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This 14-year-old girl had right medial rectus recession and right lateral rectus resection for  esotropia four years ago.  Visual acuity is right eye (OD) 20/30 and left eye (OS) 20/20.  Her cycloplegic refraction is OD +1.50 and OS +1.0 and is fully corrected with her glasses.  Her eyes are aligned for the most part in the primary position, but the parents note the right eye deviated upward occasionally.  The girl has no complaints. Picture 1 is of the patient in the primary position. In picture 2 a translucent occluder is held in front of the right eye and in picture 3 the occluder is in front of the left eye.

1.	The significant finding on examination of this patient who has a history of intermittent right hypertropia is:
	c --   a hyperdeviation in each eye behind a translucent occluder The hyperdeviation behind the occluder is the most important finding in this patient as shown in the pictures.  This is a common finding after alignment of the eyes in patients with congenital esotropia.  The eyes go up behind the occluder often with an “excyclo” movement and return to the primary position with an “incyclo” movement when the occluder is removed.
2.	The most likely diagnosis is:
	d -- dissociated vertical deviation This is a classic example of dissociated vertical deviation. If looked for carefully, this finding is seen in most patients after alignment of congenital esotropia.
3.	The next thing to do is:
	a --  no treatment now; just observe. Since the hyperdeviation is seen only occasionally by the family and the patient is not bothered, this is a condition that is probably best observed, at least for now.  If the hyperdeviation becomes manifest and is becoming a problem for the patient and/or family, surgery can be done.  Bilateral superior rectus recession is a common surgical choice.