Ocular plagiocephaly: Ocular torticollis with skull and facial asymmetry

Purpose: To observe facial asymmetry in patients with ocular torticollis to better understand its cause. Design: Observational case series. Participants: Forty-four consecutive patients with ocular torticollis in one author's (MFG) private practice were examined for facial asymmetry from January 1998 to August 1998, Some of these, as well as selective others before January 1998 were photographed for a total of 53 photos. Methods: One author (MFG) examined the frontal, maxillary, and mandibular facial areas of 44 consecutive torticollis patients for appearance of unilateral compression or reduced mass. The laterality of such findings was compared with the side of the head turn or tilt. Photographs of 53 selected ocular torticollis patients were inspected and the direction of nasal tip and columella deviation compared with the direction of head tilt or turn. Main Outcome Measures: Subjective clinical determination of appearance of unilateral facial compression or reduced facial mass. Subjective photographic determination of nasal tip and columella deviation. Results: Forty-three patients with 10 types of ocular torticollis examined were included. Forty-one of 43 showed compression or reduced mass on the same side as the head turn or tilt, including 3 with adult-onset strabismus. Eight nonsuperior oblique palsy patients had nasal deviation to the same side as the torticollis, Six of the eight had head tilts. Seventeen nonsuperior oblique palsy patients had nasal tip deviation to the opposite side of the torticollis, All were pure head turns, Eight superior oblique palsy patients had nasal tip deviation to the same side as the torticollis; nine had deviation opposite. Conclusions: Patients with multiple types of ocular torticollis, including face turns, show similar appearance of facial compression on the side of the torticollis, suggesting that the tilt or turn itself may cause the asymmetry. This includes face turn strabismus, in which facial asymmetry has not previously been described. Head tilts are frequently associated with nasal tip deviation to the side of the torticollis, head turns with deviation opposite. We refer to such asymmetric facial changes associated with ocular torticollis as "ocular plagiocephaly, Ophthalmology 2000;107:173-179 (C) 2000 by the American Academy of Ophthalmology.