Fishman comment: When a patient presents with double vision, the immediate reaction is to rule out serious neurologic causes such as stroke (CVA), brain tumor, giant cell arteritis, infection, cancer, and myasthenia gravis amongst others. However, it turns out that a leading cause of double vision in older adults is condition termed “Sagging eye syndrome (SES)” which was first described by Rutar and Demer in 2009. In younger myopic adults, a related condition called heavy eye syndrome (HES) should be considered.
This is a great article comparing these two syndromes with terrific MRI imaging descriptions.
Authors: Roland Joseph D. Tan, MD a and Joseph L. Demer, MD, PhD a,b,c,d
a Stein Eye Institute, University of California, Los Angeles
b Department of Neurology, University of California, Los Angeles
c Neuroscience Interdepartmental Program, University of California, Los Angeles
d Bioengineering Interdepartmental Program, University of California, Los Angeles
Background—Heavy eye syndrome (HES) presents with esotropia and limited abduction due to superotemporal globe shift relative to the extraocular muscles. Sagging eye syndrome (SES) was originally described in nonmyopic patients exhibiting distance esotropia and cyclovertical strabismus with limited supraduction due to lateral rectus muscle inferodisplacement caused by degeneration of the lateral rectus–superior rectus (LR-SR) band. We hypothesized that SES might also cause strabismus in high myopia.
Methods—Eleven strabismic subjects with high myopia underwent ophthalmological examination and orbital magnetic resonance imaging (MRI) to assess quantitative orbital anatomy.
Results—Of 11 subjects, 5 had HES; 6, SES. Mean axial length in subjects with HES was 32 ± 5 mm; in subjects with SES, 32 ± 6 mm. Average distance esotropia in subjects with HES was 61Δ ± 39 ; hypotropia was 26 ± 21 . Average distance esotropia in subjects with SES was 23 ± 57 ; hypertropia was 2 ± 2 . All 5 subjects with HES had superotemporal globe prolapse; the LR-SR band was thinned in 6 orbits and ruptured in 2. The mean angle between the lateral rectus and superior rectus muscles in HES was 121° ± 7°. In SES the LR-SR band was thinned in 7 orbits and ruptured in 5, with superotemporal soft tissue prolapse. The mean angle between the lateral rectus and superior rectus muscles was 104° ± 11°, significantly less than in HES (P < 0.001).
Conclusions—SES occurs in highly myopic patients who also exhibit less relative globe dislocation than in HES. Unlike HES, SES exhibits superotemporal soft tissue prolapse that may limit superotemporal globe shift. The distinction is important because surgery for HES uniquely requires creation of a surgical connection between the superior rectus and lateral rectus muscles, whereas SES may be treated with conventional surgery. SES can cause strabismus in high axial myopia. Orbital MRI is useful in differentiating SES from HES.