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An anomalous head posture becomes readily apparent during the initial part of the examination. In children it is best observed under casual conditions (e.g., while directing attention to the parents while the history is obtained). The parents or the patient may be unaware of an anomalous head posture. In most instances of incomitant strabismus, the head is rotated to avoid diplopia. For this reason, an anomalous position is often referred to as a "compensatory" head posture. Less frequently and when fusion becomes impossible or is difficult to maintain, the head is rotated such that the separation between the double images is maximized (paradoxic head posture).71 An ocular head tilt or head turn unrelated to incomitant strabismus occurs with nystagmus and a null point in certain gaze positions. Another ocular cause, unrelated to an ocular motility problem, is an uncorrected refractive error. When obtaining the history it is important to ascertain whether the anomalous posture is constant, if its direction is always the same, and whether it occurs at all or only at certain fixation distances. An anomalous head posture should always raise concern because it may cause neck strain; if left untreated, secondary scoliosis, contracture of the neck muscles,58, p.317 and facial asymmetry75 may occur.
(1) See 1.26.
(2) See 1.27.
(3) See 1.28 and 1.29.
(4) See 1.26, 1.27, 1.28 and 1.29.