A 6-year-old boy holds his head tilted toward the right shoulder. He has a right hypertropia that increases on left gaze and increases further when the head is tilted to the right. Which muscle is MOST likely palsied?

• A Right superior rectus
• B Right inferior oblique
• C Left superior oblique
• D Right superior oblique ✓

Explanation

The three-step test identifies the palsied vertical muscle. Hypertropia localises weakness to a depressor of the right eye or elevator of the left. Worsening on left gaze implicates the right superior oblique or right superior rectus, and worsening on ipsilateral (right) head tilt confirms the right superior oblique, since tilting toward the paretic side removes its cyclofusional compensation. Patients habitually tilt away from the palsied side.

Reference: AAO Basic and Clinical Science Course, Section 6: Pediatric Ophthalmology and Strabismus, 2023-2024 ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.