Compensatory Head Posture Research Articles

Functional Benefits of Adult Strabismus Surgery

The most common functional benefits from strabismus surgery in the adult patient are restoration of binocular vision and elimination of diplopia and/or a compensatory head posture. Adult patients with chronic strabismus have been thought to have the potential to achieve only a cosmetic result from surgery. On the contrary, several studies have shown that unexpected sensory fusion is possible after excellent postoperative motor alignment in these patients. Other functional benefits of strabismus surgery in the adult patient include the expansion of binocular visual fields in patients with esotropia and the psychosocial and economic benefits from restoration of ocular alignment. This paper will explore the impact of untreated strabismus in the adult patient and what changes occur in the patient's quality of life once strabismus has been successfully treated.

Congenitally Dysplastic Inferior Rectus Muscle

The authors report an unusual presentation of an idiopathic congenitally dysplastic inferior rectus muscle that responded well to surgical correction. Isolated unilateral enlargement of extraocular muscles is rare in children, and there is no definite logical explanation for its cause. A 20-month-old child presented with a congenitally enlarged posterior part of the right inferior rectus muscle with prominent hypotropia and enophthalmos since 10 months of age. Systemic disease work-up, ultrasound B-scan, computed tomography of the orbit and brain, and inferior rectus muscle biopsy were performed. Preoperatively, the child had severe hypotropia of the right eye with retraction of the globe. Work-up for systemic diseases was negative. Computed tomography scan showed thickening of the posterior two-thirds of the inferior rectus muscle. Muscle biopsy showed non-specific fibrotic changes. Strabismus surgery was undertaken at 2 years of age. Hypotropia was reduced significantly postoperatively. Compensatory head position was eliminated.

Dysphagia in spinal muscular atrophy type II

In patients with spinal muscular atrophy (SMA) type II, feeding problems and dysphagia are common, but the underlying mechanisms of these problems are not well defined. This case control study was designed to determine the underlying mechanisms of dysphagia in SMA type II. Six children with SMA type II and 6 healthy matched controls between 6.4 and 13.4 years of age were investigated during swallowing liquid and solid food in 2 different postures using surface EMG (sEMG) of the submental muscle group (SMG) and a video fluoroscopic swallow study (VFSS). The VFSS showed postswallow residue of solid food in the vallecula and above the upper esophageal sphincter (UES), which can be responsible for indirect aspiration. Better results in swallowing were achieved in a more forward head position. These findings were supported by the sEMG measurements of the SMG during swallowing. Dysphagia in spinal muscular atrophy type II is due to a neurologic dysfunction (lower motor neuron problems from the cranial nerves in the brainstem) influencing the muscle force and efficiency of movement of the tongue and the submental muscle group in combination with a biomechanical component (compensatory head posture). The results suggest an integrated treatment with an adapted posture during meals and the advice of drinking water after meals to prevent aspiration pneumonias.

Ocular muscle and eyelid surgery in thyroid-associated orbitopathy.

The aim of ocular muscle surgery in Graves' disease is to determine how an optimal normalization of ocular motility disorders - diplopia, compensatory head posture, eyelid dispositions - can be achieved. The results of ocular muscle surgery of fibrotic ocular muscles allow the following conclusions to be drawn. Correcting the motility disorder can be precisely dosed by recessing only one fibrotic ocular muscle with a strabismic angle of up to 15 degrees. This leads to reproducible and dependable results, with a dose-effect coefficient independent of the initial strabismus angle. Indications as to the amount of surgery and which side should be varied according to horizontal an vertical deviations, and are also dependent on the compensatory head posture. Improvement of the binocular visual field is possible in nearly all cases. Over corrections occur more often when the muscle is not directly fixed at the sclera but adjusted on the following day. The time factor is important both before and after the operation. Before the operation, the motility status should have been stable for at least six months. Postoperatively, within the first few days, an insufficient correction should be expected, however this should not lead to premature revision of the amount of surgery. The surgery of the vertical rectus muscles influences the eyelid position. The upper lid retraction is improved with surgery on the vertical extraocular muscle and depends on prior upper lid motility. In contrast, an increase in lower lid retraction is not dependent on an inferior rectus recession. The results permit a precise series of steps to be drawn up in Graves' disease regarding surgical indications, proportionally correcting each side, and the dosage of ocular muscle operations.

Modified method for assessment of the binocular fusional field in patients with suppression

To evaluate the usefulness of a new system using a modified Goldmann perimeter and Bagolini striated glasses for quantitative assessment of the binocular fusional field (BFF) in patients with suppression. The BFF was assessed quantitatively in ten normal patients aged 10 to 15 years by using a modified Goldmann perimeter equipped with a xenon light source. Subjective perception was elicited with the use of a crossed or single oblique streak through Bagolini striated glasses. The BFF in 15 strabismic patients with suppression were analyzed at their initial visit and at their last visit after therapy. In normal patients, extent points of the BFF on every 15 degrees meridian ranged from 48 degrees to 56 degrees . The normal BFF drawn from these average points was approximately equal to the previously published normal format of binocular single vision for strabismic patients with diplopia. Additionally, this scoring system for BFF provided quantitatively objective information during the course of their extraocular disorder in 15 strabismic patients with suppression. This new method of assessing BFF in patients with suppression can be helpful for evaluation of quantitative effects in the course of treatment for an extraocular disorder and compensatory abnormal head position.

Stereoacuity before and after operation of parks shift of neutral zone in congenital nystagmus combined with paralytic strabismus in modified Kestenbaum

Objective To evaluate thestereoacuity before and after operation of Parks shift of neutral zone in congenital nystagmus combined with paralytic strabismus. Methods Using stereograms and near stereo-acuity chart, preoperative measurement of distance and near stereoacuity in primary gaze position and neutral zone were qualitatively and quantitatively determined in 27 congenital nystagmus combined with paralytic stra-bismus. After parks shift of neutral zone, streroacuity measurement was evaluated by the similar method. The grade of stereoacuity before and after operation was analyzed Rusults Nystagmus was disappeared or obviously re-lieved in the primary gaze position, vision was improved 2-5 lines, and compensatory head posture was eliminated or improved after operation in 27 cases. The stereoacuity was gradually improved from 800 to 60 seconds of arc, peripheral to macular stereoacuity, and even foveal stereoacuity. Conclusion Congenital nystagmus combined with paralytic strabismus may partly have stereoscopic vision. The stereoscopic vision in neutral zone may be bet-ter than in non-neutral zone. The nystagmus, compensatory head posture, and distance and near stereoscopic vi-sion were improved after operation of Parks shift of neutral zone. Key words: Congenital nystagmus; Paralytic strabismus; Stereoacuity

Compensatory head posture and neck problems: is there an association? A cohort study of nystagmus patients

The aims of this study were twofold: to investigate if a compensatory head posture due to nystagmus causes long-term neck problems or adversely effects quality of life and to survey ophthalmologists on their opinions and management of these patients. A case-controlled study was carried out to assess the range of neck movements in patients with compensatory head posture due to congenital nystagmus. Exclusion criteria included known neck problems, vertebrobasilar insufficiency, and age less than 16 years. Neck movements were assessed using an inclinometer. Quality of life and disability was assessed using the American Academy of Orthopaedic Surgeons' Cervical Spine Questionnaire. One hundred and fifty consultant ophthalmologists throughout the United Kingdom were surveyed via a postal questionnaire. The range of motion in these patients (n=20) was limited when compared to matched controls especially for lateral flexion (P=0.001) and extension (P=0.003). However, despite limited movement, patients did not perceive a disability and there was no adverse effect on quality of life. In all 55% of ophthalmologists believed compensatory head posture due to nystagmus leads to long-term neck problems. About 46% had personal experience of patients with long-term neck problems due to nystagmus. Eighty-four per cent were influenced in their decision to operate by the presence of a head posture. Significant restriction in neck movements exists in nystagmus patients with compensatory head posture, although this does not appear to adversely affect quality of life.

Novel and Recurrent KIF21A Mutations in Congenital Fibrosis of the Extraocular Muscles Type 1 and 3

To characterize the disease-causing mutations and associated clinical phenotypes in 5 Chinese families with congenital fibrosis of the extraocular muscles (CFEOM). Ophthalmic investigations included visual acuity, levator function, documentation of compensatory head position, ocular motility, and slitlamp and fundus examinations. The kinesin family member 21A gene (KIF21A) was sequenced for mutation detection. Genotyping and linkage analysis were performed for the KIF21A/FEOM1 and FEOM3 loci. Four families were clinically classified as having CFEOM type 1 (CFEOM1) with full expression of severe ptosis and ophthalmoplegia. One family had CFEOM type 3 (CFEOM3) with typically varying expression of phenotypes between individuals. Recurrent heterozygous KIF21A mutations were identified in 2 CFEOM1 families (2860C>T) and the CFEOM3 family (2861G>A). In another CFEOM1 family, a novel missense mutation (84C>G, C28W) was revealed. The novel KIF21A mutation 84C>G demonstrated in a CFEOM1 family affects the kinesin motor domain, supporting that mutations may also occur outside the commonly involved coiled-coil domain. The 2861G>A mutation found in a CFEOM3 family has been previously reported in CFEOM1, further supporting that different phenotypes can arise from identical mutations. Clinical Relevance Clinical and genetic characterization are complementary tools for diagnostic, prognostic, and treatment purposes in CFEOM.

Treatment of Duane's retraction syndrome by recession of medial and lateral rectus muscles combined with Y-splitting procedure

To investigate the new surgical method and effect of treatment of Duane's retraction syndrome by recession of medial and lateral rectus muscles combined with Y-splitting procedure. Eight patients with Duane retraction syndrome underwent surgery. Among seven cases of normal direction Duane's retraction syndrome, Six patients were performed recession of medial and lateral rectus muscles with Y-splitting of lateral rectus muscle, one patient was performed recession and Y-splitting of lateral rectus muscle. One patient with inverse Duane's retraction syndrome was performed bilateral recession of medial and lateral rectus muscles combined with Y-splitting of both medial rectus muscles. All patients were followed up 1 to 12 months. Ocular alignment, ocular motility and change of compensatory head posture were evaluated. The compensatory head posture, upshoot or downshoot were eliminated. Globe retraction and narrowing of palpebral fissure got improved. Postoperative ocular alignment of 6 cases achieved orthophoria, with 2 cases of residual strabismus. Recession of medial and lateral rectus muscles combined with Y-splitting procedure is an effective method for treatment of Duane's retraction syndrome, aiming at correction of ocular deviation and head posture and elimination of globe retraction.

Operative Korrektur des Retraktionssyndroms

A causative therapy for Duane's retraction syndrome, which is the most prominent example of connatal ocular misinnervation, does not exist. Eye muscle surgery is indicated in cases with manifest strabismus in primary position and an annoying compensatory head posture to maintain binocular single vision. Different surgical approaches to the different types of Duane's retraction syndrome, mostly on the affected eye but also on the fellow eye, are described in the literature. We retrospectively analyzed the pre- and postoperative findings of 55 patients in whom we performed surgery because of Duane's retraction syndrome during the years 1999 to 2004. The type of retraction syndrome, the angle reduction in primary position and the reduction of head posture were evaluated in regard to the surgical procedure chosen. In 37 cases surgery was primary. In 25 cases a single recession of the medial rectus (16 cases) or the lateral rectus (9 cases) muscle of the affected eye was performed. For a dose-response relationship of the one-muscle recessions, the mean angle reduction in the primary position was 2 pdpt (cm/m) per mm recession. The mean reduction of head posture was 1.5 degrees per mm recession. In 10 cases combined surgery on the affected eye was performed. The correlation between the mean angle reduction and the recession was 3 pdpt (cm/m) per 1 mm. Depending on the type of retraction syndrome, the angle in primary position, the head posture and the globe retraction, different surgical options exist which aim at rehabilitation of the patient suffering from Duane's retraction syndrome.

Oculomotor nerve palsy in childhood

Background: The management of children with oculomotor nerve palsy is complicated by their variable presentation, amblyopia, potential loss of binocularity, and associated neurological disease. Our purpose was to evaluate the causes, neurological associations, treatment, and sensorimotor outcomes of a group of children who developed oculomotor nerve palsy Methods: We identified 18 children aged 14 years or younger, of whom 13 (72%) were less than 8 years old, through a retrospective record review of all children with oculomotor nerve palsy seen between January 1995 and January 2001 by one of the authors (C.J.L). Results: Congenital-onset oculomotor nerve palsy was the most frequent presentation, followed by traumatic, neoplastic, vascular, and migrainous or parainfectious etiologies. Pupil sparing was seen in I patient with neoplastic etiology. Primary aberrant regeneration was the presenting sign in a child with neurofibromatosis type 2. Amblyopia developed in 7 (39%) children and was successfully treated in 5 of the 7 (71%). Stereopsis was maintained in 6 (33%) children of whom 2 were within the amblyogenic age group. Six (33%) patients underwent strabismus surgery, and 3 of them (50%) achieved orthotropia and maintained stereopsis. Interpretation: Children with oculomotor nerve palsy require neuroimaging. Their pupillary signs, unlike those of adults, are not helpful in differentiating compressive etiologies from other causes. Good visual acuity was obtained in children within the amblyogenic age group with appropriate occlusion therapy. Stereopsis was uncommon in children who developed third nerve palsy during the amblyogenic period; preservation of stereopsis was dependent either on rapid and complete recovery, or on the child’s adoption of a compensatory head position.

Stereoacuity before and after operation of Parks shift of neutral zone in children with congenital nystagmus

To evaluate thestereoacuity before and after operation of Parks shift of neutral zone in children with congenital nystagmus. Using Yan's synoptophore random-dot stereograms and near stereoacuity chart, preoperative measurement of distance and near stereoacuity in primary gaze position and neutral zone were qualitatively and quantitatively determined in 21 children with congenital nystagmus. After Parks shift of neutral zone, streroacuity measurement was evaluated by the similar method. The grade of stereoacuity before and after operation was analyzed. Nystagmus was disappeared or obviously relieved in the primary gaze position, vision was improved 2 - 5 lines, and compensatory head posture was eliminated or improved after operation in 21 cases. The stereoacuity was gradually improved from 800 to 60 seconds of arc, peripheral to macular stereoacuity, and even foveal stereoacuity. Children with congenital nystagmus may partly have stereoscopic vision. The stereoscopic vision in neutral zone may be better than in non-neutral zone. The nystagmus, compensatory head posture, and distance and near stereoscopic vision were improved after operation of Parks shift of neutral zone.

A Case of Different Null Zones for Distance and Near Fixation

A compensatory head posture (CHP) is a common clinical feature of congenital motor nystagmus. It is usually caused by an eccentric null zone, which is the eye position where the nystagmus intensity (amplitude x frequency) is least. A patient adopts the posture to maximize the binocular visual acuity. Occasionally, a patient may have more than one null zone, leading to the adoption of different CHPs at various times.A 10-year-old boy with congenital motor nystagmus and orthophoria, and with good corrected vision in both eyes, presented with a face turn that had been noted since infancy. For distance fixation, he consistently adopted a left face turn due to a null zone in right gaze. For near fixation, he adopted a right face turn due to a null zone in left gaze. Eye movement recordings confirmed the different locations of the null zones for distance and near fixation.After a trial of base-out prisms to stimulate convergence, which eliminated his head posture at both positions, he underwent artificial divergence surgery. He has had a satisfactory result for 18 months after surgery with a satisfactory head posture and a well-controlled exophoria.Measures to induce convergence, with prisms and then surgery, can be an effective strategy to correct the head postures caused by two different null zones in a patient with congenital motor nystagmus.

The “Worth” of the Worth Four Dot Test

Worth's four dot test was first described one hundred years ago. Despite many technological advances in equipment and techniques during the last century, this simple test is still used routinely by many strabismus specialists. It is an invaluable test when used in the evaluation of long-standing and acquired strabismus in adults and in the management of complex diplopia. Techniques using the test include selecting an optimal prism, assessing the effect of a prescribed prism or compensatory head posture on the range of binocular single vision, identifying non-organic responses, differentiating monocular from binocular diplopia, especially when they co-exist, and blurred from double vision in older patients with divergence paresis. It also can be used with prisms preoperatively to determine the risks of postoperative diplopia and give clues to the presence of torsion or a visual field defect.

Surgery for Strabismus Secondary to Ethmoid Sinus Surgery

To review the outcome of surgery for strabismus due to ethmoid sinus surgery. The series comprised 13 cases, 1 of inferior rectus paresis, 1 of superior oblique paresis, 6 of medial rectus paresis, and 5 of medial rectus muscle palsy due to third nerve palsy. In the cases of paresis of the rectus muscle, resection of the rectus muscles was mainly performed. In the cases of palsy of the rectus muscle, transposition of the extraocular muscle with simultaneous recession of the lateral rectus muscle was performed. The major aim of surgery was to bring both eyes into alignment and to eliminate diplopia in the primary position. The mean preoperative horizontal deviation of 18.1 degrees of exotropia in the paresis cases was reduced to 1.4 degrees of exotropia after surgery. The mean preoperative vertical deviation of 3.8 degrees of hypertropia was reduced to 1.4 degrees of hypertropia postoperatively. The mean preoperative horizontal deviation of 35.6 degrees of exotropia in the palsy cases was reduced to 9.4 degrees of exotropia after surgery. The mean preoperative vertical deviation of 2.0 degrees of hypertropia was increased to 2.6 degrees of hypertropia postoperatively. Postoperatively, diplopia was absent in 11 cases with a slightly compensatory head posture. Surgery for strabismus due to sinus surgery induces improvements in eye position and diplopia.

Surgical management of anomalous head posture because of horizontal gaze palsy or acquired vertical nystagmus.

To confirm the effectiveness of the Kestenbaum-Anderson principle in the surgical management of compensatory head posture because of horizontal gaze palsy and acquired vertical nystagmus. Nine patients with anomalous head posture because of horizontal gaze palsy, and four patients with acquired vertical nystagmus and oscillopsia and compensatory torticollis underwent surgery according to the Kestenbaum-Anderson principle. As in the treatment of congenital nystagmus, the eyes have to be shifted in the orbits, in the direction of anomalous head posture. Homonymously based prisms were used preoperatively to assess the potential benefit of surgery. At the time of surgery, the clinical conditions of the patients had been stable for at least 1 year. After surgery, compensatory head posture and visual performances improved in all cases and the results remained stable for at least 2 years. Contrary to what is generally believed, the ocular condition of the patients with compensatory head posture secondary to neurological causes can be often improved with surgery. The aim of surgery is obviously not to modify ocular motility, but rather to improve the head position.

Clinical rationale for manifest congenital nystagmus surgery

Although electronystagmography is most useful, especially in furthering our knowledge of nystagmus, simple clinical study is the first step to any understanding of nystagmus. Ophthalmologists should be aware that they may understand a good deal about nystagmus merely by studying visual acuity in their surgery. Testing visual acuity at distance with both eyes open will lead to the qualitative and quantitative diagnosis of compensatory abnormal head postures. Testing at distance with 1 eye covered will help to distinguish between the concordant head turn, one eye fixing in abduction and the other fixing in adduction (ABD + ADD) as manifest congenital nystagmus, and the discordant head turn in which each eye fixes in adduction (ADD + ADD), as is seen in manifest latent nystagmus, for which surgery is totally different. Pseudolatent nystagmus found in congenital nystagmus with exophoria can be differentiated from latent nystagmus. This illustrates de visu (with the naked eye) the “beauty” of the movement of blocking fusional convergence and the nature of the involved mechanisms with artificial divergence surgery. Testing at near will bring out the existence of blocking convergence. Depending on the results, the clinical rationale for surgery is thus made clear: horizontal, vertical, rotatory Kestenbaum-like surgery should be used in cases of abnormal head posture, whereas artificial divergence surgery is our most satisfactory armamentarium in cases of blocking convergence. (J AAPOS 2000;4:67–74)

Torcicolo

Torcicolo e posição viciosa da cabeça (PVC) são termos empregados para descrever a condição de um desvio cefálico relativamente ao tronco. Isso pode ser devido a uma causa ortopédica (defeitos das vértebras cervicais, contraturas musculares) ou a uma ocular, representando ajustamentos para compensação de desequilíbrios oculomotores (estrabismos ou heteroforias incomitantes, bloqueio de nistagmos, fixação com um olho mal posicionado na órbita, blefaroptoses e outras menos freqüentes). A quantificação da PVC suscita uma análise sobre problemas conceituais (critérios e referenciais) e operacionais a ela relacionados. O diagnóstico diferencial entre causas ortopédicas e oculares é determinado por manobras de movimentação passiva da cabeça relativamente ao tronco e por exame do equilíbrio oculomotor (teste de cobertura, rotações oculares). Comprovando-se um fator causal ocular, sua correção é buscada por uma cirurgia que lhe seja específica, basicamente a de reposicionamento adequado do olho fixador em sua órbita e de anulação do ângulo de um estrabismo, se houver. Vários exemplos práticos são comentados.

Compensatory head posture changes in patients with obstructive sleep apnea.

The upper airway narrowing and changes in head posture and their relationship with apnea severity in patients with obstructive sleep apnea (OSA) were investigated. In 86 male OSA patients and 37 healthy men, one-night polysomnographic examination was performed and a lateral cephalogram by digital image processing system was taken in each subject. Fifteen variables concerning the upper airway dimensions, area and head postures were measured by using a computer software (NIH Image). The results showed that upper airway dimensions in the OSA group at all levels were significantly smaller than those in the control group and the results hold true when the age and body mass index were well controlled in these two groups. Significant forward inclination of the cervical column was found in the patients with an apnea index (AI) greater than 35 episodes/h. And changes in the head posture variables in the whole study group were significantly correlated with AI and airway dimensions at various levels. It was suggested that there exist significant and extensive upper airway narrowing in OSA patients even in upright position and awake state; And as the apnea severity progresses, patients may assume certain compensatory head postures in an attempt to maintain an adequate airway patency.

Duane Syndrome

Duane syndrome is an eye movement disorder characterized by marked limitation or absence of abduction and variable limitation of adduction in most cases. Characteristics in adduction include globe retraction, palpebral fissure narrowing, and vertical eye movements. Duane syndrome is predominantly found in females, left eyes, and unilaterally.Clinical findings reviewed include primary position ocular alignment, saccadic velocity, globe retraction, palpebral fissure narrowing, upshooting and downshooting, compensatory head postures, anisometropia, amblyopia, and sensory adaptations. Other points discussed are inheritance patterns, etiology, acquired Duane syndrome, and surgical implications.The etiology of Duane syndrome is an enigma. Various histopathologic, neurogenic, and embryologic findings are reported in the literature in an effort to explain reasons for the clinical manifestations of this complex syndrome. Electromyography (EMG), electro-oculography (EOG), auditory evoked potentials, and autopsy were used to test these theories.Congenital anomalies related to Duane syndrome include ocular, skeletal, auricular, and neural structures. Duane syndrome and its relationship with Goldenhar, Klippel-Feil, Wildervanck, and Okihiro syndromes will also be reviewed.