Original article
Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye
Miopexia supra-ecuatorial del recto lateral en el tratamiento del síndrome «sagging/heavy eye» miópico
P. Merino
, V. Antón, M. Chamorro, P. Gómez de Liaño, J. Yáñez-Merino
Corresponding author
Sección de Motilidad Ocular y Diplopía, Servicio de Oftalmología, HGU Gregorio Marañón, Madrid, Spain
Read
6
Timeswas read the article
3
Total PDF
3
Total HTML
Share statistics
array:24 [ "pii" => "S2173579423001354" "issn" => "21735794" "doi" => "10.1016/j.oftale.2023.06.021" "estado" => "S300" "fechaPublicacion" => "2023-10-01" "aid" => "2135" "copyright" => "Sociedad Española de Oftalmología" "copyrightAnyo" => "2023" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Soc Esp Oftalmol. 2023;98:553-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0365669123001326" "issn" => "03656691" "doi" => "10.1016/j.oftal.2023.06.008" "estado" => "S300" "fechaPublicacion" => "2023-10-01" "aid" => "2135" "copyright" => "Sociedad Española de Oftalmología" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Soc Esp Oftalmol. 2023;98:553-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo original</span>" "titulo" => "Miopexia supra-ecuatorial del recto lateral en el tratamiento del síndrome «sagging/heavy eye» miópico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "553" "paginaFinal" => "557" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 454 "Ancho" => 905 "Tamanyo" => 39843 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Dibujo de una miopexia supraecuatorial del recto lateral (a 15<span class="elsevierStyleHsp" style=""></span>mm del limbo) de la mitad o un tercio superior del vientre del músculo (con o sin división previa) a 8-10<span class="elsevierStyleHsp" style=""></span>mm de su inserción para colocarlo en una posición por encima de la línea horizontal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Merino, V. Antón, M. Chamorro, P. Gómez de Liaño, J. Yáñez-Merino" "autores" => array:5 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Merino" ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Antón" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Chamorro" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Gómez de Liaño" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Yáñez-Merino" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173579423001354" "doi" => "10.1016/j.oftale.2023.06.021" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579423001354?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669123001326?idApp=UINPBA00004N" "url" => "/03656691/0000009800000010/v1_202310012222/S0365669123001326/v1_202310012222/es/main.assets" ] ] "itemSiguiente" => array:18 [ "pii" => "S2173579423001378" "issn" => "21735794" "doi" => "10.1016/j.oftale.2023.08.004" "estado" => "S300" "fechaPublicacion" => "2023-10-01" "aid" => "2147" "copyright" => "Sociedad Española de Oftalmología" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Soc Esp Oftalmol. 2023;98:558-63" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Efficacy and safety of the XEN45 implant in glaucoma surgery: Retrospective study of our first 73 cases" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "558" "paginaFinal" => "563" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eficacia y seguridad del implante XEN45 en la cirugía de glaucoma. Estudio retrospectivo de nuestros primeros 73 casos" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 4341 "Ancho" => 1718 "Tamanyo" => 130458 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) Postoperative intraocular pressure progression. B) Need for drugs after surgery.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Rosales-Rosales, I. Garbín-Fuentes" "autores" => array:2 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Rosales-Rosales" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Garbín-Fuentes" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579423001378?idApp=UINPBA00004N" "url" => "/21735794/0000009800000010/v2_202311091359/S2173579423001378/v2_202311091359/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173579423000816" "issn" => "21735794" "doi" => "10.1016/j.oftale.2023.05.007" "estado" => "S300" "fechaPublicacion" => "2023-10-01" "aid" => "2107" "copyright" => "Sociedad Española de Oftalmología" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Arch Soc Esp Oftalmol. 2023;98:551-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "The importance of ophthalmological check-ups in Spain: Prevalence of undiagnosed ophthalmologic diseases in the Congress of Deputies" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "551" "paginaFinal" => "552" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La importancia de las revisiones oftalmológicas en España: prevalencia de enfermedades oftalmológicas no diagnosticadas en el Congreso de los Diputados" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. García-Bella, B. Burgos-Blasco, J.I. Fernández-Vigo, N. Güemes-Villahoz, J.M. Benítez-del-Castillo, J. García-Feijóo, J.A. Gegúndez-Fernández" "autores" => array:7 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "García-Bella" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Burgos-Blasco" ] 2 => array:2 [ "nombre" => "J.I." "apellidos" => "Fernández-Vigo" ] 3 => array:2 [ "nombre" => "N." "apellidos" => "Güemes-Villahoz" ] 4 => array:2 [ "nombre" => "J.M." "apellidos" => "Benítez-del-Castillo" ] 5 => array:2 [ "nombre" => "J." "apellidos" => "García-Feijóo" ] 6 => array:2 [ "nombre" => "J.A." "apellidos" => "Gegúndez-Fernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0365669123000783" "doi" => "10.1016/j.oftal.2023.04.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365669123000783?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579423000816?idApp=UINPBA00004N" "url" => "/21735794/0000009800000010/v2_202311091359/S2173579423000816/v2_202311091359/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Supraequatorial displacement with lateral rectus myopexy for treatment of myopic sagging/heavy eye" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "553" "paginaFinal" => "557" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "P. Merino, V. Antón, M. Chamorro, P. Gómez de Liaño, J. Yáñez-Merino" "autores" => array:5 [ 0 => array:4 [ "nombre" => "P." "apellidos" => "Merino" "email" => array:1 [ 0 => "pilimerino@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Antón" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Chamorro" ] 3 => array:2 [ "nombre" => "P." "apellidos" => "Gómez de Liaño" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Yáñez-Merino" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección de Motilidad Ocular y Diplopía, Servicio de Oftalmología, HGU Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Miopexia supra-ecuatorial del recto lateral en el tratamiento del síndrome «sagging/heavy eye» miópico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 454 "Ancho" => 905 "Tamanyo" => 39840 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Drawing of a suprequatorial myopexy of the lateral rectus (at 15 mm from the limbus) of the upper half or upper third of the muscle belly (with or without previous division) at 8–10 mm from its insertion to place it in a position above the horizontal line.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Suprequatorial myopexy of the lateral rectus (LR) to correct its displacement secondary to degeneration of the collagen band that joins the superior rectus (SR) and the LR is a previously published technique.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> This displacement of the LR can be secondary to collagen degeneration caused by age, or by the increase in size of the eyeball in myopic myopes with axial length >26.5 mm that causes an increase in the angle formed by the SR and the RL.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> A decade ago, Rutar and Demer defined a new type of strabismus, called sagging eye syndrome, to describe a type of horizontal and/or cyclovertical deviation of small magnitude causing diplopia.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It generally affects people over 60 years of age, and almost equally men and women, although in the Caucasian population it is more frequent in women, and in the Asian population it has been described as slightly more frequent in men. The prevalence of sagging eye is directly proportional to the age of the patients, with 60.9% being over 90 years of age.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In general, it has a very good surgical prognosis because diplopia and deviation are resolved with various surgical techniques.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> Although originally described in senile, non-myopic patients, sagging eye may also be caused by magna myopia, as well as the better known "heavy eye".</p><p id="par0010" class="elsevierStylePara elsevierViewall">The union of the muscular bellies of the SR and LR is a technique described by Yokoyama<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> used to correct the vertical deviation caused by the dislocation of the eyeball that results in the rupture of the band between the SR and LR and the inferior displacement of the LR. However, in addition to correcting hypotropia, this procedure corrects approximately 25 prismatic dioptres (Dp) of esotropia, so in cases of myopic sagging eye without associated horizontal deviation or with exotropia we cannot use the Yokoyama technique and we will have to resort to other procedures when an inferior displacement of the LR with hypotropia is observed. Similarly, if this is less than 12 Dp we can obtain surgical hypercorrection with the Yokoyama technique and suprequatorial myopexy of the LR is a better option.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of our study is to study the results of this technique in patients with sagging/heavy myopic eye.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">A retrospective study was carried out of cases with magna myopia (axial length >26.5 mm) and strabismus diagnosed as "sagging or heavy eye" that had undergone suprequatorial myopexy of the LR between 2017−2023. The surgery performed was individually indicated and deemed appropriate in each case, and was not designed for a comparative trial. Cases diagnosed with senility-related sagging eye and cases operated with the Yokoyama technique were excluded. All cases operated with the LR suprequatorial myopexy technique associated or not with folding or resection of the same muscle and strengthening or weakening on the medial rectus due to associated horizontal deviation or surgery on another vertical rectus muscle were included. Cases diagnosed clinically and/or by orbital MRI of "sagging eye or heavy eye" secondary to myopia magna, with or without diplopia, were included.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Data on amblyopia, diplopia, horizontal and vertical deviation in primary gaze position, ductions, ocular torsion, Worth test and TNO before and after surgery, orbital MRI, as well as macular pathology were collected from the patient records.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The deviation measured in Dp was performed with the alternate cover test or in cases with poor fixation due to severe amblyopia with the Krimsky test. The limitation of the ductions was graded from 0 (no limitation) to −4 (eye des not reach the midline). Amblyopia was classified as mild (best corrected visual acuity >0.4 and <0.8), moderate between 0.2 and 0.4 and severe (best corrected visual acuity <0.2). The surgical technique consisted of performing, through a fornix-type conjunctival incision in the upper temporal sector, a suprequatorial myopexy of the LR (at 15 mm from the limbus) with resorbable suture of polyglactin 6/0 (Vycril®) or non-resorbable (Dacron® 5/0) of the upper half or upper third of the muscle belly (with or without previous division) at 8−10 mm from its insertion to place it in a position above the horizontal line (imaginary line connecting the lateral and medial canthus), higher or lower depending on the previous initial deviation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Surgery was performed under topical anesthesia and checked intraoperatively. A surgical procedure on the horizontal rectus in cases with horizontal >10 Dp deviations associated with vertical deviation was associated with the same or a second procedure. The follow-up time from surgery to the end of the study was noted. Treatment was considered successful when diplopia disappeared or improved to the point of allowing a good quality of life for the patient, and vertical deviation ≤5 Dp at the end of follow-up.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The descriptive statistical study was performed with IBM SPSS Statistics for Windows version 26.0 (IBM Corp, Armonk, New York, USA). The mean and standard deviation (SD) of age, percentage of males and females, cases with diplopia, and good outcome were studied. The mean vertical and horizontal deviation in Dp preoperatively, at one month after surgery and at the end of follow-up was analysed. The mean follow-up time and its SD were noted.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">Nine cases were included in which suprequatorial LR myopexy was performed as surgical treatment of myopic sagging/heavy eye. All 9 cases (100%) were female. The mean (SD) age was 62.11 years (SD 2.6). Orbital MRI was performed in 4 of the 9 cases and showed an inferior displacement of the LR. Five of the 9 patients had undergone cataract surgery and 3 had previous refractive Lasik surgery. Of the 9 patients, 8 (88.88%) had diplopia prior to surgery. One patient did not report double vision because she had visual acuity of hand movements in the eye affected by the staphyloma affecting the macula. Regarding preoperative horizontal deviation, 3 patients had exotropia, with a mean deviation of 8 Dp (SD 6.93) and 5 patients had esotropia, with a mean deviation of 9.6 Dp (SD 5.18) and one patient had no horizontal deviation. Analysing the preoperative vertical deviation, 100% of the patients had hypotropia, with a mean value of 11.33 Dp (SD 3.16). Four patients had no limitation in ductions; 2 patients had limitation to abduction, another 2 to supraduction and another patient to both supraduction and abduction. 88.88% (8 cases) had amblyopia of the affected eye: 5 mild and 3 severe secondary to magna myopia.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Surgery was performed on 6 left eyes (3 right). In 4 of the 9 cases, the technique was associated with the operation of another rectus muscle in the same surgical time: 2 inferior rectus retractions (one total and one partial), one LR retraction and one medial rectus retraction, and in another patient both medial rectus retractions were performed in a second time to better calculate the postoperative deviation after suprequatorial myopexy of the LR (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). All operations were performed under topical anesthesia, and in 7 of the 9 cases resorbable suture was used to perform the myopexy.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The mean horizontal deviation in the immediate postoperative period (one month) was: 1.44 Dp (SD 1.94): 5 patients had no horizontal deviation in the immediate postoperative period, 4 had a mean exotropia of 3.25 Dp (SD 1.5). At last revision, mean horizontal deviation was 2.22 Dp (SD 2.11): 4 patients had no horizontal deviation, 4 patients had mean exotropia of 4 Dp (SD 0) and one patient had esotropia of 4 Dp. The mean vertical deviation in the immediate postoperative period was: 3.22 Dp (SD 3.19); 4 patients had no deviation, 4 patients had a mean hypotropia of 6 Dp (SD 1.41) and one patient had a hypertropia of 5 Dp. The patient who remained hypercorrected was a case associated with a retrograde lower rectus that had to be reoperated by advancing the lower rectus to 6 mm from the limbus, finally remaining with mild hypercorrection. At the end of follow-up, the mean vertical deviation was 3.44 Dp (SD 3.05): 3 patients had no vertical deviation, 5 had a mean hypotropia of 5.4 Dp (SD 2.19 Dp) and one case was left with a hypertropia of 4 Dp. Six of the 9 patients were left with a vertical deviation ≤5 Dp.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Analysing the effect of surgery on the ductions, the 4 patients who did not present limitation in the preoperative period remained stable. In 3 of them, the limitation disappeared after surgery (in one of them, the limitation to supraduction disappeared and in 2 others, the limitation to abduction). The patient in whom the surgical technique was associated with a lower rectus recoil presented a limitation to infraduction postoperatively (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Three of the 9 cases (33.33%) presented preoperative exciclotorsion of 5° which disappeared with surgical treatment.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Four patients had no diplopia at the end of follow-up, 5 had intermittent diplopia but it did not affect their quality of life and they considered that it had improved with surgery. The mean (SD) follow-up time after surgery was 34 months (34.62): Range, 3–108 months.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">Sagging eye is an Anglo-Saxon term used to define vertical deviation in the form of hypotropia that may be caused by myopia magna, as well as heavy eye. The "heavy eye" would cause esotropia and hypotropia with limitation of abduction and supraduction by an inferior displacement of the LR and medial displacement of the SR, and an increase in the angle formed between SR and LR of 121 ± 7° (mean ± DE); whereas in the "sagging eye" the vertical and horizontal ocular deviation would be less, as well as the angle formed between SR AND LR: 104 ± 11° (mean ± DE), significantly less than in the "heavy eye" (<span class="elsevierStyleItalic">p</span> < 0.001), with a lower displacement of the LR, but no medial displacement of the RS.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The distinction between the two entities is important because surgical treatment is different. Magnetic resonance imaging is a test that allows the differential diagnosis to be made and was key in describing both pathologies.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In our study it has been performed in 4 of the 9 cases, where inferior displacement of the LR compared to the fellow eye was demonstrated. However, we believe that the clinical signs and intraoperative findings allow us to make a correct diagnosis and surgical planning without the need to resort to radiological diagnosis, which increases the cost significantly, as long as it does not cause us to change our treatment regimen. The diagnostic criteria for sagging eye related to senility are: hypotropia, absence of hypertropia in adduction and hypotropia in adduction of either eye, greater excyclotorsion of the eye in hypotropia, Lancaster screen not showing a pattern compatible with superior oblique paresis, and absence of superior oblique atrophy on orbital magnetic resonance imaging (if available), and a difference in vertical deviation <6 Dp between both sides, left and right, with the Bielschowsky maneuver.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> For all these reasons, we do not consider it essential to perform an orbital MRI, except in individual cases.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Yokoyama surgery in the heavy eye with esotropia and hypotropia would consist of joining the SR and LR muscle bellies. However, not all cases of myopic "heavy or sagging eye" have significant esotropia or may even have exotropia, so the Yokoyama technique would not be indicated because it would cause secondary exotropia and hypercorrection of hypotropia in deviations ≤12 Dp. Therefore, myopexy of the suprequatorial LR is an alternative procedure used to resolve "heavy and sagging eye" hypotropia. Currently, given the foreign body sensation when non-resorbable suture is used, we only use resorbable suture as in any procedure where the muscle is attached to the sclera, and therefore the 2 cases operated with non-resorbable suture had a better follow-up. It can be associated with resection or folding of the LR and RM in cases with associated esotropia and exotropia (>10 Dp). In this study, myopexy of the suprequatorial LR was associated with surgery on another rectus muscle in 4 of the 9 patients to resolve both horizontal and vertical deviations and/or preoperative mixed diplopia. Cases with esotropia ≤10 Dp have not required further surgery on another muscle because suprequatorial LR myopexy can correct small esotropia up to 8−10 Dp. There are no published series describing this procedure and its results in isolation,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and therefore we cannot accurately assess the surgical dose of horizontal and vertical deviation caused by this surgery. Therefore, we do not recommend associating the surgery with a lower rectus weakening at the same surgical time. In the study by Chaudhuri and Demer<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> out of 93 operated cases, only 6 were operated with this technique, 4 of which recurred and only 2 in the series by Goseki et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However, their indications were different from those of this study, as they were esotropia in the context of age-related sagging eye<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a>.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Side effects to be taken into account with this technique would be excessive ocular extortion, which has not been observed in our series because 33.33% of the cases that presented excision prior to surgery resolved postoperatively. Of the 9 patients, 6 were left with a vertical ≤5 Dp deviation in primary gaze position. Of the 8 cases with diplopia, in 3 it was totally eliminated, while in 5 it subjectively improved because it remained intermittent. Intermittent double vision is possibly related to macular or retinal diplopia because in 3 patients macular pathology was observed that made fusion difficult or impossible.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> In one patient the frame-optotype test was performed to diagnose macular diplopia and was positive, so surgery improved the deviation but did not completely resolve the diplopia.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion, in the treatment of myopic sagging/heavy eye, supraequatorial myopexy of the LR is a therapeutic option if the hypotropia is less than 12 Dp or the Yokoyama technique is not indicated. A good result was obtained in more than half of the cases, although diplopia could only be completely suppressed in 3 cases, possibly because of the association with macular or retinal diplopia. To avoid hypercorrections that reverse the preoperative hypotropia, it is preferable to plan surgery on another vertical cycle muscle at a second time point.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">No conflicts of interest were declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres2007151" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1719750" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2007150" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1719749" "titulo" => "Palabras claves" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-05-26" "fechaAceptado" => "2023-06-26" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1719750" "palabras" => array:4 [ 0 => "Myopic sagging eye" 1 => "Heavy eye" 2 => "Diplopia" 3 => "Supra-equatorial myopexia of the lateral rectus" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras claves" "identificador" => "xpalclavsec1719749" "palabras" => array:4 [ 0 => "«Sagging eye miópico»" 1 => "«Heavy eye»" 2 => "Diplopía" 3 => "Miopexia supra-ecuatorial del recto lateral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To describe the outcome of the patients diagnosed of sagging/heavy eye associated to myopia, that were operated on with the supra-equatorial displacement with LR myopexy.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A retrospective study of 9 cases between 2017−2023. The following data were analyzed: horizontal and vertical deviation, diplopia, amblyopia, ductions, ocular torsion, sensorial test, macular pathology, and the orbital magnetic resonance. Treatment was considered Successful if the diplopia was improved or eliminated and a final vertical deviation (VD) ≤5 prism diopters (PD).</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The mean age (SD) was: 62.11 (4.6) years (100% women). A total of 88.88% presented diplopia. The mean preoperative hypotropia was: 11.33 PD (SD 3.16), and the mean final VD 3.44 PD (SD 3.05). After surgery, the hypotropia was overcorrected in one case, under corrected in 5, and orthophoria was achieved in another three. The technique was associated with surgery of another rectus muscle in 4 subjects. The mean follow-up time after surgery was 34 months (SD 34.62). Six of the 9 patients improved with a vertical deviation ≤5 PD. In 3 patients, the diplopia was eliminated, while in 5 it remained intermittent (three with macular pathology).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Supra-equatorial displacement with LR myopexy for treatment of myopic sagging/heavy eye, is a therapeutic option if hypotropia is less than 12 PD or the Yokoyama technique is not indicated. A good result was obtained in most cases, although diplopia could only be totally suppressed in three, and another five remained intermittent.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Describir los resultados de sujetos con síndrome “sagging/heavy eye miópico” operados mediante la miopexia supra-ecuatorial del recto lateral (RL).</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo de 9 casos entre 2017−2023. Se analizaron desviación horizontal, vertical, ambliopía, diplopía, ducciones, torsión, pruebas sensoriales antes y después de la cirugía, patología macular y resonancia magnética orbitaria. El tratamiento se consideró exitoso cuando desaparecía o mejoraba la diplopia y una desviación vertical (DV) ≤ 5 dioptrías prismáticas (DP) al final del seguimiento.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La edad media (DE) fue: 62,11 (4,6) años (100% mujeres). El 88,88% presentaba diplopía. La hipotropía media preoperatoria fue: 11,33 DP (DE 3,16), y la DV final 3,44 DP (DE 3,05). Tras la cirugía, la hipotropía se invirtió en 1 caso, quedó sub-corregida en 5 y se alcanzó ortoforia en otros 3. La técnica se asoció a la cirugía de otro músculo recto en 4 sujetos. El tiempo medio de seguimiento post quirúrgico fue de 34 meses (DE 34,62). Seis de las 9 pacientes quedaron con una desviación vertical ≤ 5 DP. En 3 pacientes se consiguió eliminar totalmente la diplopía, mientras que en 5 quedó intermitente (tres con patología macular).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">En el tratamiento del sagging/heavy eye miópico, el supra desplazamiento ecuatorial con miopexia del RL constituye una opción terapéutica si la hipotropía es menor de 12 DP o la técnica de Yokoyama no está indicada. Se obtuvo un buen resultado en más de la mitad de los casos, suprimiéndose totalmente la diplopía en tres y quedando en otros cinco de forma intermitente.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 454 "Ancho" => 905 "Tamanyo" => 39840 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Drawing of a suprequatorial myopexy of the lateral rectus (at 15 mm from the limbus) of the upper half or upper third of the muscle belly (with or without previous division) at 8–10 mm from its insertion to place it in a position above the horizontal line.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">BE: both eyes; R: right; Dp: prismatic diopters; E: ocular extortion; ET: esotropia; M: male; Hyper: hypertropia; Hypo: hypotropia; L: left; infra: infraduction; LA: axial length; LABD: abduction limitation; LEADD: elevation limitation in adduction; Lsupra: supraduction limitation; F: female; ERM: epiretinal membrane; NVM: neovascular membrane; RE: right eye; LE: left eye; Plega: folding; Rc: partial recession; IR: inferior rectus; LR: lateral rectus; MR: medial rectus; MRI: magnetic resonance imaging; MRs: medial rectus; XT: exotropia.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202311091359521371"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3333135.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pre- and post-operative data.</p>" ] ] 2 => array:5 [ "identificador" => "202311091359521371" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 1567 "Ancho" => 2917 "Tamanyo" => 368979 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical correction of an inferiorly displaced lateral rectus with equatorial myopexy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.Y. Clark" 1 => "R.A. Clark" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J AAPOS" "fecha" => "2016" "volumen" => "20" "paginaInicial" => "446.e1" "paginaFinal" => "446.e3" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Heavy eye syndrome versus sagging eye syndrome in high myopia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.J.D. Tan" 1 => "J.L. Demer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaapos.2015.08.012" "Revista" => array:6 [ "tituloSerie" => "J AAPOS" "fecha" => "2015" "volumen" => "19" "paginaInicial" => "500" "paginaFinal" => "506" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26691027" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "“Heavy Eye” syndrome in the absence of high myopia: A connective tissue degeneration in elderly strabismic patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Rutar" 1 => "J.L. Demer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaapos.2008.07.008" "Revista" => array:6 [ "tituloSerie" => "J AAPOS" "fecha" => "2009" "volumen" => "13" "paginaInicial" => "36" "paginaFinal" => "44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18930668" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of sagging eye syndrome in adults with binocular diplopia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T. Goseki" 1 => "S.Y. Suh" 2 => "L. Robbins" 3 => "S.L. Pineles" 4 => "F.G. Velez" 5 => "J.L. Demer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajo.2019.09.006" "Revista" => array:6 [ "tituloSerie" => "Am J Ophthalmol" "fecha" => "2020" "volumen" => "209" "paginaInicial" => "55" "paginaFinal" => "61" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31526795" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Graded partial tenotomy of vertical rectus muscles for treatment of hypertropia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.B. Yim" 1 => "A.W. Biglan" 2 => "T.H. Cronin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Trans Am Ophthalmol Soc" "fecha" => "2004" "volumen" => "102" "paginaInicial" => "169" "paginaFinal" => "175" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15747755" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Graded marginal recession: A surgical technique to correct small angle vertical deviations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.E. Brooks" 1 => "L. Habib" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3928/01913913-20160209-02" "Revista" => array:6 [ "tituloSerie" => "J Pediatr Ophthalmol Strabismus" "fecha" => "2016" "volumen" => "53" "paginaInicial" => "85" "paginaFinal" => "89" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27018881" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical procedure for correcting globe dislocation in highly myopic strabismus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Yamaguchi" 1 => "T. Yokoyama" 2 => "K. Shiraki" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajo.2009.08.035" "Revista" => array:6 [ "tituloSerie" => "Am J Ophthalmol" "fecha" => "2010" "volumen" => "149" "paginaInicial" => "341" "paginaFinal" => "342" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19939345" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of magnetic resonance imaging in heavy eye syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Maiolo" 1 => "M. Fresina" 2 => "E.C. Campos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/eye.2017.48" "Revista" => array:6 [ "tituloSerie" => "Eye" "fecha" => "2017" "volumen" => "31" "paginaInicial" => "1163" "paginaFinal" => "1167" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28362425" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sagging eye syndrome: Connective tissue involution as a cause of horizontal and vertical strabismus in older patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Z. Chaudhuri" 1 => "J.L. Demer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamaophthalmol.2013.783" "Revista" => array:6 [ "tituloSerie" => "JAMA Ophthalmol" "fecha" => "2013" "volumen" => "131" "paginaInicial" => "619" "paginaFinal" => "625" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23471194" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of extraocular muscle pulleys in incomitant non-paralytic strabismus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.A. Clark" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0974-9233.159698" "Revista" => array:6 [ "tituloSerie" => "Middle East Afr J Ophthalmol" "fecha" => "2015" "volumen" => "22" "paginaInicial" => "279" "paginaFinal" => "285" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26180464" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term surgical outcomes in the sagging eye syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Z. Chaudhuri" 1 => "J.L. Demer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/09273972.2017.1421676" "Revista" => array:6 [ "tituloSerie" => "Strabismus" "fecha" => "2018" "volumen" => "26" "paginaInicial" => "6" "paginaFinal" => "10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29297726" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Apt lecture workshop: Cutting no slack for the sagging eye syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.L. Demer" 1 => "Z. Chaudhuri" 2 => "R.A. Clark" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "JAAPOS" "fecha" => "2013" "volumen" => "17" "paginaInicial" => "e33" "paginaFinal" => "e34" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Equatorial loop myopexy in “Sagging Eye” syndrome: A case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Fresina" 1 => "L. Sapigni" 2 => "C. Benedetti" 3 => "G. Giannaccare" 4 => "E.C. Campos" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Clin Exp Ophthalmol" "fecha" => "2014" "volumen" => "5" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The dragged-fovea diplopia syndrome: clinical characteristics, diagnosis, and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.E. De Pool" 1 => "J.P. Campbell" 2 => "S.O. Broome" 3 => "D.L. Guyton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ophtha.2005.01.054" "Revista" => array:6 [ "tituloSerie" => "Ophthalmology" "fecha" => "2005" "volumen" => "112" "paginaInicial" => "1455" "paginaFinal" => "1462" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15953644" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment for central-peripheral rivalry-type diplopia (“dragged-fovea diplopia syndrome”)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.R. Hatt" 1 => "D.A. Leske" 2 => "L.D. Klaehn" 3 => "A.M. Kramer" 4 => "R. Iezzi" 5 => "J.M. Holmes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajo.2019.06.030" "Revista" => array:6 [ "tituloSerie" => "Am J Ophthalmol" "fecha" => "2019" "volumen" => "208" "paginaInicial" => "41" "paginaFinal" => "46" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31323203" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Causes of diplopia in patients with epiretinal membranes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.K. Veverka" 1 => "S.R. Hatt" 2 => "D.A. Leske" 3 => "W.L. Brown" 4 => "R. Iezzi" 5 => "J.M. Holmes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ajo.2017.04.014" "Revista" => array:6 [ "tituloSerie" => "Am J Ophthalmol" "fecha" => "2017" "volumen" => "179" "paginaInicial" => "39" "paginaFinal" => "45" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28456546" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Binocular interference vs diplopia in patients with epiretinal membrane" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.R. Hatt" 1 => "D.A. Leske" 2 => "R. Iezzi" 3 => "J.M. Holmes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamaophthalmol.2020.3328" "Revista" => array:6 [ "tituloSerie" => "JAMA Ophthalmol" "fecha" => "2020" "volumen" => "138" "paginaInicial" => "1121" "paginaFinal" => "1127" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32910144" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735794/0000009800000010/v2_202311091359/S2173579423001354/v2_202311091359/en/main.assets" "Apartado" => array:4 [ "identificador" => "5816" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735794/0000009800000010/v2_202311091359/S2173579423001354/v2_202311091359/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173579423001354?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 April | 3 | 3 | 6 |
