Long-term Surgical Outcomes in the Sagging Eye Syndrome

Inferior displacement of the lateral rectus muscle insertion in exotropia with mild V-pattern or vertical deviation

BACKGROUND

To describe clinical features and intraoperative findings of the patients with exotropia who presented mild V-pattern or vertical deviation, and to investigate the surgical outcomes of anatomical relocation of inferiorly displaced lateral rectus (LR) muscle insertion.

METHODS

Detailed ophthalmological evaluations were obtained in 42 consecutive patients, and the horizontal rectus muscle insertions were detected intraoperatively. The displaced insertion of LR muscle was corrected accompanied with classic recession-resection procedure.

RESULTS

The inferiorly displaced LR muscle insertions were detected in 19 patients (Group A), while the remaining 23 patients (Group B) had normal insertions. The mean distance of displaced insertion from the normal position was 2.92 ± 1.05 mm (range: 1.0-4.0). Mild V-pattern was more common in Group A (78.9%, 15/19) than Group B (47.8%, 11/23), and the magnitude of V-pattern in Group A (6.16 ± 3.91 PD) was also greater than Group B (3.43 ± 3.92 PD). The fundus extorsions of the affected eyes (9.68 ± 4.77 °) were greater than the contralateral eyes (5.91 ± 5.82 °) in Group A. At the 2 months follow-up, mild V-pattern and mild vertical deviation were corrected by upward transposition. The significant correlations were identified between the pre-operative misalignments and the amounts of misalignments correction.

CONCLUSIONS

Nearly half of the cases with mild V-pattern or vertical deviation resulted from the inferiorly displaced LR muscle insertion, so the intraoperative exploration of the LR muscle insertion is strongly suggested. Upward transposition may effectively correct both the mild V-pattern and vertical deviation.

Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye

PURPOSE

To describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with LR myopexy.

METHODS

A retrospective study of 9 cases between 2017-2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered Successful if the diplopia was improved or eliminated and a final vertical deviation (VD) ≤5 prism diopters (PD).

RESULTS

The mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33 PD (SD 3.16), and the mean final VD 3.44 PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another three. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation ≤5 PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (three with macular pathology).

CONCLUSION

Supra-equatorial displacement with LR myopexy for treatment of myopic sagging/heavy eye, is a therapeutic option if hypotropia is less than 12 PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent.

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.

Masquerading Superior Oblique Palsy

PURPOSE

We evaluated patients with hypertropia compatible with a diagnosis of superior oblique (SO) palsy to ascertain whether the 3-step test (3ST) can distinguish SO atrophy characteristic of trochlear nerve pathology from masquerading conditions.

DESIGN

Prospective cross-sectional study.

METHODS

In an academic practice, we performed quasi-coronal plane, surface coil magnetic resonance imaging in 83 patients clinically diagnosed with SO palsy. We evaluated alignment, SO cross-sectional area, SO contractility, and rectus muscle pulley positions.

RESULTS

A total of 57 patients with mean age 39 years (SD = 21 years) had unilateral SO palsy manifested by SO atrophy (22 congenital and 35 acquired). There was normal SO size in 26 patients with an average age of 39 years (SD =16 years) considered masquerades (8 congenital and 18 acquired). Maximum palsied SO cross-section averaged 9.5 ± 3.8 mm2, less than 18.4 ± 3.9 mm2 contralaterally (P < 10-24). In masquerades, maximum hypertropic SO cross-section was 20.7 ± 3.1 mm2, which was not different from the hypotropic SO or the contralesional muscle in SO palsy. Head tilt testing in masquerades was indistinguishable from SO palsy. In SO palsy, central hypertropia averaged 13.2 ± 9.4Δ, increasing to 21.1 ± 14.0Δ in ipsilateral tilt, and decreasing to 4.3 ± 5.3Δ in contralateral tilt. In masquerades, central hypertropia averaged 13.1 ± 8.7Δ, and was 17.7 ± 11.1Δ in ipsilateral and decreasing to 4.9 ± 5.1Δ in contralateral tilt. Upright hypertropia was larger at 17.7 ± 9.9Δ in congenital than 12.0 ± 8.4Δ in acquired SO palsy (P = 0025) but was indistinguishable from congenital masquerades. Contractile change in SO cross-section was bilaterally similar in masquerades. Relevant coordinates of rectus pulleys were similar bilaterally in masquerades.

CONCLUSIONS

The 3ST pattern characteristic of unilateral SO palsy may be mimicked in all respects by masquerades.

Can Binocular Alignment Distinguish Hypertropia in Sagging Eye Syndrome From Superior Oblique Palsy?

Purpose

Although the three-step test (3ST) is typically used to diagnose superior oblique palsy (SOP), sagging eye syndrome (SES) has clinical similarities. We sought to determine if alignment measurements can distinguish unilateral SOP from hypertropia in SES.

Methods

We studied hypertropic subjects who underwent surface-coil magnetic resonance imaging (MRI) demonstrating either SO cross-section reduction indicative of congenital or acquired palsy (SOP group) or lateral rectus muscle sag (SES group). Alignment was measured by Hess screen and prism-cover testing. Multiple supervised machine learning methods were employed to evaluate diagnostic accuracy. Rectus pulley coordinates were determined in SES cases fulfilling the 3ST.

Results

Twenty-three subjects had unilateral SOP manifested by SO atrophy. Eighteen others had normal SO size but MRI findings of SES. Maximum cross-section of the palsied SO was much smaller than contralaterally and in SES (P < 2 × 10-5). Inferior oblique cross-sections were similar in SOP and SES. In both SOP and SES, hypertropia increased in contralateral and decreased in ipsilateral gaze and was greater in ipsilateral than contralateral head tilt. In SES, nine subjects (50%) fulfilled the 3ST and had greater infraplacement of the lateral than medial rectus pulleys in the hypotropic orbit. Supervised machine learning of alignment data distinguished the diagnoses with areas under the receiver operating curves up to 0.93, representing excellent yet imperfect differential diagnosis.

Conclusions

Because the 3ST is often positive in SES, clinical alignment patterns may confound SES with unilateral SOP, particularly acquired SOP. Machine learning substantially but imperfectly improves classification accuracy.

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.

Vertical Comitance of Hypertropia in Congenital and Acquired Superior Oblique Palsy

BACKGROUND

Ivanir and Trobe have claimed that hypertropia (HT) that is greater in upgaze than downgaze, or equal to it, is characteristic of decompensated congenital superior oblique (SO) palsy and never present in ischemic, traumatic, or tumorous SO palsy. The reliability of this claim was tested in patients with SO palsy confirmed by MRI demonstration of subnormal ipsilesional SO size.

METHODS

Quasi-coronal, surface coil MRI was performed in target-controlled central gaze to identify patients with a unilateral reduction in SO cross section indicative of palsy. Nine patients gave an unequivocal history or had markedly increased vertical fusional amplitudes indicative of congenital onset (mean age 38 ± 16 years, SD). Seven patients had unequivocal acquired onset (age 47 ± 14 years and symptom duration 5.4 ± 4.8 years), including 2 with demonstrated trochlear Schwannoma and 5 with onset after severe head trauma. Fifteen patients had gradually progressive onset unequivocally not congenital yet not associated with any identifiable precipitating event (age 52 ± 20 years and symptom duration 13 ± 14 years).

RESULTS

Maximum SO cross section averaged 8.6 ± 3.9 mm2 in congenital palsy, not significantly different from 11.3 ± 3.5 mm2 in acquired palsy (P = 0.08) either unequivocally or progressively acquired, but significantly less than about 19 mm2 contralesionally in SO palsy (P < 10-4). Although mean central gaze HT was greater at 20.6 ± 8.0Δ in 9 cases of congenital than that in 22 acquired cases at 11.4 ± 6.8Δ (P = 0.002), HT was 8.4 ± 16.3Δ less in upgaze than downgaze in congenital SO palsy and 3.7 ± 11.2Δ less in acquired SO palsy. In congenital palsy, 33% of patients had HT greater in upgaze than downgaze while in 67% HT was greater in downgaze (by up to 42Δ). In acquired SO palsy, HT was greater in upgaze than downgaze or equal to it in 8 cases (36%, P = 0.87, X2). In acquired SO palsy, HT was greater in upgaze than downgaze in 37% and greater in downgaze than upgaze in 59% of cases. The HT was equal in upgaze and centralgaze in no congenital and 3 acquired cases of SO palsy. Trends were similar in unequivocal acquired and progressive acquired (noncongenital) SO palsy (P > 0.4).

CONCLUSIONS

Hypertropia is not characteristically greater in upgaze than downgaze in congenital SO palsy proven by SO atrophy on MRI. In fact, average HT is greater in downgaze than upgaze in both acquired and congenital palsy, sometimes strikingly so in the latter. The finding of HT greater in upgaze than downgaze, or equal to it, does not reliably indicate that SO palsy is congenital, nor does maximum SO cross section.

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.

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.

Characterization of the position of the extraocular muscles and orbit in acquired esotropia both at distance and near using orbital magnetic resonance imaging

PURPOSE

Age-related distance esotropia (ARDE) involves acquired esotropia at distance and phoria at near. However, distance-independent esotropia (DIE) exists esotropia both at distance and near. Thus, we examined the orbital magnetic resonance imaging (MRI) findings for DIE to assess differences in its characteristics.

METHODS

This study was a retrospective case-control study. We evaluated the efficacy of the standard coronal MRI in patients with acquired esotropia and control patients with optic neuritis. Cases with strabismus in the control group were excluded. DIE was defined as having esotropia both at distance and near, and an angle of more than 10 prism diopters at near. The condition of the lateral rectus-superior rectus band, position of rectus muscles, and the volume ratio of the globe to the whole orbit (G/WO) were examined.

RESULTS

The DIE group consisted of 12 eyes of 6 patients (77.3±7.7 years); ARDE group, 38 eyes of 19 patients (73.1±6.8 years); and control group, 34 eyes of 17 patients (70.9±4.3 years). The ratio of abnormality of the lateral rectus-superior rectus bands was higher in the DIE and ARDE groups than in the control group (p<0.01). The vertical angle of the lateral rectus deviated downwards in the control (-7.5±5.1°), ARDE (-12.2±9.1°), and DIE groups (-18.8±5.7°) (p<0.05). The tilting angle of the lateral rectus was tilted temporally in the control (-12.2±9.1°), ARDE (-20.0±8.6°) and DIE groups (-28.6±5.4°) (p<0.01). G/WO was higher in the DIE (0.28±0.01) and ARDE groups (0.27±0.02) compared to the control (0.25±0.03) group (p<0.01).

CONCLUSION

In comparison with the ARDE and control groups, the DIE group presented with abnormalities of the lateral rectus-superior rectus band, malposition of the lateral rectus, and differences in the G/WO. The DIE group showed a more severe form of ARDE.

Compartmental Strabismus

Recent reports confirm innervational compartments of select rectus extraocular muscles as well as the superior oblique.¹ Histopathological and orbital imaging studies demonstrate well defined compartmental innervation of the horizontal rectus muscles with less differentiation in the vertical rectus muscles. Acquired vertical misalignment not associated with cyclovertical muscle dysfunction has been associated with horizontal rectus muscle compartment dysfunction. Pattern and other forms of strabismus have been associated with segmental or compartmental abnormal innervation of the extraocular muscles. Taking advantage of segmental function and innervation, selective weakening and strengthening procedures have been used to treat patients with incomitant near/distance disparities, incomitant vertical and torsional strabismus, and patients with A- and V-pattern strabismus.

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.

Lateral rectus sag and recurrent esotropia in children

PURPOSE

To describe the clinical and intraoperative findings of an anatomic abnormality in children that resembles sagging eye syndrome documented in older adults and that led to recurrent esotropia after surgery.

METHODS

We reviewed records of 4 patients with substantial recurrent esotropia after bilateral medial rectus recession who required subsequent surgery combining lateral rectus resection with correction of the anatomic abnormality affecting the lateral rectus path. Binocular alignment was sequentially analyzed.

RESULTS

Three young patients (2-3 years of age) presented with acquired esotropia but minimal cycloplegic refractive error. The fourth patient (14 years of age) initially had moderate hyperopia and partially accommodative esotropia, but subsequently developed marked bilateral overelevation in adduction. In all patients, esotropia recurred within 5^Δ of preoperative deviation after bilateral medial rectus recession. Surgical exposure demonstrated that bilateral lateral rectus paths were inferiorly displaced more than one-half tendon width from their normal paths near the globe's equator, despite normal scleral insertions. Equatorial myopexy and lateral rectus resection resulted in stable esotropia correction.

CONCLUSIONS

Lateral rectus sag in children creates a type of acquired esotropia and overelevation in adduction poorly responsive to standard surgery but correctable with lateral rectus resection and equatorial myopexy that normalizes the lateral rectus path through permanent scleral fixation.