This patient highlights all of the typical features of bilateral 4th nerve palsies, including a V-pattern esotropia, reversing hypertropia on left and right gaze (also with left and right head tilt - not shown), underaction of the superior oblique in depression while adducting, and overaction of the inferior oblique in elevation while adducting. There was also 15 degrees of excyclotorsion, which could be seen on fundus photographs. The patient was able to fuse with a chin down position (up gaze) to minimize the esotropia.
Ophthalmic Atlas Images by EyeRounds.org, The University of Iowa are licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.
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