What are the causes and treatments for a sagging sensation or skin sagging?

Sagging Eye Syndrome: Causes and Treatment

Sagging eye syndrome is an age-related ophthalmologic condition caused by degeneration of the superior rectus-lateral rectus (SR-LR) connective tissue band, resulting in inferior displacement of the lateral rectus muscle and esotropia that worsens at distance; treatment is symptom-directed with prism correction for mild cases and strabismus surgery (lateral rectus resection and/or medial rectus recession) for persistent diplopia. 1

Pathophysiology and Causes

Age-Related Degeneration:

• The SR-LR connective tissue band normally maintains fixed distance between the superior and lateral rectus muscles as they course posteriorly 1
• Age-related degeneration causes this band to fail, resulting in medial shift of the superior rectus and inferior shift (sagging) of the lateral rectus 1
• As the lateral rectus sags downward, abduction becomes impaired and esotropia develops 1

Associated Risk Factors:

• Myopia is common among affected patients 1
• Female sex (54% of cases) 1
• Blepharoptosis occurs in 29% of cases 1
• Deep superior lid sulcus defect in 64% of cases 1
• History of blepharoplasty, brow lift, or facelift surgery in some patients 1

Epidemiology

Age Distribution:

• Most patients present between 60-80 years of age, with presentation most common in the seventh decade 1
• Prevalence increases dramatically with age: less than 5% under age 50 years to 60% over age 90 1
• Median age of presentation for divergence insufficiency (the broader category) is 74 years 1

Clinical Presentation

Primary Symptoms:

• Progressive or subacute-onset binocular diplopia worse at distance (e.g., while driving or watching television) 1
• Esotropia typically 10 prism diopters larger at distance than at near 1
• Small-angle vertical diplopia and torsional diplopia may be present 1
• Symptoms first become apparent with distant fixation after age 50 years 1

Examination Findings:

• Esotropia greater at distance, sometimes with small vertical deviation and cyclotropia 1
• Deviations are nearly comitant except for distance-near disparity 1
• Mild to no limitation of ocular rotation (distinguishes from strabismus fixus) 1
• High-resolution orbital imaging shows SR-LR band disruption with angle between lateral and superior rectus of 104° ± 11° 1

Treatment Algorithm

Step 1: Observation for Mild Cases

• Monitor if symptoms are mild and occasional or if patient opposes treatment 1
• Important caveat: The condition will not resolve spontaneously and is progressive 1

Step 2: Nonsurgical Management

• Prism correction: Fresnel or ground-in prisms can be temporary (prior to surgery) or long-term treatment 1
• Counsel patients that prism magnitude may need to increase over time 1
• Diplopia control without glasses will likely decline progressively 1
• Fusional exercises have little evidence: Previous studies report no benefit for divergence insufficiency 1

Step 3: Surgical Management

• Indications: Persistent diplopia when manifest distance deviation is present, symptoms are consistent, and prism glasses are unsatisfactory 1
• Surgical options:
  • Lateral rectus resection based on distance deviation 1
  • Medial rectus recession based on near deviation 1
  • Can be performed bilaterally or unilaterally 1
• Surgical dosing: Greater surgical dose than standard tables is typically needed; adjustable sutures may be beneficial 1
• Critical warning: Discuss risk of inducing postoperative diplopia at distance, particularly for patients without exophoria/exotropia or with poor divergence amplitudes 1

Treatment Goals (Prioritizing Quality of Life)

Symptom-Directed Outcomes:

• Reduction of diplopia 1
• Improvement or restoration of binocular vision and field of binocular vision 1
• Reconstruction of ocular alignment 1
• Improved eye contact and self-image 1

Differential Diagnosis Considerations

Distinguish from More Severe Conditions:

• Strabismus fixus (heavy eye syndrome): Much more extreme displacement with SR-LR angle of 121° ± 7°, frank globe prolapse, severe myopia >27mm axial length, and mechanical restriction 1
• Secondary divergence insufficiency: Associated with neurological disease, sixth nerve palsy, pontine tumors, or head trauma—requires brain imaging if abduction nystagmus, lateral incomitance, or neurologic signs present 1

Provider Requirements

Specialist Management:

• Diagnosis and management require an ophthalmologist familiar with this condition 1
• Treatment may benefit from assistance of an orthoptist or optometrist 1
• Communicate diagnosis and treatment plan with patient's other healthcare providers 1