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

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)S27-S30
JournalJournal of Neurologic Physical Therapy
StatePublished - Apr 1 2019


  • fourth cranial nerve palsy
  • ocular alignment
  • skew deviation
  • vertical diplopia

ASJC Scopus subject areas

  • Physical Therapy, Sports Therapy and Rehabilitation
  • Rehabilitation
  • Clinical Neurology


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