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This 13-year-old girl is in the examining chair as you walk in. You notice that she holds her head to the left and looks to the right. As she addresses you, this head posture remains. Before doing any examination …

1.	This child could have:
	d -- (a), (b), or (c) The first impression created by the patient can often direct the examiner to a correct differential diagnosis immediately.  In this case a left face turn can be the assumed in response to: left eye Duane I, right superior oblique palsy (although with this the child’s head is usually slightly down and if it is congenital, there can be facial symmetry), and null point nystagmus.
2.	On looking to the left, the eyes develop to-and-fro movement suggesting a diagnosis of:
	c -- null point nystagmus The appearance of nystagmus (to-and-fro movement of the eyes) when the eyes look toward the left suggests a diagnosis of null point nystagmus.
3.	The most likely eventual treatment for this would be
	e -- surgery If this is a case of null point nystagmus, surgery could be helpful.  This would consist of shifting the eyes to the left resulting in the neurologic equivalent of assuming dextroversion to bring the eyes to the primary position.  Many surgeons are doing the older Anderson procedure of recessing yoke muscles only, abandoning the Kestenbaum procedure which can result in a face turn of equal magnitude in the opposite direction.