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This 16-year-old girl had surgery for congenital esotropia at age 4 years. Six months ago she had a second surgery for a hypertropia that appeared alternately in the two eyes. This second surgery was a bilateral large superior rectus recession. She now presents with an intermittent right hypertropia and vision corrected to OD 20/30, OS 20/20 wearing OD +1.25 +2.00 x 30, OS +1.00 +1.50 x 100. The versions in the diagnostic positions, the right hypertropia in the primary position, and the alignment with the translucent occluder are as shown in the pictures.

1.	What is the most likely diagnosis?
	d -- dissociated vertical deviation (DVD) This is an example of dissociated vertical deviation (DVD). Heimann-Bielschowsky phenomenon occurs with very poor vision in one eye and starts with a downward movement and the eye goes up when occluded. Skew deviation is usually seen in older individuals and is characterized by alternate torsional movement. The superior obliques are not overacting.
2.	How would you rate the inferior oblique action?
	b -- causing abduction in the right eye in elevation because of limited adduction after the previous medial rectus recession The inferior obliques are not “overacting” in the traditional sense. But the right eye is moving outward in abduction while also looking up. Note the slight limitation of adduction in the right eye. It is reasonable to assume the right eye goes out in up gaze in this patient because of this lack of full adduction, meaning that the right inferior oblique is not functioning in its normal primary action of elevation but is functioning more as an abductor. (See the E-Resources The Strabismus Minute Vol. 2. No. 19)
3.	In the case shown here, what would be a logical choice for the next surgical procedure?
	d -- resection of both inferior rectus muscles This is a good choice in a case where there is persistent DVD after superior rectus recession but no inferior oblique overaction suggesting the need for an anterior shift of the inferior obliques.