Sagging Eye Syndrome Research Articles

Body Mass Index Is Associated With Orbital Pulley Degeneration Syndrome, Including Sagging Eye Syndrome

Sagging eye syndrome (SES), esotropia with high myopia including heavy eye syndrome, and age-related esotropia (ARE)-collectively termed orbital pulley degeneration syndrome (OPDS)-are characterized by strabismus with orbital pulley lateral rectus-superior rectus band impairment. Herein, we examined body mass index (BMI) in OPDS to determine SES-associated anthropometric characteristics. Retrospective cohort study. We compiled and analyzed the BMI of patients aged ≥50 years who underwent strabismus surgery at a single center in Shizuoka, Japan, between July 2020 and March 2023. BMI (kg/m2) was categorized into 4 groups: <18.5, 18.5 to 21.9, 22 to 24.9, and ≥25. As the boundary between OPDS and SES is ambiguous, we assumed a pure SES group by excluding patients with ARE and esotropia with high myopia from the OPDS group. Overall, 204 patients (age: 67.7 ± 9.7 years) were included in the study. There were 78/126 and 49/119 patients in the OPDS/non-OPDS and SES/non-SES groups (age: 70.4 ± 9.5/66.0 ± 9.6 years, P = .002 and 75.0 ± 6.0/66.6 ± 9.5 years, P < .001; BMI: 21.2 ± 3.3/23.2 ± 3.0 kg/m2, P < .001 and 21.2 ± 3.3/23.1 ± 3.0 kg/m2, P = .003), respectively. In the BMI-stratified analysis, OPDS and SES were more prevalent in the <18.5 BMI group than in the 22 to 24.9 and ≥25 BMI groups (P < .001 and P = .006, respectively). Logistic regression analysis, adjusted for age and sex, showed that lower BMI was associated with a higher prevalence of OPDS and SES. Patients with OPDS, including SES, had lower BMI than other patients with strabismus. Therefore, BMI may be a clinical clue to SES.

Laterality Targeting in Graded Inferior Rectus Tenotomy Corrects Lateral Incomitance of Hypertropia in Sagging Eye Syndrome

PurposeTo determine if laterally selective graded vertical rectus tenotomy (GVRT) of the inferior rectus (IR) can correct the lateral incomitance of hypertropia (HT) commonly encountered in sagging eye syndrome (SES), comparing it with inferior oblique (IO) recession. DesignRetrospective comparative interventional clinical study. MethodsWe reviewed 73 consecutive patients undergoing GVRT of the IR for correction of horizontally incomitant HT due to SES from July 2012 to October 2023. Confounding diagnoses were excluded. Using topical anesthesia, GVRT was initiated from the nasal versus temporal side corresponding to greater HT, with dosing adjusted intraoperatively until cover testing in central gaze indicated orthotropia. We compared 8 cases of IO recession to 4mm posterior and 3mm lateral to the IR insertion. ResultsNasal GVRT was performed in 41 patients (standard deviation), and temporal GVRT on 32 patients. Mean nasal GVRT was 69±15% and mean temporal GVRT was 62±17%. Mean HT in central gaze was reduced by nasal GVRT from 3.9±1.7Δ to 0.3±1.4Δ, and from 4.0±1.6Δ to 0.2±1.1Δ by temporal GVRT. Nasal GVRT corresponding to the side of the tenotomy had greater effect in contralateral gaze at 3.2±2.2Δ than ipsilateral gaze at 2.1±2.0Δ (p=0.0250), whereas temporal GVRT had greater effect in ipsilateral gaze at 4.9±2.7D than contralateral gaze at 2.9±2.9D (p=0.0002). Inferior oblique recession in 8 patients reduced lateral incomitance from 13±5.0Δ to 0.5±1.4Δ (p<0.0001). ConclusionNasal GVRT corrects about 1Δ and temporal GVRT 2Δ horizontal incomitance of HT, while IO recession corrects about 12.5Δ. Selection of GVRT laterality improves outcomes without additional risk or operating time.

Biomechanics Explains Variability of Response of Small Hypertropia to Graded Vertical Rectus Tenotomy

PurposeSmall angle hypertropia in sagging eye syndrome is conveniently treated by graded vertical rectus tenotomy, yet adjustable technique under topical anesthesia has been recommended due to variability of effect. We performed graded tenotomy in an experimental model to elucidate the effect reason for variability of response to this surgical procedure. DesignExperimental study: Methods: 32 fresh bovine rectus musculotendon specimens were prepared including continuity with insertional sclera, and extending for a total 40mm length to the proximal muscle bellies, and trimmed to 16mm width. Specimens were anchored by the clamps at the scleral insertion and muscle belly ends within a physiological chamber. After preconditioning and elongation to 10% strain was imposed by a linear motor, tensile force was allowed to stabilize at a plateau state. Then 25, 50, 75, 90, 100% marginal tenotomies were perormed progressively as remnant forces were measured. ResultsTendon thickness averaged 0.29±0.05mm and width 19.71±2.25mm. On average, remnant force decreased linearly (R2=0.985) from 4.23±1.34, 2.76±0.88, 1.70±0.73, 1.01±0.49, 0.39±0.10, and 0 N, at 0, 25, 50, 75, 90, 100% tenotomy. However, there was marked individual variability in effect among specimens, with coefficient of variation 32, 32, 43, 49, and 27%, respectively ConclusionOn average there is a linear relationship between graded rectus tenotomy and percentage force reduction, but the effect among individual tendons is large, paralleling the reported variation in surgical effect. This explains and implies continued advisability of adjustable technique in this procedure.

Age-related nonparalytic hypertropia: Clinical features.

Age-related nonparalytic hypertropia (ARNH) is reported to be involved in sagging eye syndrome, where excyclotorsion is large and the lower eye is more extorted. The primary aim of this study was to describe the clinical profiles of patients with ARNH. The secondary aim was to compare cyclotorsion in patients with ARNH with that in normal individuals. Inclusion criteria for ARNH were insidious onset of diplopia at distance after 50 years of age, nonparalytic hyperdeviation and follow-up >6 months. Objective cyclotorsion was measured as the disc-to-fovea angle (DFA) on fundus photographs obtained from two groups: 75 patients with ARNH (age, 74.1 ± 7.9 years) and 75 sex- and age-matched normal controls (73.9 ± 8.1 years). The hypertropia angle was 4.6 ± 2.8 prism dioptres. One patient also experienced diplopia at near-gaze. DFA in ARNH (right/left eye; 11.0 ± 4.8°/11.6 ± 3.9°) was larger than that of the control (6.6 ± 3.7°/9.2 ± 3.5°) (p < 0.0001). The DFA in the non-dominant eye (12.5 ± 4.1°) was larger than that in the dominant eye (10.2 ± 4.3°) (p = 0.0003). The lower eye did not have the larger DFA in 29 patients. The angle of hyperdeviation in patients with ARNH was small. The DFA in the ARNH group was larger than that in the normal group. The lower eye was not the eye with a larger DFA in 39% of ARNH, inconsistent with sagging eye syndrome. Decreased phoria adaptation (fusional ability) may trigger diplopia in patients with ARNH.

Magnetic resonance imaging findings of high myopic strabismus with sagging eye-like symptoms, heavy eye syndrome, and non-highly myopic eyes with sagging eye syndrome

ABSTRACT Introduction Progressive esotropia accompanied by restricted abduction and supraduction due to high myopia is known as esotropia fixus with high myopia or heavy eye syndrome (HES). Some conditions, such as sagging eye syndrome (SES), show esotropia for distance or cyclovertical strabismus with no abduction limitations despite highly myopic eyes. We evaluated the magnetic resonance imaging (MRI) findings and clinical features of HES, high myopia with SES-like symptoms (highly myopic SES), and SES. Methods We reviewed all patients diagnosed with HES, highly myopic SES, and SES who underwent MRI of the orbits and brain over 6 years. To quantitatively assess the orbital anatomy, we compared the conditions of the superior rectus muscle (SR), lateral rectus muscle (LR), and inferior rectus muscle (IR) using orbital MRI among the three groups. Results Among the 14 patients (27 eyes) with high myopia, 5 (9 eyes) had HES, and 9 (18 eyes) had highly myopic SES. Eleven patients (22 eyes) with SES were also compared with these 14 patients. The mean axial length was 29.6 ± 1.0 mm in participants with HES, 29.0 ± 1.5 mm in those with HES-SES, and 23.7 ± 0.9 mm in those with SES. The average distance esotropia was 48.0 ± 19.9Δprism, 4.6 ± 1.5Δprism, and 6.1 ± 4.6Δprism for participants with HES, highly myopic SES and SES, respectively. The average distance hypertropia was 5.3 ± 5.9Δprism in participants with highly myopic SES and 4.8 ± 2.7Δprism in those with SES. The mean vertical angle of the LR was 32.6 ± 10.8°, 18.1 ± 5.4°, and 14.6 ± 6.8°; the mean tilting angle of the LR was 31.6 ± 9.2°, 15.9 ± 6.0°, and 13.8 ± 5.9°; and the mean displacement angle between the LR and SR was 152.3 ± 16.7°, 125.0 ± 7.1°, and 112.5 ± 7.5° for participants with HES, highly myopic SES and SES, respectively. The LR-SR displacement angle in HES-SES was significantly larger than in SES (p < .001) but the vertical and tilting angles were not. Also, the IR shift showed no significant difference with HES-SES and HES (5.8 ± 1.4 mm and 5.3 ± 1.2 mm) but not with SES (4.0 ± 0.8 mm) (p < .0001). Discussion SES-like symptoms can develop in highly myopic eyes; however, MRI showed that the state of the LR muscle in highly myopic SES deviated almost similarly to that in SES; however, the eyeball was more dislocated than in SES. This may be useful in deciding the appropriate operative procedure.

Comparison of head tilt test between sagging eye syndrome and acquired unilateral trochlear nerve palsy

PurposeTo investigate the distinction between sagging eye syndrome (SES group) and acquired unilateral trochlear nerve palsy (Trochlear group) in the Bielschowsky head tilt test (BHTT).MethodsFifteen patients in the SES group (mean age 74.6 ± 5.2 years) and 14 patients in the Trochlear group (55.2 ± 15.9 years) visited the Department of Ophthalmology, Hyogo Medical University Hospital between November 2016 and October 2022 for treatment of their diplopia. Eye position was measured with the alternate prism cover test, and values for fixation of the dominant eye, or unaffected eye, were used. Cyclodeviation was measured with the synoptophore and the Glaucoma Module Premium Edition of the SPECTRALIS optical coherence tomography. In the BHTT, eye position was measured in three head postures: primary position (PP), head tilt to the side with hypertropia (Hyper), and head tilt to the side with hypotropia (Hypo). The differences in vertical deviation between PP and Hyper (Hyper − PP), PP and Hypo (PP − Hypo) and Hyper − Hypo were measured and compared.ResultsVertical deviation in primary position was 7.3 ± 4.5 PD in the SES group and significantly larger (17.1 ± 8.4 PD) in the Trochlear group (p = 0.002). The vertical deviation in Hyper was significantly larger in the Trochlear group with 7.7 ± 4.7 PD and 22.1 ± 9.4 PD, respectively (p < 0.001), whereas the that in Hypo was not significantly different between the two groups with 6.5 ± 3.4 PD and 8.4 ± 6.6 PD, respectively (p = 0.725). The SES group showed no significant difference according to the 3 head postures (p = 0.311), while the Trochlear group showed a significantly different with smaller mean values in vertical deviation in Hypo (p < 0.001). The difference in the vertical deviation for the 3 head postures was the largest in Hyper − Hypo (1.7 ± 2.1 PD and 13.6 ± 7.1 PD, respectively), and the accuracy of SES was at the cutoff value of 6 PD, and it was considered not to be SES if the value was 6PD or higher. The accuracy of SES determination was 100% sensitivity and 100% specificity, and the area under the curve was 1.0.ConclusionThe difference in Hyper − Hypo in the BHTT may be the most useful index in differentiating SES from acquired unilateral trochlear nerve palsy; if the difference was more than 6 PD, the probability of SES was very low.

Sagging Eye Syndrome--an Overlooked Diagnosis

Background: Sagging Eye Syndrome (SES) is a relatively unknown cause for binocular distance diplopia. SES presents with an acquired comitant or non-comitant small angle esotropia and/or hypotropia commonly occurring in the elderly population. Inferior displacement of the lateral rectus secondary to age-related degeneration of orbital connective tissue and extraocular muscles appears to be responsible for the ocular misalignment. SES patients often present with new onset or progressively worsening distance diplopia, typically warranting neuroimaging. However, through understanding SES, eye care practitioners may identify these cases, avoiding unnecessary imaging studies. Case Report: A 90-year-old male presented with complaints of intermittent horizontal diplopia at distance despite being prescribed prism for presumed decompensating phoria at his most recent eye exam. The patient noted progressing diplopia which appeared worse in right gaze. Full binocular examination revealed a non-comitant esotropia worse at distance than near. External exam revealed prominent deep superior sulci, blepharoptosis, and orbital fat loss bilaterally. Due to the progressive nature and incomitancy of the diplopia, a neuro-ophthalmology consult was obtained, and the patient was diagnosed with SES. A clinical diagnosis was made based on history, adnexal features, and motility patterns distinct to SES, obviating the need for confirmatory imaging. Conclusion: Patients presenting with new onset diplopia secondary to undiagnosed SES may prompt expensive and time-consuming investigations. It is critical that eye care practitioners accurately recognize the signs, symptoms, and clinical features of SES to avoid unwarranted imaging and patient anxiety. This case report reviews the clinical presentation, exam findings, and distinct picture of SES required for diagnosis and necessary to differentiate this condition from more serious neurologic conditions. Treatment and management will be discussed.

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

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. 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. 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). 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.

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.

AAPOS Adult Strabismus Committee's Report on the Status of Adult Strabismus Telemedicine.

To evaluate the utility of telemedicine in the treatment of adult patients with strabismus. A 27-question online survey was sent to ophthalmologists of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) Adult Strabismus Committee. The questionnaire focused on the frequency of telemedicine utilization, the benefits in the diagnosis, follow-up, and treatment of adult strabismus, and barriers of current forms of remote patient visits. The survey was completed by 16 of 19 members of the committee. Most respondents (93.8%) reported 0 to 2 years of experience with telemedicine. Telemedicine was found to be useful for initial screening and follow-up of established patients with adult strabismus, mainly to reduce wait time for a subspecialist visit (46.7%). A successful telemedicine visit could be completed with a basic laptop (73.3%) or a camera (26.7%) or could be assisted by an orthoptist. Most participants agreed that common forms of adult strabismus (cranial nerve palsies, sagging eye syndrome, myogenic strabismus, and thyroid ophthalmopathy) could be examined via webcam. It was easier to analyze horizontal than vertical strabismus. Among the paralytic forms, sixth nerve palsy was the easiest one to assess. Latent forms of strabismus can be partially diagnosed and evaluated using telemedicine, but half of the respondents underlined the importance of in-person examinations in these cases. Sixty-nine percent believed that telemedicine could be a low-cost and time-efficient health service solution. Most members of the AAPOS Adult Strabismus Committee consider telemedicine to be a useful supplement to the current adult strabismus practice. [J Pediatr Ophthalmol Strabismus. 2023;60(6):386-389.].

Sagging eye syndromeのテレビ番組を観て来院した患者の臨床的特徴

Sagging eye syndromeのテレビ番組を観て来院した患者の臨床的特徴

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

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. Retrospective cross-section study. 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. 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). Age-related orbital connective tissue degeneration may manifest as SES in the upper eyelid and as IXT in the lower eyelid.

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

PurposeAlthough 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.MethodsWe 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.ResultsTwenty-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.ConclusionsBecause 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.

Clinical characteristics of adult-onset myopic eye sagging syndrome

Patients with adult-onset, gradual, acquired, comitant esotropia present a diagnostic challenge. Heavy eye syndrome (HES) and sagging eye syndrome (SES) have been postulated to explain this pathophysiology. HES affects high myopes, typically over 10 D. SES typically affects patients over 60 from LR-SR band degeneration. In our study we review clinical, imaging and laboratory findings of patients falling outside the parameters of SES and HES.

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.

Can machine learning (ML) distinguish hypertropia (HT) in sagging eye syndrome (SES) from superior oblique palsy (SOP)?

Can machine learning (ML) distinguish hypertropia (HT) in sagging eye syndrome (SES) from superior oblique palsy (SOP)?

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.

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.

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.

Quantification of Cover Test Prior and Post Pyridostigmine in Diagnosis of Myasthenia Gravis

ABSTRACT Objective: To assess the value of measuring diplopia before and after pyridostigmine intake to differentiate myasthenia gravis from sagging eye syndrome. To establish a threshold for a positive response to pyridostigmine in the diagnosis of myasthenia gravis. Methods: 15 patients with myasthenia gravis and 15 with sagging eye syndrome diplopia were evaluated. Diplopia was measured in five positions (upgaze, downgaze, right gaze, left gaze, and primary position). After baseline measurements, the patient received a single dose (60 mg) of pyridostigmine. After 60 minutes the prism measure was performed again in five positions. Horizontal deviation, vertical deviation at distance was compared before and after a single dose of pyridostigmine in each gaze. Ocular deviations were compared between the two groups to identify the threshold with the highest sensitivity and specificity. Results: Differences between pretest deviations and posttest deviations in any gaze were found to be statistically significant only in the MG group. The optimum threshold for a positive response to pyridostigmine was a reduction of 2 prism diopters in any component in any gaze. Sensitivity for the detection of myasthenia diplopia was 80.00% and specificity was 86.67%. Conclusions: Our results suggest that measuring diplopia with prisms before and after pyridostigmine administration can help to detect patients with suspected myasthenia.