This chapter defines the various alphabet patternsAlphabet-pattern and their aetiologies. Practical steps in their assessment are offered as well as a structured approach to planning surgerySurgery. Oblique muscle over- or under-action should be addressed first prior to moving onto horizontal muscle transpositionsHorizontal muscle transposition. It is important to consider other causes of alphabet patternsAlphabet-pattern which require a different management such as in Duane or Brown syndromeBrown syndrome. Other rarer patterns are discussed as well as complications of alphabet pattern surgerySurgery.