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Strabismus > AHP > Flashcards

AHP Flashcards

1
Q

Normal head posture

A

When the body is erect and facing forwards. The median plane of the head is continuous with the median plane of the body

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2
Q

AHP aka compensatory head posture causes

A

Ocular cause or Non ocular

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3
Q

Ocular cause

A

Used to regain BSV and alleviate diplopia

The abnormal position of the head may consist of
Face turn to R or L, Chin elevation or depression, Head tilt to R or L shoulder

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4
Q

Torticollis is a combination of

A

Tilt and turn

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5
Q

Non ocular causes of AHP long

A

Congenital- Contracture of sternocleidomastoid muscle in neck
Head tilt to affected side
Head turn to unaffected side
May adopt chin elevation (head up)

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6
Q

Non ocular causes of AHP acq

A

Acquired- Deafness - unilateral/ asymmetrical - Head turn to more affected side
Shyness- Often chin depression (Head down) and variable
Mental retardation- Often variable AHP
Habit
Neurological – brain tumour
Arthritis / rheumatism
Disorders/ injuries of spine

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7
Q

Do non ocular AHP patients have ocular problems

A

Generally patients with non-ocular AHP do not c/o ocular problems, but if referred, should undergo careful motility examination to rule out co-existing motility disorders

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8
Q

Ocular causes of AHP

A

Obtain/ maintain BSV- Incomitant strabismus, A & V patterns
Separate diplopic images further- Insuperable diplopia
Gain foveal fixation- Infantile esotropia, Gross limitation preventing foveal fixation in PP
Optimise VA- Refractive errors- incorrect astigmatism , Nystagmus- have null point where nystagmus dampens and this improves VA

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9
Q

Further ocular causes of AHP

A

DVD- Head tilt towards fixing eye appears to ↓ DVD
Centralise field of vision- Bilateral ptosis- chin elevation or head up
Gaze palsies- seen in stroke patients cant move eyes to r/l
Homonymous hemianopia- cant see to one side
Avoid pain- Graves Ophthalmopathy, Blow-out #

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10
Q

Value of AHP

A

— Aids in diagnosis of affected EOM in palsies
— Aids in differential diagnosis of longstanding versus recently acquired palsies
— Degree of AHP < in longstanding palsies
— Patient less aware of AHP in longstanding
— Presence of pre-existing BSV
— Patients with a marked AHP such as a head tilt due to SO plasy, you may consider under-correction as patient is unlikely to resume normal head posture
— Longstanding- AHP not noticed, size is smaller
— Acquired- AHP noticed, size is greater
— SO palsy- extended v fusion range

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11
Q

Assessment of AHP

A

— Ensure patient sitting / standing straight
— Observe patient on same level, directly in front
— Note any facial asymmetry
— Assess if one ear more visible than other
— Check eyes are level

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12
Q

Further assessment of AHP

A

— Observe chin position from side
— Straighten head and allow patient to resume “normal” position
— Observe AHP for 1/3m, 6m, when performing visual task
— Old photos may identify duration of AHP
— AHP differs in positions in 6th nerve palsy- record this
— Ask patient if aware of AHP

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13
Q

Features of CONG AHP

A

CONG non ocular
Straightening head - difficult/ impossible
Ocular symptoms- asymptomatic
Aware of AHP- maybe
Presence of BSV- C +S HP
CT NAD
OM Full
HESS normal

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14
Q

Congential AHP cause

A

contracture of sternocleidomastoid muscle in neck

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15
Q

Features of ocular AHP

A

Straightening head - easy
Ocular symptoms- may be symptomatic
Aware of AHP- often unaware esp if longstanding and if neck ache its acquires
BSV- yes c AHP, no s AHP can have diplopia and suppress
CT- presence of strabismus. nystagmus
OM- muscle imbalance
HESS- muscle imbalance

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16
Q

Ocular AHP cause

A

Relived diplopia. neurogenic palsy, stroke

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17
Q

How to confirm congenital non ocular AHP

A

Occlusion of one eye- no change to AHP
Uniocular VA testing- no change to AHP
Medical- reasons for adopting AHP include deafness

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18
Q

How to tell if ocular AHP

A

Occlusion of one eye- head straightening on occlusion of paretic eye
Uniocular VA testing- may change to improve VA If presence of nystagmus
Medical- may c/o illness relevant to muscle imbalance

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19
Q

Recording AHP

A

Define- Small, moderate, marked, r/l
Variable or alternating
Distance(s) AHP noted
Present with and without optical correction

20
Q

Management of AHP - asymptomatic and small

A

AHP can relieve diplopia and pain and requires no active treatment

21
Q

Management of AHP- small/ moderate

A

and can be relieved using prisms, occlusion, BT and surgery- pt can develop neck muscle contraction

22
Q

Management of AHP- symptomatic and marked

A

Marked surgery is indicated. This is especially in neurogenic AND mechanical palsies, nystagmus, young children- prevent secondary contractural neck changes. Affect amount of surgery.

Consider under-correct if longstanding

23
Q

To know

A

To be able to work out why a patient adopts a AHP you need to know the primary, secondary & tertiary actions of all the EOM’s
Remind RADSIN, rectus muscles ad-duct, oblique ab-duct
SO palsy hypertropia and esotropia

24
Q

Reasons for head turn

A

Move eyes away from field of action of paresed muscle
Move eyes to a position where deviation is least
Enable eye to fixate centrally – gross limitation
Permit the use of the nose as an occluder
Utilisation of VOR-
Head turn L  eyes move R
Paralytic strabismus:
Head turned in direction of paresed muscle

25
Q

Examples of HEAD TURN TO PARESED MUSCLE

A

RLR palsy- head turn right
LSR palsy- head turn left
Right Duane’s type 1/B- head turn right

26
Q

Chin elevation and depression purpose

A

Move eyes away from field of action of paresed muscle
Utilise physiological V pattern
For comfort – mechanical

27
Q

Head up- chin elevation

A

Eyes relatively depressed
Relative convergent position of eyes

28
Q

Head down- chin depression

A

Eyes relatively elevated
Relative divergent position of eyes

29
Q

RIR palsy head posture

A

head down and right- diplopia worse on dextrodepression

30
Q

Graves opthalmopathy with -4 on elevation both eyes

A

Head up

31
Q

Left browns

A

Head up

32
Q

When the head is straight vertical meridians of eyes are

A

parallel

33
Q

When the head is tilted RIGHT

A

RE intorts due to RSO & RSR contracts and LE extorts due to LIO & LIR contracts

34
Q

When the head is tilted LEFT

A

LE intorts due to LSO & LSR contracts and RE extorts due to RIO & RIR contracts

35
Q

If LE is extorted in PP , a head tilt to the RIGHT causes

A

RE intort = vertical meridians are parallel
- Used to overcome torsion/ torsional diplopia

36
Q

Head tilt causes vertical movement e.g. L tilt

A

LE sl depressed & RE sl elevated
LE moves up sl & RE moves down sl to neutralise

37
Q

Head tilt ALWAYS TO…

A

hypotropic eye- lower eye

38
Q

Superior muscles SR + SO

A

tilt and turn SAME WAY

39
Q

Inferior muscles IR + IO

A

tilt and turn OPPOSITE WAY

40
Q

Left blow out c no pain on elevation…

A

head up

41
Q

LSO palsy

A

Head tilt right, head turn right, head down

Dextrodepression, diplopia worse to right
Right eye is lower so tilt to right
Head down so eyes are elevated

42
Q

Left medial wall with MR muscle entrapment

A

Left turn

43
Q

LIR palsy

A

R head tilt, , head turn left, head down

Laevodepression is affected R eye HoT so turn R
Diolopia worse down do move head down to elevate eye

44
Q

CPEO with bilateral ptosis

A

Head up

45
Q

Measuring had posture in clinic

A

Often an estimate – slight, moderate, marked
Photographs to see if longstanding
Goniometer used mainly in cong non ocular

Cervical range of motion (CROM) instrument
esigned to assess the range of motion in the cervical spine
CROM typically used for research- can use compass app iphone

46
Q

Use of technology to measure head posture

A

Quantitave measure
The Cambridge Face tracker
Phone compass function
May be possible to use but require further research
The Cambridge Face Tracker uses neural networks (constrained local neural fields) to recognize facial features in video.
It allows useful quantification of head posture in real time or from precaptured video. Its performance is similar to the CROM device

47
Q

Summary

A

Head turn: towards field of action of paresed muscle

Head tilt: towards side of hypotropic eye

Head up (chin elevation ): moves eyes away from field of action of paresed muscles (SR & IO) bilateral ptosis or pain

Head down (Chin depression): moves eyes away from field of action of paresed muscles (SO & IR)

Strabismus (46 decks)

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