The spasm is reduced with pre-tarsal botulinum toxin injection. There is poor eyelid closure despite lateral tarsal strips and medial canthoplasties in both eyes. The horizontal eye movement is restricted as shown by the need of the patient to move her head in order to follow the finger. Vertical eye movement is normal. She had has two previous operation to correct the right exotropia.
Cover tests show bilateral latent nystagmus worse in the right eye.
The left eye also shows DVD - dissociated vertical deviation. The pupil was spared. Examination reveals that the right eye has limited movement in those muscles supplied by the third nerve. The pupil is not involved. But with the head in the primary position, there is a left over right.