Skew deviation

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Skew deviation is an unusual ocular deviation (strabismus), wherein the eyes move upward (hypertropia) in opposite directions. Skew deviation is caused by abnormal prenuclear vestibular input to the ocular motor nuclei, most commonly due to brainstem or cerebellar stroke. Other causes include multiple sclerosis and head trauma. Skew deviation is usually characterized by torticollis (head tilting) and binocular torsion. The exact pathophysiology of skew deviation remains incompletely understood. Skew deviation appears to be a perturbation of the ocular tilt reaction, which is itself is most likely a vestigial righting response used to keep fish and other lateral-eyed animals properly oriented. [1]

There are three types of skew deviations: [2]

Type 1: Upward deviation of both eyes; sound-induced vestibular symptoms; both eyes show counterclockwise rotary upward rotation

Type 2: Hypertropia in one eye; dorsolateral medullary infarctions; excyclotropia in the ipsilateral eye; hypertropia in the contralateral eye

Type 3: Simultaneous hypertropia one eye and hypotropia in the other eye; upper brainstem lesion

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Hypertropia is a condition of misalignment of the eyes (strabismus), whereby the visual axis of one eye is higher than the fellow fixating eye. Hypotropia is the similar condition, focus being on the eye with the visual axis lower than the fellow fixating eye. Dissociated vertical deviation is a special type of hypertropia leading to slow upward drift of one or rarely both eyes, usually when the patient is inattentive.

Listing's law, named after German mathematician Johann Benedict Listing (1808–1882), describes the three-dimensional orientation of the eye and its axes of rotation. Listing's law has been shown to hold when the head is stationary and upright and gaze is directed toward far targets, i.e., when the eyes are either fixating, making saccades, or pursuing moving visual targets.

The Parks–Bielschowsky three-step test, also known as Park's three-step test or Bielschowsky head tilt test, is a method used to isolate the paretic extraocular muscle, particularly superior oblique muscle and trochlear nerve, in acquired vertical double vision. It was originally described by Marshall M. Parks.

The ocular tilt reaction (OTR) comprises skew deviation, head tilt and ocular torsion involving structures of the inner ear responsible for maintenance of balance of the body i.e. the semi-circular canals (SCC), utricle and saccule.

References

  1. Brodsky, Michael C.; Donahue, Sean P.; Vaphiades, Michael; Brandt, Thomas (March 1, 2006). "Skew Deviation Revisited". Survey of Ophthalmology. 51 (2): 105–128. doi: 10.1016/j.survophthal.2005.12.008 . PMID   16500212.
  2. Brandt, T.H.; Dieterich, M. (1991). "Different types of skew deviation". Journal of Neurology, Neurosurgery, and Psychiatry . 54 (6): 549–550. doi: 10.1136/jnnp.54.6.549 . PMC   488598 . PMID   1880519.

Further reading