Fig. 1: Schema to demonstrate our hypothesis.

As the horizontal rectus muscle is displaced inferiorly in older persons, muscle strength may be greater with upward transposition than with downward transposition. Furthermore, because the downward transposition of the lateral rectus muscle moves it closer to the insertion of the inferior oblique muscle, adhesions can occur quickly around the insertion site, which may affect the surgical outcomes. However, the lateral rectus muscle remains far from the oblique muscles after upward transposition.