Injection of local anesthetic into or adjacent to a rectus muscle can result in a myotoxic injury to the muscle.  A resulting paresis is often later followed by muscle contraction.  The typical patient with an inferior rectus muscle contracture will present initially with a hypertropia of the involved eye and limited downgaze.  With time, a hypotropia with limitation of upgaze develops in the involved eye as contracture of the damaged inferior rectus develops.

The typical surgical approach involves recession of the involved muscle.  Adjustable sutures may be of value as surgery can be unpredictable and recessions larger than anticipated are often required.  Simultaneous recession of the contralateral superior rectus muscle may be needed if the deviation in the primary position is large.  If a concurrent infraduction deficit is also present, posterior fixation suture can be considered on the contralateral inferior rectus muscle at the same time or during a subsequent surgery to minimize diplopia in downgaze.

Each patient should be considered on a case by case basis and no formula is available that will apply to all patients.