BACKGROUND: Surgical treatment of myopic strabismus fixus is challenging. Options for its correction range from conventional combined recession-resection surgery to innovative surgical procedures aiming to correct the deviated muscle paths. In this report we review our experience and compare the results of various surgical options for treatment of strabismus fixus. METHODS: We report the surgical outcomes of nine adults with acquired strabismus fixus due to myopia with a follow-up of 1 year. Patients were enrolled between May 2003 and April 2007 in this retrospective study. The surgical procedure was determined depending on the angle of deviation and extent of motility impairment. A new transposition technique was performed in one patient who had an extreme variant of strabismus fixus. RESULTS: Combined recession-resection surgery was performed in four patients with resulting small-angle esotropia. In patients with both esotropia and hypotropia due to muscle alignment, we performed an additional upward displacement of both horizontal recti muscles combined with a myopexy of the lateral rectus muscle. The results were satisfying; in particular in one patient who had a transposition procedure a significant improvement was achieved. CONCLUSIONS: For treatment of myopic strabismus fixus, a graded approach seems advisable. Combined recession-resection surgery yields good results for smaller deviations with mildly impaired motility, additional fixation techniques need to be applied once the horizontal muscle paths are deviated, and in extreme cases, a transposition procedure is required.