A. When is it appropriate to operate on a child with exotropia?
This is a question that parents and friends are often confused about. This question can be considered from 4 aspects.
1. Does the child’s eye often appear to be deviated? This is not only when the child is indoors and looking at the near, but also when he/she is looking at the far side of the eye. Intermittent exotropia tends to be more likely to be deviated when looking at a distance, but can be controlled when looking at a close distance, making it less likely for parents to find that their child has strabismus. When a child squints one eye outdoors, it is also a sign that the eye is deviated. A frequent exotropia is an indication for surgery.
2. Impaired visual function in both eyes or deterioration is an indication for surgery to correct exotropia. Children with exotropia should come to the hospital to check binocular visual function, including near stereopsis, such as: various random dots, red-blue, red-green stereopsis sharpness test chart, Titmus, etc.; and distant stereopsis, such as the same as the three-level functional examination of the visual machine; our department also has Nikon comprehensive examination instrument can also be carried out for distant stereopsis examination. In addition, we perform fusion range and simultaneous visual function check of both eyes. If the above examinations reveal that there is no longer far or near stereopsis, it is advisable to correct strabismus with surgery as soon as possible. If the fusion range is smaller compared to the previous examination, it is a sign that the visual function of both eyes has deteriorated, and combined with the frequent aggravation of strabismus, it is also suggested that surgery should be performed as soon as possible.
3. If there is myopia or myopic astigmatism, wearing glasses to correct it is good for controlling the eye position. Strabismus degree determination and binocular visual function examination should be performed under the premise of wearing suitable glasses. If you have moderate to high hyperopia, you should also wear corrective glasses before examination. Hyperopic lenses are good for relaxing the adjustment will increase the degree of exotropia. Assessment of the timing of surgery is best done with glasses. In addition, if there is a large difference in visual acuity between the two eyes, it will affect eye position control and also make the results of binocular visual function examination worse. It is advisable to improve visual acuity first, including wearing corrective glasses as well as treating amblyopia to improve visual acuity, before evaluating and considering surgery. Of course, if the difference in vision between the two eyes is not great, or if the possibility of improving vision is slim because the treatment of amblyopia in one eye has been abandoned for many years, then the actual situation should be considered and deliberated in order to choose the most beneficial and practical plan for the patient.
4. The age of surgery. Parents often ask how old is the right age for surgery? In this regard, the scale may vary from hospital to hospital or from doctor to doctor. The principle we have is that surgery can be done early for congenital permanent exotropia, and surgery can be considered when the degree of strabismus can be accurately checked and it is determined that amblyopia treatment is not needed; for intermittent exotropia, surgery should be done after the age of 4, but regular follow-up should be done to observe the changes.
When is surgery appropriate for adults with strabismus?
We found in the clinic that not only the timing of surgery for children often confuses parents, in fact, adult strabismus patients often have more confusion! One of the confusion: I am so old, can I still have strabismus correction surgery? Confusion 2: Can I still correct my strabismus after so many years? I can’t see with both eyes together, can I see with both eyes again after surgery? If they still can’t see together, will the strabismus go back soon? Confusion 3: Does it hurt to have surgery on my eyes? If I can still control my eyes from squinting outward, I don’t care about the appearance until I’m older, it’s better than surgery, right?
In fact, exotropia is not only a serious damage to the visual function of both eyes, but also has a great impact on the appearance. This effect can be significantly improved through surgery. The surgery is not very traumatic, recovery is quick, and a short period of general anesthesia can make the surgery completely painless. Since most surgeries can be completed in half an hour, and most large-angle complex strabismus can be completed in less than an hour, the amount of anesthesia is small. Patients who wish to operate under local anesthesia can also make the operation as comfortable and painless as possible by using intraoperative analgesics.
1. Patients who are in good health, have no contraindications to anesthesia, have medical clearance for surgery, and have a need for surgical improvement of strabismus can have surgery. No matter how long the strabismus has been present, surgery can be considered to correct it.
2, constant exotropia for a long time both eyes “do not see together”, and in adults, the degree of strabismus has often become very large, the possibility of restoring the visual function of both eyes after surgery is really small, but generally there are very few cases of eyes “slanted back” again. In most cases, the eye is restored to an upright position and the appearance is greatly improved, with no more significant strabismus affecting the appearance.
In a few cases, small angles of exotropia appear again, but most of them do not affect the appearance and do not need to be operated again.
3. In adults with intermittent exotropia, the degree of strabismus is often large. Although you can consciously control the orthotropia, it is easy to cause visual fatigue and even pseudomyopia, causing discomfort and even trouble in life and work. If you often need to control your eyes from strabismus and the resulting visual fatigue and distress, surgery to correct ectropia is actually more likely to benefit you and make you feel more relaxed.
Third, will there be any risks associated with the surgery?
The answer is yes, there are risks. There is no 100 percent success rate. Risks are often not due to unsuccessful surgical design or surgical steps, but rather to the complexity and differences in the human body that make the surgery not work as well as expected. There are certainly cases where the surgical design steps do not fit perfectly with the individual’s pre-existing pathology and functional changes, making it difficult to achieve the desired results.
The human body is a very complex organism, and there are very complex and subtle differences between individuals. These differences and complexities are not fully understood by the current level of medicine, and cannot be perfectly and completely repaired in each case. Human beings do not have a thorough understanding of all aspects of their organism to the extent that they know the composition of all tissues and all functions of each tissue cell, and some aspects are still very limited. For example, we know that some areas and cells of the brain control eye movements, but it is not clear in how many ways they are controlled and how many areas, tissues and cells, and neural mediators are involved in influencing one or more of these functions; although strabismus is found to occur in some people and not in most, it is not clear which tissues, cells, or mechanisms are involved in these strabismic patients. It is not clear which tissue cells or mechanisms are responsible for the problem.
So, does this mean that one should not go to surgery to correct strabismus? The truth is that early medical and vision scientists began exploring the treatment of strabismus hundreds of years ago, and strabismus correction surgery has been explored and refined for centuries. The development of a series of proven surgical approaches to address various strabismus over centuries of medical practice has confirmed that these surgical approaches now maximize the appearance and function of strabismus, restoring visual health to most patients, which in turn greatly contributes to their psychological well-being and normal school and work. These procedures are currently used by ophthalmologists (strabismologists) worldwide, confirming their effectiveness and safety. Only a very small number of people deviate from the expected results of the surgery, and most people get the expected results.
So, can the few patients who deviate from the expected outcome be improved by reoperation? The answer is yes. Although some patients may not have the desired result due to their own poor function or structure, they can still get a better result through reoperation. After trying and working hard, the number of patients who still end up with unsatisfactory results is, after all, a minority.
What should patients and parents pay attention to before deciding to have surgery?
1. After a clear diagnosis and a detailed and precise evaluation of the visual function of both eyes and strabismus measurement, communicate with the doctor to understand whether surgery is necessary and when to choose.
2.Strabismus correction surgery is an elective surgery, not an emergency surgery, and can be done after adequate mental and physical preparation.
3.Fully understand the benefits of surgery and rational expectations; fully understand the risks of surgery and treat them rationally.
4.Rational analysis of the damage and illness brought by the surgery, do not scare your child or yourself, and at the same time be prepared to undertake these inevitable processes.
V. Preparation before surgery
1.After the decision of surgery, blood tests and other necessary examinations should be performed, such as blood and urine routine, coagulation function, necessary biochemical indicators and anti-infection screening; electrocardiogram, chest X-ray or chest X-ray. Those with systemic diseases should also go to the internal medicine department for other investigations except for contraindications to surgery and general anesthesia. Before the blood draw, we recommend that the child drink plain water, so that the child is not thirsty and the blood volume is larger to facilitate the blood draw and not hinder the laboratory tests. However, no drinks containing other substances and no solid foods are allowed. Do not eat too greasy food the day before.
2, a few days before the operation, it is advisable to eat more clear food, and drink more plain water to prevent coughing and colds. Coughing and coughing can’t delay the surgery; coughing in adults also hinders the surgery, so you need to do strabismus surgery after the systemic disease is healed.
Before hospitalization, parents are advised to talk positively with their children about the surgery, taking into account the child’s personality and parenting characteristics, and let him know that the surgery will involve an infusion of fluids and “a small needle”, which will be a little painful, but bearable and necessary, and that other things are not very painful, and then sleep for a little while to dream that the surgery is complete. When you wake up, your eyes are blindfolded, which means that the surgery is done and you can come out of the operating room to see your mother. Mom and dad were waiting for him at the door of the operating room, believing that he was a very brave and smart child who could understand that this was a good thing for him and could do it without crying. We can understand that parents feel sorry for their young children, but we may also see this hospitalization as an opportunity for children to grow and improve their ability to bear.
4.Generally point 3 days of antibiotic eye drops, such as Tobias eye drops, 3-4 times a day before surgery to create a better eye environment for surgery.
5.On the day of surgery, you should fast and abstain from food and water 8 hours in advance, that is, nothing can be imported to ensure the safety of anesthesia. You can eat 4 hours after the surgery. Patients with local anesthesia should also fast and abstain from eating and water before surgery, but they can eat some time earlier after surgery.
Sixth, postoperative precautions
1. Surgery is after all an injury, although the wound is very small, smaller than the so-called minimally invasive surgical incision, and the surgical design of the site is rarely damaged, but there should still be mild redness and swelling after surgery, which is relatively obvious on the 2nd, 3rd and 4th days after surgery, and the swelling generally starts to decrease significantly on the 5th day after surgery. There may be bleeding during surgery, and 1 or 2 drops of blood may cause a small amount of blood to accumulate in the white of the eye (under the bulbar conjunctiva), which will be absorbed in about 2 weeks. Parents should understand these inevitable physiological processes and wait patiently and reassuringly for the surgery trauma to recover slowly.
2, after the surgery need to point with antibiotic eye drops, some need to add anti-inflammatory eye drops or hormone eye drops, the doctor explained clearly to follow the doctor’s instructions on time point eye. Generally 2 or 3 weeks of post-operative medication.
3, children with exotropia may have the appearance of internal strabismus or small-angle internal strabismus in the short term after surgery, which is normal and will be explained by the doctor beforehand. Studies have concluded that a small angle of internal strabismus in the short term after surgery can help prevent the recurrence of exotropia. Parents need to relax and wait for several weeks or even months, and the strabismus usually returns to its normal position slowly. Do not observe every day to create a tense atmosphere for the child, the psychological implication of mental tension is not conducive to the child’s recovery.
4, to follow medical advice review, some children need to increase some functional training after surgery to help children restore binocular vision function, some need to replace glasses in time to correct refractive error, improve the clarity of vision. These need to choose the timing in the review.