Quantitative Assessment of Inferior Oblique Muscle

Overaction Using Photographs of the Cardinal Positions

of Gaze
HAN WOONG LIM, JUNG WOOK LEE, EUNHEE HONG, YUMI SONG, MIN HO KANG, MINCHEOL SEONG,
HEE YOON CHO, AND SEI YEUL OH

PURPOSE:

To report a novel method for measuring the

degree of inferior oblique muscle overaction and to investigate the correlation with other factors.

DESIGN: Cross-sectional diagnostic study.

METHODS: One hundred and forty-two eyes (120 patients) were enrolled in this study. Subjects underwent
a full orthoptic examination and photographs were obtained in the cardinal positions of gaze. The images
were processed using Photoshop and analyzed using the
ImageJ program to measure the degree of inferior oblique
muscle overaction. Reproducibility or interobserver variability was assessed by Bland-Altman plots and by calculation of the intraclass correlation coefficient (ICC). The
correlation between the degree of inferior oblique muscle
overaction and the associated factors was estimated with
linear regression analysis.

RESULTS: The mean angle of inferior oblique muscle
overaction was 17.8 10.1 degrees (range, 1.854.1 degrees). The 95% limit of agreement of interobserver variability for the degree of inferior oblique muscle overaction
was 1.76 degrees, and ICC was 0.98. The angle of inferior oblique muscle overaction showed significant correlation with the clinical grading scale (R [ 0.549, P <
.001) and with hypertropia in the adducted position
(R [ 0.300, P [ .001). The mean angles of inferior oblique muscle overaction classified into grades 1, 2, 3, and 4
according to the clinical grading scale were 10.5 9.1 degrees, 16.8 7.8 degrees, 24.3 8.8 degrees, and 40.0
12.2 degrees, respectively (P < .001).

CONCLUSIONS: We describe a new method for
measuring the degree of inferior oblique muscle overaction using photographs of the cardinal positions. It has
the potential to be a diagnostic tool that measures inferior
oblique muscle overaction with minimal observer
dependency. (Am J Ophthalmol 2014;158:793799.
2014 by Elsevier Inc. All rights reserved.)

VERELEVATION IN ADDUCTION CAN BE OBSERVED

in multiple causes, such as inferior oblique muscle overaction, Duane syndrome, and dissociated
vertical divergence.1 Among them, inferior oblique muscle
overaction is a common ocular motility disorder characterized by vertical incomitance of the eye in lateral gaze.2
Primary inferior oblique muscle overaction often develops
during childhood in patients with infantile esotropia,
accommodative esotropia, or intermittent exotropia,3
whereas the secondary type is related to palsy of the superior oblique muscle.4
Various surgical procedures have been performed to
correct inferior oblique muscle overaction, including
myectomy, recession, extirpation, and anteriorization of
the inferior oblique muscle.510 The surgical technique
depends on the deviation in central gaze, the amount of
elevation in adduction, and the pattern of comitance;
however, the decision of the surgical plan appears to be
primarily based on individual experience and preference.
Moreover, an objective measurement of inferior oblique
muscle overaction remains a difficult task in clinical
practice.
We previously described a modified limbus test that
quantifies the angle of ocular movement using photographs
of the 9 cardinal positions of gaze.11 This technique allows
measurement of not only the angle of ocular movement but
also the axis of direction in the 9 cardinal positions of gaze.
The purpose of this study was to describe a new clinical
technique for measuring the degree of inferior oblique muscle overaction and to evaluate its performance in patients
with inferior oblique muscle overaction.

METHODS
THIS WAS A CROSS-SECTIONAL STUDY IN WHICH PATIENTS

Accepted for publication Jun 23, 2014.

From the Department of Ophthalmology, College of Medicine,
Hanyang University School of Medicine (H.W.L., J.W.L., E.H., Y.S.,
M.H.K., M.S., H.Y.C.), and Department of Ophthalmology, Samsung
Medical Center, Sungkyunkwan University School of Medicine
(S.Y.O.), Seoul, South Korea.
Inquiries to Sei Yeul Oh, Department of Ophthalmology, Samsung
Medical Center, Sungkyunkwan University School of Medicine, 81,
Irwon-ro, Gangnam-gu, Seoul, South Korea; e-mail: syoh@skku.edu
0002-9394/$36.00
http://dx.doi.org/10.1016/j.ajo.2014.06.016

2014 BY

with inferior oblique muscle overaction were enrolled from

October 1, 2011 to October 31, 2013. Institutional review
board approval was obtained at Hanyang University Guri
Hospital, and the study adhered to the Declaration of
Helsinki and Health Insurance Portability and Accountability Act regulations. Written informed consent was obtained from all patients or from 1 or both parents for
children younger than 18 years of age.

ELSEVIER INC. ALL

RIGHTS RESERVED.

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PATIENTS:

Patients enrolled in this study had inferior

oblique muscle overaction associated with intermittent
exotropia, congenital esotropia, and superior oblique
muscle palsy. All patients received full ophthalmologic
and orthoptic assessments, including history, bestcorrected visual acuity, ductions and versions, posterior
segment examination, cycloplegic refraction, cover test,
and measurement of deviation in the diagnostic positions
of gaze near and at distance by loose prism and the alternate cover test. In younger patients, deviation was
measured by means of Krimsky test or Hirschberg test.
Ductions and versions were graded on a scale of 4
(underaction) to 4 (overaction), with 0 being normal.
Inferior oblique muscle overaction was determined by
measuring vertical deviation on maximal lateral version.
A vertical deviation of approximately 10 degrees was 1,
20 degrees was 2, 30 degrees was 3, and 40 degrees
was 4.3,9 Two independent ophthalmologists with
more than 10 years of clinical experience examined the
patient and graded the rating scale of inferior oblique
muscle overaction. When there were disagreements
between observers for the rating scale of inferior
oblique muscle overaction, the observers would discuss
their reasons for selecting a particular grade and then,
if necessary, reexamine the patient together so that any
disparity was clarified. Subjects were excluded from the
study if they did not cooperate with all tests. Cases
with ocular, neurologic, chromosomal, or congenital
disease or a history of previous extraocular muscle
surgery were excluded from the study.

PHOTOGRAPHS OF THE 9 CARDINAL POSITIONS OF
GAZE: Photographs were obtained at a distance of 1 m

from the subject using a 36.8 megapixel digital singlelens reflex camera (D800; Nikon Inc, Tokyo, Japan)
with a ring flash attached to the lens. The resolution of
all selected images was 5520 3 3680 pixels. The subjects
head was firmly fixed on a chin rest with a band wound
around the head to prevent head movements, and the
subject looked at a fixation target located 6 m away.
The subject was then instructed to immobilize his or
her head with the eyes in the primary position. Head position was examined to confirm the absence of obvious
tilt or chin-up or chin-down position. To obtain photographs of the primary position of each eye, we took a
photograph of each eye fixated on a 6 m target with occlusion of the contralateral eye. Next, a Lancaster screen
was installed at a distance of 1 m from the subject, and
the subject visually tracked the fixation target along
the axis of the Lancaster screen into maximum dextrosupraversion, supraversion, levo-supraversion, levoversion, dextroversion, dextro-infraversion, infraversion,
and levo-infraversion for photographs of the secondary
and tertiary positions (Figure 1). Verbal encouragement
was used to ensure stability of the head and maximum
effort into the extremes of gaze.
794

IMAGE PROCESSING PROCEDURES:

After photographs
of the 9 cardinal positions were collected, the images
were processed using Photoshop 6.0 (Adobe, San Jose,
California, USA). The digital image of the primary position was first opened in Photoshop. The secondary or tertiary position image was then selected and copied to the
clipboard, and the contents of the clipboard were pasted
onto the image of the primary position to create a separate layer. The pasted layer was converted to a semitransparent image to help achieve better overlap with the
image of the primary position (Figure 2, Top). Using
the blending tool, the respective layers light or dark portions were converted to a transparent portion; this was
done to identify the margin of the corneal limbus
(Figure 2, Middle). The resulting image was then saved
as a TIFF file with no layers.

MEASUREMENT OF THE DEGREE OF INFERIOR OBLIQUE

MUSCLE OVERACTION: The degree of inferior oblique

muscle overaction was defined as the angle between the

directions of the visual axis of 2 eyes in the lateral
gaze. It was measured using the angle between a horizontal line and the tangent line, which corresponded to the
direction of ocular movement in the adducted position
(Figure 2, Bottom). To quantify these angles, the
processed image was loaded into the ImageJ program
(software version 1.46; National Institutes of Health,
Bethesda, Maryland, USA). The angle made by the
line joining A and B with the horizontal in Figure 2, Bottom was measured by the measuring tools in ImageJ. For
simplicity, we assumed that the line joining C and D was
on a horizontal line. Thus, the angle of inferior oblique
muscle overaction is the angular amount in the 2 lines
that is a. To determine interobserver reliability, 2 independent observers (H.W.L. and J.W.L.) measured the
degree of inferior oblique muscle overaction using the
above method.

STATISTICAL

ANALYSIS: Statistical analyses were

performed using SPSS for Windows version 17.0 (SPSS,
Inc, Chicago, Illinois, USA) and the MedCalc statistical
packages (V.12.7; MedCalc Statistical Software, Ostend,
Belgium). The intraclass correlation coefficient (ICC)
was calculated to analyze interobserver variation. Agreement between measurements is represented in BlandAltman plots.12 Linear regression analysis was performed
to assess the relationship between the angle of inferior
oblique muscle overaction and the clinical grading scale,
hypertropia in the primary position, and hypertropia in
the adducted position. Subgroup analyses based on the
type of inferior oblique muscle overaction were conducted using an independent sample t-test. One-way analysis
of variance (ANOVA) was used to compare the mean
angle of inferior oblique muscle overaction between 4
subgroups of the clinical grading scale. P values less
than .05 were considered statistically significant.

AMERICAN JOURNAL OF OPHTHALMOLOGY

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FIGURE 1. Composite photographs showing a subject displaying the 9 cardinal positions of gaze. Note elevation in adduction (arrow)
of left eye.

FIGURE 2. Image processing by Photoshop and ImageJ for quantitative measurement of the degree of inferior oblique muscle overaction. (Top) Semitransparent image of dextroversion was overlapped with the primary position image using Photoshop. (Middle) The
overlapping image was converted to identify the margin of the limbus by Photoshop. (Bottom) Quantitative measurement with ImageJ
showing the angle between a horizontal line (CD) and the tangent line (AB), which corresponds to the direction of ocular movement.
The angle of inferior oblique muscle overaction is the angular amount in the 2 lines that is a.

RESULTS
A TOTAL OF 127 PATIENTS WERE INVESTIGATED DURING THE

study period. Seven of these 127 patients were excluded, 5

because of incomplete data sets and 2 because of an
VOL. 158, NO. 4

inability to comply with the modified limbus test owing

to small lid fissures. Thus, 142 eyes of 120 patients (60
men) with a mean age of 11.2 6 10.8 years (range, 362)
were included. Of these, 102 had secondary inferior oblique
muscle overaction attributable to superior oblique muscle

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795

TABLE 1. Demographics and Characteristics of Patients With Inferior Oblique Muscle Overaction

Age (y)
Gender (male/female)
Spherical equivalent (D)
HT in the primary position (PD)
HT in the adducted position (PD)
Grading scale of IOOA
Angle of IOOA (degrees)

Total

Primary IOOA
(n 23)

Secondary IOOA
(n 97)

P Value

11.2 6 10.8 (3w62)

60 (72 eyes)/60 (70 eyes)
0.18 6 1.71 (11.0w4.0)
6.7 6 6.5 (0w30)
9.6 6 8.1 (0w40)
2.1 6 0.7 (1w4)
17.8 6 10.1 (1.8w54.1)

5.9 6 2.8
12/11
0.45 6 1.06
1.8 6 5.3
5.7 6 6.3
2.3 6 0.8
19.1 6 11.0

12.4 6 11.5
48/49
0.48 6 1.89
8.1 6 5.9
10.9 6 8.4
2.0 6 0.7
17.8 6 9.9

.008a
.818b
.024a
<.001a
.024a
.073a
.590a

D diopters; HT hypertropia; IOOA inferior oblique muscle overaction; PD prism diopters.

Data are mean 6 standard deviation, or number of subjects.
a
t test for independent samples.
b 2
x test.

palsy with a positive Bielschowsky head-tilt test, while 40

had primary inferior oblique muscle overaction associated
with intermittent exotropia (n 25), accommodative
esotropia (n 13), and congenital esotropia (n 2).
Demographics and characteristics of the patients are
shown in Table 1, together with a comparison between patients with primary inferior oblique muscle overaction and
secondary inferior oblique muscle overaction. Compared
with primary inferior oblique muscle overaction, patients
with secondary inferior oblique muscle overaction were
older (P .008), were myopic (P .024), and had greater
hypertropia in the primary position (P < .001) and
adducted position (P .024). There were no significant
differences in the degree of inferior oblique muscle overaction measured by the clinical grading scale (P .073).
The mean angle of inferior oblique muscle overaction was
17.8 6 10.1 degrees (Figure 3) and was not significantly
different between primary inferior oblique muscle overaction
(19.1 6 11.0 degrees) and secondary inferior oblique muscle
overaction (17.8 6 9.9 degrees; P .590). Interobserver
variability between the results of 2 independent examiners
was determined. The Bland-Altman strategy was applied,
comparing the differences between the 2 measurements
with the average of the 2 measurements. The mean difference between observers was 0.11 degrees, with 95% confidence limits of 1.65 degrees and 1.86 degrees (Figure 4).
The ICC between observers was 0.986. The zero difference
line lies within these confidence levels, confirming that
the mean interobserver difference is not significant.
There were significant correlations between the angle of
inferior oblique muscle overaction and the clinical grading
scale of inferior oblique muscle overaction (R 0.549, P <
.001) (Table 2; Figure 5). Significant correlation was also
seen between the angle of inferior oblique muscle overaction and the prism diopter of hypertropia in the adducted
position (R 0.300, P .001). However, the prism diopter
of hypertropia in the primary position and the angle of inferior oblique muscle overaction showed no correlation
796

FIGURE 3. Bar graph showing the distribution of patients with

different angles of inferior oblique muscle overaction.

(R 0.135, P .149). Subgroup analyses in which patients

were classified according to the clinical grading scale showed
significant differences in the angle of inferior oblique muscle
overaction (grade 1 10.5 6 9.1 degrees vs grade 2
16.8 6 7.8 degrees vs grade 3 24.3 6 8.8 degrees vs grade
4 40.0 6 12.2 degrees, P < .001 by 1-way ANOVA).

DISCUSSION
IN OUR STUDY, WE PROPOSED A NEW TECHNIQUE FOR

measuring the degree of inferior oblique muscle overaction

AMERICAN JOURNAL OF OPHTHALMOLOGY

OCTOBER 2014

FIGURE 4. Interobserver reproducibility for measurement of

the degree of inferior oblique muscle overaction by 2 observers
(H.W.L. and J.W.L.), assessed using the strategy of BlandAltman. Upper and lower dotted lines: 95% confidence intervals. SD [ standard deviation.

TABLE 2. Correlation Between the Angle of Inferior Oblique

Muscle Overaction and Clinical Grading Scale, Hypertropia
in the Primary Position, and Hypertropia in the
Adducted Position
Angle of IOOA
Total
a

P Value

Primary IOOA
R

P Value

Secondary IOOA
Ra

Clinical grading
0.549 <.001 0.593 <.001 0.532
scale
HT in the primary 0.135 .149 0.043 .833 0.248
position
HT in the adducted 0.300 .001 0.428 .029 0.333
position

P Value

<.001
.019
.001

HT hypertropia; IOOA inferior oblique muscle overaction.

a
Pearson correlation coefficient.

using photographs of the cardinal positions of gaze that is

objective, reproducible, and accurate. In a previous study,
we reported the mean degrees of versions in healthy subjects by using a modified limbus test. This has shown
good reproducibility and minimal interobserver variability
in the 9 cardinal positions of gaze. On the basis of this
methodology, in the present study we acquired measurements of the angle of inferior oblique muscle overaction
successfully in a number of patients with inferior oblique
muscle overaction. Our method can be considered a consistent and reliable technique for measuring inferior oblique
muscle overaction that does not rely on the ability of examiners and is valuable in clinical practice.
VOL. 158, NO. 4

FIGURE 5. Relationship between the degree of inferior oblique

muscle overaction and the clinical grade scale. Scatterplots
showing the degree of inferior oblique muscle overaction was
significantly correlated with the clinical grade scale (R [
0.549, P < .001).

There have been several grading systems used to evaluate

inferior oblique muscle overaction.9,1315 Most of the
previous evaluations of inferior oblique muscle
overaction were performed manually and were measured
subjectively by individual examiners; thus, the reliability
of such measurements depended on the proficiency of
examiners and measurement errors. Even the most
experienced strabismologists using clinical grading scales
would show inconsistent responses; however, no trials
have been conducted to estimate the amount of inferior
oblique muscle overaction objectively. In this study, we
demonstrated the objective measurement of inferior
oblique muscle overaction in comparison with other
methods.
Several studies have described measurements of the
amount of inferior oblique muscle overaction to evaluate
the efficacy of surgical procedures that weaken the overacting inferior oblique muscle. Costenbader and Kertesz13
conducted a retrospective study in 490 eyes with inferior
oblique muscle overaction. They divided inferior oblique
muscle overaction into 3 groups according to the prism diopters of hypertropia in the field of action of the inferior
oblique. Toosi and von Noorden14 reported the effect of
isolated inferior oblique myectomy in superior oblique
palsy. They determined inferior oblique muscle overaction
on the basis of hyperdeviation in the primary position and
in the fields of action of the inferior oblique muscle using a
deviometer. However, it is difficult to obtain accurate and
repeatable prism and alternate cover findings away from the
primary position unless sophisticated laboratory equipment
is used to ensure that measurements are taken repeatedly on
the same meridian at a specific number of degrees.

ASSESSMENT OF INFERIOR OBLIQUE MUSCLE OVERACTION

797

Although Toosi and von Noorden proposed a deviometer

for accurate measurement under identical testing conditions, this deviometer is limited by its fixed field of fixation
at 35 degrees, which may cause the examiner to miss mild
inferior oblique muscle overaction in the extreme periphery of the visual field.
Parks15 graded inferior oblique muscle overaction according to the degree of overelevation of the eye in adduction, using 3 grades in a comparative study with bilateral
inferior oblique muscle overaction patients. More recently,
inferior oblique muscle overaction was graded according to
the degree of overelevation of the eye in adduction using a
scale ranging from 0 to 4 overelevation.3,9 In maximal
lateral version, a vertical deviation of approximately 10
degrees was 1, 20 degrees was 2, 30 degrees was 3,
and 40 degrees was 4. Unfortunately, this method may
be susceptible to examiner-dependent and substantially
less accurate; moreover, there can be standardization difficulties in this method.
In the present study, we measured the degree of inferior
oblique muscle overaction with the angle between a horizontal line and the tangent line, which corresponds to
the direction of ocular movement in the adducted position.
Compared with previous methods, the main strength of our
study is that the results are not dependent on the examiners skill and experience and are not arbitrary units.
Instead, the results are directly presented in degrees, which
are measured using objective image processing. In addition,
in mild inferior oblique muscle overaction we can obtain
accurate angles through the maximally adducted position
in reference to the primary position.
In this study, a significant correlation was found between
the angle of inferior oblique muscle overaction and the
clinical 4-step grading scale. When dividing the mean
angle of inferior oblique muscle overaction into 4 different
groups using the clinical grading scale, we found that the
mean angles of inferior oblique muscle overaction were
significantly different between groups. Interestingly, it
showed an accelerating increase according to the clinical
grading scale, especially between grade 3 and grade 4.
Although there were only 3 cases in grade 4, the measurement of inferior oblique muscle overaction using the clinical grading scale did not increase linearly, contrary to the
description by Parks.16 This finding suggests that the clinical grading scale is subjective and inaccurate and thus
can express only an approximate amount of inferior oblique
muscle overaction.
The correlation between the angle of inferior oblique
muscle overaction and the prism diopters of hypertropia
in the adducted position was as good as expected; however,
no significant correlation was found with the prism diopters
of hypertropia in the primary position. When we divided
the subjects into primary inferior oblique muscle overaction and secondary inferior oblique muscle overaction, a
significant correlation between the angle of inferior oblique

798

muscle overaction and the prism diopters of hypertropia in

the primary position was noted only in the secondary inferior oblique muscle overaction group. Parks16 described
that patients with secondary inferior oblique muscle overaction have a significant vertical deviation in the primary
position; however, there is no vertical deviation or, at
most, a negligible vertical deviation in patients with primary inferior oblique muscle overaction. Furthermore,
hypertropia in the primary position could be masked owing
to bilateral symmetric inferior oblique muscle overaction.
Thus, this result implies that clinicians should be cautious
in evaluating inferior oblique muscle overaction with the
hypertropia in the primary position, especially patients
with primary inferior oblique muscle overaction.
There are some weaknesses to the present study. First,
although the clinical grading scale of inferior oblique
muscle overaction was measured by an experienced strabismologist, it is difficult to define these results as representative of the clinical grading scale. Because the
standardization of a clinical grading scale is difficult, measurement error resulting from a clinicians variability
should always be considered in interpreting the clinical
grading scale results of inferior oblique muscle overaction.
Thus, we proposed our method as an objective measurement of inferior oblique muscle overaction. Second, we
calculated the angle of inferior oblique muscle overaction
using a 2-dimensional eye model even though ocular
movement is 3-dimensional. Thus, intrinsic error was
inevitable in our method, and further research is needed
to evaluate inferior oblique muscle overaction using a 3dimensional model. Third, it is difficult to obtain photographs of the cardinal positions of gaze, especially in
young children. Although we used the toy as a fixation
target to attract the childrens attention and encourage
them to become more comfortable and familiar with the
examination, large numbers of children were excluded
from our study owing to poor cooperation. Finally, this
method is difficult to measure in patients with small lid
fissures because of challenging limbal exposure. Thus,
we tried to widen the lid fissure to produce high-quality
photographs that are appropriate for analysis when
obtaining photographs of the adducted position.
In conclusion, we proposed a new method that can
measure the degree of inferior oblique muscle overaction
objectively using photographs of the cardinal positions of
gaze. Our study demonstrated that the proposed method
can be widely used as a diagnostic tool to evaluate binocular misalignment in the lateral gaze and that the measurements were highly correlated with the clinical
grading scale, which suggests that it is possible for this
method to replace conventional diagnostic methods.
Considering its reproducibility and ease of use, we believe
the proposed method has the potential to be used as an
accurate and reliable tool to obtain predictable results
and facilitate surgical planning.

AMERICAN JOURNAL OF OPHTHALMOLOGY

OCTOBER 2014

ALL AUTHORS HAVE COMPLETED AND SUBMITTED THE ICMJE FORM FOR DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
and none were reported. This study was supported by a grant of the South Korea Healthcare Technology R&D Project, Ministry of Health and Welfare,
South Korea (HI10C2020). Contributions of authors: conception and design (H.W.L., S.Y.O.), analysis and interpretation of the data (H.W.L., J.W.L.,
S.Y.O.), writing the article (H.W.L., Y.S.), critical revision of the article (H.W.L., S.Y.O.), final approval of the article (S.Y.O.), data collection (H.W.L.,
J.W.L., E.H.), provision of resources (M.S., H.Y.C.), statistical expertise (M.H.K.), obtaining funding(S.Y.O.), literature search (H.W.L., M.S.), and logistic support (S.Y.O.).

REFERENCES
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Motility: Theory and Management of Strabismus. St. Louis:
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3. Wilson ME, Parks MM. Primary inferior oblique overaction in congenital esotropia, accommodative esotropia,
and intermittent exotropia. Ophthalmology 1989;96(7):
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4. Spencer RF, McNeer KW. Structural alterations in overacting inferior oblique muscles. Arch Ophthalmol 1980;98(1):
128133.
5. Davis G, McNeer KW, Spencer RF. Myectomy of the inferior
oblique muscle. Arch Ophthalmol 1986;104(6):855858.
6. Apt L, Call NB. Inferior oblique muscle recession. Am J
Ophthalmol 1978;85(1):95100.
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8. Raab EL, Costenbader FD. Unilateral surgery for inferior oblique overaction. Arch Ophthalmol 1973;90(3):180182.

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9. Del Monte MA, Parks MM. Denervation and extirpation of

the inferior oblique. An improved weakening procedure for
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10. Elliott RL, Nankin SJ. Anterior transposition of the inferior
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11. Lim HW, Lee DI, Lee JW, et al. Clinical measurement of the
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13. Costenbader FD, Kertesz E. Relaxing procedures of the inferior oblique; a comparative study. Am J Ophthalmol 1964;
57(2):276280.
14. Toosi SH, von Noorden GK. Effect of isolated inferior oblique muscle myectomy in the management of superior oblique
palsy. Am J Ophthalmol 1979;88(3 Pt 2):602608.
15. Parks MM. The weakening surgical procedures for eliminating overaction of the inferior oblique muscle. Am J
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Biosketch
Han Woong Lim, MD is a clinical and research fellow in the Department of Ophthalmology at Hanyang University Guri
Hospital. Dr Lim received his MD from Hanyang University College of Medicine in 2004 and completed an internship and
residency in Hanyang University Hospital in 2009. He trained in strabismus and neuro-ophthalmology at Samsung Medical
Center in 2013. His current research of interests includes measurement of ocular movement and development of diagnostic
tests in strabismus.

799.e1

AMERICAN JOURNAL OF OPHTHALMOLOGY

OCTOBER 2014

Biosketch
Sei Yeul Oh, MD is a pediatric ophthalmology and neuro-ophthalmology specialist and a Professor in the Samsung Medical
Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Dr Oh received his medical degree and did his
postgraduate training at Seoul National University. His area of interest includes strabismus, refractive error in pediatric
patients, and neuro-ophthalmology.

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