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An 82-year-old man with binocular oblique diplopia
Digital Journal of Ophthalmology 2015
Volume 21, Number 3
September 12, 2015
DOI: 10.5693/djo.03.2015.05.003
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Gaurav Jindal, MD | Yale–New Haven Hospital, New Haven, Connecticut
Aubrey Gilbert, MD, PhD | Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
Rafeeque Bhadelia, MD | Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Nurhan Torun, MD | Division of Ophthalmology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Examination
On examination, his pupils were symmetric, without any relative afferent defect. He was noted to have a left head tilt of 35°. A left head tilt was also present in the patient’s driver’s license photograph. There was a large-angle esotropia of approximately 50 prism diopters (PD). This esotropia measured approximately 45 PD on right gaze and >50 PD on left gaze. The right eye was also found to have a hypertropia of 20 PD in primary position, both at distance and at near. This worsened in left gaze to >25 PD and in right head tilt to 30 PD; it improved in right gaze to 6 PD and in left head tilt to 10 PD. There was also significant right inferior oblique overaction and complete abduction palsy of the left eye (Video 1). There was no globe retraction on adduction of the left eye, and no lid twitch, ptosis, or proptosis. Trigeminal function was normal. There was no facial asymmetry noted. The rest of the examination was unremarkable.

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Video 1
Sensorimotor examination revealing right hypertropia, right inferior oblique overaction and complete abduction palsy of the left eye.