NANOSNET

I had the opportunity of initially evaluating this 23-year-old male individual on July 21, 2025. He reports an unusual story. He says, "I woke up 2 weeks ago with tilted images" described as seeing lines of print/iPhone lines as tilted down on the right. No double vision, no unsteadiness, no dizziness.

He claims, "The tilt is most dramatic when I'm reading." In the office, he has the same "tilt" with either eye alone or with both open.

My first thought was is this possibly a 4^th nerve (superior oblique muscle) palsy – but, he exhibits within normal limits ocular motility measurements of 3-5PD (prism diopters) esophoria with 0.50PD left hyperphoria and no cyclophoria.

That fairly well rules out 4^th nerve palsy – they generally present with exophoria and 2 or more degrees of excyclophoria.

So, the patient, who is a very nice young man and a mechanical engineer, from a prestigious school, is preparing to go to Europe for a year. He volunteers the question/possibility that his symptoms are "psychological." I ask him if he is nervous and his response is, "Yes, a little."

I'm perfectly happy to just say it's nothing, go to Germany, and if you have a problem, here is the name of somebody in Berlin. Hopefully, someone, who has labored through this tale so far, will volunteer the name of a German colleague

I had the opportunity of initially evaluating this 23-year-old male individual on July 21, 2025. He reports an unusual story. He says, "I woke up 2 weeks ago with tilted images" described as seeing lines of print/iPhone lines as tilted down on the right. No double vision, no unsteadiness, no dizziness.

He claims, "The tilt is most dramatic when I'm reading." In the office, he has the same "tilt" with either eye alone or with both open.

My first thought was is this possibly a 4^th nerve (superior oblique muscle) palsy – but, he exhibits within normal limits ocular motility measurements of 3-5PD (prism diopters) esophoria with 0.50PD left hyperphoria and no cyclophoria.

That fairly well rules out 4^th nerve palsy – they generally present with exophoria and 2 or more degrees of excyclophoria.

So, the patient, who is a very nice young man and a mechanical engineer, from a prestigious school, is preparing to go to Europe for a year. He volunteers the question/possibility that his symptoms are "psychological." I ask him if he is nervous and his response is, "Yes, a little."

I'm perfectly happy to just say it's nothing, go to Germany, and if you have a problem, here is the name of somebody in Berlin. Hopefully, someone, who has labored through this tale so far, will volunteer the name of a German colleague

I had the opportunity of initially evaluating this 23-year-old male individual on July 21, 2025. He reports an unusual story. He says, "I woke up 2 weeks ago with tilted images" described as seeing lines of print/iPhone lines as tilted down on the right. No double vision, no unsteadiness, no dizziness.

He claims, "The tilt is most dramatic when I'm reading." In the office, he has the same "tilt" with either eye alone or with both open.

My first thought was is this possibly a 4^th nerve (superior oblique muscle) palsy – but, he exhibits within normal limits ocular motility measurements of 3-5PD (prism diopters) esophoria with 0.50PD left hyperphoria and no cyclophoria.

That fairly well rules out 4^th nerve palsy – they generally present with exophoria and 2 or more degrees of excyclophoria.

So, the patient, who is a very nice young man and a mechanical engineer, from a prestigious school, is preparing to go to Europe for a year. He volunteers the question/possibility that his symptoms are "psychological." I ask him if he is nervous and his response is, "Yes, a little."

I'm perfectly happy to just say it's nothing, go to Germany, and if you have a problem, here is the name of somebody in Berlin. Hopefully, someone, who has labored through this tale so far, will volunteer the name of a German colleague

I had the opportunity of initially evaluating this 23-year-old male individual on July 21, 2025. He reports an unusual story. He says, "I woke up 2 weeks ago with tilted images" described as seeing lines of print/iPhone lines as tilted down on the right. No double vision, no unsteadiness, no dizziness.

He claims, "The tilt is most dramatic when I'm reading." In the office, he has the same "tilt" with either eye alone or with both open.

My first thought was is this possibly a 4^th nerve (superior oblique muscle) palsy – but, he exhibits within normal limits ocular motility measurements of 3-5PD (prism diopters) esophoria with 0.50PD left hyperphoria and no cyclophoria.

That fairly well rules out 4^th nerve palsy – they generally present with exophoria and 2 or more degrees of excyclophoria.

So, the patient, who is a very nice young man and a mechanical engineer, from a prestigious school, is preparing to go to Europe for a year. He volunteers the question/possibility that his symptoms are "psychological." I ask him if he is nervous and his response is, "Yes, a little."

I'm perfectly happy to just say it's nothing, go to Germany, and if you have a problem, here is the name of somebody in Berlin. Hopefully, someone, who has labored through this tale so far, will volunteer the name of a German colleague

I had the opportunity of initially evaluating this 23-year-old male individual on July 21, 2025. He reports an unusual story. He says, "I woke up 2 weeks ago with tilted images" described as seeing lines of print/iPhone lines as tilted down on the right. No double vision, no unsteadiness, no dizziness.

He claims, "The tilt is most dramatic when I'm reading." In the office, he has the same "tilt" with either eye alone or with both open.

My first thought was is this possibly a 4^th nerve (superior oblique muscle) palsy – but, he exhibits within normal limits ocular motility measurements of 3-5PD (prism diopters) esophoria with 0.50PD left hyperphoria and no cyclophoria.

That fairly well rules out 4^th nerve palsy – they generally present with exophoria and 2 or more degrees of excyclophoria.

So, the patient, who is a very nice young man and a mechanical engineer, from a prestigious school, is preparing to go to Europe for a year. He volunteers the question/possibility that his symptoms are "psychological." I ask him if he is nervous and his response is, "Yes, a little."

I'm perfectly happy to just say it's nothing, go to Germany, and if you have a problem, here is the name of somebody in Berlin. Hopefully, someone, who has labored through this tale so far, will volunteer the name of a German colleague

I had the opportunity of initially evaluating this 23-year-old male individual on July 21, 2025. He reports an unusual story. He says, "I woke up 2 weeks ago with tilted images" described as seeing lines of print/iPhone lines as tilted down on the right. No double vision, no unsteadiness, no dizziness.

He claims, "The tilt is most dramatic when I'm reading." In the office, he has the same "tilt" with either eye alone or with both open.

My first thought was is this possibly a 4^th nerve (superior oblique muscle) palsy – but, he exhibits within normal limits ocular motility measurements of 3-5PD (prism diopters) esophoria with 0.50PD left hyperphoria and no cyclophoria.

That fairly well rules out 4^th nerve palsy – they generally present with exophoria and 2 or more degrees of excyclophoria.

So, the patient, who is a very nice young man and a mechanical engineer, from a prestigious school, is preparing to go to Europe for a year. He volunteers the question/possibility that his symptoms are "psychological." I ask him if he is nervous and his response is, "Yes, a little."

I'm perfectly happy to just say it's nothing, go to Germany, and if you have a problem, here is the name of somebody in Berlin. Hopefully, someone, who has labored through this tale so far, will volunteer the name of a German colleague

I had the opportunity of initially evaluating this 23-year-old male individual on July 21, 2025. He reports an unusual story. He says, "I woke up 2 weeks ago with tilted images" described as seeing lines of print/iPhone lines as tilted down on the right. No double vision, no unsteadiness, no dizziness.

He claims, "The tilt is most dramatic when I'm reading." In the office, he has the same "tilt" with either eye alone or with both open.

My first thought was is this possibly a 4^th nerve (superior oblique muscle) palsy – but, he exhibits within normal limits ocular motility measurements of 3-5PD (prism diopters) esophoria with 0.50PD left hyperphoria and no cyclophoria.

That fairly well rules out 4^th nerve palsy – they generally present with exophoria and 2 or more degrees of excyclophoria.

So, the patient, who is a very nice young man and a mechanical engineer, from a prestigious school, is preparing to go to Europe for a year. He volunteers the question/possibility that his symptoms are "psychological." I ask him if he is nervous and his response is, "Yes, a little."

I'm perfectly happy to just say it's nothing, go to Germany, and if you have a problem, here is the name of somebody in Berlin. Hopefully, someone, who has labored through this tale so far, will volunteer the name of a German colleague

I had the opportunity of initially evaluating this 23-year-old male individual on July 21, 2025. He reports an unusual story. He says, "I woke up 2 weeks ago with tilted images" described as seeing lines of print/iPhone lines as tilted down on the right. No double vision, no unsteadiness, no dizziness.

He claims, "The tilt is most dramatic when I'm reading." In the office, he has the same "tilt" with either eye alone or with both open.

My first thought was is this possibly a 4^th nerve (superior oblique muscle) palsy – but, he exhibits within normal limits ocular motility measurements of 3-5PD (prism diopters) esophoria with 0.50PD left hyperphoria and no cyclophoria.

That fairly well rules out 4^th nerve palsy – they generally present with exophoria and 2 or more degrees of excyclophoria.

So, the patient, who is a very nice young man and a mechanical engineer, from a prestigious school, is preparing to go to Europe for a year. He volunteers the question/possibility that his symptoms are "psychological." I ask him if he is nervous and his response is, "Yes, a little."

I'm perfectly happy to just say it's nothing, go to Germany, and if you have a problem, here is the name of somebody in Berlin. Hopefully, someone, who has labored through this tale so far, will volunteer the name of a German colleague

I had the opportunity of initially evaluating this 23-year-old male individual on July 21, 2025. He reports an unusual story. He says, "I woke up 2 weeks ago with tilted images" described as seeing lines of print/iPhone lines as tilted down on the right. No double vision, no unsteadiness, no dizziness.

He claims, "The tilt is most dramatic when I'm reading." In the office, he has the same "tilt" with either eye alone or with both open.

My first thought was is this possibly a 4^th nerve (superior oblique muscle) palsy – but, he exhibits within normal limits ocular motility measurements of 3-5PD (prism diopters) esophoria with 0.50PD left hyperphoria and no cyclophoria.

That fairly well rules out 4^th nerve palsy – they generally present with exophoria and 2 or more degrees of excyclophoria.

So, the patient, who is a very nice young man and a mechanical engineer, from a prestigious school, is preparing to go to Europe for a year. He volunteers the question/possibility that his symptoms are "psychological." I ask him if he is nervous and his response is, "Yes, a little."

I'm perfectly happy to just say it's nothing, go to Germany, and if you have a problem, here is the name of somebody in Berlin. Hopefully, someone, who has labored through this tale so far, will volunteer the name of a German colleague