Advancement of the Superior Oblique and Inferior Oblique Ocular Muscles

Superior oblique tucking with versus without additional inferior oblique recession for acquired trochlear nerve palsy

“…It may be an advantage of modified Harada-Ito surgery to reduce Brown's syndrome by pulling only the anterior part of the superior oblique tendon laterally and anteriorly [4,5,7,8,15,38], but this method is unlikely to have more vertical effect than conventional SOT or SOT&IOR, and it will leave more V-incomitance, particularly in case of bilateral palsy. However, irrespective of the lower vertical effect of SOT compared to SOT&IOR, it may be sensible to perform pure SOT or modified Harada-Ito surgery as a primary procedure even for severe palsy.…”

Part Iv. The Operative Treatment of Vertical Disorders

“…He considered that the gain from the latter was largely cosmetic and that prisms were required to permit binocular single vision. Wheeler (1935) was successful in shortening the affected superior oblique. He varied the site of reattachment with the actual needs of the patient.…”

“…Peter, in advising recession of this muscle, warned against its tenotomy and indeed against that of any vertical rectus. Wheeler (1935) preferred advancement of the paresed muscle and Peter and Berens recommended this as an additional operation. The results of this, however, were not entirely satisfactory.…”

“…The latter would increase the already existing intortion excess and fail to produce elevation. For further information see Wheeler, (1935). Hughes and Bogart (1942) and Hughes (1944) described their experiences in receding the trochlea for overaction of the superior oblique muscle.…”

When and how to strengthen the superior oblique muscle

“…Finally, shortening the SO tendon may produce an unacceptable limitation of elevation in adduction (iatrogenic Brown syndrome) in a substantial proportion of cases. 1,2 For this reason many surgeons have avoided SO tendon strengthening procedures altogether. It is this unusual anatomy, complex physiology, and unpredictable surgical outcome that undoubtedly led von Graefe to his famous and often repeated admonition (''Noli me tangere'') that surgery on the SO muscle should not be attempted.…”