ANOMALOUS HEAD POSTURES IN STRABISMUS AND NYSTAGMUS DIAGNOSIS AND MANAGEMENT

Abstract

Abnormal head positions are adopted in order to improve visual acuity, to avoid diplopia or to obtain a more comfortable binocular vision. The head can be turned or tilted toward right or left, with the chin rotated up or downwards or combination of these positions. The ophthalmologic examination including the assessment of versions leads to the diagnosis. When versions are free, the cause may be congenital nystagmus or strabismus with large angle. When versions are limited we suspect paralytic or restrictive strabismus. The head tilted to one shoulder suggests cyclotropia (IV Nerve Palsy) or congenital nystagmus. We present few of the above cases. An adequate surgical treatment can improve or correct the ocular deviation, diplopia and the abnormal head posture.

Conclusions: The abnormal head posture must be assessed and treated early in order to correct the ocular position and head posture. All patient presenting abnormal head position HAD TO BE investigated by an ophthalmologist.

Fig. 1

Congenital esotropia with manifest nystagmus, left eye fixing in adduction, head turned towards left, the direction of the left fixing eye – pre-op.

Fig. 2

Post-operative Fig. after bi-lateral medial rectus recession

Fig. 3

Infantile nystagmus with left face turn

Fig. 4

Post-operative after left Medial Rectus recession 7 mm, right lateral rectus recession 10 mm

Fig. 5

Congenital nystagmus with combined vertical and horizontal null zone, chin-up and left face turn position

Fig. 6

Post-operative after left medial rectus recession 8.5 mm, right lateral rectus recession 12 mm, bi-inferior rectus recession 7 mm, bi-superior rectus resection 6 mm.

Fig. 7

(up or in the middle), 8 (left), 9 (right): Right VI nerve palsy after trauma, no abduction in the right eye

Fig. 10

(up), 11(left), 12(right): After right medial rectus recession 6,5 mm and half-tendon transfer of the superior and inferior to the lateral rectus insertion.

Fig. 13

(up), 14 (left), 15(right): Right III Nerve Palsy, superior branch, exotropia and hypotropia, left head turn, no adduction

Fig. 16

(up), 17 (left), 18 (right) Post-op, Right lateral rectus recession 14 mm, right medial rectus resection 9 mm with up-ward insertion

Fig. 19

Left Congenital IV nerve Palsy; Right head tilted, facial asymmetry

Fig. 20

Left hypertropia in primary position

Fig. 21

Bielschowsky head tilted test positive: hypertropia increases in tilting the head towards to side of the palsy

Fig. 22

Post-op, head straight, ortophoria, after left inferior oblique myectomy and left superior rectus recession

Fig. 23

Normal head tilted test