Eye Muscle Surgery
Benefits Eye muscle surgery is performed to correct a misalignment of the eyes (strabismus) or to minimize involuntary shaking of the eyes (nystagmus). When thinking about strabismus it is important to remember that we have two eyes – strabismus describes an abnormal relationship between the eyes. When the eyes are pointing in different directions the brain has to deal with two very different images. In young children, the brain can (and does) "turn off" one of the misaligned eyes at any given moment; this damages depth perception (3-D vision) and can cause vision loss (amblyopia). In older children and adults the brain can not turn off one of the eyes so the misalignment causes double vision, which may lead to abnormal head positions (head tilts or face turns) in an attempt to get rid of the double vision. For people with nystagmus, there is usually a single abnormal head position where the eyes don’t shake as much (this is the null zone) – when looking towards the null zone the vision improves. For example, a girl might have a null zone in left gaze; she will always prefer to turn her eyes leftwards.

The problem here is that most of the time she will need to look at things directly in front of her body – not to the side (or up or down). She will solve this dilemma by constantly turning her face to the right and directing her eyes to the left (she get to look leftwards and in front of her body by turning her face to the right). Eye muscle surgery can be performed for strabismus on children as young as four months of age. It is usually best to perform surgery as early in life as possible, because the brain circuits for binocular (stereo) vision are easiest to “fix” in younger people. However, it is never too late to restore binocular vision, as these same brain circuits often continue to have some function even in adults.

For nystagmus, eye muscle surgery is often delayed until 3 or 4 years of age as the character of the nystagmus may change. However, it is best to correct a large face turn/head tilt before the age of two if it is present (to prevent facial asymmetry and changes to the neck muscles and bones).

In addition to restoring binocular vision, strabismus surgery may be indicated to correct a head tilt or face turn (as with nystagmus). Reconstructing a normal eye alignment also has important social and psychological benefits for many people – the medical literature demonstrates that children with misaligned eyes are more likely to have social difficulties starting at around 4 or 5 years (when other children become aware of physical differences) and many adults with strabismus have self-esteem issues.

Similarly, face turns and the actual shaking of the eyes from nystagmus can affect self-esteem. The reconstructive benefits of eye muscle surgery are not cosmetic – cosmetic surgery changes a normal body part while a reconstructive surgery restores (or creates) a normal anatomy where it did not exist before. Looking like other people –whether it is having straight eyes, or a straight head, or both – is not cosmetic. Eye muscle surgery is performed as a same day procedure; there is almost never a need to stay overnight in the hospital.

Technique For children and many adults, eye muscle surgery is performed with the patient fully asleep (general anesthesia), but some older adults can have local anesthesia if they prefer.

With local anesthesia, the patient is given a sedative and anesthesia in injected around the eye, but the patient is not fully asleep. Once the anesthesia has taken effect, the eye muscles (often of both eyes) are carefully repositioned using microsurgical techniques; the eye is NEVER taken out of the socket in this surgery. The eye muscles sit on the sclera (the white of the eye) – they are not actually “inside” the eyeball but are found between the conjunctiva (the thin skin that cover the eyeball) and the sclera.

The technique is as follows: The eye is gently held in place, then a small opening is made in the conjunctiva. The surgery is performed through this small opening as the eye muscles are repositioned (recessed means moved back, resected means pulled forward). The amount of repositioning is based on published charts and the surgeon’s experience. At the end the conjunctival opening is closed with stitches that dissolve on their own. Lasers are not used on the eye muscles because they would destroy the muscles.

  
Alternatives

Prisms can never make the eyes straight, but they can be used to control double vision. Eyeglasses are useful for certain types of strabismus (specific forms of esotropia) and if they can be used instead of surgery they should be tried. Finally, there is ALWAYS the alternative of not undergoing surgery. When I recommend surgery, it is because I consider it the best option for achieving proper alignment of the eyes and/or head as well as the restoration/preservation of binocular function.

 

Risks and Possible Complications

 

 

The eyes will be red for a few weeks after surgery.  This is not really a risk of surgery because it is a given; this is not a complication, either, because the redness is expected and does not represent infection, a risk to vision, or any sort of permanent problem.  Over the course of several weeks (sometimes, a few months), the eyes return to their normal white color.

 

Scarring is a part of healing.  Eye muscle incisions usually heal very well – it is rare that the scar can be seen without a microscope.  To further hide the scar, the incision is usually made so that the eyelid covers it.  However, everyone heals differently – a scar may be visible.  If this happens, and it is bothersome in any way, such scars can be surgically minimized.

 

Undercorrections and overcorrections can occur, since the eye muscles and brain cells of each person are unique.   Any given person may respond differently to a given amount of surgery. However, most people respond to surgery in a predictable way; an experienced surgeon is able to take individual factors into account, combining the “art” with the “science” of surgery.  Approximately 80% to 90% of patients have stable, long-term eye alignment after one surgery.

 

Temporary double vision can occur because the brain has to adjust to the new eye position.  This does not happen often, but when it does, it can last for several days to several weeks.  Most children tolerate this well and are not bothered by it.  Some adults are troubled by such double vision for longer and may be prescribed prism in their glasses (or even a patch) to eliminate the double vision until the problem resolves on its own.  If double vision does not resolve on its own then additional surgery may be needed.

 

Re-operation is required in up to 20% of patients (and perhaps more over a long enough period of time) because the brain may not "lock in" to the proper eye position the first time.  Re-operation is more likely if one of the eyes has very poor vision to start with – in this case, the likelihood of re-operation is about 50% over a lifetime.   Of course, the surgeon’s goal is to achieve straight eyes that stay that way forever and every effort is made to achieve this goal.  Re-operation is performed from 3 months to many years after the first surgery, since it takes time to ensure that the results of the first surgery have stabilized.  It is almost always possible to perform a re-operation if one is required.

 

Serious complications such as vision loss, infection, or bad anesthetic reactions are very rare. Eye muscle surgery is considered one of the safest of all eye operations – in terms of the risk of very bad complications, it is safer than cataract surgery (the most commonly performed operation in the U.S.) and safer than laser vision correction (PRK and LASIK).

 
 

Pre-surgical preparation

 

 

Financial arrangements will be worked out between PediatricEyeMD and your insurance company ahead of time.  It is my responsibility to get financial approval for the surgical fee from your insurance company.  My surgical co-ordinator, Bonnie Calabro, will inform you ahead of time if you have a co-pay or deductible for my fee. It is our office policy to collect co-pays and deductibles prior to surgery.

 

IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE COMPANY AS TO WHETHER YOU HAVE TO PAY ANYTHING TO THE HOSPITAL.

 

A general physical exam is required by the hospital prior to surgery.  Depending on the patient’s medical history, blood work or x-rays may be required – children almost never need to have blood or X-rays taken. 

 

IT IS YOUR RESPONSIBILITY TO HAVE THIS PHYSICAL EXAM COMPLETED AND THE PERMISSION FROM YOUR DOCTOR SENT TO OUR OFFICE AT LEAST 5 DAYS PRIOR TO SURGERY

 

We need to send this information to the hospital ahead of time and they have strict deadlines.

 

Consent must be obtained prior to any procedure.  Informed consent means that you understand the benefits, alternatives, and risks of surgery, that no guarantees have been made, and that all of your questions have been answered.  

 

A surgical date can be arranged at your convenience. I have reserved block time at the New York Eye and Ear Infirmary on most Fridays.  The Infirmary offers specialized nursing, surgical assistants, and anesthesiology for eye surgery and is world-renowned for the quality of care delivered.   Most patients are able to return to school or work the following Monday.

 

As for the times of surgery, patients are generally taken by age with the youngest going first (consideration is given to Shabbos observation, medical condition, and other extenuating circumstances).  The hospital staff and I do our best to ensure an "on-time" schedule. 

 

Please let us know well ahead of time if you have changed your mind about having surgery or wish to change the date – we will do everything possible to accommodate you.  Please be aware that there is an administrative rescheduling fee for failure to give timely notice when it was possible to do so (e.g. – my child had a soccer game that Friday so I called on Thursday to cancel).

 
 

The Days Before Surgery

 

You will be contacted by Ms. Calabro with the exact surgical time and to answer any other questions you may have. 

 

IF YOUR CHILD IS ACUTELY ILL (HAS A FEVER, DEEP COUGH, OR VOMITTING) IN THE DAYS PRIOR TO SURGERY, KINDLY CONTACT US AS SOON AS POSSIBLE.


  

The Day of Surgery

 

Dietary restrictions: For people younger than 2 years, absolutely no food or milk is permitted for 6 hours before surgery.  For people older than 2 years, absolutely no food or milk is permitted for 8 hours before surgery. 

 

To keep it simple, do not eat or drink milk (or any dairy products) after midnight unless you have a time slot after 3 pm.   If you have a surgery starting at 4 or 5 pm, then you can eat breakfast NO LATER than 8 am.   Pills may be taken with SIPS of water.  

 

Very small amounts of apple juice, Sprite/7-Up, Kool Aid, or water may be taken up to 3 hours before the admission time.   The anesthesiologist WILL assign a later surgical time if these rules are not followed, as it is unsafe to administer general anesthesia otherwise – the rationale for these rules is that the patient can choke on their vomit as they awaken from anesthesia.

 

IF YOUR CHILD IS ACUTELY ILL (HAS A FEVER, DEEP COUGH, OR VOMITTING) IN THE DAYS PRIOR TO SURGERY, THEN PLEASE CONTACT US AS SOON AS POSSIBLE.

 

This way, alternative arrangements can be made and other surgical patients can be rescheduled appropriately.

 

Medicines

 

If the patient takes seizure medication, then take the morning dose(s); pills may be taken with SIPS of water.   Please bring any and all of your medication IN THEIR BOTTLES to the hospital so that you can show the anesthesiologist exactly what and how much you use.

 

Length of surgery is generally less than an hour, although this can vary from 30 to 90 minutes depending on the complexity of the case. Immediately after the surgery, I will speak with the family to discuss the operation – if my next case has already started and I can’t speak a family member in person I will call and speak with them before the patient leaves the hospital.

 

Recovery involves bringing the patient from the operating room to the Post Anesthesia Care Unit (PACU) on the 2nd Floor where specialist nurses and doctors monitor the patient who is still waking up.  Once a child is safely awake, the parents will be called from the waiting room on the 9th Floor to join them.

 

Children are often teary and confused when first awakening from general anesthesia and often thrash about – please don’t mistake this for pain; just stay calm, give them love, and they will calm down as the medicine wears off.    As the patient continues to awaken, she will be encouraged to drink clear liquids or juice, and the IV will be removed.  Once the patient can safely drink without choking, is passing urine, and is “awake enough,” the anesthesia team will discharge him from the hospital.

 

Eye bandages are usually not applied.  Some people may be reluctant to open their eyes because of light sensitivity, eye soreness, or a scratchy sensation; these symptoms can last for a day or so after surgery.   You may see a few drops of pink stained tears draining from the eyes-- these can be gently wiped away with a clean washcloth or tissue. 

 

Postoperative discomfort is usually minimal, and can be treated with Tylenol or ibuprofen (Motrin, etc.) as needed.  Mild nausea is common after general anesthesia; if vomiting occurs, medication may be prescribed.

 

Discharge to home usually occurs two to three hours after surgery.   School, daycare, or work can be resumed as soon as the patient feels up to it-- usually within two to three days.

 
 

The First Week after Surgery

 

 

Typically, there will be a clear or whitish discharge from the eye(s) during the first few days after surgery.  It is also common to have pink tears for the first day or so, and for the lids to be crusted together with some blood when waking up for the first few days.  If the lids are crusted together, use a warm, clean moist towel to gently wipe away the gooey material – this is safe, and painless, if done gently.

 

Expect the eyes to be red for several weeks after surgery.  While every effort is made to keep the eyes white, blood vessels are inevitably disrupted by eye muscle surgery and bleeding occurs.  This redness is temporary and the eyes will become white again.

 

Ice compresses applied over the eyes for the first day or two after surgery will provide comfort, and will help the eyes to look better faster.  Place some ice cubes in a sealed plastic bag and cover this with a paper towel or thin cloth before placing on the eyes - do this every few hours for five to ten minutes (or, as tolerated).  However, DO NOT WORRY if this is not done, as the eyes will look "better" within a week even without the ice compresses.

 

Eyedrops help the eyes to feel and look better after surgery when the medication prescribed contains a steroid. I usually prescribe a combination antibiotic/steroid eyedrop.  Such drops are to be used twice a day on the eye(s) that had surgery until instructed otherwise.  If you cannot get the drop into the eye(s) easily, try doing it while the patient sleeps – let the drop fall into the corner of the eye by the nose.  If this fails, then don’t worry – at the end of every case I put antibiotic drops of the eyes and the risk of infection is very, very low.

 

No swimming is permitted for the first two weeks after surgery, and care should be taken to avoid getting water in the eyes when bathing/showering.  I fully encourage regular bathing/showering and hair washing beginning the day after surgery (just keep the eyes closed when bathing).
   
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