Asymmetric inferior oblique anterior transposition for incomitant asymmetric dissociated vertical deviation

  • Stacy L. Pineles
  • Guillermo Velez
  • Federico G. VelezEmail author



Inferior oblique anterior transposition (IOAT) is indicated in patients with incomitant dissociated vertical deviation (DVD) larger in adduction. In general, bilateral surgery is recommended in patients with DVD unless there is deep monocular amblyopia. The purpose of this study is to evaluate the results of asymmetric IOAT in patients with asymmetric incomitant DVD larger in adduction.


Retrospective chart review of the records of all patients with incomitant asymmetric DVD associated with inferior oblique (IO) overaction who underwent asymmetric IO weakening procedure. In all patients, the eye with more DVD in adduction underwent IOAT to the temporal corner of the insertion of the inferior rectus (IR) muscle, and the eye with less DVD underwent IOAT to a position 3–4 mm posterior to the insertion of the IR. No other muscles were operated simultaneously. No patient had previous surgery on any cyclovertical extracular muscle.


Fourteen patients were included. Mean age at surgery was 10.3 ± 8.8 years (range 4–33). Primary position DVD preoperatively was 18 ± 2 PD in the eye with the larger DVD compared to 1.1 ± 1.0 PD postoperatively (p < 0.0001). DVD asymmetry between the lateral gaze with the largest DVD and the lateral gaze with the smallest DVD was 9.8 ± 3.1 PD (range 5–14 PD) preoperatively vs 1.1 ± 1.0 PD (range 0–2 PD), (p < 0.0001). Ten patients had preoperative V-pattern >10 PD (24.7 ± 8.7 PD, range 12–50 PD) preoperatively vs no patients postoperatively (mean V-pattern 4.4 ± 2.0 PD), (p < 0.0001). Postoperative follow up was 1.6 ± 0.7 years (range 1–3 years).


In patients with asymmetric incomitant DVD, asymmetric IOAT improves lateral incomitance without increasing the risk of antielevation, limitation in upgaze rotation, or hypertropia, or worsening the DVD in the eye with less deviation preoperatively.


Dissociated vertical deviation Inferior oblique Hypertropia Strabismus 



Grant support

NIH/NEI K23EY021762 (SLP), Knights Templar Eye Foundation, Oppenheimer Family Foundation

Conflicts of interest

None of the authors have any financial conflicts of interest.


  1. 1.
    Magoon E, Cruciger M, Jampolsky A (1982) Dissociated vertical deviation: an asymmetric condition treated with large bilateral superior rectus recession. J Pediatr Ophthalmol Strabismus 19:152–156PubMedGoogle Scholar
  2. 2.
    Schwartz T, Scott W (1991) Unilateral superior rectus recession for the treatment of dissociated vertical deviation. J Pediatr Ophthalmol Strabismus 28:219–222PubMedGoogle Scholar
  3. 3.
    Bacal DA, Nelson LB (1992) Anterior transposition of the inferior oblique muscle for both dissociated vertical deviation and/or inferior oblique overaction. Binocular Vision Eye Muscle Q 7:219–225Google Scholar
  4. 4.
    Kratz RE, Rogers GL, Bremer DL, Leguire LE (1989) Anterior tendon displacement of the inferior oblique for DVD. J Pediatr Ophthalmol Strabismus 26:212–217PubMedGoogle Scholar
  5. 5.
    Mims JL 3rd, Wood RC (1989) Bilateral anterior transposition of the inferior obliques. Arch Ophthalmol 107:41–44PubMedCrossRefGoogle Scholar
  6. 6.
    Santiago AP, Rosenbaum AL (1999) Dissociated vertical deviation. In: Santiago AP, Rosenbaum AL (eds) Clinical strabismus management. W.B. Saunders, Philadelphia, pp 237–248Google Scholar
  7. 7.
    Bremer DL, Rogers GL, Quick LD (1986) Primary-position hypotropia after anterior transposition of the inferior oblique. Arch Ophthalmol 104:229–232PubMedCrossRefGoogle Scholar
  8. 8.
    Stager DR, Weakley DR Jr, Stager D (1992) Anterior transposition of the inferior oblique. Anatomic assessment of the neurovascular bundle. Arch Ophthalmol 110:360–362PubMedCrossRefGoogle Scholar
  9. 9.
    Stidham DB, Stager DR, Kamm KE, Grange RW (1997) Stiffness of the inferior oblique neurofibrovascular bundle. Invest Ophthalmol Vis Sci 38:1314–1320PubMedGoogle Scholar
  10. 10.
    Isenberg SJ, Apt L (1999) Inferior oblique weakening procedures: technique and indications. In: Santiago AP, Rosenbaum AL (eds) Clinical strabismus management. W.B. Saunders, Philadelphia, pp 449–458Google Scholar
  11. 11.
    Gobin MH (1969) Cyclotropia and Squint. Knol & Coutin, AntwerpGoogle Scholar
  12. 12.
    Black BC (1997) Results of anterior transposition of the inferior oblique muscle in incomitant dissociated vertical deviation. J AAPOS 1:83–87PubMedCrossRefGoogle Scholar
  13. 13.
    Burke JP, Scott WE, Kutshke PJ (1993) Anterior transposition of the inferior oblique muscle for dissociated vertical deviation. Ophthalmology 100:245–250PubMedGoogle Scholar
  14. 14.
    Fard MA (2010) Anterior and nasal transposition of the inferior oblique muscle for dissociated vertical deviation associated with inferior oblique muscle overaction. J AAPOS 14:35–38. doi: 10.1016/j.jaapos.2009.11.011 PubMedCrossRefGoogle Scholar
  15. 15.
    Guemes A, Wright KW (1998) Effect of graded anterior transposition of the inferior oblique muscle on versions and vertical deviation in primary position. J AAPOS 2:201–206PubMedCrossRefGoogle Scholar
  16. 16.
    Velez FG, Ela-Dalman N, Velez G (2009) Surgical management of dissociated vertical deviation associated with A-pattern strabismus. J AAPOS 13:31–35PubMedCrossRefGoogle Scholar
  17. 17.
    Velez G (2001) A clinical classification of dissociated vertical deviation for better surgical approach. In: Smith Kettlewell Eye Research Institute Festschrift for Arthur Jampolsky. The Smith Kettlewell Eye Research Institute, San Francisco, pp 59–63Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Stacy L. Pineles
    • 1
  • Guillermo Velez
    • 2
  • Federico G. Velez
    • 1
    • 3
    Email author
  1. 1.Jules Stein Eye Institute and Department of OphthalmologyUniversity of CaliforniaLos AngelesU.S.A.
  2. 2.University of Antiquia, Private PracticeMedellinColombia
  3. 3.Jules Stein Eye InstituteDavid Geffen School of Medicine at UCLALos AnglesUSA

Personalised recommendations