What to Expect After Strabismus (Eye Muscle) Surgery …

A Patient & Parent Guide to Strabismus SurgeryGeorge R. Beauchamp, M.D.

This and the following (15 & 16) chapters are written by time sequence, and describe events, what to expect after strabismus (eye muscle) 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. IVs 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 no 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 surfacethis may look like a blistering or ballooning of the surface membrane or conjunctiva, causing it to protrude between the lidscalled 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 bodys 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 bluescattering 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; itmay 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, fortwo 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.

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What to Expect After Strabismus (Eye Muscle) Surgery ...