Inferior rectus pulled-in-two syndrome: Surgical results after anterior and nasal transposition of the inferior oblique muscle

Pulled-in-two syndrome (PITS) is a serious intraoperative complication of strabismus surgery in which an extraocular muscle manipulated during the procedure is ruptured and potentially lost. Usually, there is a systemic or local condition that determines muscle weakness when put under tension. If the proximal portion of the broken muscle can be found, it can be reattached to the ocular globe or remaining muscle. If this is not possible, there are multiple varying approaches. We present three cases of PITS of the inferior rectus muscle, treated with good results with anterior and nasal transposition of the inferior oblique muscle. We propose this surgery as another potential technique if the muscle can not be retrieved.