By Sandra M. Brown, M.D.
What is Surgery for Strabismus?
Children with strabismus (crossed eyes or wandering eyes) often need surgery to straighten the eyes. The surgery involves detaching the eye muscles from the outer wall of the eyeball (the white part, called the sclera) and sewing them back on to the wall of the eye in a different place. The eyeball is not removed from the head. No surgery is performed inside the eyeball. All the surgery is done underneath the skin of the eye, and no cuts are made on the skin of the face or the eyelids. When the child is healed after surgery, no one looking at him can tell that he had surgery on his eyes.
Some children require loosening of eye muscles that pull too strongly or in the wrong direction. In this case, the eye muscle is detached from the eyeball and reattached (sutured) to the eyeball farther behind the eye. This loosens the muscle and weakens its pull. This is called a recession. Some children require tightening of muscles that pull too little. In this case, the muscle is detached from the eyeball and a small piece is cut from the end. The muscle is reattached to the eyeball in the same place. Since the muscle is shorter and tighter, it pulls more strongly. This is called a resection. Your child may require recessions, resections, or a combination of both to straighten the eyes most effectively.
Most children require surgery on both eyes, even though only one eye turns or wanders. Oftentimes, the best combination of eye muscles for surgery cannot be decided until after the child is asleep in the operating room. Therefore, unless permission to operate on both eyes is specifically denied on the preoperative consent form, Dr. Brown will make a decision at the time of surgery for the best tightening and loosening of the eye muscles. This is usually, but not always, the same plan that was discussed with you beforehand.
How Long Does the Surgery Take?
The surgery itself is usually about 30 minutes long for each muscle. However, putting a child to sleep and waking him up again also usually takes 20 to 45 minutes. Your child will be away from you for around 1 – 2 hours. You will be taken to your child in the Recovery Room as soon as possible.
When Can I Take My Child Home?
Your child will go home after he has fully recovered from anesthesia and taken some liquids by mouth. Usually strabismus surgery does not require an overnight stay in the hospital.
What to Expect after Strabismus Surgery
- Patches: After strabismus surgery your child’s eyes will not be patched.
- Redness: The whites of the eyes will be solid red in those areas where the eye muscles attach to the eyeball. This redness is harmless and will go away completely in 2-3 weeks.
- Swelling: The eyelids will be somewhat puffy for 2-3 days. This will be worse each morning and better by the afternoon. In rare situations, there is a black eye which will clear up in 1-2 weeks.
- Pain: Strabismus surgery usually does not cause very much pain. Pain medication is administered through the IV at the beginning of surgery except in children under 1 year old. Children’s Tylenol is typically all that is needed afterward. Do NOT give Motrin, Advil, ibuprofen, aspirin, or any combination medicine which may contain these medicines (read labels carefully) for 2 weeks after surgery. Cold packs may be used by older children if desired.
- Nausea: Anti-nausea medication is administered through the IV at the beginning of surgery. However, sometimes the anesthesia still causes an upset stomach. No matter how hungry your child is, feed him lightly for the first meal after surgery. Clear juice (such as apple or grape, but not orange), cereal, crackers, or soup are good to start with. Breakfast foods like pancakes and toast are also well tolerated. Avoid milk or formula for 3-4 hours (pedialyte or pediasure are fine). If light foods stay down, then you may feed your child normally. If nausea and vomiting lasts longer than 1-2 hours, feed clear liquids 3 and crackers. Some children continue to feel sick to their stomachs until the morning after surgery, but most are fine by the evening after surgery. If severe nausea persists such that nothing is kept down by the following afternoon, contact the office. Do not let your child eat pizza, ribs, happy meals, french fries, hamburgers, or anything else that is greasy immediately after surgery.
- Medications: You will be given a combination antibiotic/anti-inflammatory ointment (usually TobraDex) to use 3 times per day after the surgery. The best way to put ointment in young children is to lay them on the floor and straddle them. Sometimes it takes two adults. Pull down the lower lid to make a little pouch, and squeeze a small amount of ointment (about as much as a grain of rice) into the pouch. When the ointment is warm it squeezes out much more easily, so you may want to put it in your pocket or warm it in your hand for a few minutes first. If you absolutely cannot get it into the eyes, getting ointment onto the eyelashes is usually sufficient. The ointment blurs vision and feels sticky, so most children complain. However, it rarely causes stinging. The tube should last a minimum of 7 days. If you run out sooner, call the office for a refill.
- Tears: Because the front surface of the eye gets a little rough during the surgery, your child may make more tears than usual for 2-3 days. These tears may be pink. This is normal and harmless. The pink color is from dissolving old blood, not new bleeding.
- Vision: The vision of each eye separately is not affected by strabismus surgery. The antibiotic ointment used after surgery will cause blurry vision for 20-30 minutes after each dose. Young children rarely mind. Older children may want to schedule ointment administration at times that will not interfere with their other activities.
- Double Vision: Because there is a big change in the position of the eyes after surgery, some children have double vision. The double vision usually goes away over a few days as the brain gets used to the new position of the eye muscles. However, some children see double off-and-on for weeks. Do not encourage the child to experiment with double vision by asking about it. Do not allow the child to cover one eye with a pirate patch or bandage to avoid double vision, as this delays the brain’s adaptation to the new eye position.
- Face and Hair Washing: Face washing with a warm washcloth is fine. You may need to wash your child’s face frequently, since the eye ointment often melts down onto the upper cheeks. Avoid face soaps for 2 weeks, as they sting if they get into the eyes. Hair washing is fine as long as shampoo is kept out of the eyes (including no-tears shampoo).
- Eye Rubbing: Most children will not rub their eyes after surgery because this hurts. However, if your child is an eye-rubber, watch him and stop eye rubbing for 2-3 days after surgery. The concern is that eye rubbing will break the sutures and allow the muscles to slip behind the eye.
- School: Children who like school are usually ready to go back to school on the second day after surgery. They may play outside at recess. Activities which might lead to getting poked in the eyes or falling and hitting the eyes (soccer, football, baseball) are not allowed for 2 weeks. Children who often get dirty faces when they play should be watched to be sure dirt is not getting in the eyes. No trampolines for 2 weeks, please.
- Play Activities: Any play activity which does not have a high risk of eye injury or getting dirt on the face or in the eyes is allowed. This includes biking. See also the note about School.
- Swimming: No swimming until Dr. Brown approves it. Swimming before the skin of the eyes is healed can cause serious infection. Running through sprinklers is OK.
- Glasses: If your child wears glasses, try to get him to put them on the evening after surgery. The latest that he can wait to start wearing glasses again is the morning after surgery.
- Amblyopia Treatment: If your child is using atropine or patching one eye to treat amblyopia, generally patching and atropine are totally stopped after surgery. Usually the child will be patched right up until the day before surgery. Often atropine is stopped several weeks before surgery.
What Should I Watch For After Surgery?
Every day your child should look better than the day before. Watch for swelling, drooping, or redness of the eyelids and a “warm feeling” to the skin around the eyes. Also watch for heavy green and yellow drainage. If your child had surgery on both eyes, these problems may happen in both eyes or only in one eye. They are signs of infection – call the office immediately! It is common for children to run a low temperature for 1 day after general anesthesia, which can be treated with children’s Tylenol. High fever with drainage and pain means infection.
When is the First Follow-Up Exam?
The first follow-up visit is generally two weeks after the operation. Usually our surgery scheduler will set up the appointment at the time you schedule the surgery, and the nurses will confirm this appointment for you before you leave the hospital.
Results after Strabismus Surgery
Don’t worry if your child’s eyes seem to turn in the opposite direction than they did before the surgery. The final results after eye muscle surgery cannot be decided for at least 6-8 weeks, since the brain has to learn how to control the eye muscles in their new positions. In some cases it will take 3-4 months to decide how the brain is responding to the surgery.
Glasses After Strabismus Surgery
If your child wears glasses before surgery, he will probably continue to need them after surgery. The prescription may need to be changed, but usually not before 6-8 weeks after surgery. Only very rarely can glasses be stopped after eye muscle surgery, and this is NOT the goal of the surgery. If your child has never worn glasses, or has worn them in the past but not now, there is a small possibility that glasses will be needed after surgery. In this case, the job of the glasses is to make it as easy as possible for the child to maintain the new, straight position of the eyes. If you have any questions or concerns about your child’s eye care, please do not hesitate to call our office at (704) 782-1127. A doctor is on call 24 hours every day to answer questions and help you with your child’s care after surgery.
Copyright Sandra M. Brown MD, April 18, 2005