Superior Oblique Tendon Expanders with Inferior Recti Recessions for Chin-Up Null Point Nystagmus

Abstract

Introduction: Patients with nystagmus may adopt a chin-up head position if the null point of their nystagmus is positioned in downgaze. Large bilateral superior recti resections have been combined with inferior recti recessions to elevate the null point, thereby reducing the abnormal head position. This approach may require limitation of downgaze to be effective. Methods: In this paper, we retrospectively review three children who underwent bilateral superior oblique tendon expanders combined with inferior recti recessions to treat their chin-up head positions. All had variable amounts of chin-up, but all measured at least 20 degrees or more. All had intermittent chin-up head positions when visually concentrating, of sufficient frequency to cause functional complaints. One patient had previous strabismus surgery on all four horizontal recti. Results: Two patients had complete resolution of their abnormal vertical head position. The third showed improvement in both frequency and amplitude of the chin-up position. All patients retained full versions in downgaze. No patient complained of torsional symptoms. Conclusion: Superior oblique tendon expanders combined with inferior recti resections may reduce chin-up abnormal head positions in null point nystagmus. This method is particularly useful when previous strabismus surgery limits the number of recti muscles available for surgery. Advantages of using superior oblique tendons expanders rather than vertical recti recess/resect procedures also include sparing recti muscles in the case of future surgery, and not requiring downgaze restriction for success.