Sagging Eye Syndrome Research Articles

Sagging Eye Syndrome and Similar Conditions

Sagging Eye Syndrome and Similar Conditions

Differential Diagnosis of Acquired Esotropia in the Elderly.

To provide an overview of the differential diagnoses of acquired esotropia that occur in the elderly and to facilitate their differentiation in everyday clinical practice. The data of all patients who presented in our outpatient university department for strabology and neuroophthalmology from March 2014 to October 2015 due to esotropia with diplopia with onset after age 50 were evaluated retrospectively. Exclusion criteria were a known strabismus before the age of 50 and/or vertical deviations in the primary position. Anamnestic characteristics, accompanying findings and orthoptic parameters, were analysed. 85 patients were included in the study, 42 of them female and 43 male. The following diagnoses were made: abducens nerve palsy (n = 34, 3 of them both sides), esotropia due to myopia magna (n = 12), esotropia with accompanying neurological symptoms (n = 6) and other etiology (n = 5). In 4 cases, the diagnosis was still unclear at the end of the study. In 24 patients, none of the above diagnoses existed and the diagnosis of "sagging eye syndrome" (ETSAG) was made. The abducens nerve palsy typically showed a sudden onset of double vision, slowed abduction saccades and asymmetrical abduction ability. With unilateral abducens nerve palsy, the esotropia increased continuously from the view to the unaffected side through the primary position to the view to the affected side. Patients with ETSAG and myopia-associated esotropia, on the other hand, reported a gradual onset of double vision, showed normal abduction saccades and a slightly reduced abduction ability. The squint angle often increased slightly to both sides. Esotropia with accompanying neurological symptoms was rare and was seen in various underlying diseases. The kind of onset of the double vision, the quality of the saccades, the incomitance pattern and the ability to abduct are important parameters for the etiological assignment of an esotropia in the elderly. The characteristics of the individual diagnoses are described and differential diagnostic aspects are discussed.

Sagging Eye Syndrome: A Differential Diagnosis for Diplopia.

Sagging Eye Syndrome: A Differential Diagnosis for Diplopia.

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.

Inferior rectus displacement in heavy eye syndrome and sagging eye syndrome.

To evaluate if there is a nasal displacement of the vertical rectus muscles in heavy eye syndrome (HES) and/or sagging eye syndrome (SES) compared with age-matched controls. We reviewed the charts of all patients with the diagnosis of HES or SES who were seen at the University of California San Diego (UCSD) between the years 2008-2016 who underwent magnetic resonance imaging (MRI) of the brain and orbits. The control group included patients who had brain and orbital MRIs at UCSD in the absence of known pathology in the orbits or globes. Measurements were taken by 3 separate examiners for all groups. Twenty-four patients (16 with SES and 8 with HES) and 24 age-matched controls were retrospectively reviewed. The superior rectus (SR) of patients with HES and SES was more nasally displaced from the midline compared with that of age-matched controls (p = 0.04, p = 0.03, respectively). The inferior rectus (IR) of patients with HES but not with SES was more nasally displaced from the midline compared with that of age-matched controls (p = 0.04, p = 0.62, respectively). In all groups, the IR nasal displacement from the midline was approximately double compared with the SR. There is a significant nasal displacement of the SR in HES and SES and IR in HES. The observed IR nasal displacement in HES is a new finding and may explain the residual hypotropia and/or esotropia following surgical interventions for HES not involving the IR.

Clinical Evaluation of Strabismus in Elderly Individuals with Emphasis on the Differences between Sagging Eye Syndrome and Ocular Movement Nerve Paralysis

Clinical Evaluation of Strabismus in Elderly Individuals with Emphasis on the Differences between Sagging Eye Syndrome and Ocular Movement Nerve Paralysis

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.

High prevalence of sagging eye syndrome in adults with binocular diplopia

High prevalence of sagging eye syndrome in adults with binocular diplopia

Detailed Anatomy of the Lateral Rectus Muscle-Superior Rectus Muscle Band.

Background To elucidate the detailed anatomy of the lateral rectus muscle-superior rectus muscle (LR-SR) band by cadaver eye investigation. Methods In total, 48 eyes of 24 cadavers were observed macroscopically. The lateral rectus muscle (LRM) and superior rectus muscle (SRM) were dissected from their origins to their insertions under the dissecting microscope, and the location, width, length, and tensile strength of the LR-SR bands were measured. Results The LR-SR band is the thick ligament interconnecting LRM pulleys with SRM pulleys. The LR-SR band was covered by the orbital part of the lacrimal gland superiorly, and the intermuscular septum between the LRM and SRM was shown anterior to the LR-SR band. The length of the attachment site between the LR-SR band and the SRM was less at 8.64 ± 1.52 mm (p=0.040), its thickness was thinner at 0.74 ± 0.16 mm (p=0.002), and its tensile strength was weaker at 7.64 ± 1.82 N (p=0.028) compared to the attachment site between the LR-SR band and the LRM. Conclusions This study revealed the detailed anatomy of the LR-SR band and provided helpful information to understand heavy eye syndrome and sagging eye syndrome.

Lateral rectus sag and recurrent esotropia in children

To describe the clinical and intraoperative findings of an anatomic abnormality in children that resembles sagging eye syndrome documented in older adults and that led to recurrent esotropia after surgery. We reviewed records of 4 patients with substantial recurrent esotropia after bilateral medial rectus recession who required subsequent surgery combining lateral rectus resection with correction of the anatomic abnormality affecting the lateral rectus path. Binocular alignment was sequentially analyzed. Three young patients (2-3years of age) presented with acquired esotropia but minimal cycloplegic refractive error. The fourth patient (14years of age) initially had moderate hyperopia and partially accommodative esotropia, but subsequently developed marked bilateral overelevation in adduction. In all patients, esotropia recurred within 5Δ of preoperative deviation after bilateral medial rectus recession. Surgical exposure demonstrated that bilateral lateral rectus paths were inferiorly displaced more than one-half tendon width from their normal paths near the globe's equator, despite normal scleral insertions. Equatorial myopexy and lateral rectus resection resulted in stable esotropia correction. Lateral rectus sag in children creates a type of acquired esotropia and overelevation in adduction poorly responsive to standard surgery but correctable with lateral rectus resection and equatorial myopexy that normalizes the lateral rectus path through permanent scleral fixation.

Rectus Extraocular Muscle Paths and Staphylomata in High Myopia

To investigate the relationship between displacement of extraocular muscles (EOMs) and staphyloma in high myopia using magnetic resonance imaging (MRI). Retrospective case-control study. Setting: Institutional study. Twenty-nine highly myopic patients (46 eyes), 11 age-matched healthy control subjects (21 eyes), and 34 patients (66 eyes) with sagging eye syndrome. MRI was analyzed for aspect ratio (AR) of the ocular cross section, locations of staphylomata and EOMs, and status of superior rectus to lateral rectus (SR-LR) band ligament. Association between staphylomata with EOM paths and the LR-SR band. Several associations of staphylomata were statistically significant (P < .05). Most staphylomata were superotemporal. Myopic patients with staphyloma had larger ARs in quasi-coronal images than in myopic subjects without staphyloma or normal controls. Compared to patients with high myopia without staphyloma and normal controls, when staphyloma was present, there was more inferior LR displacement, larger LR-globe angle, and larger SR-LR displacement angle than in myopic subjects without staphyloma. Staphyloma in the superotemporal quadrant was associated with greater SR-LR angle than in other quadrants. There were significantly more ruptures of SR-LR band ligament in highly myopic patients with staphyloma than in those without staphyloma. Local staphylomata in high myopia reflect ocular asphericity and correlate with EOM paths. Myopic staphylomata are associated with inferior displacement of LR path and defect of the LR-SR band ligament.

The management of vertical deviations in sagging eye syndrome

The management of vertical deviations in sagging eye syndrome

Lateral rectus equatorial myopexy (LREM) for sagging eye syndrome (SES)

To report results of LREM for SES.

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.

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).

Heavy eye syndrome versus sagging eye syndrome in high myopia

Heavy eye syndrome (HES) presents with esotropia and limited abduction due to superotemporal globe shift relative to the extraocular muscles. Sagging eye syndrome (SES) was originally described in nonmyopic patients exhibiting distance esotropia and cyclovertical strabismus with limited supraduction due to lateral rectus muscle inferodisplacement caused by degeneration of the lateral rectus-superior rectus (LR-SR) band. We hypothesized that SES might also cause strabismus in high myopia. Eleven strabismic subjects with high myopia underwent ophthalmological examination and orbital magnetic resonance imaging (MRI) to assess quantitative orbital anatomy. Of 11 subjects, 5 had HES; 6, SES. Mean axial length in subjects with HES was 32± 5 mm; in subjects with SES, 32 ± 6 mm. Average distance esotropia in subjects with HES was 61(Δ) ± 39(Δ); hypotropia was 26(Δ) ± 21(Δ). Average distance esotropia in subjects with SES was 23(Δ) ± 57(Δ); hypertropia was 2(Δ) ± 2(Δ). All 5 subjects with HES had superotemporal globe prolapse; the LR-SR band was thinned in 6 orbits and ruptured in 2. The mean angle between the lateral rectus and superior rectus muscles in HES was 121° ± 7°. In SES the LR-SR band was thinned in 7 orbits and ruptured in 5, with superotemporal soft tissue prolapse. The mean angle between the lateral rectus and superior rectus muscles was 104° ± 11°, significantly less than in HES (P < 0.001). SES occurs in highly myopic patients who also exhibit less relative globe dislocation than in HES. Unlike HES, SES exhibits superotemporal soft tissue prolapse that may limit superotemporal globe shift. The distinction is important because surgery for HES uniquely requires creation of a surgical connection between the superior rectus and lateral rectus muscles, whereas SES may be treated with conventional surgery. SES can cause strabismus in high axial myopia. Orbital MRI is useful in differentiating SES from HES.

プリーのMRI画像所見―LR-SRバンド異常とSagging Eye Syndromeとの関係

プリーのMRI画像所見―LR-SRバンド異常とSagging Eye Syndromeとの関係

Graded vertical rectus tenotomy for small-angle cyclovertical strabismus in sagging eye syndrome

Background/aimsGraded vertical rectus tenotomy (GVRT) is postulated as effective for small-angle vertical heterotropia. We aimed to determine the dosing recommendations for GVRT in sagging eye syndrome (SES).MethodsThis was a retrospective,...

Heavy eye syndrome (HES) and sagging eye syndrome (SES) in high myopia

Heavy eye syndrome (HES) and sagging eye syndrome (SES) in high myopia