Paradoxical inferior oblique muscle overaction with A-pattern esotropia

The presence of overacting inferior oblique muscles in A-pattern esotropia is a rarely documented finding. During the last three decades, three basic schools of thought have evolved to explain A and V patterns. In certain cases an individualized approach synthesizing these three theories is needed. We saw two patients with paradoxical A-pattern esotropia with inferior oblique muscle overaction. Both cases were treated surgically by weakening both inferior oblique muscles with recession and supraplacement of both medial rectus muscles. The synthesis of these two approaches resulted in good postoperative alignment.