Question:
A 65-year-old man with a history of hypertension and diabetes presents to the OPD with diplopia and squint. On examination, the secondary deviation is more than the primary deviation. Which of the following is the most likely diagnosis?
A 65-year-old man with a history of hypertension and diabetes presents to the OPD with diplopia and squint. On examination, the secondary deviation is more than the primary deviation. Which of the following is the most likely diagnosis?
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Secondary deviation greater than primary is the signature of a nerve palsy, common in a diabetic, hypertensive elder.
Updated On: Jun 23, 2026
- Concomitant squint
- Paralytic squint
- Restrictive squint
- Pseudosquint
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The Correct Option is B
Solution and Explanation
Answer: Paralytic squint.
Step 1: The hallmark in the stem is secondary deviation greater than primary deviation. This is the classic sign of a paralytic (incomitant) squint.
Step 2: When the patient fixes with the paralysed eye, extra innervation flows to both eyes (Hering's law), so the normal eye over-deviates: secondary deviation exceeds primary deviation.
Step 3: The clinical setting fits. A 65-year-old diabetic and hypertensive is prone to microvascular cranial nerve palsies (III, IV, VI) causing acute diplopia and squint.
Why not the others: In concomitant squint the deviation is equal in all gaze positions (primary = secondary). Restrictive squint is due to mechanical tethering, not the diabetic nerve palsy picture. Pseudosquint is only an apparent deviation with normal alignment.
Ref: GPonline, Basics of Strabismus.
Step 1: The hallmark in the stem is secondary deviation greater than primary deviation. This is the classic sign of a paralytic (incomitant) squint.
Step 2: When the patient fixes with the paralysed eye, extra innervation flows to both eyes (Hering's law), so the normal eye over-deviates: secondary deviation exceeds primary deviation.
Step 3: The clinical setting fits. A 65-year-old diabetic and hypertensive is prone to microvascular cranial nerve palsies (III, IV, VI) causing acute diplopia and squint.
Why not the others: In concomitant squint the deviation is equal in all gaze positions (primary = secondary). Restrictive squint is due to mechanical tethering, not the diabetic nerve palsy picture. Pseudosquint is only an apparent deviation with normal alignment.
Ref: GPonline, Basics of Strabismus.
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