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©2013 UpToDate ® Print Email Bilateral superior oblique palsy A patient with a bilateral fourth nerve palsy demonstrates a reversing hypertropia (left hypertropia in right gaze and a right hypertropia in left gaze in the middle panels right and left). The primary position deviation is not readily apparent because of the bilateral palsy (middle row center panel). There is underaction of both superior oblique muscles (right lower and left lower panels). There is overaction of the inferior oblique muscle bilaterally (right upper and left upper panels). Reproduced with permission from: Tasman W, Jaeger E. The Wills Eye Hospital Atlas of Clinical Ophthalmology, 2nd ed, Lippincott Williams & Wilkins, Philadelphia 2001. Copyright ©2001 Lippincott Williams & Wilkins.