After strabismus surgery, a film remained. Strabismus after surgery surgery and strabismus vision correction

Strabismus is treated with various methods: glasses, hardware procedures, development and consolidation of binocular functions, surgery and rehabilitation after strabismus surgery. Elimination methods are determined by specialists and depend on a combination of some factors. First of all, on the type of change and its complexity.

There are two types of this disease:

• friendly - approximately the same alternate deviation of the left and right eyes;
• paralytic strabismus - squints one eye.

A common symptom is a "floating" gaze or deviation to the side. It often appears in infants, but disappears as they grow older. Such a syndrome in an older child is a signal of concern.

A sign of concomitant strabismus is an alternating deviation of the left and right eyes. Most often, the deflection angles are almost the same. In this case, eye mobility can be preserved and there is no double vision of the "picture" before the eyes. But there is no stereoscopic perception, that is, a person cannot feel the entire visual completeness of our environment. In addition, sometimes there is a decrease in vision with a certain pathology.

If there is a restriction in the movement of one of the eyes to the side or it is completely absent, then this is a paralytic strabismus, characterized by muscle damage. It can be congenital or acquired (a consequence of injury, disease). This defect is characterized by double vision, lack of binocular perception. Possible deviation of the head towards the squinting eye, dizziness is not uncommon. This type of disease can develop at different ages.

There are several more forms of this deviation:

• converging - the organ of vision is directed to the bridge of the nose;
• vertical - mows down or up;
• divergent - to the temple;
• atypical - the position of the eyes is not characteristic of the normal (it can be permanent or temporary, it is associated with the anatomy of the individual).

If more gentle methods of correcting strabismus cannot correct the situation, the doctor prescribes an operation. After eye surgery for strabismus, recovery begins an important period that affects its outcome.

Often, strabismus surgery does not immediately restore normal vision. Many will agree that it is a pity to look at a mowing young pretty girl or child. Without this cosmetic defect, everything would be fine. In addition, ophthalmologists recommend trying conservative methods of strabismus treatment before going under the knife.

Strabismus is a pathology in which one, both, or alternately the right and left eyes deviate from the normal position when looking directly. When a person looks at an object, the information received by each eye is slightly different, but the visual analyzer in the cortical region of the brain unites everything.

Strabismus can be congenital or acquired. Floating or squinting gaze is common in newborns, especially after a difficult birth. Treatment by a neurologist can relieve or alleviate the appearance of a birth injury. Another cause may be a developmental abnormality or improper attachment of the oculomotor muscles (see Figure 1).

infectious disease: influenza, measles, scarlet fever, diphtheria, etc.; somatic diseases; injuries; a sharp drop in vision in one eye; myopia, hyperopia, high and moderate astigmatism; stress or severe fright; paresis or paralysis; diseases of the central nervous system.

wearing special glasses; a series of eye exercises; wearing a bandage that covers one eye; surgery to correct strabismus.

Intermittent strabismus, when the right or left eye is sometimes squinted, is tried to be corrected by wearing a bandage. Long-term use of specially designed glasses often helps. Exercises to strengthen the ability to focus are recommended for almost all patients with strabismus. If all of the above methods have not corrected vision, strabismus correction surgery is performed. This type of surgery is performed both in infancy and in adulthood.

horizontal - converging and diverging relative to the bridge of the nose; vertical; a combination of the two.

Doctors encounter a convergent squint more often than a divergent squint. Along with converging strabismus, the patient may have hyperopia. Divergent squint is usually observed in people with nearsightedness.

amplifying type operation; weakening operation.

In a weakening operation, the eye muscles are transplanted a little further from the cornea, which deflects the eyeball in the opposite direction.

During augmentation surgery, a small piece of the eye muscle is removed, which leads to its shortening. Then this muscle is sewn to the same place. Surgery to correct strabismus involves shortening and weakening the required muscles, which restores the balance of the eyeball. The operation is performed on one or both eyes. The microsurgeon determines the type of surgery when the patient is in a completely relaxed state on the operating table.

In some clinics, the operation is performed under local anesthesia only for adults. and in others, all patients are given general anesthesia. Depending on age, health status and other factors, mask (laryngeal), endotracheal anesthesia using muscle relaxants or an alternative type of anesthesia is performed.

It is important that during the surgery the eyeball is motionless and there is no tone in the muscles, because the surgeon performs a special test: he assesses the degree of limitation of eye movements by moving it in different directions.

An adult after an operation can go home on the same day. The child also needs preliminary hospitalization. Most often, mothers are in the hospital with the children; they are discharged the next day after the operation. The recovery period takes about 14 days. After discharge, the patient extends the sick leave or certificate in his clinic.

It should be noted that in 10-15% of cases, strabismus is not completely eliminated and a second operation may be necessary. Surgical intervention with adjustable sutures helps to reduce the failure rate. After awakening the patient, the doctor after a while checks the condition of the eyes under local anesthesia.

In adults who have lived for a significant time with strabismus, sometimes double vision after the operation, because the brain has lost the habit of perceiving the binocular picture. If, before the operation, the doctor has established a high likelihood of developing double vision, strabismus is corrected in two stages so that the brain can gradually adapt.

A few days before the surgery, you need to take blood tests, do an ECG and consult with some specialists. Eat 8 hours before the operation. If it is scheduled for the morning, you can have dinner, and if in the afternoon, then a light breakfast is allowed. The child and his mother are admitted to the hospital a couple of days before the operation.

The procedure is performed under general anesthesia. The operation itself lasts 30-40 minutes, then the patient is taken out of anesthesia and transferred to the ward. All this time there is a bandage on the eye. After the operated patient has completely recovered from anesthesia, a surgeon examines him in the afternoon. He opens the bandage, checks the eye, instills special drops and closes it again.

Adults are then allowed to go home with detailed recommendations: what drugs to take, how to bury the eyes and when to come for a second examination. The eye patch is left until the next morning. A week later, you need to come for an examination, where the doctor will assess the healing rate and the condition of the eye. The final assessment of the position of the eyes is carried out after 2-3 months.

For several weeks after the operation, special anti-inflammatory drops and (if necessary) antihistamines are used. The eye will be red and swollen. Sometimes the next morning the eye sticks together due to accumulated pus. No need to be afraid: it is washed with warm boiled water or sterile saline.

Within a month after surgery, you need to carefully protect the eye. Do not swim, stay in dusty rooms or play sports. Children at school are exempted from physical education for six months.

A month after the operation, you need to undergo a course of treatment. To restore the binocular ability to see and recognize the correct picture, you need to undergo special hardware treatment at a medical center. Some clinics have the Amblicor complex, developed by specialists from the Institute of the Brain.

Treatment with this device is a computer video training. It helps to overcome the skill of suppressing the vision of one eye. While watching a cartoon or a movie, an EEG of the visual cortex of the brain and indications of eye work are continuously taken from the patient. If a person sees with two eyes, the film continues, and if only with one, it pauses. Thus, the brain is trained to perceive the picture from both eyes.

The main task of any surgical intervention for strabismus should be considered the restoration of the correct balance between the eye muscles responsible for the movement of the eyeball.

the formation of a special fold at the site of the tendon (tenorraphy); moving the place of attachment of the muscle to the eyeball (anteposition).

Reasons for the formation of strabismus

Strabismus can be acquired or congenital. The formation of each of them has its own causes. For example.

Most often, this type of strabismus develops in children before they reach six months. A significant role in this case is played by the existing diseases that provoked such a side effect. But episodes of the development of strabismus are not uncommon in the older age-old category. The most common causes of acquired strabismus are:

• strabismus as a result of sharply impaired vision with astigmatism, hyperopia, as well as myopia;
• refractive errors of the eye can be provoked by developing cataracts or glaucoma, and as a result, strabismus is formed;
• paralysis of the eye muscles can cause psychological disorders, as well as somatic diseases (for example: neurosyphilis, encephalitis);
• a mild degree of strabismus can provoke circulatory disorders and sudden surges in pressure, and if pathology is ignored, disability;
• experts believe that childhood diseases such as scarlet fever and measles are provoking factors for the development of strabismus.

Strabismus can develop in preschool children after a strong fright, as well as as a result of psychological trauma. These reasons for the development of pathology were recorded in older patients. Although in more rare cases.

In practice, congenital squint is very rare. Even less often, it can be found in its pure form, that is, immediately at the birth of a baby. The manifestation of pathology in the first six months of a baby's life is established as infantile. More often, a newborn has an imaginary squint. Babies of this age are unable to accurately focus their gaze, and at the same time it seems that a pathology is forming in the child.

Infantile strabismus is often formed with genetic disorders and during the period when the fetus is still in the womb. It can be caused by such diseases: cerebral palsy, Cruson's or Down's syndrome, as well as hereditary predisposition. In cases with heredity, one of the baby's relatives also has similar deviations.

At risk are babies whose mothers have suffered infectious diseases during pregnancy, used drugs, as well as medications without the appointment of specialists.

Recovery period

The cardinal method, if necessary, is carried out for both children and adults. There are 2 types of operations to correct this defect:

• strengthening - the effect on the muscle that holds the eyeball in a normal position;
• weakening - the action on the stronger muscle, which suppresses the function of the one that is responsible for the position of the eyeball.

The specialist determines the type of intervention and conducts it under general anesthesia in children and local anesthesia in adults. Innovative technologies make it possible to perform all corrective actions quickly, efficiently, with a minimum rate of injury.

Recovering from strabismus surgery in adults occurs fairly quickly. On the day of the intervention, they are allowed to go home. The procedure does not go unnoticed. There is swelling, redness, discomfort, or pain. This continues for about a week. The end of the painful stage is fully observed after a month.

After surgery, rehabilitation measures are strongly recommended:

• gymnastics for sight;
• the introduction of vitamins by instillation;
• analgesics and anti-inflammatory drugs are sometimes used;
• wearing sunglasses is applied.

An ophthalmologist is visited weekly, who monitors the state of the optic organ in the postoperative period. Physical activity during the month should be kept to a minimum. Banned: sports, steam bath, sauna. The student receives an exemption from physical education lessons.

Exercise for the eyes is needed every day, and throughout the year. This helps to strengthen the muscles, that is, to reduce the risk of relapse. In childhood, vision may fall, so the doctor selects glasses (lenses) for correction.

Rehabilitation after strabismus surgery in children is also quick and good, subject to the doctor's recommendations. Sometimes special glasses may be needed to cover the healthy eye. At the same time, the operated person is recovering much more actively.

Doctors are doing everything possible to fully restore vision, relieve a person of psychological stress, fill his world with the fullness of visual sensations. The capabilities of modern practicing doctors make it possible to solve this issue quickly and efficiently. The discipline and fulfillment of the ophthalmologist's prescriptions is the right way to an optimal result.

Although the strabismus correction operation is performed on the same day and the patient is immediately released home, this does not mean that there is no rehabilitation period. To quickly restore binocular vision, it will take some time to adhere to certain doctor's recommendations and perform special exercises for the eyes.

The first day after the operation, the eye organ will ache, slightly redden and become inflamed. This is a natural state. Also possible short-term visual impairment. During this period, each of your movements must be controlled, since any attempts to touch the eye can only result in an intensifying pain syndrome.

In children, the adaptation time is significantly reduced. The main thing is to perform the exercises prescribed by a specialist and visit an ophthalmologist.

For active recovery, a specialist may recommend using special corrective glasses, as well as covering your healthy eye from time to time. This will help to create stress on the operated organ. Muscles will develop faster and find the desired rate.

Operative intervention

Surgery for strabismus is performed for aesthetic purposes in order to restore the symmetrical arrangement of the eyes. But the surgery itself will not restore vision without complex treatment. The surgeon decides on the method of eliminating the problem directly during the operation.

After surgical correction, there is no need to wear uncomfortable prismatic glasses. This is one of the main reasons why an ophthalmologist sends a patient to a surgeon. Surgery to correct strabismus allows you to improve the quality of life, remove embarrassment due to negative perception of strabismus, and restore a good emotional state. The cost of the operation is calculated individually in each case.

Is the operation dangerous

Eye surgery always involves certain risks. When strabismus is eliminated by an operative method, a negative consequence that occurs more often than others is ghosting. It usually goes away after a while, but there are times when double vision remains. More serious risks include decreased vision quality, retinal detachment, infections, and problems caused by anesthesia. Fortunately, all these complications are extremely rare.

General health is also an important factor. The better the patient feels, the more successful the operation will be, and the faster the eye will recover. In any case, don't worry. The modern level of development of medicine, high-quality equipment and the professionalism of doctors make the likelihood of events developing in a negative way tending to zero.

Most of the patients are diagnosed with a significant improvement in vision after surgery. It happens that the complete correction of strabismus does not occur immediately, and the body needs a long time to recover after a successful operation. In some cases, a second operation may be required. Residual double vision that occurs after surgical procedures is usually eliminated with prismatic glasses.

The first days after the operation, the patient may feel discomfort and headaches, soreness with tension of the eye muscles, the feeling of the presence of a foreign object in the eye. In this case, the doctor prescribes pain medications for him. After a few days, the unpleasant symptoms go away, and the patient can return to an active life. However, heavy exercise is best avoided for a few more weeks.

Will hospitalization be required after surgery? Depends on the general condition of the patient and the recommendations of his attending physician. Most of the operations are performed on an outpatient basis, and the operated patient returns to normal life after a couple of days.

The postoperative recovery takes, on average, about a week. However, in addition to rehabilitation, a course of hardware treatment may also be required to achieve maximum results and a tangible improvement in the quality of vision. The vision will recover over a longer period. Exercises for the eyes and therapeutic procedures will help in this.

Strabismus surgery is available for patients of all ages. You can find out how much the operation costs by signing up for a personal consultation with an ophthalmologist. Average prices range from 15,000 rubles to 30,000 rubles per eye. This is a great way to reduce symptoms, correct the aesthetic effects of strabismus, and simply improve your quality of life.

Strabismus can be congenital in nature, and also result from various factors. And although some consider strabismus only an aesthetic problem, in fact, this pathology is capable of provoking the formation of many unpleasant consequences. It is very important for the patient not only to diagnose the disease in a timely manner, but also to start solving this problem as early as possible. Strabismus surgery is a radical and effective method.

1. Muscle recession involves cutting off tissues from the place of its physiological attachment. After cutting, the muscle is sutured. The specialist selects the optimal place for its future attachment. It can be a tendon as well as a sclera. As a result, the fiber is displaced back and its effect weakens. If the fiber is displaced forward, the action of the muscles, on the contrary, is enhanced.
2. The myectomy operation involves similar manipulations with cutting off the muscle. The difference from the previous type is the absence of a suture procedure.
3. Less trauma to the ocular organ can be achieved with the Faden operation. In this case, manipulations with cutting off the muscle are not performed. The fabric is immediately sewn to the sclera. In this procedure, non-absorbable sutures are used.
4. If the muscle is weakened and it is required to strengthen its action, a shortening operation is used. During surgery, part of the muscle is removed.
5. Another type of operation will help to obtain a similar effect. It involves creating a fold between the tendon and the muscle. It is possible that this fold is formed inside the body of the muscle itself.

Any of the selected strabismus correction operations is carried out in compliance with the main principles. The correction must necessarily be phased. The operation is carried out only on one eye organ. On the second, the procedure is repeated several months later (approximately 3–6). Although with a small mowing angle, the surgeon may decide to correct both eyes simultaneously, this is more often the exception.

If the patient has severe strabismus, surgery is performed in several stages. The fact is that it is undesirable to perform the operation on more than two muscles at a time.

Muscle lengthening or shortening must be carried out evenly from all sides. For example, if the muscle on the right is reduced in size, then on the left it must necessarily increase. In this case, the dimensions of the excision and increase are necessarily identical.

Observing all the main principles of surgical intervention, the specialist tries to keep the connection between the eyeball and the operated muscle as much as possible.

For adult patients, the correction is performed under local anesthesia. At the end of it, a bandage is applied to the patient. You can go home after a few hours. General anesthesia is always used for children (of any age). Without fail, the child is hospitalized for a day, but cases with a longer stay in the hospital are not excluded.

Those who have the opportunity to correct pathology in foreign clinics should pay attention to German and Israeli specialists. Their approach to such a correction is more radical. Almost all types of pathologies are corrected in one step. Another plus is the possibility of performing surgery on babies up to one year old.

What is squint

With friendly strabismus, as you might guess from the name, both eyes are subject to ailment. They mow alternately in approximately the same range. The main cause of this vision pathology is ametropia.

The main distinguishing features:

• if a person looks at a stationary object, then one eye deviates slightly to the nose or to the temple;
• however, the deviating eye may change;
• the mobility of the eyeball is preserved in all directions;
• a person does not observe double vision of the picture before his eyes;
• the patient has no binocular vision;
• the primary and secondary deflection angles of the squinting eye are almost the same;
• deterioration of vision of the squinting eye may be observed.

As a rule, a person with concomitant strabismus has other visual impairments: myopia or hyperopia, astigmatism.

The second type of pathology is paralytic strabismus. The main difference between this type of visual impairment is that the squinting eye does not move, or moves limitedly in the direction of the affected muscle. The image begins to double, and the person loses the ability to see in volume. The disease is facilitated by nerve damage, malfunctioning of the eye muscles, tumors and injuries.

The signs of this type of pathology include:

• where the muscle is affected, the eye does not move;
• primary and secondary deflection angle are different: secondary is larger;
• double vision, loss of volumetric vision;
• dizziness;
• forced slight deviation of the head towards the sore eye.

All age categories are prone to paralytic strabismus: it can develop at any age.

In addition to the above, there is a distinction between converging and diverging (exotropia) strabismus, as well as vertical. In the first case, the squinting eye deviates towards the nose. Convergent strabismus in children is diagnosed more often than in adults; during maturation, it often disappears completely. As a rule, pathology develops against the background of hyperopia.

Diverging strabismus in adults differs in that the eye deviates towards the temple. Pathology occurs with congenital or acquired myopia. With the vertical one - one eye is directed up or down relative to the healthy one.

What happens during the treatment of children in Israel?

• use of glasses, contact lenses for vision correction;
• treatment of amblyopia with hardware methods;
• activities aimed at restoring binocular vision;
• surgical intervention.

The six muscles that rotate the eye are located outside the eyeball under the conjunctiva, i.e. the mucous membrane of the eye. During the operation, the surgeons of the Department of Pediatric Ophthalmology at the Schneider Clinic displace this muscle from the attachment point and strengthen or, conversely, weaken the traction. Usually, at least two muscles must be operated on to correct strabismus. Sometimes only the muscles of the squinting eye are corrected, sometimes both.

For children, operations are performed only under general anesthesia. The choice of general or local anesthesia for adults is at the discretion of the surgeon, but the wishes of the patient are also taken into account.

Do you need glasses after the operation?

Some types of strabismus in children are corrected with glasses, some only by surgery, and sometimes both methods are needed. It is important to understand that surgical treatment of strabismus in children in Israel is not at all an alternative to glasses; it corrects strabismus that could not be cured with glasses. Thus, even after the operation, in most cases, you need to continue to wear glasses.

Do I need to cover one eye with a bandage?

Before surgery, it is sometimes necessary to cover one eye with an eye patch to strengthen the other eye and prevent it from becoming lazy. Good visual acuity in both eyes increases the chances of success for strabismus surgery. Sometimes it is necessary to continue wearing the eye patch for a period of time after surgery to improve results.

Modern surgical methods are characterized by a very high level of efficiency. However, complete success cannot be guaranteed. In some cases, after surgery, some percentage of strabismus remains, but this does not impair the functional properties of the eye and is not a cosmetic defect. Reoperation may be indicated for patients whose strabismus angle has only been partially corrected.

Since the operation is performed on the outside of the eye, there is no risk of visual impairment in most cases. When sewing muscles to the sclera (the white of the eye), the suture is applied at a certain depth of the eye. Sometimes after the operation, an infection may develop, then in most cases simple and effective treatment of children in Israel with eye drops is used.

• After the operation, the eye patch is not applied;
• In the first days after the operation, the operated person has reddening of the eyes, a feeling of discomfort in the eye and slight pain, inflammation of the choroid of the eyeball;
• It is necessary to instill eye drops;
• For several days, it is recommended to avoid getting dust in the eyes and not be in the wind; you cannot swim in the pool / sea for several weeks; there are no restrictions on doing housework;
• After a few days, you can return to school or work;
• After the operation, the following phenomena may occur: discomfort in the eyes, especially when exposed to bright light;
• Slight pain sensation when moving the eyes;
• Redness of the eyes, conjunctival edema and small discharge;
• Double vision usually resolves within a few days.

These are natural phenomena and do not need to be afraid of them. If the patient is concerned about pain, a pain reliever, such as paracetamol, should be taken. The discharge above the eyelashes is cleaned with a cotton swab dipped in warm water or with an eye tissue. The doubling in the eyes will pass when the eye muscles get used to a new position for them.

Do not forget to bury your eyes with drops that are issued upon discharge, in accordance with the doctor's recommendations. Duration of instillation is about 3-4 weeks after surgery.

What can you do after your surgery?

• No restrictions on regular household chores;
• You can read, watch TV and work at the computer. Do not be afraid to "strain your eyes";
• You can swim and wash your hair, but avoid getting water in your eyes;
• Outside the home, you should wear sunglasses and avoid getting dust in your eyes;
• Strong light should be avoided for the first week after surgery.

What should not be done after surgery?

• During the first two weeks, it is not recommended to do physical exercises that require a lot of stress;
• Children can play any games at home without restrictions; you can return to kindergarten or school a few days after the operation;
• It is not recommended to go to the swimming pool / sea for about six weeks.

When to see a doctor?

One of the rare complications after surgical treatment of strabismus in children in Israel is eye infection. If the eyes are red and very painful, with purulent discharge and swelling of the eyelids, if there is a significant decrease in visual acuity, you should immediately contact the nearest emergency room. But in the Department of Pediatric Ophthalmology at the Schneider Clinic, such complications almost never happen.

Due to the fact that the eye does not work correctly, over time it can lose its main function for good, because the brain excludes this eye from the vision process, and after a while the visual skill disappears, after which it is almost impossible to restore it.

The most effective treatment is surgery. This allows you to quickly and without consequences get rid of strabismus, the operated patients often go home the same day, and return to work or school on the third day after the operation.

However, surgical treatment of strabismus provides for subsequent long-term rehabilitation, during which you may have to take strengthening medications, and perform daily exercises for the visual organs.

Etiology of the disease

Surgical treatment of strabismus Source: optimed.by

Strabismus is the absence of a parallel position of the eyeballs when looking at objects located in the distance. With a parallel position of the eyes and coordinated movements of the eyeballs towards the objects under consideration, images from the retina of each eye merge in the visual center of the brain into a single volumetric image.

This type of vision is called binocular and is inherent in most people. With the "wrong" position of one of the eyes, when, with distance vision, the axis of one eye is shifted to the temple or nose, the images do not merge.

The brain perceives the "picture" of one eye, and the information from the other eye is "extinguished", this type of vision is called monocular. There is a gradual deterioration in the eyesight of the squinting eye - amblyopia (colloquially "lazy eye").

The cause of the disease is a violation of the synchronous work of the eye muscles and, as a result, the departure of one eye to the side. The occurrence of strabismus is influenced by:

1. lack of glasses or contact lenses with a high degree of hyperopia, myopia, or astigmatism
2. stress, trauma, diseases of the central nervous system
3. improper development of the eye muscles
4. a sharp drop in vision in one eye
5. infectious diseases.

There are two main types of strabismus:

• concomitant strabismus (characterized by maintaining full range of eye movements)
• paralytic strabismus (there is a restriction of the movement of one or two eyes, in any direction)

Varieties of friendly strabismus:

1. congenital (9-10% of patients) / acquired strabismus (90-91% of patients)
2. periodic / permanent
3. unilateral / intermittent
4. divergent and converging strabismus (with divergent strabismus the eyes are turned to the temple, with converging - towards the nose) / vertical strabismus (deviation down or up)

The earlier the correct diagnosis is made and the treatment of strabismus is started, the better the result will be, the likelihood of achieving straight eyes and maintaining high vision increases. Strabismus in children under three to four months is considered physiological, because muscle balance has not yet been established.

If after this age the strabismus has not passed, then you must definitely contact a pediatric ophthalmologist who will check if there are any reasons for the development of strabismus (farsightedness, myopia, astigmatism).

Taking into account the individual characteristics, the pediatric ophthalmologist selects a set of hardware treatment aimed at eliminating amblyopia, improving visual acuity, restoring the correct position of the eyes, and binocular vision.

There are different treatments for strabismus. Treatment of pediatric strabismus should be started as soon as the disease is detected. Hardware treatment of strabismus includes two groups of methods:

• Pleoptic treatment is a system of methods aimed at treating amblyopia:
  1. light-color stimulation (pattern-stimulation) - based on the stimulation of eye functions with a light flux concentrated in a narrow spectral range
  2. laser treatment (retinal laser stimulation)
  3. magnetostimulation (improving blood supply to the eyes)
  4. electrical stimulation (improving hemodynamics, activating metabolic processes, increasing the energy potential of tissues)
• Orthopedic treatment:
  1. liquid crystal glasses (alternating stimulation of both eyes, contributes to the development of the motor-fixation reflex, increased visual acuity and the development of binocular function)
  2. binarimeter is a new generation device that allows you to form binocular vision in vivo
  3. computer methods for strengthening binocular function and improving visual acuity
  4. training weakened accommodative function

In some cases, in addition to hardware treatment, surgery can be performed to achieve the correct position of the eyes. If the strabismus angle is large, then surgical treatment is carried out in two stages.

The favorable age for surgical treatment in children is 4-6 years (before entering school). Strabismus in adults is much more difficult to treat.

Treatment of concomitant strabismus begins with the appointment of the correct optical or laser correction. Glasses, contact lenses, or surgery can help improve visual acuity and, by restoring normal eye function, can help reduce the angle of strabismus.

In some cases, with a decrease in the vision of the squinting eye, especially in children, a "shutdown" of the non-squinting healthy eye is prescribed (direct occlusion - a sticker) so that the squinting eye is included in the act of vision.

The causes of the onset of the disease

The pathogenetic mechanism distinguishes between friendly and paralytic strabismus. In case of concomitant strabismus, the angle of deviation of the affected eye from the fixation point corresponds to the angle to which the healthy eye deviates if the patient is asked to “turn on” the squint.

Characteristic features of vision with strabismus

Eye mobility in this pathology is fully preserved, double vision does not occur (the image from the squinting eye is simply “discarded” by the brain during the processing stage). Most often it occurs against the background of ametropia (refractive error), in particular in people with hyperopia.

Other reasons:

1. anisometropia (difference in the refractive power of the eyes) over 3 diopters);
2. a sharp decrease in the vision of one eye, including against the background of a decrease in the transparency of the natural "lenses" of the eye - the cornea, lens, vitreous;
3. disruption of the retina, diseases of the optic nerve;
4. neurological diseases;
5. congenital anomalies.

Paralytic strabismus is associated with dysfunction of any oculomotor muscle or nerve that innervates it. The main differences between this form of the disease:

• restriction or absence of eye movement towards the affected muscle;
• lack of binocular vision and diplopia (double vision);
• the difference between the primary and secondary strabismus angle - the squinting eye deviates from the fixation point less than a healthy one, when trying to give the correct position to the eye, which moves the affected muscle.

The causes of the disorder vary from a birth defect to an inflammatory process, neurological disease, injury or poisoning. Sometimes diabetes mellitus debuts with paralytic strabismus, therefore, examination of patients with strabismus is always complex and exhaustive.

Hardware diagnostics of strabismus

Surgical treatment of strabismus is carried out in two ways, depending on the cause that provoked this deviation. If weakened muscles of the visual organs are identified, tenorrhaphy, anteposition, resection or the Faden procedure is indicated.

If the axis deviations were provoked by overstrain of the muscles of the optic organs, a recession, plastic surgery / removal of the oculomotor muscle or partial myotomy is performed. Before the operation, the patient is prepared, which includes:

1. delivery of laboratory tests;
2. consultation of narrow-profile specialists and other studies in the direction of the attending physician.

If the patient is shown to operate on two eyes, a phased intervention is recommended with a break of several months. To obtain successful results, experienced surgeons calculate the size of muscle areas in advance.

When significant strabismus is detected, it is not recommended to carry out restorative correction on more than two eye muscles at the same time. The shortening or enlarging is carried out evenly on each side.

It is very important to maintain the natural connection of the eye with the muscle being corrected so as not to provoke unpleasant consequences that affect the level of visual activity. That is why operations of this kind are best performed in clinics with good reviews, which have modern equipment and a staff of experienced specialists.

Why treat squint?

There is an opinion that strabismus can go away on its own - this is a serious delusion. If treatment is not started on time, serious complications may develop. If you notice the first signs of strabismus, you should immediately consult an ophthalmologist.

Danger of ignoring treatment

Refusal of treatment in childhood can lead to the inability to choose in the future many professions, for example: surgeon, artist, professional driver and a number of other specialties associated with strenuous visual work.

If, nevertheless, strabismus was not corrected in childhood, now there is an opportunity to undergo an operation to correct strabismus at any age. It is necessary for the ophthalmologist to conduct an examination, after which he will prescribe a surgical operation, based on the state of the oculomotor apparatus and the angle of deviation of the eye.

At present, it is customary to perform only such operations in which the muscles remain connected to the eyeball, since these operations can be dosed to a certain extent. The correct position of the eyes can be restored in the vast majority of cases.

In order to weaken the muscle, it is recession (pushing back), partial myotomy (incomplete dissection), tenomyoplasty (lengthening), etc.

There are two types of strabismus surgery: strengthening and weakening. The principle of weakening surgery is to change the place of attachment of the muscle, which the ophthalmic surgeon transplants further from the cornea, after which the action of the strong muscle (the one towards which the eye is deflected) is weakened.

The treatment of this ailment should not be postponed, since over time, the eye deviated to the side begins to see worse over time. With strabismus, in most cases, the ability to see normally is retained only by the eye that provides vision.

It is necessary to know that the goal of strabismus correction operations is to achieve an aesthetic effect, restore binocular vision (when the two images obtained by the eyes are joined by the brain into one) is very difficult and it is necessary to approach such treatment comprehensively and thoroughly.

Sometimes both eyes are operated at once, with some types of strabismus only one eye is operated. The essence of operations to correct strabismus is reduced to strengthening or weakening one of the muscles that move the eyeball. Such an operation is performed on an outpatient basis, under local drip anesthesia. The patient returns home the same day.

Operation statistics

Surgical intervention in the treatment of concomitant strabismus is used in cases where conservative methods cannot achieve a symmetrical position of the eyes. All children with non-accommodative strabismus and 35-40% with partially accommodative squint are subject to surgical treatment.

Most ophthalmologists consider the most favorable age for surgery to be 4-6 years (before entering school), when the effect of glasses on the strabismus angle has already been clearly defined and orthoptic exercises can already be carried out in the pre- and postoperative periods.

The exception is children with congenital and early-onset strabismus with a large deviation angle - 45 ° and more. Correction of such a large deviation with a one-time operation is impossible, therefore, surgical treatment is carried out in two, and sometimes in three stages.

The first stage - reducing the angle of strabismus - should be carried out, if possible, earlier, in the first or second year of life, as soon as the general condition of the child allows anesthesia and the operation to be performed.
The second stage - correction of strabismus - can be carried out in 4 - 5 years.

The entire period between the first and second operations, the child should receive the treatment indicated in each case: optical and therapeutic correction, direct or alternate occlusion, penalization, training of the oculomotor muscles, if possible, hardware pleoptic and orthoptic treatment.

Surgical operation often takes place in 2-3 stages, if necessary, pleoptic treatment is carried out, after the restoration of the correct position of the eyes - orthopto-diploptic.

One should not rush to the operation in children with partially accommodative strabismus and a small deviation angle - up to 10 degrees - and a clear tendency to decrease it.

In these cases, it is necessary to prolong the active conservative treatment using all the indicated and available methods, and the decision on the issue of surgical treatment should be postponed to a later date. In some of these children, the treatment of strabismus was successfully completed without surgery.

The question of the need for surgical treatment of children with convergent strabismus in cases where glasses have a symmetrical eye position and binocular vision, and without glasses, deviation to the nose is observed and binocular vision is impaired, remains controversial.

Many ophthalmologists believe that in such cases it is necessary to operatively weaken the internal rectus muscles (their recession) and achieve the correct position of the eyes without glasses.

The experience of observing such children after operations does not confirm the correctness of this position, since in some children with similar data the appearance of secondary divergent strabismus was noted. Having analyzed the cases of this unpleasant complication, we identified the reasons for its occurrence.

• The binocular vision that existed before the operation collapsed during the surgical intervention on the oculomotor muscles, and after the operation no vigorous measures were taken to restore it, to develop strong fusional reserves that could prevent the secondary deviation of the eyeball.
• In some children, a change in the configuration of the orbits due to the growth of the bones of the facial skull mattered, which, with instability or the absence of binocular vision, led to the appearance of divergent strabismus.
• In some children, the optical plus spherical correction was not weakened in a timely manner, which could have prevented the appearance of outward deviation.

We believe that if a child has a symmetrical eye position and has developed binocular vision with glasses, then there are chances to achieve this without glasses. This takes time and persistent treatment.

In such cases, the oculomotor muscles are trained on a muscle trainer, with electrical stimulation we strengthen the external rectus muscles, develop and train negative fusional reserves, carry out exercises to disconnect between accommodation and convergence, and strengthen binocular vision with orthopto-diploptic exercises.

And we succeed! Symmetrical eye position and binocular vision are gradually established without glasses. If a patient for some reason cannot receive such treatment, then even more so he cannot be operated on.

Risk of surgery

Having destroyed his binocular vision by the operation and not being able to restore it, we increase the risk of developing secondary divergent strabismus. Patients with asymmetric binocular vision should not be operated on.

In the presence of deviation in the study on the color test and with the help of striped Bagolini glasses, binocular vision is determined, and on the synoptophore in the zero position of the optical heads, the fusion of objects is determined.

After the operative restoration of the symmetrical position of the eyes, these patients develop persistent diplopia, which disappears only after the eyes return to their previous oblique position (recurrence of strabismus).

Children with such an anomaly are subject to long-term vigorous treatment to destroy and weaken the abnormal functional connections formed in the higher parts of the visual analyzer, and only after treatment can they be operated on.

Indications for surgery

In the therapeutic treatment of strabismus, different techniques are used:

1. pleoptic course aimed at increasing the visual load on the problem eye;
2. orthopedic - provides for the restoration of the binocular function of each eye;
3. diplopic method - a set of therapeutic measures aimed at obtaining a comprehensive result, provided for by the pleoptic and orthopedic course;
4. active training of the oculomotor muscles.

After therapeutic treatment, the patient is again examined by a specialist. If conservative methods have not allowed to restore the symmetry of the eyes, the patient is recommended to surgically treat strabismus. The best age for operating on young patients is 4-6 years.

During the rehabilitation period, the operated person will have to perform certain eye exercises.

The purpose of the operation: elimination of the asymmetric arrangement of the visual organs. Positive visual changes are observed after surgery. If the patient also has vision problems, additional intervention will be required, since conventional surgery to eliminate strabismus does not provide for improved vision.

Surgical treatment of strabismus gives effective results if the patient has a non-accommodating form of pathology or partially accommodative, within 35-40%.

If the deviation angle is 45% or more, one operation will not be enough to eliminate the visible defect. As a rule, in such cases, the surgical procedure is carried out in 2-3 stages, which depends on the severity.

Types of surgical intervention

Due to the fact that surgical treatment of strabismus is a very important stage in getting rid of this disease, it requires a responsible approach and careful preoperative preparation. It includes psychological preparation, full examination and correction of the detected deviations.

Of great importance is ophthalmic preparation, which will allow you to develop binocular vision instead of occlusion. Sometimes it may be necessary to weaken the nerve connections and train the oculomotor muscles.

In addition, a range of procedures may be required to improve treatment outcomes during the postoperative period. There are two types of operations:

• Laxatives.
• Enhancing.

With weakening, there is a change in the place where the muscles are attached. It simply moves inward from the cornea. This weakens the muscle that caused the eye to deviate.

Correction of strabismus

With the intensifying type of intervention, the muscle is shortened by removing one of its segments. In this case, the place of attachment of the muscle remains unchanged. After carrying out these manipulations, the eye muscles are balanced by strengthening the weak or weakening the strong muscle.

What kind of operation should be used is determined by the surgeon directly at the surgical table. This is due to the fact that this choice is influenced by many factors, for example, the following:

1. The age of the patient;
2. Location of the oculomotor muscles;
3. Strabismus angle;
4. The state of the oculomotor apparatus.

Usually several muscles are operated at once. If a patient has an alternating strabismus (there is an alternate deviation of the eyes from the central axis), then the surgical intervention is performed simultaneously on the muscles of both eyes. There are cases when a combined intervention is performed (strengthening one muscle and simultaneously weakening the other).

The surgery takes place under local anesthesia, and the final recovery takes about seven days. Doctors strongly recommend that you also undergo a course of hardware treatment.

Hardware surgery

Source: moscoweyes.ru

In general, strabismus surgery is of two types. The first type of surgery is aimed at weakening an overly tense oculomotor muscle. An example of such operations is recession, partial myotomy, muscle plastic.

The second type of surgery is aimed at enhancing the action of the weakened oculomotor muscle. An example of operations of the second type is resection, tenorraphy (shortening of a muscle by forming a fold in the muscle tendon area), anteposition.

A combination of the aforementioned types of surgery (recession + resection) is often used during surgery to correct strabismus.

If after the surgical intervention there is residual strabismus, which is not leveled by self-correction, a second operation may be required, which is usually performed after 6 to 8 months.

To achieve maximum efficiency in strabismus surgery, several basic principles must be followed.

• Excessive acceleration of the process of surgical correction of strabismus often leads to unsatisfactory results. Therefore, all manipulations should be dosed (if necessary, in several stages).
• If necessary, weakening or strengthening of individual muscles, dosed surgical intervention should be distributed evenly.
• During the operation on a particular muscle, it is necessary to maintain its connection with the eyeball.

High-tech strabismus surgery: specialists of children's eye clinics have developed a modern high-tech radio wave surgery with the principles of mathematical modeling. Benefits of high-tech eye surgery:

1. Operations are low-traumatic, thanks to the use of radio waves, the structures of the eye are preserved.
2. After the operations, there are no terrible edema, the patient is discharged from the hospital the next day.
3. The operations are accurate.
4. Thanks to the principles of mathematical calculation, we can ensure the highest accuracy and show a guaranteed result of the operation even before it is carried out.
5. The rehabilitation period is reduced by 5-6 times.

The result of the operation: highly effective strabismus surgery technologies make it possible to ensure a symmetrical gaze position in various types of strabismus, including those with small and inconsistent angles, to restore the mobility of the eyeball in paralytic strabismus in 98% of cases. This is a unique way to effectively help the patient.

Surgical treatment of strabismus in children

Conservative treatment of strabismus provides for long-term and active implementation of a complex of pleopto-orthoptic exercises. In cases where this does not eliminate strabismus, they switch to surgical treatment.

Duration of the operational process

Surgery to eliminate strabismus in adult patients can be performed at any time, depending on the patient's wishes. Before daring to undergo strabismus surgery, you need to understand that this surgical intervention will help get rid of the external manifestations of strabismus.

The return of lost vision is not possible in all cases. The choice of surgical intervention is largely influenced by the angle of deviation of the eye and the general condition of the oculomotor apparatus.

At the present time, it is customary to perform only those operations in which the muscles are not separated from the eyeballs, because these operations can be dosed to a certain extent. To weaken the muscle, they use its recession (pushing back), partial myotomy (incomplete dissection), tenomyoplasty (lengthening), etc.

To strengthen, resection (removal) of the tendon-muscle part and propraphy (forward movement) are performed. The physiological position of the eyes during these operations can be restored in most cases (up to 90%). After the operation, slight deviation (deviation) may remain.

In the future, this deviation can be eliminated with conservative orthopto-diploptic treatment. Reoperations are rarely necessary. Surgical treatment of strabismus in children and adults can be carried out in two ways: strengthening and weakening interventions are performed.

With weakening surgical interventions, the place of attachment of the oculomotor muscle is changed. It is transplanted further from the cornea. Thus, they achieve a weakening of the stretching of a strong muscle (in the direction where the eye is deflected).

Strengthening surgery consists in shortening the muscle by removing (resecting) a certain part of it. The place of attachment to the eyeball does not change. Thus, the action of the weakened opposite muscle is enhanced.

Such a surgical intervention makes it possible to restore a uniform muscle balance by strengthening or weakening one of the oculomotor muscles. The surgeon gives preference to one or another type of surgical intervention directly on the operating table.

This is due to many features that need to be taken into account: the angle of strabismus, the location of the muscles in a particular patient, the state of his oculomotor apparatus, age and other individual characteristics. Often, several muscles of the oculomotor apparatus are operated on.

Simultaneous operations, which are carried out on the muscles of the same name in both eyes, are preferred for alternating strabismus. If indicated, combined ophthalmic surgery is also performed. During which they simultaneously weaken the oculomotor muscle of one eye and strengthen (resect) the muscle of the other eye.

It is important that a good cosmetic effect is achieved as a result of surgical treatment. After all, most patients, both children, adolescents and adults, are constantly under stress because of their appearance. The operation fixes this problem.

Surgical treatment to correct strabismus is carried out under local (drip) anesthesia. The final recovery after such an operation takes about one week, but ophthalmologists strongly recommend an additional course of hardware treatment.

Experts have proven that a person with normal vision sees a slightly different image with the right and left eyes. You can check this by first closing one and then the second eye. Vision is normal - binocular.

And in order for the operated patient to see one image, and not two, only the operation is not enough. This is due to the fact that the brain is not yet used to such work. It is in order to restore physiological binocular vision that constant exercises are required for a long time.

The essence of surgical treatment

Strabismus is the result of an imbalance between the 6 oculomotor muscles. During strabismus surgery, these muscles are weakened or strengthened in such a way as to restore the lost balance and thus return the eyes to the correct position.

Muscle weakening is done by moving the end of the muscle closer to the equator of the eye so that its tone is reduced. Strengthening the muscle is done by removing part of the muscle and sewing the remainder to the place of fixation, which leads to shortening of the muscle and increasing its tone.

Adjustable suture surgery is a modern method of strabismus correction, which significantly increases the success of the operation. The essence of the method lies in the imposition of muscle sutures so that it remains possible to adjust them when the patient regains consciousness after the operation.

If after waking up the correction is insufficient, open the knot of the muscle suture and tighten the threads until the desired effect is achieved. It is important to note that modern general anesthetic techniques are safe and low-risk, and the likelihood of serious complications is roughly close to the likelihood of a road accident on the way to the hospital.

Using this method gives an additional 10% success rate. Surgery to correct strabismus in children is performed only under general anesthesia, while in adults the choice of anesthesia depends on the patient and the doctor's preferences.

Most patients return to school or work within three days of surgery. Follow the doctor's instructions and instill the prescribed eye drops within two weeks after surgery. After about three weeks after the operation, its symptoms are leveled.

The modern technique of surgical correction of strabismus is very effective, although it does not reach one hundred percent. In 10-15% of surgeries, there remains a resistive slight strabismus, which, in the opinion of most operating strabologists, does not interfere with normal life and performance of duties.

If the residual strabismus is of a high degree, it is possible to perform a second correction operation, since the operation is performed on extraocular muscles and practically does not pose a threat to vision. In very rare cases, an infection of the surgical site appears, which, fortunately, is effectively treated with antibiotic drops.

Sometimes in the early postoperative period, double vision appears, which disappears within a few days. In very rare cases, the diplopia does not go away and then there is a need for additional types of correction.

Conditions of the operation

Since the recovery after strabismus surgery is quite quick and easy, many patients from abroad combine a pleasant trip with medical tourism and undergo surgery in the Holy Land. You must arrive two to three days before the operation for a check.

After a couple of weeks after the operation, you can return home. It is important to bring all medical certificates and documents from previous examinations with you to your check-ups. The correct position of the eyes can be restored in the vast majority of cases (up to 90%). Reoperations are rarely required.

Surgical treatment of strabismus consists either in weakening the action of the strong muscle (the one towards which the eye is deflected), or, conversely, in strengthening the action of the weak, i.e., the opposite muscle. The volume and nature of the intervention are selected depending on the state of the oculomotor apparatus, the angle of strabismus and the patient's age.

In many cases, it is necessary to resort to combined operations on both strong and weak muscles, interventions in both eyes, to perform surgical treatment of strabismus in several stages.
Strabismus surgery can be performed under either general or local anesthesia.

After the operation, without fail, conservative therapy is carried out, which is aimed at the complete rehabilitation of visual functions, and apparatus treatment aimed at restoring and strengthening binocular vision, otherwise strabismus may recur.

Rehabilitation

Surgical treatment of strabismus allows you to correct a cosmetic defect, which is a strong traumatic factor for patients of any age. A one-stage operation to correct strabismus in adults can be performed on an outpatient basis; in the treatment of children, in most cases, hospitalization is necessary.

However, restoration of visual functions (i.e. binocular vision) after surgery requires an integrated approach, which includes pleoptic therapy (it is aimed at treating concomitant strabismus amblyopia) and orthopodiploptic therapy (restoration of deep vision and binocular functions).

The estimated recovery time after surgery is 1 week, but for the restoration of full binocular vision, i.e. the ability to see a three-dimensional picture with two eyes at the same time is not enough.

During the time a person had strabismus, the brain, figuratively speaking, "forgot how" to combine images from both eyes into a single image, and it will take a long enough time and considerable effort to "teach" the brain to do this again.

It should be mentioned that, like any operation, surgical correction of strabismus may be accompanied by the development of certain complications. One of the most common complications of strabismus surgery is overcorrection (the so-called overcorrection) due to calculation errors.

Hypercorrection can occur immediately after the operation, or it can develop after some time. For example, if the operation was performed in childhood, then in adolescence, when the eye grows, the child may again develop squint.

This complication is not irreparable and can be easily corrected with surgery. This surgery is performed in most ophthalmological centers in Moscow and Russia (both commercial and state).

When choosing a clinic for surgery to correct strabismus, it is important to study the capabilities of the clinic, the conditions of stay, the equipment of the clinic with modern equipment and other important points. It is equally important to choose the right doctor for the operation. after all, the prognosis of cure will fully depend on his professionalism.

If you or your relatives have already undergone surgery to correct strabismus, we will be grateful if you leave feedback about the intervention and the clinic where the procedure was performed, as well as the results obtained.

Operation results

When deciding on an operation for strabismus, you need to know that such a surgical intervention allows you to get rid of the external manifestations of strabismus, but it does not always return the ability to see well.

Operations for strabismus are of two types: strengthening and weakening. During the weakening operation, the place of attachment of the muscle changes, it is transplanted further from the cornea. That is, there is a weakening of the action of a strong muscle (the one towards which the eye is deflected).

During the reinforcing operation, the muscle is shortened by removing part of it, the place of attachment of the muscle to the eyeball remains the same. That is, the action of the weak, opposite muscle is enhanced.

As a result, such a surgical intervention allows you to restore the correct muscle balance, strengthen or weaken one of the muscles that move the eyeball.

The type of operation is determined by the surgeon directly on the operating table, since with such a surgical intervention it is necessary to take into account many features: the angle of strabismus, the location of the muscles in a particular person, the state of the oculomotor apparatus, the patient's age, and others.

As a rule, several muscles are operated on. Sometimes both eyes are operated at once, with some types of strabismus only one eye is operated. There are cases when an ophthalmic surgeon performs a combined operation on both eyes on both strong and weak muscles. This operation is performed in several stages.

It is important that the result of the surgical intervention is, first of all, a good cosmetic effect. Most people, both adults and children, adolescents constantly experience psychological trauma because of their appearance. The operation solves this problem.

Surgical treatment to correct strabismus is performed in the "one day" mode, under local drip anesthesia. On the same day, the patient returns home. The final recovery takes about a week, however, after such a surgical operation, doctors strongly recommend a course of hardware treatment.

Experts quite often mention that in a person with normal vision, each eye receives slightly different images (this can be seen by first closing one eye and then the other). Normally, vision should be binocular.

Binocular vision is vision with two eyes with the connection in the visual analyzer (cerebral cortex) of the images obtained by each eye into a single image. In order for a person to see one picture, and not two, the operation is not enough. The brain is not used to this kind of work.

One of the main results of surgery is an excellent cosmetic effect. After all, strabismus greatly complicates people's lives, especially for children and adolescents who feel some discomfort, and sometimes are ridiculed by their peers.

After the surgery, these problems become irrelevant. The difficulty lies in the fact that with normal vision, each of the eyes receives a slightly different picture, which the brain processes and combines into one.

In a person with strabismus, after surgical treatment, the brain is not able to immediately acquire the ability to combine these pictures. Therefore, for the normal functioning of binocular vision, it is necessary to carry out exercises for a long time to restore this function.

Or strabismus is a defect in the malignant system, in which one or both eyes deviate when looking straight ahead. This pathology can occur both in children and in adulthood. Treatment should be comprehensive.

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Strabismus and its consequences

Strabismus requires immediate treatment. In its absence, amblyopia develops, bilaterally impaired vision and double vision. In addition to health problems, the patient develops a number of complexes that will interfere with his normal life.

Causes

There are many reasons for the development of strabismus. Congenital pathology occurs against the background:

• abnormal development of the embryo;
• premature birth;
• genetic factor;
• congenital cataract.

The acquired deviation occurs under the influence of a number of negative factors and concomitant diseases. The main reasons for the development of strabismus:

• oncology of the retina;
• thorn;
• paralysis of the eye muscles;
• high pressure;
• brain trauma;
• diabetes;
• thyroid disease;
• optic nerve atrophy;
• encephalitis;
• astigmatism;
• cataract.

It is often observed in patients with severe psychological conditions.

Symptoms

Symptoms directly depend on the type of pathology. Strabismus can be paralytic and friendly. In the first case, strabismus occurs against the background of paralysis of one of the muscles of the eye. As a result, one eyeball deviates from the axis.

The patient ceases to perceive the image with two eyes. Frequent headaches and dizziness are observed. A person cannot determine the location of this or that object.

In the case of concomitant strabismus, both eyes can move in all directions. There is no double vision in the eyes. When trying to focus on an object, both eyes tilt to the side.

Strabismus can be accompanied by myopia, hyperopia, astigmatism, and other disorders of the visual system. In some cases, strabismus may not manifest itself in any way.

Classification

There are two main ones: friendly and paralytic. The first type most often occurs in patients with ametropia and anisometropia. With the paralytic type of deviation, double vision and impaired binocular vision are observed. This type of pathology can occur as a result of injury, toxicosis, or severe poisoning.

There are also the following forms of strabismus:

1. Convergent. The eye is directed to the bridge of the nose. Often occurs against the background of hyperopia.
2. Divergent. It is combined with myopia, with the eye directed to the temple. The cause may be a brain disorder, fear, or an infection.
3. Vertical. The eyeball can slope up or down.

Atypical forms are very rare. They are caused by anatomical abnormalities in development. For example, Down syndrome or Brown syndrome.

In terms of stability, strabismus can be permanent or permanent.

Diagnostics

Only an ophthalmologist can make an accurate diagnosis. For this, a visual examination is carried out and the causes of the disease are established. The examination involves checking visual acuity, determining the angle of strabismus and assessing eye friendliness using special mirrors. The doctor studies the mobility of the organs of vision in different directions.

A consultation with a neurologist is required to confirm the diagnosis. Treatment of strabismus begins at the time of diagnosis and can last from 2 to 3 years. In some cases, it is impossible to completely get rid of the defect, but only to improve the patient's condition.

Treatment methods

Strabismus therapy methods can be divided into traditional and surgical interventions. Traditional treatment means a number of techniques aimed at normalizing the oculomotor muscle function and increasing visual acuity.

Expert opinion

Slonimsky Mikhail Germanovich

Ophthalmologist of the highest qualification category. Has extensive experience in the diagnosis and treatment of eye diseases in adults and children. Over 20 years of experience.

Therapeutic treatment involves occlusion and hardware exposure. The first option is to wear special stickers and occluders that help integrate both eyes into the visual process. The mode of wearing such products is determined by the doctor, after a thorough examination of the patient.

Hardware therapy normalizes visual functions with targeted complex stimulation. For this, modern high-tech devices are used.

Surgical treatment is prescribed when traditional methods of therapy are ineffective. The operation allows you to restore symmetrical or close to symmetry position of the eyes by normalizing muscle balance.

Eye gymnastics is performed as an additional technique or prevention. The set of exercises is selected by the doctor. Most often these are a variety of exercises with a string, pictures or a flashlight.

Surgical therapy is based on weakening or strengthening the muscles that move the eyeball. With severe strabismus, several surgical interventions may be required at once.

Surgery is performed on an outpatient basis. The need for hospitalization depends on the patient's condition and the surgeon's recommendations. Most people return to their normal lives a few days after surgery.

Indications

For adults, the operation is performed at any age, for children - from 6 years of age. In some cases, the doctor may decide on the need for surgical treatment of strabismus at an earlier age.

Indications include impaired binocular vision and ineffectiveness of conservative therapy.

When can you be refused?

The specialist may refuse to carry out surgery. This is possible if the patient has an aggravated disease. Contraindications include the presence of respiratory tract infections: runny nose, cough and other symptoms.

Types of surgical intervention

With strabismus, several types of surgery can be performed. Depending on the indications, it is carried out:

• stitching the oculomotor muscle to the tendon or sclera;
• myectomy - muscle clipping without suturing;
• muscle part resection - removal of excess muscle fiber;
• the laying of folds on the muscle.

The essence of the intervention boils down to the fact that a too long muscle is shortened, and a short one is lengthened.

Training

The operation is performed under general anesthesia and on an outpatient basis. The patient should arrive on an empty stomach, at least 6 hours after the last meal. In the case of morning surgery, it is forbidden to eat or drink after midnight. If the procedure is scheduled for the afternoon, a light breakfast is allowed, but no later than 8 am.

1-2 weeks before surgery, you need to undergo the following examinations:

• hCV research;
• smear morphology;
• analysis of the level of potassium and sodium in the blood;
• blood clotting time;
• analysis for sugar;
• analysis for the presence of HBS antigen.

In the presence of concomitant diseases, additional studies and consultations with other specialists are prescribed. Patients over 40 years of age need to undergo an EKG study with a description, and after 60 years, an RTG chest study with a description is prescribed.

It is recommended to be vaccinated against hepatitis B before the operation. A safe level of antibodies is observed in the second week after the second dose of the drug. The third vaccination protects the body for a longer period - from 5 to 8 years. Vaccination efficacy is determined by testing for antibody levels.

How is the procedure performed?

For the operation, it is necessary to ensure the complete immobility of the eye muscles. For adults, the intervention is performed under local anesthesia, and for children under general anesthesia.

Stages:

1. Applying a special mask to the face with eye slits.
2. Fixing the eyelids with spacers.
3. Gaining access to the eye muscles through an incision in the sclera.
4. Muscle length correction.
5. Suture application.

The probability of maintaining pathology after surgery is 10-15%. To maintain the result and avoid complications, it is necessary to properly recover.

Recovery period

In the first few days after surgery, the operated eye may appear reddened and swollen. Temporary blurred vision is also normal. Due to the seams, there is a foreign object sensation in the eye.

To avoid the development of complications, a gentle regimen must be observed after the operation.

During the first weeks, it is necessary to take anti-inflammatory drugs. Most often, Tobradex is prescribed 3 times a day, 1 drop. Purulent discharge must be removed by washing with warm boiled water.

The first control is carried out one week after the intervention. The doctor evaluates the healing process and prescribes additional medications if necessary. Further control is assigned for 2-3 months.

What not to do

You cannot swim for a month after the operation. It is necessary to protect the eyes from contamination. For 2-3 weeks, you need to give up physical activity. If the correction of strabismus was carried out in a child, then he is given an exemption from physical education lessons for a period of six months.

Possible complications

Immediately after the correction, the patient may have double vision. This is normal and goes away on its own in 2-3 days. In most cases, surgery to correct strabismus goes without complications. However, it is not always possible to get a 100% result after the first intervention. In some cases, several procedures are required.

Potential complications include decreased vision, misalignment of the eye axis, or an adverse reaction to anesthesia. There is also a risk of infection.

Useful video

Strabismus. How to return a "direct" look:

The cost

The cost of treatment depends on many factors. The price for the operation is indicated for one eye. On average, surgery will cost about 27,500 rubles. Correction of paralytic strabismus will cost 82,500 rubles.

Currently, the generally accepted method of complex treatment of concomitant strabismus, which consists of optical correction of ametropia, measures to combat amblyopia (pleoptics), operations on the eye muscles, and the performance of orthotic and diploptic exercises in the pre- and postoperative periods. The need for surgical treatment of strabismus arises in cases where the constant and long enough (at least a year) wearing correctly prescribed glasses and orthoptic exercises do not lead to the elimination of deviation.

In the process of treating patients before surgery, the main attention should be paid to correcting visual fixation and increasing the visual acuity of the amblyopic eye, developing the ability of the visual analyzer to merge foveal images of objects, and obtaining a sufficient fusion width and eye mobility.

The ultimate goal of treating concomitant strabismus is to restore binocular vision. The operation should help, not hinder the achievement of the specified goal. In this regard, the modern tactics of surgical treatment of strabismus is characterized by the refusal to perform forced interventions, the even distribution of the effect of the operation on several muscles and the use of such types of operations in which the muscle remains in its plane and maintains a reliable connection with the eyeball.

The expediency of adherence to the above principles is confirmed by the results of histological studies, which show that the degree of muscle tension has a great influence on the regeneration process. Both excessively strong and weak tension negatively affect the normal recovery process in the muscle.

The optimal age for performing surgery for concomitant strabismus is considered by most ophthalmologists to be 4-6 years, when the effect of optical correction of refractive errors is already clearly visible and when it is already possible to conduct active orthoptic exercises in the pre- and postoperative periods.

It should be borne in mind that when strabismus occurs at an early age (in the first year of life), the development of the binocular visual system does not occur correctly, from the very beginning it adapts to the asymmetric position of the eyes. In such cases, early and ideally dosed surgery on the eye muscles can create conditions for the formation of normal binocular vision, if there are no contraindications from the retina. Based on these considerations, a number of authors propose to carry out operations for strabismus in early childhood, especially with very large deviation and the presence of ocular torticollis.

When examining patients before surgery, it is necessary to obtain complete data on visual acuity and visual fixation, eye refraction, strabismus angle value, the nature of vision with two eyes open, eye mobility, the ability of the visual analyzer to merge foveal images of objects and fusion reserves at the strabismus angle. The analysis of these data will make it possible to clarify the indications for the operation, determine the rational tactics of its implementation and predict the likely outcome.

If, after active pleoptic treatment, the amblyopic eye retains a low visual acuity (less than 0.3), which prevents the formation of binocular connections, then one should not rush to the operation. If there is a pronounced deviation (more than 10 °), it is still advisable to do it even before the child enters school, but take into account the possibility of reoperation in case of recurrence of strabismus. The parents of the child should be warned about this. It is better to perform such a corrective operation at the age of 10-12 years, when the development of the facial skeleton and orbits almost stops, which in the absence of binocular vision can contribute to the deviation of the eyes.

The presence of hypermetrolia in case of converging strabismus and myopia in case of divergent strabismus gives reason to expect the appearance after the operation of "partially accommodating" properties of strabismus. In such cases, optical correction of refractive errors can have a stabilizing effect on the position of the eyes in the postoperative period.

Simultaneous vision indicates less tendency to inhibition of visual perception of the deviated eye than monocular vision. This creates more favorable conditions for the joint activity of both eyes. However, the state of fusion is of paramount importance in this sense. The ability of the visual analyzer to merge foveal images of objects, revealed even before the operation, significantly increases the effectiveness of postoperative orthoptic exercises and the possibility of restoring normal binocular vision. Due to this ability, which acts as a reliable "ally" of the surgeon, even a small angle of strabismus left after surgery can be eliminated.

The more constant the strabismus angle, the better and more stable the results of the operation, as a rule. With a changing angle of strabismus, its average value should be taken into account. If, during the examination of the patient, the deviation periodically disappears and appears, and the range of deviation of the eye is significant, then the operation should not be performed.

At small angles of strabismus, the state of binocular functions should be especially carefully examined. The ability to merge at the zero position of the synoptophore objects and binocular vision detected on a color device indicate that the patient has so-called asymmetric binocular vision. In these cases, which, however, are very rare, the operation does not make sense, since after it either the previous position of the eyes will remain, or persistent double vision will appear.

With enhanced adduction, it is considered advisable to perform an operation in order to weaken the action of the internal rectus muscles. If the adduction is reduced, then the operation should be performed on the external rectus muscle.

With monolateral strabismus, it is more logical first of all to perform an operation on the squinting eye, based on the fact that pathological disorders are usually more pronounced on it. This tactic finds more understanding among the patient and his relatives, therefore, it is justified psychologically.
In case of alternating strabismus, the question of choosing an eye to perform the operation naturally loses its meaning, but in this case it is also better to first perform the operation on the eye that has large deviations from the norm (for example, in terms of the degree of mobility or visual acuity).

Based on physiological considerations, preference should be given to operations that enhance the effect of weakened muscles. It is also necessary to take into account the width of the palpebral fissure, remembering that operations that enhance the action of the muscles somewhat narrow the palpebral fissure, and weakening ones somewhat widen. This recommendation refers to strabismus without local muscle defects (fibrosis, contracture, hypertrophy, anomalies of attachment sites), which in some cases underlie congenital strabismus. In such cases, strengthening the antagonist without prior or simultaneous release of such a strengthened muscle is ineffective.

Even with significant angles of strabismus, one should not simultaneously perform operations on more than two muscles, since this greatly increases the difficulties of dosing and the likelihood of obtaining a hypereffect. If after the first stage of the operation the residual angle of strabismus remains, then the second stage of the operation on another muscle of the same eye or on the other eye is performed after 6-8 months. It is best to warn the patient or his parents about this, otherwise even the first stage of the operation carried out in accordance with the plan, which did not completely correct the strabismus, may be regarded by them as a failure.

When a pronounced horizontal deviation of the eye is combined with a vertical one, it is advisable to first perform an operation on the horizontal muscles, given that vertical deviation can be not only a consequence of muscle paresis, but also a manifestation of vertical phoria, which often disappears in the primary position of the eye. If the vertical deviation is significant and the study of the oculomotor apparatus indicates a predominant lesion of the muscles of vertical action, then an operation should be performed on these muscles.

Types of surgical interventions

To eliminate strabismus, two types of operations are used - strengthening and weakening the action of the muscles.

• Enhancing
• resection - shortening of a muscle by excising its section at the point of attachment to the sclera and suturing to this place;
• tenorrhaphy - shortening by forming a fold from her tendon;
• proraphy - an increase in the degree of muscle tension as a result of moving its tendon anteriorly (with interventions on rectus muscles) or posteriorly (with interventions on oblique muscles) with or without a fold;
• twisting - increasing the degree of muscle tension by screwing it around its axis after crossing, followed by suturing to the place of anatomical attachment.
• Laxative
• free (or complete) tenotomy - the intersection of the tendon of the muscle at the insertion site without suturing it to the sclera;
• tenotomy with a restrictive (safety) suture - fixation of the tenotomized muscle at a certain distance from the site of anatomical attachment using a suture passing through this place and the edge of the transected tendon;
• partial tenotomy - applying 2-3 incomplete incisions on the tendon of the muscle from the opposite edges, somewhat spaced from each other;
• recession - displacement of a muscle, crossed at the site of attachment, posteriorly (with interventions on the rectus muscles) or anteriorly (with interventions on the oblique muscles) with its suturing to the sclera;
• prolongation - lengthening a muscle by completely cutting its tendon in different directions and stitching the cut sections;
• fadenoperative - fixation of the muscle to the sclera behind the site of the muscle to the eyeball.

To enhance the action of the muscles, resection is usually performed. Tenorrhaphy and proraphy are rarely performed, mainly for interventions on the oblique muscles. Of the operations that weaken the action of muscles, recession is the most widespread. Prolongation, tenotomy with a safety suture and especially rarely partial tenotomy are used much less often. Free tenotomy is performed only with some atypical forms of strabismus and with surgery on the oblique muscles.

The methods of performing each of these operations are very diverse. However, this applies primarily to technical details and not to the principle of the operation itself. The use of many of these methods is unjustified: they either do not make significant changes in the course of the operation, or they overly complicate it.

Anesthesia

In children under the age of 10-14 years, operations on the eye muscles should be carried out under anesthesia, giving preference to a mixture of nitrous oxide and fluorothane. In adults and older children, local infiltration and conduction anesthesia is used. It must be remembered that painful sensations usually arise when the oculomotor muscles are stretched, which have rich innervation. To eliminate these sensations, it is necessary to inject an anesthetic into the area of \u200b\u200bthe muscle funnel.

After three times installation, a 0.5-1% solution of dicaine is injected into the conjunctival sac with 1.5-2 ml of a 2% solution of novocaine under the operated muscle, and then, slightly changing the direction of the needle, behind the eyeball. A small amount (0.3-0.5 ml) of novocaine solution should also be injected under the conjunctiva at the site of muscle attachment.

Dosing the effect of the operation

The "question of questions" in strabismus surgery is the correct dosage of the effect of the operation. It was found that there is a high direct correlation between the degree of shortening or movement of the muscle and the obtained value of the strabismus angle change. This suggests that an indicative preliminary plan for dosing the effect of the operation on the oculomotor muscles is possible.

Dosing regimen for converging strabismus according to Avetisov-Makhkamova.

• Dev<10° - рецессия внутренней прямой (MRM) = 4 мм
• Dev 10 ° - MRM recession + external straight line resection (MRL) \u003d 4-5 mm
• Dev 15 ° - MRM recession + MRL resection \u003d 6mm
• Dev 20 ° - MRM recession + MRL resection \u003d 7-8 mm
• Dev 25 ° - MRM recession + MRL resection \u003d 9 mm
• Dev\u003e 30 ° - 2-3 stages of the operation, depending on the initial value of the angle, the presence of residual deviation and the state of binocular functions.

In case of divergent strabismus, on the contrary, MRL recession, MRM resection.

It is advisable to make some dosage adjustments during the operation. If the muscle to be resected looks flabby, then the degree of its supposed shortening is increased by 1-2 mm.

It is known that under the influence of narcotic substances the eyes deviate upward and outward, and the magnitude of this deviation varies greatly. In this regard: during anesthesia, the position of the eyes on the operating table cannot be judged on the effect of the intervention on the eye muscles. Under these conditions, the principle of preliminary dosing of the operation is the only possible one.

The dosage table for strabismus correction should also be used in cases where it is performed under local anesthesia. In this case, it is possible to evaluate the result of the surgical intervention directly on the operating table and make some adjustments to the intended dosage regimen. However, such an assessment is difficult due to the fact that under the influence of novocaine, the strabismus angle also changes within a fairly wide range. It is advisable to give the patient's eyes a position of some hypereffect during the operation.

Tools

To carry out operations on the eye muscles, an eyelid speculum, fixation, anatomical and surgical tweezers, special scissors curved at an obtuse angle, muscle hooks, a measuring device (millimeter ruler, compasses, etc.), a needle holder, blunt scissors for cutting off stitches, a spatula, sharp scleral scraping spoon, needles for ligating muscle and sutures on the conjunctiva, thin curved (preferably atraumatic) needles for applying episcleral sutures. You may also need muscle clamps, a hook for the superior oblique muscle, and tweezers to fold the muscle.

Thin and strong catgut 1.0 and 2.0, silk 2.0 and 3.0 for the conjunctiva, silk 1.0 for sewing muscles and silk 3.0 and 4.0 are used as suture material for surgical interventions on the muscles of the eye. for ligating a muscle. Biological sutures are also used. Especially convenient are synthetic sutures, which do not need to be removed after surgery.

Postoperative management

After the operation, 1-2 drops of a 30% solution of sulfacyl sodium or other antiseptic are installed in the eye and a bandage, usually binocular, is applied. Dressings are done daily. The sutures from the conjunctiva are removed on the 4-5th day. If silk sutures were applied to the muscle, then they are removed on the 6-7th day.

Orthoptic and diploptic exercises, if indicated, begin as early as possible, as soon as the condition of the eyes allows. These exercises improve eye mobility, help eliminate residual deviation and restore binocular vision. The patients are discharged from the hospital on the 5-7th day after the operation.

Neither before nor after the operation should be prescribed medications acting on accommodation and indirectly on convergence, for example, atropine solution. Such drugs have a temporary effect on the position of the eyes, sometimes cause a paradoxical effect and create additional difficulties in assessing the effect of the operation.

It is better to influence the position of the eyes with a bandage. If, after correcting the converging strabismus, a hypo effect is observed, then it is advisable to leave the binocular bandage for several days. This natural elimination of accommodation also excludes the impulse for convergence, thereby causing a tendency for the divergence of the visual axes. In case of pronounced hypereffect, it is advisable to leave a monocular dressing to connect accommodation and convergence.

After surgical correction of divergent strabismus, they do the opposite: with hypoeffect, a monocular dressing is preferred, with hypereffect, binocular. Other types of "orthoptic" dressings do not justify themselves.

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Strabismus, heterotropia, or strabismus is called a failure in binocular vision, when there is an incorrect coordination of the eyes on the object in question. One or two eyes deviate from the center of the visual axis towards the nose or temple, as a result of which the fixation of the eyes on the object is disrupted. If no correction methods help, surgery will eliminate the squint.

Definition of strabismus and correction methods

Strabismus is considered to be a childhood disease, since it manifests itself precisely in childhood. The occurrence of strabismus in adults is much less common, the cause of which is often a disruption in the work of nerve connections. There are many reasons contributing to the occurrence of strabismus:

• Traumatic brain injury;
• Genetic predisposition;
• Psychological herbs;
• Poor blood circulation in the brain;
• Infectious diseases of the brain;
• Incorrect treatment of myopia and hyperopia;
• Excessive eye strain;
• Disruption of the extraocular muscles.

The strabismus test covers a holistic analysis of the organs of vision - the work and location of the muscles, the fundus and visual acuity, the angle of strabismus and the age of the patient are assessed. In the presence of strabismus, the operation is not immediately prescribed, they first try to eliminate it without surgery. The treatment has three subsequent stages:

• Optical correction;
• Pleoptic treatment;
• Orthopedic treatment.

Optical correction is a treatment using correctly selected glasses, lenses, in order to create optimal conditions for the functioning of the eyes. If there are concomitant diseases (myopia, hyperopia, astigmatism, infections), then their treatment is carried out at this stage of therapy.

Pleoptic treatment is aimed at increasing and equalizing the sharpness of both eyes to age norms.

Orthopedic treatment is essentially a preoperative stage. It is advisable to carry out it only after there is a relative equality of visual acuity between the eyes. Its goal is to form the patient's ability to turn on binocular vision (the ability to clearly see an object with two eyes) when looking away in different directions. In the absence of binocular vision, the question of prohibiting the operation may arise. Symmetry of the eyes is possible only with the same spatial perception of objects, objects with both eyes.

It is prescribed only when the maximum possibility of visual functions in both eyes is reached.

Strabismus surgery

All operations whose purpose is to correct strabismus are to correct the work of the oculomotor muscles - strengthening and weakening. Manipulations are carried out only within the framework of traditional surgery; laser correction of strabismus is not practiced. Surgical treatment of strabismus consists in cutting the muscle, and this cannot be done with a laser.

The goal of strabismus surgery is to restore muscle balance and binocular vision. But often it is possible to improve only cosmetic imperfections; restoration of visual functions after surgery requires an integrated approach and active conservative therapy. In ophthalmology, there are three directions of surgical correction of strabismus:

• Weakening muscle traction;
• Strengthening traction;
• Changing the direction of muscle action.

Weakening muscle cravings include:

• Recession, which implies surgery, as a result of which a laxative effect of muscle traction is formed, achieved by displacing the muscle attachment site to the beginning of the muscle.
• A myectomy is a procedure to remove a specific muscle from its attachment site. Basically, the indication for such an operation is muscle hypercontraction.
• Posterior fixation sutures - a recession procedure with sequential suturing of the abdomen of the displaced muscle to the sclera, slightly behind from the place of its attachment.

Aimed at restoring weakened oculomotor muscles:

• Resection is the process of excision of a certain area of \u200b\u200ba weakened muscle at the site of its attachment, followed by its fixation. Essentially, the remaining sections are stitched together.
• Tenorraphy is the process of muscle shortening by creating folds in the muscle tendon area. As a result, the shortened muscle is significantly enhanced in terms of contractile function.
• Anteposition is the process of changing (transporting) the place of muscle fixation.

Benefits of Surgical Ophthalmology:

• Low invasiveness;
• The structure of the eye is preserved;
• Accuracy of the operation;
• Small% of consequences;
• High guarantee of a good result;
• A short period of rehabilitation.

Surgical intervention to eliminate strabismus does not give a 100% guarantee for a complete correction, but the chances are great - up to 80%. If strabismus persists after the manipulation, the operation can be repeated after half a year. Do not expect that you will see "correctly" immediately after the operation. During the time that a person suffered from strabismus, the brain has lost the habit, has forgotten how to compare the visions from both eyes in one image, and it will take him a lot of time to learn this. As with any operation, complications can arise here. First of all, these are calculation errors, leading to repeated strabismus.

Strabismus surgery is performed under full or local anesthesia (according to indications) on an outpatient basis, no hospital is required - a few hours after the operation, the patient is allowed to go home. Ophthalmic operations, like all others, are performed on an empty stomach. All the necessary tests are taken in advance. During the procedure, the patient must be absolutely healthy (no ARVI, temperature, infections). The average procedure does not exceed 30 minutes. After the operation, a special bandage is applied to the patient, which is left for 12-24 hours. The sutures applied give the sensation of a foreign object in the eye, they do not need to be removed, they dissolve within 6 weeks after application. After surgery, the patient needs to use anti-inflammatory drops. With suppuration, flushing will be shown.

You must do the following:

• Carefully protect the eyes from contamination;
• Do not engage in physical labor for the first three weeks after the operation;
• Do not swim in public;
• Do not disturb the eye, do not rub it.

Careful eye monitoring is required after surgery. It is necessary to regularly visit an ophthalmologist, use the necessary drugs and rest the eyes. To restore muscles, a special system of exercises is being developed that must be performed. The assessment of the position of the eyes is checked no earlier than two months after surgery.

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