Acquired Esotropia in
a middle aged female
myope
NOSA 2004
Mark Donaldson &Lionel Kowal,
Ocular Motility Clinic, RVEEH
Jenni Sorraghan, Optometrist,
Shepparton
Case Report
51 yo WCF
6 y progressive esotropia and hypotropia
POHx
- Left anisomyopic amblyopia
- no known neurological / orbital disease
Examination findings
VA. R = 6/12
L = HM
Refr R = -0.50-1.00 x 175 L = - 40 (ret)
EOM
27  L ET
12  L hypotropia
Reduced Abduction & Elevation LE
Pre-op Photos
Poor
elevation
L ET &
hypo
For neurologists only
What now?

Axial length L 35 mm
Inf displacement LLR
Normal LLR
Nasal displacement LSR
No intracranial path
SR/LR angle = 135 deg
For Ophthalmologists and
neurologists
What is this?

Large Angle Esotropia with High
Myopia Heavy Eye Syndrome
Progressive enlargement of myopic globe after
orbital growth has finished
Globe appears to prolapse / herniate between
superior and lateral recti ?orbital septum
weakest here
Abnormal LR/SR position  abnormal function
Result: Large angle esotropia with hypotropia
From Yokoyama et al
From Yokoyama et al
New abnormal SR vector elevates less well
& adducts
Normal SR vector
normal
New abnormal
LR vector & ANTI- ELEVATOR
Large Angle ET + High Myopia
Heavy Eye Syndrome
[not really heavy]
Inferior displacement of lateral rectus
i)
Reduced abducting force of the lateral rectus
ii) LR restricts elevation
Surgical management
‘Yokoyama procedure’
Join LR & SR 15mm behind limbus with
permanent suture
Elevates the LR
Abducts the SR
Makes their function more normal
BEFORE / AFTER PHOTOS : STRAIGHT,
BETTER ELEVATION
Pre operative
Post operative
photos
Post operative photos
Conclusions: Large Angle Esotropia with High Myopia
(Heavy Eye Syndrome)
Unusual mechanism of acquired esotropia [with
hypo] in a uni- or bi- lateral myope : acquired
change in orbital anatomy and muscle
mechanics
Distinctive pathophysiology which dictates a
logical and [usually] effective treatment
Conclusions: Large Angle Esotropia with High Myopia
(Heavy Eye Syndrome)
Thank you