Execution
- 1Position the patient sitting and ask the patient to fixate on a near target.
- 2Cover one eye for one to two seconds.
- 3Rapidly move the cover to the opposite eye while watching the uncovered eye.
- 4Repeat several alternate cover cycles.
- 5Observe for vertical corrective refixation movement.
Positive outcome
A vertical corrective movement when the eye is uncovered indicates skew deviation and is a central sign in the acute vestibular syndrome context. Small horizontal phorias are not the target finding. Skew should be interpreted with head impulse and nystagmus findings rather than alone.
Studies
| Study | Reliability | Sn | Sp | LR+ | LR− |
|---|---|---|---|---|---|
| Kattah et al. (2009) | HINTS component | NA | NA | NA | NA |
CommentSkew deviation is specific enough to raise concern for central pathology, but it is not sensitive as an isolated test. It is most useful inside HINTS for acute vestibular syndrome. Diplopia, focal neurological signs, severe new headache, or inability to sit or walk independently should trigger urgent referral.
Moderate Clinical Value