Clinically, some parents often report that our children tilt their heads when watching something, especially when watching TV, which is fine at first, but then tilts over when watching. Some of them tilt their heads when they look at small objects in the distance. So these tilted heads are caused by abnormalities in the neck muscles, cervical spine development, or abnormalities in the eyes? People sometimes wonder how a crooked neck is related to the eyes. In fact, 90% of the crooked heads are caused by eye abnormalities. What is abnormal head position? If the head is not in the right position, but deviates from the front direction, making the eye deviate from the center position to look at the target in front, then the abnormal head position occurs. Abnormal head position includes jaw up, jaw in, head tilted to the right or left shoulder, face turned right or left, or a combination of these abnormal positions. Abnormal head position can be caused by ocular or non-ocular causes. What are the ocular causes of abnormal head position? 1. Ocular malposition: Sometimes patients with ocular malposition (strabismus) have different degrees of strabismus in different gaze directions. Patients usually move their head position to a certain position where the eye position is best. This helps eliminate diplopia, and/or relieves visual fatigue. For example, in a weak superior oblique muscle (fourth cranial nerve palsy), the patient will tend to move the head away from the direction of the affected eye because in this position, the eye position is least oblique. Similarly, sixth cranial nerve palsy results in inadequate function of the external rectus muscle and an abnormal head position with the face turned toward the affected eye. Sometimes, upward or downward eye gaze is corrected and the patient will adopt an abnormal head position with the jaw up or jaw in depending on which position eye position is best. Other strabismic abnormal head positions include Duane’s syndrome, Brown’s syndrome, orbital wall fractures, and limited eye movements with thyroid-related ophthalmopathy. 2. Nystagmus: Some patients with nystagmus who have reduced nystagmus in a particular direction of gaze or head position may adopt an abnormal head position with a corresponding face turn or head tilt. The position of the head when the tremor is at its mildest, or when the tremor has stopped, is called the middle band of the tremor. Reduced tremor can lead to better vision, so do not prevent such children from using abnormal head positions. 3. Unequal vision in both eyes: Sometimes children turn their eyes and move the better-seeing eye closer to the target. 4 . Ptosis: Children with ptosis usually have their jaws lifted up to help the eye see the target from underneath the drooping eyelid. 5 . Refractive error: If a child has significant refractive error, especially astigmatism, they will often turn their head to the side. It is generally believed that the face turn helps the patient see more clearly because it is viewed through the narrow gap between the eyelids, which is similar to a “small hole” mechanism. 6. Unexplained: Some children may adopt a horizontal head turn when looking away, such as when watching television. Usually, there is no definite reason for this “habit” and the child’s eye examination is normal. Can the child see when his head is tilted? Yes, he can see, and if the head position is ocular in origin, most children improve their vision by adopting an abnormal head position. Is it possible that a long-term abnormal head position can cause permanent problems? It is very possible that a significant abnormal head position can cause constant tightening of the neck muscles, which can lead to chronic neck pain or headaches. Abnormal head position can also cause abnormal growth of the facial bones, resulting in facial asymmetry. What are the non-ocular causes of abnormal head position? Congenital shortening of the neck muscles (sternocleidomastoid muscle ) can cause head tilt. This is often referred to as congenital lordosis. Usually this type of head tilt occurs after birth and can be associated with skeletal deformities, such as tilted head deformity. An in-office covered monocular test can also confirm this diagnosis. If the head tilt is due to tight neck muscles that cover one eye, the degree of head tilt remains the same. If the head tilt is due to an ocular cause, such as strabismus, the head tilt should improve when one eye is covered. Other non-ocular causes of abnormal head position include cerebral palsy, skeletal abnormalities, cervico-occipital region closure deformity, and unilateral hearing loss. Are there ways to treat an abnormal head position? Our strabismus and pediatric ophthalmologists can treat most abnormal head positions. Depending on the cause, abnormal head positions can often be treated and improved. Strabismus, nystagmus and ptosis can be treated surgically. Refractive errors can be treated with glasses, and weak vision in one eye (amblyopia) can be treated with masking, which are also options for treating abnormal head positions. Congenital oblique neck caused by contracture of the neck muscles can be treated with physical therapy.