At age 34, and after over a year in vision therapy, my optometrist and I decided it was time to consider surgery. I definitely felt hesitant about having someone cut my eyes open so I made a collection of questions to ask the surgeon. He was SO patient and he answered every single one.
So what did I ask my eye surgeon? Here were the top 27 concerns and questions that I had for my ophthalmologist.
- How long have you been an eye surgeon?
- Do you specialize in strabismus surgery?
- Would you plan to operate on my strong eye, weak eye, or both?
- How do you measure me and know what to use for a measurement when my eye turn changes?
- I can straighten my eyes, why would I have surgery if my eyes are already straight?
- Do you plan on doing a prism adaptation test before surgery?
- What do you actually do to the muscles during surgery?
- Which muscles will you be operating on?
- Do you use adjustable sutures?
- Will I need to come back for a second visit for them to be adjusted?
- What outcomes do you expect or aim for?
- What are the chances that I will need a 2nd or 3rd surgery?
- How soon do you think I would need another surgery?
- Why does it seem to take several surgeries to fix strabismus?
- Is strabismus surgery just cosmetic after several attempts?
- What are the success rates associated with strabismus surgery?
- Is a cycloid turn a concern with strabismus surgery?
- Is there a chance that I will get double vision after surgery?
- What are the chances that I go blind?
- How long does strabismus surgery take?
- What is the recovery time frame after the surgery?
- Do you think my eyes will work together after surgery?
- Do you think vision therapy and surgery combined can help someone with strabismus fix their eyes more quickly?
- Do the eyes stick better if you do the vision therapy after?
- Why wouldn’t you just keep doing vision therapy and avoid surgery?
- If the brain compensates for that angle long enough could your brain neurologically says, “this is my new normal” and stick.
- How long after surgery should I start doing vision therapy again?
Hopefully, you will be able to have some of your own questions answered, but remember that these answers were specifically for me. A female, 34 year old woman with exotropia who had 3 eye surgeries as a young child. Read about my history here.
I’ve been doing vision therapy for over a year and have gained some stereopsis in the process. My eye turn is 35 diopters and is intermittent which means that they are straight some of the time and have varying degrees of “turn,” but 35 is the measurement at it’s worst. So just take those things into account when you consider and read these Q&As.
I recorded my appointment and then attempted to transcribe my surgeon’s answers here. There were a few times I had to summarize or guess, but for the most part, these were his word-for-word responses.
1. How long have you been an eye surgeon?
2. Do you specialize in strabismus surgery?
3. Would you plan to operate on my strong eye, weak eye, or both?
It’s more of an art than a science. The only really good study comparing doing one eye to two eyes was done in children who had never had surgery, and of course part of it is how you were trained. Some centers teach you to do it on one eye if you can, others teach you to do it on both eyes to balance. There are theories behind it, but they compared the two scientifically and there are exactly the same outcomes.
Now in a case like yours, I say both eyes because you’ve had three surgeries and the muscles are not in their native positions. To get 35 diopters, a lot of it is how far I’m going to have to move your muscles. We’re going to have to move each of your muscles somewhere between 15 and 20 mm. We can’t get that amount on one eye very well, especially if it’s already back four from previous surgeries, then I’ve already lost 4 of what I can use.
4. How do you measure me and know what to use for a measurement when my eye turn changes?
Dr. P: We want you at your worst so that’s why we do it in a very standard way. When you come in and Ryan does this back and forth thing, (moving the black occluder from one eye to the other) it makes your ability to compensate evaporate. We don’t want you compensating, we want to know, what is your worst when you’re not doing anything that you can do to compensate for it and that’s what I want to fix.
5. I can straighten my eyes, why would I have surgery if my eyes are already straight?
Dr. Peterson: “Part of this we don’t understand because it’s very complicated neurology that we don’t fully understand, but we are going to move the position of the eye muscles because right now, for reasons we don’t understand, the part of your brain controlling your eye movements thinks this is how your eyes should be. (he mimicked my eyes by pointing both hands out to the sides instead of straight forward). So it is purposely holding the muscles in that direction. So taking that into account we can move the position of the muscles of the eyes so that the brain thinks the muscles are doing that when your physical eyes are actually straight.
When you can make your eyes straight, you are overcoming your natural state. You are having to expend a lot of energy to fight against that. We want your eyes to be able to stay straight at rest. And that is the goal of this surgery. So you’re not forcing it to be straight.”
6. Do you do a prism adaptation test before surgery, and what is it?
Yes. That’s where I put prisms on your glasses and have you build up. I don’t find them as useful in a case like yours. For adults they’re typically less useful if you don’t see double, because if you’re not seeing double, there’s no feedback for it.
What it’s trying to do is, let’s say that we measure you at 35, but even at 35 you are compensating and if I put a 35 prism on there your eye will go ahhh, and then relax out to 40 and then 45. I’m trying to see if there is more there. And that is very effective in kids because they’re more tenacious in how they hold that. Their visual system is more adaptable.
So there have been no studies that show that prism adaptation is effective in adults with exotropia, those are all done in kids with crossed eyes.
So yes, I do that, in the settings where has been proved useful.
7. What do you actually do to the muscles during surgery?
“The muscle is attached to the eye so I cut it to detach it, then move it to a new spot and reattach it.
The conjunctiva is the membrane that covers up your eye muscles. So I make the incision right next to the colored part of the eye, that’s where the conjuctiva attaches and then I can lift it back and so the muscle pulling your eye outward right here (points at model) I will move forward here.
This middle muscle I tighten, now it’s been moved before and if it’s still back where he put it in the first surgery I’ll pull it back up, if it’s not, I’ll fold it. So it would still be pulling your eye tight.
8. Which muscles will you be operating on?
The inside and outside muscles (lateral and medial Rectus).
9. Do you use adjustable sutures?
Dr. P: I do those, and I recommend them. Just in the last year or so I’ve used a second advance on this technique which I’ve really liked. It doesn’t leave the sutures exposed. So for 15 years I did it where I would leave the strings taped to your cheek with a patch, you’d come here and I’d take off the patch off, we have to move it, even if we’re not moving the muscles, we have to tie the suture because it’s just hanging out of your eye.
So I don’t do that anymore. The way I recommend now is I put the sutures in then I cut them much shorter and then they are all covered up, there is nothing exposed you go home then you come back in another week.
At that week point if we feel like, “oh yeah, this is off,” well I can actually reopen and get to the suture and still move it.
10. Will I need to come back for a second visit for them to be adjusted?
Dr. P: Yes, it will be one week after the surgery.
Zac: “Who is to say that in the 2nd, 3rd or 4th week it doesn’t need to be adjusted again?”
Dr. P: It might, but we can’t adjust it anymore. If that happens because the muscles have healed. They actually heal in a few days, which is why I used to do the adjustment the day of. But the advancement was that I can put a layer of this coating under the muscle so it doesn’t stick down so much, so I can get to it and move it if we have to in a week.
We will do it right here, I’ll put an eye drop in her eye, because there is no cutting. I do have to reopen the incision, but that just taking those two little stitches out, she doesn’t feel any of that.
(At this point I was nearing a panic attack so he just directed the comments to my husband…haha)
Some people tell me “that’s just not going to work for me,” and I don’t have to do the adjusting step, we can plan it that way. I like having the option, because knowing that 30% of them are going to turn again, we can catch at least some of those early on and avoid another surgery down the road, I think it’s worth it.
And if you don’t need an adjustment that’s the nice thing, I don’t have to do anything. It’s already tied off and it just dissolves.
11. What outcomes do you expect or aim for?
Physically straightening the eyes and improving fusion.
12. What are the chances that I will need a 2nd or 3rd surgery?
The best information we have from literature and science is about 30%, no matter how many you’ve had. The fact of the matter is that probably, the more surgeries you have had the more likely answer is that you will need more. If you are one that tends to recur, that pattern often repeats itself.
13. How soon do you think I would need another surgery?
A month, a year, 10 years, I’ve seen it all.
14. Why does it seem to take several surgeries to fix strabismus?
Dr. P: Neurology is not set. Even if we did nothing, the amount of your eye turning could change over time. So that neurology evolves. You probably haven’t always been a 35, so right now you’re a 35, but what if in the past you were a 20 and we did a surgery for 20 and you were going to 35, now you’d be at a 15.
We are hitting a moving target. You may be on your way to 50 so if we do a surgery for 35 well in a few years if you goes to 15 we’ll think it didn’t work when in reality that was the natural course anyway. We haven’t changed the natural course. You will have that 15 deviation no matter what we do.
15. Is strabismus surgery just cosmetic after several attempts?
Yes and no, there are always functional benefits. Some insurances get the wrong impression that it is just cosmetic, but there are clear functional benefits that we would aim for.
Even for someone who is blind in one eye who has no ability to get fusion or stereopsis, it’s not really cosmetic, it’s reconstructive. It’s like a child with cleft pallet and you try to repair it. The eyes aren’t naturally out so you’re trying to take an abnormal state of the eyes and restore it to normal.
16. What are the success rates associated with strabismus surgery?
A success means that the eye turn is less than 10 diopters. The chance of this success is about 70%.
17. Is a cycloid turn a concern with strabismus surgery?
Dr. P: It is very rare when I am working on the straight horizontal muscles.
Me: But I have a vertical deviation too.
Dr. P: Yours is only 3 or 4 so that is in the vision therapy range. To try to fix that with surgery is a bad idea. That’s way more likely to overcorrect than fix it. I would not address that surgically.
18. Is there a chance that I will get double vision after surgery?
The closer your eyes are to being straight, the easier it should be for your eyes to fuse. The closer to “0” we get you, the less double, the more fusion.
19. What are the chances that I go blind?
This is not a very risky surgery. It is less risky than lasik because I’m not working on your line (not sure on that word) vision. The nationwide average is about 1/5-10,000 chance of loosing your eyesight. So it’s super low, but it’s not zero.
20. How long does strabismus surgery take?
21. What is the recovery time frame after the surgery?
No driving, minimum 2-3 days. Some people aren’t even driving a week later so it depends on how you heal and if you have a lot of double vision. Some people get a lot of double vision in that healing phase. We are changing your eye position drastically and sometimes your brain doesn’t cope well with that initially.
So that’s variable, the average is 2-3 days to being comfortable enough to drive. It’s pretty sore for 2-3 days. You’re not going to want to anything besides sit on the couch with an ice pack on your eyes. So plan on nothing.
It will look like you are underwater, it’s really blurry. A lot of swelling, a lot of tearing (as in crying), super red, I’m making it sound great, right?
After that, you can get up and around, but no sports or exercise, no eye makeup, no swimming, keep hands away from your eyes for about a week. That’s the highest risk period for infection. So I don’t want something to pull the muscle during that first week, because if a stitch breaks, we’re in bad trouble and we don’t want it to get infected.
After the first week the chances of both of those things is really really low. You won’t feel perfect, but the risks will be lower. Your eyes are still going to be extremely red and that goes on for about 2 months.
If we adjust, you will need to give it another few days. I would say there’s a 1 out of 4 or 5 chance of needing to adjust the muscles.
22. Do you think my eyes will work together after surgery?
I don’t think that it is likely that you will get “Fixing my Gaze” kind of stereo vision, because she is the exception to the rule, but it’s possible. So I see no problem in going for it, why not?
Getting the two eyes to fuse to give you a single image is what we want with this, but going to a 3D movie and having those effects? Most people born with crossed eyes never get that even if their eyes are perfectly straight afterwards. Their brain has never learned that and to teach it that with vision therapy is a challenge.
Like Sue Barry, she is an exception to the rule. We aren’t going for that kind of stereo vision. We are going for better fusional function, absolutely.
Me: I’ve experienced stereopsis in real life, like snow and birds where it was undeniable, but I don’t see like that all the time.
Well that’s great. If you’ve done it once, that means your brain knows it then, that’s encouraging!
23. Do you think vision therapy and surgery combined can help someone with strabismus fix their eyes more quickly?
Dr. P: We have this thing that we can not cure so we have various treatments that are imperfect. I think the most powerful is surgery to get it as close as we can, physically, and then physical therapy to work on getting eyes to work together.
Me: What’s your experience with that? 24. Do the eyes stick better if you do the vision therapy after?
Dr. P: “I think so, but I can’t give a scientific answer because, sadly, most of the time surgeons and therapists are like cats and dogs, they just don’t get along. They tend to bad talk each other, which I think is unfortunate because I think we both have something to offer in a real way, because we are both dealing with something that we can never cure. We just work on treating it.
So I think there are two good treatments. What I do isn’t perfect, for sure, that’s a given. And I think what therapy does has limitations. So if we work together, I think that’s best case, but for some reason, there’s just his turf battle.
So no studies have ever been done comparing the two together.
I know that what I do is 70% successful at most so if I could have something else to help bridge that gap, bring it on. I’m all for it.”
25. Why wouldn’t you just keep doing vision therapy and avoid surgery?
Dr. P: Just working on the therapy isn’t necessarily reducing the angle, it’s helping you compensate for it. They aren’t changing the physical angle, they’re definitely helping you compensate for it.
So if we can make it so that you’re not constantly fighting against 35, but fight against 10? 8? 5 in a good case. Then wow, therapy is way more effective.
26. If the brain compensates for that angle long enough could your brain neurologically says, “this is my new normal” and stick.
Dr. P: “I don’t think so. I’m sure there are cases like that, more so with kids.
27. How long after surgery should I start doing vision therapy again?
I usually recommend giving it a couple months just because you’re in the healing phase. It’s not harmful if you say I’m going to start the next week.
There’s no studies, so we don’t know the answer, but there’s so much muscle healing and swelling that needs to remodel in that first month or two, I typically say, let your eyes heal for a couple months and then hit that vision therapy hard.
We’re all just giving our best guess there’s no science here, we don’t have studies to compare. So if want to jump right on it, go ahead. I’m not going to stop you. We all have an opinion on it, but there is no science to guide us.
That is strictly opinion.
So there you have it, every question that I could think of to ask my eye surgeon. Leave any other questions you would have asked in the comments and I will try to get them answered and add them to the list!