Several techniques have been described for extraocular muscle transfer. The underlying principle for each procedure, except superior oblique tendon transfer, is to shift the pull of antagonist muscles to a point on the globe coinciding with the insertion of the rectus muscle lying between. The procedures shown have been described by the following:

*done in the case of an absent medial rectus

A limited number of manipulations can be performed on an extraocular muscle. The muscle can be shortened and then made to stretch, at first under tension, to the original preoperative distance between origin and insertion while presumably being more ‘effective;’ the muscle can be retroplaced with the same length of muscle going between two points closer together than the original origin and insertion; or a ‘longer’ muscle connecting the original origin and insertion can be created with myotomy or tenotomy. The insertion can be shifted to a new place on the globe, retaining the same innervation but having an altered mechanical effect.

Recent innovations in strabismus surgery include change in the arc of contact produced by the Faden operation (retroequatorial myopexy or posterior fixation suture); denervation of the inferior oblique muscle; detachment of the rectus muscles with sparing of the anterior ciliary vessels; and toxin injection at the motor end-plate to weaken a muscle’s function by interference with nerve transmission at the myoneural junction. Thermal disruption of selected eye muscle fibers has been described but has not yet been proven successful.

Early strabismus surgeons had an accurate grasp of muscle function but little appreciation for orbital fascial anatomy. Numerous references to the encountering of fat during strabismus surgery suggest that even the best surgeons found orbital fat on a routine basis. Except for referring to cutting across the conjunctiva, Tenon’s capsule, and the muscle capsule, scarcely a comment on these fascial tissues is found in early literature dealing with strabismus surgery. Modern strabismus surgery differs significantly from early strabismus surgery in its attention to detail in dealing with the orbital fascia and fat. Recent description of the anatomy of the trochlea, the inferior oblique, and especially of the muscle pulleys has provided new insight for strabismus surgeons.

These tissues are thought by some surgeons to be as important as the muscle itself. This book will emphasize the importance of technique in the belief that the surgeon who exercises impeccable care when dealing with all tissues encountered in strabismus surgery will attain better results.

Some operations that have been suggested by older surgeons or a few contemporary surgeons are not mentioned even as an option in either the historical or current sections. These omissions indicate a bias, which I hope will not result in overlooking useful procedures. Only procedures of sufficient historical interest or contemporary procedures that have some rational basis will be described. When appropriate, alternative techniques will be described.

The use of adhesives and plastic sleeves and sheets or caps mentioned in previous editions now are mentioned here only as a part of the history of strabismus surgery. Like many of the procedures shown in this chapter, these techniques sounded good, were tried, but now are relegated mostly to memory.

For a more complete review of the history of strabismology, the reader is advised to consult The History of Strabismology edited by Gunter von Noorden (J. P. Wayenborgh, Belgium, 2002).