Hirschberg Reflex refers to the light reflection off of the cornea.  The test is done by shining a penlight or direct ophthalmoscope directly between the two eyes of the patient from about 2 feet.  The examiner is positioned directly behind the light source.  If eyes are properly aligned, the reflection will be slightly nasal to central in each eye. 

If an eye is turned in (esotropia), the reflection will be central to more temporal that the reflection in the fixating eye.

If one eye is turned out (exotropia), the reflection will be more nasal than the reflection in the fixating eye.

A photorefractive camera is an excellent way to test for and document Hirschberg Reflex.


The refex of the right eye is slightly nasal to central (fixating eye).  The reflex of the left eye is central indicating a small angle esotropia.
The reflex of the left eye is slightly nasal to central indicating the fixating eye.  The reflex is very nasal in the right eye indicating a large angle exotropia.

Bruckner's Reflex refers to a lightening or whiting out of the pupil when a penlight or direct ophthalmoscope is shined into the eye in the same manner as is done on the Hirschberg Test. 

Again, a photorefractive camera is very efficient in demonstrating this test result and saving the data in a patient's record. 

This test ends to be more effective on esotropes than exotropes.

Positive Bruckner's Test in the right eye of a small angle esotrope.
Extreme Brucker's phenomenon in the left eye of a large angle esotrope.
Remember case study two.  Prominent epicanthal folds are common in babies - it is part of why they are so cute!  They often give the impression that an eye is turning since little white is seen nasal to either eye.  The impression can be pronounced as a baby turns his/her head.

Hirschberg and Bruckner's are two commonly used tests to identify true esotropes from "pseudoesotropes."  Again, the camera image is a great means to demonstrate this to concerned families and pediatricians of mutual patients.  We often print or email a copy of the images we obtain to the pediatrician's office.

This baby has normal Hirschberg Reflexes and absence of Bruckner's reflex.  Eyes are aligned.