Myopic strabismus fixus with endophthalmitis.

Sir,

Convergent strabismus fixus is a rare ocular motor abnormality, in which the affected eye is more or less fixed in extreme adduction. Different causes of acquired convergent strabismus fixus have been reported such as intraocular tumor or amyloidosis. More frequently, convergent strabismus fixus is associated with high myopia. We hereby report a clinical case of bilateral myopic strabismus fixus with endophthalmitis of the right eye.

A 72-year-old woman with a history of high myopia, never corrected since childhood, was admitted for endophthalmitis complicating corneal abscess of the right eye. Furthermore, we noticed convergent strabismus [Figure 1]; no voluntary eye movement was possible. The patient reported that this progressive ocular deviation goes back to many years ago and that she never presented for it. Fundus examination of the left eye found large areas of chorioretinal atrophy [Figure 2]. Moreover heterogeneous vitreous of the right eye, magnetic resonance imaging (MRI) of the orbits demonstrated deviation and elongation of eyeballs, axial length measuring 33 mm [Figure 3], and inferomedial displacement of the lateral rectus muscle (LR) and nasal displacement of the superior rectus muscle in both eyes [Figure 4]. Evisceration of the right eye was performed given the worsening of the infection in despite antibiotics administrated locally (eye drops and intravitreal) and intravenous. Muscle biopsy during evisceration for histological analysis showed no myopathy. The patient refused surgery on his left eye strabismus.

Figure 1

Endophthalmitis of the right eye, and convergent strabismus of both eyes

Figure 2

Left eye funduscopy: large areas of chorioretinal atrophy

Figure 3

Magnetic resonance imaging: Ocular deviation and elongation, with heterogeneous vitreous in the right eye

Figure 4

Inferomedial displacement of the lateral rectus muscle and nasal displacement of the superior rectus muscle in both eyes (arrows)

In convergent strabismus fixus, the involved eye is fixed in a position of extreme adduction. Myopic strabismus fixus is classically seen in cases of high myopia (axial lengths >28 mm) characterized by a progressive esotropia and hypotropia associated with a limited elevation and abduction. Yokoyama et al. have explained this eso-hypodeviation in myopic strabismus as a consequence of shifting of the muscles secondary to elongation of the eyeball.[1] Krzizoh et al., based on MRI findings, postulated the downward displacement of the LR, reducing the abduction effect, and leading not only to an esotropia but also to a hypotropia, as major pathophysiological factor in myopic strabismus fixus.[2] In general, there are two main surgical techniques for myopic strabismus fixus, which have a different approach: (1) Conventional recession-resection surgery that mainly alters muscle forces and (2) innovative surgery procedures that allow to correct deviated muscle paths and get a normalized alignment of the muscle course by myopexy of the LR at the equator[3] or by transposition surgery.[4]

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Conflicts of interest

There are no conflicts of interest.