Which of the following is the most likely presentation of a patient with a CN VI palsy when compensating for their deviation?

Which of the following is the most likely presentation of a patient with a CN VI palsy when compensating for their deviation?

• A. Ipsilateral head tilt
• B. Contralateral head tilt
• C. Ipsilateral head turn
• D. Contralateral head turn

Answer: (C)

In CN VI palsy, the lateral rectus is weak, so the affected eye drifts inward (esotropia) and the horizontal diplopia is worst when looking toward the side of the palsy. To keep vision single, patients commonly rotate their head toward the side of the affected eye. This ipsilateral head turn shifts the gaze so that the remaining healthy eye can align with the paretic eye in a way that minimizes the mismatch between the two images, reducing diplopia. Tilt of the head is more associated with vertical/oblique muscle issues (like CN IV palsy), and turning the head away from the affected side would generally worsen the diplopia rather than improve it.

In CN VI palsy, the lateral rectus is weak, so the affected eye drifts inward (esotropia) and the horizontal diplopia is worst when looking toward the side of the palsy. To keep vision single, patients commonly rotate their head toward the side of the affected eye. This ipsilateral head turn shifts the gaze so that the remaining healthy eye can align with the paretic eye in a way that minimizes the mismatch between the two images, reducing diplopia.

Tilt of the head is more associated with vertical/oblique muscle issues (like CN IV palsy), and turning the head away from the affected side would generally worsen the diplopia rather than improve it.