title: Symptomatic excyclotorsion following inferior transposition of both medial rectus muscles in patients with bilateral trochlear nerve palsy.
abstract: OBJECTIVE
  To report the development of a large degree of excyclotorsion following inferior transposition of the medial rectus muscles in 5 patients with bilateral acquired trochlear nerve palsies that had previously undergone bilateral modified Harada-Ito procedures.
  
  
  METHODS
  The medical records of 5 patients who had undergone Harada-Ito procedure for bilateral trochlear nerve palsy between 2002 and 2010 and medial rectus muscle infraplacement surgery between 2004 and 2012 were retrospectively reviewed.
  
  
  RESULTS
  All 5 patients underwent a Fells-modified Harada-Ito procedure. All remained symptomatic due to a V pattern (eso- or exodeviation). Bilateral inferior transposition of the medial rectus muscles of either half or full tendon width was performed to alleviate this residual diplopia. The vertical transposition resulted in a symptomatic large degree of excyclotorsion (mean of 20°), which required reversal of the procedure.
  
  
  CONCLUSIONS
  After inferior transposition of both medial rectus muscles in patients with bilateral superior oblique palsy who previously had bilateral modified Harada-Ito surgery, a large excyclotorsion (>20°) can occur. This can be managed by reversing the medial rectus transposition procedure.
authors.affiliation: University Hospital Ayr, NHS Ayrshire and Arran, United Kingdom.
authors.forename: Michael
authors.initials: M
authors.lastname: Mikhail
authors.affiliation: Royal Bolton Hospital NHS Foundation Trust, United Kingdom.
authors.forename: Katherine
authors.initials: K
authors.lastname: Smyth
authors.affiliation: University Hospital Ayr, NHS Ayrshire and Arran, United Kingdom. Electronic address: Natboyle@doctors.org.uk.
authors.forename: Natalie
authors.initials: N
authors.lastname: Boyle
authors.affiliation: Aintree University Hospitals NHS Foundation Trust, United Kingdom.
authors.forename: Ian
authors.initials: I
authors.lastname: Marsh
mesh_terms: D000293:Adolescent; D000328:Adult; D004172:Diplopia / Q000601:surgery*; D005099:Exotropia / Q000601:surgery; D005260:Female; D016489:Head Injuries, Closed / Q000150:complications; D006801:Humans; D008297:Male; D015835:Ocular Motility Disorders / Q000209:etiology*; D009801:Oculomotor Muscles / Q000637:transplantation*; D013508:Ophthalmologic Surgical Procedures / Q000009:adverse effects*; D012189:Retrospective Studies; D014102:Torsion Abnormality / Q000209:etiology*; D020432:Trochlear Nerve Diseases / Q000601:surgery*; D015348:Vision, Binocular