Observations about head position or head movement can be very informative. Spasmus nutans, a benign form of acquired nystagmus, often has an associated head bob or torticollis. A patient with congenital motor nystagmus often develops a head turn to dampen the nystagmus. Although the presence of a preferred head position is not particularly helpful in deciding about etiology, it has some bearing on visual function and the type of nystagmus. Patients with a jerk nystagmus more often tend to develop head positions than patients with pendular nystagmus; this is because of Alexander's law of nystagmus, which states that a jerk nystagmus becomes worse when gazing in the direction of the fast component.4 Thus, a left jerk nystagmus becomes
much worse in leftgaze and improves dramatically on rightgaze. Therefore, a patient with a left jerk nystagmus will have a left face turn and a right gaze preference [Fig. 2-8). Old photographs can be helpful in documenting head positions.
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