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—Dr Kopf's question highlights some difficulties involved in managing superior oblique paresis combined with restriction of upgaze in adduction. In managing both our cases, we did not wish to exacerbate the patients' poor elevation in adduction and, therefore, we did not weaken the ipsilateral inferior oblique muscle.In the first case, weakening of the ipsilateral superior rectus muscle at the initial procedure successfully diminished the vertical deviation and left the contralateral inferior rectus muscle available for a subsequent procedure. We learned from the first case that the initial procedure to free the restriction of the damaged superior oblique tendon is followed by months of gradual reduction of the restriction (aided by a functioning inferior oblique muscle) and gradual progression of the superior oblique paresis. Because of this, when faced with the second case, we did not attempt to address the vertical deviation at all during the initial procedure
Bachynski BN, Flynn JT. Repairing the Superior Oblique Tendon-Reply. Arch Ophthalmol. 1986;104(3):336. doi:10.1001/archopht.1986.01050150030011