Selective Nasal Anterior Superior Oblique Tenectomy for the Treatment of Superior Oblique Myokymia

Superior oblique myokymia is a rare condition characterized by spontaneous episodes of high frequency, low amplitude, usually unilateral torsional oscillopsia. Surgical treatment is indicated when medical therapy fails to improve symptoms. The traditional surgical recommendation is an ipsilateral full-tendon superior oblique tenectomy to remove all attachments of the superior oblique tendon to the sclera. This approach will likely result in a secondary superior oblique palsy, requiring simultaneous weakening of the ipsilateral inferior oblique muscle. We report a patient presenting with diplopia and oscillopsia in the setting of superior oblique paresis and myokymia with persistent symptoms after initial superior oblique tuck. An alternative surgical approach consisting of superior oblique anterior one-third nasal tenectomy and contralateral inferior rectus recession resulted in marked improvement of oscillopsia associated with superior oblique myokymia while minimizing the risk of inducing downgaze diplopia often observed with superior oblique tenectomy.