This paper describes a case report of an extra-large V pattern measuring >60PD and the surgery required to collapse the pattern. The patient was a female aged 20 years. Angle measurements were 70PD at distance and 75PD at near in primary gaze, with measurement of about 110PD on upgaze and 45PD on downgaze. Surgical procedures included bilateral lateral rectus recessions and unilateral medial rectus resection with bilateral inferior oblique recessions and full tendon upshift of both lateral recti. Postoperatively the angle reduced to 6PD at distance and 8PD at near with the V reduced to 10PD. This report considers the mechanism of V exo pattern and the need for multiple muscle surgery in large angle cases.