I Can't See Straight

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