This presentation from Pediatric Ophthalmology Subspecialty Day 2022 considers the surgical management of sixth cranial nerve (CN) palsy, focusing on the modified Hummelsheim procedure with ipsilateral medial rectus (MR) recession. Topics discussed include the following:

• goals of surgical management for strabismus in general
• ways to do harm, such as cutting too many anterior ciliary arteries, leading to anterior segment ischemia; making diplopia worse; and increasing the risk of endophthalmitis
• significantly weakening the antagonist MR muscle, among other steps essential to surgical success
• advantages and details of the modified Hummelsheim procedure with ipsilateral MR recession