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This 36-year-old man suffered blunt trauma to the area of the right eye two months earlier.  He complains of dizziness and diplopia in all fields although on cover testing he demonstrates only a small exotropia with an “A” pattern.  His visual acuity is OD 20/20 and OS 20/20 unaided.  Refraction is plano OU.  The right pupil reacts sluggishly to light.  The media are clear and the fundus is normal in each eye.  There is a slight limitation of abduction in the right eye.  The right eye has a reading 4.0 mm less compared to the left using the exophthalmometer.

1.	The most likely diagnosis is:
	a. blow out fracture of the right orbit  b. proptosis of the left eye c. decompensated intermittent exotropia d.  right superior oblique palsy e. right third nerve palsy, partial
2.	This patient would also be likely to demonstrate:
	a. past pointing b. monocular diplopia c. decreased sensitivity to touch along the skin of the upper right cheek d.  inhibitional palsy of the contralateral antagonist e. (a) and (c)
3.	The most important next step in evaluating this patient would be:
	a. a therapeutic trial of Botox b. imaging of the orbits c. ptosis evaluation in the right eye d.  exploration of the right medial rectus e. generated force testing

For answers to the above, click here on or after October 3, 2006.