Surgery for nystagmus can be indicated in several clinical situations. Before considering surgery, pathologic causes for nystagmus must be ruled out. Red flags for pathologic nystagmus include: vertical nystagmus, asymmetric nystagmus, new onset nystagmus (not present from birth), intermittent nystagmus, and nystagmus associated with other neurological signs. Also, nonsurgical treatment for nystagmus is usually considered, in appropriate cases, before surgical intervention is entertained.
Surgery for non-pathologic nystagmus includes:
1. Surgery for nystagmus causing a consistently present abnormal head posture: typically surgery is performed to relocate the position of decreased nystagmus (optimal vision) to the primary gaze position. This can be accomplished by various means with recession/resection procedures (Kestenbaum/Anderson) being the most common. Surgery can be done for both vertical and horizontal types of nystagmus.
2. Surgery for congenital esotropia associated with nystagmus blockage: surgery is primarily to improve ocular alignment.
3. Surgery to convert manifest nystagmus to latent or manifest/latent nystagmus: this usually involves simply aligning the eyes (bilateral medial rectus recession for esotropia) which allows binocular vision, hence reducing latent nystagmus.
4. Surgery for nystagmus not associated with a consistent abnormal head posture: surgical options include large recession of all 4 horizontal rectus muscles or tenectomy (disinsertion followed by reinsertion at the original insertion site) of all 4 horizontal rectus muscles. These surgeries in selected patients can decrease nystagmus amplitude, and possibly improve visual acuity. Other visual functions (including recognition time) can also show improvement.
5. Botulinum toxin for acquired nystagmus associated with oscillopsia: see FAQ on botulinum toxin for nystagmus.