Original article
The Sensitivity of the Bielschowsky Head-Tilt Test in Diagnosing Acquired Bilateral Superior Oblique Paresis

https://doi.org/10.1016/j.ajo.2014.01.003Get rights and content

Purpose

To determine the sensitivity of the Bielschowsky head-tilt test and other commonly used criteria in identifying patients with true bilateral superior oblique paresis.

Design

A retrospective chart review was performed to identify patients seen between 1978 and 2009 who were diagnosed with acquired bilateral superior oblique paresis.

Methods

All patients had a confirmed history of head trauma or brain surgery with altered consciousness followed by symptomatic diplopia. Bilateral superior oblique paresis was defined and diagnosed by the above history, including the presence of greater extorsion in downgaze than upgaze on Lancaster red-green testing, a V-pattern strabismus, and bilateral fundus extorsion. We analyzed findings of the Bielschowsky head-tilt test, the Parks 3-step test, and reversal of the hypertropia from straight-ahead gaze to the other 8 diagnostic positions of gaze to determine these tests' sensitivity in identifying true bilateral superior oblique paresis.

Results

Twenty-five patients were identified with the diagnosis of true bilateral superior oblique paresis. The Bielschowsky head-tilt test had a 40% sensitivity, the Parks 3-step test had a sensitivity of 24%, and reversal of the hypertropia had a sensitivity of 60% in making the diagnosis of true bilateral superior oblique paresis.

Conclusions

What previously has been described as masked bilateral superior oblique paresis simply may be a reflection of inherent poor sensitivity of the Bielschowsky head-tilt test, the Parks 3-step test, and reversal of the hypertropia in diagnosing bilateral superior oblique paresis. Hence, none of these tests should be relied on exclusively to make this diagnosis.

Section snippets

Methods

The Johns Hopkins Medicine Institutional Review Board approved the study protocol and agreed to a waiver of informed consent for use in this retrospective, single-center study. The study and data collection were in accordance with the Health Insurance Portability and Accountability Act of 1996. We performed a retrospective chart review of the medical records of all patients who were seen by the senior author at the Krieger Children's Eye Center at the Wilmer Eye Institute from 1978 through

Results

Thirty-four patients were identified, of whom 25 met our inclusion and exclusion criteria. The patients' demographic profiles showed a male-to-female ratio of 1.78, with an average age of 31 years (standard deviation [SD], 11.3 years). Twenty-two patients had sustained head trauma after a motor vehicle accident, 1 patient sustained a head injury after a fall, and 2 patients had undergone surgery for resection of a brain tumor. All patients reported vertical diplopia immediately or within

Discussion

We identified 25 patients in whom the diagnosis of acquired bilateral superior oblique paresis was quite certain on the basis of the clinical history and examination. The increase in extorsion from upgaze to downgaze is statistically significant in this group and is in keeping with the findings by synoptophore from Fells and Waddell in their series of patients with bilateral superior oblique paresis.14 Our patients also have undergone strabismus surgery with the expected clinical outcome for

Brinda Muthusamy, MBChB, MRCP, FRCOphth, received her medical degree from the University of Edinburgh, UK. After her medical residency at the Oxford Radcliffe Hospitals, she obtained Membership to the Royal College of Physicians. She then completed her ophthalmology specialist training at the Bristol Eye Hospital, and is a Fellow of the Royal College of Ophthalmologists. She obtained fellowship training in Pediatric Ophthalmology and Adult Strabismus and then Neuro-ophthalmology at The Johns

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    Brinda Muthusamy, MBChB, MRCP, FRCOphth, received her medical degree from the University of Edinburgh, UK. After her medical residency at the Oxford Radcliffe Hospitals, she obtained Membership to the Royal College of Physicians. She then completed her ophthalmology specialist training at the Bristol Eye Hospital, and is a Fellow of the Royal College of Ophthalmologists. She obtained fellowship training in Pediatric Ophthalmology and Adult Strabismus and then Neuro-ophthalmology at The Johns Hopkins Hospital, Baltimore, Maryland. She is now a consultant pediatric and adult neuro-ophthalmologist at Addenbrookes Hospital, Cambridge, UK.

    David L. Guyton, MD, graduated from Harvard Medical School in 1969 and subsequently completed his residency in ophthalmology at the Wilmer Eye Institute at The Johns Hopkins University in 1976. After fellowship training in strabismus at the Baylor College of Medicine, he returned to the Wilmer Institute as Chief Resident and then as Chief of Pediatric Ophthalmology and Adult Strabismus, where he continues to serve as the Zanvyl Krieger Professor of Ophthalmology. The most recent of his 290+ publications and 11 U.S. Patents deal with remote optical systems and automated screening devices for detection of strabismus and defocus in infants and children.

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