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Pre-operative pictures:

Post-operative pictures:

This 10-year-old girl has had a drooping lid since birth. Vision is OD 6/6 and OS 1/60. The child, according to her parents, does not raise her chin to look under the lid. No fusion could be measured. Refraction is OD +0.75 and OS +0.50 +0.50 x 90. The motility is as shown in the images. The left eye fails to elevate and there is severe ptosis in the left upper lid with no levator function. On forced lid closure, the left eye elevates above the midline. The child is otherwise in good health.

1.	The diagnosis in this case is likely to be:
	d -- double elevator palsy This is an example of double elevator palsy.  It is a supranuclear defect.  The extraocular muscles work on a reflex basis as shown by some elevation on forced lid closure, bell reaction.
2.	The reduced vision in the left eye is most likely due to:
	a -- amblyopia The reduced vision is most likely due to amblyopia and is severe.  In cases of ptosis where the the patient assumes a head posture to look under the lid, amblyopia can be avoided, but that is not so in this case.
3.	Striking features in the post-operative pictures are:
	d -- ability to close the lids with some effort  This child underwent surgery as follows: left inferior rectus recession, full tendon transfer of the lateral and medial rectus superiorly to a point adjacent to the superior rectus insertion, and a frontalis suspension of the left upper lid.  She has mild left lower lid ptosis from the inferior rectus recession. She also has left upper lid lag on downgaze from the lid suspension, straight eyes in primary position with good lid height for an excellent appearance. She can close her lids with some effort, meaning that she can lubricate and protect her left cornea.