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.
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 Australian therapeutics
- Referral urgency, specialty, and letter drafting
Sources
- Skew Deviation — EyeWiki
- The Neuro-Ophthalmology Survival Guide (Pane, Miller & Burdon) — standard reference text
Standard texts: Kanski's Clinical Ophthalmology: A Systematic Approach, Oxford Handbook of Ophthalmology, Oxford American Handbook of Ophthalmology, Signs in Ophthalmology: Causes & Differential Diagnosis.