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This 58-year-old man developed this large angle esotropia over the last two years.  Before that he said that his eyes looked “normal” but that he wore “thick glasses”.   He is now aphakic having had his cataracts removed three years ago.  He states that his health is good, he has had no weight loss and retains a good appetite.

1.	What would you expect this man’s refraction to be before the cataract surgery?
	c --high myopia This strabismus occurred fairly late in life and without evidence of systemic disease in a person who had a high refractive error by history.  The refractive error associated with this diagnosis of “heavy eye"  is high myopia.
2.	With no other history or information available which of the following tests would be the most informative?
	d -- axial length measurements of the globes The mechanism of action for the “heavy eye” is a herniation of the enlarged globe through the superior temporal intermuscular membrane displacing the lateral rectus muscle downward and making it a depressor.  This large globe can also damage the innervation to the lateral rectus.
3.	Treatment for this condition would be:
	e -- none of the above The treatment of this condition is surgery directed at the specific defect.  This will require techniques such as recession, resection, rectus muscle union, muscle transfer, and repair of intermuscular membrane.  The final decision on the best surgical technique would depend on the condition of the extraocular muscles found at surgery.