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This 73-year-old woman had cataract surgery elsewhere in both eyes under local anesthesia, apparently without incident, two years earlier. Shortly after surgery she began to experience vertical diplopia. The history is vague as to whether the diplopia came on immediately or after a delay. Now the vertical diplopia is very bothersome and the patient experiences a great deal of difficulty looking up with the right eye. Vision is 20/20 in each eye. The remainder of the eye examination demonstrates a healthy pseudophakic woman with no apparent eye pathology. She would like to have the diplopia relieved. Her general health is otherwise excellent.

1.	This vertical strabismus is best described as:
	b -- acquired Brown This patient has what looks like a Brown.  That is, there is severe limitation of elevation in adduction in the right eye.  Elevation is limited to a slightly lesser degree in all other attempts at upgaze.  The fact that it came on after the cataract surgery makes this an acquired condition.  This could be called “Brown-like” or the definition of Brown can be expanded to any mechanical limitation of elevation in adduction.  It is necessary to do forced duction testing to confirm the mechanical restriction, but in this case it is very likely that the limitation of movement has a mechanical cause.  While most Brown is caused by a restriction in the area of the trochlea and the superior oblique tendon, a broader definition can include restriction anywhere in the orbit or around the eye.
2.	What is a likely cause of this strabismus?
	d -- reaction to local anesthetic The acute onset of vertical strabismus with restricted movement after cataract surgery with local anesthesia is anesthesia-related in almost every case.  The most likely cause is a toxic reaction to local anesthetic injected into the muscle.  This condition was first described around 20 years ago.
3.	The most likely treatment would be:
	a -- surgery The treatment for this condition is surgery.  The deviation is too big for prism and, also it is incomitant.  In this case the patient had right inferior rectus recession (this muscle was very tight), and left superior rectus recession resulting in single binocular vision in the useful fields of vision.