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Year : 2021  |  Volume : 59  |  Issue : 2  |  Page : 196-198

Anterior and nasal transposition of inferior oblique muscle

Department of Paediatric Ophthalmology and Strabismus, Aravind Eye Hospital, Postgraduate Institute of Ophthalmology, Coimbatore, Tamil Nadu, India

Date of Submission16-Jan-2021
Date of Acceptance04-Mar-2021
Date of Web Publication24-Jun-2021

Correspondence Address:
Dr. A Sasikala Elizabeth
Department of Paediatric Ophthalmology and Strabismus, Aravind Eye Hospital, Postgraduate Institute of Ophthalmology, Coimbatore, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_4_21

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We report the case of a 20-year-old woman who presented with residual esotropia, dissociated vertical deviation (DVD), and inferior oblique over-action (IOOA) who underwent horizontal rectus muscle surgery and anterior and nasal transposition of the inferior oblique muscle. Postoperatively, she was orthotropic and showed resolution of DVD and IOOA providing an excellent motor outcome.

Keywords: Anterior and inferior transposition of the inferior oblique muscle, dissociated vertical deviation, inferior oblique over-action

How to cite this article:
Elizabeth A S, Narendran S K. Anterior and nasal transposition of inferior oblique muscle. TNOA J Ophthalmic Sci Res 2021;59:196-8

How to cite this URL:
Elizabeth A S, Narendran S K. Anterior and nasal transposition of inferior oblique muscle. TNOA J Ophthalmic Sci Res [serial online] 2021 [cited 2021 Jul 28];59:196-8. Available from: https://www.tnoajosr.com/text.asp?2021/59/2/196/319255

  Introduction Top

The dissociated vertical deviation (DVD) is characterized by spontaneous upward drifting of one or both eyes when binocularity is blocked; when fixation is regained, the upward drift will return slowly to the primary position without any accompanying re-corrective movement in the contralateral eye.[1] The surgical procedures for treating DVD include superior rectus (SR) muscle recession with or without posterior fixation suture,[2] Y splitting of superior rectus,[3] inferior rectus (IR) muscle tucking,[4] IR resection,[5] inferior oblique (IO) muscle dis-insertion, IO recession, and IO muscle anterior transposition (ATIO).[6]

The optimal placement of IO has been debated. Stager et al. first described the procedure about transposition of the IO nasal to the nasal border of the IR insertion for a child with absent superior oblique muscle.[7] We hereby present the effective outcome of anterior and nasal transposition of IO muscle anterior nasal transposition (ANT) for a case of DVD with concurrent severe IO over-action (IOOA).

  Case Report Top

A 20-year-old woman presented with complaints of upward deviation of the right eye (RE) and residual esotropia. On reviewing her previous surgical records, she had prior left eye (LE) horizontal rectus muscle surgery (medial rectus recession 5 mm with lateral rectus [LR] resection 8 mm) along with LE ATIO (bunched and placed adjacent to the temporal pole of the IR) done 1 year ago.

On examination

Her best-corrected visual acuity in both eyes was 20/20. Her orthoptic evaluation in primary position with prism bar cover test fixing at 6 m distance showed 60 Prism Diopter (PD) esotropia. With prism under cover test, she had 16 PD RE DVD and 3 PD LE DVD. There was no significant pattern difference on measurement. She had RE IOOA graded +4. LE had normal extraocular movements, except mild limitation in elevation in abduction (−1) [[Figure 1]: 9 gaze: Preoperative photograph]. She had alternate suppression (W4DT) and did not have stereopsis.
Figure 1: 9 gaze: Preoperative photograph showing residual esotropia (e), right eye over-elevation in adduction (b), and right eye inferior oblique overaction (c) Other gaze( a,d,f-i) are normal

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Under local anesthesia, after limbal conjunctival peritomy, right medial rectus was recessed by 5.5 mm. LR and IR were isolated using Stevens hook. After hooking and isolating right IO, full-thickness locking bites were taken using double-armed 6-0 vicryl suture. Care was taken to include all the IO fibers. A hemostat was placed beyond the suture, closer to the IO insertion. Following this, the muscle was cut in front of hemostat. While reattaching the IO for ANT, the posterior fibers were attached 1 mm nasal to the nasal border of IR insertion, and then, the anterior fibers were attached 3 mm nasal to the first suture [[Figure 2] - Intraoperative picture showing ANT of IO]. LR resection of 8 mm was completed. Conjunctiva was closed with interrupted 8-0 vicryl sutures.
Figure 2: Intraoperative photograph. Black arrow indicating final position of right eye inferior oblique placed anterior and nasal to inferior rectus

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Postoperative evaluation showed orthotropia and on prism cover test showed 10 PD esodeviation and 3 PD DVD in both eyes in primary position for distance [[Figure 3] - Postoperative: 9 gaze photograph and [Figure 4] - Postoperative resolution of DVD]. She had complete resolution of RE over elevation in adduction.
Figure 3: Postoperative: 9 gaze photograph showing orthotropia (e) and resolved over elevation in adduction of the right eye (c). other gaze (a,b,d,f-i) are also normal

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Figure 4: Postoperative photograph showing resolution of dissociated vertical deviation under the Speidelman occlude over the right eye(a) and left eye(b)

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  Discussion Top

Several surgical management strategies had been described to control DVD. ATIO remains the standard treatment for DVD and IOOA.[8] Stager et al. proposed transposing IO not only anteriorly but also nasally to the nasal border of IR.[7] In this technique, the IO is positioned anterior to X axis and nasal to Y axis, which changes IO from an elevator and extorter to a depressor and intorter in adduction.[9]

Fard[10] studied, in 10 patients, the outcomes after ANT of the IO muscle for DVD associated with IOOA. For patients who had >15 PD of preoperative DVD, 100% had an excellent outcome (postoperative DVD 0–5 PD). Among patients with preoperative DVD of more than 15 PD, 53% had an excellent outcome and 47% had a fair outcome (postoperative DVD 6–10 PD). Three of 20 eyes developed (–1) under-elevation in adduction after surgery. These patients presented with bilateral asymmetric IOOA of 1 +and 3 +and DVD asymmetry of more than 10 PD.

A study by Engman et al.[11] for ATIO obtained an excellent outcome in only 25% of patients with >15 PD of DVD, suggesting that ATIO, the standard procedure, can be less effective in patients with larger amounts of DVD. Arafa et al.[12] studied the efficacy of ANT of IO in 30 patients with DVD and found 100% complete resolution of DVD <15 PD and recommended to combine superior rectus (SR) recession for larger DVD.

Farid[13] compared the results of ATIO (11 patients) versus ANT (10 patients) of IO in the management of DVD associated with IOOA. Among eyes who underwent ATIO with preoperative DVD of >14 PD, 44% had a good outcome and 56% had a fair outcome, and with preoperative DVD of <14 PD, 50% had an excellent outcome and 50% had a good outcome. Among eyes who underwent ANT, with preoperative DVD >14 PD, 37.5% had an excellent outcome and 62.5% had a good outcome, and with preoperative DVD <14 PD, 100% had excellent outcome. Postoperative hypotropia was reported in 2 out of 10 eyes with ANT procedure. They proved ANT to be equally effective to ATIO. In our case report, the patient had preoperative 16 PD DVD and IOOA (+4) attainted an excellent reduction of DVD with ANT with the resolution of IOOA with no hypotropia or IO under-action. Both the studies[10],[13] with ANT had a short follow-up of <10 months only. Literature review reveals that postoperative hypotropia and IO under-action can be expected as complications in case of asymmetric IOOA and DVD asymmetry more than 10 PD.[10] The IOAT stands as the standard procedure for managing DVD with IOOA. Bilateral ANT can be safely chosen as the procedure of choice in eyes with bilateral large symmetrical DVD >14 PD and symmetrical IOOA. Hence, proper case selection and long-term follow-up are required while choosing ANT.

  Conclusion Top

ANT procedure can be considered as a safe option for large DVD with IOOA with minimal complications. Management of DVD is case based. Proper measurement of DVD and planning appropriate procedure will provide optimal outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Von Noorden GK, Campos EC. Binocular Vision and Ocular Motility. USA: Mosby: St Louis, MO; 2002. p. 378-85.  Back to cited text no. 1
Esswein MB, von Noorden GK, Coburn A. Comparison of surgical methods in the treatment of dissociated vertical deviation. Am J Ophthalmol 1992;113:287-90.  Back to cited text no. 2
Mravicic I, Gulic MP, Barisic A, Biscevic A, Pjano MA, Pidro A. Different surgical approaches for treatment of dissociated vertical deviation (DVD). Med Arch 2019;73:386-90.  Back to cited text no. 3
Diab MK. Inferior rectus tucking versus combined superior rectus recession with posterior fixation suture (Faden) for the treatment of dissociated vertical deviation without inferior oblique overaction. J Egypt Ophthalmol Soc 2013;106:239-44.  Back to cited text no. 4
  [Full text]  
Esswein Kapp MB, von Noorden GK. Treatment of residual dissociated vertical deviation with inferior rectus resection. J Pediatr Ophthalmol Strabismus 1994;31:262-4.  Back to cited text no. 5
Stager D Jr., Dao LM, Felius J. Uses of the inferior oblique muscle in strabismus surgery. Middle East Afr J Ophthalmol 2015;22:292-7.  Back to cited text no. 6
[PUBMED]  [Full text]  
Stager DR Sr., Beauchamp GR, Stager DR Jr. Anterior and nasal transposition of the inferior oblique muscle: A preliminary case report on a new procedure. Binocul Vis Strabismus Q 2001;16:43-4.  Back to cited text no. 7
Gonzalez C, Klein B. Myectomy and anterior transposition of the inferior oblique: A new surgical procedure and its results in 49 operations. Binoc Vis Eye Muscle Surg Qtrly 1993;8:249-58.  Back to cited text no. 8
Hussein MA, Stager DR Sr., Beauchamp GR, Stager DR Jr., Felius J. Anterior and nasal transposition of the inferior oblique muscles in patients with missing superior oblique tendons. J AAPOS 2007;11:29-33.  Back to cited text no. 9
Fard MA. Anterior and nasal transposition of the inferior oblique muscle for dissociated vertical deviation associated with inferior oblique muscle overaction. J AAPOS 2010;14:35-8.  Back to cited text no. 10
Engman JH, Egbert JE, Summers CG, Young TL. Efficacy of inferior oblique anterior transposition placement grading for dissociated vertical deviation. Ophthalmology 2001;108:2045-50.  Back to cited text no. 11
Arafa MA, Eltoukhy ES, Kamal MA, Said MM. The efficacy of anterior Nasal surgery in managing inferior oblique overaction either with DVD or with V pattern. J Cli Exp Ophthalmology 2020;11:854.  Back to cited text no. 12
Farid MF. Anterior transposition vs anterior and nasal transposition of inferior oblique muscle in treatment of dissociated vertical deviation associated with inferior oblique overaction. Eye (Lond) 2016;30:522-8.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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