In a case like this - which had been operated  twice - with no operative details , it is wise to deal with the motility disorders found now , the possibilities of muscles handled before , together with presence or absence of periorbital fibrosis which is the great challenge in such cases . Multiple scenarios should be in mind before surgical interference  

1.It is obvious that the motility disorder here is consecutive exotropia and hypertropia of the Lt eye

2.According to the patient history , mostly a bimedial recession had been done in the first operation , lower conjunctival scars denotes  that the second operation was mostly an inferior rectus surgery since inferior oblique surgery has no role in correcting hyperdeviation in the primary position

3. Pre operative  Forced duction tests are negative

My decision is :

1. To correct the consecutive XT : Advancement and resection of the   previously recessed medial rectus plus LR recession

2. To correct the hypertropia ,of course the best choice is the recession of the SR but this can’t be done because these are the last 2 ciliary arteries left for this eye , the logical choice here is to downshift the insertions of the two horizontal recti , this procedure works good with me