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This 25-year-old woman reports misalignment of her eyes since childhood. She does not complain of double vision, and has no history of trauma or serious systemic or eye disease. Family history is negative. The patient prefers left gaze. Vision is 20/20 in each eye, and refraction is OD +0.50 and OS plano. The remainder of the eye examination is normal except for motility. The pictures show versions which indicate over action of the left superior oblique (LSO), and under action of the left inferior oblique (LIO) and under action of the right inferior rectus (RIR). The left hypotropia is 35 PD in primary, 40 PD in right gaze and 6 PD in left gaze. The left hypo is 25 PD in left head tilt and 35 in right head tilt (not shown). The left eye can be elevated above the midline in adduction (it appears to move fully). With the right eye covered, the left upper lid assumes a normal height suggesting a pseudo ptosis. Stereo is recorded to the Fly and 1/9 circles with question about monocular cues.

1.	Looking at versions in the 9 gaze positions, commonly called the “diagnostic positions”, the differential in this case would be:
	a. myasthenia versus chronic progressive ophthalmoplegia b. Meiges syndrome versus right superior oblique palsy c. left Brown syndrome versus left inferior oblique palsy d. “A” pattern versus “X” pattern e. none of the above
2.	Important features in this case include:
	a. results of forced ductions b. vertical deviation in the primary c. head tilt comparing right and left gaze d. size of the vertical deviation in primary e. all of the above
3.	Treatment in this case could logically include:
	a. right superior rectus recession and left superior oblique disinsertion b. ptosis surgery on the left upper lid c. right super rectus resection and left inferior rectus recession d. left inferior rectus recession right inferior rectus resection e. none of the above

For answers to the above, click here on or after March 16, 2010.