Surgical treatment outcomes in heavy eye syndrome - a case series.

Results: The study cohort comprised five patients, each presenting with unilateral high axial myopia and classic clinical features of HES, including large angle esotropia, hypotropia, and restricted abduction and supraduction. All patients displayed evident superotemporal globe prolapse on MRI imaging, corresponding to the downward displacement of the LR muscle and medial shift of the SR muscle.Following the surgical procedure, all patients demonstrated significant improvements in both vertical and horizontal deviations, effectively addressing the primary clinical manifestations of HES.Conclusions: In the management of HES, several surgical approaches have been explored, yielding mixed results. Our study, employing the technique of partial muscle splitting and scleral fixation, offers a promising avenue for effectively addressing this challenging condition. By adapting the full loop myopexy technique originally proposed by Yokoyama et al. we achieved satisfactory ocular alignment in all five patients. Notably, this approach mitigates the risk of anterior segment ischemia by preserving the unsecured portions of the SR and LR muscles along with MR retroequatorial myopexy.These findings support the consideration of this surgical technique as a safe and effective option for managing HES, providing both cosmetic and functional improvements to afflicted individuals.

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.

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.

Miopexia supra-ecuatorial del recto lateral en el tratamiento del síndrome «sagging/heavy eye» miópico / Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye

Objetivo Describir los resultados de sujetos con síndrome «sagging/heavy eye miópico» operados mediante la miopexia supraecuatorial del recto lateral. Método Estudio retrospectivo de 9 casos entre 2017-2023. Se analizaron desviación horizontal, vertical, ambliopía, diplopía, ducciones, torsión, pruebas sensoriales antes y después de la cirugía, patología macular y resonancia magnética orbitaria. El tratamiento se consideró exitoso cuando desaparecía o mejoraba la diplopía y una desviación vertical≤5 dioptrías prismáticas (Dp) al final del seguimiento. Resultados La edad media (DE) fue: 62,11 (4,6) años (100% mujeres). El 88,88% presentaba diplopía. La hipotropía media preoperatoria fue: 11,33Dp (DE 3,16), y la desviación vertical final 3,44Dp (DE 3,05). Tras la cirugía, la hipotropía se invirtió en un caso, quedó subcorregida en 5 y se alcanzó ortoforia en otros 3. La técnica se asoció a la cirugía de otro músculo recto en 4 sujetos. El tiempo medio de seguimiento posquirúrgico fue de 34 meses (DE 34,62). Seis de las 9 pacientes quedaron con una desviación vertical≤5Dp. En 3 pacientes se consiguió eliminar totalmente la diplopía, mientras que en 5 quedó intermitente (3 con patología macular) Conclusión En el tratamiento del «sagging/heavy eye miópico», el supradesplazamiento ecuatorial con miopexia del recto lateral constituye una opción terapéutica si la hipotropía es menor de 12Dp o la técnica de Yokoyama no está indicada. Se obtuvo un buen resultado en más de la mitad de los casos, suprimiéndose totalmente la diplopía en 3 y quedando en otros 5 de forma intermitente (AU)

Purpose To describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with lateral rectus myopexy. Methods A retrospective study of 9 cases between 2017 and 2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered successful if the diplopia was improved or eliminated and a final vertical deviation≤5prism diopters (PD). Results The mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33PD (SD 3.16), and the mean final VD 3.44PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another 3. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation≤5PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (3 with macular pathology). Conclusion Supra-equatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye is a therapeutic option if hypotropia is less than 12PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent (AU)

Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye.

PURPOSE: To describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with LR myopexy. METHODS: A retrospective study of 9 cases between 2017-2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered Successful if the diplopia was improved or eliminated and a final vertical deviation (VD) ≤5 prism diopters (PD). RESULTS: The mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33 PD (SD 3.16), and the mean final VD 3.44 PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another three. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation ≤5 PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (three with macular pathology). CONCLUSION: Supra-equatorial displacement with LR myopexy for treatment of myopic sagging/heavy eye, is a therapeutic option if hypotropia is less than 12 PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent.

Recovery of stereoacuity after Yokoyama procedure in patients with highly myopic strabismus with good vision.

Purpose: To report stereopsis after bilateral Yokoyama procedure in patients with highly myopic strabismus and good visual acuity. Observations: Five patients aged between 34 and 81 years with best-corrected visual acuity of 20/25 or better were operated on. The preoperative strabismus angle ranged from esotropia of 35-113 prism diopters (PD) at distance and esotropia of 40-113 PD at near. One patient had left hypotropia of 4 PD and excyclotorsion of 15°, and the other had left hypotropia of 10 PD. Their axial lengths were 27.65-33.07 mm, and the posterior globe dislocation angles were between 123 and 148° on coronal magnetic resonance imaging (MRI). Limitations of abduction were between -1 and -2. All patients complained of diplopia, and none of them showed stereopsis. The Yokoyama procedure was performed on both eyes. Postoperative alternate cover testing showed from esotropia of 2 PD to exophoria of 8 PD at distance and from exotropia of 12 PD to esophoria of 10 PD at near.Three patients recovered stereopsis of 100, 50, and 140 sec, respectively. Two cases required unilateral inferior rectus muscle recessions, and their postoperative stereopsis was 25 and 50 sec. Conclusions and Importance: The Yokoyama procedure is effective not only in cases of heavy eye syndrome but also in cases of myopic esotropia associated with a globe dislocation angle of 120° or with little abduction restriction. If visual acuity is good, stereopsis may be restored with improvement in eye deviation.

Yokoyama procedure for a woman with heavy eye syndrome who underwent multiple recession-resection operations: A case report.

BACKGROUND: Heavy eye syndrome (HES) is an acquired strabismus typically seen in eyes with high myopia. We report a classic case in which a patient was misdiagnosed with esotropia and underwent disinsertion of the medial rectus muscle and lateral rectus muscle resection procedures. CASE SUMMARY: A 71-year-old woman presented with both eyes fixed in adduction and infraduction for 33 years. She had undergone three complicated strabismus surgeries to amputate the left medial rectus (MR) muscle with lateral rectus muscle recession, but no improvement in the esotropia appeared after each operation. She was diagnosed with HES and underwent a bilateral Yokoyama procedure and recession of the right MR muscle under general anesthesia. After surgery, her eyes were binocularly aligned for 6 mo. This case suggests that pertinacious esotropia combined with high myopia must be considered in HES. Orbital imaging and ultrasonography can demonstrate anatomical abnormality and muscle paths to confirm a definite diagnosis. CONCLUSION: The Yokoyama procedure was effective in correcting HES.

Acquired Diplopia in Adults: Heavy Eye Syndrome.

Heavy eye syndrome is a condition that results in an acquired, progressive strabismus that is due to extreme myopia and long axial length. The underlying pathogenesis of the condition is due to prolapse of the supero-temporal aspect of the myopic globe causing displacement of the lateral and superior rectus muscles inferiorly and nasally, respectively. Treatments for heavy eye syndrome often target this anatomical defect and seek to re-place the globe within the extraocular muscle cone. This review will discuss current theories of pathogenesis and treatment of heavy eye syndrome.

Heavy eye syndrome in a myopic patient with prior scleral buckle surgery for rhegmatogenous retinal detachment: Differential diagnosis and management.

PURPOSE: To present a challenging case of heavy eye syndrome (HES) in a 56-year-old female who previously underwent scleral buckle surgery in both eyes. OBSERVATIONS: Ophthalmic tests indicated a diagnosis of HES, confirmed using pre and postoperative magnetic resonance imaging (MRI). A silicone band loop myopexy was performed, successfully improving large angle esotropia at primary position and motility. CONCLUSIONS AND IMPORTANCE: MRI is essential to correctly identify HES, allowing a tailored surgical intervention that may lead to better outcomes for patients. Up to our knowledge, this is the first reported case of scleral fixated silicone band loop myopexy for HES in a previously scleral buckled patient.

Yokoyama procedure for esotropia associated with high myopia: real-world data from a large-scale multicentre analysis.

PURPOSE: High myopic patients may develop strabismus due to globe dislocation out of the normal extraocular muscle cone. Surgical correction of this strabismus type is possible by joining the superior and lateral rectus muscles without the need for a scleral suture called the Yokoyama procedure. Data from large patient samples and the evaluation of a potential effect of an additional medial rectus recession (MRR) have been lacking so far. METHODS: We pooled retrospective patient data of 14 departments of ophthalmology in Germany and Switzerland and analysed determinants of postoperative results using multivariable regression models. RESULTS: We included 133 patients (mean age: 59.7 ± 13.4 years, surgery between 2008 and 2017) with a mean preoperative esotropia (both Yokoyama with and without MRR) of 23.8°±4.6°. The angle of preoperative esotropia increased with age. The postoperative esotropia was 8.7° ± 9.9°, and six patients were overcorrected. While preoperative esotropia was highly associated with postoperative results, we found no association of additional MRR with any of our postoperative outcome measures. The Yokoyama procedure had a higher absolute effect in patients with higher preoperative esotropia. CONCLUSION: Our study confirms the positive effect of the Yokoyama procedure on strabismus due to high myopia in large-scale real-world data. In some cases, MRR may be needed because of muscle contracture, although additional MRR statistically did not affect the postoperative outcome. In patients with bilateral high myopic strabismus, correction of both eyes seems beneficial. The effect size of the Yokoyama procedure appears to be mainly driven by preoperative esotropia.

Heavy eye syndrome: Myopia-induced strabismus.

Heavy eye syndrome is an important type of myopia-induced strabismus. We provide an overview of heavy eye syndrome, from its history to its most salient features. The theory of the orbital and rectus muscle pulley system as it relates to heavy eye syndrome and the prevailing theories on the pathophysiology of heavy eye syndrome in the current literature are discussed. We also highlight the presentation of heavy eye syndrome, its typical features on imaging, and differential diagnosis. Finally, we provide an overview on the management of heavy eye syndrome, including a description of several current surgical techniques.

Heavy Eye Syndrome Mimicking Abducens Nerve Palsies.

A 70-year-old woman was seen in neuro-ophthalmology consultation for a progressive right esotropia. She had a past medical history of asthma and osteoporosis, and her ocular history was significant for pathological myopia (spherical equivalent of -23.00 D OD and -21.00 D OS), bilateral cataract surgeries, and laser retinopexy for retinal tears. Twenty-five years prior to presentation, she developed binocular horizontal diplopia and was found to have a limitation of abduction to 60% and 80% of normal in the right and left eyes, respectively, by a previous neuro-ophthalmologist. She developed a progressive maculopathy in the right eye secondary to myopia, resulting in the resolution of double vision. The resolution occurred because the double vision was binocular in nature and the loss of vision in her right eye functioned similar to monocular occlusion. However, she noticed that her right eye continued to turn in toward her nose.

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

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Bilateral, Unaugmented, Loop Myopexy Performed for a Severe Case of Heavy Eye Syndrome.

AIM: To report the clinical features and surgical outcomes of one patient with heavy eye syndrome who underwent bilateral, unaugmented, full loop myopexy. METHODS: A 47-year-old lady with high myopia, high axial length, progressive esotropia, slippage of the lateral rectus (LR) inferiorly and superior rectus (SR) medially on magnetic resonance imaging (MRI) was diagnosed with heavy eye syndrome. Unaugmented loop myopexy without medial rectus (MR) recession was offered. RESULTS: On follow-up at 30 months, a small residual esotropia of 6 prism diopters (PD) at near and 10 PD at distance was achieved. Both abduction and elevation were improved in both eyes. CONCLUSIONS: The high angle of esodeviation can be challenging to correct adequately with surgery, with many options available: resection-recession, hemitranspositions (Yamada's procedure), partial loop myopexy (modified Jensen's procedure) and full loop myopexy (Yokoyama's procedure). It remains unclear which procedure is optimal for severe disease. In this case, we present bilateral, unaugmented, full loop myopexy as our preferred choice for high esotropia.

Surgical outcome of a new modification to muscle belly union surgery in heavy eye syndrome.

OBJECTIVES: To report the clinical outcomes of a new modification to muscle belly union surgery in heavy eye syndrome. METHODS: Muscle belly union was performed in patients with large-angle esotropia and characteristic findings of heavy eye syndrome on orbital imaging. After isolation of superior and lateral rectus muscle and passing a single armed suture in each muscle belly, approximation was achieved via tying of both arms of separate sutures together. Medial rectus (MR) was also recessed considering the results of the intraoperative force duction test. RESULTS: Surgery was conducted in 24 eyes of 16 patients. The mean preoperative esotropia was 93.71 ± 23.1 prism diopters (PD), which improved significantly after the operation (final esotropia: 11.53 ± 15.59 PD, P value = 0.001). Six patients also exhibited mild hypotropia preoperatively (9.33 ± 6.88 PD), which resolved completely after surgery in all cases. Evaluation of preoperative abduction limitation (minus 3.1 ± 1.83) showed a significant improvement postoperatively (minus 0.95 ± 0.68, P value = 0.000). Additionally, mild limitation of adduction (minus 1) was seen in nine patients due to large MR recession. However, none of the patients reported postoperative diplopia. CONCLUSION: Our new approach in muscle belly union surgery resulted in favorable outcomes compared with previous studies. It seems that the two-suture technique presented in this study yields more convenient approximation of muscle bellies and acts as a safety suture upon spontaneous loosening of the first applied suture.

Modified loop myopexy technique for severe high myopic strabismus fixus.

IMPORTANCE: This study introduces a modified loop myopexy technique for severe high myopic strabismus fixus. BACKGROUND: This study aims to evaluate the surgical results of loop myopexy with or without medial rectus recession for the treatment of patients with myopic strabismus fixus. DESIGN: This is a retrospective study in a Chinese teaching hospital. PARTICIPANTS: Data was collected from 25 myopic strabismus fixus patients (33 eyes) with restriction in both abduction and sursumduction. METHODS: First, the loop myopexy technique was performed. Following the loop myopexy technique, a medial rectus recession was performed if esotropia remained. If esotropia and/or hypotropia still persisted, second-stage surgery of the contralateral eye was performed. MAIN OUTCOME MEASURES: The main outcome measures were ocular deviations, eye movements and the angles of dislocation of the globe. RESULTS: At the last follow-up, mean deviation of esotropia was significantly improved (10 vs. 92 PD; p = 0.000), while mean deviation of hypotropia was improved (6 vs. 32 PD; p = 0.008). Mean abduction limitation was improved (-2.7 vs. -5.0; p = 0.000); mean elevation limitation improved (-3.2 vs. -5.0; p = 0.000). The angle of dislocation of the globe was significantly decreased (103.0 vs. 235.3 D; p = 0.002). CONCLUSIONS AND RELEVANCE: Modified Yokoyama's surgery effectively corrected the restrictive esotropia and hypotropia, restored the dislocated globe back into the muscle cone and improved the eye movement in severe myopic strabismus fixus.

Surgical treatment of heavy eye syndrome; report of two cases.

PURPOSE: To report the clinical features and surgical outcomes of two patients with heavy eye syndrome who underwent partial Jensen's procedure. CASE REPORT: A 21-year-old man and a 24-year-old woman with high myopia (-18 and -8 diopters, respectively), high axial length (27.5 and 24.6 mm), progressive esotropia (40 and 50 prism diopters), hypotropia (5 and 2 prism diopters), abduction limitation, and inferior displacement of the lateral rectus on computed tomography were diagnosed with heavy eye syndrome and underwent partial Jensen's procedure. The technique consisted of splitting the lateral and superior recti from their insertion up to the equator and uniting their superior and temporal halves respectively, with non-absorbable sutures without scleral fixation. Two months postoperatively, esotropia was reduced to 10 prism diopters in case #1 and to 25 prism diopters in case #2; limitation of abduction was also considerably diminished. CONCLUSION: Patients with heavy eye syndrome, large angle esotropia and limitation of abduction, may benefit from partial Jensen's procedure which is a simple and safe surgical option.