Neuro-Ophthalmic
Skew Deviation
Also known as: skew deviation, brainstem vertical diplopia, vertical diplopia dizziness, ocular tilt reaction, vestibular diplopia
Filed as: Urgent
Source-cited from the record's own evidence list. Clinical content programme led by Dr Ankit Mathur, PhD, Grad Cert Ocu Thera, B.S. Optom. How the clinical content is governed
Clinical decision support only
Overview
A vertical or torsional misalignment of brainstem or vestibular origin, often accompanied by dizziness, imbalance or nausea. It can resemble a fourth nerve palsy but frequently fails to follow the expected three-step pattern, and an ocular tilt reaction may be present. Because the localisation is posterior circulation, a new skew deviation warrants urgent neurological assessment rather than prism management.
Recognition
Symptoms: what patients report
- Binocular vertical, diagonal, or torsional diplopia.
- May be associated with dizziness, ataxia, imbalance, nausea, or other neurologic symptoms.
- Can resemble CN IV palsy but often does not fit a classic superior oblique pattern.
Signs: what the examination shows
- Vertical misalignment that may not follow the Parks-Bielschowsky pattern.
- Possible ocular torsion or ocular tilt reaction.
- Other vestibular or brainstem signs may be present.
- Fundus torsion: in skew the higher eye is usually incyclotorted (in a fourth nerve palsy it is usually excyclotorted).
- A vertical deviation that falls by half or more on lying down supports skew, but the test is often negative in the first two months, so a negative result does not exclude skew.
What OptoGuide™ covers for skew deviation
- Pattern reasoning: what this combination of findings points to, and its differentiators
- Don't-miss risks and escalation triggers
- Management tiers with linked New Zealand therapeutics
- Referral urgency, specialty, and letter drafting
Sources
- Skew Deviation — EyeWiki
- The Neuro-Ophthalmology Survival Guide (Pane, Miller & Burdon) — standard reference text
- The Clinical and Imaging Profile of Skew Deviation: A Study of 157 Cases. Walter E, Trobe JD. Journal of Neuro-Ophthalmology : The Official Journal of the North American Neuro-Ophthalmology Society. 2021;41(1):69-76.
- HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. Str
- Clinical Reasoning: A 23-Year-Old Woman With Fever and Vertical Diplopia. Lin DJ, Levin SN, Albin CSW, Goodheart AE, Venna N. Neurology. 2018;90(22):e2006-e2010.
- Adult Strabismus Preferred Practice Pattern. Dagi LR, Velez FG, Holmes JM, et al. Ophthalmology. 2024;131(4):P304-P401.
- Ability of an upright-supine test to differentiate skew deviation from other vertical strabismus causes. Wong AM, Colpa L, Chandrakumar M. Arch Ophthalmol. 2011;129(12):1570-1575.
- Differentiating Acute and Subacute Vertical Strabismus Using Different Head Positions During the Upright-Supine Test. Lemos J, Subei A, Sousa M, et al. JAMA Ophthalmol. 2018;136(4):322-328.
Standard texts: Kanski's Clinical Ophthalmology: A Systematic Approach, Oxford Handbook of Ophthalmology, Oxford American Handbook of Ophthalmology, Signs in Ophthalmology: Causes & Differential Diagnosis.