title: Cerebellar skew deviation and the torsional vestibuloocular reflex.
abstract: BACKGROUND
  Skew deviation is typically caused by brainstem damage, and has not been identified with focal cerebellar lesions. This vertical strabismus has been attributed to asymmetric disruption of vestibuloocular reflex (VOR) projections from otolithic receptors of the utricle to ocular motoneurons, but asymmetry of the utriculo-ocular counter-roll reflex has not been detected.
  
  
  METHODS
  Lesions localized to the cerebellum were identified by MRI in five patients with vertical strabismus. Their skew deviation was measured by prism cover tests in all patients and by search coils in three patients. The angular VOR was tested in patients and 10 controls during sinusoidal +/- 10 degree torsional, vertical, and horizontal head-on-body rotations at 0.5, 1, and 2 Hz. Static torsional VOR gain was measured by the change in torsional eye position divided by change in head position during maintained head tilt.
  
  
  RESULTS
  Static torsional VOR gains were asymmetric in each patient. Three patterns of asymmetry were identified: 1) decreased static gain in one eye in both directions; 2) decreased gains in both eyes in one direction; and 3) asymmetric gain in one direction in one eye alone. Dynamic torsional VOR gains were symmetrically reduced in both directions in both eyes in all patients.
  
  
  CONCLUSIONS
  Focal cerebellar lesions can cause skew deviation. The static torsional vestibuloocular reflex (VOR) is linked to cerebellar control of vertical vergence. Asymmetry between the eyes or in direction of the static torsional VOR provides evidence that monocular or binocular imbalance of the utriculo-ocular reflex leads to cerebellar skew deviation.
authors.affiliation: Division of Neurology, Department of Ophthalmology and Vision Science, University Health Network, University of Toronto, Ontario, Canada. agnes.wong@utoronto.ca
authors.forename: Agnes M F
authors.initials: AM
authors.lastname: Wong
authors.forename: James A
authors.initials: JA
authors.lastname: Sharpe
mesh_terms: D000328:Adult; D000368:Aged; D002526:Cerebellar Diseases / Q000473:pathology / Q000503:physiopathology*; D002531:Cerebellum / Q000473:pathology / Q000503:physiopathology*; D005133:Eye Movements / Q000502:physiology; D005260:Female; D007839:Functional Laterality / Q000502:physiology; D019416:Head Movements / Q000502:physiology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009434:Neural Pathways / Q000473:pathology / Q000503:physiopathology; D009460:Neurologic Examination; D015835:Ocular Motility Disorders / Q000209:etiology / Q000473:pathology / Q000503:physiopathology*; D009801:Oculomotor Muscles / Q000294:innervation / Q000502:physiology; D011187:Posture / Q000502:physiology; D012027:Reflex, Vestibulo-Ocular / Q000502:physiology*; D014722:Vestibule, Labyrinth / Q000502:physiology