4/17/2017 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 1 4/17/2017 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 2 4/17/2017 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 3 4/17/2017 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 4 4/17/2017 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 5 4/17/2017 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. 6 4/17/2017 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. 7 4/17/2017 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. 8 .