Abstract

A 68 year old female with no systemic illness presented with binocular vertical diplopia for 2 years which was constant in nature with no variability or ptosis. Ocular myasthenia& thyroid eye disease were ruled out by systemic evaluation 1 year back. MRI was normal. No trauma was present.
Best corrected visual acuity for 6/6, N6 with pseudophakia in both eyes. On examination there was prominent left head tilt. Patient preferred left eye for fixation. There was -1 limitation of elevation, -1 under action of inferior oblique & +1 overaction of superior oblique in left eye. There was R/L hypotropia in primary distance fixation which was increasing in right gaze and right head tilt and Park's three step showed a left inferior oblique palsy clinically which was confirmed with diplopia charting. The vertical deviation was lesser for near and supine position. Double Maddox rod test showed slight left intorsion. But fundus showed extorsion of both macula with more extorsion in the left eye.