1. Working out head tilts & face turns
LIONEL KOWAL
RANZCO SQUINT CLUB
Dunedin 2005

2. Q1: Is HT driven by visual activity?
Instruction to patient:
Close your eyes and hold your head straight.
Uncertain: pt closes eyes, Dr tilts head randomly, pt asked to straighten head
When assessing a pt with head tilt, the 1st thing to do is to determine whether it
is driven by vision. So: tell the pt to close their eyes, and with the eyes closed
to hold the head straight. If there is no clear result, tilt the head in 1-2 random
directions and ask the pt to straighten the head.

3. Both eyes closed - HT persists
HT not related to visual activity!
Causes: Vestibular problem / ocular tilt reaction / tectal pathology/ neck problems
If with the eyes closed the head tilt is unchanged then, of course, vision has
nothing to do with the head tilt, and may be due to these other problems. If the
Tilt is substantially improved then one can confidently assume it is visually
driven.
Eyes closed

4. BE closed - HT goes HT driven by visual activity
Now determine: Is HT driven by
Right eye fixing RF
Left eye fixing LF
Either eye fixing EE
Only when both eyes are fixing BE
Both eyes closed - no tilt. Now we need to work out: is the tilt driven by RE, or
by the LE, or by either eye. Or is the head tilt only present when both eyes are
fixing

5. Either eye drives HT Congenital nystagmus with oblique null
Look for other features of CN to confirm
De Decker or Sousa Dias for treatment guidelines
If either eye drives the head tilt, this is probably CN with an oblique null. This
Pt will have other features of CN - horizontal N with fast phase to either side,
There will usually be a convergence null. The eye movement recording will be
typical.

6. Special case: Head tilt to fixing eye
LF drives HT to L
2 causes:
1. Torsional null for LMLN
2. L Orbital reasons
Here we have L tilt driven by L fixation. With RE fixation, there is no tilt. The
Usual cause of this situation is a type of congenital nystagmus with the
awkward name of LMLN. This is usually H, but may have a T component as
well. This should not become a lecture about the different types of congenital
Nystagmus - but you need to know that there are different types.

7. LF drives HT to L 1. Torsional LMLN
Seen in cong ET
Can see fine torsional N on slit lamp
N degrades vision - vision improves when N blocked
This type of N [like any type of N] degrades vision. Vision improves when the
N is blocked. You can often see this N on the slitlamp. LMLN is seen in all
Cases of cong ET, tho’ not all cases of cong ET have the torsional type.

8. LF drives HT to L 1. Torsional LMLN
Preference for fixation in intorsion - HT to fixing eye recruits SO which acts as a ‘brake’ for [& is a null for] torsional component of the LMLN
Usually the dominant eye but can be the ‘wrong’ eye
We need to block the T component of LMLN. This is done by recruiting the SO
Which acts as a ‘brake’ for this type of nytagmus. And of course, the simplest
Way to recruit the SO is to tilt the head to the same side. This is not a fanciful
theory - these changes have been observed [at least in part] with eye mvmt
Recordings and are part of the explanation for the devpt of DVD.

9. Special case: Alternating Head Tilt
LF drives L tilt
RF drives R tilt
= Ciancia’s syndrome
If LF drives head tilt to L and RF drives head tilt to the R, this is the same
Mechanism - a need to see more clearly generates a need to suppress the T
Component of the N. A head tilt recruits SO wch acts as a brake on the N and
Allows clearer vision.

10. Ciancia’s syndrome
Head tilt / face turn recruits a muscle to block the torsional / horizontal component of LMLN  improves vision
T: HT to fixing eye - recruits Sup Obl to ‘brake’ T LMLN
H: FT to fixing eye - recruits Medial Rectus to ‘brake’ H LMLN
Head tilt to fixing eye has been recognised as a frequent accompaniment of
cong ET by Ciancia - Ciancia’s Syndrome is cong ET where a large part of the
clinical presentation is head tilt or face turn or both. If the T component of
the LMLN is being blocked to imporve vision, we need a head tilt to recruit
the SO. If the H component of LMLN is being blocked tto improve vision, we
have a face turn to the same side wch recruits MR wch blocks the N - more on
this shortly.

11. LF drives HT  L 2. Orbital reason
Orbital scarring
Restrictive strabismus esp Graves’
Motor reasons
Sensory reasons - acquired astigmatism from tight muscles
Another reason for head tilt to fixing eye is some orbital pathology, typically
either a tight or deficient muscle. Sometimes a motor problem - a tight muscle -
Can cause a head tilt by inducing astigmatism, and the head tilt lessens the
induced astigmatism. This is not uncommon in thyroid eye disease.

12. HT driven by binocularity
RF = LF = no HT
Strabismus the cause
Tilt R and do a cover test to discover the cause!
And now we get to the best known cause of head tilt - regular strabismus. Either
eye fixing - no tilot; both eyes fixing - tilt.
To unravel the cause, first Tilt the other way, then do a cover test to see what
the head tilt is trying to avoid.

13. Problem with R orbit RF  Head Tilt to L
Sometimes a head tilt to L can be driven by R fixation ,and is then usually due
to something wrong with the R orbit.

14. Face Turn - L Approach the same way as tilt - a few differences
Is the FT visually driven: “Close your eyes and hold your head straight”
If it’s visually driven, is it driven by:
LF RF EE BE ?
Face turns are assessed similarlyto head tilts. Close your eyes and hold your
head straight. If the head is then straightened, work out if the face turn is
Driven by RF, LF, by either eye, or only if both eyes are fixing.

15. Face Turn - Left If driven by:
LF : Fixation- in- adduction for horizontal LMLN or L orbital problem
RF : R orbital problem
EE : cong nystagmus
BE : strabismus
Consider a face turn to the L. similar to assessmsment of head tilt. If driven by
L fixation, this is due to blockage of the H component of LMLN. If driven
By either eye, this is congenital nystagmus. If only driven when both eyes are
Open, this is strabismus

16. Alternating Face Turn 2 causes 1. Ciancia’s syndrome
LF : L FT
RF : R FT
Ciancia’s syndrome: preference for fixation in adduction because [probably] recruiting medial rectus ‘brakes’ horizontal component of LMLN  improved vision
Alternating face turn has 2 causes. One is the H version of ciancia’s syndrome -
If the L wants to see more clearly, then the H component of LMLN has to be
Lessended and this is done by recruiting the LMR, and the best way to do this
is to adopt a L face turn,

17. Alternating Face Turn 2. Periodic alternating nystagmus
‘Regular’ CN with 2 null zones
Much more frequent than suspected esp albinism
CAREFUL FAT SCAN : ANY photos showing FT  R suggest PAN
There is a 2nd cause - PAN. This is MUCH more common than appreciated.
It is a type of congential nystagmus. It is quite common in albinism. At first
glance this will look just like regular cong N with face turn to the L. To the L
Of the null zone there will N with fast phase to the L, to the R of the null zone
there will be N with fast phase to the R. there will be a conveergence null .
After examining the pt for a while you will realsie everything has gone weird,
and you then notice a face turn to the R

18. Alternating Face Turn 2. Periodic alternating nystagmus
Usually asymmetric periodicity = ‘aperiodic’ say, 90% FT  L, 10% FT  R
Prolonged in- office exam
It is usually
Quite asymmetric in timing - the face turn might be to the L for 5 minutes and to
the R for only 30 seconds.

19. Astigmatism Wrong cyl axis can  head tilt
Uncorrected astigmatism : pt uses corner of palpebral fissure to act as ‘pinhole’
A cause of head tilt or face turn you do not want to miss is astigmatism - either
the wrong cyl in the glasses, or the pt adopting a face turn to get better optics
Thru a narrower edge of the palpebral aperture.

20. Working out head tilts & face turns
THANK YOU
Well , this has been a difficult topic - I hope you’ve learnt that it’s prettty
complex, but with a logical approach you should be able to understand and
Then fix any funny head posture,