We’re excited to announce that Dr. Al-Kaabi, Cornea Specialist and Surgeon, has joined iCare!
We’re excited to announce that Dr. Al-Kaabi, Cornea Specialist and Surgeon, has joined iCare!
Surgery is performed in the operating room. Under anesthesia, the operated eye(s) is held open during the surgery with a small instrument called a speculum. There are no incisions on the skin. Instead, an opening is created in the conjunctiva (the transparent membrane that covers the white part of the eye). Under this membrane, the muscles that move the eye are located. Once the muscle has been isolated, a dissolving stitch (‘suture’) is sown to the muscle. The muscle is then detached from the white part of the eye and then re-attached using the suture, tightening or slackening the muscle as needed to straighten the eye. The conjunctiva is then closed, usually with sutures that will fall out on their own within a few weeks following the surgery.
Some patients may benefit from “adjustable” sutures to help maximize the success of the eye alignment. These “adjustable” sutures allow the surgeon to slightly change the position of the eye muscles after the actual strabismus surgery has been completed. Patients undergoing general anesthesia have their sutures adjusted on the same day as their surgery, whereas patients who undergo local anesthesia have the sutures adjusted at a later time (usually the day after surgery).
Most patients with strabismus have relatively healthy eyes, eye muscles, and eye nerves. For these patients, the problem causing the misalignment actually exists in the brain rather than the eye muscles or eyes. For others, the strabismus is associated with the connective tissues around the eyeballs having weakened with time. In either case, it is important to understand that slackening and/or tightening the eye muscles with strabismus surgery does not cure the underlying problem. Instead, it simply mechanically straightens the eyes (one with respect to the other), giving the brain a chance to now keep the eyes straight for the long term. Because strabismus surgery is not a true “cure”, at least 50% of patients who have strabismus surgery may need another surgery in their lifetime to either obtain or maintain a satisfactory result. Some patients even require 3 or more surgeries.
There are 6 muscles that move each eye. Strabismus surgery is like a puzzle: for each patient, we need to pick the best combination of muscles to operate on so that we maximize the chance of great eye alignment by doing the least invasive surgery possible, in the fewest operations, with the least risk. For many patients, this means operating only on the non-dominant eye. For others, it is most appropriate to do some surgery on each eye to get the best results. For these patients, options include one surgery under general anesthesia so that the operation on both eyes can be performed on the same day, or planning multiple surgeries under local anesthesia on different days. The decision regarding which eye requires surgery is individualized to each patient.
| General Anesthesia | Local Anesthesia |
|---|---|
| For general anesthesia, an anesthesiologist will place an intravenous in the patient’s hand to put them to “sleep.” They will also place a breathing tube during surgery. The patient is “asleep” for the duration of the surgery, and does not feel or remember the surgery. However, it means a somewhat longer hospital stay on the day of the surgery, as it takes longer to recover from general anesthesia compared to local anesthesia, and some patients feel tired and/or nauseated after surgery. The majority of the patient’s day is spent at the hospital. For patients who are “asleep” under general anesthesia for strabismus surgery, Dr. O’Connor is able to operate on one or both eyes. The decision of surgery on one or both eyes is made to maximize the chance of success, speed of return to function, minimize pain, and minimize the risks of surgery. This is highly individualized to each patient. | While the thought of local anesthesia makes some patients a bit nervous, most patients do very well with this technique. In addition, it almost always means a shorter stay in the hospital and less fatigue and nausea after surgery. The patient is lightly sedated during the surgery but is awake enough that they are breathing on their own. The anesthesiologist places an intravenous in the patient’s hand to make them a bit drowsy. At the beginning of the surgery, once the patient is feeling a bit “sleepy”, the eye is anesthetized by injecting an anesthetic through the eyelid. This medication not only takes away pain during surgery, but it also prevents the eye from moving and reduces vision. Some patients are afraid that they will “see” their surgery, but the anesthetic prevents this. During the surgery, the patient is typically sleepy or relaxed, but awake enough to speak and understand directions. No breathing tube is required. An eye patch is placed at the end of surgery to protect the eye. The patient is generally allowed to leave the hospital about 30 – 45 minutes after the surgery is complete. |
| Basically, general anesthesia can be a good choice for the following patients: – Who feel strongly that they want to be asleep for the surgery – Who are likely to need surgery performed on both eyes to get the best results – Who have complicated strabismus or a history of multiple surgeries | As a rule, local anesthesia is a particularly good choice for the following patients: – Who should avoid general anesthesia due to other medical problems – Whose strabismus can be effectively treated by operating on one eye only – Who have no history of previous strabismus surgery – Who can safely stop blood thinners temporarily to undergo surgery |
It is normal to experience moderate pain after strabismus surgery. The discomfort falls into two categories:
| Cold Compress | Soak a clean facecloth in a large bowl of ice-cold tap water, wring it out, then close your eye and place it on the operated eye(s). Repeat every few minutes to keep the eyelids cool. This should be done as frequently as possible for the first 48-72 hours after surgery. (Alternatively, frozen peas or crushed ice covered by a wet face cloth can be used. However, avoid freezing the eyelid skin by limiting the time to 10 minutes before taking a 10-minute break). |
| Oral Pain Medication | Most patients will have received a prescription for pain medication. It is recommended that you fill this prescription prior to your surgery. You can begin taking the medication when you get home. It is most useful in the first week after surgery. Please follow all instructions from your pharmacist. For mild to moderate pain, you may use over-the-counter pain medications, such as ibuprofen (“Advil”) or acetaminophen (“Tylenol”) in place of your prescription pain medication. The prescription pain medication can be used as a “backup” if needed. Nausea and vomiting are extremely common after eye muscle surgery. Take over-the-counter anti-nausea medication as needed. Avoid dehydration. For patients who have been prescribed Tramacet and Tylenol #3 (Tylenol with codeine), please note the following: – Tramacet contains acetaminophen (most commonly sold as “Tylenol”). Do not take Tylenol or any other medication containing acetaminophen while taking Tramacet. – Tramacet should not be taken in combination with many anti-depressant medications. If you are taking an anti-depressant, please contact our office to arrange for alternate pain medication. – A small minority of patients have significant nausea and vomiting with Tramacet. If you experience this, please stop the medication immediately. Have your pharmacy contact us to arrange a substitute medication. – Tramacet and Tylenol #3 may cause drowsiness – do not drive. Other side effects may include constipation, itchiness, and drug dependence. Use only what you need and return the remaining pills to the pharmacy for safe disposal. – Tramacet and Tylenol #3 are controlled narcotics – you must pick them up from the pharmacy in person with your health card as proof of identification. |
| Eye Drops | Most patients will have received a prescription for post-operative eye drops. It is recommended that you fill this prescription prior to your surgery. You may start the drops when you get home (or if you have a patch on your eye, after your patch has been removed). The simplest technique to apply the drops is as follows: – Vigorously shake the bottle 30 times. – Lie down or tilt your head back so that you are facing the ceiling. – Close your eyes gently. – Place one or two drops at the inside corner of your eyelids. – Open your eyes gently. – At this point, you should feel a bit of the eye drop in your eye. The rest of the drop will be blinked out of the eye. If you are not sure whether any of the medication entered your eye, go ahead and try again as needed. – Do not use the drops more than 4 times per day for 2 weeks. You may stop using the drops sooner if you are comfortable without them. Steroid medication in the eye drops provides pain relief for many patients. However, steroids are a powerful class of medication with many potentially serious side effects. As a result, it is critical for you to contact our office if you feel the need to continue to use the drops beyond two weeks after surgery. |
It is normal to have blurred or altered vision and sensitivity to light following strabismus surgery. There are two main reasons for this:
Visual symptoms vary greatly between patients. Although some patients experience little or no symptoms, most patients gradually adjust to their new eye alignment over a few days to many weeks. It is unusual for significant symptoms to last months. It is normal for symptoms to come and go.
No. In fact, you are encouraged to use your eyes as much as you can tolerate after surgery. This should help your brain to adjust to the new eye alignment as quickly as possible.
Yes. You are encouraged to do as much with your eyes as you can tolerate. However, remember that you just had surgery – you will likely not be able to do as much as usual at first. Be patient.
As a general rule, no. Using both eyes together should help your brain to adjust to the new eye alignment as quickly as possible, and some feel that patching delays this adaptation process. However, if you are really struggling to function early after surgery, brief intermittent patching is sometimes helpful early in the first few days or weeks after surgery
Sutures. You may be able to see superficial (black) sutures – these will typically fall out on their own within a few weeks. The deep (purple or white) sutures may be harder to see – these will dissolve over months.
If the sutures are not bothering you, you do not need to do anything. However, if you are experiencing irritation from the sutures more than 2-3 weeks after surgery, you should contact our office to have them removed. (Suture removal can be done easily and comfortably in the clinic with the help of anesthetic eye drops).
No. Please do not let anyone manipulate the sutures without speaking with Dr. O’Connor first. Cutting or removing a suture inappropriately could jeopardize the success of your surgery.
Please remind us before your surgery if you are taking a blood thinner so that we can provide you with specific instructions.
General Rules:
Patients taking a non-prescription blood thinner for general health reasons:
2. Patients taking a prescription blood thinner for specific health concerns, such as a history of blood clot, artificial heart valve, stroke, heart attack:
Since surgery can treat strabismus but not cure it, the most common and important ‘complication’ of strabismus surgery by far is the need for more than one surgery to either obtain or to maintain acceptable eye alignment.
Therefore, the most common ‘risk’ of strabismus surgery is the need for another strabismus surgery in the patient’s lifetime. This means that most patients require two or more surgeries within the short term (months) or long term (years to decades).
Under-correction: Eye alignment is improved, but not as much as anticipated, or not improved at all.
Recurrence: The patient has good eye alignment initially after surgery, but the improvement does not last. The misalignment recurs after a period of time (months to decades).
Over-correction: The effect of the surgery was too strong. The eyes have been “over-aligned”, and are now turning in the opposite direction compared to before surgery. For example, an eye that was turning in before surgery is now turning out. This can produce an uncomfortable situation for the patient, both in terms of aesthetic appearance and in terms of the brain adapting to the new eye position. This is the least common out of these three issues, but is usually the most important for the patient.
1. Relatively common but less important.
This includes complications such as an abrasion or scratch on the cornea during surgery (typically heals completely within a few days), blurred vision, dry eye, temporary double vision, and bruising after surgery.
2. Very important but uncommon.
Risks of this nature include the risk that should be considered when surgery is performed anywhere in the body, such as;
a. Risks associated with anesthesia (includes eye/brain injury, seizure, coma, death)
b. Permanent or temporary loss of vision and/or eye function associated with problems, such as: prolonged or permanent double vision, infection in or around the eye, bleeding in or around the eye, and other devastating eye injuries or problems (i.e. retinal detachment, penetrating injury, hemorrhage, etc.)
In general, the risks of vision-threatening complications are much lower with strabismus surgery than with other types of eye surgery, such as glaucoma surgery. In part, this is because strabismus surgery only involves working on the outside of the eyeball, rather than within the eye itself.
As long as it takes us to do the best work possible for you. Actual operating times vary, but generally, the surgery takes 20 to 120 minutes, depending on the complexity of the case.
The surgery is a “day surgery.” Patients do not stay overnight at the hospital. Before the day of surgery, the operating room will provide you with specific instructions as to what time you need to arrive for your surgery. While it varies depending on the day and the patients, most patients having surgery under “local anesthesia” can expect to be in the hospital for 3-4 hours, while patients having surgery under “general anesthesia” can expect to be in the hospital for 4-6 hours.
Most patients will have a “pre-operative” clinic visit with Dr. O’Connor or Dr. Saleh and/or an orthoptist at the CHEO Eye Clinic to recheck the eye alignment in the weeks prior to surgery. If you wear glasses or contact lenses, it is essential that you bring them to this appointment so that your eye alignment can be properly measured. If you have questions about your surgery, please write them down and bring them to this appointment. This appointment is your opportunity to ask any questions that you may have about the surgery. Please let our team know as soon as possible if you need a note for time off work after surgery, or if you require completion of an insurance form. Please also note that there is a fee for these types of services as they are not insured under the provincial health insurance plans.
After strabismus surgery, the suture that is positioning a muscle in its new location is sometimes adjusted (tightened or slackened) in the hopes of getting the eye a bit straighter once the patient is no longer under anesthesia. For patients who have surgery under general anesthesia, the “adjustment” is usually done at the end of the surgical day, before the patient leaves the hospital. For patients who have surgery under local anesthesia, the patient usually needs to return to see Dr. O’Connor or Dr. Saleh 24-48 hours after surgery to have the “adjustment” completed. Adjustable sutures are a useful tool in the right situation but are not appropriate for all strabismus surgeries. Dr. O’Connor or Dr. Saleh will let you know if this is something that they are considering for your surgery to help give you the best possible result – in some cases a final decision is made during the surgery.
Yes. The eye produces mucous in response to the surgery. Use a clean face cloth with warm tap water to wash and clean the lashes and around the eye as needed. Gently wipe the eyelid from the inner corner to the outer corner of the eye. Do not rub your eye or put pressure on the eyelid. Avoid applying eye makeup and contact lenses for 1-2 weeks.
In general, you should expect a slow gradual improvement in your symptoms over days to weeks. You should contact iCare if you are concerned, in particular, if you experience vision loss, increasing pain, sudden eyelid swelling, fever, green discharge, or a sudden change in eye alignment or sudden inability to move the eye in one or more directions.
These are dry eye symptoms that are exceedingly common after surgery, and the recovery process can be very slow for some patients (many months). Please use preservative-free artificial tears during the day (such as Hylo) and ointment (such as Ocunox) at bedtime to keep the eyes well-hydrated as they are healing.
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