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Background  The purpose of this study was to evaluate the efficacy of a quantitative analysis method for comitant exotropia using video-oculography (VOG) with alternate cover.    Methods  Thirty-four subjects with comitant exotropia were included. Two independent ophthalmologists measured the angle of ocular deviation using the alternate prism cover test (APCT). The video files and data of changes in ocular deviation during the alternate cover test were obtained using VOG. To verify the accuracy of VOG, the value obtained using VOG and the angle of a rotating model eye were compared, and a new linear equation was subsequently derived using these data. The calculated values obtained using VOG were compared with those obtained using the APCT.    Results  Rotation of the model eye and the values obtained using VOG demonstrated excellent positive correlation ( R  = 1.000;  p  < 0.001). A simple linear regression model was obtained: rotation of the model eye = 0.978 × value obtained using VOG for a model eye – 0.549. The 95% limit of agreement for inter-observer variability was ±4.63 prism diopters (PD) for APCT and that for test-retest variability was ±3.56 PD for the VOG test. The results of APCT and calculated VOG test demonstrated a strong positive correlation. Bland-Altman plots revealed no overall tendency for the calculated values obtained from VOG to differ from those obtained using APCT.    Conclusions  VOG with alternate cover is a non-invasive and accurate tool for quantitatively measuring and recording ocular deviation. In particular, it is independent of the proficiency of the examiner and, can therefore, be useful in the absence of skilled personnel.    Trial registration  ClinicalTrial.gov,  NCT03119311 , Date of registration: 04/17/2017, Date of enrolment of the first participant to the trial: 04/25/2017.

A quantitative analysis method for comitant exotropia using video-oculography with alternate cover