My approach for treating this entity is still in a state of evolution and is not fully satisfactory. Also, in addition to surgery on the incarcerated superior oblique tendon, many patients underwent simultaneous surgery on other vertical or horizontal muscles, which was dependent on the magnitude of the deviation, the presence of restriction that persisted after the incarcerated tendon was freed up, and their incomitant pattern. Consequently, I cannot provide a standard treatment approach for all patients with this syndrome. This confirms the idea that complex strabismus may begin with a specific cause (eg, a restriction) and then become multifactorial as other muscles become contractured. In this series, the most common manifestation of this fact was the presence of contracture of the superior rectus muscle in the affected eye. When that was found, the contractured muscle was recessed. Despite the heterogeneity of these patients, some general treatment principles have evolved. Initially, I simply tried to free the incarcerated tendon; however, in 3 of the 4 patients on whom I tried this approach, the adherence recurred shortly thereafter. This treatment was successful only in case 4 (Figure 3). Castanera de Molina described a similar lack of success in treating the syndrome by simply freeing the incarcerated tendon (written communication, August 22, 2006). In the subsequent 2 patients, I fashioned a sling of 6-0 polyglactin suture material and used that to hold the tendon approximately 5 mm posterior to the nasal corner of the superior rectus muscle insertion. In these patients the tendon scarred to the sclera at the site of the sling, resulting in further symptoms and abnormalities of motility. Both tenectomy and recession of the tendon to the superior nasal quadrant in the manner described by Prieto-Díaz9 proved successful in eliminating the symptoms of incarceration syndrome. However, depending on the patient's history and findings, this treatment often resulted in the clinical picture of a fourth cranial nerve palsy. In many of the cases in which I either freed and mobilized the tendon or recessed the tendon, I had to disinsert the superior rectus muscle to complete the dissection of the superior oblique tendon. The Table indicates the patients in whom this was necessary. In general, I needed to do this if the prior surgical procedure did not involve recessing or disinserting the superior oblique tendon. In patients on whom either of those procedures were performed, the original insertional end of the tendon ended up at the nasal border of the superior rectus muscle, thus making it unnecessary to detach the superior rectus muscle to visualize the entire superior oblique tendon. Most recently, I have been performing a split tendon lengthening procedure in a manner similar to the one reported by Bardorf and Baker10 and leaving the distal end of the tendon attached where I found it. Although this approach appears successful in eliminating the findings of superior oblique tendon incarceration syndrome, it still necessitated additional surgery in some patients to treat an ipsilateral fourth nerve palsy. Despite this fact, this approach is currently my preferred method of treating this condition. In many cases in this series, other muscles were also operated on simultaneously in addition to the superior oblique tendon. Most often this involved recession of the ipsilateral superior rectus muscle, and sometimes it included surgery to correct horizontal deviations.