Optic Nerve Sheath Tethering in Adduction Occurs in Esotropia and Hypertropia, But Not in Exotropia

Purpose: Repetitive strain to the optic nerve (ON) due to tethering in adduction has been recently proposed as an intraocular pressure-independent mechanism of optic neuropathy in primary open-angle glaucoma. Since strabismus may alter adduction, we investigated whether gaze-related ON straightening and associated globe translation differ in horizontal and vertical strabismus.

Methods: High-resolution orbital magnetic resonance imaging was obtained in 2-mm thick quasi-coronal planes using surface coils in 25 subjects (49 orbits) with esotropia (ET, 19 ± 3.6Δ SEM), 11 (15 orbits) with exotropia (XT, 33.7 ± 7.3Δ), 7 (12 orbits) with hypertropia (HT, 14.6 ± 3.2Δ), and 31 normal controls (62 orbits) in target-controlled central gaze, and in maximum attainable abduction and adduction. Area centroids were used to determine ON path sinuosity and globe positions.

Results: Adduction angles achieved in ET (30.6° ± 0.9°) and HT (27.2° ± 2.3°) did not significantly differ from normal (28.3° ± 0.7°), but significantly less adduction was achieved in XT (19.0° ± 2.5°, P = 0.005). ON sheath tethering in adduction occurred in ET and HT similarly to normal, but did not in XT. The globe translated significantly less than normal, nasally in adduction in XT and temporally in abduction in ET and HT (P < 0.02, for all). Globe retraction did not occur during abduction or adduction in any group.

Conclusions: Similar to normal subjects, the ON and sheath become tethered without globe retraction in ET and HT. In XT, adduction tethering does not occur, possibly due to limited adduction angle. Thus, therapeutic limitation of adduction could be considered as a possible treatment for ON sheath tethering.