Sixth cranial nerve palsy is a common cause of paralytic strabismus, often leading to esotropia and limitation of abduction. Management of residual esotropia can be particularly challenging in long-standing cases or in patients with previous strabismus surgery.

We report a case of a 63-year-old woman presenting with binocular diplopia and residual esotropia following prior surgery for left sixth nerve palsy. Clinical examination revealed a 20 prism diopter esotropia in primary gaze, severe limitation of abduction, and a compensatory head turn. A partial Hummelsheim transposition combined with intraoperative botulinum toxin injection into the medial rectus muscle was performed. of the compensatory head posture.

In the immediate postoperative period, exotropia with adduction limitation was observed, which gradually improved over time. At 6 months, the patient achieved orthotropia in primary position, with significant improvement in ocular motility and complete resolution of the compensatory head posture.

Partial Hummelsheim transposition combined with botulinum toxin represents an effective and safe option for the management of residual paralytic esotropia, particularly in previously operated patients, as it allows satisfactory ocular alignment while preserving anterior segment circulation.