What Is the Kestenbaum Procedure?

Kestenbaum procedure is a surgical procedure to correct the head tilt associated with nystagmus.
Kestenbaum procedure is a surgical procedure to correct the head tilt associated with nystagmus.

Kestenbaum procedure is a surgical procedure to correct the head tilt associated with nystagmus. Nystagmus is a condition where the eyeballs move rapidly and uncontrollably. They are of three types:

  • Horizontal nystagmus (side-to-side movement of eyes)
  • Vertical nystagmus (up and down movement of eyes)
  • Rotary nystagmus (eyes move in a circle)

Nystagmus generally affects both the eyes, and the movements may be slow or rapid. The eyes may rapidly shake when looking in a particular direction. People with nystagmus may tilt or turn their head for a clear vision. Tilting or turning the head may slow down the eye movements. In some cases with eye shaking, the patient may have a null point, wherein the patient turns their head toward the right to allow them to look to their left effortlessly. Generally, nystagmus occurs as the areas of the brain that control eye movements fail to work.

Nystagmus is of two types:

  • Congenital: This type of nystagmus starts in infants between six weeks and three months old.
  • Acquired: This type of nystagmus occurs later in life.

Kestenbaum procedure involves repositioning of eye muscles that coordinate eye movements mostly in children. It also alleviates abnormal head position associated with nystagmus by shifting the null point to the center. The main goal of this procedure is to coordinate the eye movements along the direction of the head turn.

What to expect during a Kestenbaum procedure?

Before the procedure:

  • The surgeon decides on the muscle that needs to be repositioned.
  • The number of muscles, amount of surgery, and muscle selection depend upon the type and amount of deviation.
  • The surgeon carries out an eye examination to assess the eye’s movement. 
  • The surgeon may ask you to undergo certain eye tests, such as:
    • Stereoacuity
    • Worth four-dot test
    • Test for binocular single vision
    • Evaluation for postoperative diplopia
    • Double Maddox rod
    • Lancaster red/green test for torsion
    • Ambyloscope/synoptophore testing
  • The surgeon might give a muscle relaxant along with general anesthesia for sustained muscle contraction for up to 20 minutes.
  • You may have to stop blood thinners before the surgery after consulting the physician.

During the procedure:

  • Once the anesthesia becomes effective, the physician retracts the lids and the lashes out of the field. 
  • Next, the physician makes a small cut near the eyeball that penetrates the inner layer of the eyeball.
  • The physician with the help of a hook isolates the desired muscles.
  • After isolating the muscles, the physician recesses (detaches) the affected muscle from the eye and resects (reattaches) it farther back on the eye to weaken the strength of the muscle if it is too strong.
  • In some cases, if the muscle is too weak, the surgeon may use a recession procedure to reduce the strength of the opposing muscle to achieve a balanced function of the eye muscles.

After the procedure:

  • Monitoring for one to two weeks after surgery is necessary.
  • The physician may prescribe oral antibiotics, corticosteroids, or nonsteroidal antiinflammatory drugs.
  • It would take around one to three months for stabilization.
  • Complications of the Kestenbaum procedure include:
    • Ptosis (eyelid drooping)
    • Misalignment of the eyes that may recover after sometime
    • Infection
    • Bleeding
    • Detachment of retina


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