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diagnostic positions of gaze

The diagnostic positions of gaze are the nine positions in which a deviation is measured to study ocular motility. They are the primary position, the secondary positions of right, left, up and down, and the tertiary positions of up and right, up and left, down and right, and down and left.1 The primary position is the straight-ahead position of the eyes, with the head erect and the eyes on a point just below the horizon.2

Measuring the deviation in each position with the prism and cover test detects incomitance, confirms a paresis, and identifies the muscle or muscles involved in a paralysis.1 To tell a paretic deviation from a paralytic one, the examiner measures each position with either eye fixating.1 In each eccentric cardinal position one muscle of each eye has its greatest power to hold the eye there, and the two muscles act together as a pair. Those directions differ from the actions of the same muscles in primary position.3

Some texts still call the eight eccentric positions the cardinal positions. Strictly, the cardinal positions are only the secondary positions, so diagnostic positions is the clearer name for the full set.1

More detail

Tests made 25 or 30 degrees from primary position say little about how the patient uses the eyes in daily life. They still make diagnostic points, and a deviation present only in extreme gaze may not need surgery.1

For a recent paresis of a vertically acting muscle, three questions settle the diagnosis. The first asks whether a right or left hyperdeviation is present in primary position, the second whether it increases in elevation or depression, and the third whether it increases in dextroversion or levoversion.1 The second answer points to an elevator or a depressor of one eye, and the third separates a vertical rectus from an oblique muscle.1

Sources (6)
  1. von Noorden and Campos, Binocular Vision and Ocular Motility, ch. 12
  2. The Ophthalmic Assistant, ch. 2
  3. Pickwell's Binocular Vision Anomalies, ch. 17
  4. Rutstein, R., Daum, K. (1997). Anomalies of Binocular Vision: Diagnosis & Management. Mosby.
  5. Remington, L. A. (2012). Clinical anatomy and physiology of the visual system. Elsevier Health Sciences.
  6. Khurana, A. K. (2019). Theory and practice of optics and refraction. Elsevier Health Sciences.

Reviewed October 2026

Related terms

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