What causes the Pathophysiology of misalignment?

A) The misalignment can be due to

1. Weakness of one of the EOMs
2. Over action of one of the EOM
3. The muscle is prevented by acting because of a problem with the antagonist
   a. The antagonist fails to relax (ocular neuromyotonia)
   b. Simultaneous unwanted contraction (aberrant reinnervation), or
   c. Restrictive ophthalmopathy (something preventing it from relaxing)

B) It can be by infiltration,

C) It can be by fibrosis of the muscle or muscle getting stuck by some means( eg: blow out fracture)

D) The misalignment need not always due to a eye movement problem

• Failure to keep the eyes in the parallel position due to vestibulo- ocular dysfunction can also produce diplopia  Eg: Skew deviation

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