The operations of strabismus

Preparing for surgery
Preoperatively there should always be a routine physical examination on the child. Blood and urine tests are usually unnecessary. The child's stomach should be empty during the administration of general anesthesia and solid foods should be avoided from the night before.

At the hospital the day of surgery an effort must be made, not to keep the child for a long time away from his parents. If the child is very anxious and the hospital allows it, parents can follow it into the operating room until the moment it falls asleep from the anesthesia, and then wait in the waiting room.

Surgery
During surgery incisions are not made on the faces’ skin or on the eyelids. Surgical incisions are made in the conjunctiva using small scissors and not by scalpel or laser. The eyelids remain open by using a simple lid retractor and special hooks are used for capturing the muscles. The strategy of the operation has been decided in advance and depends on the type and extent of strabismus.

The correction of strabismus is done by various techniques that alter the strength of the muscles responsible, either by weakening or by strengthening them. The weakening of a rectus muscle is usually achieved with posterior displacement of the insertion of the sclera for a few millimeters. Thus the muscle will continue moving the eye, but not as strong as to cause strabismus.

Amplification of a rectus muscle is usually achieved by clamping, which means by excision of a tendon’s and muscle’s part and then stapling the rest in the normal insertion position. In some cases, surgery is a combination of muscle strengthening and weakening of the competitor, eg shortening the lateral rectus with simultaneous posterior displacement of the medial rectus in order for the muscle not to suffer the whole "weight" of the correction.

The measurements made during the preoperative check from the surgeon, are very detailed. Special tables give the amount of shortening or posterior displacement, which should be done according to the different angles of strabismus. A very useful technique, usually used in adolescents or adults, is the use of adjustable sutures, usually along with the posterior transfer.

Adjustable sutures allow the correction of a muscle power after surgery, where it is difficult to accurately determine the clinical outcome. Though, it is not suitable for very young children, who will not be cooperative for the adjustment.

Sometimes surgery may involve the healthy eye. If, for example, the angle of the horizontal strabismus is too large, it is preferable to share the amount of correction in both eyes.

At the end of surgery the incisions of the conjunctival are closed with small sutures, which are absorbed after a certain period.

Recovery
The duration of a strabismus operation is approximately one hour, but this of course, varies from case to case. After the operation the child begins waking up from the anesthesia and is transferred to the recovery room.

There, the specialized nursing staff will observe him until he recovers completely, and will make sure his parents are already beside him, ready to reassure him because after recovery he is expected restless and may start crying. His eyes will be covered with bandages or eye gauze and look very red and sore. There may even be blood in his tears. All this is normal and does not cause any interference.

In a few hours the child will be ready to go home. Because his digestive system is also affected by anesthesia, it may take several hours until he will be able to tolerate solid food. For the pain he may be given a children’s pain reliever, but especially important is the care and affection that his parents will show. The hugs from his parents or the use of a crib, if the child is that young and can use one, is advisable, and can help the child overcome  psychologically this test.

The next day the operated eye will stop weeping, and the child will be ready for a light breakfast. Parents should discourage him from rubbing his eyes and is good for a few days to limit somewhat the intense activities. Showering is not prohibited but it is most likely that the ophthalmologist will recommend  avoiding swimming or bold splash in the tub for 1-2 weeks.

Progress
The results of surgery are visible immediately after the child opens his eyes. The alignment of the eyes is more likely to change, especially during the first 2 weeks, which is the usual healing phase. Six weeks after surgery, the surgeon will be able to know exactly how successful the correction actually was.

The ophthalmologist will systematically continue observing the child for the next 6-12 months. The course will be successful when the best possible vision is achieved (with glasses or by covering the healthy eye) and when the eyes are practically aligned.

However, sometimes a second or even a third surgery cannot be avoided. The reason isn’t the "failure" of the first intervention but the loss of alignment, which can happen gradually, even after several years.