The clinical features of superior oblique paresis vary widely depending on the type. Common features include an ipsilateral hypertropia that increases on contralateral gaze, and a positive head tilt test with the hypertropia increasing on head tilt to the side of the hypertropia. Congenital superior oblique paresis is commonly associated with ipsilateral inferior oblique overaction and relatively less superior oblique underaction. Acquired superior oblique paresis, on the other hand, has relatively normal versions, minimal inferior oblique overaction, but significant extorsional diplopia. The head tilt test can help differentiate primary inferior oblique overaction from inferior oblique overaction secondary to superior oblique paresis. A positive head tilt test indicates a superior oblique paresis and a negative head tilt test suggests primary inferior oblique overaction.