Childhood Eye Muscle Surgery: Everything You Need to Know

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Eye muscle surgery, sometimes also called strabismus correction surgery, is used to treat eye deviation that's caused by uneven eye muscles. Strabismus surgery in toddlers, children, or adults may involve one or both eyes. Children might be diagnosed with strabismus (crossed eyes) during a vision screening, or parents might notice that a child's eyes are not aligned with each other. Full healing takes a few weeks, and this intervention corrects crossed eyes and can prevent certain long term vision problems.

What Is Eye Muscle Surgery?

Eye muscle surgery can loosen, tighten, or relocate your eye muscles. Sometimes more than one surgery is needed for optimal correction, and each procedure may be scheduled at a different time.

This eye operation can include cutting, placing sutures, reattaching, and/or folding tiny sections of one or more of the muscles that move your eye, You have six muscles that move each eye. One end of each muscle attaches directly to your eye, and the other end attaches to the bone of your eye socket. These muscles are located towards the back of your eyeball, distributed on the sides and above and below each eyeball.

Eye muscle surgery is a minimally invasive procedure, in which the ophthalmologist (eye surgeon), gets access to the eye muscles by placing small incisions in the conjunctiva, which is the thin clear covering over the sclera (the white part of the eye).

Eye muscle surgery is an outpatient procedure. Local anesthesia or general anesthesia can be used for pain control.

Contraindications

This surgery isn't right for everyone. It is only used for certain conditions and the risks may be higher than the benefits if you have certain underlying conditions.

Inflammatory disease, immune deficiency, or a bleeding disorder can increase the risk of postoperative complications after eye muscle surgery and may interfere with healing.

If the eye is infected or injured, eye muscle surgery can cause additional damage to the eye. These problems must be resolved before proceeding with eye muscle surgery.

Eye muscle surgery is not a way to treat double vision or crossed eyes that result from neurological issues like a stroke or a brain tumor.

Potential Risks

Eye muscle surgery can cause complications due to the anesthesia or the procedure itself.

Specific problems include:

  • Immediate effects: Adverse effects of this surgery can include infection, bleeding, or swelling around the eye. These issues can often be treated without long term consequences.
  • Vision impairment: Damage to structures in the eye or severe endophthalmitis (inflammation in the eye) can lead to lasting vision loss.
  • Bulging eyes: Exophthalmos (bulging eyes) isn't dangerous and can occur due to scarring behind the eye or as a result of the relocation of the eye muscles.
  • Eye deviation: Overcorrection or under correction can actually increase eye deviation after surgery.

Serious problems would be apparent within a week after the surgery and can cause pain, bruising, swelling, or vision changes.

Purpose of Eye Muscle Surgery

Eye muscle surgery is done when one or more of the six eye muscles in each eye is weak or has a structural problem. The resulting asymmetry in the way the two eyes move can cause one eye to deviate horizontally or vertically. The pupils of the eyes can appear to be off-center. And sometimes, the eyes may bulge or move involuntarily.

Strabismus is the most common reason for eye muscle surgery. This condition is fairly common, is usually noticed in early childhood, and can cause blurred or double vision. Parents and children also become concerned about the appearance of their eyes from a cosmetic standpoint.

Other conditions that might be treated with eye muscle surgery:

  • Ambylopia: Strabismus puts a child at risk for developing amblyopia, a type of vision deficit. With amblyopia, the brain favors one eye more than the other. Sometimes eye muscle surgery is done after amblyopia has already started.
  • Thyroid eye disease: Thyroid disease, which generally develops during adulthood, can cause swelling of the eye muscles. Thyroid medication is the most common treatment, but sometimes the eye changes are treated with eye muscle surgery.
  • Myokymia: Myokymia is a condition in which tiny muscles twitch. It usually affects the eyelid, but it can involve the eye muscles, especially the superior oblique muscle. Medical therapy is the first line of treatment, but if the condition persists and causes problems like headaches, dizziness, or impaired vision, eye muscle surgery can be an option.
  • Nystagmus: A condition characterized by involuntary jerking eye movements, nystagmus is often associated with severe dizziness, nausea, and difficulty with walking and balance. Eye muscle surgery is a treatment option for some cases of nystagmus.

You or your child could be a candidate for eye muscle surgery if eye muscle irregularity is a cause of your symptoms. Your doctor will evaluate your symptoms with an eye examination, which includes a visual acuity test and testing of your eye muscles.

How to Prepare

If not completed already, your doctor will recommend that your child have a general physical examination to ensure that they are healthy enough to have surgery and receive anesthetic medication. A detailed eye examination, and possibly imaging tests like a computerized tomography (CT) scan may be used to plan the specifics of the procedure.

Pre-operative testing can include complete blood count (CBC), blood chemistry tests, and a chest X-ray.

Location

The surgery will be done in an operating room located in a hospital or surgical center.

What to Wear

You can wear anything for the procedure appointment. If you have bangs near your eyes, they should be pulled back and your hair shouldn't have hair cream or other products in it.

Food and Drink

You need to abstain from food and drink the night before getting general anesthesia. If your child is young, the timing may be adjusted and your child's anesthesiologist will give you more specific instructions.

Medications

Your child's doctor will recommend that your child stop taking blood thinners like aspirin and non-steroidal anti-inflammatory products (NSAIDs) one week before surgery to minimize bleeding.

You might also need to place antibiotic or steroid ointment in the eye for a few days prior to eye muscle surgery.

What to Bring

You need to have a form of identification, health insurance information, and a method of payment for any portion of the cost that you are required to pay. Adults should have someone to drive home after surgery because vision can be temporarily impaired after the operation.

Young children might be permitted to bring a special toy or blanket to the pre-operative area on the day of surgery.

Pre-op Lifestyle Changes

Depending on the specifics of the procedure and the eye muscles involved, sometimes a patch is worn over the eye, or eyeglasses might be worn for several weeks prior to surgery. These strategies are used to prevent vision problems and muscle problems from worsening in the weeks leading up to surgery.

What to Expect on the Day of Surgery

You will need to register and sign a consent form on the day of surgery. You will go to the pre-operative area. Temperature, pulse, blood pressure, respiration, and oxygen are checked. An intravenous (IV, in a vein) line will be placed in the arm or hand.

Same day blood tests can include CBC and electrolyte tests.

If your child has a significant infection, like a cold or flu, you will probably be advised to reschedule the surgery.

Before the Surgery

Anesthesia might be given by IV, and sometimes young children are given their anesthetic medication by inhalation with a breathing mask.

  • If general anesthesia is used, the medication will control pain, paralyze the muscles, and induce sleep. A breathing tube will be placed in the throat for breathing assistance during surgery.
  • If monitored anesthesia sedation and local anesthesia are used, anesthetic medication will be used to induce drowsiness. Then the local anesthetic medication will be placed in the eye with a needle or as drops.

Before surgery, your ophthalmologist might place antibiotic ointment on your eye.

During the Surgery

Eye muscle surgery should take about 30 to 60 minutes. It is performed with the eyelids open. A small retractor is used to gently hold open the eyelids.

Your ophthalmologist will rotate the eye and make an incision into conjunctiva. The eye does not need to be moved out of its normal position.

The next step is for your ophthalmologist to locate the muscle or muscles that need repair. This is a minimally invasive procedure, and the muscles are directly visible through the conjunctival incision without the aid of a camera.

Surgical techniques used in eye muscle surgery can include:

  • Resection: Cutting small muscle fibers to make a specific muscle smaller or shorter and stitching it back into its place on the eye
  • Recession: Separating a muscle from where it adheres to the eye and stitching it to a different position on the eye
  • Plication: Folding the muscle and stitching it to form a new shape and size

Your surgeon might use an adjustable suture to secure your eye muscle in place. An adjustable suture can be tightened or loosened to fine-tune the eye muscle correction. The adjustment can e made two to four hours after surgery or on the next day.

After the muscle is in place, the incision that was made in the conjunctiva is repaired with absorbable sutures.

The anesthesia is stopped. If general anesthesia was used, the breathing tube will be removed and the anesthesia team will make sure that breathing is stable before taking you or your child to the recovery area.

After the Surgery

Your child will be monitored closely after surgery. You might be able to stay with your child in the post-operative recovery area. They will receive antibiotic drops or antibiotic ointment in the surgical eye to prevent an infection. They will also be given pain medication as necessary.

Some children experience mild nausea while general anesthesia is wearing off. Sometimes ginger drinks or salty or bland food can help.

Your child's ophthalmologist will check on them within a few hours after the eye operation. If there are no complications, your child (or you, if you are the one who had the surgery) can go home.

You will receive instructions about eye care and a schedule for making a follow-up appointment. Additionally, you will be given a list of signs of complications to look out for.

Recovery

You will likely have a follow-up visit within a few days after surgery, and again a few months after surgery. Throughout the healing and recovery process, you need to keep your eye clean to prevent an infection.

Healing

Discomfort or a scratchy sensation may develop, and it can last for several days after eye muscle surgery. You may notice a very small white bump on the white part of the eye. This is a suture knot and will eventually dissolve. Sometimes the eye looks red for several weeks after surgery.

Generally, an over-the-counter pain reliever, like acetaminophen, can control mild discomfort. If the eyelids appear swollen, ice packs may be applied.

Antibiotic-steroid eye drops may be given to prevent infection and help the eyes heal. Use this as directed by your doctor.

Call your doctor if signs of complications develop, such as:

  • Fever
  • Pus draining from the eye
  • Bleeding from the eye
  • Cloudy vision
  • Severe pain
  • Worsening swelling

Coping With Recovery

Your child can be physically active when they feel like it, but it's important to protect the eye from outside contamination as the conjunctival incision heals.

Swimming, getting bathwater into the eyes, and wearing contact lenses should be avoided until your doctor gives the green light.

Your child may be instructed to wear a patch to cover the eye for the first few days after surgery. Unlike the eye patch that might have been recommended before surgery to prevent worsening of vision and eye movement, a patch after surgery is used to protect the eye from contamination.

Long Term Care

After your post-operative visits, you will still need to see your optometrist or ophthalmologist for annual eye examinations so that any vision or eye problems can be identified and managed at an early stage.

The eye may begin to deviate after surgery, either due to over-correction or under-correction. Often, non-surgical management, such as eye muscle exercises or botulism injection can help treat mild eye deviation.

If you have exophthalmos as a result of this surgery, you may notice a tendency to have dry eyes. Usually, eye drops can help with this problem.

Possible Future Surgeries

Sometimes eye muscle correction requires multiple surgical steps, with separate procedures. So a subsequent surgery might be scheduled months after the first one.

And in some situations, post-operative eye deviation may require another eye muscle surgery for repair.

Lifestyle Adjustments

In general, you shouldn't expect to have to make adjustments to your lifestyle as a result of having had eye muscle surgery. You might need to wear corrective lenses or do eye muscle exercises if you have an eye condition that requires maintenance care.

A Word From Verywell

Eye muscle surgery is fairly common. It's usually done during childhood, but sometimes adults need this type of surgery too. Healing and recovery are generally fairly quick and uncomplicated. You can expect to see a visible improvement in eye deviation right after surgery.

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  1. American Academy of Opthalmology. Adult strabismus surgery. Updated May 29, 2020.

  2. Simonsz HJ, Rutar T, Kraft S, et al. Endophthalmitis after strabismus surgery: incidence and outcome in relation to age, operated eye muscle, surgical technique, scleral perforation and immune state [published online ahead of print, 2020 Jun 13]Acta Ophthalmol. 2020;10.1111/aos.14446. doi:10.1111/aos.14446

  3. Ing MR, Shortell J, Golez J. Extraocular and Intraocular Infections Following Strabismus Surgery: A ReviewJ Pediatr Ophthalmol Strabismus. 2019;56(4):214-221. doi:10.3928/01913913-20190425-01

  4. Tandon A, Oliveira C. Superior oblique myokymia, a reviewCurr Opin Ophthalmol. 2019;30(6):472-475. doi:10.1097/ICU.0000000000000619

  5. Akbari MR, Mirmohammadsadeghi A, Mahmoudzadeh R, Veisi A. Management of Thyroid Eye Disease-Related StrabismusJ Curr Ophthalmol. 2020;32(1):1-13. Published 2020 Mar 23. doi:10.1016/j.joco.2019.10.002

  6. Rahimi Varposhti M, Moradi Farsani D, Ghadimi K, Asadi M. Reduction of oculocardiac reflex with Tetracaine eye drop in strabismus surgeryStrabismus. 2019;27(1):1-5. doi:

  7. American Association for Pediatric Opthalmology and Strabismus. Strabismus surgery. Updated March 2019.

  8. Huston PA, Hoover DL. Surgical outcomes following rectus muscle plication versus resection combined with antagonist muscle recession for basic horizontal strabismusJ AAPOS. 2018;22(1):7-11. doi:10.1016/j.jaapos.2017.09.004