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ULY CLINIC

13 Septemba 2025, 03:26:01

Ocular deviation

Ocular deviation refers to abnormal eye movement, which may be conjugate (both eyes move together) or disconjugate (one eye moves separately). This sign may result from ocular, neurologic, endocrine, or systemic disorders affecting the muscles, cranial nerves, or brain centers controlling eye movement. Occasionally, it signals life-threatening conditions such as a ruptured cerebral aneurysm.

Normally, eye movement is controlled by extraocular muscles innervated by cranial nerves III (oculomotor), IV (trochlear), and VI (abducens). Disconjugate deviation may result from unequal muscle tone (nonparalytic strabismus) or cranial nerve paralysis (paralytic strabismus). Conjugate deviation may arise from cerebral cortex or brainstem disorders, typically presenting as gaze palsy.

Emergency interventions

If ocular deviation is noted:

Assess vital signs immediately
Evaluate level of consciousness (LOC), pupillary changes, motor or sensory dysfunction, and severe headache
Gather history from family about behavioral changes and recent head trauma
Provide respiratory support if needed
Prepare the patient for emergency neurologic tests, such as CT scan

History and Physical Examination

History

Duration and onset of ocular deviation
Presence of diplopia, eye pain, headache
Associated motor/sensory changes or fever
History of hypertension, diabetes, thyroid, neurologic, or muscular disorders
Ocular history: prior extraocular muscle imbalance, trauma, or surgery

Physical Examination

Observe for ptosis, head tilt, or compensatory facial turns
Inspect for eye redness or periorbital edema
Assess visual acuity
Evaluate extraocular muscle function using six cardinal fields of gaze

Medical causes

Condition	Features	Associated Findings
Brain tumor	Ocular deviation depends on tumor site/extent	Morning headaches, memory loss, dizziness, vision loss, motor/sensory dysfunction, aphasia, lethargy → coma, papilledema, vomiting, increased ICP
Cavernous sinus thrombosis	Diplopia, ocular deviation	Photophobia, exophthalmos, orbital/eyelid edema, corneal haziness, absent pupillary reflexes, fever, headache, malaise, nausea/vomiting, seizures
Diabetes mellitus	Isolated third cranial nerve palsy	Ocular deviation, ptosis, sudden diplopia, eye pain
Encephalitis	Abrupt onset ocular deviation	Fever, headache, vomiting, nuchal rigidity, seizures, aphasia, ataxia, hemiparesis, cranial nerve palsies, altered LOC
Head trauma	Variable deviation based on trauma site	Soft tissue injury, bony deformity, periorbital edema, otorrhea/rhinorrhea, diplopia, nystagmus, behavioral changes, headache, increased ICP signs
Orbital blowout fracture	Inferior rectus entrapment	Limited extraocular movement, downward/inward globe displacement, diplopia, pain, periorbital edema, nausea, ecchymosis
Orbital tumor	Gradual ocular deviation	Proptosis, diplopia, blurred vision
Stroke	Variable deviation depending on site	Altered LOC, contralateral hemiplegia, sensory loss, dysarthria, dysphagia, homonymous hemianopsia, diplopia, bladder/bowel dysfunction, seizures, headache
Thyrotoxicosis	Exophthalmos-induced deviation	Limited gaze, diplopia, lid retraction, wide-eyed stare, tearing, lid edema, tachycardia, weight loss, tremors, enlarged thyroid, heat intolerance

Table 1: Summary of ocular deviation, its characteristics, and causes in cranial nerve damage:

Cranial Nerve	Type of Deviation	Clinical Characteristics	Common Causes / Conditions
CN III (Oculomotor)	Eye deviates down and out; ptosis	- Limited adduction, elevation, depression - Pupil may be dilated (mydriasis) - Ptosis of upper eyelid	- Diabetic neuropathy - Aneurysm (posterior communicating artery) - Trauma - Tumors
CN IV (Trochlear)	Eye deviates upward when looking medially	- Difficulty looking down when eye adducted - Vertical diplopia - Head tilt away from affected side	- Head trauma - Congenital palsy - Microvascular ischemia
CN VI (Abducens)	Eye deviates medially (esotropia)	- Inability to abduct the affected eye - Horizontal diplopia	- Increased intracranial pressure - Trauma - Microvascular disease (diabetes, hypertension)
Multiple cranial nerves (III, IV, VI)	Complex or total ophthalmoplegia	- Eye may be fixed or “frozen” in one position - Ptosis, pupil involvement may occur	- Cavernous sinus syndrome - Brainstem lesions - Tumors or infections affecting orbit or cranial nerves
Internuclear ophthalmoplegia (MLF lesion)	Disconjugate gaze: adduction deficit on affected side	- On attempted lateral gaze, affected eye fails to adduct - Nystagmus of abducting eye	- Multiple sclerosis (young adults) - Stroke (older adults)

Notes:

Ocular deviation can be conjugate (both eyes move together abnormally, e.g., gaze palsy) or disconjugate (one eye deviates independently, e.g., cranial nerve palsy).
Assessment includes eye movement testing, pupillary reflexes, and ptosis evaluation.

Special considerations

Monitor vital signs and neurologic status for acute neurologic disorders
Implement seizure precautions if indicated
Prepare for diagnostic tests: blood studies, orbital/skull X-rays, CT scan

Patient counseling

Explain the disorder and treatment plan
Educate on warning signs of altered LOC or visual changes
Advise on maintaining a safe environment and minimizing stress

Pediatric pointers

Most common cause: nonparalytic strabismus
Normal binocular vision develops by 4 months
Mild strabismus requires early detection using corneal light reflex and cover tests to preserve vision and cosmetic appearance
Mild strabismus may indicate retinoblastoma, often presenting as whitish pupillary reflex before age 2

References

Ansons AM, Davis H. Diagnosis and Management of Ocular Motility Disorders. West Sussex, UK: Wiley Blackwell; 2014.
Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
Roy FH. Ocular Differential Diagnosis. Clayton, Panama: Jaypee–Highlights Medical Publishers; 2012.