Dr Madhu Karna Consultant Pediatric Ophthalmologist

1. Abnormal head posture
Dr Madhu Karna
Consultant Pediatric Ophthalmologist

2. Normal head posture
Eyes usually remain in frontal plane
gaze away momentary - followed by prompt
repositioning of the head to face the object of regard.
12 grams of force is required (relatively little effort)
to maintain eyes in primary position

3. Maintaining gaze to one side with face straight ahead, is tiring
Natural tendency- rotate the head, facing the object of regard
Gaze to
one side
Gaze to the side- more tension on all horizontally acting
muscles holding the eyes in position

4. How do the eyes get to side gaze?
Saccade
During rapid
refixation muscles
contract up to 100°
gm or more at peak
velocity of 200 /sec.
Velocity depends on
speed of moving
object followed, a few
degrees per sec.
Pursuit
The eyes track in a
slow following
movement
Oculocephalic
Influenced by middle
ear static factors.
Confirms intact
muscle/neural arc
A few degrees/sec.
Depends on head
movement
Eye muscles are under more tension in gaze away from primary

5. Anomalous head posture
• To achieve comfortable vision - to avoid
diplopia, to gain better vision in the
case of nystagmus, find the null.
• Can occur in congenital ET and is
always seen in spasmus nutans.

6. Compensatory Head Posture for Diplopia
The head (face) moves where the eye(s) movement is limited, for
VI N palsy-OD Greater ET in right gaze, less in left gaze
To avoid diplopia the person turns his face right, while the
eyes assume levoversion.
The object of regard is straight ahead by egocentric
localization.

7. The chin is down and the head tilted left
while the eyes look up to the right.
This compensates for both the vertical
and the torsional defect.
Head posture in right superior oblique palsy

8. Other Head Posture Strategies
Brown’s right eye -
Face Up - Left

9. Duane I syndrome (ET)
limited abduction OD -
Face Right

10. SR palsy or
IR restriction
one or both
eyes
Chin Up
Also "A" or
“V”
Patient fusing in down gaze or may
have null nystagmus in down gaze

11. IR palsy with
limited depression
one or both eyes
Chin Down also
with “A” or “V” pattern
fusing in up gaze or
null nystagmus in up gaze

12. Excyclo Torsion
Down Gaze
Bilateral S.O. Palsy Chin Down

13. An anomalous head posture to
attain the null point in horizontal
nystagmus may reverse in cases
of periodic alternating
nystagmus. The “period” may be
up to several minutes

14. In cases of restricted movement of the eye(s) from
mechanical restriction or muscle weakness, resulting in
diplopia, think of the head as the eyeball. The head
moves where the eye cannot. The eyes then move
opposite the head (face) direction to avoid the direction of
limited movement thereby avoiding diplopia

15. THANK YOU