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Anderson, Heather A.; Manny, Ruth E.; Cotter, Susan A.; Mitchell, G Lynn; Irani, Jasmine A.

Effect of Examiner Experience and Technique on the Alternate Cover Test

publication date
December 1, 2009
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To compare the repeatability of the alternate cover test between experienced and inexperienced examiners and the effects of dissociation time and examiner bias.



Two sites each had an experienced examiner train 10 subjects (inexperienced examiners) to perform short and long dissociation time alternate cover test protocols at near. Each site conducted testing sessions with an examiner triad (experienced examiner and two inexperienced examiners) who were masked to each other's results. Each triad performed the alternate cover test on 24 patients using both dissociation protocols. In an attempt to introduce bias, each of the paired inexperienced examiners was given a different graph of phoria distribution for the general population. Analysis techniques that adjust for correlations introduced when multiple measurements are obtained on the same patient were used to investigate the effect of examiner and dissociation time on each outcome.



The range of measured deviations spanned 27.5 prism diopters (Δ) base-in to 17.5Δ base-out. The absolute mean difference between experienced and inexperienced examiners was 2.28 ± 2.4Δ and at least 60% of differences were ≤2Δ. Larger deviations were measured with the long dissociation protocol for both experienced and inexperienced examiners (mean difference range = 1.17 to 2.14Δ, p < 0.0001). The percentage of measured small deviations (2Δ base-out to 2Δ base-in) did not differ between inexperienced examiners biased with the narrow vs. wide theoretical distributions (p = 0.41). The magnitude and direction of the deviation had no effect on the size of the differences obtained with different examiners or dissociation times.



Although inexperienced examiners differed significantly from experienced examiners, most differences were <2Δ suggesting good reliability of inexperienced examiners' measurements. Examiner bias did not have a substantial effect on inexperienced examiner measurements; however, increased dissociation resulted in larger measured deviations for all examiners.


Vision therapy is well worth the response, time and effort. Our Son had a hard time focusing and writing neatly. After vision therapy Seth could complete a task in half the time if previously took. His abilities to focus improved greatly and so did his handwriting.

Also, he was better at listening. As a parent, we wanted learning to be fun for our Son, and vision therapy made this possible.

Amanda T.

Vision Therapy is well worth the expense, time and effort. Our son had a hard time focusing handwriting neatly. After vision therapy Seth could complete a task in half the time it previously took his abilities to focus and improved greatly and so did his handwriting.

Also, he was better at listening. As a parent you wanted learning to be fun for our son and vision therapy made this possible.

Alexa H.

Vision Therapy has given or son the tools he needs to be able to scan and read the written word more effectively and efficiently.

He love working with John and these working sessions give him the motivation to gladly work on his homework assignments.

It amazed us to see the difference in the tracking of his eyes and along a line of it's from the beginning to the end of the treatment.

Dr. McBryar , Kristen and John  are all marvelous and we would recommend them to anyone I only wish that we would have found them sooner!

Charlotte M.

Prior to coming to the institute for vision development my son complained of daily headaches. Therapy has eliminated his headaches completely. I love knowing my son is able to learn pain-free for the rest of his life because of the work that has been done over just a few weeks in this office. He he absolutely loved coming that didn't even feel like going to a doctor or therapy. We are grateful for the relief he was able to find by coming here.

Thank you!

Olivia C.

Seems much less frustrated with life

Reads non-stop and fast

Spelling abilities have been hugely improved

Seems much more confident

Thank You!!!

Kelly O.

When we first came to the practice, my son did not have huge issues, but lots of small ones- trouble with reading, sports (hitting the baseball consistently), coordination, etc- that were not easily detectable,but when put together presented issues. The staff here were all very professional and loving towards him. While I was concerned in the reading, my son was concerned with the athletic side. Seeing improvement night off the bat gave him confidence that i have nor seen in him and made him want to not only Come to therapy, but also made him want to work hard. He has surpassed his grade level and above in reading and hit his first home run this year! Thank you!!!

Alice M.
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