340 Copyright © SLACK Incorporated Exotropia-Hypotropia Complex in High Myopia Sumit Monga, MS, DNB, FRCS; Ramesh Kekunnaya, MD, FRCS; Virender Sachdeva, MS From Jasti V. Ramanamma Children’s Eye Care Centre, L.V. Prasad Eye Institute, KAR Campus, Hyderabad, India (SM, RK); and Nimagadda Prasad Children’s Eye Centre, L.V. Prasad Eye Institute, Visakhapatnam, India (VS). Submitted: February 7, 2013; Accepted: July 18, 2013; Posted online: November 26, 2013 The authors have no financial or proprietary interest in the materials presented herein. The authors thank Paaraj Dave, MS, Fellow, from V. S. T. Glaucoma Centre, LVPEI, Hyderabad, India, for helping in the statistical analysis. Correspondence: Ramesh Kekunnaya, MD, FRCS, Pediatric Ophthalmology, Strabismus & Neuroophthalmology, Jasti V. Ramanamma Children’s Eye Care Centre, Kallam Anji Reddy Campus, L.V. Prasad Eye Institute, L.V. Prasad Marg, Banjara Hills, Hyderabad 500034, India. E-mail: drrk123@gmail.com doi: 10.3928/01913913-20131125-01 ABSTRACT Purpose: To highlight the association of exotropia-hy- potropia complex in cases of high myopia and its surgi- cal outcome. Methods: A retrospective study of 15 consecutive pa- tients, diagnosed as having high myopia and exotropia- hypotropia, observed between January 2002 and May 2012 was performed. The main outcome measures were clinical presentation, orbital imaging features, and the surgical outcome of cases. Results: Of the 15 patients, 9 were female. The median age was 23.5 years (range: 10 to 35 years). Thirteen cas- es had unilateral high myopia in the deviated eye. The mean axial length of the deviated eye was 29.43 ± 1.51 mm. Eight patients (53%) had a history of progressive eye deviation in adulthood. All patients had amblyo- pia of the deviating eye. The mean preoperative exo- tropia was 37.2 ± 8.72 prism diopters (PD) (range: 18 to 50 PD). The mean preoperative hypotropia was 12.73 ± 5.58 PD (range: 5 to 20 PD). An elevation deficit was noted in 6 patients (40%). On orbital imaging, high myopic eyes with deviation did not show significant displacement of rectus muscles in comparison to fel- low eyes (P > .05, all rectus muscles). Eight cases (53%) were surgically managed with a median follow-up of 7 months. Intraoperatively, one case was found to have misplaced muscle insertion. Successful alignment was achieved by surgery on either horizontal rectus muscles alone (37%), or in combination with vertical muscles (62%). Conclusions: Exotropia-hypotropia complex can occur in association with high myopia. No specific etiologic factors, clinical or radiological, were identified in this study. Successful alignment may be achieved in these cases using tailor-made strabismus procedures. [J Pediatr Ophthalmol Strabismus 2013;50(6):340- 346.] INTRODUCTION There has been a continuing evolution in under- standing the etiopathogenesis of strabismus in high myopia. 1-3 The combination of esotropia-hypotro- pia complex, also called the heavy eye syndrome, has been shown to be caused by superotemporal globe prolapse due to axial distension of the globe. 2,3 The latter has been shown to cause displacement of su- perior and lateral rectus muscles. 2 In contrast, there has only been a brief mention of the association of exotropia-hypotropia complex in cases of high myo- pia. 2 Herein, we report the occurrence of exotropia- hypotropia complex in cases of high myopia that presented at our tertiary care center. PATIENTS AND METHODS In this retrospective study, the medical re- cords of 15 consecutive patients with high myopia