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Strabismus Surgery

A squint, or strabismus, is where the eyes are not lined up correctly on the target that a person is looking at. The movement of each eye is controlled by 6 muscles, and requires complex interactions between the visual environment and the brain to maintain fixation on a given object.

Not all strabismus needs to be fixed surgically. Some types of strabismus will be made much better by the use of glasses to fix a focusing problem. In adults, strabismus that is not causing double vision only needs fixing if the cosmetic appearance of the misaligned eyes is of sufficient concern. However, as the visual system of a child is not completely developed, fixing a strabismus earlier than later will often result in a more stable alignment long-term, even though the vision of each eye may not improve. For this reason, children with no double vision may still be offered surgery to straighten the eyes. The risks and benefits of surgery to straighten the eyes need to be weighed up for each individual.

Strabismus surgery involves operating on the eye muscles (even though they may not be the cause of the problem) to tighten and/or loosen them in such a way as to bring the eyes back in to proper alignment. This is almost always done under a general anaesthetic (with you asleep), and as a day stay procedure. Should strabismus surgery not be desired, other alternatives include no treatment (with risks of ongoing diplopia, cosmetic concerns and/or visual development implications), prescribing special glasses with prisms incorporated into the lenses (if the deviation is small enough, and does not vary in different directions of gaze), or wearing a patch over the deviating eye (not an option for a child as would lead to severe amblyopia).

The surgeon will formulate a surgical plan for you, based on the measurements of your strabismus before the surgery. Your surgeon will perform an appropriate amount of surgery on your muscle(s), based on surgical tables drawn up from the results of thousands of strabismus operations by several strabismus surgeons. The surgery will involve making an incision through the conjunctiva (the surface skin of the white of the eye), allowing exposure of the relevant eye muscle(s), which lie on the surface of the white of the eye (the tough outer wall of the eye – the sclera). The eye is rotated within (not removed from!) the eye socket to allow this. Stitches are then placed through the eye muscle at a specific point, and the muscle then stitched to the sclera at a measured point so that the muscle is loosened or tightened as desired. The stitches do not pass inside the eyeball, but pass through the tissue of the sclera. The conjunctiva is then stitched closed. The operation takes about 30 minutes per muscle that is operated on.

Adjustable stitches
In older children or adults, and especially when the strabismus is complex (i.e. previous surgery etc.), adjustable stitches may be used. Here, the stitches attaching the muscle to the sclera are placed and tied normally, but the ends of that stitch are left long, and taped to the cheek or forehead of the patient. Then, once the patient is awake and alert, the surgeon will examine the alignment of the eyes again and will be able to relax or tighten that stitch if needed. To do this the patient will be lying flat, some numbing drops applied to the eye, and a speculum (wire clip) placed under the eyelids to keep the eye open. The surgeon will then use fine forceps to grab the relevant ends of the stitch and loosen or tighten it. This process might be repeated several times until the surgeon is happy with the alignment. Although a little daunting and uncomfortable, the adjustment is not painful and is very useful especially in cases where the effect of eye muscle surgery may not be as expected from the surgical tables.

Most patients are able to go home within a few hours. You will need someone to take you home and to stay with you for at least 24 hours. Your vision will probably be blurry for the first day or two, and you may also have some double vision. This is not unusual, and should settle promptly. Your surgeon can tell you what sort of double vision you may experience (if any) after your surgery. Your eyes will also be quite red and watery, and you will have a gritty feeling in your eyes. There may also be some postoperative nausea. Your surgeon will have prescribed some eye drops (usually a steroid anti-inflammatory and an antibiotic) to use, which will help your discomfort, but regular paracetamol (or similar) should also be used.

The redness and grittiness may last for a few days to a week or so, and it would be best for you to stay away from work or school for that time, until you are comfortable. You must avoid swimming for a month, and avoid water getting in your eyes when you shower for the first fortnight. You must not rub the eye, and avoid any heavy lifting or strenuous activity. All the stitches used in the surgery are dissolvable, and won’t need removing.

It is important for parents of children undergoing strabismus surgery to be aware that your child is still at risk of developing a lazy eye (amblyopia) after surgery, will still need to wear their glasses, and may still require patching of an eye to maximize its vision. Your surgeon will discuss these aspects with you, but ongoing follow-up is vital.

The success rate of strabismus surgery varies widely for different conditions and patients, and depends also on the definition of success. In general, around 8 out of 10 patients will be pleased with the improvement they note with their eyes after one operation.

Because each eye and patient responds differently to the same amount of strabismus surgery, a key risk is that of an over- or under-correction (that is, too much or too little effect). This might result in the eyes being turned in where they were turned out (or vice versa), or just that the surgery ‘hasn’t quite done enough’. Long-term results can also change over time, especially in children where the face and eye have not finished growing. This means that a good result early on might change over subsequent years. Therefore, up to 30% of patients having strabismus surgery may need to have another strabismus operation in their lifetime.

You must let your surgeon know straight away if you
• Have a temperature over 38 degrees, or chills
• Develop severe pain, tenderness or increased swelling in the eye
• Develop increased redness in the eye
• Get a sticky pus discharge from the eye
• Notice a significant change in the alignment of the eyes compared to the initial post-operative result
• Develop blurriness or double vision that persists
• Have nausea or vomiting
• Notice black spots or a black curtain in your vision
• Have any concerns about your surgery

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When we deal with your eye problems, you can expect to be treated with the same degree of care and commitment as if you were a member of our family.

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