Sagging Eye Syndrome: Causes, Symptoms, Diagnosis & Treatment

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When you become aged there are many diseases that caught you like heart problems, respiratory issues, neurological issues, and bone weakness, etc. but the most common problem that every aged person is facing nowadays and even centuries is eye problems. Weakness of eyes, cataracts, myopia, etc are the most common problems.  Here is also a problem for aged persons is sagging eye syndrome. In this article, we will provide all the relevant information about sagging eye syndrome. 

eye problems

What is Sagging Eye Syndrome?

Sagging eye syndrome (SES) is a mechanical problem of horizontal and vertical acquired strabismus that exhibits in the aged phase in addition to bilateral blepharoptosis (ptosis with high cover creases) and deepening of the sulcus. Patients with sagging eye syndrome usually presented blepharoptosis and superior sulcus defect. 

sagging eye syndrome
 Eyelids Drooping

How Does Our Pulleys System Work?

Our eye muscles drive using a method of extraocular muscles that are formed up of connective tissue.  The system acts as a pulley system would so that the eyes may move in several different ways.  Sagging eye syndrome is when this pulley system begins to fall and possibly break entirely.  

Sagging eye syndrome: connective tissue involution as a cause of horizontal and vertical strabismus in older patients

This can occur in the region where the lateral rectus and superior rectus band.  This lateral rectus muscle commands the eye’s capacity to push outward.  If the lateral rectus is not going correctly the eye will lead to move inward causing horizontal double vision. 

The superior rectus muscle commands the eye’s ability to see uphill.  If the superior rectus muscle is not going correctly then the eyes will go down and you will see the erect dual vision.


Extraocular muscles are enclosed by connective tissue that acts as utility support and a mechanical pulley. The mechanical properties of pulleys are condemned for the support and winding characteristics of the eye. The symptoms of sagging eye syndrome are;

  • Headache
  • Double vision (diplopia) 
  • Functional deficits 
  • Difficult to see the far objects 


The first step when the patient came for a checkup, is the duty of the doctor or health care provider to take the proper history and after that do the proper examination of external features. The external features show the adnexal signs such as; 

  • Retraction of the upper eyelid into the superior orbit 
  • Floppy lower lids 
  • High upper eyelid crease
  • Some patient also presents with bilateral ptosis
  • Aponeurotic blepharoptosis

After examining the external features move towards the sensorimotor examination. In this we are examining the following; 

  • ARDE: incomitant esotropia poor in range and internal gaze with no strabismus or little phoria for close and no vertical difference
  • ARDE and CVS: incomitant esotropia with a tiny hypotropia in one side
  • Supraduction deficit
  • Normal horizontal adduction range
  • Normal horizontal saccadic velocities
  • CVS only: hypotropia with no horizontal variation

When you are done with all the steps of examination, now it’s time for an MRI. Magnetic resonance imaging resolution presented superotemporal bowing of the LR-SR band in more moderate cases and the sudden end of an attenuated band remnant in the superolateral area in more critical cases.


There is an interdisciplinary plan when identifying the signs of these patients. The optometrists are perfect in managing this situation as surgery is normally kept for severely significant patients and those who have failed for trial prisms. Management includes; 

Observation: Since most of the cases have enough fusional abilities they do not undergo double vision for near with that so these patients can possibly handle without the requirement for intervention.

Prism: Sagging eye syndrome seldom allows a variation of more than 10 PD (Prisms Deviation).  Inpatients with spectacle-dependent a momentary Fresnel prism or strong ground in prism are usually helpful in controlling the double vision for distance without producing diplopia. When patients are spectacle independent a surgical approach could be given.

Surgery: Patients with sagging eye syndrome can be treated surgically if they do not react to or do not covet prism therapy. Different surgical procedures are present when administering with the sagging eye syndrome including alteration insufficiency esotropia and cycle vertical strabismus. 


Patients with sagging eye syndrome usually presented blepharoptosis and superior sulcus defect. Optometrists play a very important role in this disease to deal with diplopia patients because the person is facing difficulty seeing the objects and causes double visions which irritate the person.

The proper management should be taken to treat it. If the prism is failed then move to surgery and offer and describe the patient about it.