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Heavy eye syndrome precipitated by superotemporal Ahmed glaucoma valve implantation in a woman with axial high myopia
Journal Pre-proof Heavy eye syndrome precipitated by superotemporal Ahmed glaucoma valve implantation in a woman with axial high myopia Arif O. Khan, MD, James Bacon, MD PII:
S1091-8531(20)30016-1
DOI:
https://doi.org/10.1016/j.jaapos.2019.12.003
Reference:
YMPA 3132
To appear in:
Journal of AAPOS
Received Date: 4 October 2019 Revised Date:
2 December 2019
Accepted Date: 3 December 2019
Please cite this article as: Khan AO, Bacon J, Heavy eye syndrome precipitated by superotemporal Ahmed glaucoma valve implantation in a woman with axial high myopia, Journal of AAPOS (2020), doi: https://doi.org/10.1016/j.jaapos.2019.12.003. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2020, American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.
Heavy eye syndrome precipitated by superotemporal Ahmed glaucoma valve implantation in a woman with axial high myopia Arif O. Khan MD,a,b and James Bacon, MDa Author affiliations: aEye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; bDepartment of Ophthalmology, Cleveland Clinic Lerner College of Medicine at Case Western University, Cleveland, Ohio Submitted October 4, 2019. Revision accepted December 3, 2019. Correspondence: Arif O. Khan, MD, Eye Institute, Cleveland Clinic Abu Dhabi, PO Box 112412 Abu Dhabi, United Arab Emirates (email: [email protected]). Word count: 1,195
A 56-year-old woman with pseudophakia and glaucoma was referred because of left eye hypotropia and esotropia noted following superotemporal Ahmed glaucoma valve implantation in that eye. Examination suggested left heavy eye syndrome, and it was confirmed the patient had high axial myopia before her cataract surgeries. Both nasal displacement of the left superior rectus muscle and inferior displacement of the left lateral rectus muscle were noted intraoperatively. Removal of the glaucoma drainage device, posterior loop myopexy of the superior rectus muscle to the lateral rectus muscle, and implantation of a new glaucoma drainage device inferonasally improved the strabismus. Case Report A 56-year-old woman was referred to the Strabismus Service of Cleveland Clinic Abu Dhabi for assessment of left eye hypotropia and esotropia that occurred immediately following superotemporal Ahmed glaucoma valve implantation in that eye. Nonocular history was significant for diabetes and obesity. Four years prior to presentation she had undergone right eye cataract surgery with trabeculectomy followed by left eye cataract surgery with left eye corneal transplantation for a long-standing corneal scar. Four months prior to presentation she underwent left eye superotemporal Ahmed glaucoma valve implantation and noted inward and downward displacement of the left eye immediately following this procedure. On examination, best-corrected visual acuity in the right eye was 20/150 (refraction of +3.00 −1.00 ×021); in the left eye, hand motions (refraction of +3.00 −1.00 ×022). There was bilateral mild lid ptosis, fullness to the left temporal eyelid, a left esotropia of approximately 25∆-30∆, and a left hypotropia of approximately 30∆-35∆ (Figure 1A). Ductions and versions in the right eye were significant for −2 supraduction and abduction, with mild limitation to adduction; in the left eye, for −4 supraduction and abduction left eye, with mild limitation to
adduction and infraduction. Slit-lamp examination revealed a superotemporal trabeculectomy bleb in the right eye, a superotemporal Ahmed glaucoma valve bleb in the left eye, a clear corneal graft in the left eye, and pseudophakia of both eyes. Intraocular pressure (IOP) was controlled at 10 mm Hg in the right eye and 11 mm Hg in the left eye. Fundus examination revealed severe chorioretinal atrophy and tilted optic nerve heads as is typical for high myopia. Axial lengths were 33.11 mm in the right eye and 31.15 mm in the left eye. Two months after presentation, the strabismus remained unchanged, and IOPs remained controlled. The patient opted for strabismus surgery, despite the risk of its interfering with glaucoma control, and a combined procedure of strabismus surgery and Ahmed glaucoma valve revision in the left eye was planned. Forced duction testing of the left eye during general anesthesia was significant for resistance to abduction (−3) and supraduction (−2). Viscoelastic was injected into the anterior chamber, and the fibrous capsule encasing the superotemporal Ahmed valve was exposed using a limbal approach. The superior rectus muscle was displaced nasally; the lateral rectus muscle, inferiorly. There were adhesions of the superior rectus muscle and of the lateral rectus muscle to the fibrous capsule. Once these adhesions were carefully dissected free, both the posterior fibrous capsule encasing the Ahmed glaucoma valve and the Ahmed glaucoma valve itself were dissected free and removed from the eye. This allowed space superotemporally for a loop myopexy. A 6-0 polypropylene suture was placed full thickness through the temporal half of the superior rectus muscle 14 mm posterior to its insertion and tied. The same suture was brought through the superior half of the lateral rectus muscle approximately 14 mm posterior to its insertion and tied. This brought the posterior portions of the superior rectus and lateral rectus muscles to close proximity and the eye from an esotropic hypotropic position to a straight-ahead
position under general anesthesia. The superior conjunctival was then closed with buried 8-0 polyglactin 910 suture. Through an inferonasal conjunctival incision, a new Ahmed glaucoma valve was implanted in the inferonasal quadrant with its tube in the anterior chamber. On the first postoperative day, the patient was orthotropic in primary position (Figure 1B) with improved left eye ductions (−2 supraduction, −2 abduction, −1 adduction). IOP was controlled (right eye, 9 mm Hg; left eye, 7 mm Hg), the tube was in good position, and there was minimal anterior chamber cell. At 1 and 3 months postoperatively the alignment, ductions, and IOP in the left eye were maintained. Discussion In this patient with axial high myopia, significant heavy eye syndrome was precipitated in the left eye by superotemporal implantation of a glaucoma drainage device. Removal of the device, with inferonasal implantation of a new one, and posterior loop myopexy of the superior and lateral rectus muscles improved primary position deviation and ductions. Heavy eye syndrome is well-recognized complex of esotropia-hypotropia that occurs spontaneously in the setting of high axial myopia (often axial lengths of >30 mm).1,2 In this form of strabismus, the posterior portion of the elongated globe prolapses superotemporally from the muscle cone against the orbital wall. This mechanically displaces the superior rectus muscle nasally and the lateral rectus muscle inferiorly. The muscle displacement affects muscle function and leads to a restrictive esotropia-hypotropia. Posterior loop myectomy to bridge the gap between the superior rectus muscle and the lateral rectus muscle is often sufficient to correct the strabismus, particularly if it is performed before secondary contracture of the medial rectus muscle or the inferior rectus muscle.3-5 A similar but distinct form of nonmyopic strabismus in the elderly is sagging eye syndrome, which is related to age-related degeneration of the
connective tissue band between superior rectus muscle and lateral rectus muscle.6,7 Although strabismus is known to be a potential complication of glaucoma drainage device implantation, heavy eye syndrome precipitated by device implantation has not, to our knowledge, been reported previously. In general, strabismus following glaucoma drainage device implantation can be due to extraocular muscle damage (related to regional anesthetic, surgical technique, or postoperative scarring) or to a mechanical effect from the glaucoma drainage device or its bleb.8 Implantation of a glaucoma drainage device implantation superonasally can potentially interfere with superior oblique tendon function and induce Brown syndrome.9 Superotemporal implantation of a glaucoma drainage device is often preferred because there are no extraocular muscles in that quadrant. However, as in our case, in the setting of axial high myopia, superotemporal glaucoma drainage device implantation can cause heavy eye syndrome. With axial lengths of >30 mm in both eyes, our patient was at risk for spontaneously developing heavy eye syndrome. In fact, she may have had some degree of heavy eye syndrome in the left eye that was not obvious before glaucoma drainage device implantation but could have been detected by an orthoptic examination before the glaucoma surgery. The limited ductions in the right eye could be related to mild heavy eye syndrome in that eye. Nevertheless, despite the possibility of some degree of heavy eye syndrome in the left eye before the glaucoma surgery, an obvious strabismus was clearly precipitated in that eye by the superotemporal device implantation. Glaucoma surgeons should be aware that implantation in the superotemporal quadrant could precipitate heavy eye syndrome in patients with high axial myopia. Literature Search An unrestricted PubMed search was performed in October 2019 using the terms strabismus, glaucoma drainage device, and glaucoma valve.
References 1.
Krzizoh TH, Kaufmann H, Traupe H. Elucidation of restrictive motility in high myopia by magnetic resonance imaging. Arch Ophthalmol 1997;115:1019-27.
2.
Aoki Y, Nishida Y, Hayashi O, et al. Magnetic resonance imaging measurements of extraocular muscle path shift and posterior eyeball prolapse from the muscle cone in acquired esotropia with high myopia. Am J Ophthalmol 2003;136:482-9.
3.
Yamaguchi M, Yokoyama T, Shiraki K. Surgical procedure for correcting globe dislocation in highly myopic strabismus. Am J Ophthalmol 2010;149:341-6.e2.
4.
Wong I, Leo S-W, Khoo B-K. Loop myopexy for treatment of myopic strabismus fixus. J AAPOS. 2005;9:589-91.
5.
Akar S, Gokyigit B, Aribal E, Demir A, Göker YS, Demirok A. Surgical procedure joining the lateral rectus and superior rectus muscles with or without medial rectus recession for the treatment of strabismus associated with high myopia. J Pediatr Ophthalmol Strabismus 2014;51:53-8.
6.
Rutar T, Demer JL. “Heavy Eye” syndrome in the absence of high myopia: a connective tissue degeneration in elderly strabismic patients. J AAPOS 2009;13:36-44.
7.
Chaudhuri Z, Demer JL. Sagging eye syndrome: connective tissue involution as a cause of horizontal and vertical strabismus in older patients. JAMA Ophthalmol 2013;131:61925.
8.
Roizen A, Ela-Dalman N, Velez FG, Coleman AL, Rosenbaum AL. Surgical treatment of strabismus secondary to glaucoma drainage device. Arch Ophthalmol 2008;126:480-86.
9.
Prata JA, Minckler DS, Green RL. Pseudo-Brown’s syndrome as a complication of glaucoma drainage implant surgery. Ophthalmic Surg 1993;24:608-11.
Legends FIG 1. A, Preoperative clinical photograph, primary position, showing left esotropia and left hypotropia. Deformation of the left eyelid is from the bleb of the Ahmed glaucoma valve. B, Clinical photograph, primary position, on postoperative day 1 showing the left eye in primary position. In both photographs, the corneal reflex right eye seems temporally displaced because of her angle kappa, but that eye is in primary position.
S1091-8531(20)30016-1
DOI:
https://doi.org/10.1016/j.jaapos.2019.12.003
Reference:
YMPA 3132
To appear in:
Journal of AAPOS
Received Date: 4 October 2019 Revised Date:
2 December 2019
Accepted Date: 3 December 2019
Please cite this article as: Khan AO, Bacon J, Heavy eye syndrome precipitated by superotemporal Ahmed glaucoma valve implantation in a woman with axial high myopia, Journal of AAPOS (2020), doi: https://doi.org/10.1016/j.jaapos.2019.12.003. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2020, American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.
Heavy eye syndrome precipitated by superotemporal Ahmed glaucoma valve implantation in a woman with axial high myopia Arif O. Khan MD,a,b and James Bacon, MDa Author affiliations: aEye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; bDepartment of Ophthalmology, Cleveland Clinic Lerner College of Medicine at Case Western University, Cleveland, Ohio Submitted October 4, 2019. Revision accepted December 3, 2019. Correspondence: Arif O. Khan, MD, Eye Institute, Cleveland Clinic Abu Dhabi, PO Box 112412 Abu Dhabi, United Arab Emirates (email: [email protected]). Word count: 1,195
A 56-year-old woman with pseudophakia and glaucoma was referred because of left eye hypotropia and esotropia noted following superotemporal Ahmed glaucoma valve implantation in that eye. Examination suggested left heavy eye syndrome, and it was confirmed the patient had high axial myopia before her cataract surgeries. Both nasal displacement of the left superior rectus muscle and inferior displacement of the left lateral rectus muscle were noted intraoperatively. Removal of the glaucoma drainage device, posterior loop myopexy of the superior rectus muscle to the lateral rectus muscle, and implantation of a new glaucoma drainage device inferonasally improved the strabismus. Case Report A 56-year-old woman was referred to the Strabismus Service of Cleveland Clinic Abu Dhabi for assessment of left eye hypotropia and esotropia that occurred immediately following superotemporal Ahmed glaucoma valve implantation in that eye. Nonocular history was significant for diabetes and obesity. Four years prior to presentation she had undergone right eye cataract surgery with trabeculectomy followed by left eye cataract surgery with left eye corneal transplantation for a long-standing corneal scar. Four months prior to presentation she underwent left eye superotemporal Ahmed glaucoma valve implantation and noted inward and downward displacement of the left eye immediately following this procedure. On examination, best-corrected visual acuity in the right eye was 20/150 (refraction of +3.00 −1.00 ×021); in the left eye, hand motions (refraction of +3.00 −1.00 ×022). There was bilateral mild lid ptosis, fullness to the left temporal eyelid, a left esotropia of approximately 25∆-30∆, and a left hypotropia of approximately 30∆-35∆ (Figure 1A). Ductions and versions in the right eye were significant for −2 supraduction and abduction, with mild limitation to adduction; in the left eye, for −4 supraduction and abduction left eye, with mild limitation to
adduction and infraduction. Slit-lamp examination revealed a superotemporal trabeculectomy bleb in the right eye, a superotemporal Ahmed glaucoma valve bleb in the left eye, a clear corneal graft in the left eye, and pseudophakia of both eyes. Intraocular pressure (IOP) was controlled at 10 mm Hg in the right eye and 11 mm Hg in the left eye. Fundus examination revealed severe chorioretinal atrophy and tilted optic nerve heads as is typical for high myopia. Axial lengths were 33.11 mm in the right eye and 31.15 mm in the left eye. Two months after presentation, the strabismus remained unchanged, and IOPs remained controlled. The patient opted for strabismus surgery, despite the risk of its interfering with glaucoma control, and a combined procedure of strabismus surgery and Ahmed glaucoma valve revision in the left eye was planned. Forced duction testing of the left eye during general anesthesia was significant for resistance to abduction (−3) and supraduction (−2). Viscoelastic was injected into the anterior chamber, and the fibrous capsule encasing the superotemporal Ahmed valve was exposed using a limbal approach. The superior rectus muscle was displaced nasally; the lateral rectus muscle, inferiorly. There were adhesions of the superior rectus muscle and of the lateral rectus muscle to the fibrous capsule. Once these adhesions were carefully dissected free, both the posterior fibrous capsule encasing the Ahmed glaucoma valve and the Ahmed glaucoma valve itself were dissected free and removed from the eye. This allowed space superotemporally for a loop myopexy. A 6-0 polypropylene suture was placed full thickness through the temporal half of the superior rectus muscle 14 mm posterior to its insertion and tied. The same suture was brought through the superior half of the lateral rectus muscle approximately 14 mm posterior to its insertion and tied. This brought the posterior portions of the superior rectus and lateral rectus muscles to close proximity and the eye from an esotropic hypotropic position to a straight-ahead
position under general anesthesia. The superior conjunctival was then closed with buried 8-0 polyglactin 910 suture. Through an inferonasal conjunctival incision, a new Ahmed glaucoma valve was implanted in the inferonasal quadrant with its tube in the anterior chamber. On the first postoperative day, the patient was orthotropic in primary position (Figure 1B) with improved left eye ductions (−2 supraduction, −2 abduction, −1 adduction). IOP was controlled (right eye, 9 mm Hg; left eye, 7 mm Hg), the tube was in good position, and there was minimal anterior chamber cell. At 1 and 3 months postoperatively the alignment, ductions, and IOP in the left eye were maintained. Discussion In this patient with axial high myopia, significant heavy eye syndrome was precipitated in the left eye by superotemporal implantation of a glaucoma drainage device. Removal of the device, with inferonasal implantation of a new one, and posterior loop myopexy of the superior and lateral rectus muscles improved primary position deviation and ductions. Heavy eye syndrome is well-recognized complex of esotropia-hypotropia that occurs spontaneously in the setting of high axial myopia (often axial lengths of >30 mm).1,2 In this form of strabismus, the posterior portion of the elongated globe prolapses superotemporally from the muscle cone against the orbital wall. This mechanically displaces the superior rectus muscle nasally and the lateral rectus muscle inferiorly. The muscle displacement affects muscle function and leads to a restrictive esotropia-hypotropia. Posterior loop myectomy to bridge the gap between the superior rectus muscle and the lateral rectus muscle is often sufficient to correct the strabismus, particularly if it is performed before secondary contracture of the medial rectus muscle or the inferior rectus muscle.3-5 A similar but distinct form of nonmyopic strabismus in the elderly is sagging eye syndrome, which is related to age-related degeneration of the
connective tissue band between superior rectus muscle and lateral rectus muscle.6,7 Although strabismus is known to be a potential complication of glaucoma drainage device implantation, heavy eye syndrome precipitated by device implantation has not, to our knowledge, been reported previously. In general, strabismus following glaucoma drainage device implantation can be due to extraocular muscle damage (related to regional anesthetic, surgical technique, or postoperative scarring) or to a mechanical effect from the glaucoma drainage device or its bleb.8 Implantation of a glaucoma drainage device implantation superonasally can potentially interfere with superior oblique tendon function and induce Brown syndrome.9 Superotemporal implantation of a glaucoma drainage device is often preferred because there are no extraocular muscles in that quadrant. However, as in our case, in the setting of axial high myopia, superotemporal glaucoma drainage device implantation can cause heavy eye syndrome. With axial lengths of >30 mm in both eyes, our patient was at risk for spontaneously developing heavy eye syndrome. In fact, she may have had some degree of heavy eye syndrome in the left eye that was not obvious before glaucoma drainage device implantation but could have been detected by an orthoptic examination before the glaucoma surgery. The limited ductions in the right eye could be related to mild heavy eye syndrome in that eye. Nevertheless, despite the possibility of some degree of heavy eye syndrome in the left eye before the glaucoma surgery, an obvious strabismus was clearly precipitated in that eye by the superotemporal device implantation. Glaucoma surgeons should be aware that implantation in the superotemporal quadrant could precipitate heavy eye syndrome in patients with high axial myopia. Literature Search An unrestricted PubMed search was performed in October 2019 using the terms strabismus, glaucoma drainage device, and glaucoma valve.
References 1.
Krzizoh TH, Kaufmann H, Traupe H. Elucidation of restrictive motility in high myopia by magnetic resonance imaging. Arch Ophthalmol 1997;115:1019-27.
2.
Aoki Y, Nishida Y, Hayashi O, et al. Magnetic resonance imaging measurements of extraocular muscle path shift and posterior eyeball prolapse from the muscle cone in acquired esotropia with high myopia. Am J Ophthalmol 2003;136:482-9.
3.
Yamaguchi M, Yokoyama T, Shiraki K. Surgical procedure for correcting globe dislocation in highly myopic strabismus. Am J Ophthalmol 2010;149:341-6.e2.
4.
Wong I, Leo S-W, Khoo B-K. Loop myopexy for treatment of myopic strabismus fixus. J AAPOS. 2005;9:589-91.
5.
Akar S, Gokyigit B, Aribal E, Demir A, Göker YS, Demirok A. Surgical procedure joining the lateral rectus and superior rectus muscles with or without medial rectus recession for the treatment of strabismus associated with high myopia. J Pediatr Ophthalmol Strabismus 2014;51:53-8.
6.
Rutar T, Demer JL. “Heavy Eye” syndrome in the absence of high myopia: a connective tissue degeneration in elderly strabismic patients. J AAPOS 2009;13:36-44.
7.
Chaudhuri Z, Demer JL. Sagging eye syndrome: connective tissue involution as a cause of horizontal and vertical strabismus in older patients. JAMA Ophthalmol 2013;131:61925.
8.
Roizen A, Ela-Dalman N, Velez FG, Coleman AL, Rosenbaum AL. Surgical treatment of strabismus secondary to glaucoma drainage device. Arch Ophthalmol 2008;126:480-86.
9.
Prata JA, Minckler DS, Green RL. Pseudo-Brown’s syndrome as a complication of glaucoma drainage implant surgery. Ophthalmic Surg 1993;24:608-11.
Legends FIG 1. A, Preoperative clinical photograph, primary position, showing left esotropia and left hypotropia. Deformation of the left eyelid is from the bleb of the Ahmed glaucoma valve. B, Clinical photograph, primary position, on postoperative day 1 showing the left eye in primary position. In both photographs, the corneal reflex right eye seems temporally displaced because of her angle kappa, but that eye is in primary position.