In some cases of strabismus in children and adults, strabismus treatment consists of glasses, prisms, patching or blurring of one eye, botulinum toxin injections, or a combination of these treatments. Other times, eye muscle surgery is necessary to straighten the eyes.
In children with some types of constant strabismus, early surgery may be recommended to improve the chance of restoring or promoting normal binocular vision.
In adults, eye alignment surgery is not strictly cosmetic. Cosmetic surgery is enhancement surgery, such as restoring youthful appearance in a normal aging person. Eye alignment surgery restores normal appearance and is considered reconstructive. There are many other benefits beyond restoring normal appearance: improved depth perception or binocular vision, improved visual fields, eliminating or minimizing double vision and improved social function — as eye contact is hugely important in human communication. It is important to discuss the goals and expectations of the surgery with your ophthalmologist.
During strabismus surgery, one or more of the eye muscles are strengthened, weakened or moved to a different position to improve alignment. Strabismus surgery is usually performed as an outpatient procedure and does not require an overnight hospital stay.
Preoperative tests for strabismus surgery
Before surgery, a specialized examination called a sensorimotor examination will be performed in the ophthalmologist's office to assess the alignment of the eyes to determine which muscles are contributing to the strabismus and which muscles need to be altered (weakened, strengthened, or moved) to improve the alignment of the eyes. Prisms are used to measure the degree of the strabismus. These preoperative tests help guide the surgeon in determining the surgical plan. Often both eyes require surgery, even if only one is misaligned. Sometimes the exact surgical plan is determined based on findings at the time of the surgery, especially in reoperations.
Medications and strabismus surgery
Strabismus surgery rarely causes significant bleeding. However, some surgeons may suggest that you stop taking blood thinners, aspirin, aspirin-containing products, ibuprofen or certain nutritional supplements that can affect bleeding for a week before the surgery. Withholding these medications should also be discussed with the prescribing doctor to assess the risk of NOT taking the medication. If a pain medication is necessary during this time, acetaminophen (Tylenol) can be used as a substitute.
The strabismus surgery procedure
Strabismus surgery in children requires general anesthesia. Before surgery, a medication is often given to children to alleviate their anxiety of being separated from their parent. In adults, the procedure can be done with general or local anesthesia. Either way, the patient must fast for about eight hours before the procedure. For this reason, pediatric cases are often scheduled in the early morning.
The eye is never removed to perform the surgery. The eyelids are gently held open with a lid speculum. A small opening is made through the conjunctiva (the mucous membrane surface of the eye) to access the muscle. The muscle is then weakened, strengthened or moved to change its action with dissolvable sutures. Most strabismus surgeries are less than one to two hours; however, the patient will be at the surgery center for several hours including pre-operative and post-operative care.
In standard strabismus surgery, the muscle is weakened, strengthened or moved and a permanent knot is placed. In adults, there is the added advantage that an adjustable suture can be used. Instead of a permanent knot, a temporary knot is placed. After the surgery, with the patient awake, alignment can be reassessed, and if necessary, adjustments can be made before a permanent knot is placed to minimize the chance of an over-correction or under-correction. This is typically done the day of or the day after the surgery.
Any patient that has surgery, whether under general anesthesia or local anesthesia with sedation, needs to be monitored after surgery. Children can return to school after two days. Adults should not drive the day of surgery or the day after and may need up to a week before returning to work. You may have double vision that can last hours to days or a week or more, rarely longer. Exercise caution with activities like driving if you have double vision.
Pain is minimal and usually over-the-counter medicines, such as ibuprofen (Motrin) or acetaminophen (Tylenol), and cool compresses are adequate. Adults and older children may need prescription pain medicine.
The main restriction after strabismus surgery is not swimming for two weeks.
The eye will be red for one to two weeks, rarely longer, especially if it is a reoperation.
Potential risks of strabismus surgery
The chance of any serious complication from strabismus surgery that could affect the sight or well-being of the eye is exceedingly rare. However, there are risks with any surgery, including:
- Sore eyes;
- Residual misalignment;
- Double vision;
- Corneal abrasion;
- Decreased vision;
- Retinal detachment;
- Anesthesia-related complications.
How successful is strabismus surgery?
Strabismus surgery is a common procedure and most patients will see a large improvement in the alignment of their eyes after surgery. In some cases, you may need additional surgery or prism glasses to optimally align the eyes. Each case of strabismus is unique and should be discussed with your ophthalmologist to understand the goals and expectations of surgery.