Heavy eye syndrome (HES) is an atypical form of strabismus, primarily caused by a significant elongation of the axial length of the eye, which leads to a disruption of normal topographic relationships between the posterior pole and the extraocular muscles. Clinical symptoms of HES include late-onset convergent strabismus (esotropia) with a vertical component and restricted ocular motility in the context of substantial eye enlargement associated with high myopia. Identification of the pathognomonic sign (dislocation of the posterior pole from the muscle cone) requires the use of multislice computed tomography (MSCT) of the orbits. Considering the mechanism of HES development, the surgical treatment of choice is various techniques for approximating the superior and lateral rectus muscles, which can be regarded as pathogenetically oriented treatment. If necessary, these procedures may be supplemented by classical interventions. The use of classical surgical techniques (recession and resection) as standalone first-stage treatments for HES is inadvisable, not only due to their insufficient efficacy but also because they may complicate subsequent pathogenetically oriented interventions.