In an inferior oblique (IO) palsy, which head tilt direction does the patient typically adopt to compensate?

• A. Contralateral to the lesion
• B. Ipsilateral to the lesion
• C. No head tilt
• D. Downward head tilt

Answer: (B)

When the inferior oblique is weak, the eye tends to lose elevation in adduction and the vertical/torsional alignment becomes problematic, especially in positions where that muscle would normally act. The head is often tilted to bring the visual axes into a configuration where the remaining, intact eye muscles can compensate most effectively, reducing the diplopia the patient experiences. In inferior oblique palsy, this compensatory strategy is to tilt the head toward the side of the lesion. By positioning the head ipsilaterally, the brain can better align the images using the other ocular muscles and vestibulo-ocular reflex, preserving single vision more comfortably. Tilting away from the lesion or not tilting at all doesn’t provide the same relief, and a downward tilt doesn’t specifically address the vertical-torsional imbalance caused by the weakened inferior oblique.