Figure 4.

Our surgical approach to abnormal head posture associated to nystagmus. In patients whose nystagmus decreases with convergence, base-out prisms are tested and if the nystagmus shows significant improvement or disappears, an artificial divergence surgery is proposed. Remember that this strategy is frequently useful in discordant nystagmus and in vertical head turns. Otherwise, a surgical procedure of the horizontal muscles may be simulated with prisms because it could suffice in any type of abnormal head turn. Finally, pure vertical or torsional abnormal head positions may seldom need surgery on the vertical rectus and/or oblique muscles. In children under two years of age, botulinium toxin injected in the retrobulbar space* or in the muscles** is preferred to surgery.