The diagnosis of paralysis of a single ocular muscle on occasion may be difficult, especially if the condition has existed for some time and compensatory changes in other muscles have occurred. When more than one muscle in the same eye is paralytic, a much more difficult task is encountered, and if one or more muscles in each eye are paralyzed, the diagnostic picture can be most confusing and wholly unintelligible. Not only may more than one muscle be paralyzed, but all degrees of paresis of these muscles may be found, together with other complications such as innervational overaction and underaction, spasm, contractures and fibrosis of other muscles not involved primarily. Moreover, the patient may fix in primary or secondary deviation or may vary fixation in different deviations of gaze. It can be safely said that only those who have had the experience are aware of the difficulties that sometimes attend
KREWSON WE. DIAGNOSIS OF MULTIPLE OCULAR MUSCLE PARALYSES. JAMA. 1950;144(7):534–537. doi:10.1001/jama.1950.02920070022006
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