Squint Surgery In Children

This information aims to answer some of the questions you may have about squint surgery. The information does not cover everything as every patient and squint is different. Your surgeon will discuss your particular case with you. Please ask the clinical staff about anything you want to be made clear.

What are the aims of surgery?

  • To improve the alignment of the eyes, to make the squint smaller in size.
  • In some patients, to reduce or try to eliminate double vision or to protect or restore binocular vision.
  • Occasionally to improve head posture.

What happens before the day of surgery?

A pre-assessment is performed in the weeks leading up to the operation date.

What happens on the day of surgery?

Squint surgery is nearly always a day case procedure. Squint surgery is a common eye operation. It involves weakening or strengthening or altering the action of one or more of the extraocular muscles which move the eye. The muscles may be recessed (to weaken), resected (to strengthen), their insertions moved (to alter their action) or less commonly altered in some other way (advanced, plicated, tucked, belly sutured permanently to the globe etc).
The muscles are sutured into their new positions. The operation is carried out under general anaesthetic. The operation usually takes up to 60 minutes depending on the number of muscles that need surgery. Parents can go down to the operating theatre with your child and stay until he/she is asleep but cannot come in to watch the surgery. Remember to discuss which eye(s) is/are being operated on and why.

What are the success rates?

Overall about 90% patients/parents perceive some improvement in the squint after surgery. However, there is some unpredictability in the procedure, so that the squint may not be completely corrected by the operation. Many patients require more than one operation in their lifetime. If the squint returns it may be in the same or in the opposite direction and may occur at any time. The operation does not change visual acuity or refractive error. More patching may be needed after the operation.

Does the surgery cure the need for glasses or a lazy eye?

No, the operation does not aim to change the vision or need for glasses.

What are the risks of the operation?

Parents can be informed that squint surgery is generally a safe procedure. However, as with any operation, complications can and do occur. Generally these are relatively minor but on rare occasions they may be serious.

  • Under and overcorrection

The original squint may still be present (undercorrection) or the squint direction may change over (overcorrection). Occasionally a different type of squint may occur. Some patients may require another operation.

  • Double vision

Double vision after surgery is normal and often settles in days or weeks. Some patients may continue to experience double vision on side gaze. Permanent primary position diplopia is very rare in children.

  • Allergy/stitches

Mild allergy to postop drops: itching/irritation/ redness/puffiness of the eyelids. It usually settles quickly when the drops are stopped. Infection or abscess around the stitches. Cyst or granuloma related to the wound or sutures: occasionally needs further surgery.

  • Redness

Can take up to 3 months to resolve, occasionally the eye remains discoloured (red, yellowish) permanently, particularly with repeated operations.

  • Scarring

Most of the scarring of the conjunctiva not noticeable by three months, but occasionally visible scars will remain, especially with repeat operations.

  • Lost or slipped muscle

Muscle may slip back from new position during the operation or shortly after, limiting eye movements. May require further surgery and not always possible to correct. The risk of slipped muscle requiring further surgery is about 1 in 1,000.

  • Scleral perforation

If suture passed too deep or thin sclera: may require antibiotic treatment and laser/cryo treatment. Can affect sight (via endophthalmitis, vitreous haemorrhage, retinal detachment). Risk is up to 2%.

  • Infection

Infection is a rare complication but the risk increases if drops are not instilled as directed and treatment not sought promptly. Significant infection is extremely rare but in the worst cases can cause loss of vision in the eye (endophthalmitis, orbital cellulitis).

  • Loss of Vision

Very rare, loss of vision in the eye being operated can occur. Risk of serious damage to the eye or vision is approximately 1 in 30,000.

  • Anterior segment ischaemia

The blood circulation to the front of the eye can rarely be reduced following surgery, producing a dilated pupil and blurred vision. This usually only occurs in patients who have had multiple surgeries. The risk is about 1 in 13,000 cases.

  • Anaesthetic risks

Unpredictable reactions occur in around 1 in 20,000 cases and death in around 1 in 100,000.

What will it be like after the operation?

Eye(s) will be swollen, red and sore and the vision may be blurry. Start the drops that evening, and painkillers suitable for age of the child, such as paracetamol and ibuprofen suspension, can be taken. The pain usually wears off within a few days. The redness and mild discomfort can last for up to 3 months particularly with repeat squint operations.

Care after the operation

  • Use the eye drops as directed
  • Attend your follow up appointment(s) to ensure the eye is healing well
  • Use cooled boiled water and a clean tissue or cotton wool to clean any stickiness from the eyes
  • Don’t rub the eye(s)
  • No swimming for 4 weeks
  • Continue using glasses if have them
  • Your child will need a few days to one week off nursery or school.

Squint Surgery in Adults

This information aims to answer some of the questions you may have about squint surgery. However, it does not cover everything as every patient and squint is different. Your surgeon will discuss your particular case with you. Please ask the clinical staff about anything you want to be made clear.

What is the aim of surgery?

  • To improve the alignment of the eyes, to make the squint smaller in size.
  • In some patients, to reduce or try to eliminate double vision.
  • Occasionally to improve an abnormal position of the head.

How is the surgery done?

Squint surgery is a very common eye operation. It usually involves tightening or moving one or more of the outside eye muscles which move the eye. These muscles are attached quite close to the front of the eye under the conjunctiva, the clear surface layer. The eye is never taken out of the socket during surgery. Stitches are used to attach the muscles in their new positions.
Squint surgery is nearly always a day case procedure so you should be in and out of hospital on the same day.
There are two kinds of squint operation – adjustable and non-adjustable:

Non adjustable surgery

The operation is usually carried out under general anaesthetic. The operation usually takes up to 60 minutes depending on the number of muscles that need surgery. When you have recovered from the anaesthetic and the nurses are happy for you to be discharged, you are free to go home – usually a few hours later.

Adjustable surgery

Squint surgery using an adjustable suture may give a better result in certain types of squint e.g. patients who have had a squint operation before, patients with a squint due to injury or patients with thyroid eye problems.

Part 1 – The main operation

The main part of the operation is carried out in the operating theatre usually under general anaesthetic (with you asleep).

Part 2 – Adjusting the stitch

Once you have woken up from the anesthetic the final position of the muscles is adjusted when you are awake and able to look at a target. This is particularly useful for treating double vision. If you wear glasses for distance or near, these will need to be brought in with you for this part of the operation. Adjustment is usually done on the ward, after drops of anaesthetic have been put into the eye to take away any pain. You may however feel a pressure sensation.

Before the day of surgery

A pre-assessment is performed in the weeks leading up to the operation date.

What happens on the day of surgery?

You will be asked to come early so that you can be prepared for surgery. You should not drink or eat before the operation: the exact timings of this will be given before the day of the operation. Before being discharged after the operation, you will receive eye drops with instructions and a follow up appointment.

Does the surgery cure the squint?

Overall about 90% patients feel some improvement in their squint after surgery. The amount of correction that is right for one patient may be too much or too little for another with exactly the same size squint, so that the squint may not be completely corrected by the operation. Although the eyes may be straight just after surgery, many patients require more than one operation in their lifetime. If the squint returns it may drift in either the same or opposite direction. We can’t predict when that drift may occur.

What are the risks of the operation?

Squint surgery is generally a safe procedure. However, as with any operation, complications can and do occur. Generally these are relatively minor but on rare occasions they may be serious.

  • Under and overcorrection

As the results of squint surgery are not completely predictable, the original squint may still be present (undercorrection) or the squint direction may change over (overcorrection). Occasionally a different type of squint may occur. These problems may require another operation.

  • Double vision

You may experience double vision after surgery, as your brain adjusts to the new position of the eyes. This is common and often settles in days or weeks but may take months to improve. Some patients may continue to experience double vision when they look to the side in order to achieve a good effect when the eyes look straight ahead. Rarely, double vision whilst looking straight ahead can be permanent in which case further treatment might be needed. If you already experience double vision, you might experience a different type of double vision after surgery. Botulinum toxin injections are sometimes performed before surgery to assess your risk of this.

  • Allergy/stitches

Some patients may have a mild allergic reaction to the medication they have been prescribed after surgery. This results in itching/irritation and some redness and puffiness of the eyelids. It usually settles very quickly when the drops are stopped. You may develop an infection or abscess around the stitches. This is more likely to occur if you go swimming within the first four weeks after surgery. A cyst can develop over the site of the stitches, which occasionally needs further surgery to remove it.

  • Redness

The redness in the eye can take as long as 3 months to go away. Occasionally the eye does not completely return to its normal colour, particularly with repeated operations.

  • Scarring

Most of the scarring of the conjunctiva (skin of the eye) is not noticeable by three months, but occasionally visible scars will remain, especially with repeat operations.

  • Lost or slipped muscle

Rarely one of the eye muscles may slip back from its new position during the operation or shortly afterwards. If this occurs, the eye is less able to move around and, if severe, further surgery can be required. Sometimes it is not possible to correct this. The risk of slipped muscle requiring further surgery is about 1 in 1,000.

  • Needle penetration

If the stitches are too deep or the white of the eye is thin, a small hole in the eye may occur, which may require antibiotic treatment and possibly some laser treatment to seal the puncture site. Depending on the location of the hole, the sight may be affected. The risk of the needle passing too deeply is about 2%.

  • Anterior segment ischaemia

The blood circulation to the front of the eye can very rarely be reduced following surgery, producing a dilated pupil and blurred vision. This usually only occurs in patients who have had multiple surgeries. The risk is about 1 in 13,000 cases.

  • Infection

Infection is a rare complication but the risk  increases if drops are not instilled as directed and treatment not sought promptly. Significant infection is extremely rare but in the worst cases can cause loss of vision or the eye (endophthalmitis, orbital cellulitis).

  • Loss of vision

Although very rare, loss of vision in the eye being operated can occur from this surgery. Risk of serious damage to the eye or vision is approximately 1 in 30,000.

  • Anaesthetic risks

Anaesthetics are usually safe but there are small and potentially serious risks. Unpredictable reactions occur in around 1 in 20,000 cases and unfortunately death in around 1 in 100,000.
Remember: these complications are detailed for your information and that the vast majority of people have no significant problems. After the operation the eye(s) will be swollen, red and sore and the vision may be blurry. The eye may be quite painful.
Start the drops you have been prescribed that evening, and painkillers such as paracetamol and ibuprofen can be taken. The pain usually wears off within a few days. The redness and discomfort can last for up to 3 months particularly with adjustable and repeat squint operations.
You should not sign any legal documents or drive for 48 hours after the general anaesthetic.
We would advise that you may need one or occasionally two weeks off work. Work and normal activities including sport can be resumed as soon as you feel comfortable to do so. It is quite safe to use the eyes for visual tasks, for example reading, watching television. You should return for follow up as advised.

Summary of care after the operation

  • Use the eye drops
  • Use painkillers such as paracetamol and ibuprofen if the eyes are painful
  • Use cooled boiled water and a clean tissue or cotton wool to clean any stickiness of the eyes and avoid water entering the eyes from the bath or shower for the first two weeks
  • Don’t rub the eye(s) as this may loosen the stitches
  • No swimming for 4 weeks
  • Attend the postop clinic appointment
  • Continue using glasses if you have them
  • Avoid contact lens wear in the operated eye(s) until advised it is safe by the doctor or orthoptist

Selective Laser Trabeculoplasty

Selective Laser Trabeculoplasty (SLT) is a procedure used to reduce the pressure in the eye (also known as intra-ocular pressure). A laser beam is applied to the drainage channels, which helps to unclog them. This means the aqeous humour flows through the channels better, reducing the pressure in the eye. This is not a permanent treatment, and may need to be repeated in the future to control the eye pressures adequately. The procedure does not require admission to hospital and is carried out in the outpatients department.

Refractive Surgery

Most refractive errors can be corrected (or at least improved) by means of Refractive Surgery. This is a generic term, which comprises both Laser Refractive Surgery and correction by means of lens implants inside the eye. The latter is called Phakic intraocular lens (IOL) surgery.
Most refractive errors can be corrected (or at least improved) by means of Refractive Surgery. This is a generic term, which comprises both Laser Refractive Surgery and correction by means of lens implants inside the eye.

Presbyopia

Presbyopia is a vision condition which makes it difficult to focus on close objects. During middle age, usually beginning in the 40s, people experience blurred vision at near points, such as when reading, sewing or working at the computer.
Presbyopia is a natural part of the ageing process of the eye. It is not a disease, and it cannot be prevented. Presbyopia is diagnosed with a routine eye examination. Eyeglasses with bifocal or progressive addition lenses are the most common correction for presbyopia.

Posterior Vitreous Detachment

PVD is a common degenerative change, which affects one or both eyes in many people after middle age. It may present earlier in shortsighted patients or those who have sustained traumas to the eyes.
Thickening of the jelly casts shadows on the retina and are seen as floating shapes. These black “floaters”in your vision move with the eye and then settle as the eye rests. These are often described by patients as a “cobweb” or “insects”.
You may also be aware of flashing lights, like little flickers in the outer periphery. Usually these do not highlight a problem, however, it is important to have the eye thoroughly checked, as occasionally a retinal tear or a retinal detachment may occur.

Post-Operative Instructions

Following Retinal Surgery on leaving the hospital you are advised to have a quiet evening at home and to avoid strenuous exercise.
For General Anaesthetic patients, as above and:

  • Do not drive a vehicle
  • Do not make any crucial financial decision
  • Do not eat heavy meals or drink alcohol for 24 hours after being discharged

Paediatric Strabismus

Facts

A squint is a condition where your eyes look in different directions. One eye turns inwards, outwards, upwards or downwards while the other eye looks forwards. The medical name for a squint is strabismus.

The misalignment of the eyes can be caused by different factors. It can be an early developmental problem where the brain struggles to identify that the two eyes should work as a pair. It can be caused by an abnormality with the eye muscles or an uncorrected vision problem, such as myopia (shortsighted), hypermetropia (longsighted) or Astigmatism.

When to see a doctor?

Squints in children are relatively common. They usually develop before a child is five years of age, but they can appear later.

Up to around three months of age, many babies occasionally squint as their vision develops. This is normal and nothing to worry about. If your child still has a squint after this age, you should visit your Doctor. It is very important that a squint is picked up and treated as early as possible to avoid vision problems developing. If a squint is identified when a child is young, there is a good chance that it will be successfully treated.

Can adults get a squint?

Occasionally, squints that have been corrected during childhood reappear in adulthood. New squints in adults, without any history of a squint in childhood, can be caused by problems with the ocular muscles and/or the eye movement system. You should visit your Doctor as soon as possible if you develop a new squint. They should refer you to an ophthalmologist who will carry out an examination to identify the cause.

Squints that affect adults may cause double vision because the brain has been trained to collect images from both eyes. Squints may also cause a cosmetic problem in adults; in such cases, the appearance of a squint can lead to low self-esteem

What is Amblyopia?

Amblyopia is also known as a ‘lazy eye’. Amblyopia is an early childhood condition where a child’s eyesight in one eye does not develop as it should. The problem is usually in just one eye, but can sometimes affect both of them. Amblyopia affects approximately 2% of children.

When a patient has amblyopia the brain focuses on one eye more than the other, virtually ignoring the ‘lazy eye’. If that eye is not stimulated properly the visual brain cells do not mature normally.

What causes a ‘lazy eye’?

Anything that interferes with clear vision in either eye during the critical period (birth to 6 years of age) can cause amblyopia. The most common causes of amblyopia are constant strabismus (constant turn of one eye), anisometropia (different vision/prescriptions in each eye), and/or obstruction of an eye due to cataract, trauma, lid droop, etc.

Why does my child need to wear a patch?

Occlusion (patching) is used to make a lazy eye work on its own and so improve the vision by encouraging the development of the nerve pathways from that eye to the brain. The patch is worn over the good eye and the amount of time the patch must be worn is decided by the Orthoptist/Ophthalmologist and relates to the extent of the visual problem. If patching is implemented early on, a good level of vision can be achieved. When patching is started in an older child, it is more difficult to achieve good vision.

What is an Orthoptist?

An Orthoptist specialises in diagnosing and treating visual problems involving eye movement and alignment.

The Orthoptist at Moorfields Dubai provides clinical support to all the specialist services at the hospital. She sees both adults and children who have strabismus (a squint), disorders of eye movements, or binocular vision.

What is an Optician?

An Optician will see adults and children for refraction; with this assessment, an optometrist can determine the optical power of the eye, the presence of any “refractive” error that requires spectacle correction, and the best vision that an eye can achieve with an appropriate correction. Younger children have drops to make the pupil (the dark center of the eye) larger and this makes the test more accurate.

What is an Ophthalmologist?

An Ophthalmologist is a specialist in medical and surgical eye problems. Since ophthalmologists perform operations on eyes, they are considered to be both surgical and medical specialists. They will check both the structure and health of the eye. They will make the final decision on the management and will do any surgical procedures required.

Keratoconus

Keratoconus is a progressive thinning of the cornea. The cornea is the clear front window of the eye, which, along with the intra-ocular lens, focuses light on to the retina. The cornea normally is a smooth, round dome-shaped structure; however in keratoconus it becomes very thin and irregular and it starts to protrude from the centre or below the centre like a cone. This causes blurry vision that is often not completely correctable with glasses.
The disease is multifactorial in origin but there is a strong genetic component which makes it more frequent in certain parts of the world or within certain families.

Hypermetropia

A refractive condition of the eye in which vision is better for distant objects than for near objects. It can be called far sightedness or hypermetropia. Symptoms of Hypermetropia can include; blurred vision, asthenopia (eye strain), accommodative dysfunction, binocular dysfunction, amblyopia and strabismus. It results from the eyeball being smaller than average, causing images to be focused behind the retina. Hypermetropia should be diagnosed by a qualified Optometrist, Ophthalmic Surgeon or Eye Specialist.
A full Optometric Examination should be performed to assess the degree and extent of the problem. Eyeglasses and contact lenses are the treatment of choice for most people with far sightedness but refractive surgery can also cure some cases of hyperopia.

Diabetic Retinopathy

Introduction

  • Diabetic retinopathy is a complication of diabetes and leads to high blood sugar, resulting in retinal disease, which can interfere with its ability to transmit images to the brain through the optic nerve.
  • Blood vessels in the retina play an important role in supplying it with oxygen and nutrients, which keep it healthy and working effectively.

Diabetic Retinopathy can result in damage to the blood vessels; these may then bleed, leak or become blocked leading to cell damage in the retina itself.
There are varying forms and levels of severity of diabetic retinopathy – for example, when the retina becomes very damaged, new blood vessels may grow on it and can burst, leading to bleeding and blurred vision. If the macula (the central area of the retina) is affected – this is called Diabetic Maculopathy – the disease has reached a much more advanced and serious stage.
High blood pressure combined with diabetes leads to an even more dangerous condition.

Types of Diabetic Retinopathy

Non Proliferative Diabetic Retinopathy
Generally, this type of diabetic retinopathy does not affect vision because at the initial stage there are just a few enlarged blood vessels, with very minimal bleeding and leaking in the retina.
An examination of the retina by an ophthalmologist will reveal some marks indicating the presence of the condition.
Proliferative Diabetic Retinopathy
This condition can lead to seriously impaired vision as blood vessels grow in the retina and the threat is bleeding from these vessels which can lead to retinal damage, and even to retinal detachment at the back of the eye. Laser treatment is essential to avoid serious long term damage.
Diabetic Maculopathy
Diabetic maculopathy occurs when blood vessels leak into the central area of the retina, which can lead to it swelling and affecting the quality of vision. Laser procedures, injections or surgery are the main treatment options.
Exudates are deposits in the retina from leaky vessels. Haemorrhages in the retina of varying sizes.
Microaneurysms.
Optic Nerve with abnormal new vessels that have bled. Scars from previous laser treatment.
Vitreous haemorrhage in front of the retina.
End stage proliferative Diabetic Retinopathy with fibrousbands.
Retinal Detachment.
Cross sectional scan showing thickening of the macula and exudates.
Exudates (yellow) and haemorrhages in the central retina

Can it be prevented?

Compliance with treatment for diabetes helps control blood sugar levels and blood pressure and so the serious complications of diabetes, including diabetic retinopathy.
Treatment compliance along with regular check ups to monitor blood pressure will help avoid the serious long term effects of diabetes; positive lifestyle choices from balanced diet to regular exercise and not smoking all have a beneficial effect.

What can I do?

Early diagnosis and treatment of diabetes and diabetic retinopathy will generally help prevent serious vision loss for most patients and regular visits to the doctor and ophthalmologist are an essential part of the monitoring process.

Ocularist

[:en]An Ocularist makes and fits artificial eyes. Our aim at Moorfields Eye Hospital Dubai is to create a hand-crafted eye with a very natural look indistinguishable from the real eye. Made from acrylic, these artificial eyes are very strong, easy to maintain and are comfortable to wear. The Ocularist also provides a polishing and repair service.
To visit Our Staff Section click here[:ar]يقوم أخصائي العيون الاصطناعية بصناعة وتركيب العيون الاصطناعية. نحن في مستشفى مورفيلدز دبي للعيون نحرص على توفير عيون مصنوعة يدوياً تتميز بمظهر طبيعي تماماً ولا يمكن تمييزها عن العين الحقيقية. تصنع العيون الاصطناعية من الأكريليك، وهي لهذا تتمتع بصلابة عالية كما تسهل العناية بها وهي مريحة عند الاستخدام. كما يوفر أخصائي العيون الاصطناعية خدمات صقل العيون الاصطناعية وإصلاحها.
لزيارة صفحة طاقم العمل، اضغط  هنا.[:]