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Manoj V. Parulekar, MBBS; Shuan Dai, MBBS, MS, FRANZCO; J. Raymond Buncic, MD, FRCSC; Agnes M. F. Wong, MD, PhD, FRCSC

Arch Ophthalmol. 2008;126(7):899-905.

Objectives  To investigate whether ocular torsion and vertical misalignment differ in the upright vs supine position in skew deviation and to compare these findings with those in trochlear nerve palsy.

Methods  Ten patients with skew deviation, 14 patients with unilateral peripheral trochlear nerve palsy, and 12 healthy subjects were prospectively recruited. With subjects first in the upright position and then in the supine position, ocular torsion was measured by double Maddox rods and vertical misalignment was measured by the prism and alternate cover test.

Results  In patients with skew deviation, the abnormal torsion and vertical misalignment in the upright position decreased substantially with change to the supine position, whereas in patients with trochlear nerve palsy, it changed little between positions. Torsion was decreased by 83% in patients with skew deviation, 2% in patients with trochlear nerve palsy, and 6% in healthy subjects (P < .001). Similarly, vertical misalignment was decreased by 74% in patients with skew deviation and increased by 5% in patients with trochlear nerve palsy and 6% in healthy subjects (P < .001).

Conclusions  Our findings provide the basis for additional clinical tests to support the classic 3-step test: ocular torsion and vertical misalignment that decrease from the upright position to the supine position indicate skew deviation, whereas torsion and vertical misalignment that do not change significantly between positions indicate trochlear nerve palsy.

Author Affiliations: Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children (Drs Parulekar, Dai, Buncic, and Wong), Department of Ophthalmology and Vision Sciences, University of Toronto (Drs Buncic and Wong), and Department of Ophthalmology, University Health Network (Dr Wong), Toronto, Ontario, Canada.

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