Penlight Cover Test (Partial Removal of Fixation)

Penlight cover test (partial removal of fixation): during in-person clinical encounters, the maneuvers below are best tested with complete (or near complete) removal of fixation (e.g., Frenzel or video Frenzel goggles). Removal of fixation is more challenging during virtual evaluations but can be approximated using the penlight cover test. Instruct the patient to go into a dark area and shine a light from a cell phone or torch into one eye (holding the light source at a distance of 2-3 inches from the eye to make fixation more challenging due to the brightness of the light) while occluding the fellow eye with the other hand. Assess for spontaneous nystagmus or nystagmus in eccentric gaze. If a dark area is not available, the following tests can be completed in normal lighting, but abnormalities may be more subtle since removal of fixation will accentuate peripheral vestibular nystagmus.