Outpatient Surgery
Two Weeks Before Surgery
One Week Before Surgery
If You become ill before Surgery
The Day Of Surgery
Surgery
Anesthesia
Pain Management
Care at Home
Bills
STRABISMUS SURGERY
Outpatient Surgery
Eye muscle surgery is routinely performed on an outpatient basis. The surgery is performed in surgery centers and hospitals from Westlake to Santa Barbara. Check-in is one and a half hours prior to the scheduled surgery time. Surgery may last from 15 to 90 minutes, and recovery may last 1 to 2 hours. Patients will go home the same day. Adults undergoing an anesthesia are forbidden to drive afterwards until the next day. The entire time at the surgery center may be five (5) hours.
Two Weeks Before surgery
Stop taking aspirin, aspirin containing products (Excedrin, etc.), ibuprofen (Motrin, Advil, etc.), and warfarin (Coumadin) two weeks before surgery. Tylenol (acetaminophen), Celebrex or Vioxx (prescription drugs similar to aspirin) may be taken as a replacement for aspirin, if needed.
One Week Before Surgery
THE PREOPERATIVE EYE EXAMINATION: You will be mailed a list of all your appointments necessary for your surgery. You must attend every appointment listed in order to proceed with surgery. We will see you within one (1) week before surgery for preoperative examination and consultation. These appointment times are subject to change on short notice. The surgical coordinator will confirm your surgery schedule at this visit.
You will also be given a written set of instructions regarding what to do and what not to do before and after your procedure. The surgical coordinator will review these in detail with you and answer your questions. Any other questions will be answered by Dr. Davidson after the final eye alignment and eye movement measurements have been determined.
THE PREOPERATIVE PHYSICAL:
A medical evaluation (History & Physical exam, "H&P") by your Primary Care Provider (PCP) performed within thirty (30) days of your procedure is required by all outpatient surgery facilities. Any additional preoperative tests such as complete blood count (CBC), urinalysis, EKG and/or a chest X-ray may be required depending upon your age and medical history. In general, we order no pre-operative lab work as many large studies (including those at the Mayo Clinic) have shown blood and X-ray studies to be irrelevant. However, each institution has its requirements with which we are forced to comply. Therefore, be sure to ask your PCP about this.
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. We make every effort to obtain all the necessary paperwork and send it to the surgery center ahead of your surgery date. Ultimately, however, it is your responsibility. If the H&P is not on your chart the morning of surgery, your case will be cancelled.
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PREREGISTRATION: Preregistering at the center can insure a smooth admission and minimize any last minute surprises with insurance, health information or pre-operative requirements. We strongly encourage patients to register within one week prior to the scheduled surgery.
Illness
If you (or your child) become sick soon before the day of surgery, please let us know immediately so that we can reschedule your surgery as well as use the surgery time for someone else. Surgery may need to be postponed because anesthesia cannot be safely administered to anyone with an active cold, productive cough, chest congestion or moderate fever. It is usually safe to proceed with anesthesia several weeks after the symptoms of a cold have subsided.
THE DAY OF SURGERY
For adults, 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. The precise times and medication recommendations will be directed by the anesthesiologist who usually calls patients at home the night before surgery.
Prepoperative Area
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 depending on the day’s progress.
Anesthesia
The anesthesiologist will be assigned to your case the evening before your surgery date. If you have a favorite anesthesiologist, you must make these arrangements in advance. In some but not all centers, children, if apprehensive, may be accompanied by one parent (with gown, cap and mask provided) until the child is asleep. If you would like to do this, let the anesthesiologist know in advance. Some anesthesiologists forbid this practice and others encourage it. It will therefore, depend upon whom you have for your anesthesiologist. Young children are administered a breathing gas from a mask held under or near their faces. 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 calm them prior to administering the inhaled anesthetic. 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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The Strabismus Surgery Procedure
The procedure involves moving the eye muscles from their origin to a different location on the surface of the eyeball. It is not necessary to make an incision in the skin, remove the eye, nor enter the inside of the eyeball to perform the procedure. Blood transfusions are not necessary for eye surgery. An eyelid speculum gently separates the lids to prevent them from closing during the procedure. The eye is carefully rotated as if looking to the side. The skin of the eye (conjunctiva) is lifted and the muscle just below is secured with a special holder, followed by removing the muscle from the eye surface and reattaching it to the outside wall of the eyeball in a new location using suture which will dissolve in 6-8 weeks. The conjunctiva is replaced in its original position with dissolving sutures smaller than an eyelash. Short-acting anesthetics are placed on the muscles during the procedure. Long-acting anesthetics are injected around the eye muscles at the end of the case using a specially designed soft plastic cannula. Long-acting strong non-narcotic pain reliever (Toradol) is given intravenously ("IV") at the end of surgery as well.
Length of Surgery
Most eye muscle operations take about thirty (30) minutes of operating time once we get started, although this can vary from fifteen (15) to ninety (90) minutes. 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.
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 30 minutes to 2 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.
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 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 temporarily after the surgery is completed. If the adjustment is scheduled for one (1) hour later in the recovery area, the patch is removed and the suture is adjusted. Patients leave the center without an eye patch. However, if the adjustment is scheduled for later in the day or the next day, the eye patch will remain on until removed in the office.
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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. During the surgery a special suture is attached to the muscle and tied in a slip knot and a patch is applied to the eye to prevent accidental loosening of the stitch. The suture adjustment takes place between 1 and 24 hours following the surgery. The patch is removed. After anesthetic drops, Dr. Davidson makes some fine adjustments of the eyes to the desired position. The suture material is then trimmed and securely fastened. The patient leaves without a patch.
Postoperative Pain and Nausea
There is usually little discomfort from the surgery. Tylenol and/or Motrin syrup is recommended for children. Please give the medication three times daily for two or three days even if the child does not ask for it. If Tylenol is not sufficient, adults may be given a stronger pain-reliever such as Darvocet or Vicodin to be taken for one (1) to three (3) days. The anesthesia may produce temporary nausea, which will pass within twenty four (24) hours.
Rarely does nausea need special medication. Nausea is a side effect of the stronger pain relievers, so use judgment in taking them. The majority of patients will sleep for several hours following surgery. Some children will keep their eyes closed for a day or more due to the scratchy sensation caused by the small sutures. These sutures are thinner than eyelashes but can nevertheless feel irritating especially during blinking. A cold washcloth or icepacks may feel good draped over the eyes to sooth the deeper soreness.
Postoperative Examination
The first postoperative visit is scheduled within one (1) week after the procedure. It is intended to rule-out infection, and obtain a preview of the final result which may become apparent only after six (6) weeks to three (3) months. If an adjustment is made in the recovery room immediately following the surgery, the first visit is scheduled at six (6) weeks postoperatively. Subsequent visits will be scheduled at this time.
Care at Home
We routinely use Tobradex drops, 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 drops, the eyes will heal perfectly well without it. Prescriptions for these medications will be given to you at the pre-operative visit. Please have them filled before the surgery date, and bring them with you to every appointment. Apply one drop inside the lower lid three times daily for seven days, beginning the day of surgery.
Children who do not like eyedrops, may lie down on the bed and keep the eyes closed. A drop is placed at the inner corner of the eye and gently "blinked" in either by the child opening the eye slightly or by the adult lifting the eyelid momentarily. If the child absolutely refuses and applying the drops becomes an ordeal, do not force the issue. Sometimes a drop can be placed while the child is sleeping each night, and this can be adequate. 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. Artificial tears are recommended to be used for rinsing the eyes of dried secretions, and to lubricate the eyes if any scratchy sensation is present.
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The only restriction is staying out of swimming pools for seven (7) 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 two (2) weeks following surgery. It may be impossible to prevent young patients from rubbing their eyes, but do your best. We have seen only two cases of infection since1992 due to eye rubbing after strabismus surgery. Physical overexertion should also be avoided for two (2) weeks. 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. Blood thinning medications such as aspirin or Coumadin (warfarin) may be resumed after three (3) days.
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. A scratchy sensation due to the fine sutures will go away as the sutures dissolve over one to two weeks. Some eyelid swelling and rarely bruising will improve over one week. The more extensive the surgery, the longer the recovery period.
Reoperations generally involve more swelling and discomfort. The eyes will stay red for several weeks, and all of the pinkness will fade back to white after several months. The incisions for strabismus surgery rarely leave a visible scar. Double vision may take a couple of weeks to resolve. The final result is appreciated between six (6) weeks and three (3) months. Therefore, a small amount of drifting of the eyes during the recovery period is common. In patients who undergo surgery for exotropia (outward drifting of an eye), we expect the eyes to be crossed with some double vision for two (2) to four (4) weeks. This is because there is a strong tendency for recurrence of the exotropia. An early overcorrection will allow a recurrence to result in straight eyes. This is not the case for esotropia (inward turning) or hypertropia (vertical drifting).
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. If an adjustable suture is performed, the one week visit may not be necessary. You should make the first postoperative appointment when you book your surgery. Please do not hesitate to call in the meantime (805) 667-2020 if there are any questions. We are always on call for you and can be reached by calling the office 24 hours a day, 7 days a week.
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. It is ultimately your responsibility to assure that authorization for the surgery is obtained prior to the procedure. If you do not have authorization, or are not eligible for services after we have made efforts to obtain such, your surgery may either be cancelled, or it will be performed at your cost. Your insurance company may refuse to pay or may pay a reduced amount for our services. In any case, you will be responsible for payment of all bills not covered by your insurance.
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