Management of Heavy Eyeball Syndrome--our experience.

Sir,

We read with great interest the case report by Jethani and Amin[1] and the subsequent discussion on management and the need to operate on Inferior rectus by Bhambhwani et al.[2] We would like to congratulate the authors on successful management of this rare and interesting clinical entity and would like to share our experience in the management of a similar case.

A 56-year-old Vietnamese lady presented to the Orbis Flying Eye Hospital program held in Hanoi, Vietnam in May 2015. The patient complained of deviation of the right eye started 10 years ago, gradually increasing in severity. She had a history of wearing eyeglasses since a young age and complained of difficulty in doing daily work without her glasses. There was no history of face turn. In 2012, the patient underwent phacoemulsification with posterior chamber intraocular lens in the bag for both eyes. The uncorrected visual acuity on presentation was 20/63 in the right eye, and 20/50 in the left eye. There was no family history of similar problems in the family members.

Extraocular movements were restricted in abduction (−4 in the right eye, −2 in the left eye) and elevation (−3 in the right eye, −1 in the left eye). Cover test and prism bar test showed that this patient had 90-prism diopters (PD) bilateral esotropia and 10 PD hypotropia in the right eye [Fig. 1a]. Posterior segment examination revealed tessellated tigroid fundus, myopic macular degeneration with posterior staphyloma in both eyes.

Figure 1

(a) Preoperative photo shows extraocular movements showing restriction in abduction (−4 in the right eye, −2 in the left eye) and elevation (−3 in the right eye, −1 in the left eye). (b) Postoperative photo shows improved movement of both eyes

Orbital magnetic resonance imaging showed nasally shifted superior rectus (SR) and inferiorly shifted lateral rectus (LR) [Fig. 2]. Axial length measured with the A Scan was 31.47 mm and 31.95 mm in the right and left eye, respectively.

Figure 2

Coronal scan of magnetic resonance imaging showing (a) nasally displaced superior rectus and (b) inferiorly displaced lateral rectus

We performed loop myopexy between SR and LR of both eyes 12 mm from the limbus and bilateral medial rectus recession of 5 mm under general anesthesia with adjustable sutures in the left eye.

Postoperatively, the patient had residual 10 PD exotropia and no hypotropia 1 day postoperatively. Abduction was improved in both eyes but remained slightly restricted (−1). After 5 mm left medial rectus advancement of the adjustable suture, exotropia decreased to 6 PD [Fig. 1b].

Surgical management of such cases is complex and has evolved over years. It ranges from conventional maneuvers of resection recession procedures that mainly affect muscle forces[34] to modified procedures that include transposition techniques that alter the muscle paths.[56] We believe that loop myopexy of the SR and LR muscles with MR recession (in the case of tight muscles) is sufficient to restore the dislocated globe back into the muscle cone and to achieve improvement of esotropia, hypotropia, abduction, and supraduction in patients with large angle strabismus and displaced SR and LR. Using adjustable suturing improves the predictability and final outcome in such complex cases.

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