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Original Investigation
July 2018

Use of a Binocular Optical Coherence Tomography System to Evaluate Strabismus in Primary Position

Author Affiliations
  • 1National Institute for Health Research Biomedical Research Centre for Ophthalmology, Moorfields Eye Hospital National Health Service Foundation Trust and University College London Institute of Ophthalmology, London, England
  • 2Optometry and Vision Science Research Group, School of Biomedical Sciences, Ulster University, Coleraine, England
  • 3Experimental Psychology, University College London, London, England
JAMA Ophthalmol. 2018;136(7):811-817. doi:10.1001/jamaophthalmol.2018.1973
Key Points

Question  Can binocular optical coherence tomography (OCT) be used to measure the size of strabismus?

Findings  This study included 15 participants with strabismus and 15 healthy volunteers. In participants with strabismus, binocular OCT imaging correctly revealed the type and direction of the deviation and had fair agreement in misalignment size with the alternating prism cover test.

Meaning  These data suggest binocular anterior segment OCT imaging can provide measurements of strabismus with fair agreement to alternating prism cover test, and thus could be useful for diagnosis and monitoring.


Importance  Current clinical methods for assessing strabismus can be prone to error. Binocular optical coherence tomography (OCT) has the potential to assess and quantify strabismus objectively and in an automated manner.

Objective  To evaluate the use of a binocular OCT prototype to assess the presence and size of strabismus.

Design, Setting, and Participants  Fifteen participants with strabismus were recruited in 2016 as part of the EASE study from Moorfields Eye Hospital National Health Service Foundation Trust, London, England, and 15 healthy volunteers underwent automated anterior segment imaging using the binocular OCT prototype. All participants had an orthoptic assessment, including alternating prism cover test (APCT), before undergoing imaging. Simultaneously acquired pairs of OCT images, captured with 1 eye fixating, were analyzed using ImageJ (National Institutes of Health) to assess the presence and angle of strabismus.

Main Outcomes and Measures  The direction and size of strabismus measured using binocular OCT was compared with that found using APCT.

Results  The median age for participants with strabismus was 55 years (interquartile range [IQR], 33-66.5 years) and for the healthy group, 50 years (IQR, 41-59 years); 15 participants (50%) were women, and 25 participants (83.3%) were white. The median magnitude of horizontal deviation was 20∆ (IQR, 13-35∆) and for vertical deviation, 3∆ (IQR, 0-5∆). Binocular OCT imaging correctly revealed the type and direction of the deviation in all 15 participants with strabismus, including horizontal and vertical deviations. The APCT and OCT measurements were strongly correlated for the horizontal (Pearson r = 0.85; 95% CI, 0.60-0.95; P < .001) and vertical (r = 0.89; 95% CI, 0.69-0.96; P < .001) deviations. In the healthy cohort, 9 of 15 participants (60%) had a latent horizontal deviation on APCT results (median magnitude 2∆, range 2-4∆). Six (40%) had orthophoria. Horizontal deviations were observed on OCT imaging results in 12 of the 15 participants (80%), and a vertical deviation was visible in 1 participant (6.7%).

Conclusions and Relevance  These findings suggest that binocular anterior segment OCT imaging can provide clinicians with a precise measurement of strabismus. The prototype can potentially incorporate several binocular vision tests that will provide quantitative data for the assessment, diagnosis, and monitoring of ocular misalignments.