Hypertropia (Vertical Strabismus)

What is Hypertropia?

Hypertropic Eyes Graphic

In general, strabismus (or tropia) is defined by frequency (intermittent or constant), laterality (right, left, or alternating), and direction (horizontal or vertical).

Horizontal strabismus is termed esotropia (inward turn of the eye) or exotropia (outward turn of the eye). Vertical strabismus is termed hypotropia (downward turn of the eye) or hypertropia (upward turn of the eye).

Therefore, Hypertropia is a form of vertical strabismus where one eye is deviated upwards in comparison to the other eye.

Causes of Hypertropia

The most common cause of hypertropia is palsy (weakness) in one of the cranial nerves, the third or fourth nerve. Hypertropia may also co-exist with infantile strabismus, esotropia or exotropia. Other causes of hypertropia include problems that may be congenital (present at birth) or develop later:

  • 3rd or 4th cranial nerve palsy
  • Brown syndrome: Problem with a tight eye muscle tendon
  • Duane syndrome: Problem with wrong innervation of the eye muscles

Signs and Symptoms of Hypertropia

Hypertropia may be intermittent (happening occasionally) or constant, and the symptoms may be barely noticeable. The most common symptoms are:

  • One or both eyes wandering upward
  • Head tilt to compensate for the eye misalignment

Those with Hypertropia may also be experiencing the following, whether they are aware of it or not.


Suppression is not perceived by the patient, but rather by the observer. Suppression happens when the visual system suppresses the image coming from the deviated eye. The amount of suppression, which can vary from small suppression scotomas in binocular fusion to large suppression areas on the affected side and amblyopia, depends on various factors such as the size of the strabismus and age of onset.


Diplopia is the medical term for double vision. In the case of a hypertropia, the diplopia is vertical.


Vision confusion occurs when two images are perceived in the same location, due to a misalignment of retinal correspondence points on the fovea. This symptom is rare, when compared to diplopia.

Tests Used to Assess Hypertropia

Hirschberg Test


Krimsky Test


Cover/Uncover Test


Simultaneous Prism Cover Test


Worth 4 Dot Test


Red Filter Test


Maddox Rod Test


Bagolini Striated Lens Test

This test is very similar to the Maddox rod test, with the exception that Bagolini striated lenses allow for a better view of the peripheral visual field, giving more binocular clues. This way, less dissociation is present and a better distinction between a small suppression scotoma with peripheral fusion and a large suppression scotoma is possible.

Treatment of Hypertropia

Treatment for hypertropia aims to ensure proper vision in both eyes and aligning the eyes. Common treatment options include:

  • Glasses to correct vision problems such as nearsightedness, farsightedness, or astigmatism that may be contributing to the hypertropia. This may include the use of prism lenses.
  • Vision Therapy, again often in conjunction with glasses or prism lenses.
  • Eye patch over the strong eye to improve the vision in the weak eye.
  • Surgery on the eye muscles to realign the eyes.

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