My son (daughter) is undergoing strabismus surgery!! Now what?

Strabismus is an ophthalmological pathology characterized by the misalignment of both eyes when the visual axes aren’t coincident with each other. Clinically, strabismus isn’t just an aesthetic situation. It can condition different symptoms and changes in visual development, depending on how old the patient is when it appears:

1. Amblyopia
2. Loss of binocular, depth, and tridimensional vision
3. Abnormal position of the head
4. Diplopia or double vision
5. Low visual acuity and fatigue

The treatment for strabismus always depends on the patient’s case. It can involve using glasses (with or without optical penalization – the “ocular patch”), orthoptics training, or surgery. These therapeutical options are often complementary and not necessarily mutually exclusive.

On the other hand, visual rehabilitation is a process in which the treatment will have to be adjusted to the patient and their development stage, especially in childhood. This means that patience and perseverance are fundamental for the patient, their parents (in the case of a child), and the doctor.

Whenever the surgery is proposed, as parents and even as patients, it’s perfectly normal to have doubts and wonder if undergoing the surgery is the best option at the time, which are the goals, and what to expect for the future…

IS THE SURGERY NECESSARY OR MANDATORY? IS IT URGENT?

Surgery isn’t always an option for strabismus treatment. It may not even be an adequate solution for all kinds of strabismus. However, when the ophthalmologist suggests it, it’s because he has a specific goal in mind:

1. Improve the ocular alignment, bettering the development of binocular vision – this functional objective (improve visual function that is still maturing) is only possible to achieve when the procedure is done during childhood;
2. Improve the ocular alignment and reverse the diplopia (double vision) – this functional objective aims to correct the reduced eyesight and is only applied to patients with diplopia (especially in adults, teens, and children over 7-8 years of age);
3. Correct or reverse a abnormal head position, secondary to strabismus;
4. Aesthetic intent.

Even though the surgery isn’t mandatory, it may have benefits for a child’s development, especially when its objectives are the ones described in points 1 to 3. Strabismus surgery is RARELY defined as urgent.

WHAT IS THE STRABISMUS SURGERY?

Oculomotricity, the coordinated movement of both eyes, depends on the action of 6 muscles (in each eye) that are attached to the surface of the eye. Through brain commands, they allow the eyes to move in various directions in a conjugated and rhythmic way. In strabismus cases, there is a discrepancy in the coordination of these muscles from one eye to the other.

The surgery consists of repairing the muscles (strengthening or weakening them according to the patient’s needs) and using different techniques, to balance both eyes. Accessing the muscles takes microscopic incisions in the conjunctiva (the transparent mucous membrane that covers the eye). The healing process won’t leave any noticeable marks, namely on the skin.

WHERE DOES THE PROCEDURE OCCUR? HOW’S THE ANESTHESIA PROCESS?

The surgery is performed in a properly equipped operating room (OR) with all the necessary material and human resources, including a surgeon (ophthalmologist), an anesthetist, and specialized nurses.

The patient usually goes under general anesthesia. For this purpose, patients are required to go through a rigorous fasting period before the surgery which usually takes 6 hours.

HOW LONG DOES THE SURGERY TAKE? IS HOSPITALIZATION REQUIRED?

The surgery (from anesthesia administration to the end of the surgical procedure) takes anywhere between 60 and 90 minutes. Its duration, however, can be influenced by the patient’s general health, whether they’ve already undergone a strabismus surgery, how many muscles are being treated, and which technique is being used.

The surgery occurs in an outpatient regimen, meaning that the patient will be discharged after 1 to 3 hours of monitorization in recovery, after waking up from general anesthesia.

ARE THERE ANY SURGICAL RISKS? HOW’S THE POST-SURGERY PERIOD?

Like in any other surgical procedure, there are associated risks. Even if their severity and chances of occurring are low, patients should be informed about them. Understanding the risks might help with correcting them in case they occur.

1. Red-eye: red, shot eyes are expected after this surgery, and are not considered an adverse effect;
2. Foreign body sensation and photophobia (eye discomfort in bright light): these side effects are normal during the first days and the symptoms improve with the prescribed treatments (eye drops);
3. Pain in gaze mobilization: this depends on the person, but most people tolerate it without requiring painkillers;
4. Infection: orbital cellulitis is an important complication, even if it’s rare. The surgery is always performed in an aseptic environment, with the patient complying with antibiotic therapy aimed at minimizing this risk.. During the post-surgery period, the patient is monitored by their ophthalmologist who’ll know which signs to be on the lookout for;
5. Diplopia or double vision: depending on the initial pathology and the technique used, double vision might even be considered an expectable and transient symptom after the surgery. It might go away on its own or there might be a need for treatment with glasses or additional surgery. Treatment options vary with each case and should always be discussed with your ophthalmologist;
6. General anesthesia risks: It always depends on the general health and family history of the patient. Pre-surgery preparation is fundamental to anticipate any complications.

Now you understand that strabismus surgery is a SAFE procedure.

Therapeutics after the surgery is fundamental and easy to implement. They consist of eye drops (usually a mix of anti-inflammatory and antibiotics). Although a few children are averse to using them, they can eventually be persuaded with patience and calmness. In the first few days, patients might be able to use oral anti-inflammatory medication and painkillers, however, that’s uncommon.

The patient will be discharged without having to use an ocular bandage, except in particular situations. They should be aware of their surroundings and avoid potentially contaminated environments, water from the ocean or pool, as well as contact sports, and intense workouts.

Patients usually return to their regular activities quickly, 3 to 5 days after the surgery. Children can return to school safely and adults can drive and work at the computer if they feel comfortable enough.

Sources:
American Association for Pediatric Ophthalmology and Strabismus – https://www.aapos.org/glossary/strabismus-surgery

Some videos are up for consultation regarding a few surgical techniques.