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This 20-year-old man has a complaint of the left eye being lower. He wants it “fixed”. He has visual acuity of 6/6 in the right eye and 6/18 in the left. Refraction is OD plano and OS -2.00 + 1.00 x 25. He recently had refractive surgery in the left eye for what presumably was a higher refractive error; was it hyperopia? No information on this is available. The reduced vision in the left eye is presumably amblyopia. Examination of the eyes reveals no abnormality except for the alignment, refractive error, and reduced vision in the left eye. No more information is available. The man was told he needs surgery on the left eye and is coming to you for a second opinion.

1.	Looking at the pictures of the lids, it is likely that:
	d -- the left eye demonstrates pseudo ptosis This patient demonstrates pseudo ptosis of the left eye.  Notice the full excursion of the left upper lid when the patient looks up.
2.	Your best response to the patient’s request for surgery would be:
	c -- If surgery is done, it should be on the right eye. Surgery, if done, should be on the right eye.  The left hypodeviation and ptosis appears to be a secondary deviation; that is, it occurs in response to fixation with the eye that has the paretic muscle.
3.	If you were asked to make a diagnosis, you would most likely say the patient has:
	a -- right superior oblique palsy This man appears to have a right superior oblique palsy and fixes with the “paretic” eye producing an inhibitional palsy in the other eye.  Take a careful look at the pictures.  Enlarge them if you wish.  In left gaze the patient is fixing with the right eye and a left hypotropia is present.  If the patient had been fixing with the left eye, overaction of the right inferior oblique would have been seen.  On right head tilt, the vertical deviation is greater and is manifested as a right hypertropia.  This confirms the diagnosis of right superior oblique palsy.