Acquired Esotropia in Acquired Esotropia in a middle aged female a middle aged female

myopemyope

NOSA 2004NOSA 2004

Mark Donaldson &Lionel Kowal, Mark Donaldson &Lionel Kowal, Ocular Motility Clinic, RVEEHOcular Motility Clinic, RVEEH

Jenni Sorraghan, Optometrist, Jenni Sorraghan, Optometrist, Shepparton Shepparton

Case ReportCase Report

51 yo WCF

6 y progressive esotropia and hypotropia

POHx - Left anisomyopic amblyopia

- no known neurological / orbital disease

Examination findingsExamination findings

VA. R = 6/12 L = HMRefr R = -0.50-1.00 x 175 L = - 40 (ret)

EOM 27 L ET12 L hypotropia

Reduced Abduction & Elevation LE

Pre-op PhotosPre-op Photos

Poor elevation

L ET & hypo

For neurologists onlyFor neurologists only

What now?What now?

Axial length L 35 mm

Normal LLR

No intracranial path

Inf displacement LLR

Nasal displacement LSR

SR/LR angle = 135 deg

For Ophthalmologists and For Ophthalmologists and neurologistsneurologists

What is this?What is this?

Large Angle Esotropia with High Large Angle Esotropia with High Myopia Myopia Heavy Eye SyndromeHeavy 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 alFrom Yokoyama et al

From Yokoyama et alFrom Yokoyama et al

normal

New abnormal SR vector - elevates less well& adducts

New abnormalLR vector & ANTI- ELEVATOR

Normal SR vector

Large Angle ET + High Myopia Large Angle ET + High Myopia

Heavy Eye SyndromeHeavy Eye Syndrome[not really heavy][not really heavy]

Inferior displacement of lateral rectus

i) Reduced abducting force of the lateral rectus

ii) LR restricts elevation

Surgical managementSurgical management

‘Yokoyama procedure’

Join LR & SR 15mm behind limbus with permanent suture

Elevates the LRAbducts the SR

Makes their function more normal

Post operative Post operative photosphotos

BEFORE / AFTER PHOTOS : STRAIGHT, BEFORE / AFTER PHOTOS : STRAIGHT, BETTER ELEVATIONBETTER ELEVATION

Pre operative Pre operative Pre operative Pre operative

Post operative photosPost operative photos

Conclusions:Conclusions: Large Angle Esotropia with High Myopia Large Angle Esotropia with High Myopia(Heavy Eye Syndrome)(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:Conclusions: Large Angle Esotropia with High Myopia Large Angle Esotropia with High Myopia(Heavy Eye Syndrome)(Heavy Eye Syndrome)

Thank you