Sagging Eye Syndrome
Sagging eye syndrome, which can be seen in older patients without the prerequisite of myopia, presents with a mild- to moderate-angle esotropia at distance (ie, divergence insufficiency), full lateral gaze, and minimal hypotropia with limited supraduction (see Chapter 8). The lateral rectus–superior rectus band degenerates, with inferior displacement of the lateral rectus muscle, in conjunction with the prolapse of connective tissue superotemporally, but there is no globe prolapse. In addition, patients often experience degenerative changes that can cause deep superior sulci, high lid creases, and ptosis resulting from levator aponeurosis dehiscence. Sagging eye syndrome is the mechanism underlying divergence insufficiency in the elderly. Augmented medial rectus muscle recession is typically successful in correcting the esotropia.
Rutar T, Demer JL. “Heavy eye” syndrome in the absence of high myopia: A connective tissue degeneration in elderly strabismic patients. J AAPOS. 2009;13(1):36–44.
Excerpted from BCSC 2020-2021 series: Section 5 - Neuro-Ophthalmology. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.