PURPOSE: To describe options for the management of vertical deviations after vertical rectus muscle transposition surgery (VRT). METHODS: Retrospective case series including 7 children who underwent VRT for esotropic Duane syndrome and developed the complication of a vertical deviation. RESULTS: Eighty-two consecutive children underwent VRT for Duane syndrome. Seven eyes of 7 patients (4 boys, 3 girls) were found to have induced vertical deviations postoperatively. Average length of follow-up was 12.7 months (range, 3-28 months). Median induced vertical deviation was 10.1(Delta) (range, 8-12). All patients required only one additional surgery to ameliorate the vertical deviation. At final follow-up, the mean vertical tropic deviation was 0. Six patients were operated on within 4 days of VRT. Surgical strategies included recession of one vertical rectus muscle and repositioning of a posterior fixation suture. CONCLUSIONS: In children undergoing VRT for esotropic Duane syndrome, the complication of a vertical deviation occurred in 8.5% of cases. The vertical deviation was completely ameliorated in each case by one surgical procedure involving recession of one of the transposed muscles.