Profesionales médicos

Aug. 21, 2025

A new surgical approach for correcting excyclotropia has shown promising results, according to a retrospective case series conducted by Mayo Clinic researchers. The study evaluated the effectiveness of a procedure known as superior oblique anterior fiber plication (SOAFP), with or without an anterior knot, allowing for postoperative adjustment.

Several surgical procedures have been described to correct excyclotropia by repositioning the superior oblique tendon fibers, which site posteriorly on the globe. These procedures include modifications to the original Harada-Ito technique with advancement or resection of the anterior fibers of the superior oblique muscle and use of adjustable sutures. Approaches using adjustable sutures on the superior oblique can be technically challenging.

"Double vision disrupts the quality of life for patients," says Erick D. Bothun, M.D., an ophthalmologist at Mayo Clinic in Rochester, Minnesota, and lead author of this study. "Commonly strabismus surgeons tackle the horizontal or vertical deviations and shy away from fixing torsion. This conservative approach can lead to residual symptoms. This study conveys our experience with a novel surgical approach for correction of extorsion that entails tightening just the anterior fibers of the superior oblique anterior with a uniquely positioned, anterior knot that allows for the addition of an accessible adjustable short-tag sliding knot suture."

The study included 14 patients, ranging in age from 21 to 92 years, who underwent SOAFP in 18 eyes. In 12 eyes, SOAFP was the sole procedure, while six eyes underwent additional horizontal rectus muscle modifications, including recession, resection and plication. Ocular alignment was assessed using prism and alternate cover tests, as well as double Maddox rod evaluations, at multiple time points: preoperatively, at the initial postoperative visit and at the final follow-up (approximately 6 to 8 weeks postsurgery).

Preoperative extorsion varied between 2 and 30 degrees, with a mean of 10.14 ± 7.01 degrees. A unilateral or bilateral plication ranging from 2 mm to 30 mm (mean, 8.93 mm ± 5.63) was performed. Initial postoperative assessments indicated a mean intorsional shift of 11.18 ± 7.37 degrees, with a correction effect of approximately 1.86 degrees per millimeter of plication. Further adjustments were made in three eyes to achieve a stronger plication effect targeting 5 degrees of intorsion.

By the final follow-up, conducted 61 ± 23 days after surgery, mean extorsion was significantly reduced to 1.21 ± 2.29 degrees, ranging from 5 degrees of extorsion to 3 degrees of intorsion. The final mean intorsional shift was 9.14 ± 7.53 degrees, equating to an average correction of 1.16 ± 0.50 degrees per millimeter of plication. Encouragingly, 13 out of the 14 patients demonstrated notable improvement in diplopia.

This study, published in the Journal of AAPOS in 2024, highlights SOAFP as an effective and adjustable surgical option for treating excyclotropia. "Managing ocular torsion is challenging for strabismologists," says Dr. Bothun. "This approach makes surgical correction more approachable and leads to better outcomes. I have heard from colleagues that because of this technique, they have gone back to doing surgery for this ocular motility disorder."

"The procedure allows for precise targeting and correction of ocular misalignment, contributing to significant improvements in visual function for most patients," says Dr. Bothun. "Since publishing and discussing the study results, this procedure is now being performed globally. I have received messages from colleagues across the U.S., Europe and Asia expressing appreciation. Further research and clinical application may help to continue to refine the approach and assess its long-term outcomes."

For more information

Anderson M, et al. Novel superior oblique anterior fiber plication with or without adjustable sliding knot for extorsion. Journal of AAPOS. 2024;28:103927.

Refer a patient to Mayo Clinic.