Chapter 12:

Most strabismus is covered by health insurance. Some policies have restrictions on so-called “pre-existing” conditions, who may perform your surgery, where it may be performed, what will be “covered”, copayments and deductibles, what will be paid and to whom, and other limitations. The insurance company or health plan, as part of the contract between and among employers, beneficiaries and others, generally imposes these restrictions. Similar restrictions are placed on providers, including surgeons under contract to the insurance company or health plan. Those contracts require all parties to “play by the rules”. There are often significant frustrations created by these rules and rulings of the managed care or insurance carriers. While your surgeon’s staff will assist you in knowing how your policy(ies) will affect reimbursement for your care, the ultimate responsibility for understanding your policy, and what it will provide, is yours. Your surgeon’s office responsibility is to provide you, and where contractually required, your insurance or managed care company with information about your diagnosis and proposed treatment. A fact of life is that these matters are often complicated and take time and resources to sort out. You may rest assured that any frustration you may experience is at least matched by your surgeon and his or her staff.

Once it has been determined what options are available, scheduling is a matter of matching your (or your child’s) medical needs with an appropriate facility at which your surgeon has obtained privileges and the combined schedules of the necessary parties. Apart from acute trauma, timing of most strabismus surgery is generally not medically critical. Nonetheless, once the decision has been made, it is generally advantageous—gaining the benefits of correction and avoiding long term fretting about surgery—to you or your child to proceed at an early convenient time.

It is reasonable and prudent to gain prior advice from doctors that provide ongoing care—such as pediatricians, internists and family practitioners—prior to proceeding with surgery. This will maximize the safety to you or your child through communication. There are also general guidelines about what preoperative testing, such a blood and urine tests, chest X-rays, and EKG that may be important to your anesthesiologist and health facility in determining the advisability and safest method of administering an anesthetic and performing surgery. Please be certain share any ongoing medical problems and issues with your surgeon and anesthesiologist prior to surgery. In particular, inform them about any allergies you may have to medicines, any bleeding tendencies you may have, and any past or family history of problems with anesthesia.

Since strabismus surgery is almost always elective in the sense of timing, every effort is taken to avoid taking unnecessary risk. Therefore, if a person is experiencing a temporary illness—for example, upper respiratory congestion, significant cough/sore throat, vomiting and/or diarrhea, and especially fever—it is often wise to postpone surgery. Please inform your surgeon if you are concerned about your or your child’s health before surgery, so that arrangements may be changed if necessary before coming to surgery.

It is unsafe to perform surgery soon after eating solid food. Therefore, a very important aspect of the hours preceding surgery is the restriction of the intake of solid foods and liquid drinks. The very important concern is that as anesthesia is being administered, food—indeed, any stomach contents—may be vomited and aspirated into the lungs, causing inability to breathe or pneumonia; in the worst case, this may be life threatening. The risk of aspiration of stomach contents in to the lungs increases with both volume of material in the stomach and its pH (acidity), and both increase with any food and drink. Your surgeon and anesthesiologist will provide you with detailed instructions about when to stop all intakes of liquids and food. In general, if surgery is to be performed in the morning, nothing should be taken by mouth after midnight the preceding evening. The following is a table of advice for children, based upon age and time of surgery. Please be certain to follow these instructions or those of your anesthesiologist. BEWARE: hungry children and adoring parents will often assume “just one bite” or “sip” will be acceptable; it will not be and will likely require delay or rescheduling of the surgery. Children will need constant supervision to assure they are in compliance with these requirements. One last note: clear liquids, such as water or apple juice, means you can see through them; orange or grapefruit juice and especially milk, for example, are not clear liquids.

For Infants and Children Under Thirteen Years of Age:

·        8 HOURS: Solid high fat food is allowed until 8 hours prior to the scheduled procedure (Meat, cheese, fried food)

·        6 HOURS: Solid low-fat food is allowed until 6 hours prior to the scheduled procedure (Formula, milk, cereals, breads, fruit juice with pulp)

·        4 HOURS: Breast mild is allowed until 4 hours prior to the scheduled procedure

·        2 HOURS: Clear liquids are allowed until 2 hours prior to the scheduled prodedure (Water, Pedialyte, apple juice, Popsicles, clear Jell-O, Kool-Aid or Gatorade)

For Adolescents and Adults:

·         Nothing to eat or drink after midnight prior to surgery; or at least eight hours prior to surgery.

·         Should be taken as usual with a sip of water up to 2 hours prior to the procedure

·         For asthma may be given at any time

Chapter 13: 

Most hospitals or surgical facilities will ask you to arrive one to three hours before surgery. Although details and timing will vary, the purpose of this time is to perform administrative check-in procedures, acclimate and educate you or your child to and about the facility and procedure, and perform a check of vital signs such as height, weight, blood pressure, temperature and blood oxygen (with a monitor on a finger). Some of these aspects may be completed on a day before the surgery. All necessary paper work, including medical record documentation and review of informed consent forms will be organized and completed as necessary.

Your anesthesiologist and the operating room nurse will visit with you prior to going to surgery. Children, although often not infants, generally receive a premedication such as Versed, whose purpose is to relieve anxiety, calm them, decrease separation anxiety from family, and reduce unpleasant memories of the experience. This medicine may be given either as an oral liquid or nasal spray. Adults may have an IV started and receive premedication via this route.

Several people will be in the operating room, including anesthesia, nursing, and surgical staff. The anesthesiologist/ anesthetist, circulating nurse, surgical scrub nurse/technician and surgeon will be in constant attendance. Additional personnel may include and assistant surgeon or surgical assistant of your and your surgeon’s choosing. In other specified circumstances, personnel in training, such as residents and fellows may be present.

In the operating room, anesthetic gases are generally administered to children through a (scented) mask. After the children are asleep, a breathing tube is placed in the throat, either in or over the laryngeal opening to the lungs. By this means, breathing can be monitored and, as necessary, controlled throughout the procedure. IV’s are placed in children after they are asleep. In adults with IV’s in place, anesthetic agents may be administered as oxygen is breathed by mask. After asleep, a breathing tube is placed as above. 

There will be continuous monitoring of key functions during surgery, under constant observation of anesthesia staff. These functions include breathing and respiratory functions, blood oxygen, temperature, blood pressure, and heart beats (EKG). Most strabismus surgery lasts less than one hour.  

Chapter 14:

This and the following (15 & 16) chapters are written by time sequence, and describe events—expected and possible—after surgery; but it should not be read that way. In other words, understanding these matters prior to surgery should be helpful in knowing what to expect or what may be of concern. Please consider them in the context of understanding the consequences and risks of the procedure (please also see Chapter 10).

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 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 a “step-down” 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.

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 not 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 (a “shiner”) 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 conjunctival scar may be minimized with careful technique; many surgeons will place the incision above or below the normal eye lid position (called a cul-do-sac incision), so that it may only be observed by pulling the lids up or down. Bluish discoloration of the sclera (or white) of the eye relates to the thinness of sclera under a normally positioned muscle. When muscles are recessed, this thinner sclera will sometimes appear as an oval shaped bluish discoloration (blue for the same reason the sky is blue—scattering of light). This is quite variable, and not seen in all persons. When a muscle is recessed, it is detached; where it was previously attached, the sclera is thicker and a low ridge or elevation is seen. The ridge is generally more prominent in adult patients. Multiple or complicated operations may lead to extended inflammation and scarring, and may be seen as raised and red tissue on the white of the eye. This scar (and redness) can often be surgically improved with removal of the scar (called “debulking”) and repositioning of the conjunctiva; it may recur, although generally to a lesser degree.

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 your. 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.

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 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. 

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.

Chapter 15:

Unsatisfactory alignment is usually apparent to all parties. Over and under corrections may be apparent to observers, or to the patient. This may be known by observation of the alignment proper, or by symptoms such as double vision. Remember that early post-operative alignment (within the first week following surgery) does not always indicate final alignment. Generally, the results of surgery can be reliably assessed at six to eight weeks following surgery.

In children, double vision is uncommon or quite transient. The child’s brain is able to adapt to the new alignment of the eyes very rapidly. Yet even if double vision does occur, it may be a positive indication! For example, if a child has been suppressing the vision in one eye before surgery, the appreciation of two images may indicate that they are being received simultaneously. One way for such children to resolve the double vision is to fuse, or process the images binocularly; such fusion can be beneficial long term in the development of vision and maintenance of straight eyes.

Infection in strabismus surgery is very uncommon. Three strategies have proven effective in its control. First, careful preparation with sterilizing agents at the time of surgery limits the number of bacteria in the area. Second, some surgeons will routinely use prophylactic antibiotics taken by mouth after the surgery. And third, prompt attention to the possible signs of infection can permit early institution of antibiotic therapy and prevent complications. The signs of infection are usually not subtle! The combination of large amounts of swelling and redness of the lids plus fever and unremitting and worsening pain suggest the possibility of infection. Call you doctor if you are concerned!

Loss of vision can occur, yet is extremely rare. The usual cause of loss of vision is infection that spreads to the inside of the eye. The coat of the eye is thin, and an aggressive infection can spread along suture tracks. The key to successful treatment is early detection. Please note the signs of infection as above.

Serious problems with anesthesia are so rare as to be difficult to measure in the population of persons undergoing strabismus surgery. There has been a quiet revolution in anesthetic procedures and safety within the past 20 years. Modern medicines and monitoring techniques, coupled with highly skilled medical personnel, have made a general anesthetic extraordinarily safe. In healthy persons, the risk of serious complications is probably on the order of one in one million. Please be certain to share with your doctors, especially your surgeon and anesthesiologist, all of your current medicines, allergies and medical problems. Make special mention of neurological problems, diseases involving muscles, and any problems with anesthesia family members may have had in the past.  

Chapter 16:

This booklet is meant to explain many aspects of strabismus and its surgical treatment. Hopefully, it will dispel some common misunderstandings about how the procedures are performed. The following are some common misapprehensions.

It is not necessary to remove the eye to perform strabismus surgery. The muscles attach to the sides of the eye and the surgery is performed with the eyes simply turned to the side, much as one turns one’s eyes to look in normal directions of gaze.

Lasers are not required (or appropriate) for strabismus surgery. Lasers generally are used to destroy tissue to mold or remove it. In strabismus surgery, the goal is to move or modify muscles (and tendons) to weaken or strengthen their actions, thereby to change the angle between the eyes. Hence, removing or destroying tissue would be counter productive.

Anesthesia is no longer very risky. Modern anesthesia techniques and agents have made it very safe. This is not to say that there is no risk, simply that it is so small as to be difficult to measure. Anesthesia in healthy persons, including children of all ages, carries a probable major risk on the order of one in a million or less. 

Surgery cannot be performed in the office. Because anesthesia must be administered, surgery must be performed in a hospital or outpatient surgical facility. Generally a general anesthesia is required and appropriate.

 Bandaging the eye(s) is not necessary following surgery. No patches need be applied; however, if comfort is increased, one or both eyes may be covered.

 You will be able to see following surgery. Since the muscles are attached to the outside of the eye, there is little effect on seeing. Blurring of the vision is common following surgery, and may be associated with preparation before surgery (including eye drops that dilate the pupil and sterilizing irrigating solutions), and tearing and mucus secreting reactions after surgery. These effects are temporary, generally lasting a few to 48 hours. Surgery generally changes refractive error (strength of glasses) very little, and so glasses will not need to be changed. Glasses (minus prisms!) may be worn immediately after surgery.

 You will be able to return to school or work within a very few days following surgery. While there will be bruising and some soreness, most persons are able to be up and about soon enough to return to school or work in two to five days.