Squint surgery, what happens on the day
The date is booked and there are three weeks to worry in. Here is what actually happens to your child's eye that morning, what the days afterwards look like, and the one thing this operation is not for.
- The eyeball is not removed from the socket and there is no cut in the skin. The surgeon works through the thin clear layer over the white of the eye.
- It is done under general anaesthetic, usually takes under an hour, and most children go home the same day.
- The white of the eye stays red for several weeks and sometimes months, which is expected rather than a complication.
- School is usually about a week away, sand and face paint wait two weeks, swimming four weeks and contact sport six.
- The operation corrects where the eye points, not how well it sees. Glasses and lazy eye treatment carry on separately.
The consent form has been signed, the date is in the calendar, and now there are three weeks to think about it. That is usually when the questions start arriving, and the one that arrives first is almost never about the operation. It is about what will be done to her while she is asleep and nobody is watching.
So let me start there, because the answer settles most of the fear in a single sentence.
Do they take the eye out to do the operation?
No. The eyeball is not removed from the socket during squint surgery, and no cut is made in the skin anywhere. I say this at least once a week and I have watched more than one parent put a hand flat on the desk with relief. It is the most persistent picture parents carry, and it is simply not what happens.
What the operation does is loosen or tighten the small muscles that sit on the outside of the eyeball and steer it. Those muscles attach to the white of the eye, and they are reached from the front. The eye stays exactly where it lives. If you have read how the two eyes learn to work as a pair, this is that system being rebalanced by a few millimetres.
What happens on the day itself?
Your child is asleep under a general anaesthetic, the operation usually takes less than an hour, and most children go home the same day rather than staying overnight. In the British health service a parent can go into the operating room with their child and stay until the anaesthetic has been given. Practice here varies from hospital to hospital, so ask yours at the pre-operative visit, and ask early enough to arrange work leave around the answer.
For a child, general anaesthetic is nearly always the choice. There is a version of this surgery where the stitches are adjusted afterwards while the patient is awake, and it is offered only to people who can cooperate fully with that adjustment, which rules out the age group most of my squint patients belong to.
Afterwards a pad may be placed over the treated eye. It usually comes off the next day, and sometimes before you leave the hospital. Antibiotic or antibiotic and steroid drops or ointment go in at the end of the operation, and you may be sent home with drops to continue for a few days. If your child fights eye drops, and most do, the technique for getting drops into a small human is worth practising before the day rather than in the car park after it.
What does the surgeon actually do to the muscle?
Two things, depending on which way the eye is pulling. A muscle can be weakened by detaching it and reattaching it further back on the eyeball, so it is no longer taut, rather like an elastic band that has been let go. Or it can be strengthened by shortening it and putting it back at its original attachment, like cutting a band and then stretching it to the same length again.
The eyelids are held open with a small instrument called a lid speculum, so nothing needs to be held by hand. The surgeon opens the thin clear membrane that covers the white of the eye, works on the muscle underneath, and closes up. Sometimes both eyes are operated on to get the alignment right, even when only one eye looks turned, and that is planned in advance rather than decided on the day.
The stitches dissolve on their own. They sit behind the eye, so there is nothing for you to see afterwards and nothing to come back and have removed.
How red and sore will the eye be afterwards?
Red, and for longer than you expect. It is normal for the white of the eye to be red after this operation, and it can take several weeks and occasionally months for that redness to clear completely. Nobody warns families enough about this, and the photograph on day three is a shock if you were not told.
The soreness is a different timescale from the redness. The eye is scratchy and sore with movement, often described as feeling like grit or sand, and that part usually improves after a few days. Simple painkillers such as paracetamol help, and your surgeon will tell you which one and how much for your child's weight. Children under sixteen should not be given aspirin.
Two more things that alarm parents and are expected. Tears can be blood tinged, and the eye can water, for a couple of weeks. And the stitches itch until they dissolve, which can also take weeks, so this is the fortnight to be firm about not rubbing. Double vision is common too, and usually passes after a week or so, though it can last longer.
When can he go back to school, and when can he swim?
School is usually about a week away. In the British guidance, most people return to exercise and sport at around a week as well, sand and face paint wait two weeks, swimming waits four weeks, and contact sports wait six. Those are the ranges I use as a guide, and your own surgeon sets your child's dates, because they know what was done to which muscle.
Full recovery takes several weeks, which is longer than the week off school suggests. A child can be back in class and still be halfway through healing, so expect some tiredness and some complaining about bright light in that period.
The two rules worth guarding are the swimming one and the no rubbing one. Pool water and a healing surface do not belong together, and a school holiday with a pool in it is the usual reason families ask me to shorten that four weeks. I do not shorten it.
Will she still need her glasses, and will her sight improve?
If your child wore glasses before the operation, she will most likely still need them afterwards. The glasses correct the focus of the eye. The surgery corrects where the eye points. They are two separate jobs and fixing one does not remove the need for the other.
This is the part I make sure parents hear properly. Squint surgery is about alignment. It is not a treatment for sight. If a lazy eye came along with the squint, that is treated on its own track, usually with glasses and patching, and sometimes it is treated before the operation rather than after. Surgery can improve the alignment of the eyes even where a squint has been left for years, but sight that was not developed in early childhood may not come back later. That is the real reason we are impatient about the years before school, and it has nothing to do with how the eye looks.
Will one operation be enough?
Often, and not always. Needing further surgery to correct the squint fully is quite common, particularly where the squint was severe. I would rather you hear that from me now than feel that a second operation means the first one failed, because it does not.
The honest list of risks is short and you are entitled to all of it. Permanent double vision, which may need special glasses. Infection, or a collection of pus or fluid around the eye. A muscle slipping out of position. A small hole being made in the eye while the muscle is stitched. Loss of vision, which is very rare. Ask the surgeon to talk you through each of these rather than reading them for the first time on a form.
Afterwards, come back if the squint is visible again or getting worse, if there are new symptoms such as double vision, eye strain or headaches during close work, or if your child is being teased about their eyes. That last reason is a real reason. A squint that appears or changes suddenly at any point is a different matter and needs looking at quickly rather than at the next routine appointment.
- The pain is getting worse after the first few days instead of settling.
- The lid becomes more swollen and red, or there is thick discharge, or your child has a fever.
- Your child's sight changes or drops in the operated eye.
- The double vision is worsening rather than easing over the first week or two.
- The eye looks suddenly more turned than it did the day after surgery.
Common questions
Do they take the eye out to do the operation?
How long does squint surgery take, and does she stay overnight?
Can I stay with him until he is asleep?
How red will the eye be afterwards, and for how long?
When can he go back to school, and when can he swim?
Will she still need her glasses after the operation?
Will one operation be enough?
- NHS · Squint, surgery · www.nhs.uk
- AAPOS · Strabismus surgery · aapos.org
- NHS · Squint · www.nhs.uk
- Moorfields Eye Hospital · Strabismus (squint), children's eye conditions management · www.moorfields.nhs.uk
- AAPOS · Amblyopia (lazy eye) · aapos.org