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Surgical correction for childhood squint

Published by Bupa's health information team, July 2009.

A squint is a condition that causes one eye to look in a different direction to the other when focusing on an object. It is also called strabismus. Surgical correction for a squint is used to straighten your child's eye so that both eyes point in the same direction.

Squint is usually diagnosed in a baby or when your child is very young. Your child may be born with a squint or may develop one. It is also possible to develop a squint in adulthood. Squints affect approximately one in 20 children.

Your care will be adapted to meet your individual needs and may differ from what is described here. So it's important that you follow your surgeon's advice.

• About surgical correction for squint
• What are the alternatives?
• Preparing for your procedure
• About the procedure
• What to expect afterwards
• Recovering from surgical correction for squint
• What are the risks?
• Questions and answers
• Related topics
• Sources

About surgical correction for squint

The operation is carried out by an ophthalmologist, a doctor who identifies and treats conditions affecting the eyes. He or she will use a combination of surgical techniques to weaken and strengthen the muscles that control eye movement. This will straighten the eye with the squint so that both eyes point in the same direction.

The age at which your child has the operation will vary depending on how much the squint is affecting his or her vision. During childhood, the development of vision can be greatly affected by any problems or conditions affecting the eyes.

With a squint, the main aim of surgery is to improve your child's vision by bringing the eyes into alignment. This will allow them to have binocular single vision (BSV). Depending on your child's sight, it may be possible that they have some depth perception (stereopsis) following surgery.

It's important that any lazy eye (amblyopia) or refractive error (such as long- or short-sightedness) is treated before surgery is undertaken.

Squints can have a cosmetic effect on your child that they may be particularly sensitive about.

Surgery is normally carried out between the age of six months and two years if your child is born with a squint. If your child develops a squint when they are older and depending on the cause, surgery will be performed as early as possible after diagnosis. However, the decision to operate should be made after discussions with your child's ophthalmologist and when you, as parent or guardian, are happy for it to go ahead.

If you child has a squint as a result of a neurological disorder, such as cerebral palsy, it's best to wait until they are over the age of two. This is because these types of squints can change in angle and direction in infancy.

What are the alternatives?

An orthoptist can teach your child exercises to treat his or her squint and any associated amblyopia (lazy eye). An orthoptist is a health professional who specialises in eye movement problems such as squints, lazy eyes and double vision.

In some cases, prescription of glasses may encourage realignment of the eyes. Glasses will also help if your child's vision is poor and may improve vision in any associated lazy eye. Glasses can also be made up with a prism to compensate for any double vision in adults.

Botulinum toxin can be injected in very small amounts into the eye muscles to paralyse them. This can be used to weaken a muscle which is pulling the eye in the wrong direction. The treatment is temporary (lasting only a few months before re-treatment becomes necessary) and is normally only used on adults.

Preparing for your procedure

Your surgeon will explain how to prepare your child for his or her operation.

Surgical correction for a squint is usually carried out as a day-case. This means that your child will be able to go home the same day.

The operation is carried out under general anaesthesia. This means your child will be asleep during the procedure. Typically, your child must not eat or drink for about six hours before a general anaesthetic. Often the operation is planned for the morning, so that your child will only have to miss breakfast.

Before his or her operation, a nurse will ask you questions about your child's general health. The nurse will also check that your child has not had anything to eat or drink and measure his or her heart rate and blood pressure. You must tell the nurse if your child has had any allergic or unusual reactions to medicines in the past, or has any history of bleeding problems in the family.

The ophthalmologist will visit your child before the operation. This is a good time to ask any questions.

If you and your child are happy for the operation to proceed, a consent form must be signed. This confirms that you understand the risks, benefits and alternatives to treatment and have given your permission for it to go ahead.

If you have parental responsibility for the child, you will be asked to sign the consent form. This confirms that you understand the risks, benefits and alternatives to treatment and have given your permission for it to go ahead. People with parental responsibility are usually, but not always, the child's birth parents. If your child is old enough, he or she may wish to sign this form too.

About the procedure

The surgery performed will vary, depending on the type of squint your child has and the ophthalmologist's chosen technique.

The muscles around the eye are accessed through small cuts in the thin outer semi-transparent coat of the eye (the conjunctiva). The small cuts are made just a few millimetres back from the cornea (the clear window at the front of the eye).

The most commonly used techniques are muscle recession, when the muscle is detached from the eye and moved further back so that it becomes weakened, and muscle resection, when a section of the muscle is removed to tighten and strengthen it. Your surgeon may choose to operate on muscles in both eyes depending on the nature of the squint.

During the operation muscle adjustments are measured carefully to ensure that the squint is corrected to exactly the right amount. However, everybody reacts differently to surgery so the results of the operation can't be guaranteed and further surgery is sometimes required. It's important to discuss this with your child's ophthalmologist before the operation takes place.

The operation will take approximately one hour.

What to expect afterwards

Usually dissolvable stitches are used during the operation. Dissolvable stitches don't need to be removed. The length of time they take to dissolve depends on the type of stitch used but they will usually disappear within a month or two.

Your child will be monitored for a short while after the operation. He or she may be groggy, and feel or be sick. Your child will need to rest on a bed or on your lap until the effects of the general anaesthetic have passed.

A clear shield may be placed over the eye after surgery but no dressings will be needed. Normally, your child will return home without anything covering his or her eye/s.

A nurse will give you advice about caring for your child's eyes before you go home. Typically you will be advised not to take your child swimming for three weeks or so. You will usually be given eye drops for your child and a date for a follow-up appointment with your ophthalmologist and orthoptist.

Recovering from surgical correction for squint

Your child may feel some discomfort for a few days after the operation. If needed, you can give him or her over-the-counter painkillers such as paracetamol or ibuprofen syrup (for example, Calpol or Calprofen). Follow the instructions in the patient information leaflet that comes with the medicine and ask your pharmacist for advice. Do not give aspirin to children under 16.

Children tend to recover very quickly following surgery and any redness or watering isn't usually associated with pain or discomfort for more than a day or two.

Contact your GP or the hospital if your child complains of severe pain or shows signs that pain is getting worse. For example, babies and toddlers cry more when they are in pain and are difficult to settle.

The appearance of the eye/s may be quite bloodshot at first. This is caused by small amounts of blood under the translucent outer coat of the eye, However, this usually goes away within a couple of months.

Infection is rare following squint surgery. However, if you notice a sticky discharge coming from your child's eye, contact your doctor.

What are the risks?

Surgical correction for squint is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.

Side-effects

These are the unwanted but mostly temporary effects of a successful procedure, for example, feeling sick as a result of the general anaesthetic.

Common initial side-effects to surgical correction for squint include discomfort, watering and redness of the eye. Most of these symptoms usually resolve within a week or two.

Any over-correction or under-correction of the squint will become obvious in the months following surgery and further surgery may be needed.

Occasionally, parents notice that a child's eye does not look as 'white' as it did prior to surgery. This is a part of the healing process and is usually unavoidable and untreatable, but it may become less apparent over time. Eye drops prescribed for use after surgery will help control the healing response.

Complications

This is when problems occur during or after the operation. Most children are not affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, infection, excessive bleeding.

Complications specific to surgical correction of squint include:

• the squint may return
• slipped or lost muscle - when a muscle drops back behind the eyeball either during surgery or afterwards if not securely attached to the eye (this may require further surgery to correct)
• penetrating injury to the eye - this happens in less than one in a hundred operations and occurs when the muscle is re-attached to the thin outer coat of the eye (the sclera) - it can lead to serious infection in the eye or the retina to become detached (although this is rare)
• suture granuloma - scar tissue forms because of an overactive healing response to the stitches used to re-attach the muscle to the eye
• double vision (usually a problem in adults rather than children since children's brains can 're-learn' to interpret the images delivered from each eye after surgery)
• rarely poor blood circulation to the front part of the eye can result from operating on three or more muscles

The exact risks are specific to you and differ for every person, so we have not included statistics here. Ask your surgeon to explain how these risks apply to you.

Related topics

• Deep vein thrombosis (DVT)
• General anaesthesia
• Non-steroidal anti-inflammatory medicines (NSAIDs)
• Paracetamol
• Squint

Sources

• Simon C, Everitt H, Kendrick T. Oxford Handbook of General Practice. 2nd ed. Oxford: Oxford University Press, 2007:950-51
• Denniston AKO, Murray PI. Oxford handbook of opthalmology. Oxford: Oxford University Press, 2008:126-31
• Guidelines for the management of strabismns and amblyopia in childhood. The Royal College of Ophthalmologists. www.rcophth.ac.uk, accessed 24 February 2009
• Khaw PT, Elkington AR. ABC of eyes. London: BMJ Publishing Group, 2002:45-48
• Personal communication. Dr Scott Robbie, UCL Institute of Ophthalmology Division of Molecular Therapy, 30 March 2009
• Scleritis. eMedicine. www.emedicine.com, accessed 24 February 2009

This information was published by Bupa's health information team and is based on reputable sources of medical evidence. It has been peer reviewed by Bupa doctors. The content is intended for general information only and does not replace the need for personal advice from a qualified health professional.

Publication date: July 2009