Abduction-Release Sign in Heavy Eye Syndrome

BACKGROUND: Heavy eye syndrome (HES) is characterized by progressive esotropia and hypotropia with high myopia. Diagnosis is based on the clinical presentation and is often supported by imaging. In this study we describe a novel clinical sign observed in patients with HES. METHODS: We conducted a cross-sectional, retrospective analysis of patients with limitation in elevation in adduction, examined between February 2025 and June 2025. Examinations were not masked to diagnosis. Presence of the Abduction-Release Sign on examination was recorded and compared between patients with HES and those with other diagnoses who served as controls. The sign is elicited when the patient is asked to abduct the eye, then in a slow circular motion bring the eye upward and into an adducted position. RESULTS: We identified 14 cases with limitation in elevation in which the sign was tested. Four had HES and 10 had other diagnoses (60% had thyroid eye disease, 20% had Brown syndrome, and 20% other diagnoses). Mean spherical equivalent was -17.8 ± 8.0 D in the HES group and +0.17 ± 2.3 D in the control group. Of the 4 patients with HES, all had a positive Abduction-Release Sign on examination, compared with none in the control group (P = 0.001). CONCLUSIONS: Among this cohort of patients with limitation in elevation, the presence of the Abduction-Release Sign was significantly associated with HES. This examination finding might be useful in the evaluation of patients with HES together with traditional examination and imaging findings. Its utility may be limited in severe cases, because abduction may be insufficient to elicit the sign. It might also offer insights into the structural and functional changes that occur in this syndrome.