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 = 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? 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 neurologists What is this? 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

normal New abnormal SR vector - elevates less well & adducts New abnormal LR vector & ANTI- ELEVATOR Normal SR vector

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

Post operative photos BEFORE / AFTER PHOTOS : STRAIGHT, BETTER ELEVATION Pre operative

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