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This 8-year-old boy at age 2 years had a bimedial rectus recession for esotropia present from birth.  The parents now notice that his eyes “shoot up” when he looks to the side.  Vision is OD and OS, 20/20.  Cycloplegic refraction is OU +0.50 sph.  There is no fusion measured with the stereo test and he alternates on testing with the four lights.  The boy denies diplopia and has no complaints. As shown in the pictures, he has a small “V” pattern and strabismus sursoadductorius (elevation in adduction) referred to usually as overaction of the inferior obliques.  Behind the translucent occluder each eye elevates slowly with a vergence movement and returns with a similar movement when the cover is removed.

1.	To diagnose a “V” pattern the difference between the horizontal alignment in up and down gaze should be how many prism diopters?
	c -- 15 15 prism diopters difference in the horizontal deviation in up and down gaze is required to diagnose a “V” pattern.
2.	The behavior of the eyes, upward movement, behind the translucent occluder means that the boy has:
	c -- dissociated vertical deviation (DVD) This is an example of dissociated vertical deviation.  If looked for carefully, this is seen in a high percentage of children treated with surgery for congenital esotropia.
3.	A reasonable treatment plan would be:
	b -- bilateral inferior oblique anterior transposition Anterior transposition of the inferior obliques bilaterally will treat both the inferior oblique overaction and the DVD.