Purpose <p>To compare the outcomes of Nishida procedure versus single horizontal muscle upward transposition (SHMT) for the management of monocular elevation deficiency (MED).</p> Methods <p>A retrospective review was conducted on patients who underwent either Nishida or SHMT procedure for MED and completed a follow-up &gt; 6 months. Operative details, ductions, versions, fundus torsion, and angle of deviation were analyzed before and after surgery.</p> Results <p>Thirty-two patients were identified; 12 in the Nishida and 20 in the SHMT group. The mean age was 13.8 ± 13.5 years. The mean preoperative vertical angle of deviation was 24 ± 8 PD in the Nishida group and 24 ± 6 PD in the SHMT group. Ipsilateral inferior rectus recession was performed in 3 patients in the Nishida group and 17 patients in the SHMT group. Mean follow-up was 8.5 ± 8.2 months. The postoperative improvement of elevation in adduction and abduction was comparable in both groups (<i>P</i> = 0.47 and 0.16, respectively). Depression deficits occurred in 3 patients (25%) in the Nishida group and 1 patient (5%) in SHMT group (<i>P</i> = 0.14). None of the patients in either group developed an abduction or adduction deficit. No change in fundus torsion occurred with SHMT. Mean postoperative vertical angle was significantly lower (<i>P</i> = 0.009) in the SHMT group (0 vs. 3 PD). Improvement of elevation was significantly better in those with acquired onset MED than congenital MED in both groups.</p> Conclusions <p>Both Nishida and SHMT procedures were equally effective in improving the elevation in monocular elevation deficit. Postoperative vertical deviation was slightly smaller with SHMT.</p>