My turn for journal club this month, I find I am seeing a lot of the Cyclovertical Saggy Eye Syndrome patients of late and I find it hard to differentially diagnose between this and a 4^th nerve palsy.

Cyclovertical strabismus tend to be smaller in my opinion. Sometimes I do get a slightly positive BHTT for these too. Does anyone have any tips or tricks for helping to diagnose between these?  

This study compares subjective cyclovertical deviations and objective ocular torsion between elderly patients with Cyclovertical Saggy Eye Syndrome and Superior Oblique Palsy.