Superior oblique muscle surgery

The anatomy and actions of the superior oblique muscle are discussed as a basis for logical surgical procedures. Weakening procedures are indicated for overaction or for a short superior oblique tendon. Tenectomy is performed nasal to the superior rectus while selective tenotomies for bilateral overaction are performed temporal to the superior rectus. Recession of the whole tendon on an adjustable suture is preferred for unilateral superior oblique overaction. Tendon tucking for unilateral superior oblique palsy is performed temporal to the superior rectus and inevitably causes a degree of pseudo-Brown's syndrome. Tucks may be used bilaterally in bilateral cases. Alternatively, anterior tendon advancement corrects tensional symptoms. It may be graded from a maximum advancement to the upper border of the lateral rectus to suit the degree of tension. Adjustable sutures may be used. Superior oblique tendon transfer for long-standing third nerve palsies may produce paradoxical eye movements in the long-term due to scarring.