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Purpose To compare one-muscle versus two-muscle surgery for moderate-angle hyperdeviations due to presumed unilateral fourth nerve palsy. Design Retrospective chart review Methods 73 patients (5 to 86 years) underwent either one- or two-muscle surgery at our institution, for moderate hyperdeviation, due to presumed unilateral fourth nerve palsy, measuring 14 to 25 PD in straight ahead gaze at distance fixation. Six week and 1-year motor success was defined as zero vertical deviation or 1–4 PD undercorrection at distance, overcorrection as any reversal of hypertropia, and undercorrection as >4 PD. Diplopia success was defined as no diplopia, or only rarely for distance straight ahead and reading. Results 28 patients underwent one-muscle surgery, and 45 patients underwent two-muscle surgery. Motor success was similar (64% vs 67%, P>0.99 at 6 weeks; 47% vs 55%, P=0.8 at 1 year, n=46), but there were more undercorrections at 6-weeks with one-muscle surgery (36% vs 16%, p=0.09), and more overcorrections at 6-weeks with two-muscle surgery (0% vs 18%, p=0.02). Diplopia success was also somewhat similar between one- and two-muscle surgery at 6 weeks (73% vs 60%, p=0.5) and 1 year (45% vs 59%, P=0.5). Conclusion For moderate angle hyperdeviations due to presumed unilateral fourth nerve palsy, there appears no clear advantage of two-muscle surgery for motor outcomes. Diplopia success at was similar between one- and two-muscle surgery, due to a greater number of less symptomatic undercorrections with one-muscle surgery, and a smaller number of more symptomatic overcorrections with two-muscle surgery.

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