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Case of the week 58 ( June 2012 )
Left Superior Oblique Palsy

20 years old girl complaining of this anomalous head posture , the mother noticed that since only 2 years but old photos tell that this AHP was present since early childhood, she denied diplopia , vision is normal OU, no history of trauma or any general illness

 See video of this patient

Superior oblique palsy is the most common oculo-motor nerve palsy encountered by strabismologists and should not present any diagnosis difficulties   . when a strabismologist is asked about head tilt found in old photographs , the diagnosis of congenital superior oblique palsy should arise as a first possibility.
The 3 step test (positive Bielschowsky test) - Hypertropia in the primary position increases on looking nasally and on head tilt to the same side of the hypertropia - is diagnostic of SO palsy
  In cases of class I superior oblique palsy like this case with a maximum hyperdeviation of no greater than 25 prism diopters weakening of the antagonist inferior oblique is effective.

الموقع المصري للحول وامراض الجهاز الحركي للعين

The Egyptian Site of Strabismus & Oculomotor Disorders