Abstract
Intraoperative surprises involving the extraocular muscles are rather common. Most are promptly recognized and easily corrected, rarely having adverse impact on surgical outcome. However, on occasion, unexpected intraoperative events present significant challenges to the surgeon and may result in surgical complications. Intraoperative surprises involving the extraocular muscles usually relate to problems caused by anatomic variation or surgical mishaps. Surgical complications frequently occur as the consequence of a cascading series of events that may include anatomic variation as well as one or more surgical mishaps. Anatomic variation can be congenital or acquired and ranges from minor anomalies to major malformations, including absent muscles. Lost muscles probably represent the most significant problem caused by surgical mishaps. Recovery of lost muscles may be best served by a two-tier approach, first employing the sub-Tenon's route utilized in the original strabismus procedure. If the lost muscle cannot be recovered using this route, a variety of orbital approaches can be considered. These approaches are usually best accomplished using a team with special expertise in strabismus surgery, orbital surgery, and, at times, other specialities.