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inferior oblique muscle involvement in thyroid associated ophthalmopathy ( tao ) has long been completely disregarded ( nugent et al 1990 ; aydin et al 2003 ) . however , such involvement has recently been reported ( kakizaki et al 2007 ) .
although the case showed inflammation in the inferior oblique muscle , this appeared to be an old inflammation .
indeed , post - therapeutic improvement of the inflammation was a little difficult to judge from magnetic resonance imaging ( mri ) . here
, we report a case of inferior oblique muscle involvement in tao with typical inflammation , in which post - therapeutic improvement could easily be confirmed by mri .
he was in an euthyroid state with increases of thyrotropin receptor antibody and thyroid - stimulating antibody . to evaluate an orbital inflammation ,
mri was undertaken with a 1.5-tesla system ( ge signa : ge medical systems , waukeshaw , wi , usa ) using a custom - designed 5 inch surface coil .
slice thickness was 3 mm , interslice gap 0.5 mm , and field of view 140 mm  140 mm with a 256  192 matrix .
sagittal t2-weighted spin echo sequences ( echo time , 80 ms ; repetition time , 2,500 ms ) sliced parallel to the optic nerve demonstrated swelling of the left inferior oblique muscle ( figures 1a  c ) compared with the contralateral homonymous muscle ( figures 1d  f ) .
coronal t2-weighted spin echo sequences ( figure 2a ) also showed this swelling , which was revealed as inflammatory by comparing coronal t1-weighted spin echo sequences ( echo time , 12 ms ; repetition time , 600 ms ; figure 2b ) .
as well as left inferior oblique muscle involvement , bilateral inferior ( figures 1a  f ) and medial rectus muscles ( not shown ) were enlarged . to reduce the inflammation from these involvements , steroid pulse therapy ( 500 mg / day methylpredonisolone for 3 days and repeated the following week ) and radiotherapy ( 20 gy over 10 days at 2 gy / day ) were instituted as treatment .
one month after these treatments , sagittal t2-weighted images ( t2wi ; figures 3a  c ) demonstrated the resolution of the inflammation in the left inferior oblique muscle simultaneously with decreased muscle size .
the size of the contralateral homonymous muscle was not changed between prior and post therapy ( figures 3d  f ) .
coronal t2wi ( figure 4a ) and t1-weighted images ( figure 4b ) also illustrated the resolution of the left inferior oblique inflammation .
the other muscular lesions were also improved , but the inflammation of the left inferior rectus muscle remained ( figure not shown ) , resulting in the persistent diplopia .
extraocular muscle involvements are representative symptoms of tao ( dickinson and perros 2001 ) , but inferior oblique muscle involvement has long been disregarded ( nugent et al 1990 ; dickinson and perros 2001 ; aydin et al 2003 ) .
however , we recently reported a case of tao with inferior oblique muscle involvement ( kakizaki et al 2007 ) . here
, we presented another case involving inflammatory swelling of the inferior oblique muscle that significantly resolved after medical intervention .
sagittal mri images are useful to detect such lesions ( kakizaki et al 2007 ) .
size differences were easily noticed by comparing the lesion with the contralateral homonymous muscle without swelling .
the muscle swelling of the inferior oblique muscle could also be detected from careful observations of the coronal images , although sagittal t2wi can more clearly demonstrate a lesion of the inferior oblique muscle .
a 70-year - old man with thyroid associated ophthalmopathy showed inflammatory swelling of the left inferior oblique muscle that was significantly improved by steroid pulse therapy and radiotherapy . 
 sagittal t2-weighted magnetic resonance images were useful to detect the lesion and to evaluate the effects of treatment .