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Case Reports in Ophthalmological Medicine
Volume 2017, Article ID 1708734, 3 pages
Case Report

Sagging Eye Syndrome or Nemaline Rod Myopathy? Divergence Insufficiency with Levator Dehiscence as an Overlapping Symptom between Two Diagnoses

1Hospital Authority, Hong Kong
2Department of Ophthalmology, Columbia University Medical Center, New York, NY, USA
3Department of Neurology, Columbia University Medical Center, New York, NY, USA
4Department of Radiology, Division of Neuroradiology, Columbia University Medical Center, New York, NY, USA
5Department of Pathology and Cell Biology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY, USA

Correspondence should be addressed to Stephanie S. L. Cheung; ude.nworb.inmula@gnuehc_einahpets

Received 16 October 2016; Accepted 13 December 2016; Published 15 January 2017

Academic Editor: Nicola Rosa

Copyright © 2017 Stephanie S. L. Cheung et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


A 78-year-old woman complained of gradual, painless onset of horizontal binocular diplopia associated with progressive axial weakness. Physical examination revealed esotropia that was greater at distance than at near vision, bilateral levator dehiscence, and normal abducting saccadic speeds. Given the age of the patient and compatible clinical findings, the diagnosis of Sagging Eye Syndrome (SES) was made. However, further work-up with a muscle biopsy suggested Sporadic Late-Onset Nemaline Myopathy (SLONM) as the cause of her progressive muscle weakness. Although rare, external ophthalmoplegia has been described in the literature as a presenting symptom in SLONM. To elucidate the pathological mechanism for the patient’s diplopia, an MRI of the orbits was performed, which revealed findings consistent with SES. This case aims to highlight the importance of integrating clinical findings during the diagnostic process and serves as a reminder that diplopia can be a common symptom for an uncommon diagnosis.