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Posted on 09-14-2016

Suture Self: Further Adventures in Strabismus Surgery

From time to time my colleagues talk about who has seen the patient with the greatest number of strabismus surgeries. Some of us have seen people who have had numbers in the double digits. I can’t remember what the largest number was. The record in my office was a thirty-something woman who had undergone ten eye muscle surgeries. These were performed over the course of many years, at least two decades. A while back I posted a story on this blog – told to me by a colleague – that described a surgical consultation in which the doctor’s initial plan consisted of operating on one eye on two separate occasions and then operating on both eyes to complete the treatment. What I heard yesterday was a lot like this story only without the benefit of any kind of warning.

Yesterday I spoke with a concerned mom who asked about doing vision therapy with her seven year old daughter who has had four eye muscle surgeries (five if you count the first round done on both eyes as two). As mentioned above, my colleagues and I have seen many people who have had this many eye muscle surgeries over the course of their lives. What is different in this case is that all of these surgeries were performed within an eight month period. For further context, the mother herself recently had her fifth eye muscle surgery for what she described as the exact same “genetic condition”.

Initially the then six year old girl had what the parents described as an intermittent turning out of the left eye. The surgeon said he thought that both eyes were turning out and attempted to treat the problem with lenses. What started as an intermittent left eye turn (my gut tells me to trust the parents’ observations) began to worsen, becoming more frequent. Unfortunately, the lens strategy did not fix the problem and eye muscle surgery was performed on both eyes last June. This resulted in what the mother described as a “huge and constant” turning in of the left eye (remember, that eye was turning out intermittently at first). This new, totally different problem created by the first surgery was treated surgically two months later. This surgery resulted in the left eye no longer turning in but now looking much lower than the right eye. More important, a vertical misalignment of the eyes, which is not an uncommon side effect of eye muscle surgery, is much more detrimental to the function of the visual system than a horizontal misalignment. And it is much more difficult to treat either with vision therapy or surgery. After three months of agonizing and searching and ultimately selecting a new surgeon, the next surgery not only failed to fix the vertical problem but led to the return of the left eye turning in. What the mother described as the final surgery was done in February this year. Cosmetically at least this yielded some improvement.

Now her eyes appear straight most of the time except when she positions her head and eyes in certain ways, which causes the left eye to turn in and down. This as far as I know at the moment is the only complaint. Mom and daughter are mainly concerned with how the eyes look, which is a very understandable desire.

Every eye muscle surgery creates problems such as permanent scar tissue that reduces the ability of the muscle (which in most cases was not damaged in any way prior to surgery) to move freely. Eye muscle surgery also permanently damages specialized fibers critical to communication between the eye and the brain about where the eye is pointing. All I could promise the mother was that the best way to help the eyes stay straight was to maximize the ability of the brain to use the two eyes together properly and that I would do everything possible to help her daughter achieve her goal with vision therapy and lenses.

These are the kinds of things that inspired me to write A Parent Guide to Strabismus, Eye Muscle Surgery & Vision Therapy. I think parents should have access to as much information as possible before deciding to have invasive, irreversible surgery done on their child, especially since multiple surgeries are not at all uncommon. Behavioral optometrists have helped many young children avoid eye muscle surgery thanks to vision therapy and therapeutic lenses. We have also helped many people who have had one or more eye muscle surgeries improve their visual abilities, visual comfort and quality of life with vision therapy and lenses. Sometimes eye muscle surgery is necessary, but the long term results of such surgery can only be enhanced by including vision therapy as part of the treatment plan.

Make sure you check out all the options before agreeing to eye muscle surgery for your child or yourself.

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