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The simplest maneuver for the analysis of diplopia consists of asking the patient to follow an object or penlight into the six cardinal positions of gaze When the position of maximal separation of images is identi ed, one eye is covered and the patient is asked to identify which image disappears The red-glass test is a more reliable enhancement of this technique A red glass is placed in front of the patient s right eye (the choice of the right eye is arbitrary, but if the test is always done in the same way, interpretation is simpli ed) The patient is then asked to look at a ashlight (held at a distance of 1 m), to turn the eyes sequentially to the six cardinal points in the visual elds, and to indicate the positions of the red and white images and the relative distances between them The positions of the two images are plotted as the patient indicates them to the examiner (ie, from the patient s perspective) (Fig 14-6) Two similar methods of examination are described below It must be remembered that the red-glass test distinguishes one of two muscles responsible for the movement in the direction of maximal separation of images If the white image on right lateral gaze is to the right of the red (ie, the image from the left eye is projected outward), then the left medial rectus muscle is weak In testing vertical movements, again, the image corresponding to the eye with the paretic muscle is the one projected most peripherally in the visual eld For example, if the maximum vertical separation of images occurs on looking downward and to the left and the white image is projected farther down than the red, the paretic muscle is the left inferior rectus; if the red image is lower than the white, the paretic muscle is the right superior oblique As already mentioned for a supplementary test, correction of vertical diplopia by a tilting of the head implicates the superior oblique muscle of the opposite side Separation of images on looking up and to the right or left will similarly distinguish paresis of the inferior oblique and superior rectus muscles The examiner is aided by committing to memory the cardinal actions of the ocular muscles shown in Fig 14-5 and Table 14-2 There are several alternative methods for studying the relative positions of the images of the two eyes One, a re nement of the red-glass test, is the Maddox rod, in which the occluder consists of a transparent red lens with series of parallel cylindrical bars that transform a point source of light into a red line perpendicular to the cylinder axes The position of the red line is compared with the position of a white point source of light seen with the other eye Another, the alternate cover test, requires less cooperation than the red-glass test and is, therefore, more useful in the examination of young and inattentive patients It does, however, require suf cient visual function to permit central xation with each eye The test consists of rapidly alternating an occluder or the examiner s hand from one eye to another and observing the deviations from and return to the point of xation, as described above in the discussion of tropias and phorias Detailed descriptions of the Maddox rod and alternate cover tests, which are the ones favored by neuro-.

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