Skew deviation e ocular tilt reaction versus paralisia do nervo troclear / Skew deviation and ocular tilt reaction versus trochlear nerve palsy

Skew deviation é o desalinhamento vertical dos olhos causado por disfunção unilateral no tronco cerebral, cerebelo ou sistema vestibular periférico, comprometendo as vias por onde transitam impulsos dos órgãos otolíticos aos núcleos oculomotores. Está frequentemente associado a torção ocular e inclinação da cabeça, compondo, assim, a ocular tilt reaction. Neste artigo os autores ressaltam aspectos históricos, fisiológicos, etiopatogênicos e clínicos que contribuem para caracterizar ambas as condições, além da diferenciação clínica com a paralisia do nervo troclear.

Skew deviation is the vertical misalignment of the eyes caused by unilateral dysfunction in the brain stem, cerebellum or peripheral vestibular system, resulting imbalance in otolith input to the oculo-motor system. It's often associated with ocular torsion and head tilt, which together comprise the ocular tilt reaction. In this article the authors emphasize the historical, physiological, etiopathogenesis and clinical aspects that contribute to characterize both conditions, and help to differentiate them clinically from trochlear nerve palsy.

Wall-Eyed Monocular Internuclear Ophthalmoplegia (WEMINO) with Contraversive Ocular Tilt Reaction

Wall-eyed monocular internuclear ophthalmoplegia (WEMINO) with contraversive ocular tilt reaction has not been previously reported. A 71-year-old woman suddenly developed blurred vision. Examination revealed left internuclear ophthalmoplegia, left exotropia, right hypotropia, and rightward head tilt. Magnetic resonance imaging showed a tiny infarction at the area of the left medial longitudinal fasciculus in the upper pons. WEMINO with contraversive ocular tilt reaction may be caused by a paramedian pontine tegmental infarction that selectively involves the medial longitudinal fasciculus.

Ocular Tilt Reaction

PURPOSE: To report the clinical manifestations of patients with ocular tilt reaction (OTR) and the differential point from other disorders with abnormal head posture. METHODS: The clinical manifestations of four patients who complained of abnormal head posture and diplopia and who were diagnosed to have OTR from January, 2001 to January, 2002 were investigated. The diagnoses were made with alternate cover test, duction and version test, Lancaster test, Bielschowsky head tilt test, fundus photography, and brain MRI. RESULTS: All the four patients showed ipsilateral head tilt, ocular torsion, and vertical deviation. Type of their OTR was tonic OTR. Subjective tilting of visual vertical was observed in one patient. Only with the 3-step test, OTR could be misdiagnosed as an extraocular muscle palsy. The most important sign in differentiation from other disorders of abnormal head posture was ocular torsion. Duction and version examination and tilt of subjective visual vertical were also helpful for the differentiation. CONCLUSIONS: OTR should be considered in patients with ocular torsion, vertical deviation and ipsilateral head tilt. In patients with diplopia and head tilt, examination of ocular torsion should be performed with the 3-step test in order not to make a misdiagnosis of extraocular muscle palsy.