1. V true paradoxical head tilt and accompanying fundus extorsion.There is bilateral disc pallor as well. Correct me if I am wrong

    1. Agree. However, the discs are normal. The “pallor” you see in the photographs is over-exposure artifact.

    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.

  2. @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.

  3. 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.

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

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