Anomalous head posture: An unusual presentation of intermittent exotropia

Akshay Mohan; Shweta Singh; Priyanka Sharma; Siddharth Agrawal

doi:10.4103/ijo.IJO_1702_22

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CASE REPORT

Year : 2023 | Volume : 3 | Issue : 1 | Page : 109-111

Anomalous head posture: An unusual presentation of intermittent exotropia

Akshay Mohan, Shweta Singh, Priyanka Sharma, Siddharth Agrawal
Department of Ophthalmology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission	11-Oct-2022
Date of Acceptance	23-Nov-2022
Date of Web Publication	20-Jan-2023

Correspondence Address:
Siddharth Agrawal
Department of Ophthalmology, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1702_22

Abstract

Intermittent exotropia (IXT) usually presents with occasional outward deviation of the eye, asthenopia, headache, diplopia, or photophobia. We report here an unusual presentation of IXT in a 21-year-old man, with an anomalous head posture (AHP) of face rotation towards left as the primary symptom. On examination, there was lateral gaze incomitance, and improved fusion range in dextroversion explained his AHP.

Keywords: Anomalous head posture, intermittent exotropia, lateral gaze incomitance

How to cite this article:
Mohan A, Singh S, Sharma P, Agrawal S. Anomalous head posture: An unusual presentation of intermittent exotropia. Indian J Ophthalmol Case Rep 2023;3:109-11

How to cite this URL:
Mohan A, Singh S, Sharma P, Agrawal S. Anomalous head posture: An unusual presentation of intermittent exotropia. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:109-11. Available from: https://www.ijoreports.in/text.asp?2023/3/1/109/368162

Ocular reasons for anomalous head posture (AHP) include (i) improvement in visual acuity, as in nystagmus and oblique astigmatism^[1]; (ii) minimizing diplopia by enabling fusion or by increasing separation of images^[2]; (iii) centralizing the visual field as in unilateral visual loss.

Common symptoms of intermittent exotropia (IXT) include occasional outward deviation of the eye (usually noticed by others), asthenopia, headache, diplopia, or photophobia. These symptoms depend on fusional control of the patient and with gradual decrease in fusional control in adulthood, the deviation becomes constant, suppression develops, and the patient becomes asymptomatic except for cosmetically concerning outward deviation. Variability in deviation in lateral gazes in patients of IXT has been reported and recommendations have been made to alter the surgical dosage accordingly.^[3] This lateral gaze incomitance is asymmetrical usually.^[4] AHP may occur in patients with fusion maldevelopment nystagmus syndrome (FMNS) associated with IXT, where the head posture helps in minimizing the amplitude of nystagmus.

We report here a unique presentation of IXT (in the absence of comorbid conditions like FMNS or dissociated vertical deviation [DVD]) where the patient presented with AHP as the primary symptom. To the best of our knowledge (PubMed search) this has not been reported so far.

Case Report

A 21-year-old man presented with an unacceptable AHP in his photographs [Figure 1]. He was concerned that all his photographs had the same head posture and he had to make significant efforts to keep his head straight. Outward deviation of either eye had also been occasionally noticed by his friends and family. His photographs consistently showed face rotation towards the left [Figure 2].

Figure 1: Collage of patient's photographs showing the AHP (face rotation to left)

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Figure 2: The deviation is well controlled with better stereo acuity at 15 degree dextroversion. (a) gaze (b) magnified view showing Hirschberg corneal reflex

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On examination, his unaided visual acuity was 6/6, N6 in both eyes. Anterior segment and posterior segment examination were within normal limits. Ocular movements were full in all gazes. AHP (Face left ~15°) was observed during binocular visual acuity assessment. Primary ocular deviation was straight. Examination after patch test revealed an exodeviation of ~20° (Hirschberg corneal light reflex) with each eye fixing. The angle of strabismus was measured via prism cover test in all gazes which showed exotropia of 55 prism diopters (PD) in primary gaze. There was no vertical gaze incomitance; however, the angle was 45 PD in dextroversion [Figure 3]. His ability to control the deviation was better in dextroversion. Stereopsis on Randot's stereoacuity test in primary gaze and levoversion was 400 seconds of arc (A) which improved to 100 A in dextroversion. No associated comorbid condition like nystagmus or DVD was noticed in the patient.

Figure 3: Nine gaze photographs of the patient. Primary gaze photographs fixing each eye

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The patient was unwilling for surgery presently and remains in follow-up.

Discussion

The main symptom of the patient was AHP which was more noticeable on photographs. The lateral gaze incomitance enabled better control and stereopsis in dextroversion, explaining his AHP. The case highlights the following points:

AHP may be a presenting symptom of IXT. Lateral gaze incomitance should be specifically looked for.
AHP may be adopted in IXT to exploit the advantage of lesser deviation and better fusion in lateral gaze.
When surgical correction is planned, dose modification may be required to overcome the incomitance. Lesser recession of lateral rectus (LR) may be advisable when the deviation is lesser in lateral gaze.^[5],[6] The medial rectus (MR) resection may be increased to achieve the target angle in primary position.

Conclusion

AHP and lateral gaze incomitance should be looked for in IXT. They may warrant modification in surgical plan.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Teodorescu L. Anomalous head postures in strabismus and nystagmus diagnosis and management. Rom J Ophthalmol 2015;59:137-40.
2.	Noorden GK, Helveston EM. Strabismus. A Decision Making Approach. St. Louis: Mosby; 1996. p. 52–60.
3.	Parks MM. Comitant exodeviations in children. In: Strabismus. Sympsium of the New Orleans Academy of Ophthalmology. St Louis: Mosby-Year Book; 1962. p. 45.
4.	Meyer E, Noorden GK von, Avilla CW. Management of consecutive esotropia. In: Mein J, Moore S, editors. Orthoptics. Research and Practice. London: H Kimptom; 1981. p. 236.
5.	Rosenbaum AL, Santiago AP. Surgical dose tables. In: Clinical Strabismus Management Principles and Surgical Techniques. Philadelphia, PA: WB Saunders Company; 2001. p. 553.
6.	Moore S. The prognostic value of lateral gaze measurements in intermittent exotropia. Am Orthopt J 1969;19:69-71.