Dr. Farzavandi considered a few options, one of which was left eye inferior oblique anteriorization. Her concern was that procedure would not correct 13° of excyclotorsion in downgaze.
A second option was to perform a Harada Ito procedure in the left eye as the second stage in the presence of residual torsion. However, scarring in the surgical area was a major consideration.
The third surgical option was a combined left eye inferior oblique anteriorization and a Harada Ito procedure. Dr. Farzavandi was concerned about the risk of overcorrection and possibly additional torsional symptoms.
The fourth option was recession of the inferior rectus of the right eye to address the hypertropia and balance torsion. However, in this case the parents did not consent to surgery on the good eye.
It was while Dr. Farzavandi was contemplating the aforementioned options that she heard a presentation by Professor Vincent Paris, associate professor of ophthalmology, Liege University, Belgium.
Dr. Paris recommended an anteronasal transposition of the inferior oblique muscle in the left eye with the aim of converting the muscle from an extorter to an intorter. Stager and colleagues reported this procedure previously (Binocul Vis Strab Q. 2001;15:43-44).
Dr. Farzavandi performed the procedure on the patient under discussion after receiving parental consent. She isolated the inferior oblique muscle in the standard manner, disinserting it from the insertion, and securing with 6-0 Vicryl suture. The inferior rectus muscle was slung in order to move the inferior oblique muscle from the temporal to the nasal quadrant.
She used a Gass hook, which has a eyelet at the hook tip, to pass the traction sutures without having to create extensive peritomies (Figure 3).
An inferior medial fornix incision was made to isolate the medial rectus muscle, and the lower border exposed, to facilitate moving the inferior oblique muscle from the temporal to the nasal quadrant inferior to the lower border of the medial rectus muscle, Dr. Farzavandi described.