 of 68% and provided a predictive equation to derive clinic equivalent measurements from photographic estimates.
Conclusion:
We believe our simple method provides robust evidence that a photographic estimation can provide the basic information of the size of the deviation to plan possible surgeries, especially in situations of a tele-consultation. This is an easy approach to both understand and master and should form the armamentarium of most orthopticians and strabismologists.
