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Indian J Ophthalmol. 2020 Jan;68(1):170-173. doi: 10.4103/ijo.IJO_196_19.

Surgical management of Helveston syndrome (triad of A- pattern exotropia, superior oblique overaction and dissociated vertical deviation) using 'Four Oblique' procedure.

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Department of Paediatric Ophthalmology and Strabismus, K.B. Haji Bachooali Eye Hospital; Department of Paediatric Ophthalmology and Strabismus, Advanced Eye Hospital, Navi Mumbai; Department of Paediatric Ophthalmology and Strabismus, Agashe Hospital, Kurla, India.
Department of Paediatric Ophthalmology and Strabismus, K.B. Haji Bachooali Eye Hospital, Navi Mumbai, India.



To report the surgical outcomes in six patients of Helveston syndrome using a "four oblique" procedure. The popular methods for surgical management include superior rectus recessions alone or combined with superior oblique tenectomy. However, large angle exotropia correction would entail a higher risk of anterior segment ischemia when the superior rectus needs to be operated along with the horizontal recti. Hence, we evaluated the long-term results of this uncommon procedure.


This was a retrospective review of six patients diagnosed to have manifest dissociated vertical deviation (DVD) with A pattern exotropia with bilateral superior oblique over action. All patients underwent horizontal muscle recessions/resections for exotropia along with bilateral posterior tenectomy of the superior oblique with inferior oblique anterior transpositioning.


The median age was 10 years (Range 5-26 years). The mean postoperative follow-up was 26 ± 14.02 months (Range 12-48 months). The mean reduction in exotropia was from 36.5 ± 21.06 PD (Range 15-65 PD) to 6.1 ± 3.06 PD (Range 3-10 PD). The procedure corrected the A pattern from a mean 23 ± 7 PD (Range 15-35 PD) to 7.6 ± 3.2 PD (Range 3-10 PD). The average DVD in the right eye reduced from 14 ± 4.3 PD (Range 8-20 PD) to 5.3 ± 1.2 PD and in the left eye from 14.33 ± 3.6 PD (Range 10-18 PD) to 4.1 ± 1.1 PD. The DVD asymmetry reduced from 6.33 ± 3.4 PD to 1.5 ± 1.3 PD.


"Four oblique" procedure with horizontal muscle surgery seems to be an effective method for significantly correcting the A pattern as well as reducing the DVD with good long-term outcome in our case series.


A-pattern exotropia; dissociated vertical deviation; inferior oblique anteropositioning; superior oblique over action; superior oblique tenectomy

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