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Right eye

Left eye

A 26-year-old female presents with a slight right head tilt, minimal “V” pattern, overaction of the right inferior oblique, underaction of the right superior oblique, and a small esotropia. She has 20/20 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 and is asking your opinion after the patient has left the clinic.

1.	What do you see in the photos?
	b -- possible fundus torsion It looks like there could be extorsion of both eyes, but the addition of the lines indicate that only the right eye is extorted.  The fundus picture is not entirely normal because of the torsion that is pretty well confirmed by the reference lines.  The disc is neither cupped nor swollen. Right eye Left eye
2.	What did you hear in the history or see in the photos that makes these photos possibly relevant?
	e -- (c) and (d) Overaction of the right inferior oblique and underaction of the right superior oblique suggests right superior oblique palsy that would be associated with extorsion of the right eye.  The age of the patient and the history of two prior surgeries are not specifically related to the fundus torsion.
3.	What does history of the right head tilt suggest?
	a -- a possible anomalous direction for tilt given the findings If this is indeed a right superior oblique palsy with right fundus extorsion, overaction of the right inferior oblique and underaction of the right superior oblique, then a right head tilt would be in the wrong direction or anomalous.