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What is strabismus surgery?

Strabismus surgery addresses problems with eye misalignment, in which the eyes are not straight. Although we are a children’s hospital, our surgeons perform strabismus surgery for both children and adults.

With strabismus, the eyes can be turned inward or crossed (esotropia), turned outward or wandering (exotropia), misaligned vertically (hypotropia or hypertropia) or some combination of these. Some refer to this condition as a “lazy eye” or "cross eye."

The goal of strabismus surgery is to get the eyes straighter and to improve symptoms like double vision and eye strain. In young children, straightening the eyes can also improve visual development and help prevent or improve amblyopia, a condition in which the brain doesn’t develop good vision from a deviated eye. The second goal may be to ensure the eyes work better in unison, or work as a team, to improve the patient’s depth perception or three-dimensional vision. A third goal may be to improve the appearance of the eyes and to increase self-confidence and eye contact with others.

Ophthalmologists, medical doctors who have specialized training in eye surgery, perform this type of surgery. Our strabismus surgeons at Children’s Hospital Colorado have all undergone advanced fellowship training in strabismus surgery after their general ophthalmology training.

Types of strabismus surgery  

The ophthalmologist will take careful measurements of the eye misalignment in your or your child’s clinic visit and develop a surgical plan. Strabismus surgery in general involves “tightening” or “loosening” one or several of the six extraocular muscles on each eye that control the eye position. These muscles lie underneath the conjunctiva (clear tissue that covers the front of the eye) and attach to the surface of the eyeball.

During the surgery, the surgeon will make a small cut through the conjunctiva to access the specific extraocular muscle. The surgeon cleans the muscle so they can clearly see its attachment point on the eye, and depending on the misalignment, the surgeon will either tighten or loosen the eye muscle:

  • Resection is used to tighten the muscle. The surgeon cuts and removes a small portion of the muscle, shortens it and reattaches it to the eye with a suture. Due to the shortening, it will pull much more strongly than before, and act like it’s been tightened.
  • Recession is used to loosen the muscle. The surgeon cuts and removes the muscle from the eye, then reattaches the muscle further back on the eye to pull less.

After the extraocular muscle is adjusted, the surgeon may close the conjunctiva with tiny stitches or leave the incision to heal on its own. Although several variations of these procedures may be performed, the general idea of “tightening” or “loosening” still applies.

In some strabismus procedures, in which the surgeon only wants a temporary effect, the surgeon may treat a tight muscle with botulinum toxin (Botox). This paralyzes the muscle for around 3 months and allows it to relax from its tightened state. After 3 months, the surgeon may repeat the procedure or decide a more permanent surgery is necessary.

In some adult patients, the surgeon may recommend that adjustable sutures be used. In this procedure, the surgeon doesn’t tie down the final knots during the surgery, but instead ties a temporary knot, and allows the patient to provide feedback on their symptoms after surgery. Further adjustments can be made to the muscle position once the patient is awake, and once the patient and the surgeon are happy, the final knots are tied down and the surgery is made permanent.

What to expect during strabismus surgery  

The procedure usually takes about 45 minutes to 90 minutes, depending on how many muscles need to have surgery, and whether there’s any scar tissue from prior surgeries. Most strabismus surgeries are done under general anesthesia, so the patient is asleep and doesn’t remember anything about the surgery, and performed as outpatient procedures so they can go home the same day.

Our surgeons use dissolvable stitches (sutures) to reattach the muscle(s) to the eye. These slowly dissolve as the body heals, meaning that you or your child doesn’t need to return to get the stitches removed.

Some patients find the idea of eye surgery frightening, but fortunately, strabismus surgery is exceptionally safe. The risk of post-operative infection of the surgical area is very low and risk of infection inside the eye (endophthalmitis) is even lower (around 1 in 350,000). Strabismus surgery may be associated with some mild irritation after surgery but isn’t usually painful.

For pediatric patients, our child life team provides exceptional support in the pre-operative area, helping children feel safe and supported.  

What to expect after strabismus surgery?  

Strabismus surgery is typically not very painful. Afterward, most patients have some mild eye discomfort, which over the counter medications like acetaminophen and ibuprofen can control. The surgeon often prescribes an eye ointment, which helps soothe any eye scratchiness, prevent infection, improves comfort and speeds up healing after the procedure.  

The white part of the eye will be red or bloodshot after strabismus surgery, which can worsen over the first few days, but will lessen over time.  This redness is not painful but can look dramatic to parents and caregivers.

Patients who have had strabismus surgery will often have mild blurry vision after surgery, and the ointment used after surgery can make this temporarily worse. They may also have some double vision that is new or different than what they had prior to surgery, which typically improves over a few days but may take several weeks to fully go away.

The patient may eat and drink in the recovery area, immediately after surgery. Eye soreness and scratchiness usually lasts 1 to 2 days after surgery. Most children go back to their normal daily activities the day after surgery.

While normal bathing and showering is fine, strabismus surgeons usually recommend that the patient avoids getting in dirty water, like a swimming pool or hot tub, for 2 weeks after surgery. Returning to school or work is at the discretion of the patient; many children will be ready to go back to school a few days after surgery, but older children and adults may want to take a week or two away from visually demanding tasks like school and work. The final position of the eyes doesn’t occur for 6 to 8 weeks.  

Why choose us for strabismus surgery?  

Some conditions that cause strabismus, such as thyroid eye disease (Graves' disease), can make surgery more challenging because there is more scar tissue and changes to the muscle structure. In very complex situations, the surgeon may recommend adjustable sutures or even that the surgery be performed in several different steps. At Children’s Colorado, our strabismus surgeons are experienced with difficult cases, including reoperations and patients that have had trauma. Our surgeons can provide the highest level of care for patients with complex problems.

Our hospital is also equipped with excellent pediatric anesthesia care, which can put children who are undergoing surgery, and their families, at ease. With experience performing strabismus surgery for both children and adults, our eye surgeons are experts at handling even the most challenging cases.  

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