Dr. Ken Wright performs an inferior oblique recession with anteriorization. Conjunctiva is first dissected just temporal to the inferior rectus insertion and the intermuscular septum is opened. The lateral rectus muscle is hooked with a Jameson hook to provide traction. A traction suture could be alternatively used. Dr. Wright uses a double hook to expose the inferior oblique in the inferior temporal quadrant. The inferior oblique is hooked, taking care to avoid the vortex vein. Tenon's capsule and orbit fat are cleared and the intermuscular septum is opened. The entire inferior oblique muscle is hooked, the insertion sites are exposed, and check ligaments are bluntly dissected down to the muscle belly.

With a Jameson hook maintaining traction, Dr. Wright places the grooved Wright hook beneath the inferior oblique to allow passage of locking bites on either edge of the muscle and to secure the muscle. Once the bites are secure, the Jameson hook is removed, and the Wright hook is pulled straight up to expose the inferior oblique insertion site where the muscle is then disinserted from sclera.

To anteriorize the inferior oblique muscle, the inferior rectus muscle is first hooked. Dr. Wright places a shallow, partial-thickness scleral bite 3 mm posterior to the inferior rectus insertion to reattach the inferior oblique. The second scleral bite is 3 mm posterior to the first to ensure the posterior fibers of the inferior oblique remain posterior. Anteriorization of the posterior fibers can lead to anti-elevation syndrome and hypotropia. The muscle is sutured in place and the conjunctiva is closed with 6-0 plain gut suture. Video adapted from Pediatric Ophthalmology and Strabismus (Oxford University Press, 2012).