• Six patients had residual diplopia at near in the downgaze position after surgery for bilateral fourth nerve palsy. They all showed a large excyclotropia in the downgaze position that was associated with a "V"-pattern esotropia and could not fuse in the reading position because of the size of the excyclotropia. They were treated with bilateral recessions of the inferior recti, which resulted in an expansion of the single binocular field of vision in downgaze, with an elimination of diplopia in the reading position. None experienced a deterioration in their alignment in the primary position.
Kushner BJ. 'V' Esotropia and Excyclotropia After Surgery for Bilateral Fourth Nerve Palsy. Arch Ophthalmol. 1992;110(10):1419-1422. doi:10.1001/archopht.1992.01080220081026