An individualized stepwise surgical approach to complex post-traumatic hypertropia

Objective

To describe an individualized, stepwise surgical strategy for secondary hypertropia after complex ocular trauma, emphasizing intraoperative titration of ocular alignment under local anesthesia. The patient developed progressive left hypertropia after multiple procedures, including pars plana vitrectomy, silicone oil tamponade, and macular hole closure. Severe limitation of elevation in the fellow eye further complicated surgical planning.

Methods

A 44-year-old man developed progressive left hypertropia 4 months after multiple surgeries for left ocular trauma. Preoperative examination showed L/R 20° and a 50-prism-diopter deviation at 33 cm on Krimsky testing. Visual acuity in the left eye was hand motions. The right eye had complete limitation of elevation in the primary position, adduction, and abduction.

A unilateral, stepwise procedure was performed on the left eye under local anesthesia. The inferior oblique muscle was anteriorly transposed to the temporal side of the inferior rectus insertion. Because residual hypertropia persisted, approximately 50% of the superior rectus tendon width was then divided. Ocular alignment and patient feedback were assessed intraoperatively to guide titration of the surgical effect.

Results

After inferior oblique anterior transposition, the deviation improved from L/R 20° to approximately L/R 10°. Following partial-width superior rectus tenotomy, it was further reduced to approximately L/R 5°. The patient was satisfied with the immediate alignment, and surgery on the fellow eye was avoided. No intraoperative complications occurred.

Conclusion

An individualized, stepwise, and intraoperatively titratable approach may be useful for post-traumatic hypertropia when bilateral motility abnormalities limit conventional surgical planning. Inferior oblique anterior transposition combined with partial-width superior rectus tenotomy enabled controlled correction while preserving surgical flexibility. Management should consider not only deviation magnitude, but also previous ocular surgery, restrictive or paralytic factors, fellow-eye motility, and intraoperative response. Long-term follow-up is required to assess alignment stability and binocular visual outcomes.

Yan Bai is an ophthalmologist with clinical expertise in strabismus, ocular motility disorders, and the surgical management of complex post-traumatic ocular conditions. Her clinical and research interests focus on individualized surgical planning, intraoperative adjustment techniques, and functional reconstruction in patients with complicated strabismus. She is committed to improving ocular alignment and visual outcomes through tailored, evidence-based treatment strategies.