I Can't See Straight

In May of 2014 this 30 year old right handed patient was referred for consultation regarding diplopiaand dizziness. The patient relates that she had been told that she had tired eyes as a child. Two and ahalf years ago she began to have intermittent exodeviation. She was seen locally and diagnosed ashaving a IV nerve palsy and treated with 2 diopters of base in prism and 2 diopters of base upprism. Six months before her referral she began to complain of double vision. The patient attributed theonset of double vision to a car accident in 2007. On examination visual acuity was correctable to 20/20and 20/25. Color was intact. Visual fields demonstrated an inferior Seidel scotoma on the rightside. There was no afferent pupillary defect. Motility examination revealed severe limitation in up gazeOD > OS with 45 diopters of right exotropia and 12 diopters of right hypotropia. Counter clockwisetorsional nystagmus was noted. Slit lamp examination and applanation tensions were within normallimits. Funduscopic examination revealed no evidence of disc edema or optic atrophy. OCT revealedsome epiretinal surface changes, but no obvious epiretinal membrane. Imaging studies were obtained