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This 12-year-old girl has a history of "downward deviation" of the left eye since early childhood. This is associated with drooping of the left upper lid. She has a slight left head tilt and slight mid-facial hypoplasia on the left. The right hyper increases with left eye fixation. The left eye has some limitation of elevation and the right eye a limitation of depression. Visual acuity is 6/6 in each eye and the refraction is +0.50 in each eye. The girl does not record stereo acuity. She denies double vision. The right hyper/left hypo measures around 45 prism diopters in all fields of gaze, but is more with right head tilt.

1.	The ptosis of the left upper lid in the primary position seen in this patient is an example of:
	b -- pseudo ptosis This patient has pseudo ptosis because lid height on the left is normal when fixing with the left eye and the excursion is full looking up.  The left eye is down because the patient is fixing with the eye with a hyper deviation.   If the right eye has a paretic muscle this would be a secondary deviation.
2.	The left facial hypoplasia, left head tilt, increased right hyper in right head tilt, overaction of the right inferior oblique, and underaction of the right superior oblique all shown by this patient suggest a diagnosis of:
	e -- all of the above All of the individual features listed point to a diagnosis of congenital superior oblique (a vertical muscle) palsy with fixation with the paretic eye causing what is called "inhibitional" palsy of the contralateral antagonist (a terrible name!)
3.	At the time of surgery it would be appropriate to:
	e -- all of the above Since this patient is a bit unusual in that there is limitation of depression in the right eye in all directions, careful evaluation of the patient should be made while asleep and before deciding on the type of surgery to be done.  The most likely findings would be:  a lax or even absent right superior oblique tendon and a tight left inferior rectus.

You are urged to have a look at the superior oblique palsy patients in “Clinical Challenges” on E-Resources and to go to E-Learning to see the certificate on the superior oblique.  This can be accessed by going to E-Learning and obtaining “instant” credentials by following a few simple instructions and providing a minimum of information.