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step 3 discussion :

If the deviation increases on right head tilt and decreases on left head tilt, as it does in this example patient, then the right superior oblique is implicated as the paretic culprit. The reason for this is because the right superior oblique and right superior rectus muscles work together to incyclotort the right eye in right head tilt. Usually they offset each other in terms of vertical movement, because the superior oblique depresses and the superior rectus elevates. However, in the case of the paretic right superior oblique, the elevating action of the right superior rectus is unopposed and causes an increase in the right hypertropia when the patient tilts his or her head to the right.