Abstract
A 12 year old boy with leukemia developed meningitis and a related unilateral third cranial nerve paresis. A recess-resect procedure of the horizontal rectus muscles with graded supraplacement was used to treat the associated hypotropia and exotropia. Following correction of the horizontal and vertical strabismus, the patient expressed symptoms of diplopia with a torsional component and had inability to fuse the two images. Assessment revealed incyclotorsion of the globe with overaction of the ipsilateral superior oblique muscle. A superior oblique tenotomy was performed after which the patient's symptoms subsided. Torsional considerations should be a component in the evaluation of patients with third cranial nerve palsy.