Superior Oblique Underaction Research Articles

Traumatic superior oblique tendon rupture with ptosis: A case report

The traumatic rupture of the superior oblique tendon with ptosis is extremely rare, and the surgical treatment is very challenging. We reported a case of a 41-year-old man with superior oblique tendon rupture and ptosis due to an iron hook injury. The ocular movement disorders were not obvious except for mild superior oblique underaction but were accompanied by severe extorsion. The distal stump of the superior oblique tendon was shortened and anchored to the periosteum of the supra-nasal orbital margin near the trochlea. Post-operative follow-up revealed the surgical outcome was better than expected, which resulted in significant improvement in binocularity and cosmetic outcomes without complication in the present case. The exploration of the levator palpebral superioris (LPS) in the early post-traumatic stage might not be necessary in circumstances without eyelid laceration. Shortening and anchoring of the ruptured superior tendon could restore almost normal binocularity, decrease the extorsion, and avoid acquired Brown syndrome.

Long-Term Efficacy of Inferior Oblique Myectomy Accompanied with Tenon’s Capsule Closure: Objective Analysis Using Nine-Gaze Photographs

Background: The aim is to evaluate the long-term efficacy of inferior oblique (IO) myectomy combined with Tenon's capsule closure to prevent muscle reattachment to the sclera. Methods: We retrospectively reviewed the medical records of 18 patients with primary and secondary IO overaction who underwent IO myectomy accompanied by Tenon's capsule closure. Patients were followed up for at least 1 year after the surgery. The main outcome measures included oblique muscle dysfunction, which was objectively graded through computerized analysis of nine-gaze photographs, and the amount of vertical deviation in the primary position using alternate prism cover testing. Results: After a mean follow up of 2.5 years, the grade of IO overaction decreased from +2.2 ± 1.0 to -0.8 ± 1.0 (p < 0.001). In patients with secondary IO overaction with superior oblique (SO) palsy, SO underaction improved from -2.2 ± 1.5 to -0.2 ± 1.8 (p = 0.006). Successful vertical deviation in the primary position of seven prism diopters or less was achieved in 83.3% of the patients. Underaction of the IO was observed in 11.1% of patients, whereas none of the patients showed antielevation syndrome. Conclusion: IO myectomy combined with Tenon's capsule closure might be safe and effective for the treatment of primary and secondary IO overaction in the long term.

Superior oblique tendon thinning as a surgical treatment for Brown syndrome

To evaluate the results of a superior oblique thinning technique for the treatment of congenital Brown syndrome. The medical records of consecutive patients at a single institution who were diagnosed with congenital Brown syndrome and underwent superior oblique thinning were retrospectively reviewed. In all cases, the prism cover test was used to assess ocular alignment. Standardized nine-gaze photographs were used to evaluate ocular rotations. Ocular torsion was measured using fundus retinography. Intraoperatively, all patients showed a positive forced duction test for elevation from adduction that became negative after a strongly maintained traction test maneuver. A total of 21 eyes of 20 consecutive patients (mean age, 5.8±2.5years) were included. Preoperatively, 16 patients were orthotropic in primary position; 4, hypotropic. Postoperatively, all patients were orthotropic in primary position. Limitation of elevation in adduction improved from -3.4±-0.6 (range, -2 to -4) to 0.6±1 (range, 0 to -3; P<0.01). Fundus retinography showed >1° change in ocular torsion after surgery in 3 of 6 patients (P>0.5). Superior oblique underaction or hypertropia did not occur. No superior oblique palsy appeared in any patient. There were no changes beyond 3months postoperatively except for 1 patient who relapsed 9months after surgery and 1 patient who improved after 4years. Superior oblique thinning is effective in improving elevation in adduction and hypotropia in primary position in patients with Brown syndrome associated with a thickened superior oblique tendon.

How Successful is Combined Superior and Inferior Oblique Muscle Surgery in Young Children with Superior Oblique Underaction Presenting in Infancy with a Severe Head Tilt?

Background/Objective:To evaluate the success of combining ipsilateral inferior and superior oblique muscle surgery in young children with congenital unilateral superior oblique under action who present in infancy with a large socially noticeable head-tilt.Methods:A consecutive retrospective case series of young children was analysed. The success of surgery in eliminating the head-tilt was evaluated by pre- and post-operative ocular motility assessment focusing on the vertical misalignment in primary position and downgaze, the magnitude of the head-tilt in degrees and the status of the superior oblique tendon.Results:Five children had a mean age at first surgery of 41 (range 25–63) months, a mean primary position vertical deviation of 26 (25–30) prism dioptres, a head-tilt of 30 (20–35) degrees and a mean post-operative follow up of 24 (8–43) months. While there was a uniform surgical plan, nonetheless each operation required individualisation based on a spectrum of per-operative superior oblique tendon findings. The head tilt was eliminated in 40% and reduced in the remainder, to a mean of 7 (0–18) degrees and with a mean post-operative primary position vertical misalignment of 3 (range 0–10) and of 10 (range 0–40) prism dioptres in downgaze.Conclusion:Combined, ipsilateral oblique muscle surgery reduced the severe head tilt and primary position alignment to a psychosocially and functionally acceptable level. For the majority, the outcome was stable or associated with further decremental improvement. A persistent downgaze vertical tropia occurred in children with macroscopically abnormal superior oblique tendons but these cases were not identifiable clinically pre-operatively.

Efficacy of isolated inferior oblique anteriorization on large-angle hypertropia associated with unilateral superior oblique palsy

To evaluate the results of inferior oblique anteriorization for the treatment of large-angle hypertropia secondary to superior oblique palsy and to determine predictors of success and the occurrence of antielevation syndrome. In this prospective study, 25 patients with unilateral congenital and acquired superior oblique palsy who had a primary position hypertropia of at least 25Δ underwent inferior oblique anteriorization in the paretic eye. Postoperative changes in vertical deviation of primary position and contralateral gaze, abnormal head posture, extorsion, associated horizontal deviation, inferior oblique overaction, superior oblique underaction, and elevation in abduction were examined. Surgical success was defined as residual hypertropia in primary position of ≤4Δ at final examination. The mean age of patients at surgery was 19.8±11.9years (range, 4-49). The mean preoperative deviation in the primary position was 27.6Δ ± 3.2Δ; in contralateral gaze, 35.0Δ ± 3.8Δ; these measurements decreased postoperatively to 4.7Δ ± 5.6Δ and 7.0Δ ± 5.5Δ, respectively, after a median follow-up of 8months. The success rate was 72%, with no difference between patients with a preoperative deviation of 25Δ-29Δ and those with deviation of 30Δ-35Δ. In a multivariate logistic regression, preoperative extorsion was negatively related to success (OR=8.01; P=0.03). At the final follow-up, 4 patients (16%) showed antielevation syndrome and were clinically asymptomatic. In unilateral superior oblique palsy, one-muscle surgery, including inferior oblique anteriorization, can be conducted to resolve large-angle hypertropia of >25Δ. Excyotorsion is a risk factor that increases the likelihood of failure.

Surgical outcomes of three different weakening procedures of inferior oblique muscle in the treatment of unilateral superior oblique palsy

BackgroundTo compare surgical outcomes and complications of three inferior oblique weakening procedures; Inferior Oblique Myectomy (IOM), Inferior Oblique combined Resection-Anterior Transposition (IORAT) and Inferior Oblique Anterior Transposition (IOAT) in the management of unilateral Superior Oblique (SO) palsy.MethodsRetrospective review of medical records of all patients with unilateral SO palsy who underwent one of the aforementioned IO weakening procedures at Benha University hospital was performed. Patients were excluded if surgery was bilateral or combined with other vertical muscle surgery. Primary outcome parameters were improvement of Hypertropia (HT) in primary gaze, side gazes, on alternate head turn, Inferior Oblique Overaction (IOOA), Superior Oblique Underaction (SOUA), correction of head tilt and postoperative complications.ResultsThe review reveals a total of 65 patients with unilateral SO palsy; 54 congenital and 11 acquired, who met the study criteria and were classified into 3 groups; IOM group (24cases), IORAT group (19cases) and IOAT group (22cases). Compared with IOM, both IORAT and IOAT induced significant correction of HT in primary position, ipsilateral gaze, contralateral head tilt and IOOA. IORAT was significantly more effective than IOAT in correction of HT in ipsilateral gaze and contralateral head tilt while there was no statistical difference between the three groups in correction of HT in ipsilateral gaze, contralateral head tilt and SOUA. Postoperative Anti-elevation was significantly recorded following IORAT (6 cases, 31%) than IOAT (3 cases, 13%) and IOM (one cases, 4%).ConclusionsThe IORAT and IOAT were more superior to IOM in correction of IOOA and HT in the primary position and some other gaze positions. However, superiority of IORAT over the other two procedures should be weighed against its significant association with postoperative underaction of IO muscle and anti-elevation syndrome.

The stability of horizontal ocular alignment of triad exotropia after one-step triple surgery.

A-pattern exotropia, superior oblique muscle overaction, and dissociated vertical deviation may coexist and are referred to as triad exotropia. The present study evaluated the postoperative stability of horizontal ocular alignment of triad exotropia and possible prognostic factors. Medical records of patients with triad exotropia who had one-step triple surgery of superior oblique muscle weakening, superior rectus muscle recession, and lateral rectus muscle recession were reviewed. The horizontal alignment and postoperative drift of triad exotropia were analyzed and compared with constant exotropia. The triad exotropia showed a mean of 7.7△ (± 8.5△) eso-drift, while the constant exotropia was (3.5△ ± 3.4△) exo-drift. Multiple linear regression analysis showed that the degree of superior oblique muscle overaction after surgery (P = 0.011) was the only factor associated with horizontal drift. Patients with superior oblique muscle underaction showed larger eso-drift when compared to patients without superior oblique muscle underaction (- 18.0△ ± 11.1△ vs. - 5.1△ ± 5.7△; P = 0.024). The final success rates of the triad exotropia and constant exotropia groups were 53.3% and 69.2%, respectively, and the overcorrection rates were 26.7% and 2.6% (P = 0.035). An overall trend of eso-drift in primary position occurred in triad exotropia after triple surgery up to a follow-up of 25months. Patients presenting superior oblique muscle underaction after surgery seemed to have large angles of eso-drift, which might be taken into account in surgical planning and follow-up.

Stereopsis before and after Inferior Oblique Weakening Surgery.

PurposeTo analyze stereopsis change before and after inferior oblique weakening surgery.MethodsWe retrospectively reviewed the medical records of 31 patients who had undergone inferior oblique weakening surgery. The factors analyzed included sex, age at surgery, preoperative and postoperative visual acuity (VA), time from first detection to surgery, degree of inferior oblique overaction (IOOA), primary/secondary IOOA, exotropia/hypertropia, bilaterality, and type of surgery.ResultsEighteen patients with a mean age 7.3 ± 3.1 years exhibited stereopsis of 60 arc seconds or better before surgery and 17 had stereopsis better than 60 arc seconds after surgery. Postoperatively, stereopsis improved in 13 patients and deteriorated in 9. Better preoperative VA and the absence of superior oblique underaction were associated with better preoperative stereopsis. Better preoperative VA, postoperative VA, and the presence of head tilt were associated with better postoperative stereopsis. Unilateral inferior oblique weakening surgery and accompanying hypertropia were associated with improved stereopsis, while the absence of hypertropia was associated with deteriorated stereopsis.ConclusionsIn this retrospective study, 58.1% of patients tended to have bifoveal fixation. When a vertical deviation is present in the primary position due to unilateral IOOA, IO weakening surgery can be expected to improve binocular function.

Are we overlooking masked bilateral congenital superior oblique palsy in children: is it possible to diagnose before surgery?

To describe the characteristics of children who had subsequent contralateral superior oblique underaction (SOUA) and inferior oblique overaction (IOOA) after unilateral inferior oblique weakening surgery and to identify suggestive clinical features for masked bilateral fourth nerve palsy. The medical records of children who underwent unilateral inferior oblique tenotomy as a single procedure for unilateral superior oblique palsy were all reviewed. Diagnosis was based on evaluation of ocular misalignment in nine diagnostic gaze positions and presence of SOUA, IOOA, and abnormal head position. The study was conducted with 29 children. All children had preoperative unilateral IOOA and SOUA. Eleven children (37.9%) had hyperesodeviation in the affected eye, while others (62.1%) had hyperexodeviation. The mean age at surgery was 6.66±1.87 (4-10) years. The mean vertical deviation, exodeviation, and the amount of IOOA were decreased postoperatively (p<0.001 for all). Among the 29 children, 22 had no residual ipsilateral IOOA, 2 had ipsilateral IOOA, and 5 had ipsilateral inferior oblique underaction (IOUA) at last visit. Three children had contralateral SOUA, IOOA, and hyperdeviation at follow-up visits, one of whom had IOUA on the operated eye. There was no difference of preoperative features between children with or without subsequent contralateral superior oblique palsy. Bilateral congenital superior oblique palsy may be overlooked in children in spite of detailed preoperative evaluation. Masked bilaterality should always be kept in mind in cases with unilateral pathology. Patients should be informed about the possibility of bilaterality.

Two cases of fourth nerve palsy in pregnancy

Aim: To present two cases of recent-onset fourth nerve palsies during pregnancy.Methods: Two pregnant patients presented to A&amp;E with recent-onset diplopia due to isolated right superior oblique palsy. Patient 1, aged 42, complained of a 5-day history of intermittent vertical diplopia at 38 weeks gestation. Patient 2, aged 34, presented with constant horizontal and vertical diplopia at 34 weeks gestation.Results: Two months after giving birth, patient 1 attended the eye clinic reporting her symptoms had completely resolved within 5 days from onset. Patient 2 reported her symptoms resolved within 3 months. Both patients fully recovered, therefore no further management or investigation was required. They both gave birth at term without complication. Patient 1 presented with a slight hyperphoria in primary position, demonstrating binocular single vision (BSV). Ocular motility and Hess chart showed a very slight right superior oblique under-action. Her blood pressure, fundus and media were normal and no underlying pathology was found. No further investigations were undertaken. Patient 2 presented with a slight exotropia and right hypertropia in primary position, with diplopia and no BSV demonstrable. Further orthoptic testing showed right superior oblique under-action. No pathology was found.Conclusions: Cranial nerve palsies developing in pregnancy are rare but have been reported. No pathology was found in our cases; however, the literature does suggest that serious cases could be apparent and should therefore be considered.

Deficiency of depression in adduction: clinical characteristics and surgical management of the “inverted Brown pattern”

To evaluate the clinical characteristics and surgical management of patients with an "inverted Brown pattern," which is defined clinically as a hypertropia with greatest deviation in down-and-in gaze of the higher eye, having the appearance of superior oblique muscle underaction but without significant inferior oblique muscle overaction. The medical records of patients with this misalignment pattern who had cyclovertical muscle surgery at our institution from 2003 through 2015 were retrospectively reviewed; medical records were analyzed for pre- and postoperative motility patterns, fundus torsion, intraoperative findings, and type of strabismus surgery. A total of 45 patients presenting with a hyperdeviation worse in down-and-in gaze of the higher eye were included in the study. Of these, 25 (56%) had previously had inferior oblique-weakening procedures. The remainder included those with untreated superior oblique paresis (22%), previous orbital trauma (18%), or other ocular surgery (4%). The mean preoperative hyperdeviation in straight-ahead gaze was 8.7(Δ), compared with 0.9(Δ) postoperatively. Surgical success, defined as the absence of diplopia in straight-ahead gaze and not requiring further cyclovertical surgery, was achieved in 78% of patients. The motility pattern referred to as the "inverted Brown pattern" can develop in patients with orbital trauma, as previously described, or in association with superior oblique muscle paresis, most commonly after prior surgery to weaken the inferior oblique muscle. Weakening or reweakening of the inferior oblique muscle appears to correct this misalignment pattern, despite the absence of significant inferior oblique overaction preoperatively.

Alternating IV Nerve Palsy and Ptosis as a First Sign of Childhood Ocular Myasthenia Gravis

A previously healthy 5-year-old girl was referred because of sudden-onset diplopia. Her examination demonstrated moderate right ptosis, left inferior oblique overaction and superior oblique underaction, and a positive Bielschowsky head tilt test to the left. This suggested a left fourth nerve palsy, but the right ptosis remained undefined (Figure). Ophthalmic and neurological examination and cranial magnetic resonance imaging were otherwise normal. Ten days later, a right fourth nerve palsy with a right ptosis and left adduction deficit was evident.

Superior oblique tucking for treatment of superior oblique palsy.

To investigate the efficacy and safety of isolated superior oblique tucking in the treatment of congenital superior oblique palsy. Twenty-one patients with unilateral congenital superior oblique palsy and lax superior oblique tendon underwent isolated superior oblique tucking and retrospective analysis of the amount of tucking procedure, preoperative and postoperative vertical deviation in the primary position and reading position, abnormal head posture, ocular motility, and corrected objective torsion. Patients were evaluated before and 6 to 12 months after surgery. The average vertical deviation in the primary position was 10.9 ± 3.3 prism diopters (PD) before surgery and 1.5 ± 2.6 PD after surgery (n = 21, P < .05). The average vertical deviation in the reading position was 15.6 ± 3.6 PD before surgery and 2.6 ± 3.1 PD after surgery (P < .05). The average corrected vertical deviation was 9.9 ± 3.2 PD in the primary position and 13.0 ± 3.4 PD in the reading position (P < .05). The amount of tucking ranged from 5 to 12 mm (mean: 8.3 ± 2.3 mm), which was not related to the corrected vertical deviation in the primary and reading positions, the preoperative vertical deviation in the reading position, or the corrected objective torsion. After surgery, all patients had head posture that was normal or less than 5°. Unremarkable superior oblique underaction and negative head tilt test were found in all patients after surgery. All patients had mild Brown syndrome after surgery, but none were symptomatic. Isolated superior oblique tucking is an efficient and safe procedure for treatment of superior oblique palsy with hyperdeviation less than 15 PD in the primary position and remarkable superior oblique underaction. The superior oblique forced duction test was the most important criterion for planning surgery.

Absent trochlear nerve with contralateral superior oblique underaction

Absent trochlear nerve with contralateral superior oblique underaction

Superior Oblique Tucks for Apparent Inferior Oblique Overaction and V-pattern Strabismus Associated with Craniosynostosis

Introduction: Apparent inferior oblique overaction and apparent superior oblique underaction are common in strabismus associated with craniosynostosis, and in many cases are likely due to excyclotorsion of the globes, with the rectus muscles acting with oblique vectors. We present a patient with craniosynostosis who underwent bilateral superior oblique tucks to specifically address the excyclotorsion of the globes.Methods: A 16-year-old male with Saethre-Chotzen syndrome presented with apparent bilateral inferior oblique overaction and apparent bilateral superior oblique underaction. He had 30 prism diopter (PD) esotropia and 5 PD left hypertropia by simultaneous prism and cover test (SPCT) at distance and near fixation. Fundus exam revealed marked excyclotorsion of both globes. The superior oblique tendons were tucked 10 mm bilaterally, using a 6-0 mersilene suture and the medial rectus muscles were recessed 5.5 mm on an adjustable suture with a 10-mm inferior displacement. Surgical results were reviewed at 6 weeks and 2 years postoperatively.Results: At 6 weeks and 2 years postoperatively, apparent inferior oblique overaction, apparent superior oblique underaction, and V-pattern esotropia were markedly improved. At 2 years, SPCT measurements were 8 PD esotropia in primary position at distance and 4 PD esotropia and 3 PD left dissociated vertical deviation at near.Conclusions: Bilateral superior oblique tucks are useful in addressing the excyclotorsion that leads to apparent inferior oblique overaction and V-pattern strabismus associated with craniosynostosis.

Adjustable Superior Oblique Tendon Spacer with Application of Nonabsorbable Suture for Treatment of Isolated Inferior Oblique Paresis

To evaluate and report the outcomes of a superior oblique tendon spacer procedure using nonabsorbable adjustable sutures in patients with inferior oblique (10) paresis. This interventional case series included 6 eyes of 6 patients with 10 paresis. All met Bielschowsky/Parks Three-step Test criteria to identify an isolated 10 paresis. In all patients, the superior oblique tendon was exposed; 2 nonabsorbable polyester sutures were placed 3 mm apart, and the tendon was cut. With the use of a slipknot, the cut ends of the tendon were separated 5 to 7 mm. Tendon separation was adjusted intraoperatively according to the fundus torsion and exaggerated traction test. The mean duration of follow-up was 8.1 months (range, 5-12 [corrected] months). Four patients had congenital 10 paresis and 2 had iatrogenic 10 paresis following denervation/myectomy of 10. Mean primary position hypotropia improved from 15.2 prism diopters (PD) before surgery to 2.7 PD in congenital 10 paresis and from 11.5 PD to 2.5 PD in iatrogenic 10 paresis. In congenital 10 paresis, mean preoperative superior oblique overaction and 10 underaction was +2 and -2, which decreased to 0 and -1.25 respectively; fundus incyclotorsion resolved in all patients. Superior oblique overaction and 10 underaction improved in iatrogenic 10 paresis as well. In no patient did an overcorrection develop. The adjustable superior oblique tendon suture spacer procedure is an effective and safe option for correcting 10 paresis without developing iatrogenic superior oblique paresis.

Comparison of Inferior Oblique Myectomy, Recession, and Anterior Transposition in Unilateral Congenital Superior Oblique Palsy

Purpose: To compare the clinical outcomes of myectomy, recession, and anterior transposition (AT) of the inferior oblique muscle in congenital unilateral superior oblique palsy. Methods: A total of 40 patients who were followed for longer than three months postoperatively and, who underwent inferior oblique myectomy, recession, or AT were evaluated retrospectively. Results: We compared the result of inferior oblique myectomy, recession, and AT in congenital unilateral superior oblique palsy. The decreased amounts of inferior oblique overaction (IOOA) were 2.240.67, 2.000.76, 3.001.15 for myectomy, recession, and AT, respectively. Improvement of superior oblique underaction was 0.800.66, 0.860.83, 1.000.58, and the changes in hyperdeviation were 10.96PD, 8.25PD, 14.86PD for myectomy, recession, and AT, respectively. There were no significant differences among the surgical methods. The proportion of patients who showed IOOA in the contralateral eye after operation were 20.0% in myectomy, 25.0% in recession, and 57.1% in AT. Conclusions: The efficacies of myectomy, recession, and AT of inferior oblique muscle in the congenital unilateral superior oblique palsies showed no significant differences among methods. The AT group tended to show a larger effect than did the other methods, along with a high development percentage of contralateral eye IOOA. Based on these results, AT of the IO shoud be selectively chosen in more severe cases.

MR imaging of familial superior oblique hypoplasia

BackgroundCongenital superior oblique palsy is usually associated with a structural abnormality of the superior oblique tendon. There have been many reports of familial congenital superior oblique palsy. However, there has...

The Clinical Characteristics of Superior Oblique Palsy Associated With Intermittent Exotropia

Purpose: The goal of this study was to determine the clinical characteristics of patients with intermittent exotropia (IXT) associated with hypertropia. Methods: This study recruited 268 hospital patients with IXT associated with hypertropia. After taking history, measuring the angle of deviation, conducting an ocular motor examination, performing a Bielschowsky head tilt test and taking a fundus photograph, the clinical characteristics of 23 patients diagnosed with superior oblique palsy (SOP) were investigated. Results: Twenty-three patients (8.6%) of the 268 subjects with IXT associated with hypertropia were diagnosed with SOP. The average angle of exodeviation was 17.13.8PD and the angle of hypertropia at primary position was 12.95.9PD. Excyclotorsion of an eyeball was observed in 19 patients (82.6%), the Bielschowsky head tilt test was positive in all patients, and head tilt or face turn was found in 12 (52.2%) patients. All subjects had inferior oblique overaction, and 20 (86.9%) had superior oblique underaction. Operations to weaken the inferior oblique muscle of the paralytic eye and for horizontal muscles were conducted at the same time. The angle of exodeviation and the angle of hypertropia were, on average, 1.83.6PD and 2.42.2PD, respectively, 6 months after the operation. Conclusions: When patients with intermittent exotropia have hypertropia, the possibility of SOP should be considered. SOP can be detected by determining a history of head tilt and conducting a Bielschowsky head tilt test. Surgical treatment for SOP is advised.

Clinico-Radiologic Findings of Entrapped Inferior Oblique Muscle in a Fracture of the Orbital Floor

A 51-year old man presented with vertical and torsional diplopia after reduction of a blowout fracture at another hospital one year ago. He had no anormalies of head position and 14 prism diopters (PD) right hypertropia (RHT) in the primary position. In upgaze no vertical deviation was found, and hyperdeviation on downgaze was 35PD. Bielschowsky head tilt test showed a negative response. Distinct superior oblique (SO) and inferior rectus (IR) underaction of the right eye was noted but IO overaction was mild on the ocular version test. Double Maddox rod test (DMRT) revealed 10-degree extorsion, but fundus extorsion was minimal in the right eye.Thin-section coronal CT scan showed that there was no fracture line on the anterior orbital floor, but a fracture remained on the posterior orbital floor. Also, the anterior part of the right inferior oblique muscle was vertically reoriented and the medial portion of the inferior oblique muscle was not traced on the coronal CT scan. The patient underwent 14 mm right IO recession and 3 mm right IR resection. One month after the surgery, his vertical and torsional diplopia were eliminated in the primary position.