Strabismus pp 311-336 | Cite as

Complicated Strabismus

  • Burton J. Kushner


This chapter includes an eclectic collection of redacted versions of e-mail consultations I have received about complex strabismus cases. I consider this entire chapter advanced information, so I will not be repeatedly using that icon. For the most part I have avoided giving “outcomes” for these case presentations, and I am anticipating many readers will be troubled by this and may consider it an unfortunate omission. Over the years, I have received many e-mail consultations that are strikingly similar to one another. For presentation here, I often combined the salient points from multiple patients to end up with one conflated (perhaps hypothetical) patient presentation. In that case an “outcome” would also be fictitious. In addition, it is unfortunately the rule, rather than the exception, that I do not get follow-up from the ophthalmologist requesting advice. I am often unsure if they even followed my advice. In addition, my recommendations only represent one of many possible acceptable approaches—there are many roads to orthophoria. I have often felt that my making a recommendation, and then writing that it worked well, conveys the inappropriate idea that my approach was the one right one, and all others are incorrect. My intention in presenting these cases is to outline a thought process of how one may approach complex strabismus. For each one I will list one or more take-home “pearls” that the case was chosen to highlight.


Amniotic membrane Angle kappa Anti-elevation syndrome (AES) Brown syndrome Diplopia Dissociated vertical divergence (DVD) Divergence insufficiency Esotropia (ET) Excyclotropia Exotropia (XT) Flap tear Fourth cranial nerve palsy Harada-Ito procedure Heavy eye syndrome Hypertropia (HT) Hypotropia (HYPO) Incyclotropia Inferior oblique anterior transposition (IO AT) Masked bilateral superior oblique palsy Mitomycin C Nystagmus Orbital floor fracture Pulleys Pullover sutures Rotary forced ductions Scleral buckling surgery Superior oblique (SO) incarceration syndrome Superior oblique palsy (SOP) SO posterior tenectomy SO tuck Third nerve palsy Thyroid eye disease (TED) Torsion 


  1. 1.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Kushner BJ. Superior oblique tendon incarceration syndrome. Arch Ophthalmol. 2007;125:1070–6.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Kushner BJ. The inferior oblique muscle adherence syndrome. Arch Ophthalmol. 2007;125:1510–4.CrossRefGoogle Scholar
  4. 4.
    Guyton D, Weingarten P. Sensory torsion as the cause of primary oblique muscle overaction/underaction and A- and V- pattern strabismus. Binocul Vis Eye Muscle Surg Q. 1994;9:209–36.Google Scholar
  5. 5.
    Kushner BJ. Unexpected cyclotropia simulating disruption of fusion. Arch Ophthalmol. 1992;110:1415–8.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Scott A. Posterior fixation: adjustable and without posterior sutures. In: Lennerstrand G, editor. Clinical strabismus management. Boca Raton: WB Saunders; 1994. p. 399.Google Scholar
  7. 7.
    Kushner BJ. Paresis and restriction of the inferior rectus muscle after orbital floor fracture. Am J Ophthalmol. 1982;94:81–6.CrossRefGoogle Scholar
  8. 8.
    Metz HS. The use of vertical offsets with horizontal strabismus surgery. Ophthalmology. 1988;95:1094–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Kushner BJ. Torsion and pattern strabismus: potential conflicts in treatment. JAMA Ophthalmol. 2013;131:190–3.CrossRefGoogle Scholar
  10. 10.
    Oh SY, Clark RA, Velez F, Rosenbaum A, Demer J. Incomitant strabismus associated with instability of rectus pulleys. IOVS. 2002;43:2169–78.Google Scholar
  11. 11.
    Bardorf CM, Baker JD. The efficacy of superior oblique split Z-tendon lengthening for superior oblique overaction. J AAPOS. 2003;7:96–102.CrossRefPubMedGoogle Scholar
  12. 12.
    Chaudhuri Z, Demer JL. Sagging eye syndrome: connective tissue involution as a cause of horizontal and vertical strabismus in older patients. JAMA Ophthalmol. 2013;131:619–25.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Clark RA. The role of extraocular muscle pulleys in incomitant non-paralytic strabismus. Middle East Afr J Ophthalmol. 2015;22:279–85.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Kushner BJ. The diagnosis and treatment of bilateral masked superior oblique palsy. Am J Ophthalmol. 1988;105:186–94.CrossRefPubMedGoogle Scholar
  15. 15.
    Apt L, Call NB. Inferior oblique muscle recession. Am J Ophthalmol. 1978;85:95–100.CrossRefPubMedGoogle Scholar
  16. 16.
    Kushner BJ. Restriction of elevation in abduction after inferior oblique anteriorization. J AAPOS. 1997;1:55–62.CrossRefGoogle Scholar
  17. 17.
    Kushner BJ. The effect of anterior transposition of the inferior oblique muscle on the palpebral fissure. Arch Ophthalmol. 2000;118:1542–6.CrossRefGoogle Scholar
  18. 18.
    Ellis FJ, Stein LA, Guyton DL. Masked bilateral superior oblique muscle paresis. A simple overcorrection phenomenon? Ophthalmology. 1998;105:544–51.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Burton J. Kushner
    • 1
  1. 1.Department of Ophthalmology and Visual SciencesUniversity of Wisconsin-MadisonMadisonUSA

Personalised recommendations