Long-term follow-up after vertical extraocular muscle surgery to correct abnormal vertical head posture

To report outcomes of vertical extraocular muscle surgery to correct abnormal vertical head posture in children with horizontal infantile nystagmus.

Retrospective case series of seven patients evaluated at one institution with abnormal vertical head position (chin-up or chin-down) in the setting of horizontal infantile nystagmus. All patients underwent bilateral vertical extraocular muscle surgery with the same surgeon. Pre- and postoperative vertical head position under binocular viewing conditions was the primary outcome measure. Secondary outcomes included visual acuity, stereopsis, degree of cyclotorsion, and residual ocular alignment.

Seven children with infantile nystagmus syndrome, ranging in age from 4 months to 5 years at presentation, underwent extraocular muscle surgery to correct chin-down or chin-up head position associated with a null position in the setting of horizontal nystagmus. Five children had other ocular pathology (albinism, n = 4; cone-rod dystrophy, n = 1). Five of the seven patients had combined vertical recti and oblique muscle surgery. Three of the patients had additional extraocular muscle surgery to correct horizontal misalignment (exotropia, n = 2; esotropia, n = 1). One patient underwent a separate Kestenbaum procedure (bilateral horizontal resection/recession) to correct concomitant horizontal face turn. Median postoperative follow-up was 8.0 years (range 1-9.5 years). Postoperatively, three patients had complete resolution of their abnormal head position, and three had an improvement in their head posture, with a mean reduction in original vertical head position of 25 degrees. One of these patient had a reversal of their head position from a chin-up to a small chin-down position. Only one patient had no clinically significant improvement in their head position. No patients had signs or symptoms of cyclotorsion postoperatively.

Combined vertical recti and oblique muscle surgery can successfully improve and even resolve vertical head posture, and prevents cyclorotary disorders postoperatively.