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This 16-year-old girl had surgery for congenital esotropia at age 4 years. Six months ago she had a second surgery for a hypertropia that appeared alternately in the two eyes. This second surgery was a bilateral large superior rectus recession. She now presents with an intermittent right hypertropia and vision corrected to OD 20/30, OS 20/20 wearing OD +1.25 +2.00 x 30, OS +1.00 +1.50 X 100. The versions in the diagnostic positions, the right hypertropia in the primary position, and the alignment with the translucent occluder are as shown in the pictures.

1.	What is the most likely diagnosis?
	a. Heimann-Bielschowsky response b. skew deviation c. alternating superior oblique overaction d. dissociated vertical deviation (DVD) e. none of the above
2.	How would you rate the inferior oblique action?
	a. overaction b. causing abduction in the right eye in elevation because of limited adduction after the previous medial rectus recession c. showing significant strabismus sursoadductorius d. cannot determine or make any judgment from the pictures e. none of the above
3.	In the case shown here, what would be a logical choice for the next surgical procedure?
	a. no further surgery should be done b. inferior oblique myectomy c. anterior transposition of the inferior obliques d. resection of both inferior rectus muscles e. none of the above

For answers to the above, click here on or after September 23, 2008.