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A 16-year-old girl presented with left eye large-angle exotropia. On examination, we found bilateral limitation of adduction. CT orbit showed hypoplastic medial rectus bilaterally, but intraoperatively we found absent medial recti on both sides. This case report explains discrepancy between the imaging and the intraoperative findings and discusses the management dilemma in view of the risk of anterior segment ischaemia and how marked exodeviation and adduction limitation was tackled by the new technique of transposition myopexy, a modification of the procedure described by Nishida along with recession of lateral rectus to achieve good alignment. This procedure changes the vector forces of the vertical rectus without splitting or tenotomy of the muscles.

Bilateral medial rectus aplasia and a modified surgical approach of transposition myopexy of vertical recti