Cause Of Diplopia Research Articles

Изолированная невропатия блокового нерва: собственное наблюдение и современные представления

Neurologically isolated trochlear nerve (TN) injury is uncommon. We describe the case of acute vertical diplopia development in a 64-year-old man who considered himself healthy. The cause of diplopia was neuropathy of TN. The diagnostic search gave reason to assume that TN damage was associated with microangiopathy caused by arterial hypertension and dyslipidemia newly diagnosed in the patient. A diagnostic algorithm for acute vertical diplopia and the range of diseases for differentiation with isolated TN neuropathy are discussed, as well as the prognosis and patient’s management. The association of isolated TN neuropathy with migraine and the risk of ischemic stroke is considered.

Graves' orbitopathy as the cause of diplopia in old age-Differences between young and old

Endocrine orbitopathy (EO) is an autoimmune disease mostly associated with a disease of the thyroid gland, which leads to inflammation, adipogenesis and fibrosis. The severity of EO can vary greatly between individuals, which makes it difficult to exactly predict the natural course of the disease; however, this is important to be able to individually adapt the treatment. The aim of this study was to compare the clinical features, course, treatment and prognosis for patients with EO under 50 years old with older patients. The results of the study with a focus on motility are presented in this special issue. The hospital records of a randomly selected sample of 1000 patients from the EO databank in Essen (GODE), which includes 4260 patients, were analyzed. The patients were divided into two groups: group 1 ≤50 years and group 2 >50 years. Only patients with complete data sets were included in the statistical analyses. Younger patients (n = 484) presented significantly more frequently with milder EO (53% vs. 33%, p < 0.0001), whereas older patients (n = 448) more frequently suffered from moderate or severe forms (44% vs. 64%, p < 0.0001). Older patients showed more severe strabismus, motility and clinical activity scores (5.9 vs. 2.3 prism diopters, PD/310° vs. 330°, both p < 0.0001, CAS 2.1 vs. 1.7, p = 0.001). Proptosis and the occurrence of optic nerve compression showed no significant differences between the groups (3% each). Multiple logistic regression showed that the necessity for a second eye muscle surgery was most strongly associated with a previous decompression (OR = 0.12, 95 % CI 0.1-0.2, p < 0.0001), followed by orbital irradiation and age. In summary, younger patients with EO presented with milder clinical features, such as a lower rate of restrictive motility disorders and weaker expression of signs of inflammation. Therefore, older patients needed steroids, irradiation, eyelid and eye muscle surgery more frequently; however, the risk of dysthyroid optic neuropathy and the necessity of a second eye surgery were not or only slightly associated with age.

Neuro-ophthalmological Consultations in the Emergency Department of a Tertiary Referral Emergency Center

Purpose: We report the clinical features, diagnoses, and treatments of patients with neuro-ophthalmological diseases presenting to a tertiary referral center emergency room (ER) of South Korea.Methods: We retrospectively analyzed the medical records of 205 patients who visited the ER of the Asan Medical Center and then were referred to our neuro-ophthalmology department from May 2020 to April 2022. The initial diagnoses of ophthalmology residents were compared to the final diagnoses of neuro-ophthalmologists. We describe the symptoms, diagnoses, and treatments.Results: The median time from the onset of symptoms to the ER visit was 3 days; diplopia (49.1%) and vision loss/a visual field defect (38.9%) were the chief complaints. The most common causes of diplopia were isolated cranial nerve 4 (37.5%), 6 (22.9%), and 3 palsy (18.4%) and supranuclear palsy (9.2%). In patients with vision loss/visual field defect, the most common causes were optic (20.5%), ischemic (17.1%), and compressive (8.0%) optic neuropathies. For 121 cases (59.0%), multidisciplinary consultations with the departments of neurology, neurosurgery, and internal medicine were scheduled. After initial management in the ER, 38 diagnoses (18.5%) changed after evaluation by neuro-ophthalmologists.Conclusions: Over half of all neuro-ophthalmology patients presenting to an ER required comprehensive interdisciplinary evaluation and over a third required inpatient treatment.

Diplopía binocular: estudio retrospectivo de 204 casos

ObjectivesTo describe the prevalence and form of onset of different causes of binocular diplopia in our setting. MethodsWe conducted a single-centre, cross-sectional, retrospective study reviewing the medical records of all patients visiting a tertiary-level centre between May 2019 and June 2021 with binocular diplopia as the main symptom. All patients underwent a complete neuro-ophthalmological evaluation and complementary tests for the aetiological diagnosis of diplopia. Data were collected on demographic variables, ocular deviation pattern, complementary test results, and diagnosis. ResultsA total of 204 patients with binocular diplopia were identified during the study period. The most frequent causes of diplopia overall were fourth nerve palsy (19.12%), sixth nerve palsy (14.71%), decompensated strabismus (14.22%), sagging eye syndrome (12.25%), third nerve palsy (10.78%), myasthenia (7.35%), supranuclear disorders (6.37%), and myopic esotropia (5.88%). Presentation was acute (≤2 weeks progression) in 51% of cases. The most frequent causes of acute-onset diplopia were sixth nerve palsy (27.88%), third nerve palsy (21.15%), fourth nerve palsy (19.23%), supranuclear disorders (12.5%), and decompensated strabismus (6.73%). The most frequent causes of subacute/chronic presentation (more than 2 weeks) were decompensated strabismus (22%), sagging eye syndrome (22%), fourth nerve palsy (19%), myopic esotropia (12%), and myasthenia (11%). ConclusionsThe most frequent aetiology of diplopia in our environment was fourth nerve palsy, followed by sixth nerve palsy, decompensated strabismus, and sagging eye syndrome. Knowing the frequency of each cause of diplopia can help prioritise neuroimaging studies in each case.

An unusual cause of diplopia and blurred vision in a patient with renal insufficiency.

We report the interesting case of a 75-year-old patient who presented with sudden onset of diplopia and a blurred vision of the right eye. Recurrent headaches in the temporal region were reported as further symptoms. Clinical examination revealed abduction restriction on the right side and bilateral vascular congestion in the anterior segment of the eye, and marked chemosis. As relevant pre-existing conditions, the patient had severe hypertension, long-standing nicotine abuse (>50py), 3-vessel coronary artery disease, myocardial infarction 33 years ago, and cardiac bypass surgery five years ago. Furthermore, the patient suffered from chronic renal failure stage G5D, according to Kidney Disease Outcomes Quality Initiative (K/DOQI), with the need for dialysis. For this reason, a polytetrafluoroethylene loop shunt was created on the right cubital region five years ago, which underwent thrombectomies one year ago and three months ago. During the last revision, the shunt was extended to the internal jugular vein to improve patency, which was not reported by the patient with a language barrier, and no documentation from the external hospital was available.

Prise en charge des diplopies binoculaires aux urgences ophtalmologiques du Centre hospitalier régional universitaire de Tours

To describe the etiologies of binocular diplopia for patients presenting to the ophthalmologic emergency department of the Regional University Center Hospital (CHRU) of Tours. This is a retrospective study of the medical records of patients who presented with binocular diplopia in the ophthalmic emergency department of the CHRU of Tours between January 1st and December 31st, 2019. Binocular diplopia was classified as paralytic or non-paralytic according to the ocular motility examination. One hundred twelve patients were included. The median age was 61 years. Internal referral from other hospital services represented 44.6% of the patients. On ophthalmological examination, 73.2% had paralytic diplopia, 13.4% non-paralytic diplopia and 13.4% normal examination. Neuroimaging was performed in 88.3% of cases, with 75.7% of patients receiving it on the same day. Oculomotor nerve palsy was the most frequent cause of diplopia in 58.9%, the majority represented by abducens nerve palsy (60.6%). The most frequent etiology of binocular diplopia was ischemic, with microvascular damage in 26.8% of cases and stroke in 10.7% of cases. Among patients assessed in an ophthalmological emergency department setting, one in ten patients had stroke. It is essential to inform patients of the urgent nature of ophthalmological evaluation in the case of acute binocular diplopia. Urgent neurovascular management is also mandatory and should be based on the clinical description provided by the ophthalmologist. Neuroimaging should be performed as soon as possible, based on the ophthalmologic and neurological findings.

What you need to know about assessing a patient with diplopia.

Diplopia occurs when two images are subjectively seen of a single object. It has a variety of causes, which range in severity from benign to sight or life threatening if left untreated. Clinical assessment of diplopia includes taking a comprehensive history to delineate the exact type of visual disturbance experienced by the patient and examination to pinpoint the aetiology, which is crucial for further management. This article discusses the causes of diplopia, along with risk factors and other associated symptoms, to facilitate diagnosis and management. Efficient and effective diagnosis is important, as some pathologies require immediate treatment to save the eyesight and/or life of the patient. This article will concentrate solely on binocular diplopia.

Evaluation of diplopia as a vital and remarkable ocular finding among cancer patients.

Diplopia is an important and debilitating symptom of malignancies due to different pathogenetic mechanisms. Data is lacking in the literature because of the rarity of the diplopia in patients with cancer. We aimed to evaluate the etiological and clinical factors of diplopia in patients with different types of cancer. We retrospectively investigated 22 cancer patients with diplopia who were admitted between 2018 and 2021. The diagnosis of primary cancer, the underlying factors causing diplopia, and the life expectancy after diplopia were evaluated. Among available data of 620 cancer patients applied to our ophthalmology department, 22 (3.55%) had diplopia. Paralytic strabismus was found in 19 patients and restrictive strabismus was found in 3 patients. Among the paralytic cases, 6th nerve palsy was found to be the most common with a rate of 68%. In 18 of 22 (82%) patients, the cause of diplopia was due to orbital or brain metastasis or local invasion. Two patients had diplopia secondary to radiotherapy and 2 had diplopia due to chemotherapy. Metastasis is the most common cause of diplopia in patients with cancer and screening for metastasis is crucial as soon as diplopia begins for a better life expectancy.

Diplopia, COVID-19 and Vaccination: Results from a Cross-Sectional Study in Croatia.

The aim of this study was to explore diplopia as a symptom of undetected COVID-19 infection or as a possible side effect of COVID-19 vaccination. We examined 380 patients with diplopia admitted to the Department of Ophthalmology of the University Hospital Centre Sestre milosrdnice in Zagreb, Croatia, from July 2020 to June 2022. After excluding patients with confirmed organic underlying diplopia causes or monocular diplopia, we linked the patient information with the national COVID-19 and vaccination registries. Among the 91 patients included in this study, previously undetected COVID-19 infection as the possible cause of diplopia was confirmed in five of them (5.5%). An additional nine patients (9.9%) were vaccinated within one month from the onset of their symptoms, while the remaining 77 had neither and were therefore considered as controls. The breakdown according to the mechanism of diplopia showed no substantial difference between the vaccinated patients and the controls. We detected marginally insignificant excess abducens nerve affection in the COVID-positive group compared with that in the controls (p = 0.051). Post-vaccination diplopia was equally common in patients who received vector-based or RNA-based vaccines (21.4 vs. 16.7%; p = 0.694). COVID-19 testing should be performed for all cases of otherwise unexplained diplopia. The risk of post-vaccination diplopia was similar in both types of vaccines administered, suggesting a lack of evidence linking specific vaccine types to diplopia.

Application of Soft Directional Prismatic Contact Lenses to Correct Diplopia.

To verify whether diplopia due to a small-angle strabismus within 8 prism diopters (PD) could be corrected by applying soft directional prismatic contact lenses, obtaining higher comfort and quality of vision for the patients. A prospective study was undertaken by enrolling consecutive patients affected by vertical and/or horizontal diplopia and small-angle strabismus within 8 PD. The patients were tested for best corrected visual acuity, refraction, cover test for near and for distance, ocular motility test, prismatic fit test, corneal topography, tear film evaluation, binocular vision test, head position evaluation, retinography, and optical coherence tomography of the posterior and anterior segment. Custom soft contact lenses, made in Benz G5X material, were designed and developed for this study. All patients were first corrected with prismatic glasses according to their degree of strabismus and ametropia. Then they were asked to wear custom-made directional prismatic contact lenses with appropriate simultaneous correction of strabismus and ametropia. The patients were then asked to answer whether the comfort and quality of vision was higher with directional prismatic contact lenses or prismatic glasses. Eight patients were enrolled with different causes of diplopia caused by a strabismus of 8 PD or less. The soft directional prismatic contact lenses could resolve diplopia in 100% of patients. All patients reported greater comfort and quality of vision with directional prismatic contact lenses. The study demonstrated that diplopia resulting from an angle of strabismus within 8 PD can be corrected through the use of soft directional prismatic contact lenses, obtaining greater quality of vision free of aberrations. [J Pediatr Ophthalmol Strabismus. 2023;60(4):248-252.].

Surgical techniques for sagging eye syndrome: avoiding lateral rectus surgery

Sagging Eye Syndrome (SAS) is a common cause of diplopia in older adults, caused by weakening of the superior rectus-lateral rectus band, leading to inferior displacement of the lateral rectus, with resultant esotropia, hypotropia, and excyclotorsion. A review of surgical results of adults with diplopia due to SAS over a 4-year period was performed.

Diplopia following microvascular decompression surgeries: illustrative cases

BACKGROUNDMicrovascular decompression is an effective treatment strategy for trigeminal neuralgia. However, there may be inadvertent complications involving adjacent cranial nerves during or months after the operation. This case lesson highlights the potential manifestations, both optical and nonneurologic (monocular) and binocular diplopia, after microvascular decompression in two patients. Neurosurgeons should recognize monocular versus binocular causes of diplopia after neurosurgical microvascular decompression.OBSERVATIONSThe authors reported on two patients who presented with diplopia after microvascular decompression for trigeminal neuralgia. The first patient had binocular diplopia with a paradoxical head tilt potentially due to a contiguous trochlear nerve palsy. The second patient had monocular diplopia due to dry eye syndrome from trigeminal nerve dysfunction. However, within 2 years after their operations, both patients had resolution of their diplopia without additional surgical intervention.LESSONSBoth monocular and binocular diplopia can be presenting symptoms of cranial neuropathies after microvascular decompression for trigeminal neuralgia. Most cases of postoperative diplopia (both monocular and binocular) resolve spontaneously over time without additional neurosurgical treatment.

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

PurposeTo provide a new classification system for diplopia and evaluate the etiology and clinical features of diplopia subtypes in south China.MethodsIn 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.ResultsA 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.ConclusionsThis 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.

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

Diplopia following endoscopic brow lift

The endoscopic brow lift is the most widely used for the rejuvenation of the upper face nowadays. Even though this procedure has such advantages, there are reports about complications associated with this procedure, including bleeding and hematoma, lagophthalmos, alopecia, and nerve injury. But, there is almost no research reporting on diplopia occurring after an endoscopic brow lift. We would like to report on an analysis about the causes of diplopia with a research literature review since diplopia occurred in 6 cases out of 426 cases of the endoscopic brow lift performed from January 2013 to April 2020. There were characteristic findings of left superior oblique muscle palsy in all 6 patients. The subjective symptoms of double vision were improved in all patients at the follow-up appointment 2 to 4 months after surgery. There is no information on the incidence or mechanisms about diplopia which occurs in endoscopic brow lift. Diplopia should be considered as a possible complication during surgery, and it will be necessary to further discuss the anatomical understanding and cautions in surgical procedures. Level of evidence: Level V, therapeutic study

Thyroid autoantibodies in adults with acquired binocular diplopia of unknown origin

Patients with acquired adult-onset strabismus mainly present with binocular diplopia. Although cranial nerve palsies are reportedly the most common cause of binocular diplopia in adults, thyroid disease can also cause diplopia. In patients with thyroid-associated ophthalmopathy, upper lid retraction and proptosis are the most common initial findings, but diplopia could be the first manifestation. So far, there has been little information on the diagnostic value of thyroid autoantibodies in patients with strabismus. Therefore, we examined adults with acquired binocular diplopia from 2008 to 2016 and evaluated the presence of thyroid autoantibodies and the relationship between thyroid autoantibody status and clinical characteristics in adults with acquired binocular diplopia. Thyroid autoantibody tests were performed for all patients, unless other causes of diplopia were identified. Fifty one (39%) of 132 patients were positive for thyroid autoantibodies. In the thyroid autoantibody-positive (TAb+) group, microsomal autoantibodies, thyroid-stimulating hormone receptor antibodies, thyroglobulin antibodies, and thyroid-stimulating antibodies were observed in 30, 27, 12, and 7 patients, respectively. The vertical deviation and grade of duction limitation were greater in the TAb+ group. The presence of ocular torsion was 15.5% and 39.5% in the TAb− and TAb+ groups, respectively. Thyroid autoantibody evaluation may be helpful in adults with idiopathic acquired binocular diplopia.

Anatomic Factors Predicting Postoperative Strabismus in Orbital Wall Fracture Repair

This study is aimed to determine the relationship between orbital fracture sites in each CT scan view and postoperative diplopia. Data for 141 patients of orbital wall fracture were analyzed retrospectively. One group of examiners reviewed sagittal, coronal and axial CT scans. Descriptive statistical analysis was used to assess each fracture area and its potential relationship with the occurrence of postoperative diplopia. Among the three anatomical views, sagittal sections were significantly associated with post-operative diplopia (PD) (p = 0.044). For orbital wall fractures in a single location, C1 (p = 0.015), A1 (p = 0.004) and S3 (p = 0.006) fractures were significantly related to PD. Orbital wall fractures found in more than one location resulted in a higher probability of PD in all sections:, C1 + C2 group (p = 0.010), C1 + C2 + C3 group (p = 0.005), A1 + A2 group (p = 0.034), A3 + A1 group (p = 0.005), S1 + S2 group (p < 0.001), S2 + S3 group (p = 0.006) and S1 + S2 + S3 group (p < 0.001). For combinations of two or three sections, we found that only fractures involving both coronal and sagittal sections led to a significantly increased risk of PD (p = 0.031). PD is the main posttreatment complication of orbital bone fracture reduction. In addition to the known myogenic cause (failure to relieve entrapment) of diplopia, both trauma and surgical manipulation can compromise ocular motor nerve function and possibly result in the development of neurogenic causes of diplopia. Careful assessment of patient symptoms (whether preoperative diplopia is present), and the location of orbital fractures (and the influence of related musculature, fat, and nerves) on CT scans are strongly related to surgical success.

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.

Understanding and evaluating diplopia

Diplopia or double vision is a frequent reason for ophthalmology consultation. Monocular diplopia is usually ocular or retinal in origin, whereas binocular diplopia is often due to neurological causes. Detailed history beginning with any childhood visual disorders or head tilt and covering comorbid conditions and drug intake is essential. The alignment of images and direction of maximum separation point to the muscle(s) are involved. Temporal profile including onset, progression, and fluctuations along with comorbid conditions helps to narrow down the etiology. Refraction, ocular examination, and fundoscopy can identify ocular and retinal conditions; meticulous examination of ocular ductions and versions is mandatory to localize the cause of diplopia and to initiate investigations for the underlying disease process. Isolated ocular motor palsies are mostly due to microvascular ischemia; in the absence of red flags, investigation may be deferred for 6–8 weeks. Large vertical fusional amplitudes may be a clue to a decompensated congenital trochlear palsy. A partial third nerve palsy with early pupillary involvement, progressive signs, involvement of multiple cranial nerves, and elderly patients with rapid Erythrocyte Sedimentation Rate (ESR) are some situations warranting early imaging and other investigation. Myasthenia gravis and thyroid disease may present with diplopia and ophthalmic manifestations alone without systemic symptomatology. Immunoglobulin G4-related orbital myositis and anti-GQ1b antibody-mediated ocular neuropathies are relatively recently recognized immune-mediated conditions that may present with diplopia to an ophthalmologist. Ophthalmoplegic migraine has been renamed recurrent ophthalmoplegic neuropathy and is a diagnosis of exclusion at initial presentation.

Long-term Surgical Outcomes in the Sagging Eye Syndrome

ABSTRACTBackground/aims: Strabismus due to sagging eye syndrome (SES) caused by age-related connective tissue involution is now an established cause of diplopia in older people. High suspicion of the condition results in early recognition, often obviating extensive neurological investigations and enabling surgical correction of the strabismus.Methods:This retrospective study reviewed surgical results in 93 patients (40 males) of average age 68 ± 12 years, who had small-angle strabismus due to SES, during the 20-year period 1994–2014.Results: In central gaze, mean distance pre-operative esotropia was 4.2 ± 7.5Δ (mean, SD), while mean hypertropia was 4.7 ± 5.9Δ. Surgeries comprised medial rectus (MR) recession; lateral rectus (LR) resection; plication, imbrication, and superior transposition of the LR to the superior rectus (SR) for esotropia; and graded vertical rectus tenotomy (GVRT) or vertical muscle recession for hypertropia. Mean post-operative immediate and long-term deviation after 316 ± 265 months average follow-up was 0.2 ± 1.2Δ and 1.1 ± 2.7Δ esotropia (both distance), respectively, and 0.00Δ and 1.1 ± 2.7Δ, respectively, for hypertropia. Strabismus recurred in 19 cases.Conclusions: Progressive connective tissue involution in SES may occasionally result in symptomatic recurrences of the small-angle strabismus in about 20% of patients, irrespective of surgical procedures performed, possibly because of progressive involutional changes. This risk should be disclosed pre-operatively.