Review of the skew deviation
Abstract Introduction: Skew deviation is a lack of vertical alignment of the eyes that cannot be explained as a result of paralysis of the eye muscles. We will review the pathophysiology of this syndrome, its clinical expressivity and how to diagnose it. Methods: Narrative review. Results: The skew deviation is the result of a lesion in the vestibular-ocular neural pathway. Being a cross-way, depending on where the pathology is located, the lack of ocular alignment can affect one or the other eyeball. In both peripheral and central lesions, it can be accompanied by lateral tilt of the head and ocular torsion, which determines the triad known as "ocular-cephalic tilt reaction". For the diagnosis of the skew deviation, in addition to the observation we will use the "cover test" and the rod of Maddox. Discussion: Although the physiopathology of these clinical manifestations is very interesting, it is an infrequent process, still to be understood and with little locator value. Conclusion: Skew deviation always requires discarding, through imaging tests, central neurological pathology. In the context of acute vertigo, it may be the only indicator of involvement of the Central Nervous System.
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Baloh, RW; Kerber K. Clinical neurophysiology of the vestibular system. 4.a ed. New York: Oxford University Press; 2011. 455 p.
Bateman JA, Chang A, Capo-Aponte J. Cerebellar ischemia manifesting as vertical diplopia: a case study on skew deviation. Mil Med. 2015;180(1):168-73. https://doi.org/10.7205/MILMED-D-14-00292 / PMid:25562880
Brandt T, Dieterich M. Pathological eye-head coordination in roll: tonic ocular tilt reaction in mesencephalic and medullary lesions. Brain. 1987;110 (Pt 3):649-66. https://doi.org/10.1093/brain/110.3.649 / PMid:3495315
Brandt T, Dieterich M. Vestibular syndromes in the roll plane: topographic diagnosis from brainstem to cortex. Ann neurol. 1994;36(3):337-47. https://doi.org/10.1002/ana.410360304 / PMid:8080241
Brandt TH, Dieterich M. Different types of skew deviation. J Neurol Neurosurg Psychiatry. junio de 1991;54(6):549-50.
Brandt, T; Dieterich, M; Strupp M. Vertigo and Dizziness. 2.a ed. London: Springer-Verlag; 2013. 189 p.
Brodsky MC, Donahue SP, Vaphiades M, Brandt T. Skew deviation revisited. Surv Ophthalmol. 2006;51(2):105-28. https://doi.org/10.1016/j.survophthal.2005.12.008 / PMid:16500212
Carmona, Sergio; Asprella Libonati G. Una aproximación fisiopatológica a la evaluación clínica del paciente con vértigo. En: Neuro-otologia. 3a ed. Buenos Aires: Libreria Akadia editorial; 2013. p. 19-25.
Hernowo A, Eggenberger E. Skew deviation: clinical updates for ophthalmologists. Curr Opin Ophthalmol. 2014;25(6):485-7. https://doi.org/10.1097/ICU.0000000000000105 / PMid:25250734
Kennedy SA, Noble J, Wong AMF. Esotropia. Can Med Assoc J. 2012;184(11):1279-1279. https://doi.org/10.1503/cmaj.111566 / PMid:22249982 PMCid:PMC3414601
McCaslin, DL; Dundas, JA; Jacobson G. Balance function assessment and management. En: The bedside assessment of the vestibular system. 1.a ed. United Kingdom: Plural publishing; 2008. p. 63-97.
Moguel-Ancheita S, Castellanos-Pérez Balde CG, Orozco-Gómez LP. Desviación oblicua. Diagnóstico estrabológico y alternativas de tratamiento. Cir Cir. 2009;77(4):267-73. PMid:19919787
Ng D, Fouladvand M, Lalwani AK. Skew deviation after intratympanic gentamicin therapy. Laryngoscope. 2011;121(3):492-4. https://doi.org/10.1002/lary.21279 / PMid:21344424
Schlenker M, Mirabella G, Goltz HC, Kessler P, Blakeman AW, Wong AMF. The Linear Vestibulo-Ocular Reflex in Patients with Skew Deviation. Investig Opthalmology Vis Sci. 2009;50(1):168-74. https://doi.org/10.1167/iovs.08-2254 / PMid:18775861 PMCid:PMC5104545
Wertheimer NP, Pinel B. Otolith dysfunction in skew deviation after brain stem lesions. J Vestib Res. 2000;10:179-92.
Wong AMF. New understanding on the contribution of the central otolithic system to eye movement and skew deviation. Eye. 2015;29(2):153-6. https://doi.org/10.1038/eye.2014.243 / PMid:25323854 PMCid:PMC4330270
Wong AMF. Understanding skew deviation and a new clinical test to differentiate it from trochlear nerve palsy. J AAPOS. 2010;14(1):61-7. https://doi.org/10.1016/j.jaapos.2009.11.019 / PMid:20227626 / PMCid:PMC5154745
Zee DS. Considerations on the mechanisms of alternating skew deviation in patients with cerebellar lesions. J Vestib Res. 1996;6(6):395-401. https://doi.org/10.1016/S0957-4271(96)00041-9
Bateman JA, Chang A, Capo-Aponte J. Cerebellar ischemia manifesting as vertical diplopia: a case study on skew deviation. Mil Med. 2015;180(1):168-73. https://doi.org/10.7205/MILMED-D-14-00292 / PMid:25562880
Brandt T, Dieterich M. Pathological eye-head coordination in roll: tonic ocular tilt reaction in mesencephalic and medullary lesions. Brain. 1987;110 (Pt 3):649-66. https://doi.org/10.1093/brain/110.3.649 / PMid:3495315
Brandt T, Dieterich M. Vestibular syndromes in the roll plane: topographic diagnosis from brainstem to cortex. Ann neurol. 1994;36(3):337-47. https://doi.org/10.1002/ana.410360304 / PMid:8080241
Brandt TH, Dieterich M. Different types of skew deviation. J Neurol Neurosurg Psychiatry. junio de 1991;54(6):549-50.
Brandt, T; Dieterich, M; Strupp M. Vertigo and Dizziness. 2.a ed. London: Springer-Verlag; 2013. 189 p.
Brodsky MC, Donahue SP, Vaphiades M, Brandt T. Skew deviation revisited. Surv Ophthalmol. 2006;51(2):105-28. https://doi.org/10.1016/j.survophthal.2005.12.008 / PMid:16500212
Carmona, Sergio; Asprella Libonati G. Una aproximación fisiopatológica a la evaluación clínica del paciente con vértigo. En: Neuro-otologia. 3a ed. Buenos Aires: Libreria Akadia editorial; 2013. p. 19-25.
Hernowo A, Eggenberger E. Skew deviation: clinical updates for ophthalmologists. Curr Opin Ophthalmol. 2014;25(6):485-7. https://doi.org/10.1097/ICU.0000000000000105 / PMid:25250734
Kennedy SA, Noble J, Wong AMF. Esotropia. Can Med Assoc J. 2012;184(11):1279-1279. https://doi.org/10.1503/cmaj.111566 / PMid:22249982 PMCid:PMC3414601
McCaslin, DL; Dundas, JA; Jacobson G. Balance function assessment and management. En: The bedside assessment of the vestibular system. 1.a ed. United Kingdom: Plural publishing; 2008. p. 63-97.
Moguel-Ancheita S, Castellanos-Pérez Balde CG, Orozco-Gómez LP. Desviación oblicua. Diagnóstico estrabológico y alternativas de tratamiento. Cir Cir. 2009;77(4):267-73. PMid:19919787
Ng D, Fouladvand M, Lalwani AK. Skew deviation after intratympanic gentamicin therapy. Laryngoscope. 2011;121(3):492-4. https://doi.org/10.1002/lary.21279 / PMid:21344424
Schlenker M, Mirabella G, Goltz HC, Kessler P, Blakeman AW, Wong AMF. The Linear Vestibulo-Ocular Reflex in Patients with Skew Deviation. Investig Opthalmology Vis Sci. 2009;50(1):168-74. https://doi.org/10.1167/iovs.08-2254 / PMid:18775861 PMCid:PMC5104545
Wertheimer NP, Pinel B. Otolith dysfunction in skew deviation after brain stem lesions. J Vestib Res. 2000;10:179-92.
Wong AMF. New understanding on the contribution of the central otolithic system to eye movement and skew deviation. Eye. 2015;29(2):153-6. https://doi.org/10.1038/eye.2014.243 / PMid:25323854 PMCid:PMC4330270
Wong AMF. Understanding skew deviation and a new clinical test to differentiate it from trochlear nerve palsy. J AAPOS. 2010;14(1):61-7. https://doi.org/10.1016/j.jaapos.2009.11.019 / PMid:20227626 / PMCid:PMC5154745
Zee DS. Considerations on the mechanisms of alternating skew deviation in patients with cerebellar lesions. J Vestib Res. 1996;6(6):395-401. https://doi.org/10.1016/S0957-4271(96)00041-9
Mena-Domínguez, E. A. (2017). Review of the skew deviation. Revista ORL, 9(2), 127–131. https://doi.org/10.14201/orl.17348
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