Extra-large V pattern in exotropia: a rare case and its management.

V pattern arises when the eyes diverge more in up-gaze, as compared to down-gaze, leading to vertical gaze incomitance of a horizontal strabismus. In most cases, the magnitude of V pattern is small to moderate, and a single surgical procedure for the same is enough to correct it. We describe a rare case where an extra-large V pattern (>60 Prism Dioptres (PD)) was present along with large exotropia (70 PD). Craniosynostosis or facial asymmetry was not present. The extra-ocular motility evaluation revealed mild over-elevation in adduction and extreme divergence in up-gaze. Examination of the fundus showed ex-cyclotorsion of both the globes. The V pattern was managed by bilateral inferior oblique muscle recession and full thickness upshift of both lateral rectus muscles. The exotropia was treated by bilateral lateral rectus recession and right eye medial rectus resection. Postoperatively, both the exodeviation and V pattern reduced to less than 10PD. The ex-cyclotorsion was also reduced after the surgery. There was restoration of binocularity and the near stereopsis improved to 170 secs of arc. Thus, extra-large V pattern strabismus may need a combination of procedures to achieve a good motor and sensory outcome.