PURPOSE: To report the indications, operative strategies, and surgical outcomes of patients who undergo vertical and horizontal rectus muscle surgery for incomitant strabismus despite being orthophoric in primary gaze. DESIGN: Retrospective, interventional case series. METHODS: • Setting: Academic practice at Boston Children's Hospital. • Patient Population: Eight orthophoric patients who underwent strabismus surgery to treat vertical/horizontal incomitance. • Observation Procedures: Review of surgical strategies, strabismus measurements in diagnostic gaze positions, development of post-op diplopia. • Main Outcome Measures: Preserved single vision in primary gaze, comitance, reoperation rate, and patient/surgeon satisfaction. RESULTS: Surgical strategies included 1) simultaneous recession of ipsilateral antagonist rectus muscles; 2) recession or resection of one rectus muscle with balancing surgery on the fellow eye; 3) restricting range of one muscle (combined resection and recession or posterior fixation suture); 4) creating an acceptable deviation in primary gaze. Mean follow-up was 5.4 months (median, 2 months; range, 2-25). No patient had new-onset primary gaze diplopia. Median incomitance improved by 9.5 PD. No patient required additional surgery. Patient satisfaction and surgeon assessment of outcomes were high. CONCLUSIONS: Although the risk of operating on orthophoric patients with incomitant strabismus may discourage surgeons from offering treatment, the use of specific strategies to address incomitance can preserve alignment in primary gaze while improving patient satisfaction. These strategies may also benefit patients with incomitant strabismus that is symptomatic in primary gaze.