Anterior transposition of the inferior oblique and anti-elevation syndrome - how far to go?

Purpose : To study the incidence of postoperative anti-elevation syndrome in relation to the magnitude of anterior transposition of the inferior oblique. Methods : A retrospective chart review was conducted for all patients submitted to anterior transposition of the inferior oblique from 2000 to 2020. Anti-elevation syndrome was defined as limitation of elevation of the abducting eye, resulting in a secondary upshoot of the contralateral adducting eye. Results : A total of 312 eyes of 170 patients were enrolled in the study. The incidence of anti-elevation syndrome was 20.4% when the inferior oblique was positioned 4 mm posterior to the temporal border of the inferior rectus insertion; 23.5% when sutured 2 mm posterior to the temporal border of the inferior rectus insertion and 32.8% when placed at the same level of the inferior rectus insertion with two sutures vertically aligned. When the posterior border of the inferior oblique was horizontally aligned with the anterior border and positioned adjacent to the inferior rectus insertion, in a "J shape" fashion, the incidence of anti-elevation was 41.8%. Conclusions : The anterior transposition of the inferior oblique with "J" deformity increases the risk of anti-elevation syndrome. Additionally, placing the sutures more anteriorly than 2 mm posterior to the inferior rectus insertion increases the incidence of this finding.