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This 2-year-old girl was first seen at age 18 months (six months ago) with ptosis of the right upper lid.  It was not blocking the visual axis and the child seemed otherwise healthy.  The family could not pinpoint the time of onset of the ptosis and it was considered to be congenital and observation was decided as the best thing to do.  Now the child appears with bilateral ptosis and exotropia with limitation of ocular movement in all directions. The pupils reacted normally. The patient does not object to occlusion of either eye and appears in no particular distress. Her eye examination except for the ptosis and motility findings was normal.  She has normal motor skills for her age.  She is able to eat without difficulty.

1.	The most likely diagnosis is:
	a. bilateral third nerve palsy b. neurofibromatosis c. myasthenia gravis d.  congenital fibrosis syndrome e. Duane syndrome
2.	An appropriate initial clinical test would be:
	a. the heat test b. the edrophonium (Tensilon) test c. muscle biopsy d.  forced ductions e. pupillary reactions
3.	Treatment for this condition could include:
	a. pyridostigmine (Mestinon) b. adrenal corticosteroids c. ibuprofen d.  selenium e. (a) and (b)

For answers to the above, click here on or after June 19, 2007.