Question 10

A two year old girl is brought in to clinic by her parents for "abnormal head position". They have noticed over the past year or so that she has developed a chin up head positioning. She has had moderate ptosis of the right upper eyelid since birth but now that she is getting older, they have noticed the head positioning. On your exam, you notice ptosis of the right upper eyelid, mild amblyopia of the right eye, normal pupil exam and normal dilated fundus exam with mild symmetric hyperopia on cycloplegic refraction. On alignment, she has a 20pd right hypotropia in primary gaze that increases in upgaze and decreases in down gaze. On EOM exam, you notice limited elevation in both abduction and adduction of the right eye. Otherwise EOMs are full OU. What is the most likely diagnosis?