The topic of ocular torticollis is a constant source of doubt for many professionals working in pediatrics. No one is ever completely sure whether a child’s head position is due to visual needs. This is even more complicated in babies or young children, as asking them directly doesn’t make sense (imagine asking a baby: “If you change your head position, do you see double?”). Clinical tests are also challenging due to their particular level of cooperation… am I right?
What is ocular torticollis?
It is an abnormal head position caused by a visual need to fuse images from both eyes or to stabilize the image. The term ocular torticollis is not as common as it may seem. Sometimes, it is referred to as an abnormal head position due to ocular or visual causes, but these two words do not mean the same thing—did you know that? Ocular refers to aspects related to the eye as an organ, whereas visual includes neurological pathways and brain areas that work intensely to make perception useful for adapting to the environment. But okay, most people don’t make such a fine distinction, even though I consider it essential.
There are various visual and neurological disorders that may require an adjustment in head position to “see properly.” The most common ones include nystagmus and vertical or torsional deviations (where one eye is positioned higher than the other or rotated along an anteroposterior axis). Refractive errors can also contribute, and there are many different types of deviations… There are always many types of everything!
The abnormal head position may involve tilting, rotation, and even flexion-extension, depending on the visual issue. However, the aspect that causes the most confusion—especially for physiotherapists—is head tilting. When the head is rotated, it is usually due to nystagmus, which is easier to identify.
To make matters more complicated, many physiotherapists working with congenital muscular torticollis (CMT)—or what they think is CMT, which is not always the case—tend to improve rotation significantly, but a residual tilt often remains. I’ll explain how to fix that another day.
So, is the tilt caused by something in the neck or something in the eyes?
How can we differentiate ocular torticollis—sorry, visual torticollis—wait, neurovisual torticollis?
- Observe the eyes when the child is looking at an object and when they are not focusing on anything specific. Look for signs of trembling and note whether the head tilt becomes more pronounced over time. The abnormal position tends to become more noticeable with visual fixation, especially when looking at objects up close. You can ask the caregiver if they’ve noticed that the child tilts their head more when bringing a spoon close to their mouth, for example.
- Change the head position while the child is looking at an object. This is the basis of the Bielschowsky diagnostic maneuver. If the head is tilted to the right, tilt it to the left—if one eye clearly deviates more, or if it trembles (in cases of nystagmus), then you have your answer. If the child presents rotation instead of tilting, adjust the rotation while observing the eyes.
- If you’re a physiotherapist or kinesiologist, assess the condition of the tissues and perform a passive mobility test. If the issue is truly visual, there should be no significant resistance to passive movement in tilting or rotation while the child is lying down. If you find tense tissues and restricted movement, then the cause is clearly musculoskeletal.
- For babies, use the Fernández lateral suspension test. This is the most reliable method to detect a musculoskeletal issue. However, when dealing with visual causes, the response is less clear. You can find more details about this test in this book. An essential resource for physiotherapists and kinesiologists that solves many diagnostic challenges.
- When in doubt, refer the child to an ophthalmologist or vision specialist. Keep in mind that even a minor deviation or a small strabismus could be a sign of a serious problem. If there’s any uncertainty, always seek a proper diagnosis.
So, as you can see, the symptoms of musculoskeletal and ocular (visual) torticollis can be very similar. That’s why it’s crucial to analyze the situation carefully—observing both the eyes and head, modifying the head position, and using specific tests for the neck.
With all this in mind, hopefully, you’ll be able to detect these cases more confidently.
See you on the journey!
Iñaki
P.S. I’ve included some references below. But if you really want to deepen your knowledge on this topic, look for training courses by Lucila To. In my opinion, she is one of the best optometrists in Europe, offering incredible courses for those who truly want to learn and not waste time.
Bibliography
Teodorescu L.Rom ANOMALOUS HEAD POSTURES IN STRABISMUS AND NYSTAGMUS DIAGNOSIS AND MANAGEMENT. J Ophthalmol. 2015 Jul-Sep;59(3):137-40.
Akbari MR, Khorrami-Nejad M, Shakor YA, Dehghanian Nasrabadi F, Kangari H, Dalvand H.The Frequency and Manifestations of Ocular Causes of Abnormal Head Posture. J Binocul Vis Ocul Motil. 2024 Jan-Mar;74(1):9-16. Epub 2023 Nov 20.
Boricean ID, Bărar A Understanding ocular torticollis in children.. Oftalmología. 2011;55(1):10-26.
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