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A 70 year old woman reports that she has new diplopia. When she closes either eye, the second image disappears. Eye movements are full without nystagmus. The first examiner performs the cover test and finds no refixational movements in the uncovered eye. The second examiner finds that there is an outward refixational movement of the uncovered eye.

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    Why was there a difference in the results of the two examinations?

    Correct! This is the most common technical error in using the cover test. If patients do not understand to bring the viewed target into focus, they will fail to execute a refixational movement to place the viewed target onto the fovea. In that circumstance, ocular misalignment in any plane will be overlooked. The single Maddox rod test might reveal the ocular misalignment.