: To report presentation of hypertropia with esotropia in a case of anisometropic Heavy eye syndrome (HES).

Case: 33-years old lady referred to strabismus clinic for evaluation. Corrected visual acuity was 2/10 and 4/100 and refraction was -24-3.25×103 and -10.25-0.75× 34 in the right and left eye respectively. There was esotropia of 45 PD and hypertropia of 25 PD in her left eye. Abduction limitation was present in both eyes but more severe in right eye, supra-duction was also limited in the right eye. A large macular scar was seen in the left eye. On orbital MR imaging lateral rectus was displaced inferiorly and superior rectus path was displaced nasally on both sides but more prominent on the right side. The assessment was bilateral HES (Heavy eye syndrome) that was more severe on dominant right eye.

Unilateral suture myopexy on right side and bilateral medial rectus recession was performed which resulted in orthophoria and improved comitancy in side gazes and this result lasted in one year follow up

Conclusion: In cases of anisometropic HES, the severity of symptoms may not equal on both eyes and by changing fixation, hypertropia may appeare instead of expected hypotropia. In this situation unilateral myopexy on more severe side result in vertical balance between eyes. Bilateral medial rectus recess may be required to correct esotropia.