Compensatory Head Posture Research Articles

Reading Performance and Compensatory Head Posture in Infantile Nystagmus after Null Zone Training.

This study aimed to assess the visual function, reading performance, and compensatory head posture (CHP) in schoolchildren with infantile nystagmus. A total of 18 participants aged between 13 to 18 years old were divided into spectacle (n = 9) and null zone group (n = 9) based on their visual acuity. Visual acuity (LogMAR), contrast sensitivity (Pelli–Robson), reading time and rate (Tobii TX300), and CHP were measured pre and post null zone reading training. Participants in the null zone group received 10 sessions of training (5 weeks). Visual acuity and contrast sensitivity of participants in the spectacle and null zone groups were not significantly different pre and post training. Reading performance, i.e., reading time (z = −1.36; p = 0.173) and reading rate (z = −0.06; p = 0.953), of participants in the spectacle group was not significantly different after 5 weeks. Reading time (z = −2.55; p = 0.011) and reading rate (z = −2.07; p = 0.038 of participants in the null zone group showed significant improvement post training. After 5 weeks, CHP improved in six out of the nine participants (66.7%) of the null zone group and was unchanged in all participants in the spectacle group. Null zone reading training could benefit children with infantile nystagmus in improving reading performance and compensatory head posture.

The surgical therapy of paralytic strabismus caused by trauma

Objective To investigate the surgical therapy timing and efficacy of paralytic strabismus caused by trauma. Methods A retrospective study. Twenty-three patients with paralytic strabismus caused by trauma were collected from Jan. 2016 to Jan. 2018. The effects of different therapy time and methods were analyzed. The follow up time was more than half a year. Results Six of 7 cases with an onset time less than half a year had a good eye position. No diplopia or compensatory head occurred. Of 16 cases with an onset time more than half a year, there were 13 cases with a good eye position, without diplopia or compensatory head posture, but restriction of eye movement was remained in all cases. Conclusion Early and effective treatment is necessary for the paralytic strabismus caused by trauma. The early unconventional treatment combined with a variety of strabismus techniques can relieve diplopia, improve eye position and eye movement and expand the range of binocular monocular vision as soon as possible. Key words: Strabismus, paralytic; Surgical; Trauma

Visual functioning in adults with Idiopathic Infantile Nystagmus Syndrome (IINS)

ABSTRACTPurpose: IINS is associated with mild/moderate visual impairment, strabismus and compensatory head postures (CHP), which can negatively impact quality of life. Standard visual acuity assessments tend to underestimate the effect of IINS on visual functioning. Published evidence on the effect of INS on quality of life is slowly emerging. Our study examines visual functioning of adults with IINS using the National Eye Institute Visual Function Questionairre-25 (VFQ-25).Methods: 38 participants were recruited to participate in the study. All participants underwent detailed clinical examination, as well as appropriate investigations and were asked to complete the self administered VFQ-25.Results: 35/38 participants completed the questionnaire. The mean age of the population was 35.1 years (range 17-64). Mean overall VFQ-25 score at baseline was 65 (SD 13, range 34-91). Participants specifically demonstrated lowest scores for the impact of IINS on mental health, role limitations and dependency. 26/35 of participants were not driving, either due to sub-normal vision, lack of confidence or difficulties with contrast sensitivity.Conclusions: IINS can have a greater than expected impact on an individual’s quality of life, without necessarily causing markedly reduced visual acuity. Our study showed lowest scores in the domains of mental health and wellbeing. Patients also reported reduced visual functioning in driving, which can impact adversely on employability and independence. Visual functioning questionnaires such as the VFQ-25 may provide more functional information on the impact of nystagmus on an individual’s quality of life than objective measures such as high contrast Snellen and/or LogMAR visual acuity.

Horizontal Deviations in Congenital Brown Syndrome.

To report the incidence of horizontal deviations requiring surgical correction in patients with congenital Brown syndrome. In a retrospective study, the medical records of all children who underwent a surgical correction of congenital Brown syndrome at Schneider Children's Medical Center of Israel from 1998 to 2016 were reviewed, analyzing the presence of preoperative primary position horizontal misalignment. Overall, 19 eyes (8 right and 11 left eyes) of 16 patients (7 males, 9 females; mean age: 4.2 ± 2.6 years) were included in this study. Fourteen patients (88%) had surgery for correction of a compensatory head position, including 8 patients (50%) with a head tilt and 6 patients (38%) with a chin-up position, and 2 patients had surgery for primary position hypotropia. All of them underwent a weakening procedure of the superior oblique tendon, by either Z-tenectomy (81%, n = 13) or suture elongation of the superior oblique tendon (19%, n = 3). Fifty-six percent of patients (n = 9) had primary position horizontal deviation before surgery, including 50% (n = 8) exodeviations, ranging from exophoria of 4 prism diopters (PD) to exotropia of 30 PD, and one esotropia of 14 PD. Fifty percent of patients (n = 8) had surgery to correct the horizontal deviation by a recession of either one (31%, n = 5) or two (19%, n = 3) muscles. Mean preoperative horizontal deviation (9.3 ± 3.4 PD) decreased significantly following surgery (1.7 ± 1 PD, P = .001) (paired t test). Significant horizontal misalignment is often present in patients with congenital Brown syndrome and its correction should be considered at the time of surgery. [J Pediatr Ophthalmol Strabismus. 2018;55(2):113-116.].

Correction of Eyes and Lip Canting after Bimaxillary Orthognathic Surgery

Patients who have a lower facial asymmetry with compensatory head posture (developmental facial asymmetry) may have minor temporomandibular (T-M) joint problems and tend to mask their asymmetry by tilting the head for camouflage of their chin deviation. However, this compensatory head posture can give the impression of orbital dystopia and c spine deviation. When these patients undergo bimaxillary orthognathic surgery, orbital canting and head tilting improves gradually without the need for camouflage, and bleary eyes become clearer. We evaluated 13 patients who underwent LeFort I osteotomy combined with bilateral sagittal split osteotomy of the mandible for developmental facial asymmetry to quantitatively observe whole facial postural changes after surgery. Pre-operative and post-operative 1:1 full-face photographs of the patients were analyzed to compare the degrees of head tilting and orbital canting and the sizes of the eye opening. After bimaxillary orthognathic surgery, eye canting decreased from 2.6° to 1.5°, eye and lip lines came closer to parallel, and the degree of head tilting decreased from 3.4° to 1.3°. The eyes also appeared to open wider. Correction of lower facial skeletal asymmetry through bimaxillary orthognathic surgery improved head tilting and orbital canting gradually by eliminating the need of compensatory head posture. Facial expressions also changed as the size of the eyes increased due to the reduction of facial muscle tension caused by T-M joint dysfunction.

Aspects cliniques sensoriels et moteurs des syndromes de rétractions congénitaux : syndrome de Stilling-Duane et syndrome de Brown

Congenital Brown syndrome and Stilling-Duane syndrome, two rare causes of strabismus are caused by fibrosis of one or more extraocular muscles. This series aims to report the clinical sensory and motor features of patients with Brown or Stilling-Duane syndrome. Seventeen patients' records were retrospectively assessed for: the ocular deviation in primary position and in the 9positions of gaze, head tilt, visual acuity and binocular vision. Eleven patients with Stilling-Duane syndrome had a mean age of 12years, and monocular involvement, most frequently of typeI. The ocular deviation was variable; 16patients had an abnormal head position, while 50% presented with amblyopia, and only 37% achieved fusion in the compensatory head posture. Six patients presented with congenital Brown syndrome at mean age of 6years. Three had a moderate form, 3had a severe form with vertical deviation in primary position, compensatory head position, amblyopia and binocular vision impairment. The motility impairments depend highly on the identified syndrome, its classification and its severity. Therefore, these two retraction syndromes present some common features. Strabismus in primary position may lead to amblyopia and binocular vision impairment. Clinical motility and sensory assessment is essential, though difficult, to establish the diagnosis and the management of patients with retraction syndromes.

Evaluation of the Role of Displacement Surgery in the Management of Congenital Nystagmus.

IntroductionThe aim of this study was to assess the effectiveness of displacement surgery in damping of ocular oscillation and management of compensatory head posture in patients of congenital nystagmus.MethodsThis study was carried out in 2014. The participants were 50 patients with congenital nystagmus that dampens in a certain direction of gaze with or without abnormal head posture and with or without strabismus. Patients underwent the augmented modified Kestenbaum (augmented parks) procedure. Data were analyzed by SPSS version 15, using Chi-square text, exact test, and Mann Whitney U test.ResultsIn this study, 12 patients (80%) were noticed clinically to have damping of nystagmus while 3 patients (20%) had no damping of nystagmus. Twelve patients (80.0%) had no post-operative abnormal head position, while 3 patients (20.0%) had residual abnormal head position. There was a statistically significant difference between the pre-operative BCVA in primary position and post-operative BCVA in primary position (p = 0.001 for both right and left eyes).ConclusionThe displacement surgeries (e.g. Kestenbaum procedure) for the treatment of patients with congenital nystagmus is an effective procedure for correction of abnormal head posture, improving the visual acuity in the primary position and damping of nystagmus in patients with congenital nystagmus who have null points away from the primary position.

Nonsurgical and Orthoptic Management of Nystagmus

There are a number of ways orthoptists in pediatric ophthalmology practices can help patients with nystagmus. Treatment of amblyopia by conventional patching or with atropine or Bangerter filters can be monitored by the orthoptist. Optical treatment including manipulation of refractive error or use of contact lenses has been proven to improve visual function. Also, prisms can help determine a surgical plan for an abnormal head posture. If surgery is not indicated, then prisms can improve vision or eliminate the need for a compensatory head posture. This paper will describe in detail the use of prisms in patients with nystagmus.

Nonsurgical and Orthoptic Management of Nystagmus

ABSTRACTThere are a number of ways orthoptists in pediatric ophthalmology practices can help patients with nystagmus. Treatment of amblyopia by conventional patching or with atropine or Bangerter filters can be monitored by the orthoptist. Optical treatment including manipulation of refractive error or use of contact lenses has been proven to improve visual function. Also, prisms can help determine a surgical plan for an abnormal head posture. If surgery is not indicated, then prisms can improve vision or eliminate the need for a compensatory head posture. This paper will describe in detail the use of prisms in patients with nystagmus.

Clinical characteristics and surgical treatment of idiopathic congenital nystagmus in 224 patients

To study clinical characteristics and surgical treatment of idiopathic congenital nystagmus (ICN). A retrospective study was conducted in 224 patients with ICN in Tianjin eye hospital from July 2007 to February 2013. There were 224 patients, 158 (70.54%) males and 66 (29.5%) females, mean age was (11.6±8.4) years and (11.4±6.4) years separately. Horizontal nystgamus happened in 215 cases, 3 cases were vertical type and 6 cases were mixed. 214 cases were with no history of operation and 10 patients had ever underwent surgeries before. Furthermore, 151 patients combined with strabismus and refractive error, anterior segment or retinal disorders, which accounting for 67.4% of all the patients. 48 patients were associated myopia, 30 patients with hyperopia, 43 patients with strabismus. Among them, 153 cases of compensatory head position direction were horizontal with face turn, 43 cases (43/153, 28.1%) showed face turning to the left, 110 cases (110/153, 71.9%) showed face turning to the right. Surgeries were designed according to the compensatory head position and head retroversion angle. For 15 patients with double intermediate zones, the position which was often used with good visual function was chosen for operation design. As for the patients with nystagmus and strabismus, the transfer null zone to primary position for the dominant eye and strabismus surgery for the other eye was chosen. And for complicated patients with compensative head position, the dominant head posture were designed for surgery. ICN is dominated by male with variable clinical manifestations. Surgical choice for ICN depends on the direction of head position and if there is strabismus accompanying it.The aim of ocular muscle surgery is to transfer null zone to primary position. (Chin J Ophthalmol, 2016, 52: 574-578).

Surgery for Supranuclear Monocular Elevation Deficiency

Purpose: We report a novel approach to surgery for monocular elevation deficiency (MED).Methods: A retrospective review of 5 patients undergoing surgery for supranuclear MED between 2003 and 2014. All patients had intact Bell’s phenomenon, hypotropia, limited elevation above the primary position, and negative forced duction testing of the paretic eye. Preoperatively all patients preferred chin-up head posture and three had pseudoptosis or ptosis. One of the 5 had prior vertical muscle surgery. Surgery correction for the MED consisted of near maximal superior rectus recession on the contralateral sound eye.Results: Compensatory chin-up head position and alignment in primary position was improved in all patients. Average age at surgery was 5.3 years. Average superior rectus recession was 9.7 mm. Mean follow-up was 4.8 years (range 12 months to 11.5 years). The vertical deviation of the paretic eye in primary position postoperatively was orthotropic for 2, hypotropic for 2, and overcorrected for 1.Conclusions: In cases of supranuclear MED (double elevator palsy) contralateral superior rectus recession based on the innervational principle is a simple and reliable alternative surgical approach compared to published results of the Knapp transposition procedure. Additionally, it holds the possibility for decreased complications and less complicated future surgical treatment options.

The surgery for congenital nystagmus with strabismus

Objective To investigate the efficacy of different surgeries for congenital nystagmus with strabismus.Methods The data of 24 cases who underment operation for congenital nystagmus with strabismus were retrospectively studied.The surgery was designed based on the location of intermediate zone,compensatory head posture,the degrees of strabismus and the dominant eye.The correction of compensatory head posture was performed in dominant eye and the correction of strabismus was performed in undominant eye.Results All patients were followed up for 3-12 (6.38 ±2.18) months.The compensatory head posture disappeared after surgery in 20 cases(83.33％) and was much improved in 3 cases(12.50％) with residual head tilt within 15° in the original direction.Overcorrection was observed in one case (4.17％).The eye position was normal in 18 cases (75.00％),slight undercorrection or overcorrection in 5 cases (20.83％),and apparent undercorrection in one case (4.17％) after surgery.Nystagmus in the primary position of gaze was reduced or disappeared in all cases.Binocular visual acuity in the primary position of gaze was improved over 2 lines compared with preoperative one in all cases.The binocular visual acuity and degree of head tilt were significantly improved after surgery (P ＜ 0.01).Conclusion Reasonable design of surgery for congenital nystagmus with strabismus can have good clinical efficacy,which should correct strabismus and compensatory head posture. Key words: Nystagmus, congenital; Strabismus; Operation

Clinical features and surgical outcomes of isolated inferior rectus muscle paralysis

Purpose: To describe clinical features of patients with unilateral isolated inferior rectus (IR) muscle paralysis along with type of surgical treatment and results after surgery.Methods: Patients diagnosed with unilateral isolated IR muscle palsy between 2009 and 2012 that required surgical treatment were included in the study. Diagnosis of IR muscle palsy was done by hypertropia with the largest angle in depression and abduction and inferior rectus muscle underaction.Results: Twenty-two patients remained in the study; 17 patients (77.3%) had left eye involvement. IR muscle paresis was traumatic in 12 patients (54.5%), congenital in 9 patients (40.9%), and vascular in 1 patient (4.5%). Limitation of duction in the gaze of IR muscle was −2 to −3 in all cases. 3 patients, paradoxically, had contralateral compensatory head tilt (compensatory head tilt to the opposite side of IR muscle palsy). Intraoperatively, we did not detect any gross abnormalities in the IR muscles. The surgical plan at the first operation was IR muscle resection alone in 13 patients (59.1%). At the last follow-up visit, 15 patients (68%) had no deviations in primary position and downgaze. Three cases needed reoperation.Conclusion: The presence of both ipsilateral and contralateral compensatory head postures in our patients showed that three-step or head-tilt test is not helpful in the diagnosis of IR muscle palsy. In comparison with other studies, more patients in our study were treated with IR muscle resection alone. Also, our reoperation rate was lower than other studies. Absence of gross abnormality in the IR muscles at the operation and partial nature of the paresis may explain these good results. Thus, a considerable number of IR muscle palsy cases with the above characteristics may be treated successfully by one muscle surgery (IR muscle resection).

Clinical progression of untreated bilateral Brown syndrome

To present the natural history of bilateral Brown syndrome in patients without surgical intervention. The medical records of cases of bilateral Brown syndrome not treated surgically with long-term follow-up from 1987 to 2012 were retrospectively reviewed. A total of 9 cases were included. The majority of patients in this series had idiopathic Brown syndrome, were diagnosed in early childhood, and had minimal ophthalmic sequelae. Of the 9 patients, 8 were diagnosed with bilateral Brown syndrome at their first ophthalmologic assessment. The age range at first diagnosis was 3-6 years of age. The mean follow-up period was 7.9 years; the median, 5 years (range, 1-20 years). At the most recent follow-up visit, 6 patients remained orthophoric in primary position; 1 patient had a micro-esotropia; 1 had developed an exotropia of 30 D; and 1 had developed a right hyperphoria. All patients without concurrent horizontal strabismus developed normal stereopsis and visual acuity, with minimal or no compensatory head position or downshoot in adduction. Patients in this case series show minimal, if any, long-term visual impairment.

Abnormal head posture is not equal to compensatory head posture

All head position disorders can be called abnormal head posture, but abnormal head posture is not equal to compensatory head posture. Only abnormal head posture in connection with extraocular muscle disorders can be called compensatory head posture. Compensatory head posture is usually adopted to optimize visual acuity or to obtain single binocular vision. Abnormal head postures involve not only extraocular muscle disorders but also skeletal, muscular, neurologic, otolaryngologic and some eye disorders.

Partial rectus muscle transposition for strabismus with lateral rectus muscles paralysis

To investigate surgical approach for paralytic strabismus with lateral rectus muscles paralysis and evaluate its clinical effects. Design retrospective, observational case series. 28 patients (31 eyes) who underwent augmented partial rectus muscle transposition (APRMT) in the treatment of paralytic strabismus with lateral rectus muscles paralysis from May 2009 to May 2011 at Eye & ENT Hospital of Fudan University were included in this study. The following data were analyzed: (1) The procedure that was performed, (2) The angle of deviation of primary position, (3) The presence of compensatory head posture, (4) The presence of diploma in the primary position, (5) The binocular single visual fields, (6) The motility of the affected eye. According to the results of rectus muscle forced traction test and examination before and after operation, among 31 eyes in 28 patients, 8 eyes were treated with APRMT, 10 eyes were treated with recession of antagonistic muscle of paralytic rectus muscle combined with APRMT, 7 eyes were treated with APRMT and recession of yoke muscle, 6 eyes were treated with APRMT and recession of yoke muscle combined with recession of antagonistic muscle. 17 among 28 patients were orthotopicin the primary position while others were in mild under correction with deviation no more than 10 prism degrees during 5 months (range: 3-8 months) follow-up in average. The diploma and abnormal head posture were eliminated in 26 patients except one patient who was appeared with 10 prism degrees under correction postoperatively and was resolved by wearing prisms thereafter. Binocular single visual fields were extended from 27.0° ± 6.4 ° preoperatively to 40.5° ± 4.8 ° postoperatively (t = -34.692, P < 0.001). Ocular movement was improved from -4.9 ± 0.4 to -2.9 ± 0.9 postoperatively (t = -13.418, P < 0.001). APRMT can safely and effectively correct the primary position in paralytic strabismus with lateral rectus muscles paralysis, eliminate the presence of diploma in primary position and abnormal head posture, and improve the ability of the ocular movement, furthermore, significantly expand the scope of binocular single visual fields. The results also demonstrate that rectus muscle forced traction test is a key measurement to determine the surgical procedure.

Clinical results of Laser in situ Reratomileusis (LASIK) in 14 myopic patients with congenital nystagmus

Objective To explore the effectiveness of LASIK for the myopia with congenital nystagmus.Methods The LASIK for the myopia with nystagmus were performed on 14 patients (28 eyes).The diopters were-5.00D ～-12.00D.All patients were excluded from corneal inflammation,keratoconus and other eye diseases.All of the 14 patients were horizontal impulsive nystagmus.The nystagmus value was 4 ～8 mm,the frequency of the nystagmus were 2 ～ 3 times every second.Ten patients were mild compensatory head-posture,four patients were severe compensatory head-posture.Results After LASIK surgery,the amplitude of nystagmus was smaller than before.The value of nystagmus was 3 ～ 6 mm and the frequency of the nystagmus were 1 ～ 2 times every second.There was no statistical difference between the postoperative naked vision and the preoperative best corrected vision.The average diopter of preoperation was (-5.21 ±0.48 ) D.The average diopter of postoperation was (-0.32 ± 0.25 ) D after 1 year follow-up.Conclusion LASIK for the myopic patients with nystagmus was precise and safe. Key words: LASIK; Nystagmus; Myopia

Absence of the fourth cranial nerve in congenital Brown syndrome

To elucidate the aetiology of congenital Brown syndrome. Four consecutive patients diagnosed with unilateral congenital Brown syndrome had a comprehensive standardized ocular motility examination. Any compensatory head posture was measured. Brain magnetic resonance imaging (MRI) with regard for the IV cranial nerve (CN) was performed in all patients. Orbital MRI was performed in 2/4 patients, with images acquired in eight directions of gaze and superior oblique (SO) muscle areas compared. CN IV could not be identified bilaterally in two patients, but was absent only on the side of the Brown syndrome in the two other patients. On the normal side, orbital MRI revealed a smaller SO muscle area in upgaze than in downgaze, demonstrating normal actions of this muscle. On the side of the Brown syndrome, the SO area remained the same in upgaze and in downgaze and approximately symmetric to the area of SO in downgaze on the normal side. These cases add further anatomical support to the theory of paradoxical innervation in congenital Brown syndrome. CN IV was absent in two patients on the side of the Brown syndrome, but without muscle hypoplasia. SO muscle size did not vary in up- and downgaze, which we interpreted as a sign of constant innervation through branches of CN III.

Secondary or New Compensatory Head Posture after Anderson-Kestenbaum Surgery

To report clinical findings and surgical management of 4 patients with congenital nystagmus who presented with a new or reversal of their original horizontal compensatory head posture (CHP) after Anderson-Kestenbaum (A-K) surgery. Retrospective chart review. All 4 patients demonstrated a 40°-45° horizontal face turn at the time of their initial surgery and 3 underwent 20% and one 30% augmented A-K surgery to correct the CHP. The new CHP or reversal of the original CHP was observed at a mean of 4 years (range 1-9 years) after the initial surgery. The reversed CHPs measured 20°, 40°, 20°, and 20°, respectively. These new or residual CHPs were surgically managed in 3 patients and an acceptable head position was achieved in all patients. This series of patients points out the occurrence of secondary null points and reversed CHP after surgical correction of initial CHP.

Nystagmus and Reduced Visual Acuity Secondary to Drug Exposure In Utero: Long-Term Follow-up

To investigate nystagmus and other visual system abnormalities among children exposed to opiates and benzodiazepines in utero. Retrospective case series comprising clinical examination and case note review of 25 children with nystagmus and reduced vision who were exposed to controlled drugs during pregnancy. Twenty-four children were exposed to opiates, of whom 13 were also exposed to diazepam. One child was exposed to diazepam alone. All children had horizontal nystagmus, which was either fine pendular or jerk type. The nystagmus had a latent element in 4 children and 8 adopted a compensatory head posture. Where the time of onset of nystagmus was known, it was always prior to 6 months of age. At least 9 children (36%) had delayed visual maturation. The mean initial logarithm of the minimum angle of resolution binocular best-corrected visual acuity (BCVA) was 0.54 at an average of 22 months of age. Thirteen children were followed up for 6 months or longer and their BCVA improved to 0.4 at an average age of 48 months. The nystagmus was clinically improved in only 5 patients. Electroretinogram testing was normal in the 4 children tested. The only ocular structural abnormality was binocular optic nerve hypoplasia in 2 children. Exposure to opiates and benzodiazepines in utero may be associated with permanent nystagmus and reduced visual acuity. This is most likely the result of insult(s) to the central nervous system rather than the eyes.