A 26-year-old presents with a slight right head tilt, small “V” pattern, overaction of the right inferior oblique, underaction of the right superior oblique, and a small angle esotropia. She has 20/20 (6/6) vision in each eye. There is a history of two prior eye muscle surgeries done before age 10 but no details are available. You are only hearing about this patient from a colleague who has just obtained fundus photos. The patient has already left the clinic and your colleague is asking for your opinion.


    1. With paradoxical head tilts, the presumption is that if the patient cannot fuse with the expected head tilt direction, they then tilt in the opposite direction to move the diplopic images further apart and therefore less confusing.

  1. @Dr. Chakraborty your comment about EXPECTING a left head tilt is correct. As discussed in the answer to question 3, this case highlights a paradoxical head tilt. While this should always raise questions, it does happen. The proposed reason is that the patient alleviates the discomfort of diplopia by making the images further apart rather than closer together. When encountering this clinical situation, one should always reassess to ensure that the remaining examination elements are consistent with the proposed diagnosis.

  2. Considering this case shows a IV cranial nerve palsy in the right eye, it would be expected a slight LEFT head tilt, not right head tilt.

  3. Interesting case. Going beyond the external finding of strabismus and capturing the fundus photo. Good case to learn.

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