Large angle esotropia with high myopia and a lost medial rectus muscle: a case report.

A 67 year old woman presented with her left eye fixed in adduction and infraduction. She had previous complicated strabismus surgery 18 years ago with a report of intraoperative loss of left medial rectus (MR) muscle (not retrieved at the time of surgery). An Orbital MRI of the left eye showed reattachment of the MR muscle to the globe and an axially enlarged globe associated with inferior displacement of the lateral rectus and nasal displacement of the superior rectus muscles. In ultrasonography the axial lengths were 24.1 mm in the right and 29.9 mm in the left eye. She underwent staged surgery: The first stage was a recession of the left MR muscle and union procedure on the SR and LR muscles followed by a second adjustable suture procedure under topical anesthesia, of right MR recession, right LR resection and left IR recession. After 12 months her eyes were still binocularly aligned. Unilateral high myopia must be considered in progressive esotropia. Imaging and ultrasonography can demonstrate anatomical abnormality and muscle paths to confirm the definite diagnosis. Union procedure described by Yokoyama is an effective procedure in correcting this strabismus associated with high myopia.