Introduction

While I was considering strabismus surgery as an adult, I tried searching online for a detailed explanation of the whole strabismus surgery process and could not find much info.  I had so many questions about what to expect, what goes on for during the surgical consultation and pre-op, how recovery would be, costs, etc…  Luckily I found a support group called Eyes Apart (http://health.groups.yahoo.com/group/EyesApart/).  Its members were very helpful in answering my questions and sharing their experience.  I decided to keep this journal of my experience for myself as well as for other adults who might be considering this surgery. 

Of course, as a disclaimer, this journal is just describing my treatment.  Everyone’s eye situation is different and your doctor may decide on different testing and treatment.

History

My official diagnosis is Partially Accommodative Esotropia since I was probably 2 years old.  My eyes cross inward because I am far-sighted, especially when I’m viewing something up close.  While glasses help with the crossing somewhat, I still have some residual crossing that the glasses don’t correct.  (Fully accommodative esotropia patients’ eyes are completely straightened with glasses.  In those cases, surgery is usually not recommended and most kids outgrow it by their teens.)   I have alternating esotropia, which means that either eye can cross depending on which eye I am focusing with (if I am focusing with my right eye, my right eye will be straight and my left eye will turn inwards; if I am focusing with my left eye, my left eye will be straight and my right eye will turn inwards).  Luckily, I see out of both eyes equally well, so somehow I did not develop amblyopia (lazy eye).   Since I was a child, my treatment plan consisted solely of wearing eyeglasses and 1 surgery.  I did not do patching nor vision therapy. 

I had one eye surgery when I was 5 years old in the 80s.  Back then, there was a 1 night stay at the hospital.  My memory is very foggy since I was so young, but I remember reporting to the hospital on the first day for various eye testing, blood work, and playing in the playroom.  The pediatric patients slept in a large group room.  A chair for one parent was next to each bed.  They even served ice cream cups and fruit punch at night (I was supposed to be sleeping maybe, but I was staring around and saw them wheel in the snack cart.  That surely made my day!).  Day 2 morning was surgery day and I went home that same afternoon.  All I remember about that day was crying intensely as I was wheeled into the operating room and mom couldn’t come with me.  I caught a glimpse of my eye doctor trying to calm me down…my next memory is throwing up several times and ruining my shirts.  My mom had to change my shirt several times, and then it was time to go home.  I don’t recall how recovery was like of whether or not it was painful, but I DO remember hating that eye ointment I had to use for a week.

This year, I will be going back to the same hospital for my 2nd strabismus surgery.  Strabismus surgery is now a one-day outpatient surgery for both children and adults at almost every surgical center and hospital.  I tried to do a search for the reason of change in overnight stays to no avail.  My only guess is change in insurance coverage.  Patients now report to their doctor for pre-op testing a few days before surgery.

Getting an Appointment

At the very start of this process, I was a bit hesitant about making an appointment with a pediatric ophthalmologist.  After all, I am an adult and would feel so out of place in a waiting room full of little kids.  However, pediatric ophthalmologists are the way to go for strabismus surgery.  Because this eye problem is typically corrected as a child, pediatric ophthalmologists have the most experience doing this type of surgery.  I learned that although their official title is a pediatric ophthalmologist, almost all of them will see adults as well for strabismus surgery (you’ll have to go back to your regular eye doctor for any future checkups not related to strabismus surgery though).

I made an appointment with the first potential surgeon (2.5 weeks wait time), but I didn’t have a good feeling about that practice.   The doctor seemed entirely competent, but I just didn’t seem to feel comfortable with the practice itself; it felt too big with too many different doctors. Patients were shuffled from one waiting area to another waiting area.   I felt like I was part of an assembly-line.

I called to make an appointment with a second doctor at the end of March and he just happened to have a very early morning opening the following Monday, so I got in.  I also made an appointment with a third doctor (4 weeks wait time), but after seeing the second doctor and liking him, I decided to cancel the 3rd appointment.

Initial Surgical Consultation

The initial surgical consultation comprised of a full thorough eye exam including vision, glaucoma testing, and dilation.  The doctor also did measurements of my eye to see how crossed they were with a prism bar (looks like a ruler).

He then shined a really bright light into each of my eye with a magnifying glass to see the inside of my eye more closely.  I think it was also to see my how my previous eye surgery’s scarring was.  I think my first surgery was only on my righteye, and the doctor thought so too since he couldn’t see any scar on my left eye.

In addition, I had the 3D-vision test (you look at a picture of a fly and a few shapes to see if you see it pop out), which I failed miserably.  In another test to see which eye you used, I was given a red and green lens glasses to wear and the doctor would turn on some circular light where you had to tell him if you saw 2 or 3 lights.  I saw either 2 or 3 lights depending on which eye I used.

Another test he performed was to determine the likelihood of me developing double vision after the surgery.  In this test, he selected some prisms, put them over my eye, and asked if I saw 1 or 2 images.  I saw 1 image all the time.

After all these tests, we began the discussion of surgery.  From both doctor appointments I saw, I was told there is an 80% success rate, which appear to be standard percentage that is typically quoted even in articles about strabismus on the internet.  There is basically no way to really determine success exactly.  There is a 1 in 30,000 chance that an infection can occur inside the eye and cause the loss of eyesight, which my surgeon is unsure how that happens since strabismus surgery is on the outer eye, not inside.  My surgeon has not seen this before in his patients.  He did mention that most cases of outer eye infection after surgery he has seen have been in teenagers (maybe because of non-compliance or inadequate compliance of post-surgical medication application).  At any rate, this type of infection can be fixed relatively easily.

We then went on to discuss treatment plan.  He proposed doing surgery on my left eye since my right eye was operated on previously.  When I signed the surgical consent, I signed for the “left eye or both eyes” though in case he finds something wrong on the left eye during surgery.

I was also supposed to go to my primary care doctor for a checkup to get a sign-off that I am ok for anesthesia and surgery.  I don’t see my primary care doctor a lot, so he mentioned that for adults, the hospital can do the physical on the day of the surgery.  You just have to get to the hospital earlier.

I was given a choice of surgical dates throughout May.  The middle of May worked best for my work schedule, so I chose that.  After the visit, I made an appointment for a Pre-Op appointment exactly 1 week prior to surgery date.  He will re-measure me then.

Here are some questions you can ask the doctor at this appointment (copied from a very helpful and long-time member (George) from the Eyes Apart yahoo group):

  • Does the surgeon do adult surgeries routinely?  How many, what results? 
  • Is surgery on both eyes recommended at once even if only one eye is crossed?
  • What deviation in diopters is the bad eye? How many muscles will be repositioned in each eye? (Two in each eye is standard)
  • What is the average diopter deviation after surgery that the surgeon typically obtains on patients? (Up to 10 diopters deviation is considered cosmetically straight)
  • Will adjustable sutures be used?
  • Is general anesthesia recommended? (most do)
  • Does the surgeon typically use the same anesthesiologist? 
  • How long will the procedure take? (typically 45 minutes to an hour)
  • Will I have double-vision? For how long?
  • What is the probability my eyes might cross the other way?
  • Are eye exercises or vision therapy recommended after the surgery?
  • Do I have to do anything to get insurance pre-approval or will the office take care of it? 

Pre-Op Visit

Today was my pre-op visit.  He did much of the same exam as during my initial consultation, including a vision test, the 3D glasses test, the prism test for double-vision, and re-measurement of my eyes with the prism bar while I looked far, near, down, and up.  I am happy there was no dilation this time!

I was also given 2 prescriptions for use after surgery.  One was Tylenol 3 for pain, and the other one was Tobradex eye drops, an antibiotic and anti-inflammatory medication.  Wow is this eye drop expensive!!!  I got the generic version and even then, a mini 5mL bottle retails for about $110 and with my insurance, I still had to pay $69 since I didn’t meet my deductible yet.  It really made me thankful for other aspects of my health because medicine is very expensive.  I am to use it 4 times a day for a week.  I don’t even know if there is enough liquid in this bottle to use it that many times.

The doctor gave me an opportunity to ask any other questions I might have had. He mentioned that I would receive a call from someone the night before surgery day to tell me what time my surgery will be.

Surgery Day

 The afternoon before my surgery day, the admitting department called and told me my surgery was scheduled for 4pm and I had to arrive at the hospital by 1:30pm.  Later that evening, they called me with a time change and that surgery would now be 3pm and I had to arrive at the hospital by 12:30.  No eating or drinking was allowed 8 hours before surgery time, so that meant no eating by 7am for me.  I surely would not be awake and have eaten by 7am, so the last time I ate or drank water was 7pm the night before. 

At 12:30pm, I reported to the Admitting Office Reception Desk at the hospital.  I sat there for about 15 minutes before I was called in to register.  I had to show them my insurance card and photo ID and give them some other personal information.  In return, they gave me a blue folder of information such as “A Patient’s Guide to Surgery”, “Your Rights as a Hospital Patient”, and  “The Joint Commission Public Notice”.  They also gave me my hospital identification bracelet.  After the first person registered me and printed out the necessary papers, I went to another person at registration, where he re-verified that the information is correct. They are really serious about making sure information is correct and not missing.   All my papers are put into this red binder, where the spine has your name and surgery time written on mask tape.  

The person handed me my red binder of papers to take up to the Ambulatory Surgery Center on the third floor.  I signed in there and sat in the waiting area for about 20 minutes.  A nursing assistant then called me the dressing room to change into hospital attire. This included a gown, a super wide pair of pants, a cap, socks with grips, and a robe.  I had to take everything off except my underwear.   They provided me with a bag and a locker to store my personal things in.  The nursing assistant then took my weight, height, temperature, blood pressure, and asked me for a urine sample (I think the urine sample only applies to females of child-bearing age to make sure you are not pregnant.).  She then brought me over to sit in one area.  I thought this would be the area I would get my pre-surgical testing done since I didn’t do it with my own doctor.  Nope. 

After about 15 minutes of sitting in that area, they took me to the pre-surgical area where all patients await to be called to the operating room.  I think that area was full so they had patients sit elsewhere until it cleared out a bit.  It was probably 2pm when I got here.  A nurse came over to confirm what operation I was having done, marked my forehead with an X surgical site, and asked if I had any allergies or previous surgeries.  I noticed some patients had hospital pants on and other patients had their own pants and shoes on.  I deduced that patients undergoing general anesthesia had to put on hospital pants, while patients undergoing local or less than general anesthesia didn’t. 

This is where the waiting game for me began.  3pm came and went and I was still not called for my operation yet.  The surgeon was delayed with other surgeries, understandably enough.  I would want my surgeon to spend as much time as needed to fix my problem as well.  I had a few episodes of hunger pangs where I really wanted a sip of water.  At around 4pm, an anesthesiologist came over to talk to me.  She told me I would be getting general anesthesia and would be put to sleep by an IV.  She asked if I had any loose dentures, drug allergies, and whether I or my family members had any reactions to anesthesia previously.  She then told me to open my mouth to check my airway. 

I thought my surgery time probably got moved back to the original 4pm; however that time came and went and still there were no signs of being called while the number of people in the waiting area was dwindling.  I was starting to get worried whether they would cancel appointments if the delay got too late. Thankfully they don’t and that they stay open until 11pm. 

Around 4:30pm, an internist came to see me to do the medical clearance assessment I was supposed to do with my primary doctor. He basically just asked me whether I had heart problems, lung problems, high blood pressure, diabetes, etc… and then just took a listen to my lungs.  I wasn’t made to do a blood test nor an ekg. Whew!  So far, every single person I came in contact with has been so pleasant.  

I guess the only area for improvement is to improve privacy for patients.  The waiting area was a room full of all pending surgical patients and their family members.  When the nurse, anesthesiologist, and the internist came to talk to me, it was in front of everyone else and the person sitting close to you can hear your conversations.  For example, I overhead the internist tell a patient her lungs were not good and that they were going to give her a nebulizer. 


The hospital’s Pre-Surgical area. This is where adult patients wait to be called for surgery. (The post-recovery area after coming out of the PACU, looks the same as well) The wide lounge chairs are for the patients and you can open it up for feet support; these chairs are surprisingly very comfortable. The regular chairs next to the lounge chairs are for the family members. As you can see, there is not a lot of privacy. In the afternoon, all seats were full of waiting patients. This picture was taken early evening, where I was one of a few patients remaining.

By 5pm, I was probably one of the three patients remaining in the holding area.  I was getting restless and slightly even more nervous.  By this time, I was no longer hungry nor thinking about food or water; it just disappeared.  At 6pm, I was finally called down to the 2nd floor operating room; but of course, there was a bit more sitting and waiting.  It was 6:30pm when I was finally got called into the operating room.  At this time, the family member accompanying you had to leave and go back to the waiting room to wait.  

Upon entering the operating room, I was greeted by friendly nurses, assistants, anesthesiologist, and my surgeon (this anesthesiologist was not the same one as the one I talked to in Area A though).  It made my heart jump a bit out of anxiety to see the actual room.  Everything suddenly got so real.  The room and the operating table was a bit smaller than I imagined (been watching too many medical TV shows and getting distorted impressions), but very clean and orderly.  

I had to remove my robe (but got to keep my gown, pants, socks, and cap on) and lie on the narrow operating table.  Someone buckled my thighs to the table and covered me with blankets.  The anesthesiologist then asked me what operating I was having (as a time-out double-checking procedure I guess to avoid getting the wrong patient) and whether I had any problem with anesthesia before.  I vomited as a child during my first surgery and she told me she would give me some medicine to help, but there was no 100% guarantee.   

She started an IV on the back of my hand (that kinda hurt!), put on the pulse oximeter, and began strapping an oxygen mask on my face with black rubber ties.  If I was fully alert and not high on her medication, I think the straps would be creepy.  It looked like it was some gagging device.   I had never ever seen this on TV before.  I googled it after I came home and here’s what it looked like (per google, the official name is “mask harness”) You decide for yourself.

 

But luckily, while I was aware of what was happening to me, I don’t think my brain was really processing it; I was just numb to it all (no pun intended) and then I was completely out after that. 

Going under wasn’t quite what I imagined it to be.  I wasn’t given advanced notice that she would be pushing the anesthesia medicine now, didn’t get asked to count to 10, didn’t feel myself getting sleepier, and didn’t even remember closing my eyes.  I just went from fully alert to asleep.  Kinda freaky.  Moment of realization: These medical TV shows are distorting my perception of reality!! 

The next thing I know, surgery is done and I am waking up in the Peri Anesthesia Care Unit (PACU).  While my eyes are not yet open, I hear mumbles of conversation around me, I feel the blood pressure cuff inflating at times, I feel there is a pulse oximeter on my finger, and I also feel there is an airway tube of some sort in my mouth (The internet is great.  It tells me this airway tube is an Oropharyngeal Airway.  I thought all breathing tubes were supposed to be out right after surgery and then I thought maybe I had some unknown breathing difficulties because they kept the breathing tube on me, which lead me to googling, and now I know they are two different things. Whew, what a mouthful of run-on sentences) with an oxygen mask over it.   The staff when must have detected some changes on the monitors to show I was awake because only seconds later, they came over to tell I was out of surgery, took the airway tube out of my mouth, asked if I was cold or in pain, and put a pillow under my head.  I was able to answer them, but then I went back to sleep for a while.   

I woke up again after a nap (have no idea of time frame that passed) and tried to turn my head to the monitors to look at my vital signs since I was curious but couldn’t see it.  Also, my right eye was glued shut from the mucus.  Surprisingly, the pain wasn’t that bad at all.  The nursing staff must have once again detected something on the monitors because they came over to take the  blood pressure cuff, heart rate monitor wires (when was that put on?), oxygen mask, and pulse oximeter off and wheeled me back up to the 5th floor Area B, for post-recovery patients.  There, you can see your family members again.  

On the first step I took from the gurney to the post-recovery chair, I felt a short wave of light-headedness.  I kept expecting to vomit like my previous experience, but either because I starved all day, or because of the good medicine I got, I didn’t.  The nurse there wiped my blood-stained tears and helped me apply some cold compresses to the eye with gauze.  This helps with the swelling.  I was also provided with a cup of water, tea, and jello.  I wasn’t that hungry at this point.  My IV was hooked up with Lactated Ringer’s solution and maybe that provided me with nutrients.  I did drink the cup of water though and noticed my throat felt a bit sore, but not too bad.  

The nurse then gave me my post-operative/discharge information at 9pm (the paper copy I got to take home was signed at 8pm; otherwise, I would have no notion of time at this point).  I then closed my eyes and dozed some more while the cold compress was on my eye.  I could have slept in that chair all night if allowed.  At some point upon waking and sitting for a while, I asked the nurse whether I had to finish up the IV bag before I could leave.  She told me no, I would be overfilled with fluids if I did since that was the 2nd IV bag already (and this bag was half empty already).  I must have been out for a long long time!  I was told that as soon as I urinated, I would be allowed to leave.  I immediately went to the bathroom and only had a little bit of pee to show for it despite the big bags of IV I got.  

The nurse removed my IV and I was allowed to change into my regular clothes and leave.  When I left, there was maybe 1 more patient who just got wheeled into the post-op area. We walked out of the hospital around 10pm and got home around 10:30pm.  As I was walking out of the hospital building, I felt a bit nauseous and was so sure I would vomit.  I dry-heaved a couple of times and even got a bag ready in case I did.  Very thankfully, it was just a false alarm.  It had been a very long day and I was dead tired.  I got home, changed to pajamas, brushed my teeth, and went to sleep.  I didn’t even try to get a look at my eye in the mirror. 

At midnight, I woke up feeling good as new and well-rested (I guess I had been sleeping on and off since 6:30pm anyway).  And remember the big bags of IV that got fed into me?  I got up to pee copious amounts and woke up 2 more times during the night to do so.  Since I was up at midnight, I decided to try the cold compress on my eye for several minutes and then forced myself to go back to sleep, which I did extremely easily.