Working out head tilts face turns LIONEL KOWAL

Working out head tilts & face turns LIONEL KOWAL RANZCO SQUINT CLUB Dunedin 2005

Q 1: Is HT driven by visual activity? Instruction to patient: Close your eyes and hold your head straight. l Uncertain: pt closes eyes, Dr tilts head randomly, pt asked to straighten head

Both eyes closed HT persists l HT not related to visual activity! l Causes: Eyes closed Vestibular problem / ocular tilt reaction / tectal pathology/ neck problems

BE closed - HT goes l HT l driven by visual activity Now determine: Is HT driven by – Right eye fixing RF – Left eye fixing LF – Either eye fixing EE – Only when both eyes are fixing BE

Either eye drives HT l Congenital nystagmus with oblique null l Look for other features of CN to confirm l De Decker or Sousa Dias for treatment guidelines

Special case: Head tilt to fixing eye l LF l 2 drives HT to L causes: l 1. Torsional null for LMLN l 2. L Orbital reasons

LF drives HT to L 1. Torsional LMLN l Seen in cong ET l Can see fine torsional N on slit lamp l N degrades vision - vision improves when N blocked

LF drives HT to L 1. Torsional LMLN l Preference for fixation in intorsion HT to fixing eye recruits SO which acts as a ‘brake’ for [& is a null for] torsional component of the LMLN l Usually the dominant eye but can be the ‘wrong’ eye

Special case: Alternating Head Tilt l LF drives L tilt l RF drives R tilt l= Ciancia’s syndrome

Ciancia’s syndrome l Head tilt / face turn recruits a muscle to block the torsional / horizontal component of LMLN improves vision l T: HT to fixing eye - recruits Sup Obl to ‘brake’ T LMLN l H: FT to fixing eye - recruits Medial Rectus to ‘brake’ H LMLN

LF drives HT L 2. Orbital reason Orbital scarring l Restrictive strabismus esp Graves’ l Motor reasons l Sensory reasons - acquired astigmatism from tight muscles l

HT driven by binocularity l RF = LF = no HT l Strabismus l Tilt the cause R and do a cover test to discover the cause!

RF Head Tilt to L Problem with R orbit

Face Turn - L l Approach the same way as tilt - a few differences l Is the FT visually driven: “Close your eyes and hold your head straight” l If it’s visually driven, is it driven by: l LF RF EE BE ?

Face Turn - Left l l l If driven by: LF : Fixation- in- adduction for horizontal LMLN or L orbital problem RF : R orbital problem EE : cong nystagmus BE : strabismus

Alternating Face Turn 2 causes 1. Ciancia’s syndrome l LF : L FT l RF : R FT l Ciancia’s syndrome: preference for fixation in adduction because [probably] recruiting medial rectus ‘brakes’ horizontal component of LMLN improved vision

Alternating Face Turn 2. Periodic alternating nystagmus l ‘Regular’ CN with 2 null zones l Much more frequent than suspected esp albinism l CAREFUL FAT SCAN : ANY photos showing FT R suggest PAN

Alternating Face Turn 2. Periodic alternating nystagmus Usually asymmetric periodicity = ‘aperiodic’ say, 90% FT L, 10% FT R l Prolonged in- office exam l

Astigmatism l Wrong cyl axis can head tilt l Uncorrected astigmatism : pt uses corner of palpebral fissure to act as ‘pinhole’

Working out head tilts & face turns THANK YOU