Amblyopia Surgery: Everything You Need to Know

Amblyopia (lazy eye) is a condition in which one eye does not function properly. Therefore, the brain only works with the better-seeing eye and ignores images from the weaker eye. Its symptoms include unequal vision in the eyes and impaired depth perception. This results in permanently decreased vision in the ambylopic eye that is not correctable with glasses or contact lenses.

Non-surgical interventions are more common than surgery for managing the causes of amblyopia. However, when appropriate, surgery can help to correct some of the causes in children. These can include strabismus (crossed eyes), cataracts, refractive errors, and a droopy eyelid.

This article discusses when surgery is an option for amblyopia. It also covers the purpose of surgery, what to expect, and recovery.

When Is Surgery an Option for Amblyopia?

Surgery may be an option for certain eye conditions that cause amblyopia. However, surgery doesn't treat amblyopia itself.

The most common treatments for amblyopia are wearing glasses or an eye patch. These can help your weaker eye learn to work in coordination with the brain. If you have surgery to fix a condition that causes amblyopia, you may still need to wear glasses or a patch afterward for a certain amount of time.

Conditions Treated With Surgery

The following lists some eye conditions that may lead to amblyopia and what surgeries may be used to correct them. Most of these procedures are minimally invasive with a small incision, and some are done with laser surgery. General anesthesia or monitored anesthesia sedation with local anesthesia are required to prevent the child from moving during the procedure.

Refractive Vision Impairments

Sometimes, a refractive vision impairment such as myopia (nearsightedness), hyperopia (farsightedness), or astigmatism can cause amblyopia. This can happen if the vision defect affects only one eye, or if it affects both eyes unequally.

Vision correction might reverse amblyopia, especially if done at a young age. However, most cases of refractive correction in children can be treated with glasses and occasionally contacts.

Surgery is generally reserved for children with anisometropic amblyopia who do not respond to standard treatment. Anisometropic means that there is a large difference in prescription between the two eyes.

Surgery may also be used with children with serious vision impairment who are unable to wear glasses for developmental, sensory, or other reasons. As a result, only a small percentage of children are suitable candidates for this surgery.

When surgery is needed, photorefractive keratectomy (PRK) is more commonly performed on children than LASIK (laser-assisted in situ keratomileusis) surgery. That's because PRK doesn't have certain risks that LASIK has.

With PRK, the ophthalmologist uses a laser to shape the cornea. This helps improve how the light focuses on the retina to correct vision.

Strabismus

Strabismus, or crossed eyes, can sometimes cause amblyopia. In strabismus, your eyes are pointed in two different directions. For instance, one eye may be focused straight ahead, while the other is turned to the inside.

To avoid double vision, your brain then focuses on the eye that sees straight ahead and ignores the other eye, This keeps the weaker eye from developing correctly, leading to amblyopia.

Eye muscle surgery may be recommended for treating strabismus. This surgery is performed on the muscles to realign the eye. It works by tightening the eye muscles (resection procedure) or loosening the eye muscles (recession procedure).

In a recession procedure, the eye muscle is detached and reattached further from the front of the eye so the muscle is weaker. In a resection procedure, the eye muscle has a section removed to make it shorter and stronger.

Cataracts

Cataracts are a clouding of the eye's lens. It not only affects adults, but it can occasionally affect children, too. It may be something they're born with or something they develop in childhood.

Without treatment for cataracts, vision distortion can lead to amblyopia. That's because children's eyes and brains are still developing in their ability to process vision.

In this case, the first step to resolving amblyopia is cataract surgery. The procedure involves removing the cloudy lens in your eye and replacing it with an artificial lens.

Afterward, most children need ongoing treatment to help improve the connections between the brain and eyes. They may need to wear an eye patch, glasses, or contact lenses.

Droopy eyelid

Droopy eyelid, also called ptosis, is when the upper eyelid droops over the eye and blocks your vision. In some cases, it can cause amblyopia, since one eye can see better than the other.

Ptosis surgery involves tightening the levator muscle, which lifts the eyelid. It might also involve attaching the eyelid to other muscles that can help lift it.

After surgery, amblyopia is treated by using an eye patch, special eyeglasses, or eye drops to help the weaker eye get stronger.

Contraindications

While useful for these eye issues, surgery is not recommended for all types of vision defects that cause amblyopia. For example, if the visual defect is caused by dysfunction of the brain's occipital lobe (the primary vision area), surgery will not correct it.

Health issues like a bleeding disorder, inflammatory disease, or immune dysfunction can increase your risk of complications. You and your healthcare provider will have to weigh the risks and benefits of surgery in your case.

An acute illness or infection can be a contraindication to surgery and will need to resolve before the procedure can proceed.

Potential Risks

In addition to the standard risks associated with surgery and anesthesia, these ophthalmic surgeries have certain potential complications.

Problems that may occur due to surgery include:

• Bleeding
• Structural damage to the eye
• Swelling
• Infection

These complications might require immediate intervention. If not adequately resolved, an adverse surgical event may result in a lasting vision issue that could be worse than the original problem.

Blurry vision, decreased vision, or blindness are potential rare and unforeseen complications in any ophthalmic surgery.

Purpose of Surgery

Amblyopia is the leading cause of vision impairment in children. Surgery, along with follow-up treatment, can help relieve the following effects of amblyopia:

• Decreased vision in one or both eyes
• Misaligned eyes (one eye turned inward)
• Head tilting
• Squinting
• Impaired depth perception 

Symptoms of amblyopia are not always obvious. In fact, many people with amblyopia do not complain about vision difficulties or eye movement issues. Often, amblyopia is diagnosed with a routine eye examination, such as a refraction test.

The American Academy of Ophthalmology suggests that children should have their eyes examined and vision tested as newborns, before age 1, and again before age 3.

Addressing amblyopia as early as possible is important. Early treatment can prevent permanent vision loss later in life. Vision deficits in amblyopia can occur due to several mechanisms that change the way the brain processes visual information:

• When vision is better in one eye, the brain may adapt and preferentially use the better eye, ignoring the eye with impaired vision. When one eye is not used, vision declines further and eye alignment may be impaired as the weaker amblyopic eye starts to drift.
• Asynchronous eye movements can cause blurred or double vision. The brain suppresses one of the images by favoring one eye. This causes the vision to decline in the other eye.

Surgery may be necessary to correct structural defects in the eye. However, even with surgery, follow-up treatment is typically needed to correct amblyopia. This involves strengthening your weaker eye by increasing its use.

One example is patching. Wearing a patch over the good eye forces the brain to start using the weaker eye so it can become stronger. As an alternative, prescription eye drops are sometimes used to blur the vision in the stronger eye for the same purpose.

How to Prepare

If surgery is recommended, the ophthalmologist (eye surgeon) will plan the procedure based on observation of the eyes. This may include an eye examination, eye muscle testing, tests for depth perception, and imaging tests such as a computerized tomography (CT) scan.

Specific testing might be needed to evaluate issues like congenital cataracts.

You and your healthcare provider will discuss the necessary correction, as well as whether the surgery will be done with a laser. There are several types of laser eye surgeries, such as laser-assisted surgery for cataracts. LASIK or PRK surgery both use lasers to correct refractive issues.

Additionally, pre-operative testing includes anesthesia preparation. This can include a chest X-ray, electrocardiogram (EKG), complete blood count (CBC), and blood chemistry tests. It may also include a test for COVID-19.

Location

The surgery will take place in a hospital or surgical center operating room, or an eye surgery suite.

These ophthalmic surgeries are generally outpatient procedures, meaning you will go home on the same day.

What to Wear

You or your child can wear anything comfortable for the procedure appointment. Eye makeup (or makeup around the eyes) should be avoided, and any hair that can get in or near the eyes should be pinned back and free of styling products.

Food and Drink

Depending on the type of anesthesia used, there will be restrictions in terms of food and drink.

All surgeries done in an operating room under some level of sedation require fluid and food restriction before surgery. Depending on the age of the child, the number of fasting hours may vary. The surgical or anesthesia team will provide specific instructions.

Medications

Typically, blood thinners and anti-inflammatory medications must be stopped for several days before surgery.

Additionally, use of lubricating eye drops or antibiotic ointment may be needed for several days before the surgery. You may also be given a prescription for other medications, such as steroids or a diuretic if there is swelling or inflammation in the brain or eye.

What to Bring

On the day of surgery, you need to bring a form of identification, insurance information, and a method of payment for any portion of the surgery you will be responsible for paying.

If you are having surgery as an adult, someone must be available to drive you home on the day of the procedure.

Children might be allowed to bring a small comfort item to the pre-operative surgical area on the day of surgery.

Pre-Op Lifestyle Changes

Before your surgery, you or your child might be instructed to wear an eye patch on the stronger eye. This can prevent eye muscle weakness or diminished vision from worsening in your weaker eye.

What to Expect on the Day of Surgery

When you arrive at the surgery appointment, you will need to register and sign a consent form. You will be asked to show identification and insurance information.

If your child is having an eye operation, you may be permitted to go with them to the pre-operative area. Same-day testing may include CBC, electrolyte tests, and a urine test. If an infection is detected, the surgery may need to be rescheduled.

Vital signs, including temperature, blood pressure, pulse, and breathing rate will be monitored. Typically, oxygen saturation will be checked with a pulse oximeter as well.

An intravenous (IV, in a vein) line will be placed in the arm or hand. The ophthalmologist and anesthesiologist may come to do a pre-operative check shortly before surgery.

Then, when it is time for surgery, you will go to the operating room or procedure suite.

Before the Surgery

Preparation includes getting the eye ready for an incision and administering anesthesia.

• With general anesthesia, anesthetic medication is injected through the IV or inhaled through a mask. This medication induces sleep and inhibits pain and muscle movement. A breathing tube is inserted into the throat for mechanical breathing during surgery.
• For IV sedation, anesthetic medication is injected into the IV, inhaled through a mask, or taken by mouth to induce drowsiness. Then local anesthetic medication is injected into the eye with a tiny needle or as eye drops.

Sometimes, an antibiotic ointment is applied to the eye prior to surgery.

During the Surgery

Specific corrective techniques can include:

• PRK surgery: Your ophthalmologist will use eye drops to numb your eyes. They'll remove the outer layer of cells on your cornea using a brush, blade, laser, or alcohol solution. A laser will be used to reshape your cornea.
• Eye muscle surgery: The surgeon makes a small incision in the conjunctiva to access the eye muscles. In a recession procedure, the surgeon reattaches a muscle at a point where it's looser. With a resection procedure, the surgeon shortens the muscle and reattaches it to make it tighter.
• Cataract surgery: In pediatric cataract surgery, a small opening is made in front of the lens capsule. The surgeon inserts an instrument that suctions the inner part of the cloudy lens. An artificial lens is sometimes placed in this surgery or in a second surgery. Dissolvable stitches are used to close the incision.
• Ptosis surgery: The surgeon will make an incision in the crease of the eyelid and shorten the muscle that lifts the lid. In another technique, small incisions are made around the eyebrow and eyelid, and special material is used to connect the eyelid to the eyebrow.

Anesthesia will be stopped or reversed and, if general anesthesia was used, the breathing tube will be removed. The anesthesia team will ensure that you or your child are breathing independently before releasing you to the recovery area.

After the Surgery

While waiting for the anesthesia to wear off, vital signs and oxygen levels will be monitored. Pain medication will be given as needed.

Use of the bathroom without assistance will be permitted. The nurse will ensure that small amounts of food and drink are tolerated.

If no complications occur, then you should be discharged to go home within a few hours after the procedure. You will get instructions about activity restrictions, eye care, who to call if complications arise, and necessary follow-up appointments. A prescription for pain medication and possibly an antibiotic will also be written.

Recovery

Recovery after ophthalmic surgery and necessary eye care during this time varies and depends on the specific procedure that was done.

Protecting the eye from contamination is important after eye muscle surgery. And you may need to avoid exertion after cataract surgery.

If you are unsure about your recovery period instructions, be sure to call your surgeon's office.

Healing

As you are healing from any type of ophthalmic surgery, there are some general considerations to keep in mind.

Keep your eye clean and dry for several weeks after your procedure. Try not to touch your eye and do what you can to prevent dirt, germs, and everyday products (like shampoo) from entering the eye as well.

You might be given a prescription for antibiotics or other medications. Be sure to take them as directed.

You might experience mild pain, discomfort, or swelling for a few days. The pain can usually be managed with over-the-counter pain medication like Tylenol (acetaminophen), and the swelling can be managed with a cold pack.

But if you have more pain or swelling than what you were told to anticipate, you should get in touch with your practitioner's office. Also inform your healthcare provider if any signs of complications arise, including:

• Fever
• Pain
• Eye swelling
• Draining pus
• Bleeding from the eye
• Bruising around the eye
• Vision changes

Coping With Recovery

For at least the first week after surgery, you will need to avoid strenuous activities (like heavy lifting) and active motion (like riding a roller coaster) so your eye can heal. Your healthcare provider will give you a timeline for when you can restart these types of activities.

You should be able to read and look at a computer, but give yourself some rest so you don't get exhausted or experience headaches.

Excessive sunlight or bright lights can interfere with healing. You will need to wear sunglasses to protect your eyes from excessive light after you stop wearing a patch.

Sometimes, physical therapy is needed for your eyes. This can include eye movement exercises to strengthen weakened muscles.

Long-Term Care and Vision

Generally, after surgery and recovery are complete, you should experience an improvement in your vision.

That said, you might still have some vision defects after surgery. Your vision might be different than it was before. Your healthcare provider might give you a new prescription for eyeglasses several weeks or months after you heal. You may also need use prescription eye drops to help strengthen your weaker eye. (Children may need to wear a patch.)

After surgery, you will need to have regular eye examinations. If you have a condition that affects your eye health, you might continue to have long-term treatment for that condition.

After any type of eye surgery, dry eyes can be a problem. Using eye drops for lubrication can help prevent this problem.

Possible Future Surgeries

If you have a severe complication, like excessive bleeding or damage to your eye, you could have emergency surgery to alleviate that problem.

And you might need future surgery if you develop another surgically correctable eye problem at a later date.

If your surgery is part of a plan that includes several procedures, you will need to have the next surgery at some point.

Summary

Amblyopia happens when one eye doesn't have clear vision, and the brain ignores images from that eye. It's typically treated with non-surgical methods, including wearing a patch over the stronger eye.

Sometimes the cause of amblyopia can be treated with surgery, but only in children. Examples include strabismus, cataracts, refractive errors, and droopy eyelid. However, after surgery, amblyopia will likely need additional treatment to strengthen the connection from the eye to the brain.

A Word From Verywell

Surgical treatment for the causes of amblyopia includes a variety of methods. If you or your child has been diagnosed with amblyopia, surgery isn't likely to be the first therapeutic step. But if surgery is recommended by your ophthalmologist, the outcome can improve your quality of life.