When the conjunctiva is recessed because of tightness that restricts free movement of the eye, it is usually necessary to move the limbal margin of the conjunctiva back 5 to 7 mm or to the insertion site of the recessed muscle. In the rare case where conjunctival recession is performed without recessing the rectus muscle, the limbal margin is moved to a point just covering the insertion of the muscle. When the conjunctiva is severely scarred it may be excised and the cut edge of conjunctiva attached to underlying sclera. This step may be carried out medially as far as the plica semilunaris. Because the medial conjunctiva containing the plica semilunaris and caruncle has more tissue and because the medial recti are the most frequently operated extraocular muscles, medial conjunctiva is the area most frequently in need of revision. In contrast to reddened scars of the conjunctiva, clear subconjunctival cysts which occur occasionally after eye muscle surgery can be removed, sometimes intact, without the need to recess the conjunctiva provided the overlying conjunctiva remains elastic. When reoperating a patient who has undergone a previous conjunctival recession, it is necessary to enter sub-anterior Tenon's space at the point where conjunctiva had been recessed. The sclera in the area of conjunctival recession becomes re-epithelialized with a thin layer that adheres tightly to underlying sclera. It should not be disturbed. Patients are usually comfortable after conjunctival recession. Ointment is used twice a day after surgery (switching to drops in the morning if ointment causes blur) and no patching is necessary. It is also important to remember that conjunctiva becomes extremely thin and friable in older patients. Even some patients in their 20's may have very thin conjunctiva. Nearly all patients 30 years and older have very thin conjunctiva. Therefore, it is impractical to attempt a cul-de-sac incision in an older patient unless the surgeon has inspected the conjunctiva and has determined that it could withstand the necessary manipulation. Eyes with longstanding esotropia usually have a foreshortened conjunctiva that restricts abduction. A limbal incision is made in the usual manner encompassing approximately 2 to 3 clock hours centered over the muscle's insertion with radial relaxing incision approximately 10 mm long. For closure with recession, conjunctiva-Tenon's is sutured to sclera with three interrupted 8-0 Vicryl sutures used. With the conjunctiva sutured in place, the bare sclera is left to re-epithelialize in a day or so. With a severely scarred conjunctiva, the entire conjunctival flap may be excised and the cut end of conjunctiva sutured to underlying sclera and the relaxing incision sites sutured to adjacent conjunctiva-Tenon's. When medial scarring is extensive, the medial conjunctiva can be excised as far medially as the plica semilunaris. The plica is then sutured directly to underlying sclera far medially (Figure 4).   Figure 4 A Tight, scarred conjunctiva B For conjunctival recession A is attached to A1 and C to C1. A third suture is placed in the center. C Conjunctival recession sutures are placed. D The conjunctival recession is completed. E Scarred medial conjunctiva F Very thick conjunctiva can be excised G and the cut edges of conjunctiva sutured to sclera. H In extreme cases of conjunctiva scarring, I Pratt-Johnson has excised conjunctiva to the caruncle.