26 April 2026
Conducting a binocular vision assessment is an integral part of the eye examination.
Many elements combine to form an effective test – from the key role of communication to interpreting findings in the context of reported symptoms.
For newly qualified optometrists, it can be challenging to piece together all the information that is collected during an eye examination and work out its clinical significance.
OT approached experienced optometrists for their guidance on how early career optometrists can enhance their confidence in conducting a binocular vision assessment.
Perfecting the fundamentals
When early career optometrists are considering how they can improve their binocular vision skills, Leightons Chandlers Ford optometrist, Rebecca Rushton, recommends starting with the basics.
“Understand what is happening when you use cover test and ocular motility testing. A lot of issues can be understood with just these two tests,” she observed.
She added that the general rule of thumb ‘if it ain’t broke, don’t fix it’ holds true for binocular vision testing – altering prisms in an asymptomatic patient is generally inadvisable.
“If possible, sit in with an orthoptist. I picked up some brilliant tips for testing binocular vision and children during my pre-reg hospital placement,” Rushton shared.
“These are people who work exclusively with binocular vision issues, and they can help you get to grips with what you might deal with in practice,” she added.
Linklater & Warren Opticians optometrist, Josie Evans, emphasised the value of a good history and symptoms in binocular vision testing.
“It can help you swiftly narrow down your differential diagnoses and triage the urgency of your findings,” she highlighted.
Asked if there are any aspects of binocular vision testing that newly qualified optometrists commonly struggle with, Evans noted that understanding how different tests and results piece together can be challenging – as well as how this information may influence a practitioner’s management.
“When you’re thinking about which test to do, note the reasoning in your mind: I’m doing this test because of X, the results will be outside of typical range if they are Y, and this will support my diagnosis or management because of Z,” the optometrist advised.
“With this methodical approach, you will develop a better understanding of how the pieces of the binocular vision puzzle fit together,” she explained.
Evans highlighted that practise is key when it comes to binocular vision testing.
“I’ve heard optometrists say they’re not good at it, but as with everything, the more you do it the easier it becomes. Practise, ask colleagues, follow-up with patients you refer –all this will help your learning,” she said.
“I found the professional certificate in paediatrics very useful in refreshing my knowledge and confidence, and there is an abundance of brilliant CPD available,” Evans added.
The importance of context
Optometrist and director of Rawlings Opticians in Winchester, Rachael Smith, noted that newly qualified practitioners often struggle with interpreting results in context –especially linking symptoms to findings and knowing when results are clinically significant.
“Always take a thorough history, always check current glasses for prism, prioritise symptoms over numbers, and test fixation disparity over the current glasses then double check using trial frame or phoropter,” she advised.
“Time of day counts – remember what you measure at 10am may be very different by early evening, so there may be instances where you want to bring the patient back for 10 minutes to recheck at the end of the day,” Smith shared.
The optometrist highlighted that, in binocular vision testing, accuracy matters more than speed.
“Don’t rush. Be confident managing common conditions like convergence insufficiency, but know your limits and refer when needed,” she said.
Smith shared that seeking relevant CPD and asking for feedback from experienced colleagues can help a newly qualified practitioner to improve their binocular vision skills.
“Using real cases and reflecting on outcomes will build confidence and clinical judgement quickly,” she said.
Locum optometrist, Frank Eperjesi, highlighted that not all binocular vision anomalies need to be referred.
“Many can be dealt with using an optimum prescription, prisms or in-practice vision therapy,” he said.
Eperjesi added that some binocular vision anomalies may be stable and longstanding.
“If a person has recent onset diplopia or amblyopia that has not responded well to full time glasses use for four months then referral would be warranted,” he said.
Eperjesi recommended that newly qualified optometrists ask experienced colleagues for help if they are uncertain during a binocular vision test.
“Ask colleagues to call you into their room if they see a person with a binocular vision anomaly so you can assess the eye movements. Practice might not make you perfect but it will definitely make you better,” he said.
Remind yourself that no optometrist is all-knowing and that the necessity for lifelong learning within our profession applies to all optometrists
Seeing the big picture
Optometrist and Wales Optometry Postgraduate Education Centre senior lecturer, Dr Grant Robinson, reflected that, in his experience, overly focusing on the details can get in the way of gaining a general understanding of a patient’s binocular status among newly qualified optometrists.
“In my early years I remember spending a long time using fixation disparity to establish what prism to give to a patient complaining of horizontal diplopia and getting nowhere. When I sought counsel from a more experienced colleague, they just got the patient to look straight ahead, held up a prism and said ‘Is it still double now?’,” Robinson highlighted.
“I appreciate it wasn’t accurate but it was a straightforward method of resetting the situation and it did give me perspective,” he said.
Robinson recommends that newly qualified optometrists are mindful of the questions they ask and the instructions they give.
“Communication is key and in the binocular vision world patients can find it difficult to describe exactly what they are experiencing,” he said.
“If your directions to the patient are not clear then that can compound the situation when the results of tests are conflicting,” Robinson highlighted.
Robinson shared that in his opinion there are ‘four key pillars’ that can help an optometrist to determine what the cause of a binocular vision issue is.
These are: performing a cover test, watching the eyes move around, establishing the prescription and assessing how the patient focuses and converges.
“Be mindful that these investigations cannot be rushed. Breathe and have a think about the overall clinical picture after each test,” Robinson recommended.
He highlighted the importance of active listening, noting that many binocular vision issues may share simple refractive error symptoms, such as blurred vision, double vision, a frontal headache and eye strain.
“You need to spend more time listening to the patient than talking at them,” Robinson noted.
He highlighted that if a practitioner feels anxious when a patient complains of diplopia or a child is booked in with potential strabismus, they should consider what is the source of this unease.
If they lack confidence in this area of practice, Robinson recommended being proactive in seeking opportunities to improve their ability.
“Remind yourself that no optometrist is all-knowing and that the necessity for lifelong learning within our profession applies to all optometrists,” he said.
“Empower yourself to take responsibility and address your deficits by looking for sources of evidence-based assessment and management. It is never too early to embed these good practices,” Robinson emphasised.
Comments (0)
You must be logged in to join the discussion. Log in