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Primary gaze

Left gaze

This 10-year-old boy has had strabismus since birth. His right eye is exo and hypodeviated, the right upper lid is ptotic, and the pupil is dilated. Visual acuity is OD 20/70 and OS 20/20. Refraction is OD +1.00 and OS +0.50. The eye examination is otherwise unremarkable. In the two pictures shown, the primary position shows the exo and hypodeviation and ptosis in the right eye. In left gaze note that the right upper lid is higher. The boy has had two surgical procedures in the right eye but it is not known what has been done.

1.	The most likely diagnosis in this case is:
	a. congenital third nerve palsy b. congenital essential exotropia c. double elevator palsy d. right Brown syndrome e. none of the above
2.	The elevation of the right upper lid in left gaze is due to:
	a. Sherrington’s law b. largely unknown factors c. misdirection of the right third nerve d. left eye preference e. none of the above
3.	Which of the following would you consider as the best treatment option?
	a. In a case like this, no further surgery can be done. b. A ptosis crutch would be a good option for the right eye. c. The best thing to do now is to put pilocarpine in the right eye to constrict the pupil. d. A large recession of the left lateral rectus and resection of the left medial rectus. e. none of the above

For answers to the above, click here on or after May 27, 2008.