Causes, background, and characteristics of binocular diplopia in the elderly

[Differential diagnosis of vertical strabismus in the elderly]

Due to the demographic changes, the number of older patients in ophthalmological practices and clinics, including those with diplopia, is increasing. Some of the patients report not only horizontally shifted double images but also or only vertically shifted double images. Vertical double vision often causes significant diagnostic problems for ophthalmologists. The underlying condition could urgently require further neurological, neuroradiological and/or internal medical diagnostics (e.g., skew deviation, 4th nerve palsy, myasthenia, Graves' orbitopathy, orbital floor fracture, orbital mass, 3rd nerve palsy) but the cause of diplopia could also be a condition in which overdiagnosis should be avoided (e.g., sagging eye syndrome, the prevalence of which significantly increases with increasing age; decompensated strabismus due to inferior oblique muscle overaction, myopia-associated vertical tropia). For some diseases early diagnosis is important for a better prognosis, e.g., tumor diagnosis, Graves' disease and stroke. This article presents an overview of the most common and most important differential diagnoses of vertical tropia in patients over 50 years of age.

Diplopia in the Younger Adult (≤65 Years Old) Compared With Older Adult (>65 Years Old) Population-Presentation, Progression, and Outcome

BACKGROUND

Despite the impact of new-onset diplopia on the quality of life, there are few studies concerning new-onset diplopia in seniors. This study aimed to describe the epidemiology, etiology, prognosis, and outcome of different treatments in the older adults compared with younger adult patients presenting with new-onset binocular diplopia.

METHODS

A retrospective chart review of patients ≥18 YO with new-onset binocular diplopia presenting between 2010 and 2021. Data collected included age at presentation, gender, duration of time since diplopia onset, imaging results, known trigger, etiology, treatment, and follow-up.

RESULTS

Two hundred ten patients were included. Of them, 75 patients were ≤65 YO (35.7%, the "younger adult group") and 135 > 65 YO (64.3%, the "older adults group"). The common etiology in both groups was neurogenic (54.7% ≤ 65 vs 62.2% >65, P = 0.29). Cranial nerve palsies were more commonly microvascular in the older adults (96.0% vs 74.1%, P = 0.005), whereas tumor-related cranial nerve palsies were more frequent in younger adults (14.81% vs 2.04%, P = 0.03). A restrictive etiology was observed in 20% of younger adult compared with 11.1% of older adults group (P = 0.08). Sagging eye syndrome (SES) was the second most common etiology in the older adults group at 11.9%, compared with 1.3% in the younger adult group (P = 0.01). Decompensated phoria/tropia appeared in 16% of younger adult group compared with 11.9% of older adults (P = 0.4), with an obvious trigger (mostly cataract surgery) in the latter (80% older adults vs 20% younger adults, P = 0.019). Positive imaging findings were found in 46.7% of patients ≤65 compared with 25.3% of >65 (P = 0.01) and complete spontaneous resolution of diplopia was noted in 32.1% of the older adults compared with 11.8% of younger adults (P = 0.003).

CONCLUSIONS

Neurogenic diplopia was the most common etiology for both groups, but is more prominent in the older adults. Noticeable findings in the older adults were SES diagnosis, identification of triggers for impaired fusion/diplopia, and a paucity of positive findings in imaging results. It is important to know these differences not only for managing seniors better, but also to minimize symptoms of binocular diplopia after lens-related procedures.

Demographic and clinical characteristics of age-related distance esotropia

BACKGROUND

Age-related distance esotropia (ARDE), is an acquired, small, comitant esodeviation that is greater at distance than at near. It occurs in older adult patients without a history of neurological event or prior strabismus. It has been observed more frequently in White adults than in other racial groups. The purpose of this study was to assess the demographic and clinical characteristics of patients with ARDE presenting at a tertiary neuro-ophthalmology clinic.

METHODS

In this retrospective study, ICD-9/10 (ICD-9 378.85 and ICD-10 H51.8) codes were used to identify all patients with ARDE from 2005 to 2020 seen in a single tertiary neuro-ophthalmology clinic. ARDE was defined as esotropia greater at distance than near with associated clinical signs of adnexal tissue laxity. Patients with history or findings compatible with other etiologies of strabismus, such as thyroid eye disease, neuromuscular disorders, sensory deviations, sudden onset of diplopia, and high myopia, as well as those with prior strabismus surgery, were excluded.

RESULTS

A total of 89 patients (59 females [66%]) met inclusion criteria. Mean patient age was 76.6 years. All patients were White except for a single patient of African descent. Mean follow-up time was 25.2 months. Mean esodeviation at distance on presentation was 6.6Δ. Of the 87 patients electing nonsurgical treatment, 80 achieved remission of diplopia symptoms with prism therapy alone. Of the 89 patients, 59 had no neuroimaging.

CONCLUSIONS

ARDE in our neuro-ophthalmology clinic population was diagnosed almost exclusively in older White adults. Prism therapy was effective for a majority of our patients.

Analysis of Facial Features of Patients With Sagging Eye Syndrome and Intermittent Exotropia Compared to Controls

PURPOSE

To compare the facial features of patients with sagging eye syndrome (SES) and other ophthalmic diseases, and to evaluate the diagnostic usefulness of facial features for SES.

DESIGN

Retrospective cross-section study.

METHODS

We evaluated frontal facial photographs of patients >60 years of age with SES and intermittent exotropia (IXT), and control patients who visited the ophthalmology outpatient clinics of 2 institutions between June 2020 and December 2021. Three ophthalmologists evaluated each eye for sunken upper eyelid, blepharoptosis, and baggy lower eyelid, using a scoring scale. The average scores for each parameter among the 3 groups were analyzed. Patients with glaucoma, visual acuity <16/20, SES with a vertical strabismus angle of ≥6 Δ, IXT that could not be maintained in the phoria position during photography, a history of previous oculoplastic or ophthalmic surgery, and use prostaglandin analogs for cosmetic purposes were excluded.

RESULTS

A total of 86 patients were included: 23 with SES, 28 with IXT, and 35 in the control group. All were Japanese. In all, 45 patients were male and 41 were female. The mean age was 72.7 ± 7.4 years. The sunken upper eyelid scores were significantly higher in the SES group than in the control and IXT groups (P < .001), whereas the baggy lower eyelid scores were significantly higher in the IXT group than in the control group (P < .05).

CONCLUSIONS

Age-related orbital connective tissue degeneration may manifest as SES in the upper eyelid and as IXT in the lower eyelid.

Visual disorders and mal de debarquement syndrome: a potential comorbidity questionnaire-based study

Aim: Mal de debarquement syndrome (MdDS) is a neurological condition characterized by a constant sensation of self-motion; onset may be motion-triggered (MT) or non-motion-triggered/spontaneous (NMT/SO). People with MdDS experience similar symptoms to those with vertical heterophoria, a subset of binocular visual dysfunction. Hence, we aimed to explore potential visual symptom overlaps. Methods: MdDS patients (n = 196) and controls (n = 197) completed a visual health questionnaire. Results: Compared with controls, the MdDS group demonstrated higher visual disorder scores and visual complaints. NMT/SO participants reported unique visual symptoms and a higher prevalence of mild traumatic brain injury. Conclusion: Our findings suggest visual disorders may coexist with MdDS, particularly the NMT/SO subtype. The difference in visual dysfunction frequency and medical histories between subtypes, warrants further investigation into differing pathophysiological mechanisms.

Comparison of subjective cyclofusion ranges and objective ocular torsion in normal participants according to age

PURPOSE

To investigate the relationship between subjective cyclofusion ranges and objective ocular torsion in normal participants according to age.

METHODS

This cross-sectional study included 120 participants aged ≥ 20 years with no ocular diseases. The subjective cyclofusion ranges were measured centrifugally and centripetally in the direction of excyclotorsion and incyclotorsion, respectively, concurrently with rotational diplopia production by rotation using synoptophore. Disc fovea angle (DFA) was defined as the angle formed by two lines: a line passing through the center of the optic nerve papilla and fovea and a horizontal line passing through the center of gravity of the optic papilla using fundus photographs.

RESULTS

The participants were aged 49.1 ± 17.7 years. The total cyclofusion centrifugal (sum of extorsion and intorsion) and centripetal ranges were 10.9 ± 2.2° and 7.2 ± 1.8°, respectively, both of which decreased in participants in their 60 s and 70 s (p < 0.01). The DFA was - 7.0 ± 3.4° in the right eye (- : excyclo, + : incyclo) and - 8.0 ± 3.2° in the left, which was associated with age (p < 0.001). The correlation between the DFA and centrifugal (r =  - 0.13, p = 0.16) and centripetal (r =  - 0.002, p = 0.99) cyclofusion ranges of extorsion was not significantly different. The centrifugal (r = 0.37, p < 0.001) and centripetal (r = 0.40, p < 0.001) cyclofusion ranges of intorsion were positively correlated.

CONCLUSION

Subjective cyclofusion ranges decreased in both extorsion and intorsion in the elderly. Objective ocular torsion showed excyclotorsion with age. When strabismus surgery is performed in elderly patients with torsional strabismus, the decrease in subjective cyclofusion ranges should be considered.

Etiology and Clinical Features of Diplopia in South China: Analysis of 303 Cases

Purpose

To provide a new classification system for diplopia and evaluate the etiology and clinical features of diplopia subtypes in south China.

Methods

In this retrospective study, all patients presenting with diplopia over the period from 2012 to 2014 in south China were reviewed. Patients were categorized into 3 groups according to their extraocular muscle (EOM) dysfunction: single EOM (sEOM), multiple EOMs (mEOMs), and a comitant strabismus group. Clinical data evaluated included age, sex, medical history, etiology and duration of diplopia, ocular alignment, and ocular motility.

Results

A total of 303 patients were enrolled. The most common type of EOM dysfunction was sEOM (158 cases, 52.1%), followed by mEOMs (n = 119, 39.3%), and finally the comitant strabismus group (n = 26, 8.6%). Overall, the most common cause of diplopia involved orbital diseases. Within the sEOM group, microangiopathy (n = 42, 26.6%) and trauma (n = 41, 25.9%) were the major etiologies, with the lateral rectus (LR) (n = 86, 54.4%) being the most frequently involved. There were 12 (4.0%) patients who were considered as nasopharyngeal carcinoma (NPC)-associated diplopia (10 caused by radiation neuropathy following radiation therapy). Thyroid associated ophthalmopathy (TAO, 56 cases, 47.1%) was the predominant etiology found in the mEOMs group. Acute acquired comitant esotropia (AACE, 14 cases, 53.9%) was the most common etiology in the comitant strabismus group.

Conclusions

This new classification system for assessing diplopia as based on EOM dysfunction represents an easy-to-follow approach that can be readily adapted for the clinical use. While microangiopathy and trauma represent common etiologies of diplopia, both orbital diseases and NPC-associated diplopia also warrant special attention when assessing diplopia within patients in south China.

Prevalence and clinical features of sagging eye syndrome in Korean patients

Purpose

To retrospectively analyze the relative frequency and describe the clinical features of sagging eye syndrome in Korean patients from a single center.

Methods

We retrospectively analyzed the medical records of patients with diplopia, aged over 40 years, who visited Chosun University Hospital from January 2018 to December 2020. The relative frequency of sagging eye syndrome was examined by classifying the cause of diplopia. Clinical features, such as age, sex, strabismus type, angle of deviation, treatment method, and prognosis were evaluated.

Results

A total of 128 patients were identified, of which 23 (18%) were diagnosed with sagging eye syndrome, including 12 male patients (52.2%) and 11 female patients (47.9%). Their mean age was 74.6 ± 7.6 years (range, 61–89 years), and all patients were over 60 years. Among the 62 patients with diplopia and age over 60 years, the relative frequency of sagging eye syndrome was 23 (37.1%), the highest among all age groups. Among the 23 patients with sagging eye syndrome, nine patients (39.1%) had only distance esotropia, with a mean distance esotropia value of 10.1 ± 8.6 prism diopters (PD) (range, 4–25 PD) at the first visit; nine patients (39.1%) had a combination of esotropia and vertical strabismus, with a mean esotropia value of 6.2 ± 4.8 PD (range, 2–12 PD) and a vertical angle of 4.7± 3.2 PD (range, 2–10 PD); and five patients (21.7%) had only vertical strabismus, with an average vertical strabismus angle of 3.3 ± 1.6 PD (range, 4–8 PD). Furthermore, 17 out of 23 patients (73.9%) used prism glasses, in whom the symptoms of diplopia disappeared. Finally, only three patients (13.0%) underwent surgery.

Conclusions

Sagging eye syndrome in Korean patients was identified in those over 60 years with a similar male-to-female ratio. Moreover, nonsurgical treatments, such as prism glasses, largely helped relieve the symptoms of sagging eye syndrome.

The Correlation between Hypertropia and Head Tilt in Congenital Unilateral Superior Oblique Muscle Palsy

Purpose:

To evaluate the correlation between the angle of deviation in different gazes and the amount of head tilt in patients with congenital unilateral superior oblique muscle palsy (SOP).

Methods:

This case series study was performed on 20 consecutive SOP patients with head tilt. Based on the Bielschowsky three-step test, the angle of deviation was measured in different gazes. Furthermore, the hypertropia difference between the two lateral gazes (gaze difference) and the two head tilt sides (bilateral head tilt difference) was calculated. For measuring head tilt, close-up pictures from 40 cm with a habitual abnormal head position were captured and analyzed by the Corel Draw X7 software.

Results:

The mean age of patients was 13 ± 9 years (range, 2.5–31 years). The mean angle of hypertropia in ipsilateral and contralateral head tilt was 24.5 Δ ± 7.1 Δ and 6.5 Δ ± 4.2 Δ, respectively (P < 0.001), and in ipsilateral and contralateral lateral gaze positions, it was 8.2 Δ ± 5.5 Δ and 22.5 Δ ± 6.1 Δ, respectively (P < 0.001). The mean of bilateral head tilt hypertropia difference was 18 Δ ± 5.3 Δ and gaze hypertropia difference was 14.3 Δ ± 6.16 Δ. There was a positive correlation between bilateral head tilt hypertropia difference and the amount of head tilt (R = 0.609, R² = 0.371, P = 0.004, the amount of head tilt = 0.39 × [Bilateral head tilt hypertropia difference] +1.77). The amount of head tilt also had a positive correlation with the gaze hypertropia difference (R = 0.492, R² = 0.242, P = 0.028, the amount of head tilt = 0.27 × [gaze hypertropia difference] +4.81).

Conclusion:

In SOP patients, the amount of head tilt had a positive correlation with bilateral head tilt hypertropia difference and also gaze hypertropia difference.

Acute-onset binocular diplopia in neurological unit: Aetiological factors and diagnostic assessment

OBJECTIVES

To investigate the aetiology of acute-onset binocular diplopia (AOBD) in neurological units and identify the key diagnostic procedures in this setting.

MATERIALS AND METHODS

Clinico-demographic data from patients hospitalized for AOBD from 2008 to 2019 were retrospectively reviewed. AOBD due to an underlying neurological disorder known to cause diplopia was addressed as secondary diplopia. Ophthalmoparesis plus was defined when subtle neurological signs/symptoms other than ophthalmoparesis were detected during neurological examination.

RESULTS

A total of 171 patients (mean age 57.6 years) were included in the study. A total of 89 subjects (52%) had an oculomotor disturbance consistent with sixth nerve palsy, and 42 (24.6%) showed multiple oculomotor nerve involvement. The most common cause of AOBD was presumed to be microvascular in 56 patients (32.7%), while a secondary aetiology was identified in 102 (59.6%). Ophthalmoparesis plus and multiple oculomotor nerve involvement significantly predicted a secondary aetiology in multivariable logistic regression analysis. Brain CT was never diagnostic in isolated ophthalmoparesis. A combination of neuroimaging examinations established AOBD diagnosis in 54.9% of subjects, whereas rachicentesis and neurophysiological examinations were found to be performant in the remaining cases.

CONCLUSIONS

AOBD may herald insidious neurological disease, and an extensive diagnostic workup is often needed to establish a diagnosis. Neurological examination was pivotal in identifying patients at higher risk of secondary aetiology. Even in cases of apparently benign presentation, a serious underlying disease cannot be excluded. Brain MRI was found to perform well in all clinical scenarios, and it should be always considered when managing AOBD.

Sagging eye syndrome

The pulley is the functional origin of the extraocular muscles and prevents their dislocation from the muscle cone. The pulley degenerates with age and may progress to cause the sagging eye syndrome (SES). Divergence paralysis, a type of distance esotropia, occurs when the lateral rectus muscle pulley and lateral rectus-superior rectus (LR-SR) band show degenerated symmetry OU. Cyclovertical strabismus of a small angle occurs when the lateral rectus muscle pulley and LR-SR band show degenerated asymmetry OU. Patients with SES have distinctive features, such as baggy eyelids, deep superior sulcus deformity, and aponeurotic ptosis. SES is the leading cause of non-paralytic diplopia, and its rate increases with age, with 60% of the patients being women. One-third of the cases of SES are distance esotropia of 9Δ on average, and two-third of the cases are small-angle hypertropia of 4Δ on average. Diplopia is cured with surgery, and each case needs to be differentiated from the heavy eye syndrome for diagnosis and treatment.

Characteristics of diplopia in a pediatric population

PURPOSE

To evaluate the characteristics of diplopia in children at a single tertiary eye care center.

METHODS

The medical records of patients with diplopia onset at age 18 years or younger presenting during the period 2015-2018 were reviewed retrospectively. Demographic information, clinical characteristics, diagnoses, treatment, and outcome data were collected. The exact χ² test was used to compare groups and select post hoc analyses were performed using the Fisher exact or exact χ² tests.

RESULTS

A total of 244 patients (average age, 12.2 years at presentation) were included. The most common clinical diagnoses were nonparalytic strabismus (49.2%), trauma (9.4%), and cranial nerve palsies (9%). There was no statistically significant difference in median age of diplopia onset in those with nonparalytic strabismus, cranial nerve palsies, and vision- or life-threatening conditions. There was a statistically significant difference in timing of onset of diplopia at presentation in vision- or life-threatening conditions compared to nonparalytic strabismus (P < 0.0001) and cranial nerve palsies (P = 0.01) and for neurologic symptoms in vision- or life- threatening conditions compared to nonparalytic strabismus (P = 0.032) and cranial nerve palsies (P = 0.0051). In patients with more than one neurologic symptom, the majority (58.3%) had a vision- or life-threatening condition. Initial interventions included observation (28.7%), prisms (18.4%), updating refractive correction (14.3%), and strabismus surgery (11.1%). In patients with follow-up data, 5.3% had resolution of diplopia prior to their clinic visit, and 46.6% had resolution after initial intervention.

CONCLUSIONS

In our study cohort, most children who presented with diplopia had nonemergent conditions. In those with life-threatening conditions, diplopia tended to have an acute onset and associated neurologic signs and visual symptoms.

Functional Anatomy of Muscle Mechanisms: Compensating Vertical Heterophoria

PURPOSE

Magnetic resonance imaging (MRI) of extraocular muscle function was used to evaluate the role of newly recognized mechanisms underlying compensation of large heterophoria by vertical fusional vergence (VFV).

DESIGN

Prospective case series.

METHODS

At one academic center, 8 adults with large hyperphoria and supernormal VFV underwent MRI during monocular and binocular fixation of a centered, near target. Contractility of the rectus and superior oblique (SO) extraocular muscles in hypertropic and hypotropic eyes was determined from changes in posterior partial volume (PPV).

RESULTS

Five of 8 patients could sustain binocular fusion in the scanner. In those patients, VFV corrected approximately 5-degree misalignment, approximately 5-fold greater than normal VFV. Vertical strabismus was compensated mainly by significant contractility of the lateral more than the medial compartment of the inferior rectus (IR) in both eyes (P < .005). The superior rectus (SR) and inferior oblique muscles had no significant contractile contribution, although the hypotropic SO relaxed significantly. The IR lateral compartment and SR medial compartment significantly co-relaxed when binocular fusion was attained from monocular target fixation (P < .01).

CONCLUSIONS

Although VFV protects patients from small muscle imbalances over the lifespan, even enhanced VFV may be inadequate to avert diplopia. Compensation of hyperphoria by VFV is accomplished mainly by IR muscle relaxation in the hypotropic eye, principally in its selectively innervated lateral compartment, whereas the SO contributes little. Fusion involves compartmentally selective co-relaxation in hypotropic eye vertical rectus muscles. Taken together, these overall findings suggest a physiologic basis to prefer therapeutic surgical weakening of the medial IR in the hypotropic eye.

Ocular abnormal head posture: A literature review

Purpose:

Methods:

Results:

Conclusion:

Differential Diagnosis of Acquired Esotropia in the Elderly

AIM

To provide an overview of the differential diagnoses of acquired esotropia that occur in the elderly and to facilitate their differentiation in everyday clinical practice.

METHODS

The data of all patients who presented in our outpatient university department for strabology and neuroophthalmology from March 2014 to October 2015 due to esotropia with diplopia with onset after age 50 were evaluated retrospectively. Exclusion criteria were a known strabismus before the age of 50 and/or vertical deviations in the primary position. Anamnestic characteristics, accompanying findings and orthoptic parameters, were analysed.

RESULTS

85 patients were included in the study, 42 of them female and 43 male. The following diagnoses were made: abducens nerve palsy (n = 34, 3 of them both sides), esotropia due to myopia magna (n = 12), esotropia with accompanying neurological symptoms (n = 6) and other etiology (n = 5). In 4 cases, the diagnosis was still unclear at the end of the study. In 24 patients, none of the above diagnoses existed and the diagnosis of "sagging eye syndrome" (ETSAG) was made. The abducens nerve palsy typically showed a sudden onset of double vision, slowed abduction saccades and asymmetrical abduction ability. With unilateral abducens nerve palsy, the esotropia increased continuously from the view to the unaffected side through the primary position to the view to the affected side. Patients with ETSAG and myopia-associated esotropia, on the other hand, reported a gradual onset of double vision, showed normal abduction saccades and a slightly reduced abduction ability. The squint angle often increased slightly to both sides. Esotropia with accompanying neurological symptoms was rare and was seen in various underlying diseases.

CONCLUSIONS

The kind of onset of the double vision, the quality of the saccades, the incomitance pattern and the ability to abduct are important parameters for the etiological assignment of an esotropia in the elderly. The characteristics of the individual diagnoses are described and differential diagnostic aspects are discussed.

Standard coronal orbital magnetic resonance imaging is an effective technique for diagnosing sagging eye syndrome

PURPOSE

The aim of this study was to determine the importance and efficacy of the standard coronal magnetic resonance imaging (MRI) analysis method for the correct clinical diagnosis of the sagging eye syndrome.

METHODS

This retrospective study evaluated the standard coronal MRI efficacy by comparing the positions of the orbital pulleys and extraocular muscles in patients with sagging eye syndrome as well as controls. The participants included 50 patients with sagging eye syndrome (aged 73.3 ± 6.7 years) and 17 age-matched control patients (aged 70.9 ± 4.3 years) that presented optic neuritis. The participants were classified into groups of age-related distance esotropia and cyclo-vertical strabismus. Lateral rectus-superior rectus band condition, lateral rectus vertical angle, lateral rectus tilting angle, and superior rectus-lateral rectus displacement angle were examined.

RESULTS

The lateral rectus-superior rectus band was more frequently disordered in the two groups than that in the control. The lateral rectus vertical and tilt angle examinations exhibited a significant difference in the age-related distance esotropia [(- 13.3 ± 10.9°, p < 0.05) and (- 24.1 ± 9.5°, p < 0.01)] and cyclo-vertical strabismus [(- 11.9 ± 6.9°, p < 0.05) and (- 20.8 ± 9.3°, p < 0.01)] groups compared with those in the control group [(- 7.5 ± 5.1°) and (- 12.2 ± 9.1°)]. The superior rectus-lateral rectus displacement angle did not present a significant difference between the patients and control groups.

CONCLUSIONS

Patients with sagging eye syndrome exhibited disordered orbital pulley and extraocular muscle malposition, as determined by standard coronal magnetic resonance imaging, indicating the effectiveness of the procedure for diagnosing sagging eye syndrome.

The Adnexal Phenotype of Sagging Eye Syndrome

PURPOSE

The sagging eye syndrome (SES) describes a condition that presents with age-related distance esotropia, alone or in combination with cyclovertical strabismus. It has a high prevalence in those aged over age 40 years presenting with binocular diplopia. The authors aim to characterize the adnexal phenotype of those who have been diagnosed with SES.

METHODS

In this case-control study, patients were recruited from a prospectively maintained clinical and imaging database. The inclusion criteria required that subjects be above the age of 18 years and have a diagnosis of age-related distance esotropia or cyclovertical strabismus due to SES. Age-matched controls were selected from a validated database of normal faces that were not affected by any medical or surgical conditions. The margin to reflex distance from the upper eyelid, margin to reflex distance to the lower eyelid, the tarsal platform show, intracanthal distance, and inferior scleral bow were measured. Differences in the measurements between patients and controls were analyzed using a 2-tailed Student t tests.

RESULTS

Twenty-two patients and 22 age-matched controls (11 males and 11 females per group) were included for study. Females with SES had a significantly greater margin to reflex distance to the lower eyelid and inferior scleral bow, with a lower tarsal platform show and margin to reflex distance from the upper eyelid than controls. Male patients with SES had a significantly greater margin to reflex distance to the lower eyelid and inferior scleral bow with a significantly lower margin to reflex distance from the upper eyelid and tarsal platform show than controls.

DISCUSSION

This study supports the growing body of evidence which suggests that the SES represents age-related mechanical changes in the orbit that manifest as a specific adnexal phenotype.

Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia

PURPOSE

Sagging eye syndrome (SES), horizontal and/or vertical strabismus caused by orbital connective tissue degeneration, was first defined 10 years ago. This study investigated SES and other causes of acquired binocular diplopia in adults presenting to a single institution since the description of SES.

DESIGN

Retrospective observational case series.

METHODS

Medical records were reviewed of all new patients over the age of 40 who presented to the Stein Eye Institute with binocular diplopia between January 2015 and December 2018. Clinical causes of diplopia were tabulated in patients grouped by age and sex. In patients with SES, we tabulated binocular alignment, types of treatment, and surgical outcomes.

RESULTS

There were 945 patients of mean age 66.5 years, of whom 514 (54.4%) were female. The most common cause of diplopia was SES (31.4%). The 297 patients with SES were older at 71.2 years (P < 0.0001) and more predominantly female at 59.9% than other patients (52.0%; P = 0.023). The relative proportion of SES patients among all diplopic patients increased with age from 4.7% under age 50 years to 60.9% over the age of 90. Age-related distance esotropia was present in 35% and cyclovertical strabismus in 65% of cases of SES. Strabismus surgery was performed in 50% of cases of SES. Mean esotropia at distance decreased from 6.9 ± 0.7Δ preoperatively to 0.3 ± 0.3Δ postoperatively. Preoperative hypertropia decreased from 3.0 ± 0.3Δ to 0.7 ± 0.2Δ postoperatively. Surgery resolved diplopia in all cases.

CONCLUSIONS

It is important to recognize that SES is a very common cause of adult binocular diplopia.

Acute onset binocular diplopia: a retrospective observational study of 100 consecutive cases managed at a tertiary eye centre in Saudi Arabia

OBJECTIVE

To evaluate the demography, aetiology and clinical course of acute onset binocular diplopia (AOBD) in patients presented as emergency and managed at the neuroophthalmology clinic of a tertiary eye care centre in Saudi Arabia.

PATIENTS AND METHODS

A retrospective review of the medical records of 100 consecutive patients who attended the emergency department of Dhahran Eye Specialist Hospital with isolated, AOBD. The exclusion criteria were: (a) monocular diplopia, (b) binocular diplopia accompanied with neurological deficits other than ocular muscles dysfunction and (c) thyroid eye disease. All patients were followed until resolution of the diplopia or onward referral to another specialty for further management.

RESULTS

Male:female ratio was 2:1. Median age of the cohort was 56 years (range 18-90 years). Associated nerve palsy included: abducens nerve (n = 57 patients), oculomotor (n = 32 patients) and trochlear nerve (n = 3 patients). Microvascular ischaemia and ocular myasthenia gravis were two most common pathogenic mechanisms. AOBD resolved spontaneously in 98% of patients.

CONCLUSION

AOBD, though an alarming and distressing condition, carries reassuringly good prognosis in majority of patients. High risk factors for vascular disease in Middle-Eastern population are reflected in microvascular aetiology as the major cause.