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Ocular Misalignment in Dizzy Patients—Something's A-Skew

Gold, Daniel R., DO; Schubert, Michael C., PT, PhD

Journal of Neurologic Physical Therapy: April 2019 - Volume 43 - Issue - p S27–S30
doi: 10.1097/NPT.0000000000000271
Special Interest Articles

Background and Purpose: Both central (eg, brain stem, cerebellum) and peripheral (eg, vestibular, fourth cranial nerve palsy) etiologies can cause a vertical misalignment between the eyes with a resultant vertical diplopia. A vertical binocular misalignment may be due to a skew deviation, which is a nonparalytic vertical ocular misalignment due to roll plane imbalance in the graviceptive pathways. A skew deviation may be 1 component of the ocular tilt reaction. The purposes of this article are (1) to understand the pathophysiology of a skew deviation/ocular tilt reaction and (2) to be familiar with the examination techniques used to diagnose a skew and to differentiate it from mimics such as a fourth cranial nerve palsy.

Summary of Key Points: The presence of a skew deviation usually indicates a brain stem or cerebellar localization. Vertical ocular misalignment is easily missed when observing the resting eye position alone.

Recommendations for Clinical Practice: Physical therapists treating patients with vestibular pathology from central or peripheral causes should screen for vertical binocular disorders.

Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology-Head and Neck Surgery, and Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland (D.R.G.); and Laboratory of Vestibular Neuroadaptation, Departments of Otolaryngology—Head and Neck Surgery and Physical Medicine and Rehabilitation, Johns Hopkins University, School of Medicine, Baltimore, Maryland (M.C.S.).

Correspondence: Michael C. Schubert, PT, PhD, Laboratory of Vestibular Neuroadaptation, Department of Otolaryngology—Head and Neck Surgery, Johns Hopkins University, School of Medicine, 601 North Caroline St, Rm 6245, Baltimore, MD 21287 (

This study was submitted for the special issue dedicated to the International Conference on Vestibular Rehabilitation.

The authors declare no conflict of interest.

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© 2019 Academy of Neurologic Physical Therapy, APTA