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Anomalous Head Postures in Strabismus and Nystagmus - Diagnostic and Management

Luminita Teodorescu

Bucharest, Romania



Abnormal head position is adopted in order to improve visual acuity, avoid diplopia or obtain a more comfortable binocular vision. The head can be turned or tilted toward right or left, with the chin rotated up or downwards or combination of these positions. The ophthalmologic examination including the assessment of versions leads to the diagnosis. When versions are free, the cause may be congenital nystagmus or strabismus with large angle. When versions are limited we suspect paralytic or restrictive strabismus. The head tilted to one shoulder suggests cyclotropia (IV Nerve Palsy) or congenital nystagmus. We present few of the above cases. An adequate surgical treatment can improve or correct the ocular deviation, diplopia and the abnormal head posture.

Conclusion: The abnormal head posture must be assessed and treated early in order to correct the ocular position and head posture. Any patient presenting abnormal head position HAS TO BE investigate by an ophthalmologist.



Luminita Teodorescu, MD

OFTAPRO Ophthalmology Clinic Bucharest, Romania
e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.



There is nearly always a significant reason for an abnormal or compensatory head position and the patient often may adopt it unconsciously. The cause may be an ocular, muscular, skeletal or neurological disease. Very rare it may be a habit, without any reason to adopt it.

The most common cause is an ocular disease. The posture is adopted on order to:

  1. Improve visual acuity or obtain a more comfortable binocular vision, like in: unilateral amblyopia, oblique astigmatism, nystagmus
  2. To avoid diplopia – in patients where fusion can be obtained, the deviation and diplopia disappear in the compensatory position. If the cause is an ocular disease, we can do a simple test: occluding one eye prevents diplopia and the compensatory head posture will disappear.
  3. To increase the separation of the images when there is no fusion like in a large angle strabismus

The ophthalmologic examination must emphasize the assessment of ductions and versions: When versions are free, the cause may be a congenital nystagmus, infantile esotropia, dissociated vertical deviation, large deviation with amblyopia.

In congenital nystagmus, the null zone is the position of gaze in which the nystagmus dampened and the visual acuity (VA) is better. When the null zone is not in primary position, the patient adopts a face turn, a head tilt, or a chin up or down position, especially during tasks when better vision for distance is required: TV, testing VA, blackboard. At near, the VA is often better because convergence associated with near vision block the nystagmus and no head turn is needed. Surgery is aimed to improve the head position, i.e. to shift the null zone toward the primary position. The rule is that eyes should always be shifted in the direction of the head posture.

We use as technique, von Noorden “Large Anderson” operation: only 2 recessions of the yoke muscles: 7 mm Medial rectus (MR) recession of the adducted eye 10 mm Lateral Rectus (LR) recession of the abducted eye


 JPSS 2 1 2008

Figure 1: Congenital esotropia with manifest nystagmus, left eye fixing in adduction, head turned toward left, the direction of the left fixing eye – pre-op


Figure 2: Post-op picture after bi-lateral medial rectus recession and no head turn


Figure 3: Congenital nystagmus, left head turn, pre-operative 


Figure 4: Congenital nystagmus, left head turn post-operative


Figures 5, 6: Right VI nerve palsy after trauma, no abduction in the right eye


Figure 6

When versions are limited we suspect, according to the clinical features: III or VI Nerve Palsy, Duane syndrome, general fibrosis syndrome, thyroid ophthalmopathy, orbital fractures.

The rule is: “The head moves where the eye cannot”, in order to avoid diplopia.


  1.  The abnormal head posture must be assessed and treated early in order to correct the ocular position and the head posture
  2. An adequate surgical treatment improves or corrects the strabic deviation, diplopia and the abnormal head posture
  3. In congenital paresis with early surgical treatment the torticolis was resolved, we could prevent the facial asymmetry, the contracture of the neck muscles and the secondary scoliosis
  4. In acquired paralysis we should wait 6 moths to 1year for the spontaneous recovery, even partial. Adequate treatment could obtain fusion.


Figure 7 


Figure 8 


Figure 9 

Figures 7, 8, 9: After right medial rectus recession 6,5mm and half-tendon transfer of the superior and inferior to the lateral rectus insertion.



Figure 10 


Figure 11


Figure 12

Figures 10, 11, 12: Post-op, Right lateral rectus recession 14mm, right medial rectus resection 9mm with up-ward insertion.


 Esotropic Duane syndrome in the left eye:


 Figure 13 esotropia, left head turn


Figure 14 adduction with narrowing of the palpebral fissure and enophthalmos 


Figure 15 limited abduction with widening of the palpebral fissure


Figure 16 post-op picture after bi-medial rectus recession 6mm, head and eyes straight 

The head tilted to one shoulder suggests cyclotropia (IV Nerve Palsy), congenital nystagmus, Brown syndrome or non-ocular causes.

The patient tilts the head to compensate the tilted image.


Figure 17 Left Congenital IV nerve Palsy; Right head tilt, facial asymmetry


 Figure 18 Left hypertropia in primary position


Figure 19 Bielschowsky head tilt test positive: hypertropia increases in tilting the head towards to side of the palsy


Figure 20 Post-op, head straight, ortophoria, after left inferior oblique myectomy and left superior rectus recession