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Analysis of Facial Features of Patients With Sagging Eye Syndrome and Intermittent Exotropia
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This retrospective cross-sectional study analyzed the facial features of Japanese patients (aged >60 years) with sagging eye syndrome (SES) and those with intermittent exotropia (IXT) who were compared with controls. The results revealed that the facial characteristic of a sunken upper eyelid was significantly associated with SES, while the presence of a baggy lower eyelid was associated with both SES and IXT but not with controls. Additionally, blepharoptosis scores were similar among all three groups. The anatomy relevant to these associations is discussed in this article.
- This study suggests that the presence of a sunken upper eyelid is likely associated with SES, whereas the presence of a baggy lower eyelid is more likely to be associated with IXT.
abstract
This abstract is available on the publisher's site.
Access this abstract now Full Text Available for ClinicalKey SubscribersPURPOSE
To compare the facial features of patients with sagging eye syndrome (SES) and other ophthalmic diseases, and to evaluate the diagnostic usefulness of facial features for SES.
DESIGN
Retrospective cross-section study.
METHODS
We evaluated frontal facial photographs of patients aged > 60 years with SES and intermittent exotropia (IXT), and control patients who visited the ophthalmology outpatient clinics of two institutions between June 2020 and December 2021. Three ophthalmologists evaluated each eye for sunken upper eyelid, blepharoptosis, and baggy lower eyelid, using a scoring scale. The average scores for each parameter among the three groups were analyzed. Patients with glaucoma, visual acuity less than 16/20, SES with a vertical strabismus angle of 6 Δ or more, IXT that could not be maintained in the phoria position during photography, a history of previous oculoplastic or ophthalmic surgery, and those using prostaglandin analogs for cosmetic purposes were excluded.
RESULTS
A total of 86 patients were included: 23 with SES, 28 with IXT, and 35 in the control group. All were Japanese. Forty-five patients were male and 41 were female. The mean age was 72.7 ± 7.4 years. The sunken upper eyelid scores were significantly higher in the SES group than in the control and IXT groups (p < 0.001), whereas the baggy lower eyelid scores were significantly higher in the IXT group than in the control group (p < 0.05).
CONCLUSIONS
Age-related orbital connective tissue degeneration may manifest as SES in the upper eyelid and as IXT in the lower eyelid.
Additional Info
Analysis of facial features of patients with sagging eye syndrome and intermittent exotropia compared to controls
Am J Ophthalmol 2022 Oct 18;[EPub Ahead of Print], K Kunimi, T Goseki, K Fukaya, S Takahashi, E IshikawaFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Sagging eye syndrome (SES) is described as a degeneration of the lateral rectus–superior rectus band, which is postulated to permit an inferior sagging of the lateral rectus pulley resulting in esotropia, cyclovertical strabismus, or both.1,2 It is considered to be the leading cause of adult-onset strabismus. Magnetic resonance imaging is usually considered to be confirmatory, as the diagnosis is typically based on history and clinical findings. External signs include a sunken upper eyelid, blepharoptosis, and/or a baggy lower eyelid.
In this retrospective study, patients with SES, intermittent exotropia, and a control group were included. Facial photographs of these patients were randomized and evaluated for a sunken upper eyelid, blepharoptosis, and a baggy lower eyelid by three ophthalmologists. A previously reported scoring scale was utilized, which was described in detail in the paper. A statistical analysis found that the patients with SES scored significantly higher than the other groups for the sunken upper eyelid characteristic. Both the SES and intermittent exotropia groups scored higher than the control group for the baggy lower eyelid characteristic, while there were no significant differences in the three groups for blepharoptosis.
The strength of this paper is identifying that SES could be differentiated from control patients based on an independent ophthalmologist’s assessment of a sunken upper eyelid and a baggy lower eyelid according to previously reported standardized criteria. I found the inclusion of intermittent exotropia as a diagnostic subgroup to be confusing. At first glance, a reader might think that intermittent exotropia is a subtype of SES, which is not the case. It probably would have made sense to compare SES with the control group and reserve the intermittent exotropia group for a separate follow-up study.
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