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A 62-year-old man presented with torsional diplopia after a transantral decompression and bilateral inferior and medial rectus recessions for severe dysthyroid ophthalmopathy. With double Maddox rod testing he measured 35° of left incyclotropia in primary position and 45° of incyclotropia in downgaze. The patient underwent bilateral superior oblique tenectomies and bilateral inferior rectus advancement partway to the original insertion. Postoperatively he was orthotropic in all gaze positions. Large amounts of torsional strabismus may be encountered in dysthyroid ophthalmopathy. Superior oblique tenectomies are effective in addressing incyclotorsion produced from large inferior rectus recessions, secondary overaction or primary dysthyroid involvement of the superior oblique muscle.
Strabismus associated with dysthyroid ophthalmopathy is caused by restriction of vertical and horizontal ocular rotations secondary to fibrosis of the extraocular rectus muscles. Cyclotorsion is less common1 and is generally thought to be a …