To Introduce a Difficult Instance of Weighty Eye Disorder (HES)

Gentian Kristo^*
*Correspondence: Gentian Kristo, Maxillofacial Surgery Department, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy, Email:

Editorial

Heavy eye syndrome (HES), or myopic strabismus fixus, is an acquired progressive type of esotropia associated with severe myopia. Patients with HES present with eyes that are in esotropia with limited abduction due to elongation of the axial length and herniation of the sclera between the superior rectus (SR) and lateral rectus (LR). Inferior displacement of the LR causes hypotropia and limits abduction, while nasal displacement of the SR causes esodeviation and restricts supraduction. Loop myopexy is used to modify the SR and LR positions, thus restoring their physiological function [1].

A 56-year-old female presented to our strabismus clinic complaining of progressive esotropia over several years. She had a history of retinal detachment in both eyes, which had been treated with a scleral buckle more than 15 years prior to presentation. However, the esotropia was present about 5 years before the retinal procedures. Upon examination, her visual acuity was 20/100 in the right eye and 20/300 in the left eye. Anterior segment examination showed long standing mid dilated pupil related to previous ocular procedures in the right eye with aphakia and a normal left eye with early cataractous changes. Fundus examination showed degenerative myopic changes and a scleral buckle of excellent height. Ocular motility examination showed limitation of elevation -2 in both eyes [2]. The right eye had moderate abduction limitation −2, while the left eye had severe abduction limitation −3. In primary gaze, she had an angle esotropia of >90 Δ and a small left hypotropia. The axial length was measured 29.8 mm in the right eye and 30.5 mm in the left eye. Magnetic resonance imaging (MRI) confirmed the diagnosis [3].

A high-resolution T2-weighted MRI.3T scanner (GE Discovery 750W MRI; General Electric, Milwaukee, WI, USA) was used. The MRI data was transferred to the picture archiving and communication system (PACS) in the original digital imaging and communications in medicine (DICOM) format through AGFA workstation. Orbital coronal MRI images were evaluated [4]. The LR and SR muscles positions were determined relative to the globe center from quasicoronal images and correlated with LR-SR band structure. The LRSR dislocation angle was defined as the angle formed between the centroid of LR and SR and the centroid of the globe, in accordance with the method of Yokoyama et al. The LR-SR band was qualitatively assessed as thinning, discontinuity, or displacement by examining adjacent quasicoronal image planes. The treating physician decided to plan for loop myopexy with a scleral band in both eyes plus bilateral medial rectus (MR) recession. Under general anesthesia, forced duction test showed bilateral tightness in abduction and supraduction. Intraoperatively, there were encircling style 240 scleral buckles in both eyes placed almost 15 mm from the limbus. The MR was approached through a fornix incision and recessed 8 mm using a hang-back technique [5].

Then, through a superotemporal fornix incision, the nasally displaced SR was hooked and isolated from the surrounding attachments. The same was done for the LR, which had been displaced inferiorly. Manipulation of the existing scleral buckle was avoided to prevent avoidable retinal complications. Afterward, a scleral tunnel was made 12 mm from the limbus in the superotemporal quadrant, posterior to the existing scleral buckle. A style 240 silicone band was passed under the SR and then through the tunnel and under the LR.

Conflict of Interest

The authors declare that there is no conflict of interest associated with this manuscript.

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