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Overview
• General considerations Abnormal Head Positions • General categories of head postures in the Eye Clinic • Non-ocular causes of head postures • Ocular causes of head postures Jeffrey T. Lynch, MD, MPH • Practical approach to diagnosis & Pediatric Ophthalmology & Adult Strabismus management Associated Eye Care, LTD
General Considerations General Considerations
• “Torticollis” Tortus (Twisted) + Collum • Assessment is often multidisciplinary (Neck) – Pediatrician/Generalist – Orthopedic surgeon • Eye conditions leading to AHP “Ocular – Neurologist Torticollis” – Otolaryngologist – Physiotherapist
• Caused by muscular, skeletal or neurologic – disorders Ophthalmologist/Optometrist
Torticollis in Children General Considerations
• Drivers of “ocular torticollis” – To optimize visual acuity – To maintain single binocular vision – To center a narrowed field with respect to the body
• Our Job: Is this ocular or non-ocular torticollis?
Hoyt & Taylor, 2013
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General Considerations Overview
• If ocular cause found, treatment can usually • General considerations eliminate or reduce the problem and restore normal head posture. • General categories of head postures • Non-ocular causes of head postures • Untreated ocular cause can lead to changes in neck muscles and produce a secondary torticollis, • Ocular causes of head postures which may persist even if underlying ocular cause • Practical approach to diagnosis & is rectified. management
• Some head tilts in early childhood can lead to changes in facial bones/facial symmetry.
General Categories of AHP Face Turn
• Torticollis can involve rotation of the head around any of the 3 main axes
Hoyt & Taylor, 2013 Hoyt & Taylor, 2013
Chin-up Chin-down
Hoyt & Taylor, 2013 Hoyt & Taylor, 2013
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Head Tilt Overview
• General considerations • General categories of head postures • Non-ocular causes of head postures • Ocular causes of head postures • Practical approach to diagnosis & management
Hoyt & Taylor, 2013
Non-Ocular Causes Overview
• General considerations • General categories of head postures • Non-ocular causes of head postures • Ocular causes of head postures • Practical approach to diagnosis & management
Ocular Causes - Head Postures Face Turn
• Step 1 - Help yourself: What is the head position?
• Face turn • Chin-up • Chin-down • Head tilt
• Combination of above
Hoyt & Taylor, 2013
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Common Causes: Face Turn Right Face-Turn
• Nystagmus – Infantile – Acquired
• Incomitant Strabismus – Horizontal muscle abnormalities – Vertical muscle abnormalities
• Uncorrected refractive error • Eccentric fixation • Homonymous hemianopia • Miscellaneous – Monocular blindness, ocular motor apraxia
Hoyt & Taylor, 2013
Chin-up Common Causes: Chin-up
• Nystagmus – Infantile or acquired
• Strabismus – Elevation deficits (Innervational or mechanical) – Pattern Strabismus (“A pattern” ET or “V pattern” XT)
• Ptosis
• Uncorrected refractive error
• Supranuclear gaze disorder
• Superior visual field defects
Chin-up Chin-down
Hoyt & Taylor, 2013
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Common Causes: Chin-down Chin-down
• Nystagmus – Infantile or Acquired
• Strabismus – Depression deficits (innervational or mechanical causes) – Pattern Strabismus (“A pattern” XT or “V pattern” ET)
• Uncorrected Refractive Error
• Supranuclear gaze disorders
• Inferior Visual Field defects
Hoyt & Taylor, 2013
Head Tilt Common Causes: Head Tilt
• Nystagmus – Infantile or Acquired
• Strabismus – Vertical muscle problems (innervational or mechanical) – Cyclotropia – Horizontal muscle problems
• Refractive errors
Right Head Tilt Overview
• General considerations • General categories of head postures • Non-ocular causes of head postures • Ocular causes of head postures • Practical approach to diagnosis & management
Hoyt & Taylor, 2013
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Practical Approach Physical Features
• Is it ocular or non-ocular? • Facial Asymmetry
• Remember your “toolbox” • Neck Deformities – Physical features – Observe the patient • Anomalies of trunk or extremities – Review old photographs/videos – Palpation of neck muscles – Occlusion of one eye – Visual acuity/refraction – Eye movements • These findings suggest either a – Measuring head posture musculoskeletal cause or a chronic ocular – Visual fields – Fundus exam palsy.
Physical Features Observing the Patient
• Is the head position consistent?
• Does it manifest only under certain conditions – Example: Only seen with fixation on fine visual targets
• If nystagmus is present, observe patient for several minutes – Periodic alternation of head posture Periodic Alternating Nystagmus
• Head thrust with changes in fixation oculomotor apraxia
Review Old Photos/Videos Palpation of Neck Muscles
• Documentation from early life confirms • In musculoskeletal torticollis, neck muscles are chronic nature tight! • Ask for serial photos from different ages. • Passive straightening of head is difficult
• Rare for cases of ocular torticollis to develop extreme neck muscle contracture.
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Occlusion of one eye Occlusion of one eye
• If ocular torticollis is to maintain binocularity, then occluding one eye abolishes or reduces the magnitude of the posture
• This testing can be falsely negative if chronic problem has led to “habit” posture in addition to original compensatory head position
• Particularly helpful in children with head tilt
Vision Refraction
• Check first in preferred head position • Essential part of exam • Then check in forced primary position • Cycloplegic retinoscopy necessary in children
• Trial of spectacles may eliminate head posture
Eye Movements Measuring the Head Posture
• Versions & Ductions • In addition to documenting the orientation of • Alternate cover testing the posture, estimate the angle. • Nine gaze positions (+tilts)
• This may assist in documenting change over • Helps identify incomitant strabismus or time. nystagmus null zone
• Special attention to position opposite that of the preferred abnormal orientation.
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Visual Fields Fundus Examination
• Automated perimetry or Confrontation Visual • Evaluate for abnormalities Fields – Retinal traction? • Looking for Hemifield or Altitudinal defect – Fundus Pathology?
• Evaluate for low-amplitude nystagmus
• Evaluate for cyclotropia
Fundus Examination Summary
Kwang et al, 2013 Hoyt & Taylor, 2013
Summary References
• Caldeira JAF. Abnormal head posture: an ophthalmological • First, help yourself: Determine type of head approach. Binocular Vis Strabismus 2000; 15:237-39 posture • Hoyt C, Taylor D. Pediatric Ophthalmology & Adult Strabismus, 4th Ed. Elsevier Saunders, 2013: 822-835, 1030-1032. • Kraft SP, O’Donoghue EP, Roarty JD. Improvement of compensatory head postures after strabismus surgery. Ophthalmology 1992; • Second, use your “toolbox” to narrow 99:1301-08 • Kushner, BJ. Ocular causes of abnormal head postures. differential Ophthalmology 1979; 86: 2115-25 • Kwang HS et al. Ocular Torsion among patients with intermittent exotropia. Relationships with disease severity factors. American Journal of Ophthalmology. Vol 155 (1) 177-182, Jan 2013. • Communicate the information to your doctor. • Van Heuven WAJ, Zwaan J. Decision Making in Ophthalmology: An They, and the patient will be grateful. algorithmic approach, 2nd Edition, pp. 156-157.
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