Inferior oblique anterior transposition according to a different grading scale for hyperdeviation with inferior oblique overaction

Published:March 09, 2022DOI:



      To define an inferior oblique anterior transposition (IOAT) grading scale in patients with hyperdeviation and inferior oblique overaction (IOOA), which we planned based on the data we obtained in our previous retrospective study.


      Prospective cohort study.


      Thirty-eight patients who underwent graded IOAT.


      The patients were divided into 5 groups according to the amount of hyperdeviation in the primary position (PPHD). The inferior oblique muscle was transposed 2 mm posterior, 1 mm posterior parallel, 1 mm anterior, and 2 mm anterior to the inferior rectus insertion, respectively. Surgical success was defined as success (PPHD ≤3 PD), partial success (PPHD >3 and ≤6 PD), and nonsuccess (PPHD >6 PD).


      The mean amount of hyperdeviation correction in groups after IOAT was 9.50 ± 0.9 PD (range, 8–10 PD), 12.43 ± 1.5 PD (range, 11–14 PD), 16.67 ± 1.4 PD (range, 15–18 PD), 19.57 ± 1.7 PD (range, 16–21 PD), and 22.57 ± 5.8 PD (range, 14–30 PD), respectively. Surgical success was achieved in 34 patients (89.5%) after surgery, partial success was achieved in 3 patients (7.9%), and nonsuccess was observed in 1 patient (2.6%). All patients in our study had unilateral IOOA preoperatively, and IOOA developed in the contralateral eye of 9 patients (23.7%) during postoperative follow-up. In group 5, 4 patients (57.1%) developed –2 upgaze limitation, but surgery was not required.


      A high success rate can be achieved with this grading of IOAT in primary and secondary IOOA cases accompanying hyperdeviation in the primary position.
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        • Guemes A
        • Wright KW.
        Effect of graded anterior transposition of the inferior oblique muscle on versions and vertical deviation in primary position.
        J AAPOS. 1998; 2: 201-206
        • Goldchmit M
        • Felberg S
        • Souza-Dias C.
        Unilateral anterior transposition of the inferior oblique muscle for correction of hypertropia in primary position.
        J AAPOS. 2003; 7: 241-243
        • Farvardin M
        • Bagheri M
        • Pakdel S.
        Combined resection and anterior transposition of the inferior oblique muscle for treatment of large primary position hypertropia caused by unilateral superior oblique muscle palsy.
        J AAPOS. 2013; 17: 378-380
        • Lee DC
        • Lee SY.
        Effect of modified graded recession and anteriorization on unilateral superior oblique palsy: a retrospective study.
        BMC Ophthalmol. 2017; 17: 27
        • Jeon H
        • Kwon H
        • Choi HY.
        Modified anterior transposition of the inferior oblique muscle.
        J AAPOS. 2018; 22 (e361): 361-365
        • Gunduz A
        • Firat M
        • Ozsoy E
        • Cankaya C.
        Effect of inferior oblique anterior transposition in correcting vertical hyperdeviation in primary position.
        Can J Ophthalmol. 2019; 54: 75-82
        • Del Monte MA
        • Parks MM.
        Denervation and extirpation of the inferior oblique: an improved weakening procedure for marked overaction.
        Ophthalmology. 1983; 90: 1178-1185
        • Stager DR.
        The neurofibrovascular bundle of the inferior oblique muscle as the ancillary origin of that muscle.
        J AAPOS. 1997; 1: 216-225
        • Haugen OH
        • Nepstad L.
        A standardized recession of the inferior oblique extraocular muscle—a safe and self-grading surgical procedure for trochlear nerve palsy: a 10-year material.
        Acta Ophthalmol. 2019; 97: 491-496
        • Raoof N
        • Burke JP.
        Isolated inferior oblique myectomy for vertical deviations of at least 20 prism diopters in the primary position.
        J AAPOS. 2016; 20: 112-116
        • Hatz KB
        • Brodsky MC
        Killer HE. When is isolated inferior oblique muscle surgery an appropriate treatment for superior oblique palsy?.
        Eur J Ophthalmol. 2006; 16: 10-16
        • Sieck EG
        • Madabhushi A
        • Patnaik JL
        • Jung JL
        • Lynch AM
        • Singh JK.
        Comparison of different surgical approaches to inferior oblique overaction.
        J Binocul Vis Ocul Motil. 2020; 70: 89-93
        • Yanyali A
        • Elibol O
        • Talu H
        • Karabas L
        • Alp B
        • Caglar Y.
        A comparative study of the effectiveness of disinsertion and anterior transposition of the inferior oblique in the treatment of unilateral superior oblique palsy.
        Strabismus. 2001; 9: 83-90
        • Molinari A
        • Ugrin MC.
        Frequency of the superior rectus muscle overaction/contracture syndrome in unilateral fourth nerve palsy.
        J AAPOS. 2009; 13: 571-574
        • Nejad M
        • Thacker N
        • Velez FG
        • Rosenbaum AL
        • Pineles SL.
        Surgical results of patients with unilateral superior oblique palsy presenting with large hypertropias.
        J Pediatr Ophthalmol Strabismus. 2013; 50: 44-52
        • Yoo JH
        • Kim SH
        • Seo JW
        • Paik HJ
        • Cho YA.
        Self-grading effect of inferior oblique recession.
        J Pediatr Ophthalmol Strabismus. 2013; 50: 102-105
        • Toosi SH
        • von Noorden GK.
        Effect of isolated inferior oblique muscle myectomy in the management of superior oblique muscle palsy.
        Am J Ophthalmol. 1979; 88: 602-608
        • Farid MF
        • Anany M
        • Abdelshafy M.
        Surgical outcomes of three different weakening procedures of inferior oblique muscle in the treatment of unilateral superior oblique palsy.
        BMC Ophthalmol. 2020; 20: 298
        • Chang YH
        • Ma KT
        • Lee JB
        • Han SH.
        Anterior transposition of inferior oblique muscle for treatment of unilateral superior oblique muscle palsy with inferior oblique muscle overaction.
        Yonsei Med J. 2004; 45: 609-614
        • Clifford L
        • Roos J
        • Dahlmann-Noor A
        • Vivian AJ.
        Surgical management of superior oblique paresis using inferior oblique anterior transposition.
        J AAPOS. 2015; 19: 406-409
        • Moon K
        • Lee SY.
        The effect of graded recession and anteriorization on unilateral superior oblique palsy.
        Korean J Ophthalmol. 2006; 20: 188-191
        • Kushner BJ.
        Restriction of elevation in abduction after inferior oblique anteriorization.
        J AAPOS. 1997; 1: 55-62
        • Cho YA
        • Kim JH
        • Kim S.
        Antielevation syndrome after unilateral anteriorization of the inferior oblique muscle.
        Korean J Ophthalmol. 2006; 20: 118-123
        • Mostafa AM
        • Kassem RR.
        Comparative study of unilateral versus bilateral inferior oblique recession/anteriorization in unilateral inferior oblique overaction.
        Eur J Ophthalmol. 2018; 28: 272-278
        • Stein LA
        • Ellis FJ.
        Apparent contralateral inferior oblique muscle overaction after unilateral inferior oblique muscle weakening procedures.
        J AAPOS. 1997; 1: 2-7
        • Ozsoy E
        • Gunduz A
        • Ozturk E.
        Inferior oblique muscle overaction: clinical features and surgical management.
        J Ophthalmol. 2019; 20199713189
        • Marshall M
        • Parks D.
        The overacting inferior oblique muscle: the XXXVI Deschweinitz Lecture.
        Am J Ophthalmol. 1974; 77: 787-797