To investigate the veracity of Jampolsky's statement that Bielschowsky's head tilt test is inverted if performed with the patient in the upside-down position and to interpret its neuromuscular mechanism. We present a series of 10 patients selected from a referred sample who were diagnosed with superior oblique paresis. Hypertropia was measured in the primary position, with the head erect and tilted toward both shoulders with the patient in the erect, supine, and upside-down positions. The last position was achieved by hanging the patient upside-down.
As expected, our results showed the veracity of Jampolsky's statement. The forced tilt difference was inverted or significantly decreased when the test was performed in the upside-down position. Moreover, in all patients, Bielschowsky's phenomenon was neutralized in the supine body position, in which hypertropia with the head erect tended to vanish.
In 3 patients, it disappeared completely. This study showed that, in patients with superior oblique paresis, differences in the extent of hypertropia in Bielschowsky's test tended to vanish when the test was performed with the patient in the supine position and invert when it was performed with the patient in the upside-down position. The compensatory head tilt during certain oculomotor anomalies has the goal of reducing hypertropia, avoiding diplopia, and maintaining fusion 1.
The forced head tilt difference means the difference in the magnitude of vertical deviations when hypertropia is measured with the head tilted toward both shoulders; this primarily occurs in patients Teste de oftalmologista online dating superior oblique paresis and superior rectus contracture Jampolsky's syndrome 2. InDavid Robinson 3after a mathematical analysis of his Robinson's model of the oculomotor plant with regard to large vertical deviations in the head tilt test, concluded that only a contractured superior rectus muscle could account for such a large forced tilt difference in some patients with superior oblique palsy.
The conventional Teste de oftalmologista online dating explanation for Bieslschowsky's test 4 is based on the otolith static reflex, which is responsible for the counter-rolling of eyes induced by head tilting toward the shoulders. When the head is tilted toward the right shoulder, for instance, the right eye tends to incycloduct, which is induced by the otolith system, through the innervation of its intorsional muscles, namely the superior rectus and superior oblique muscles.
These muscles are antagonists in vertical and horizontal actions; therefore, when they are simultaneously innervated, they compensate for each other and result in no vertical or horizontal eye movement.
However, they are synergistic when it comes to torsion. When they are simultaneously innervated by right head tilting, as in the case of right superior oblique palsy, the superior rectus muscle overcomes the depressor action of the weakened superior oblique muscle and elevates the eye 5.
Jampolsky stated, in 6that if Bielschowsky's test is performed with the patient in an upside-down position, the forced tilt difference would give a mirror image, that is, an inverted one. This led to interesting speculations about the otolith mechanism and the muscular mechanics of the forced head tilt difference. This study aimed to investigate the veracity of this statement and interpret the underlying neuromuscular mechanism.
Patients with superior oblique "Teste de oftalmologista online dating" were selected, and the deviation with the head tilted to both sides was measured with the patient in the erect, supine, and upside-down positions. After the procedure was explained to the subjects or legal guardians for Teste de oftalmologista online dating and accepted by free will, informed consent was obtained.
Ten patients [8 unilateral and two asymmetric bilateral Patients 7 and 10Table 1 ] consecutively examined in the Santa Casa and CEMA hospitals who presented with the clinical picture of superior oblique paresis were prospectively examined. The mean age was The measurements are in prism diopters.
The affected eye is indicated by the side of the arger hypertropia in Bielschowsky's test in the erect body position. The data necessary for diagnosing unilateral superior oblique paresis included the following: Asymmetric superior oblique paresis was diagnosed according to the criteria discussed by Souza-Dias in another paper 7.
For this research, we measured the deviations in the primary position with the head erect and maximally tilted to both shoulders, with the patient in the erect, supine, and upside-down positions.
Ipsilateral superior rectus contracture was investigated during surgery with the forced duction test "knife-edge" maneuver, proposed by Jampolsky in 8. After external, anterior segment, and fundus examinations and refractometry, a thorough ocular motility examination was performed, with special attention to the alternate prism and cover test in all positions of gaze and in the primary position with the head tilted toward Teste de oftalmologista online dating shoulders.
All patients showed extorsion of the affected eye as diagnosed by the double Maddox test and, in some of them, fundoscopy. The upside-down position was achieved in the 2 young patients by an adult hanging them by the legs and in the remaining 8 adults by utilizing a special slanting bed that was specifically built for this investigation Figure 1. The boy is hung from the legs by an adult, while the adult is strapped in a slant stretcher designed for this purpose.
In order to avoid Teste de oftalmologista online dating, let us define 2 terms. Hypertropia of an eye indicates that the affected eye is deviated toward the top of the head, and hypotropia of an eye indicates that the affected eye is deviated toward the feet, regardless of the patient's body position.
In all patients, the forced head tilt difference was neutralized or tended to vanish when the test was performed with the patient in the supine position, while it was inverted or significantly decreased in magnitude when the patient was in the upside-down position.
As seen in table 1there was a complete inversion Patient 2 or an almost complete inversion Patient 3 of the forced head tilt difference when the test was repeated with the patient in the upside-down position. In all the other patients, there was Teste de oftalmologista online dating clear tendency for inversion.