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This 42-year-old woman underwent ethmoid sinus surgery 2 ½ months ago. Immediately after surgery she noted a large XT and presented for an eye examination. Except for the motility that can be observed in the pictures, the eye examination was normal. The patient has double vision, but the images are so far apart that the double vision is not a big problem. She complains of her appearance and the inability to adduct the right eye. As can be seen in the pictures her eyes are close to alignment in right gaze but in all other positions a large exotropia is noted, increasing to a maximum in left gaze.

1.	Upon taking the history and observing the patient initially you conclude:
	a. The patient could have an unknown toxic reaction paralyzing the medial rectus. b. Myasthenia should be ruled out. c. This condition could be related to the sinus surgery. d. This is a late appearing exotropic Duane. e. There is no way to speculate until further work up is accomplished.
2.	Given that the eye examination is normal, what would be a good test to order?
	a. electromyogram b. acetycholine esterase inhibitors c. A-scan ultrasound d. imaging of the orbit e. none of the above
3.	The patient asks you what she can expect in the way of needed treatment to “fix” her eyes.
	a. surgery b. orthoptics c. medical treatment d. prism e. patch

For answers to the above, click here on or after August 24, 2010.