Eye Muscle Surgery: What to Expect

Outpatient surgery

Eye muscle surgery is routinely performed on an outpatient basis. The surgery is performed on the 4th Floor of the Phillips Ambulatory Care Center, Suite 4M, 10 Union Square East. New York, NY 10003. (212) 844-8245. Fax (212) 844-8340.

One week before surgery

Stop taking aspirin, aspirin containing products, or ibuprofen (Motrin, Advil, etc.) one week before surgery. Tylenol (acetaminophen) may be taken as a replacement for aspirin, if needed. All patients, especially those with any chronic medical problems such as

diabetes mellitus, high blood pressure, heart disease, lung disease or kidney disease, must undergo a medical reevaluation by their doctor within one (1) week of the surgery. You will be responsible for making the appointments with your doctor for preoperative testing and preoperative physical examination. Please ask your doctor to provide any pertinent medical records including electrocardiogram (EKG) tracings, blood test results, and his or her evaluation of your current medical condition. You should bring these records with you when you come to our office for your preoperative evaluation. Please make sure that we have all this information at least three (3) days prior to your surgery. If parents or patients wish to, they can arrange with the surgical coordinator and the surgery staff to visit the surgery and recovery areas in advance.

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The week of surgery

We must see you 1-3 days before surgery for preoperative testing and consultation with us. Please bring all the medicines you are currently taking, to our office in the Phillips Ambulatory Care Center at Beth Israel Medical Center, third floor Suite 3B (between 14th and 15th Street). The surgical coordinator will tell you the time of the surgery at this visit. There are occasional changes to your exact time of surgery until 1 day in advance; however, you will be informed of any such changes. Our surgery day is usually Thursday, with the preoperative examination occurring on Monday. The preoperative tests performed will depend on your age and medical history. The following tests are routinely performed on all patients:

• Medical evaluation by physician.

• Complete blood count (CBC) and urinalysis

• Blood chemistries, EKG and/or a chest X-ray may be ordered, if indicated.

All pre-surgical requirements must be met at least three (3) days prior to the date of surgery. This includes history and physical, signed consent form, lab work and medical clearance where appropriate. Be sure to bring with you any medicines you are taking, along with the details of anything significant in your past medical history. Blood transfusions are almost never necessary for eye surgery.

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The day of surgery

DO NOT EAT ANYTHING AFTER MIDNIGHT!!!!

No food/solids should be taken by mouth (including milk and milk products) for eight (8) hours prior to surgery. For children, clear liquids, including apple juice, Gatorade, water and Pedialyte can be taken up until three (3) hours prior to surgery. It is important to stress that formula, milk and orange juice are NOT clear liquids. All essential medications may be taken with small sips of water.

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Illness

If you or your child becomes sick before the day of surgery, please let us know immediately so that we can use the time for someone else as well as reschedule your surgery. Surgery may need to be postponed because anesthesia can not be administered to anyone with an active cold, significant cough, chest congestion, fever or ear infection, or anyone taking antibiotics for these conditions. It is usually safe to proceed with anesthesia several weeks after the symptoms of a cold have subsided, and 1-2 weeks after institution of therapy for an ear infection.

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Preparation for surgery

The Ambulatory Surgery Unit personnel will prepare you for surgery, including giving you a hospital gown, taking your temperature and other "vital signs," and giving any preoperative medication that may have been ordered by the Anesthesia staff (usually minimal medication, if any). Your clothes and other belongings will be cared for at the Ambulatory Surgery Center via the use of a personal locker. Do not bring valuables with you! You are invited to bring any special toy, blanket, etc., which may make your child feel more comfortable in the hospital surroundings. Family members can wait in the Ambulatory Surgery Reception area. The time surgery actually begins may be earlier or later than your scheduled time. Most patients are in the surgery center for 6-8 hours and may not be ready to be discharged until 4-7 p.m.

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Anesthesia

Children, if apprehensive, may be accompanied by a parent (with gown, cap and mask provided) until the child is asleep. If you would like to do this, the Anesthesia staff is usually happy to have your help. If you are anxious, however, your child will perceive this, and the situation will be worse rather than better. Young children are put to sleep by breathing gas from a mask held under or near their faces, not clamped tightly. An intravenous (IV) line and endotracheal tube are placed after they are asleep and are removed before they are fully awake. Older children and adults are given an IV line beforehand so that intravenous medications can be used to put them to sleep prior to administering gas, or, for those adults having local anesthesia, so that sedative medications can be given. The anesthesiologist may need to alter the above anesthetic routine depending upon the age, specific needs and medical condition of the patient.

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Length of surgery

Most eye muscle operations take about one (1) hour of operating time once we get started, although this can vary from thirty (30) minutes to two (2) hours. Do not be concerned if we seem to be taking a long time; this usually means we simply started late. Once your child or family member leaves the preoperative suite, we may not get started for some time if the preceding operation went longer than expected. After young children are asleep, establishing an IV can be time-consuming. During the operation is often a good time for those waiting to take a walk or get something to eat.

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Recovery Area

The patient's relatives will be notified in the waiting area when surgery is finished, for reassurance that all is well. Patients undergoing general anesthesia will be kept in the Recovery area within the operating suite for several hours until they are completely awake and it is safe for them to be discharged from the Recovery area. Patients undergoing local anesthesia are kept in the Recovery Room for a short observation period. An adult family member can generally stay with patients shortly after they arrive in the recovery area.

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Eye patches

We generally do not use eye patches after eye muscle surgery unless we have used an adjustable suture (on older children and adults). Children and most adults, however, may not want to open their eyes at first, other than intermittently, because of mild discomfort. Bloody tears may drain from the operated eye or eyes, and these can simply be wiped away with a tissue or washcloth. Patients undergoing eye muscle suture adjustment will have a patch placed temporally during the surgery. Several hours later in the recovery area the patch is removed and the suture is adjusted after which the patient goes home. Patients usually leave without eye patches.

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Adjustable sutures

The doctor decides at the preoperative examination whether adjustable sutures are appropriate. Adjustable sutures allow the surgeon to fine-tune the alignment of the eyes after the actual surgery. The suture adjustment takes place between 3 and 5 hours following the surgery. While in the recovery area, the patch is removed. The doctor then makes some fine adjustments of the eyes to the desired position. The suture material is then trimmed and securely fastened. The patient may leave once released by the recovery area nurse.

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Postoperative pain and nausea

There is usually little, if any, pain from the surgery. Most patients require no pain medication. Tylenol tablets or syrup may be used for mild pain. The anesthesia may produce temporary nausea. The majority of patients will sleep for several hours following surgery.

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Postoperative examination

You will be evaluated for discharge in the mid to late afternoon. Children are discharged at that time. General anesthesia usually wears off in time for discharge by four (4) to five (5) hours after the surgery. If an adjustable suture has been used (with older children and adults), we have to wait four (4) to five (5) hours after the surgery for the anesthesia to wear off before we can perform the adjustment prior to discharge. The patch will be removed at that time and left off. Drops will be put in the eye to numb the surface, and the suture will be adjusted as necessary to fine-tune the eye alignment. Sometimes, the eyes are left in slightly overcorrected position on purpose. As the eyes heal during the one (1) or two (2) weeks following surgery, they may drift slightly back in the direction they were before the surgery. This desired overcorrection may produce temporary double vision. Due to the required waiting time after surgery before adjustment can be done, the last patient operated on may not be able to leave until 6:00 or 7:00 p.m. Be sure to have a responsible adult escort available to drive or accompany you home!

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Care at home

Pain medication is rarely necessary after discharge, but some patients find that Tylenol is helpful. The only medicine we use routinely is Maxitrol Ointment, a combination antibiotic/steroid to help the eyes heal faster and prevent infection. Even this is not absolutely necessary however, and if a young child will not tolerate application of the ointment, the eyes will heal perfectly well without it. The tube of ointment is usually given to you before discharge. Be sure to get it or a prescription for it before you leave. Put one-half inch of the ointment inside the lower lid (or directly on the eyes of squeamish children) each night for a week, beginning the day after surgery. It blurs the vision so use it before bedtime instead of during the day. Some patients may feel the sutures, which cause a slight itching, irritation or a temporary gritty feeling. The sutures we use dissolve on their own and do not have to be removed. The only restriction is staying out of swimming pools for five (5) days. Otherwise, resuming normal activity is perfectly all right as soon as the patient feels up to it. Hair washing, bathing and showering will not interfere with the surgery. Try to avoid rubbing the eyes for 12 weeks following surgery. Physical overexertion should also be avoided for 2 weeks. Avoid smoke filled environments for at least a week. Sunglasses can be worn at anytime, as the eyes may be a little sensitive to bright sunlight. The wearing of makeup and contact lenses can be resumed a few days after the surgery.

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Recovery

Young children recover quickly, usually behaving normally by the next morning. Older children may feel uncomfortable for a few days, and adults may take four (4) to seven (7) days to feel comfortable. The more extensive the surgery, the longer the recovery period. The eyes will stay red for several weeks, and all of the pinkness may not disappear for several months. We usually use the type of incision (inside the upper or lower lid) that rarely leaves a visible scar.

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Return appointments

Unless there is reason to see you sooner, we will give you a return appointment the week after surgery and a second follow-up appointment six (6) weeks later. You should make the first postoperative appointment when you book your surgery. Please do not hesitate to call in the meantime (212) 844-8080 if there are any questions. There is always an Ophthalmologist on call for Beth Israel Medical Center who can be reached by calling the page operator (212) 420-4262 or you may come to the Beth Israel Emergency Room.

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Bills

There are generally three (3) bills that you or your insurance company will receive: one (1) covering the surgeons fees, one (1) from the anesthesiologist, and one (1) from the hospital covering all facility, equipment and service charges. Please ask us if you have any questions about the bills or the billing procedures. Some insurance companies require a second surgical opinion, pre-admission authorization, or both. Our staff will assist you in obtaining these. If you do not meet these requirements, the insurance company may refuse to pay or may pay a reduced amount. In that case, you will be responsible for payment of all bills not covered by your insurance. It is our intention to make your surgical experience as pleasant and comfortable as we can. If there is anything special you need, or any question at all, please do not hesitate to ask us!

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Copyright © H. Jay Wisnicki, M.D.