Development and Clinical Validation of a Digital Eye-Tracking-Based Cover Test for Ocular Misalignment.
Digital eye-tracking cover test detects ocular misalignment with high sensitivity and specificity.
Development and Clinical Validation of a Digital Eye-Tracking-Based Cover Test for Ocular Misalignment.
To develop and clinically validate the DIVE Cover Test (DIVE Cover Test), a portable eye-tracking-based digital implementation of the cover test, and to assess its diagnostic accuracy, agreement with the clinical reference standard (classic cover test [CCT]), and repeatability across cover-uncover test (cover-uncover test) and alternate cover test (alternate cover test) phases and across horizontal and vertical axes.
Sixty-eight participants aged 3 to 74 years, including healthy controls and patients referred for strabismus evaluation.
Agreement between DIVE Cover Test and CCT was strongest for horizontal deviations, particularly during alternate cover test (mean difference -1.3 prism diopters [PD]; limits of agreement -8.0 and 5.4 PD).
Intermethod ICCs were high for horizontal deviations (cover-uncover test 0.93; alternate cover test 0.96) and moderate-to-high for vertical deviations (both phases 0.81).
The DIVE Cover Test test-retest repeatability was excellent (ICC ≥0.93 across axes and phases), with narrow limits of agreement (±3.8 to ±4.6 PD).
The DIVE Cover Test demonstrates high diagnostic accuracy, strong agreement with the clinical reference standard, and excellent repeatability. Phase-specific (cover-uncover test vs. alternate cover test) and axis-specific (horizontal vs.
vertical) analyses support the DIVE Cover Test as a practical, portable, and objective tool for quantifying ocular misalignment in clinical settings.