Skew deviation refers to any acquired vertical binocular deviation that is caused by lesions affecting supranuclear input to the nuclei of cranial nerves III, IV, and VI rather than lesions affecting the cranial nerves themselves. These lesions are limited to the brain stem, but the location is highly variable and may occur at any level from midbrain to medulla. The vertical deviation may be comitant, such as with strabismus, or incomitant, sometimes mimicking cranial nerve IV lesions (deviation greater in downgaze and in adduction). Skew deviation is not specific for any etiology.
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