Age-related Distance Esotropia Research Articles

Demographic and clinical characteristics of age-related distance esotropia

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. 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. 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. 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.

Prevalence and clinical characteristics of age-related distance esotropia

ABSTRACT Age-related distance esotropia (ARDET) is characterized by an esodeviation greater at distance than near in older aged patients and generally managed with prism spectacles or surgery. The purpose of this study is to describe the prevalence, clinical characteristics, and natural history of age-related distance esotropia in a defined population. The medical records of all adult (≥19 years of age) residents of Olmsted County, Minnesota, diagnosed with an esodeviation at least 2 prism diopters (PD) greater at distance than near, from 1 January 1985, through 31 December 2004, were retrospectively reviewed. Seventy-three (9.7%) of 751 new cases of adult-onset strabismus were diagnosed with age-related distance esotropia during the 20-year period. The mean age of onset was 70 years (range, 19 to 93 years) and 48 (65.8%) were female (p = .007). The mean angle of esodeviation was 7.6 (range, 2 to 20) prism diopters (PD) at distance and 0.4 (range, 10 PD of XT to 12 PD of ET) PD at near. The Kaplan–Meier rate of progression, as defined by a ≥ 6 prism diopter (PD) increase in esotropia, was 50% by 15 years after diagnosis. Half of the patients had hypertension, while one-third had coronary artery disease or other cardiac comorbidities. Age-related distance esotropia comprised 1 in 10 adults with new-onset strabismus in this population and was significantly more common among women. Hypertension and cardiovascular disease may be risk factors for this form of strabismus, and approximately half of the patients worsened over a 15-year period.

Objective excyclotorsion in age-related distance esotropia

ABSTRACT Age-related distance esotropia (ARDE) is thought to be caused by sagging eye syndrome. Sagging of the lateral rectus derives from the naturally occurring aging process and induces excyclotorsion of the eye. To date, no study has compared the cyclodeviation in ARDE with that in the age-matched individuals without strabismus. This study aimed to measure the objective cyclotorsion on fundus photographs of ARDE patients and compare the findings with those for normal age-matched individuals. Objective cyclotorsion was measured by determining the disc-to-fovea angle (DFA) on fundus photographs, which were obtained from two groups: 38 consecutive patients with ARDE (age, 74.1 ± 7.9 years), 76 normal age-matched controls (age, 73.9 ± 8.1 years). DFA in ARDE patients was not different from that in the control group (Welch’s t-test: ARDE vs Control, right eye; 7.7° ± 2.9° vs 6.8° ± 3.9°, p = .18. Left eye; 10.0° ± 4.5° vs 9.4° ± 3.6°, p = .54. Sum of both eyes; 17.6° ± 5.8° vs 16.2° ± 4.7°, p = .21). These findings suggest sagging of the lateral rectus is not the sole cause of ARDE. Another aging-related factor, such as decreased phoria adaptation, might also be responsible for ARDE.

Призматический этап лечения пациентов с возрастной дистанционной эзотропией

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

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. 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 ± 6.7years) and 17 age-matched control patients (aged 70.9 ± 4.3years) 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. 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. 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.

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. 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. 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. 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

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

Magnetic resonance imaging findings of age-related distance esotropia in Japanese patients with high myopia.

This study aimed to investigate the characteristics of the extraocular muscles and the orbital connective tissue pulleys in Japanese patients with age-related distance esotropia (ARDE) and high myopia using magnetic resonance imaging (MRI). This was a retrospective case-series study. High-resolution coronal MRI scans of 12 orbits were obtained in 6 patients with ARDE and high myopia (age range: 51-69years). We analyzed the images to determine the positions of the rectus muscle pulleys relative to the center of the globe, the integrity of the lateral rectus-superior rectus muscle (LR-SR) band, and the LR angle (the angle between the major axis of the LR and the vertical plane). The distance esotropia ranged from 4 to 25∆, and 3 cases exhibited vertical deviations. The mean (±standard deviation (SD)) axial length was 28.5 (±1.6) mm. The mean positions of the medial rectus muscle pulley and LR pulley were 1.3mm inferior and 1.4mm inferior, respectively, to those seen in the normal control group in our previous study (P = 0.002 and P = 0.05, respectively). All 12 orbits had abnormal elongated LR-SR bands, and 8 orbits (67%) displayed ruptured LR-SR bands. The LR angle (mean±SD; 18.8° ± 8.5°) increased significantly with the inferior displacement of the LR pulley (R2 = 0.77, P = 0.0002). Inferior displacement of the LR pulley and abnormal LR-SR bands were seen in Japanese ARDE patients with high myopia, as was found in ARDE patients without high myopia. The LR angle might be useful for judging the degree of LR pulley displacement.

Long-term evolution of age-related distance esotropia

To evaluate the evolution of horizontal deviation and fusional amplitudes both at distance and at near in patients with age-related distance esotropia (ARDET). The medical records of consecutive patients diagnosed with ARDET between January 2008 and March 2016 were reviewed retrospectively. Patients with at least 60months' follow-up were eligible for inclusion. Horizontal deviation, fusional convergence amplitude, and fusional divergence amplitude both at distance and at near were compared. Of 131 cases reviewed, 31 patients were identified for inclusion. Median age at diagnosis was 73years. Median distance esodeviation was 6Δ esotropia at initial examination (range, 2Δ-12Δ esotropia) and 8Δ eostropia at final examination (range, 2Δ-25Δ esotropia). Median near deviation was orthophoria at initial examination (range, 10Δ exophoria to 8Δ esophoria) and 4Δ esophoria at final examination (range, 4Δ exophoria to 14Δ esophoria). Median fusional divergence amplitude at distance was 4Δ at initial and at final examinations. At near, median fusional divergence amplitude was 8Δ at initial and at final examinations. Median fusional convergence amplitude at distance was 14Δ at initial examination and 12Δ at final examination. At near, median fusional convergence amplitude was 26Δ at initial and at final examinations. Base-out prisms were prescribed in all patients. In 23 patients the prism correction gradually increased. Strabismus surgery was performed in 3 patients. Our patients with ARDET experienced a slight increase in distance esodeviation (P<0.001), whereas no significant change in fusional amplitudes was observed over time (P≥0.05).

Advances in research of divergence insufficiency

Divergence insufficiency is acquired esotropia at distance fixation with symptomatic uncrossed diplopia but fusion at near. It can be divided into two forms: primary isolated form and secondary form associated with neurologic abnormalities, also called divergence palsy. The clinical features of divergence insufficiency include small esotropia only at distance but orthotropia or small esophoria at near, comitant deviation at lateral gaze, reduced divergence fusion, full abduction and normal saccadic velocities in abduction. Primary divergence insufficiency is a benign condition predominantly occurring in adults older than 50 years. Recently, studies on the etiology of age-related distance esotropia, also called sagging eye syndrome, have demonstrated that the degenerative changes of orbital tissue could induce the inferior displacement of the inferior rectus pulley, different from the neurological etiology in abducens nerve palsy and secondary divergence insufficiency. The treatment goal is to relieve diplopia. Both prism and regular surgeries including medial rectus recession and lateral rectus resection are effective. Some unusual surgeries have been applied in divergence insufficiency, but further investigations with large samples are needed. The recent research advances in the etiology, diagnosis, differential diagnosis and treatment of divergence insufficiency are reviewed in this article. (Chin J Ophthalmol, 2017, 53: 552-556).

Orbital magnetic resonance imaging is useful in age-related distance esotropia

PurposeTo describe findings for orbital magnetic resonance imaging (MRI) in patients with age-related distance esotropia (ARDE). MethodsWe compared 31 orbital MRI from patients with ARDE (77±7 SD years) with 2 control groups: 32 orbits from individuals aged 18–50 years (33±8 SD years) and 16 orbits from individuals aged >60 years (77±7 SD years). MRI scans were acquired using 3D fast field echo in T1 sequence without fat saturation. Exclusion criteria for all groups were neurological or thyroid disease and a relevant ophthalmological history (e.g., high myopia, diplopia from another etiology, complicated cataract surgery, etc.). Muscle displacement and characteristics of the lateral rectus–superior rectus (LR–SR) intermuscular band were analyzed. ResultsThe analysis of the muscles and angles revealed a series of statistically significant differences (p<0.07) between the groups. Subjects with ARDE had LR pulley positions 1.32±0.19mm lower than in younger controls, and the medial rectus (MR) pulley positions were 0.68±0.19mm lower than in younger. Older controls had LR and MR pulley positions 0.85±0.20mm and 0.49±0.23mm lower than in younger. ARDE subjects had LR pulley positions 0.46±0.26mm lower than in older control group. The LR–SR band was absent in 35.5% of ARDE patients and in 12.5% of older control group (p=0.168). ConclusionsMRI showed that displacements of LR and LR–SR band degeneration could facilitate the diagnosis of patients with ARDE.

Surgical Treatment of Adult-Onset Esotropia: Characteristics and Outcomes.

To describe the characteristics of the strabismus, surgical management, and outcomes of patients who underwent surgery for adult-onset esotropia. This was a retrospective case study of patients at an academic tertiary referral center who underwent surgical treatment of esotropia acquired at or after age 18 years. Primary outcome measures were resolution of diplopia in primary position and a deviation of 10 prism diopters or less in primary gaze. Additional clinical parameters were assessed. Of 248 patients with adult-onset esotropia who underwent strabismus surgery, all experienced diplopia preoperatively except those with sensory esotropia. The four most common diagnoses were cranial nerve VI palsy in 36% (90 of 248), thyroid eye disease in 18% (45 of 248), age-related distance esotropia in 15% (38 of 248), and decompensated latent esodeviations in 13% (31 of 248) of patients. A variety of surgical procedures were employed, and adjustable sutures were used in 79% (196 of 248). Approximately 80% (158 of 197) of patients present at the 2-month postoperative follow-up visit were aligned within 10 prism diopters, and 72% (140 of 195) experienced resolution of diplopia. Success rates were significantly higher in patients with adjustable sutures. Reoperation rates were low overall at 15% (37 of 248) and were highest in cranial nerve VI palsies and lowest in age-related distance esotropia. Dose-response calculations showed a non-significantly smaller effect per millimeter of recession and resection in cranial nerve VI palsy and age-related distance esotropia. The causes of adult-onset esotropia are diverse. A variety of surgical approaches are employed and, in conjunction with adjustable sutures, provide a good rate of diplopia resolution and acceptable ocular alignment. [J Pediatr Ophthalmol Strabismus. 2017;54(2):104-111.].

Age-related distance esotropia: Clinical features and therapeutic outcomes

Abstract Objective To describe the clinical characteristics and surgical outcomes of a group of patients with age-related distance esotropia (ARDE). Methods A retrospective study was conducted on a consecutive case series of 16 adult patients diagnosed with ARDE between 2008 and 2015. The clinical features evaluated included mean age and gender, primary position deviations at distance and near, measured in prism dioptres (pd), treatment offered in each case, and post-surgical deviations. Ductions and versions were full, with no evidence of lateral rectus paresis. None of these patients had any obvious underlying neurological disorder, such as, high myopia or thyroid disease. A good result is considered to be the disappearance of diplopia in all positions of gaze. Results A total of 16 patients (11 females [68.8%]) were identified. The mean age at diagnosis was 78.19 ± 6.77 years. The mean initial esodeviation was 2.25 ± 3.08 pd at near (−4 to +8 pd) and 9.5 ± 4.18 pd at distance (2–18 pd). Treatment was not necessary in 5 cases because the symptoms were intermittent or well-tolerated. Of the 11 patients with symptoms, one was corrected with an external base therapeutic prism. Botulinum toxin was administered in another patient, without satisfactory results. Unilateral medial rectus muscle recession was performed on one patient, and unilateral lateral rectus plication on 7 patients, indicating prisms before surgery. One patient refused surgery despite continuous diplopia in far vision. After a mean follow-up of 16.5 months, all operated patients were asymptomatic. Conclusions Not all patients with ARDE require treatment, as the tolerance to diplopia varies from one subject to another. Both medial rectus weakening and lateral rectus strengthening provides excellent results.

Esotropia asociada a la edad: manifestaciones clínicas y resultados terapéuticos

ObjectiveTo describe the clinical characteristics and surgical outcomes of a group of patients with age-related distance esotropia (ARDE). MethodsA retrospective study was conducted on a consecutive case series of 16 adult patients diagnosed with ARDE between 2008 and 2015. The clinical features evaluated included mean age and gender, primary position deviations at distance and near, measured in prism dioptres (pd), treatment offered in each case, and post-surgical deviations. Ductions and versions were full, with no evidence of lateral rectus paresis. None of these patients had any obvious underlying neurological disorder, such as, high myopia or thyroid disease. A good result is considered to be the disappearance of diplopia in all positions of gaze. ResultsA total of 16 patients (11 females [68.8%]) were identified. The mean age at diagnosis was 78.19±6.77 years. The mean initial esodeviation was 2.25±3.08 pd at near (−4 to +8 pd) and 9.5±4.18 pd at distance (2 to 18 pd). Treatment was not necessary in 5 cases because the symptoms were intermittent or well-tolerated. Of the 11 patients with symptoms, one was corrected with an external base therapeutic prism. Botulinum toxin was administered in another patient, without satisfactory results. Unilateral medial rectus muscle recession was performed on one patient, and unilateral lateral rectus plication on 7 patients, indicating prisms before surgery. One patient refused surgery despite continuous diplopia in far vision. After a mean follow-up of 16.5 months, all operated patients were asymptomatic. ConclusionsNot all patients with ARDE require treatment, as the tolerance to diplopia varies from one subject to another. Both medial rectus weakening and lateral rectus strengthening provides excellent results.

Divergence Insufficiency Esotropia: Surgical Treatment

Divergence insufficiency esotropia, or acquired comitant esotropia that is at least 10Δ larger at distance than at near, is most often seen in older adults, and may also be known as “age-related distance esotropia.” Surgical treatment is often indicated for patients who do not tolerate prism therapy, or for those with large angles of esotropia. Surgical treatments have evolved with our understanding of the disease-state. Currently, accepted treatments include lateral rectus resection and medial rectus recession. These surgeries can be performed unilaterally or bilaterally. New surgical techniques such as lateral rectus equatorial myopexy are under investigation and may hold promise as future therapies.

Treatment of age-related distance esotropia with unilateral lateral rectus resection

To report the results of a series of patients who underwent lateral rectus resection of a single muscle using nonadjustable sutures to correct acquired concomitant esotropia (age-related distance esotropia). The medical records of patients with symptomatic age-related distance esotropia who were treated by unilateral lateral rectus resection were retrospectively reviewed. Pre- and postoperative near and distance prism diopter measurements were compared. The average age of the patients was 79.8 years (range, 68-90 years). The mean lateral rectus resection was 4.9 ± 1.3 mm. All patients had complete resolution of diplopia after surgery. Median distance esotropia measurements in primary gaze were reduced from 16.0(Δ) preoperatively to 0(Δ) postoperatively (P < 0.005) at final follow-up. Any preoperative near esotropia was also completely resolved. In this patient cohort, age-related distance esotropia was effectively managed solely with unilateral lateral rectus resection.

Characteristics and surgical results in patients with age-related divergence insufficiency esotropia

To describe the clinical characteristics and surgical outcomes of a group of patients at least 40 years of age with adult-onset divergence insufficiency esotropia. The medical records of consecutive adult patients diagnosed with divergence insufficiency between 1977 and 2011 were retrospectively reviewed. Clinical features evaluated included age at diagnosis, visual acuity, primary position deviations at distance and near, treatment offered, postsurgical deviations, and presence of neurological diagnosis based on medical history. A total of 85 patients (52 females [61%]) were identified. The mean age at diagnosis was 74years. The mean visual acuity in the better-seeing eye was 20/23; in the worse-seeing eye, 20/27. The mean initial esodeviation was 12(Δ) at distance and 5.4(Δ) at near. Seven patients (8%) had been diagnosed with neurological disease and 5 with bilateral abducens nerve pareses without limitation of abduction. Therapeutic prism was used by 60 patients (69%). Bilateral medial rectus muscle recessio (mean, 4.3 mm per muscle) was performed on 37 patients. The average postoperative deviations were 0.6(Δ) of esodeviation at distance and 3(Δ)of exodeviation at near. Few patients with age-related distance esotropia have accompanying neurological disease. Bilateral medial rectus muscle recessions effectively reduced esotropia at distance, with a slight tendency for overcorrection at near.

Age-related distance esotropia – fusional amplitudes and clinical course

Background: Age-related distance esotropia (ARDET) is a form of acquired strabismus that affects elderly patients and manifests as an esotropia greater with distance fixation. Limited information exists regarding fusional amplitudes and deficient divergence in this disorder.Methods: In this retrospective study, patient characteristics, ocular alignment and motility, and clinical course of patients with ARDET were recorded. Fusional amplitudes were analyzed to assess whether deficient divergence was present in patients with ARDET.Results: Twenty patients with ARDET were identified. Median age was 77.5 years (range, 59 to 89 years) and median best-corrected visual acuity was 20/25. Median esotropia angle with distance fixation was 5.5Δ (range, 2 to 18Δ); median angle with near fixation was esotropia 2.5Δ (range, exotropia 3Δ to esotropia 13Δ). Fusional divergence amplitudes were decreased in all but two patients. The median amplitude with distance fixation was 4.5Δ for break (range, 1 to 11Δ) and 2Δ for recovery (range, 0 to 9Δ). In 5 patients, the fusional divergence amplitude was as large or larger than the esotropia angle. Most patients remained stable throughout a mean follow-up of 18 months (range, 3 to 37 months). Nineteen patients were managed with prisms. Strabismus surgery was performed in one patient.Conclusions: Fusional divergence amplitude was deficient in most but not all patients with ARDET. In this study, most patients with ARDET remained stable and free of diplopia with prism treatment.

Distance esotropia in the elderly

Aim To describe the clinical features of an under-recognised small esodeviation and horizontal diplopia on distance fixation seen in elderly patients not associated with lateral rectus underaction or coexisting neurological...

Divergence Insufficiency Esotropia Is a Misnomer—Reply

We thank Mittelman for his thoughtful comments emphasizing points that he has previously published.1 We agree that the terms divergence paralysis esotropia (DPE) and divergence insufficiency esotropia are misnomers. In our article, we noted the existence of multiple terms for this form of strabismus and that we had used the term DPE to permit convenient reference to the prior literature.2 We further agree with Mittelman that the term age-related distance esotropia (ARDE) is better suited than the foregoing terms to describe small-angle distance esotropia in older patients. However, is ARDE the optimal term for the field to adopt for future use? Changes in nomenclature are difficult owing to factors such as a large existing literature using older terms and the association of older terms with presumed pathophysiological mechanisms that may still be embraced by a large number of clinicians.3 Optimal terminology should be descriptive of findings when pathophysiological mechanisms are unknown but should be related to mechanisms when mechanisms have been clearly demonstrated. The controversial consideration is the level of evidence necessary to persuade a professional field of the correctness of a particular mechanism vs that field’s natural reticence to change longstanding practice. Even when there is overwhelming evidence of a particular mechanism, professionals tend to change nomenclature only slowly, often as generational replacement limits the rate of paradigm shift.4 In the case of DPE/ARDE, we believe that application of high-resolution magnetic resonance imaging has now unequivocally revealed the mechanism of the strabismus to be an involutional effect of orbital connective tissue degeneration, not a neurological deficit. Even another term, sagging eye syndrome, has been proposed,5 for which DPE/ARDE is only one manifestation to which may be added aponeurotic blepharoptosis and cyclovertical strabismus.6 We recently published findings that patients with DPE/ARDE nearly always have bilateral rupture of the lateral rectus–superior rectus band ligament that supports the lateral rectus muscle, along with lengthening and alteration in the paths of the rectus extraocular muscles.6 These alterations reflect extremes of gradual effects of aging on orbital connective tissues and are not always limited to adults in the age range considered elderly.6 Moreover, acute connective tissue rupture can even produce sudden-onset distance diplopia, simulating a neurological condition. We agree with Mittelman that as our population ages, ophthalmologists will increasingly encounter patients with esotropia limited to distance viewing. Mittelman has correctly recognized that DPE/ARDE is not a neurological disorder but is instead a mechanical disorder, and he has done a service to our patients by emphasizing that it does not involve a neurological deficit of divergence. Now that we know ARDE is one important manifestation of sagging eye syndrome, we agree that it would be appropriate to adopt Mittelman’s suggested term ARDE in future studies.