Eye Muscle Surgery for Strabismus: Correcting Eye Alignment Through Eye Muscle Surgery

Surgery can help correct misalignment of the eyes. This misalignment is usually recognizable by the fact that affected individuals squint (strabismus). For this reason, eye muscle surgery is sometimes referred to as strabismus surgery.

The squint caused by the misalignment of the eyes is not merely a cosmetic issue. It can also lead to severe visual impairment. Surgery is therefore often necessary during childhood to prevent long-term damage caused by the misalignment.

Eye muscle surgery is an option not only for strabismus but also for eye tremors (nystagmus) or eye-related forced head postures.

Whenever the mechanics, mobility, or position of the eyes are affected, surgery can help. Doctors perform eye muscle surgery only when other options are not available to restore symptom-free vision.

In children, surgery is often performed due to potential developmental consequences. Adults typically undergo the procedure for cosmetic reasons.

Diagram of the eye muscles of the left eye

Surgery is not necessary for every type of eye misalignment. Minor misalignments, in particular, usually have no effect on vision. The brain compensates for this minimal disturbance without any problems.

In adults, eye muscle surgery can be performed at any time. In children, however, doctors wait to perform the surgery until the child can see equally well with both eyes. Visual acuity is fully developed by around age 6.

Therefore, eye muscle surgery is generally recommended no earlier than preschool age. Before that, other methods are used to encourage the affected eye to align properly. If these methods are unsuccessful, you should consider surgery.

Untreated misalignments from childhood usually stabilize with age, so vision does not deteriorate further. Surgery is not necessary.

In rare cases, a misalignment may develop in adulthood due to paralysis of an eye muscle. In such cases, eye muscle surgery may be beneficial to restore vision.

If the eye muscle surgery is performed under general anesthesia, you must not eat anything for approximately six hours before the procedure. This includes cloudy liquids. Therefore, drink only water.

You should also stop drinking water two hours before the eye muscle surgery. You should refrain from smoking on the day of the procedure. If you are taking any medications, please inform the doctor. He or she must adjust the anesthesia accordingly.

The type of anesthesia used usually depends on the patient’s age. For children, doctors generally use general anesthesia to prevent unexpected reactions during the procedure. The same applies to patients who are particularly anxious or sensitive.

Normally, local anesthesia is sufficient for eye muscle surgery. The anesthesia suppresses reflexes. Movement is not possible, and the patient feels nothing.

Depending on the condition, eye muscle surgery may proceed differently:

• In cases of strabismus, doctors surgically correct the angle of the squint. To do this, they align the optical axis of the deviating eye parallel to that of the healthy eye.
• If overly tight eye muscles are causing the misalignment, doctors reposition the muscles away from the eyeball. If the muscles are too weak, they tighten them to correct the misalignment of the eyes. It is not necessary to make an incision in the eye itself. During eye muscle surgery, doctors make an incision only in the conjunctiva. However, this incision usually heals very quickly.
• Furthermore, during surgery, doctors can also treat a paralyzed muscle. To do this, they weaken the opposing muscle and remove it. 
• Sometimes, the surgery involves only a fold to correct double vision.
• In cases of severe misalignment, multiple procedures are necessary to achieve the best possible outcome for the patient.

Detachment of the tendon of the left medial rectus muscle

During the procedure, doctors open the conjunctiva and then suture it back together. This causes swelling around the eye. Doctors use a special suture to close the conjunctiva. This suture dissolves on its own after about a week.

 However, as the suture dissolves within the first few days after the procedure, it may cause an uncomfortable sensation in the eye. The eye perceives the remnants of the suture as a foreign body and produces a larger amount of tears. The duration of eye muscle surgery depends on the complexity of the procedure. The more muscles are involved, the longer the surgery takes.

Generally, all patients can go home the same evening if they feel well after the surgery. Only rarely do patients need to stay in the hospital for observation after the procedure. Even in such cases, however, a quick discharge within a few days is expected.

After eye muscle surgery, patients usually experience slight swelling and redness of the conjunctiva. The swelling continues to increase over the first four days but then gradually subsides and heals. Thorough postoperative care is essential after eye muscle surgery. This is the only way to ensure the healing process proceeds optimally and to minimize long-term complications. To this end, the patient must apply special eye drops to the operated eye at least three times a day. In some cases, the treating physician may also prescribe ointments following eye muscle surgery.

To administer the drops properly into the affected eye, you must gently pull down the lower eyelid. It is also recommended to look upward. It’s best to perform this procedure in front of a mirror. Many people find it helpful to have someone else present while administering the eye drops. Children, in particular, should only use eye drops under the guidance and assistance of an adult. This ensures that the drops or a small amount of ointment reach the lower conjunctival sac directly. During this follow-up treatment, be careful not to touch the eyeball with the bottle, as this could cause injury to the recently operated eye.

Special considerations for children

After eye muscle surgery, children often do not open the affected eye because the new situation is unfamiliar to them. This is not a cause for concern and is completely normal. 

So do not insist that the child open the eye. Instead, give your child enough time to adjust to the situation. As long as the child does not open the eye, you can skip the treatment with drops and ointments.

After a while, the child will try to open the eye on their own. From that point on, you should begin follow-up treatment with eye medications.

After eye muscle surgery, patients do not need to follow any special guidelines. The only exception is visiting public swimming pools. You should avoid these for about three weeks after the surgery. The chlorine in the water can damage the recently operated eye and impair the healing process.

Reading, flying on an airplane, and physical activity are permitted. However, be sure to attend your regular follow-up appointments with your ophthalmologist.

Before you are discharged from the hospital, your doctor will schedule your next follow-up appointment. It is very important that you keep this appointment.

Generally, the first follow-up appointment takes place a few days after eye muscle surgery. However, if you experience any symptoms before then, you must immediately seek medical attention at the nearest doctor’s office or hospital. This is especially important in cases of high fever or severe pain.

The risks of eye muscle surgery are very low compared to other surgeries. Complications during the procedure are extremely rare.

In rare cases, postoperative bleeding or an infection may occur after the surgery. Additionally, you may experience pain when moving your eyes during the two days following the eye muscle surgery. 

However, this is not dangerous and is no cause for concern. You will notice a significant improvement within a few days. If the pain is unbearable, you can treat it with special pain relievers. To do so, simply consult your treating physician after the surgery.

If the result is not as desired, you may need to undergo eye muscle surgery again. In complex cases, treatment generally requires multiple surgical procedures.

The conclusion regarding eye muscle surgery is that this procedure represents an effective way to specifically treat misalignment of the eyes. The surgery involves working on the eyeball, using techniques such as repositioning, resection, or folding of the eye muscles. Fine suture techniques are used to achieve a precise result. According to the *Deutsches Ärzteblatt*, the correction of strabismus is one of the established procedures in ophthalmology. The procedure can significantly improve eye alignment, particularly in cases of bothersome double vision or pronounced strabismus.

In procedures involving the outer eye muscles, the angle of the squint is specifically adjusted so that the eyes are realigned parallel to each other. This is particularly important in cases of paralytic strabismus, where a muscle is paralyzed. By shortening or repositioning several eye muscles, the misalignment of the eyes can be surgically corrected. The strabismus surgery is individually tailored to the angle of deviation, depending on the specific clinical presentation, such as normosensory late-onset strabismus. Early treatment is also crucial in childhood to prevent long-term limitations.

The procedure can be performed as an inpatient procedure or under local anesthesia and is often carried out on both eyes to ensure binocular vision. An experienced ophthalmologist plans and performs the adjustment of the eye muscles. After surgery, eye movements are initially restricted but return to normal as healing progresses. In rare cases, complications such as bleeding may occur, which is why careful postoperative care is important. The operated eye should be protected, and physical exertion should be avoided.

Overall, eye muscle surgery helps achieve a stable eye position and an upright head posture. By selectively removing or weakening an eye muscle, the balance of the muscles can be restored. Modern techniques ensure highly stable results, even though multiple procedures may be necessary in some cases. The treating physician oversees the entire process to ensure the best possible function and aesthetic outcome.

What is eye muscle surgery?

Eye muscle surgery is a surgical procedure in which the eye muscles are adjusted to correct strabismus. This improves eye alignment and optimizes the coordination between both eyes.

When is strabismus surgery necessary?

Strabismus surgery is necessary when there is a misalignment of the eyes or when double vision occurs. Surgery may also be appropriate for paralytic strabismus.

How is the surgery performed?

The surgery is usually performed under general or local anesthesia. The eye muscles are accessed through the conjunctiva and adjusted by repositioning or resection.

What are the risks?

Like any surgical procedure, eye muscle surgery can carry risks such as bleeding or infection. However, complications are rare.

What is the recovery process like?

After surgery, the eye may be red and can be treated with eye drops and ointments. The healing process is generally uncomplicated, and the results stabilize after a few weeks.