After slinging both the inferior and medial recti muscles, a small tunnel was created under the conjunctiva over the inferior rectus muscle to “string across” the inferior oblique muscle. The inferior oblique muscle was then brought across below the inferior rectus muscle.
The next step was to determine the position at which the inferior oblique muscle should be transposed. Dr. Farzavandi opted for the midpoint between the inferior rectus and the medial rectus muscle at about 3 mm along the spiral of Tillaux, just below the lower border of the medial rectus muscle.
The concern at this point was the type of suture—i.e., absorbable or non-absorbable, and she opted for the absorbable suture (Figure 4).
Postoperatively, the patient had no head tilt. She had orthophoria in primary position with no diplopia except in upgaze (Figure 5).
There was no excyclotorsion in primary position and 3° of excyclophoria on downgaze, which she was able to fuse well (Figure 6).
The compromise was limited elevation in adduction in the left eye, because of absence of the inferior oblique action in upgaze.
“This procedure is a viable option with a stable surgical result,” Dr. Farzavandi said. “It can be considered as a primary procedure of choice in patients with severe superior oblique palsy with a large degree of excyclotorsion.”