Question about post-op extropia surgery

[elleness]

My 2 1/2 yr. old daughter had exotropia surgery 7 weeks ago.  After surgery, her eyes were very crossed.  The doctor had me patch my daughter's eye for 4 hrs. a day, and the crossing is better, but not completely gone.  The eye that was weak is crossing in still.  The doctor still has me patching her eye (3hrs a day now) and has her wear glasses (has been wearing them for 3 weeks now).  I am wondering if it is normal for her eye to still be crossing in 7 weeks after surgery?  I know that I have to wait for her eye to heal completely to know the results of the surgery, but am wondering if you have dealt with this situation before and if there is hope that my daughter eye will align when it is healed, and with the help of patching and glasses.  Is there a round about time frame of how long it will take to see the results?  Thanks!! :)

[ASullivan757]

Is there anything that separates overcorrection verses actually being crossing as a result of being farsighted?

[ASullivan757]

Good Evening,
I have found myself reading anything and everything possible since my daughters Surgery on 8/13/14.  She had progressive intermittent exotropia.  She was +3.50 prior to the surgery but never wore glasses.  Prior to the surgery she was drifting outward almost constantly when looking far away.  Since the surgery she has been cross-eyed sometimes, however her right eye is almost always turned in.  We took her to another ophthalmologist on Friday to get an opinion on the right eye since we could not get a hold of her doctor and he said that we should patch her left eye for an hour a day for a month and follow up.  
We finally got to see the doctor that did her surgery yesterday and he said that she is measuring between 15-20 pd on both eyes (the left is generally only if blocked or when looking at something close up.  I left there with three options and really don't know what to do:
1) Do nothing
2) Patch but he gave three options for patching
-patch the left eye for an hr a day
-patch both eyes, but patch the left for several day and the right for only 1 day so we are strengthening both but not as much for the left since it is her stronger/dominant eye
-patch the left eye for 2 hrs a day and the right eye for an hr a day
3) Patch using one of the above and have her wear glasses (+3.50 in both eyes) to see if that helps bring her eyes into alignment either only when wearing glasses or permanently with or without glasses.  

He said that a second surgery may be needed if the glasses do not work.  He was concerned that because she was farsighted prior to surgery that the farsightedness is causing her eyes to cross and that it may be able to be treated with glasses but he said that he does not know right now and that only time will tell.  He said the second surgery would be done after about 3 months if it is necessary.  

I am wondering if we go with the most aggressive route: Glasses plus patching the left eye twice a day and the right eye for an hour a day, could this cause any problems?  Should we give this more time doing nothing or only patching as the 2nd opinion suggested.  The doctor that did the second option was listed as a top doctor.

I don't want to hinder her healing process in any way and want to help my daughter.  Can the glasses hinder her healing or make her eyes become dependent in order to be in alignment?  Also if the glasses were going to help bring the eyes into alignment how soon would we see that?  Would it be hours, days, weeks?  

He was only recommending the glasses if we noticed her crossing more than right after surgery which I do think she is doing but I wasn't paying much attention to the crossing.  I was focusing more on the right eye.

THANK YOU SO MUCH FOR YOUR RESPONSE.

[John C Hagan III, MD, FACS, FAAO]

Maybe and maybe not. No way to tell. This cases are notoriously difficult to predict. Follow the surgeons recommendations.

JCHMD

[azhardiman]

My daughter had strabismus surgery for intermittent exotropia in December 2013 and her eyes were crossed post surgery.  Now I think they look great even through they do still have some slight crossing sometimes.  So it's 3.5 months post surgery and the doctor wants her to start wearing glasses to address the fact that she is still crossing sometimes.  You noted that it can take 4-6 months to settle so is this a normal course of action to start the glasses now?  Is there still a chance that by 6 months she will be perfectly straight?

[John C Hagan III, MD, FACS, FAAO]

Best of luck JCH MD

[Dinafalah]

Thank you!

[John C Hagan III, MD, FACS, FAAO]

Yes there is a chance but its too early to tell. Discuss with her surgeon.
JCH MD

[Dinafalah]

Hi,
My daughter just did a surgery about 4 days ago as she has exotropia.  I am about to freak out as today after 4 days of pain, i noticed that it still drifts out!!
is there any chance it will be corrected?

[John C Hagan III, MD, FACS, FAAO]

=

[elleness]

Thanks for your prompt responses. :)  and thanks for the rough figures.  I appreciate your feedback very much.  

[John C Hagan III, MD, FACS, FAAO]

Yes patching before surgery can often improve success. I cannot tell you about patching after surgery.

These are very rough figures: Eyes can be made cosmetically straight (not this does not mean perfect vision, perfectly straight and working perfectly together to give 100% depth perception) only that among classmates and out in public the eyes will appear straight.

70% to 75% one operation75-90%   two operations  95% three operations.

You can ask your Ped Ophthal for their estimate

JCHMD

[elleness]

Thanks for your reply!  I have done a lot of research but I like to hear it from a doctor myself. It makes me feel a lot better.  My daughter's PO said that the second surgery is most likely going to take if we patch before surgery.  I know you said patching alone won't cure the condition, but will patching before surgery possible help with the success of a second surgery?  Thanks so much for your response.  I have to remain positive I know, its just hard some days...but I will continue the patching and hope that the second go with surgery will "stick".  Oh, she did make it clear that even if the eyes are straight with a second surgery, that patching and glasses will most likely still be a maintain treatment till maybe she is 10yrs old...so she did let me know that.

[John C Hagan III, MD, FACS, FAAO]

There is no medicine nor any surgery that works 100% of the time. If you will do your own independent research on the internet you will find that under and over correction, second and even third perations are very common.  I used to do a lot of eye muscle surgery, when we hired a ped ophthalmologist for our practice I stopped. Parents were always informed that the surgery did not guarentee straight eyes, that second or third operations may be necessary, that there were risks of damage to the eye and a very very small risk of death during anesthesia. Also that surgery likely would not eliminate the need for glasses. It sounds like the second opinion concurred with the operating surgeon.

Very expensive and time consuming visual therapy, usually pushed by non-physician optometrists has not been shown to be helpful except for convergence insufficiency and then the success is usually low and temporary.

Continued patching does not cure the condition but in a very very small % of children improves their control. In my experience once the patching stopped the eye control faltered again.

JCH MD

[elleness]

Well we had a follow up appointment yesterday.  It will be 3 months since my daughter had surgery Nov. 6th.   Her PO told me that Cayman will most likely end up with a second surgery.  I am devastated by the news.  My daughter is A LOT worse after surgery than before.  Before surgery she had binocular vision 50 percent or more of the time.  Her eye only went out maybe 50 percent of the time, but mainly when she was tired.  Now my daughter only uses her eyes together 5 percent of the time.  Her eye is almost constantly crossed at 10 degrees.  I am so hearbroken.  We actually got a second opinion from another PO a couple weeks ago, and he also said that this will most likely end in getting a second surgery.  

With all that said, I feel our PO rushed into the first surgery.  I feel it might of corrected itself if we patched her good eye longer.  Anyways, now her PO is saying we have to patch her good eye 8 to 10 hrs. a day.  She said this is so my daughter will use her bad eye just as much as her good eye (alternating), and at that point a second surgery can be done.  She said, otherwise the surgery will continue to fail.  She went on to say the my daughter falls into the 20 percentile (surgery not working, and needing another surgery).  I want to know if there is hope that a second surgery will take, or will this happen again?  I am terrified.  What used to be barely noticeable to most people, its noticeable all the time.  Also, vision therapy, what are your views on that?  I also asked her about prism glasses and she said that she does not need those because that would confuse her brain and that would be saying surgery is a definite yes in the future (she also said she generally waits till a little older to go with prisms, my daughter is 2 1/2yrs old).  Right now her glasses are a very low prescription because she sees very well in both eyes.  Its just the crossing that makes her a little far sighted, and the glasses are supposed to help with crossing a little.  I want to know if you have any feedback to give me.  Thank you so much.

[elleness]

Some days I feel so discouraged...because her eye turning in seems to be worse some days.  Her eyes also seem to move around a lot to adjust..  I just am so concerned because her eyes are so much worse after the surgery than before...but am trying to understand that it could be ok in the end of 6 months.  I am also surprised our PO doesn't want to see my daughter sooner than February 11th, since it will be over a month since she saw her last if we wait till then.  I would think she would want to see her sooner than that to take a look at her eyes...any thoughts?    

[John C Hagan III, MD, FACS, FAAO]

You're welcome. These forums are brought to you as a public service by the American Academy of Ophthalmology, America's Eye MDs-Physicians.

see www.geteyesmart.org

JCH MD

[elleness]

Thanks for the information.  You have been extremely helpful!!! :)

[John C Hagan III, MD, FACS, FAAO]

Congential crossed eyes is present at birth,   accommodative crossed eyes usually occurs between age 2-4 years   exotrophia or intermittent exotrophia usually is present by age 18 usually at a much younger age.

JCH MD

[elleness]

Thanks for the heads up.  My 12 month old doesn't have any signs.  My 2 1/2 yr old showed signs at 3 months old..  don't know if their is a common age where it shows up..??  

[John C Hagan III, MD, FACS, FAAO]

Keep the faith mom. And besure that all blood relatives that have children have them checked EARLY for strabismus. Any or your or their children have a 20% chance of having strabismus whereas the risk in familes with history of squint is 2%

JCH MD

[elleness]

Thanks so much!  It seems everyday her eye isn't crossing in as much as the day before.  It seems it is slowly working its way to the center...very interesting to see (don't know if it's just my imagination).  Her eyes still drift and adjust quite a bit but the glasses seem to help her keep her eyes straight about maybe 50 % of the time.  Much better than right after surgery.  Her doctor mentioned that it is crossing in about 5 degrees, but to me it crosses in sometimes more than that at certain times but not very often....and even the other eye crosses in so slightly, but not very noticeable...I guess its all a part of healing. But the good thing it is getting better, and that is a good sign!  :)

[John C Hagan III, MD, FACS, FAAO]

Very good chance this will have a happy ending. When I was doing children eye surgery I was unhappy with straight eyes the day after exotropia surgery while the parents were very happy. These eyes almost always drift out so over-correction was my goal.

JCH MD

[elleness]

Thanks Dr. for your response and words of encouragement.  It makes me feel a lot better.  I have been stressing, looking at her eye everyday since the surgery because they aren't straight.  I am very happy to know there is hope, and may be permanent hope at that.  Thanks again so much for your response, it makes me sigh with relief. :)

[John C Hagan III, MD, FACS, FAAO]

The highest success permanently occurs when the eyes are crossed some after surgery, higher success than if they appear perfectly straight. Your surgeons treatment seems excellent. By success we mean the position of the eyes 4-6 months after surgery.
JCH MD