One of the first steps in examination is to be an astute observer of the patient. In some instances this involves observing a patient’s gait as they walk down the hallway or enter an exam room. When the doctor’s staff conducts diagnostic testing before she or he greets the patient, this may involve the doctor’s initial visual impressions of the patient in the chair. But in some instances you either don’t pick up on subtle cues the first time around, or the patient may present differently the second or third time you see her than the first time. In Malky’s case, I suspect I simply wasn’t as astute an observer on her prior visit to our office as I was yesterday.
Here, with her mother’s consent, is a picture of Malky as she sat in my exam chair yesterday. What do you notice?
Just by my priming you, I’m guessing that you’ll detect the subtle asymmetry. Malky has what I’ll call a cyclorotation of her right orbit (slanting downward to the right) and a corresponding slant of her right shoulder downward. You’ll also note that her right earring is slightly lower than her left earring, indicating the subtle slope of the cranium downward to the right. She also has a subtle face turn toward the right. In case all this is difficult to see, here are linear reference points.
I mentioned in a blog a couple of years ago that Adelbert Ames Jr., a pre-eminent experimental psychologist last century responsible for the Ames Illusion and the design of the leaf room, had significant facial asymmetry and resultant cyclophoria. His happens to match Malky’s. You can see Ames’ right orbit sloped downward, his right shoulder lower, and his right ear lower than his corresponding left head-neck-shoulder anatomical landmarks.
Once you begin to notice craniofacial asymmetries, you’ll increase your own visual abilities in being a more sensitive observer. You might say that you’ll up the sensitivity of your JNDs as if you had an internal protractor to gauge the degrees of tilt.
I eyeballed Malky’s asymmetries to be in the neighborhood of 10 degrees. In addition to the objective slants, slopes, tilts, and turns, we clinically see these skews translated into measurement asymmetries thorough cyclorotation on the Van Orden Binocular Behavior Pattern, Cheiroscopic Tracings, or Maddox Rod in free space. Most often the patient will have compensatory postural skews that allow them to report good subjective alignment and ranges in their head/body posture, but exhibit significant vertical or cyclovertical imbalance when you insists that they sit up straight and hold their head in a straight position. They invariably reveal fusion anomalies in the field opposite to their habitual skew. A personal favorite quick probe in free space is the Press Three Step in which the patient reports normal fusion in habitual posture, but diplopia or unstable fusion when tilting their head or body 180 degrees opposite to the habitual angle.
In the old days, when kids wore real shoes with heels, the oculo-cranio-facial asymmetry could easily be seen to translate in postural skews down through the shoulders, pelvic region and feet evident in wearing down the heel on one side faster than the other side. So in Malky’s case, her right heel would wear down considerably faster than the left heel, because her postural skew shifts weight-bearing toward that side. Naturally we can address the visual sequelae through vectors of prism or expand cylcofusional vergence ranges through vision therapy. But sometimes the patient is better served by an osteopathic or physical therapy approach that gets more directly at the whole body – specifically craniosacral therapy. After all, this is a head-to-toe issue of which oculo-visual manifestations are just a component.