Why should some people with severe axial myopia develop a marked esotropia combined with hypotropia? Although rare, this unusual form of restrictive extraocular muscle imbalance is well recognised. Various suggestions regarding its aetiology have been proposed. Several point to an underlying anatomical cause; the large, myopic globe leading to an imbalance of the structures within the orbit which results in a limitation of normal ocular rotations.12 In this issue of the journal Krzizok and co-workers (p 625) present magnetic resonance imaging (MRI) and surgical findings in a series of such patients with high myopia and strabismus. Their high definition magnetic resonance scans demonstrate that the lateral rectus muscle takes a pathological course, developing an inferotemporal deviation at the equatorial plane, in a significant percentage of these patients. This finding is confirmed at operation and surgery aimed specifically at correcting the abnormal path of the muscle proves curative.

This paper illustrates well how newer and more accurate imaging techniques …