Primary IO overaction
This girl has congenital esotropia with
bilateral overaction of the inferior obliques
and underaction of the superior obliques, Also
note the antimongoloid fissures. This feature
could be associated with pulley heterotopy. In
this case the medial pulleys would be displaced
upward and the lateral pulleys displaced
downward. The traditional treatment for a case
like this is bimedial rectus recession with
bilateral inferior oblique weakening. However,
some cases treated this way have persistent
overaction of the inferior obliques. This could
result from unrecognized, or untreated, pulley
displacement contributing to the vertical
incomitance. Combined inferior oblique weakening
and down shift of the recessed medial recti
could also be done. As an extreme, weakening of
the inferior obliques and tuck of the superior
oblique, if they are loose, could be done along
with bimedial rectus recession, but I think that
is too much surgery for this girl.
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