Unusual Presentation of Hypertropia in a Case of Anisometropic Heavy Eye Syndrome

Purpose: To report the presence of hypertropia with esotropia in the case of anisometropic Heavy Eye Syndrome (HES). Case Report: A 33-years old lady referred to the strabismus clinic for evaluation. The patientchr('39')s esotropia started at the age of 12 and gradually increased. Corrected visual acuity was 2/10 and 4/100 and refraction was -24-3.25×103 and -10.25-0.75× 34 in the right and left eyes, respectively. There was esotropia of 45 PD and hypertropia of 25 PD in her left eye. Abduction limitation was present in both eyes but more severe in the right eye; supra-duction was also limited in the right eye. A large macular scar was seen in the left eye. On orbital, MR imaging lateral rectus was displaced inferiorly and the superior rectus path was displaced nasally on both sides, but more prominent on the right side. The assessment was bilateral HES that was more severe on the dominant right eye. Unilateral suture myopexy on the right side and bilateral medial rectus recession was performed, which resulted in orthophoria and improved comitancy in side gazes and this result lasted in a one-year follow-up. Conclusion: In cases of anisometropic HES, the severity of symptoms may not equal on both eyes and by changing fixation, hypertropia may appear instead of expected hypotropia. In this situation, unilateral myopexy on the more severe side result in a vertical balance between eyes. Bilateral medial rectus recess may be required to correct esotropia.