Jonathan M. Holmes, MD (Rochester, MN), Colin A. McCannel, MD (Rochester, MN), David A. Leske, BS (Rochester, MN)


To describe the spectrum of strabismus complications associated with the superior oblique (SO) tendon caused by improper scleral buckle placement, to describe treatment and possible prevention.


In a retrospective chart review, we identified six cases of vertical and torsional strabismus requiring superior oblique procedures to address diplopia following scleral buckling for retinal detachment (RD). All cases required careful surgical exploration to define the problem and individualize the surgical plan.


All cases had 360 degree encircling buckles placed at the time of RD surgery, with or without a radial segment, and 3 (50%) had previous scleral buckle revisions. Post buckle strabismus ranged from 5 prism diopters (pd) to 30 pd hypertropia and 5 to 15 degrees of excyclotorsion or 10 degrees of incyclotorsion. Intraoperatively, 5 of the cases were found to have inadvertent anteriorization of superior oblique tendon by the buckle. The SO tendon was most often found scarred to the medial insertion of the superior rectus. In one case, the tendon was found posteriorly displaced by the buckle. The torsional and vertical strabismus was addressed by either advancing the anterior fibers of the SO tendon, advancing or recessing the entire tendon, or releasing scar tissue to allow the tendon return to its normal anatomical position. Simultaneous recession of the superior rectus or inferior rectus was performed as dictated by intraoperative forced ductions and preoperative measurements.


Vertical and torsional strabismus may result from suboptimal placement of a circumferential buckle, and will most often require surgical repositioning of the SO tendon using an adjustable suture technique, while leaving the buckle intact. Prevention of SO complications during scleral buckling involves meticulous attention to placing the buckle over the undisturbed SO tendon.