History:  The patient is a two-year-old girl who has been noted to have an intermittent exodeviation since shortly after birth. The primary position deviation in the distance is 35 prism diopters (XT). This decreases in down-gaze and increases in up-gaze. Exact measurement of the V pattern is difficult due to poor cooperation. Refractive error is -1.00 in each eye, and she has been wearing glasses for six months with no effect on the alignment. The child appears to see well with either eye and demonstrates no objection to occlusion. Other milestones have been normal, and the family history for strabismus is negative.  Birth history and development are unremarkable.  The most prominent feature in this child's strabismus is 4(+) overaction of both inferior obliques and significant underaction of superior obliques.   Of note, the girl also has anti-mongoloid lid fissures. Diagnosis:  "V" pattern exotropia

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