Strabismus surgery is designed to correct strabismus, a condition in which the eyes don’t align properly. People with strabismus may have one eye that consistently points a different direction– up, down, or to one side. Sometimes, the same eye may point consistently in the same direction; in other cases, strabismus may swap eyes or come and go. Sometimes, it is treated with special glasses, patches, or injections. However, in some cases, these treatments may not be enough. Strabismus surgery, performed on the muscles of the eye, is designed to straighten the eyes and restore normal binocular vision.
Why Is Strabismus Surgery Necessary?
Strabismus surgery may be performed on either adults or children, often based on the severity of the eye’s misalignment. The surgery is designed to restore normal binocular vision and make it possible for the eyes to operate together again. Strabismus may make it difficult to drive, participate in athletic events, or even participate in normal social interactions since so many human interactions rely on eye contact. Strabismus is far from merely cosmetic. It may create double vision or problems with depth perception in sufferers. Surgery is often recommended in children to help with normal visual development while adults may need surgery, rather than patches or blurring of one eye, to correct an ongoing problem.
Before Strabismus Surgery
Before strabismus surgery is performed, you’ll undergo a test in your ophthalmologist’s office to determine which muscles contribute to the strabismus. Your doctor wants to see exactly which muscles are causing the problems. In some cases, muscles will need to be weakened during the surgery; in others, they will be strengthened. Your doctor will use a series of prisms to get a better look at your eyes and the muscles that contribute to its movement.
During the Surgical Procedure
Typically, strabismus surgery is performed as an outpatient procedure. Unless there are unexpected complications, there is no reason for you to need to stay in the hospital overnight. The procedure itself is generally over within an hour or two; however, the patient can expect to remain in the hospital for several hours for preoperative care and postoperative recovery.
If strabismus surgery is performed on a child, the procedure is generally done under general anesthesia. That is, the patient is asleep for the duration of the procedure. This helps alleviate anxiety and may make it easier on the child in the long run. Adults may have the option of general anesthesia or a local anesthetic, depending on the severity of the condition and their anxiety. Your doctor may have a preference for general or local anesthetic and will communicate this to you before your procedure.
During the surgery, the eye is held open with a lid speculum. The doctor will make a small incision in the mucous membrane of the eye to allow them to access the eye muscles. Then, they will strengthen, weaken, or move those muscles, depending on the type of modification needed to straighten the affected eye. In some cases, only one eye will need surgical intervention. Even if only one eye is misaligned, however, both eyes may require surgery in order to achieve better alignment and vision. Your doctor will let you know what is necessary for your procedure ahead of time.
How Does the Surgeon Approach the Eye Muscles?
The eye muscles attach to the sclera (wall of the eye). The muscles are covered by a thin layer of transparent tissue called the conjunctiva. The eyelids are held open by a lid speculum. The surgeon incises the conjunctiva to access the eye muscle(s) and uses small instruments to isolate the muscle. No skin incisions are made. The eyeball is NOT removed from the eye socket during strabismus surgery.
What is a recession?
A recession weakens function by altering the attachment site of the muscle on the eyeball. Once the muscle has been identified, a suture is placed through the muscle at the attachment site to the eye. The muscle is detached from the surface of the eye and reattached further back from the front of the eye, loosening the resting tension of the muscle.
What Is a Resection?
A resection strengthens muscle function by reattaching a muscle to the eyeball at the original insertion site after a portion is removed. A suture is placed through the muscle at the intended new attachment site. The segment of muscle between the suture and the eyeball is removed and the shortened muscle is reattached to the eye.
What Is a Resection/Plication?
A resection strengthens muscle function by shortening the muscle and then reattaching it to the eyeball at its original position. A suture is placed through the muscle at the new intended length. The segment of muscle between the suture and the eyeball is removed or folded over (plication), and the shortened muscle is reattached to the eye [See figure 2].
What Is an Adjustable Suture?
Strabismus surgery involves sewing the eye muscle to the wall of the eye after altering the insertion position and/or the length of the muscle. Standard strabismus surgery (no adjustable suture) utilizes a permanent knot tied during the surgical procedure. Adjustable suture technique utilizes a bow-knot or slip-knot (temporary knot) in an accessible position. After surgery, the eye alignment can be altered by adjusting the temporary knot. The adjustment is typically done with the patient awake and the operated eye numbed, so adjustable suture surgery generally may only be offered to patients who are able to fully cooperate with the adjustment process. This adjustment may be done in the postoperative room, the next day, or later in the week, depending upon the surgeon’s preference. A patch is usually applied to the eye if the time until adjustment is sufficiently long.
What to Expect After Strabismus (lazy eye) Surgery
You, your child or family member will go directly from the operating room to recovery area, where constant monitoring continues under the observation of anesthesia and nursing staff until patients awake. Parents or family (generally one member) may be invited to be present in the recovery room, although usually are reunited in the so-called ―step down‖ recovery area. Breathing tubes are removed either in the operating room or recovery room; either is appropriate and safe. Thereafter, patients are moved to an area where family join in the continuing awakening and recovery process. IV’s are generally removed in this area after liquids are being taken by mouth.
Clear liquids are offered at this time. Popsicles are a popular option for children. There should be no excessive concern about rubbing the eyes. Doing so will be uncomfortable, and even children will not harm themselves or what was done in the surgery, once they have completely emerged from anesthesia. A cool, moist washcloth over the eyes is generally soothing.
Appearance: Short and Long Term
Immediately after surgery, tears on operated eyes will be blood tinged; this is normal and related to the fact that the surface of the eye is moist and very vascular (many vessels). This usually clears in a few hours, and has no significance to the outcome.
They may be safely wiped away with a moist cloth. The first few days after the surgery, there is also an excess secretion of mucus in response to the surgery. This presents itself as moist or dried secretions that accumulate on the eyelashes, and may ―stick‖ the eye lids together. Some children will resist wiping these secretions away with a moist cloth, and that will cause no harm. Eventually, within a matter of a few days, they will dislodge and no harm will ensue.
Bruising is unavoidable. On the surface of the eye, this appears bright (or blood) red. This is so because the blood lies beneath a clear membrane (the conjunctiva). The amount of bruising will vary from person to person, and even from eye to eye. While this observation is the most dramatic after surgery, it is probably the least meaningful, in that it will all go away within about two weeks. In children and on first muscle operations, the redness may last only 7 to 10 days. If a resection or reoperation of a muscle has been performed, there is more likely to be swelling on the surface—this may look like a blistering or ballooning of the surface membrane or conjunctiva, causing it to protrude between the lids—called chemosis. This may take longer to resolve, lasting three weeks or more. After the bruise is gone, it will take several weeks for healing to be complete, and redness may gradually diminish over several months.
Sometimes there is bruising of the lids as well. This is more common in older adults with fragile blood vessels, persons who have been on blood thinners such as aspirin and Coumadin, persons undergoing reoperations, and persons having surgery on the oblique (superior and especially the inferior) muscles.
After all healing is complete, there are subtle and unavoidable evidence that surgery has been performed. Ophthalmologists, observant patients and families, and occasionally others routinely make these observations. They generally derive from the anatomy of eye muscles as they attach to the globe, and the body’s normal healing responses. With careful technique, they can be minimized, but not entirely avoided. Four examples of these are:
1) evidence of incision on the surface (scar),
2) bluish discoloration of the white of the eye underlying a recessed muscle,
3) a ridge on the white of the eye where the muscle previously attached, and
4) persistent thickening and redness of the white of the eye in the region of muscles undergoing complicated or reoperation procedures.
The experience of pain seems to vary widely after strabismus surgery. The typical experience, especially for first-time operations, is moderate pain that responds to Tylenol or Motrin. The duration of pain varies from a few hours to several days. There is surface irritation associated with the preparation and incision; and there is aching soreness, associated in particular with movement of the eyes. The former generally lasts up to 48 hours, and the latter typically up to one week. Please bear in mind that individual circumstances vary widely. Adults often appear to experience more discomfort than children. The day of surgery is generally the most uncomfortable. However, especially for children, a nap in their own bed at home seems to be the best medicine. After this nap, children will sometimes awake as if ready to go at full speed with normal activities. Some adults will have minimal pain, others significantly more. Prior to surgery, please inform your surgeon about previous experiences with and tolerance to pain, plus medications known to be effective for you. In general, the more muscles requiring surgery and the performance of reoperations (previous eye or strabismus surgery) will increase the degree of discomfort. In some instances, particularly older children and adults, eye drops may help to decrease inflammation and assist in pain control.
Activities and Ability to Function
Returning to normal activities after surgery is rapid. Most persons, even children, will choose and return quite rapidly to their normal lives. While there is some variation in ability to function following surgery, most persons will be able to do basic things within hours to a few days following surgery. General rules of thumb include:
. If the activity is not painful, it is likely to be acceptable
. One should avoid potential contamination of the eyes with irritants, such as soaps and shampoo, for two to three days
. Swimming (head submerged) should be avoided for several days.
. Driving should be a matter of individual confidence; some may drive as early as the day following surgery
Alignment, Double Vision and Head Position
Alignment of the eyes should be improved immediately after surgery. This may be somewhat obscured by bruising and swelling. Alignment may, and likely will change as healing occurs. Therefore, no final conclusions about the effectiveness of the procedure can be rendered in the first few days after surgery. Experience has shown, however, that certain patterns may be discerned. It is encouraging if eyes were crossed before surgery and completely straight following, and if double vision present before and absent immediately after. However, sometimes double vision will take a few days to weeks to resolve, even with successful surgery. If double vision was not present before surgery, it may even be an encouraging sign; it is after all the brain perceiving images simultaneously. With time, hopefully, the brain will ―lock in‖ and fuse to receive the images together as binocular vision.
In the instance of intermittent or manifest exotropia, it is generally beneficial to initially overcorrect somewhat, and this may lead to temporary crossed eyes and double vision. As the muscles (typically the lateral recti) heal, they tend to pull the eyes outwardly and predictably. Occasionally, patching of one eye or prisms may be useful in reestablishing binocular vision while muscles heal. These methods are occasionally useful in early apparent over corrections of esotropia and hypertropia as well.
When surgery is performed to correct abnormal head positioning, the effect is usually immediate; in fact, in some instances it may be slightly overcorrected, only to return to a straighter position. In general, no final conclusions about the effectiveness of surgery can be made in the first week following surgery. By six to eight weeks after surgery, healing is nearing completion and more accurate assessments may be made. Even after this time or with apparent success there can be changes, particularly in cases where there is no binocular visual function or evolving medical conditions such as thyroid eye disease.
Wearing Glasses and Contact Lenses
Glasses may be worn immediately following surgery. The surgery does not change the prescription of glasses to any appreciable degree. However, if glasses have prism in them prior to surgery, then glasses without prism should be acquired for use immediately after. Contact lenses are generally not comfortable for approximately two weeks following the procedures.
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