A Squirmy Situation?

In this case report, a 14-year old girl presented with a three month history of binocular vertical diplopia and left upper eyelid ptosis. Visual acuity was 20/15-2 in the right eye and 20/20 in the left eye. Pupils measured 8 mm in dark and constricted to 3 mm in bright light, with no relative afferent pupillary defect. Palpebral fissures measured 10 mm in the right eye and 8 mm in the left eye. Lid crease measurements were 4 mm in the right eye and 6 mm in the left eye. Marginal reflex distance was 3.5 in the right eye and 2 mm in the left eye. Ocular ductions showed -1 limitation of abduction in the right eye, with normal elevation, adduction and depression. In the left eye, she had -2 adduction, -1 elevation, -1 abduction and full range depression. Alignment showed a12-prism-diopter (PD) exotropia (XT) and 3-PD right hypertropia (RHT) in primary position, a 35-PD XT and 8-PD right hyperphoria in left gaze, and a 2-PD esophoria in left gaze.