—I would like to thank Drs Jacobson and Pesicka for elucidating the etiology of superior oblique muscle dysfunction following surgery in the periorbital region. Transient superior oblique muscle dysfunction after anterior ethmoidal artery ligation has been reported1 and is probably a more common deficit in the postoperative period than recognized. As Jacobson and Pesicka mentioned, their patient's diplopia was not recognized until external lid swelling had resolved.I suggest that this phenomenon is not always recognized and reported due to external lid swelling and the prevention of binocular vision and subjective complaints of diplopia. If one is to hypothesize a similar mechanism for most cases of superior oblique dysfunction following surgery to the periorbital region (such as following blepharoplasty, ptosis repair, and ethmoidectomy),2,3 it would be difficult to explain a purely vascular phenomenon based on the ligation of specific arteries. One could speculate about an ischemic
Couch JM. Transient Superior Oblique Palsy Following Arterial Ligation for Epistaxis-Reply. Arch Ophthalmol. 1991;109(3):321. doi:10.1001/archopht.1991.01080030022018
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