Skew Deviation and Inferior Oblique Palsy

The tonic ocular tile reaction (OTR) consists of triad of findings, including a head tilt, a vertical strabismus, and bilateral ocular torsion where the head and the superior pole of both eyes are rotated towards the lowermost eye. We have previously presented cases where the OTR can mimic a superior oblique palsy, but the hypertropic eye is incyclotorted rather than excyclotorted. We postulated that such deviations could be produced by damaging the otolithic projections corresponding to projections of the contralateral anterior semicircular canal (on the side of the hypotropic eye).