heavy eye/ sagging syndrome

Question 1

Presentation

Answer 1

Progressive, large angled Esotropia and hypotropia with diplopia (bigger in the distance as they have restricted abduction) - ductions = versions as it is mechanical

Limitation of abduction and elevation

Increased axial length - muscles have to stretch more to around the eye

High Myopia >25Dioptres

Ptosis/Pseudoptosis in presence of Hypotropia

Pseudo Proptosis due to High Myopia - worried about unilateral proptosis, is it myopia or due to something pushing the eye forward

Question 2

Aetiology

Answer 2

Orbital connective tissue degeneration

Myopic globe elongation causes the posterior globe to prolapse from the muscle cone

Inferior displacement of the horizontal rectus pulleys in elderly patients - SR AND LR UNDERACTION

MRI studies have shown thinning of the ligament band between the Lateral rectus and Superior rectus

Question 3

Differential diagnosis
Heavy vs Sagging

Answer 3

sagging Eye Syndrome can occur in elderly hyperopic patients - age related problem

• Minus Myopic elongation

Sagging Eyes are associated with Ptosis, > Hypotropia and <Esotropia

Question 4

Management

Answer 4

initially Conservative with Prisms/Occlusion

• Surgery is the best option but takes time
• MR Recession +/- LR Resection may not be enough and won’t correct the Hypotropia

Question 5

Other differentials

Answer 5

• Graves Orbitopathy
• Myasthenia Gravis - checking for fatigue
• Neurogenic Palsies - e.g. 6th, shouldn’t see vertical diplopia, ductions should be greater than versions as it is neurogenic
• Age related Distance Esotropia