What are Beilchowski’s three step test ?

Step 1 

Find the resting position misalignment.

Due to diplopia patient have tilting of eye first correct it. For example if the patient has the Left eye low right eye up. Problem can be Either depressors are weak on the right side i.e. Right IR(inferior Rectus)  or SO(superior Oblique).Or elevators of the left eye could be at fault.

Step 2

To find out where is the maximum misalignment.

Ask the patient to look to the right and left.

Misalignment is maximum to looking towards the left side. For example, if the patient has Right eye is up and left eye is down and maximum separation is looking towards the left so the right superior oblique is weak.

Problem is Right superior oblique is weak.

OR Left superior rectus is weak.

Adducted eye is up on right and abducted eye is down in left .

Step 3

Lateral rotation where is the maximum separation. For example, on turning to the right disconjugation is maximum. Turning to the right side you are putting the right intorters into action and left extorters into the action.

Right turning the introrters are SR and SO .when the Superior oblique is weak the eye right eye SR is acting and pushes the eye to upwards,on the left side if the superior recus is abnormal it is an intorter nothing will happen.

On turing to left the extorters acting nothing will happen.

The separation of the images increase when the head is tilted to the side of palsy.

Deficit improves when the head is tilted to the opposite side.

BeilchowskyJs head rotation test

Pitfalls of the three step test - namely, the conditions in which the rules breakdown.

1. Restrictive ocular myopathies
2. Long-standing strabismus
3. Skew deviation
4. Disorders involving more than one muscle.

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