This 6-year-old girl had a bimedial rectus recession and right lateral rectus resection for a large angle esotropia performed at age two years.  She has no fusion as measured in the usual clinical setting but her alignment is excellent in the primary position.   But lately, the family has noticed a new problem.

1.	Significant strabismus can be seen in this girl.  The following describes the condition(s):
	d -- This girl has a strabismus triad : "A" pattern, overaction of the superior obliques, and dissociated vertical deviation (DVD).  This strabismus can occur as a primary condition or after surgery for congenital esotropia as it did in this patient. This combination occurs in part as a feature of the congenital esotropia syndrome (DVD) and as an aftermath of surgery ("A" pattern and "overaction" of the superior obliques).
2.	In order to diagnose an "A" pattern the following is required:
	b -- To confirm an "A" pattern, a 10 prism diopter increase in exotropia or decrease in esotropia is measured in the distance with accommodation controlled.  To diagnose  a "V" pattern, the opposite is required but with a difference in horizontal deviation measurement of 15 prism diopters.
3.	This strabismus could be treated with the following:
	d -- This condition can be treated surgically by weakening the superior rectus muscles to decrease the amplitude of deviation for the DVD and a careful weakening of the superior obliques.