diff --git a/extensions/cornerstone/src/Viewport/Overlays/ViewportOrientationMarkers.tsx b/extensions/cornerstone/src/Viewport/Overlays/ViewportOrientationMarkers.tsx
index 3bf776ed7..c390308b8 100644
--- a/extensions/cornerstone/src/Viewport/Overlays/ViewportOrientationMarkers.tsx
+++ b/extensions/cornerstone/src/Viewport/Overlays/ViewportOrientationMarkers.tsx
@@ -1,12 +1,6 @@
-import React, { useEffect, useState, useMemo, useRef } from 'react';
+import React, { useEffect, useState, useMemo } from 'react';
 import classNames from 'classnames';
-import {
-  metaData,
-  Enums,
-  Types,
-  getEnabledElement,
-  utilities as coreUtilities,
-} from '@cornerstonejs/core';
+import { metaData, Enums, getEnabledElement } from '@cornerstonejs/core';
 import { utilities } from '@cornerstonejs/tools';
 import { vec3 } from 'gl-matrix';
 
@@ -22,75 +16,36 @@ function ViewportOrientationMarkers({
   servicesManager,
   orientationMarkers = ['top', 'left'],
 }: withAppTypes) {
-  // Rotation is in degrees
-  const [rotation, setRotation] = useState(0);
-  const [flipHorizontal, setFlipHorizontal] = useState(false);
-  const [flipVertical, setFlipVertical] = useState(false);
+  const [cameraModifiedTime, setCameraModifiedTime] = useState(0);
   const { isViewportBackgroundLight: isLight } = useViewportRendering(viewportId);
   const { cornerstoneViewportService } = servicesManager.services;
 
-  // Store initial viewUp and viewRight for volume viewports
-  const initialVolumeOrientationRef = useRef<{
-    initialViewUp: number[] | null;
-    initialViewRight: number[] | null;
-  }>({
-    initialViewUp: null,
-    initialViewRight: null,
-  });
-
   useEffect(() => {
-    initialVolumeOrientationRef.current.initialViewUp = null;
-    initialVolumeOrientationRef.current.initialViewRight = null;
-
-    if (viewportData?.viewportType !== 'stack' && element && getEnabledElement(element)) {
-      const { viewport } = getEnabledElement(element);
-      const { viewUp, viewPlaneNormal } = viewport.getCamera();
-
-      const viewRight = vec3.create();
-      vec3.cross(viewRight, viewUp, viewPlaneNormal);
-
-      initialVolumeOrientationRef.current.initialViewUp = [...viewUp];
-      initialVolumeOrientationRef.current.initialViewRight = [...viewRight];
-    }
-  }, [element, viewportData]);
-
-  useEffect(() => {
-    const cameraModifiedListener = (evt: Types.EventTypes.CameraModifiedEvent) => {
-      const { previousCamera, camera } = evt.detail;
-
-      const { rotation } = camera;
-      if (rotation !== undefined) {
-        setRotation(rotation);
-      }
-
-      if (
-        camera.flipHorizontal !== undefined &&
-        previousCamera.flipHorizontal !== camera.flipHorizontal
-      ) {
-        setFlipHorizontal(camera.flipHorizontal);
-      }
-
-      if (
-        camera.flipVertical !== undefined &&
-        previousCamera.flipVertical !== camera.flipVertical
-      ) {
-        setFlipVertical(camera.flipVertical);
-      }
-    };
-
+    const cameraModifiedListener = () => setCameraModifiedTime(Date.now());
     element.addEventListener(Enums.Events.CAMERA_MODIFIED, cameraModifiedListener);
 
     return () => {
       element.removeEventListener(Enums.Events.CAMERA_MODIFIED, cameraModifiedListener);
     };
-  }, []);
+  }, [element]);
 
   const markers = useMemo(() => {
-    if (!viewportData) {
+    if (!viewportData || cameraModifiedTime === 0) {
+      return '';
+    }
+
+    if (!element || !getEnabledElement(element)) {
+      console.log(`ViewportOrientationMarkers :: Viewport element not enabled (${viewportId})`);
+      return '';
+    }
+
+    const ohifViewport = cornerstoneViewportService.getViewportInfo(viewportId);
+
+    if (!ohifViewport) {
+      console.log(`ViewportOrientationMarkers :: No viewport (${viewportId})`);
       return '';
     }
 
-    let rowCosines, columnCosines, isDefaultValueSetForRowCosine, isDefaultValueSetForColumnCosine;
     if (viewportData.viewportType === 'stack') {
       const imageIndex = imageSliceData.imageIndex;
       const imageId = viewportData.data[0].imageIds?.[imageIndex];
@@ -100,58 +55,25 @@ function ViewportOrientationMarkers({
         return false;
       }
 
-      ({
-        rowCosines,
-        columnCosines,
-        isDefaultValueSetForColumnCosine,
-        isDefaultValueSetForColumnCosine,
-      } = metaData.get('imagePlaneModule', imageId) || {});
-    } else {
-      if (!element || !getEnabledElement(element)) {
-        return '';
-      }
+      const { isDefaultValueSetForRowCosine, isDefaultValueSetForColumnCosine } =
+        metaData.get('imagePlaneModule', imageId) || {};
 
-      if (
-        initialVolumeOrientationRef.current.initialViewUp &&
-        initialVolumeOrientationRef.current.initialViewRight
-      ) {
-        // Use initial orientation values for consistency, even as the camera changes
-        columnCosines = [
-          -initialVolumeOrientationRef.current.initialViewUp[0],
-          -initialVolumeOrientationRef.current.initialViewUp[1],
-          -initialVolumeOrientationRef.current.initialViewUp[2],
-        ];
-        rowCosines = initialVolumeOrientationRef.current.initialViewRight;
-      } else {
-        console.warn('ViewportOrientationMarkers::No initial orientation values');
+      if (isDefaultValueSetForColumnCosine || isDefaultValueSetForRowCosine) {
         return '';
       }
     }
 
-    if (
-      !rowCosines ||
-      !columnCosines ||
-      rotation === undefined ||
-      isDefaultValueSetForRowCosine ||
-      isDefaultValueSetForColumnCosine
-    ) {
-      return '';
-    }
+    const { viewport } = getEnabledElement(element);
+    const p00 = viewport.canvasToWorld([0, 0]);
+    const p10 = viewport.canvasToWorld([1, 0]);
+    const p01 = viewport.canvasToWorld([0, 1]);
+    const rowCosines = vec3.sub(vec3.create(), p10, p00);
+    const columnCosines = vec3.sub(vec3.create(), p01, p00);
 
-    const markers = _getOrientationMarkers(
-      rowCosines,
-      columnCosines,
-      rotation,
-      flipVertical,
-      flipHorizontal
-    );
+    vec3.normalize(rowCosines, rowCosines);
+    vec3.normalize(columnCosines, columnCosines);
 
-    const ohifViewport = cornerstoneViewportService.getViewportInfo(viewportId);
-
-    if (!ohifViewport) {
-      console.log('ViewportOrientationMarkers::No viewport');
-      return null;
-    }
+    const markers = _getOrientationMarkers(rowCosines, columnCosines);
 
     return orientationMarkers.map((m, index) => (
       <div
@@ -168,16 +90,7 @@ function ViewportOrientationMarkers({
         <div className="orientation-marker-value">{markers[m]}</div>
       </div>
     ));
-  }, [
-    viewportData,
-    imageSliceData,
-    rotation,
-    flipVertical,
-    flipHorizontal,
-    orientationMarkers,
-    element,
-    isLight,
-  ]);
+  }, [viewportData, imageSliceData, cameraModifiedTime, orientationMarkers, element, isLight]);
 
   return <div className="ViewportOrientationMarkers select-none">{markers}</div>;
 }
@@ -189,18 +102,13 @@ function ViewportOrientationMarkers({
  *
  * @param {*} rowCosines
  * @param {*} columnCosines
- * @param {*} rotation in degrees
- * @returns
  */
-function _getOrientationMarkers(rowCosines, columnCosines, rotation, flipVertical, flipHorizontal) {
+function _getOrientationMarkers(rowCosines, columnCosines) {
   const rowString = getOrientationStringLPS(rowCosines);
   const columnString = getOrientationStringLPS(columnCosines);
   const oppositeRowString = invertOrientationStringLPS(rowString);
   const oppositeColumnString = invertOrientationStringLPS(columnString);
 
-  // Round to 4 decimal places (after rotate right 3 times and flip horizontally -> rotation is 90.00000000000001)
-  rotation = Math.round(rotation * 10000) / 10000;
-
   const markers = {
     top: oppositeColumnString,
     left: oppositeRowString,
@@ -208,43 +116,6 @@ function _getOrientationMarkers(rowCosines, columnCosines, rotation, flipVertica
     bottom: columnString,
   };
 
-  // If any vertical or horizontal flips are applied, change the orientation strings ahead of
-  // the rotation applications
-  if (flipVertical) {
-    markers.top = invertOrientationStringLPS(markers.top);
-    markers.bottom = invertOrientationStringLPS(markers.bottom);
-  }
-
-  if (flipHorizontal) {
-    markers.left = invertOrientationStringLPS(markers.left);
-    markers.right = invertOrientationStringLPS(markers.right);
-  }
-
-  // Swap the labels accordingly if the viewport has been rotated
-  // This could be done in a more complex way for intermediate rotation values (e.g. 45 degrees)
-  if (rotation === 90 || rotation === -270) {
-    return {
-      top: markers.left,
-      left: invertOrientationStringLPS(markers.top),
-      right: invertOrientationStringLPS(markers.bottom),
-      bottom: markers.right, // left
-    };
-  } else if (rotation === -90 || rotation === 270) {
-    return {
-      top: invertOrientationStringLPS(markers.left),
-      left: markers.top,
-      bottom: markers.left,
-      right: markers.bottom,
-    };
-  } else if (rotation === 180 || rotation === -180) {
-    return {
-      top: invertOrientationStringLPS(markers.top),
-      left: invertOrientationStringLPS(markers.left),
-      bottom: invertOrientationStringLPS(markers.bottom),
-      right: invertOrientationStringLPS(markers.right),
-    };
-  }
-
   return markers;
 }