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This 18-year-old girl was examined by the surgeon prior to LASIK. He noted that the patient might have strabismus and referred the patient to a strabismus surgeon. The girl has 20/30 vision in each eye wearing -6.00 D -3.00 D X 180 in both eyes. She has “fusion” at near but suppresses the right eye at distance. She has a left head tilt which was also seen in childhood pictures. Neither the patient nor her family were aware of or concerned about “squint”.

1.	Based on the history and study of the pictures, is it likely that this patient has strabismus?
	e -- (a) and (d) This patient definitely has strabismus.  Just looking at the right hyper in the primary position tells you this, but the head tilt adds even more information, suggesting a right superior oblique palsy.
2.	What information about this patient is important when it comes to answering first question above?
	e -- (a), (b), and (c) The right hyperdeviation in primary with a left head tilt of long standing and the increased right hyper with right head tilt (positive Bielschowsky) makes it clear that this patient has a right superior oblique palsy.
3.	When it comes to making a decision about how to deal with this patient, the strabismus consultant should:
	e -- none of the above This girl needs eye muscle surgery, but not on both eyes.  She needs just a weakening procedure of the right inferior oblique.  For a minimal effect, a recession of the right inferior oblique could be done.