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This 16-year-old patient had resection of the right medial rectus and recession of the right lateral rectus for intermittent exotropia.  Immediately after surgery he appeared as shown above.  This is a new finding.  He had no limitation of upgaze before the surgery.

1.	The findings in this patient suggest a diagnosis of:
	a -- An inability to look up fully in adduction is called Brown syndrome, provided a mechanical limitation is demonstrated.  This case looks like a Brown but must be confirmed by showing that forced elevation in adduction is limited.  This usually (virtually always) requires general anesthesia in a child and would be done in a case like this at the time of surgery.  Duane syndrome can cause down shoot but with narrowing of the fissure of the involved eye and limitation of abduction, adduction or both.  Double elevator palsy affects upgaze in all upgaze positions.  There is no history of trauma to support diagnosis of blow out fracture.
2.	A likely cause of this limitation of upgaze after surgery is:
	c -- Limitation of vertical movement of an eye occurring after any surgery of the lateral rectus should raise suspicion that the inferior oblique has been inadvertently included when hooking the lateral rectus.  This surgical complication can cause limited elevation and sometimes depression in an eye ranging from mild to severe.
3.	The most effective management of this condition is:
	d -- Since the most likely cause of this acquired Brown is inclusion of the inferior oblique in the lateral rectus, the treatment would be surgery.  In most cases, this calls for freeing the inferior oblique from the lateral rectus and then excising the inferior oblique lateral to the inferior rectus.