Strabismus

1-435-986-2020

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Just because you see well does not mean your child does!

We often take it for granted that our children see as well as we do. This may not be the case if your child has a lazy eye. Normal vision develops early in life when the brain learns to fuse the images from both the left and right eye forming a single image what is referred to as binocularity. Lazy eye or amblyopia on the other hand is a reduction in vision that results from abnormal visual development in infancy and early childhood. Amblyopia is the leading cause of decreased vision among children affecting 2-3% of the population.

Amblyopia develops when the nerve pathways between the brain and eye are not properly stimulated. As a result, the brain favors the eye with the clearer image and turns off or blocks the image from the eye with poor vision. Turning off an eye is called suppression. As the brain suppress the lazy eye early in life, clear vision does not have a chance to develop and both eyes are not used together effectively resulting in reduced binocularity. Most cases of amblyopia affect only one eye, but some cases are bilateral. Lazy eye is hereditary and commonly seen among children born prematurely or with a low birth weight, or have a family history, childhood cataracts or a serious eye disease.

There are three common causes of lazy eye:

Strabismic. The most common cause of lazy eye is strabismus (eye turn or wandering eye) an imbalance in the muscles responsible for aligning the eyes resulting in one eye pointing in or out, up or down. When the eyes are not aligned, two different images are being sent to the brain resulting in double vision. The brain is then forced to turn off the image coming from the misaligned eye to create a single image. The child only uses his straight eye to see, and vision in the turned eye does not have a chance to develop.

Deprivation. The most severe type of amblyopia in terms of vision loss resulting from an obstruction that “deprives” the child of clear vision in the eye. Examples include a cloudy area in the lens (cataract), droopy eyelid, or opacity.

Refractive. The result of a significant difference between the vision in each eye, due to nearsightedness, farsightedness or an imperfection on the surface of the eye (astigmatism) making it difficult for the eyes to focus together. An infant has no way of telling his parent’s one of his eyes does not see as clear as the other. Since it is difficult for the visual system to fuse a clear image with a blurred image, the brain learns to suppress the blurred eye causing vision to stop developing in that eye.

Signs and symptoms of lazy eye include:

  • An eye that wanders in or out, up or down
  • Eyes that may not appear to work together
  • Poor depth perception (3D vision)
  • Early eye examination is key to detection and diagnosis

We begin to see children as early as 6 months of age to screen for lazy eye and eye turns. As part of the examination, a thorough medical, ocular and family history is taken, visual acuity is assessed for each eye looking for differences in vision between the eyes or reduced in vision, tests are done to check focusing, binocularity, eye teaming, eye tracking, the need for correction such as glasses and/or contact lenses, and an ocular health assessment.

If a child is diagnosed with amblyopia, depending on the cause and the degree to which the vision is affected, treatment options can include corrective eyewear such as glasses and/or contact lenses to help equalize the vision in both eyes; eye patches to stimulate the weaker eye, eye drops to temporarily blur vision in the stronger eye in order to encourage the use of the weaker eye; vision therapy or eye exercises to help establish binocularity, focusing and eye tracking; and/or surgery to align the eyes or correct the droopy eyelid or remove the cataract.
Ideally, the earlier the treatment is initiated the better the outcome as the connections between the eye and brain are forming. If amblyopia is left untreated, permanent vision loss can occur.

Background and indication for eye muscle surgery:

Eye muscle surgery or “strabismus surgery” is an outpatient procedure. The goal of surgery is to surgically align your child’s eyes to better achieve binocular fusion (the eyes working together to give maximal depth perception) and to improve or normalize the field of vision (the total visual area, including “side vision”). Surgery is intended to align or straighten the eyes without much effort on the part of the child. Eye muscle surgery involves either tightening or
weakening one or more of the six muscles on the surface of the eye. Nothing is done inside of the eye to change the vision. The eyes are never taken out during surgery.

eye

When strabismus surgery is recommended, we feel that the risk of not doing surgery is higher than the risk of surgery. Each child heals differently. We carefully measure the amount of misalignment using prisms prior to surgery, so the correct amount of surgery can be ccomplished.


Risk


The success rate of this surgery varies from person to person and depends on their particular condition. Usually we can make the eyes 80+% better aligned than before the surgery. The most common risk is that additional surgery will be needed. Some infrequent complications include, ut are not limited to: allergy to sutures, risk of infection, bleeding, change in pupil size and a remote chance of loss of vision. We have not ever had any serious ocular complications in our practice.

Prior to Surgery


A history and physical needs to be completed by your primary care doctor. Please make sure your eye doctor knows of any allergies and a complete medical history even if you think it may not be important. Follow the surgery centers advice on when to stop feeding solids and clear liquids prior to surgery. You can call Coral Desert Surgery Center prior to surgery and ask to speak to them about the particulars regarding feeding or other concerns. If your child is under 2, it is very important to drink close to the maximal time limit, so your child will be nicely hydrated the morning of surgery. Do not give any food/ drink after the recommended time or your child’s surgery may have to be postponed. The nurse from Coral Desert Surgery Center will call you the Friday before surgery with your scheduled arrival time and to answer any last minute questions.

Surgery


Drop down: We feel that this type of surgery should be performed in a surgical facility. During the surgery the eye is never removed! Rather, the eye is merely rotated and a small incision is made under the eyelid, in the clear membrane covering the white part of one or both eyes. Through this incision, the appropriate surgery is then performed on the surface of the eye to improve the strabismus. There are no skin incisions and usually no visible scarring of the eye surface as a result of this surgery.

Normally the surgery takes approximately an hour and a half. This does not include the time required to move the patient into the operating room or time in the recovery room. Children require general anesthesia for the surgery.

Young children are put to sleep with a mask. An IV is placed after they are sleeping. Older children go to sleep more easily with an IV. Numbing cream can be placed on the skin so the insertion of the IV doesn’t hurt. For children older than 18 months, one parent may go back into the operating room until the child is sleeping. This can be very difficult for the parent and we recommend that the least anxious parent accompany the child as an anxious parent will unwittingly make the child anxious. Often parents choose to have the nurse take their child to the operating room instead of the parent. This usually works well for the child.


What to expect after surgery


After surgery the eyes are uncomfortable and “scratchy”, but not very painful. Each child reacts differently. Some are more sensitive to discomfort than others. Many children do not want to open their eyes for a day or two. This is normal. Children usually only require Tylenol for discomfort. When your child is waking from anesthesia, he or she should be kept from rubbing the eyes. Eye rubbing should not affect the surgery, but can increase the chance of infection. Extra hand washing is recommended for the first week after surgery. Water must be kept out of the eyes for up to 2 weeks after surgery. We recommend a “beauty solon” style bath using a hand-held sprayer (these can be purchased inexpensively from any local hardware/ home improvement store).

There will be some swelling and discharge after the surgery. Immediately after surgery, some children may cry for up to an hour, mainly due to the disorienting effects of anesthesia. Often children will sleep for the remainder of the day. Take it easy with foods, as children may vomit. Vomiting once or twice is normal; however, call your doctor or report to the hospital immediately if your child appears to be very ill or has a fever (this is not normal).

You may want to prop your child’s head up slightly at night and expect a small amount of bloody discharge on the pillow the next morning. Mild swelling should be expected and the child should be able to open their eyes within the next day or so. The swelling should decrease as each day goes by. If the swelling increases significantly, contact your doctor immediately, particularly if there is pain. It takes around six weeks for the eye muscles to heal. If the position of the eyes are way out of line any time after surgery, contact your doctor.

Children (especially older children) that have eyes that were drifting outward prior to surgery will usually (but not always) have double vision for a limited period of time after surgery (typically over the weekend after surgery). This is normal. This usually resolves within a week, but occasionally lasts longer. Often after surgery to fix eyes that drift out (exotropia), the eyes will appear crossed a bit for the next week or so after surgery. This is normal and expected.

You will be given a tube of ointment to use on your child’s eye/ eyes. We will put ointment in the eyes at the end of surgery, so you will not need to put in any until before bedtime or the next morning. Usually we recommend putting in about a 1/2 pea size amount inside the lower lid/lids three times a day for a week and then before bedtime for another week or two (or until the tube runs out). When you pull down the lower eyelid (by pressing on the upper cheek bone), you may see purplish blue spots. These are the stitches and will dissolve on their own usually in a few weeks.

Our doctor will usually call you at home in the evening after surgery is completed to see if you have any additional questions. Usually children and adults after eye muscle surgery can return to school or work early the next week after surgery.

We can be reached at the office at 435.986.2020 at any time which will contact the doctor on call if after hours.


Follow up


Your doctor will usually want to see you for a follow-up appointment within the next week after eye muscle surgery. Often we do not need you to bring your child for follow-up after naso-lacrimal (tear duct) surgery unless there are concerns.

FAQ

Can anything be done for adults with misaligned eyes?


Yes. Recent treatment advances allow most adults with misaligned eyes to have surgical correction.

Is eye straightening as an adult strictly cosmetic?


No. Eye alignment surgery improves eye function in most adults and can lead to social and economic
benefits.

Does my insurance cover the expense of this surgery?


Although eye muscle surgery is reconstructive (not cosmetic), one should check with the insurance
carrier to determine their specific policy.

Is eye muscle surgery risky for adults?


No. However, every surgical procedure has some risks. For strabismus surgery, the most common risks
are residual misalignment and double vision (usually temporary). Health risks vary with the general health of the
individual.

How successful is eye muscle surgery?


Most individuals have significant improvement in eye alignment with one surgery. Occasionally the surgery is only partially successful and additional surgery may be indicated.

How painful is this type of surgery?


Discomfort after eye muscle surgery is usually a foreign body sensation in the eye, lasting several days.
Over-the-counter pain medication often reduces the discomfort, although stronger medication is sometimes prescribed. Most patients return to full activity in several days. Some surgeons limit swimming and heavy physical activity for several weeks after surgery.

Section


Many adults with Strabismus have said, “I am embarrassed by my misaligned eyes and avoid looking people in the eye.” Or “It seems to me that people are distracted by my wandering eye causing problems with social interaction and difficulty getting the job I want.”
Eyes can be straightened at any age and should be considered as a treatment alternative if it enhances
quality of life. Increased social interaction, improved self-confidence and employment opportunities are all potential
benefits of having surgery to align the eyes. All individuals deserve to know the options.

Is hospitalization required for eye alignment surgery? How will this affect normal activities?


Eye alignment surgery is almost always performed as an outpatient procedure. Following surgery most individuals return to nearly all normal activities within a few days.

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