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In the article entitled "Multiple Mechanisms of Extraocular Muscle ‘Overaction,’" Dr Kushner provided lucid and well-illustrated descriptions of loss of elasticity (contracture, true shortening) and gain in elasticity (expansure, true lengthening) of extraocular muscles.¹ Dr Kushner, however, failed to mention alternate explanations² for 2 examples of the inferior oblique (IO) muscle "overaction" (IOOA) that he analyzed. Overaction of the IO muscle secondary to superior oblique muscle palsy may be almost exclusively contracture with no hypertrophy seen on magnetic resonance imaging³ for the majority of patients for whom the hypertropia in contralateral upgaze is no larger than the hypertropia in straight contralateral gaze,⁴ with the positive Bielschowsky result mainly due to the superior oblique muscle paresis, which is Bielschowsky's original explanation. In contrast, the primarily overacting IO muscle associated with infantile esotropia usually appears greatly hypertrophied at surgery,⁵ a hypertrophy that explains why the contralateral upgaze hypertropia is larger than the . . . [Full Text of this Article]

AUTHOR INFORMATION
James L. Mims III, MD

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Alternate Explanations for Inferior Oblique Muscle "Overaction"—Reply
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