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EXPECTATIONS AND INSTRUCTIONS FOLLOWING SQUINT SURGERY FOR CHILDREN

The Procedure

The eye is shaped like a large marble and the muscles look like elastic bands attached to the side of the eye. When the muscles move the eye changes position. Surgery involves attaching and reattaching the muscles to another place on the eye. The incision goes through the white part of the eye. Most of the time the healing hides any scarring so it can hardly be seen after 2-3 months unless you know exactly where to look and look very carefully.

Normally a first surgery takes an hour from the time that the patient is brought in to the Operating Room until the time the patient goes to the Recovery Room. Re-operations take longer.

An extra consultation dedicated to discussing this surgery can be made for both parents to attend. If you think you will need extra time this can also be arranged. If details have not been explained to your satisfaction you must make another appointment.

BEFORE SURGERY

What to do:
- Make sure you understand and follow the fasting instructions given to you.
- Know what time you need to be at the hospital.
- Dress your child in loose clothing which opens down the front.
- Pack towel and container in case your child is sick on the way home from hospital.
- Purchase pain relief (see 'After Surgery' section).

To Reduce Anxiety in Children Before Surgery:
 

What if my Child is Sick?

If your child has a chronic illness or syndrome ask your GP or pediatrician if the anaesthetist needs to be informed in advance. We will provide you with the anaesthetist's contact details before the surgery.

Asthma

If your child has asthma go to the GP about 10 days before the surgery to discuss increase in regular medications before the surgery.

If your child has a cough or cold two days before the date scheduled for surgery, go to your GP for a checkup and let this office know the outcome of that visit.

If your child has a fever or noises on the chest on the day of surgery you should come to the hospital but it is likely that the anaesthetist will not proceed, and we will schedule another date.

AT THE HOSPITAL

Prior to surgery a nurse and anaesthetist will assess your child. Generally, the order of an operating list is from youngest to oldest child. There will inevitably be some waiting involved so bring toys and books to keep kids occupied.

Anaesthetic:
- One parent can accompany your child to theatre.
- Your child may be anaesthetised with gas or injection, please discuss these techniques with the anaesthetist.
- Once asleep, you will be escorted from the theatre and Dr Kowal or the assistant surgeon will tell you how long the surgery will take and where to meet them after the procedure.
Day case vs. overnight stay:
Children go home the same day providing:
" The operation is less than 1˝ hours duration
" Home is less than 1˝ hour's drive
" The child recovers well from the general anaesthetic.

Children who come from far away are usually discharged in the care of their parents to a nearby hotel. Dr Kowal usually needs to see the child within 24 hours of the surgery to assess that sutures haven't slipped etc., and sometimes the next day as well. You should plan to stay for 2 days after the surgery.

Car parking on the day of your Surgery
If your surgery is being performed at the RVEEH, there is a 'Wilson' car park at 410 Albert St., East Melbourne. They have an early bird rate of $19 if you enter before 10 a.m. and exit after 3 p.m. Otherwise their rates are $18 per hour for the first 3 hours and then $8 per additional hour. (Rates valid as of June, 2016).

If your surgery is at St Vincent's Private , East Melbourne there is a car park in Grey Street, a little past the hospital on the other side of the street.

There is also metered street parking available around both hospitals but be
sure to keep an eye on the time as parking inspectors frequent the area.

.AFTER SURGERY:

 

Emergence agitation
Some children (maybe 5-10%) are extremely agitated when they emerge from anaesthetics. They scream and thrash around and this is extremely distressing to parents. This reaction is not predictable and probably reflects a weird side-effect of the particular cocktail of anaesthetic drugs. IT DOES NOT LAST and within 10 or 20 or 30 minutes your child will be fine. Don't panic. Be comforting. It gets better.

Pain relief:
- These days we usually leave the intravenous access in until discharge from hospital so that intravenous Panadol and anti-vomiting drugs can easily be given.

Dr Kowal will usually give an injection of anaesthetic around the eye for post-op pain relief as well. This injection can sometimes cause a weird eye position for up to 24 hours and the preliminary surgical result cannot be assessed accurately over this time.

- Panadol and Nurofen alternating every 4 hours while awake in the first 24 hours following the operation for irritability and discomfort. You can add an extra dose of panadol half an hour after each scheduled dose of nurofen if you want.

- Children are sometimes frightened to open their eyes after surgery. Reassure them that it's fine to keep them closed and just wait.

What to expect:
1. Eyelids may be swollen. Ice packs are very good at lessening this swelling and for helping any pain. Make-up remover pads (DeMakeUp) soaked in ice water feel good. At no time should the lids get more swollen or red during the day. This may be a warning sign for possible infection and you should call our office.
2. There will be red stained tearing for one or two days.
3. In the first day after surgery the amount, colour and intensity of redness on the operated eye(s) can be quite scary - it always gets better, and starts getting visibly better within 2-3 days. Sometime in the second week after surgery most of the redness has gone though it can take several weeks to look normal.
4. There will be some sticky discharge in the mornings that may stick the eyelids together. Wipe away any discharge using a freshly opened pack of cotton balls or make-up remover pads with saline solution. The best saline solution is a FRESH bottle of "Normal Saline for Contact Lens Users" which you can buy in a 500ml bottle for about $3. Green or pus like discharge which continues throughout the day could be a warning sign of infection. Please call Dr Kowal or the Emergency Department at The Royal Victorian Eye and Ear Hospital (main switchboard 9929 8666).
5. Usually no eye patch is required.
6. A child will be irritable for 1-2 days. Expect some sleep and behaviour disturbance for several days. Some children are very frightened by the whole experience and need patient TLC for a few days. Some children bounce back very quickly and are fine within a few hours.
7. Vomiting:
" Vomiting is uncommon with modern anaesthetic techniques. The patient will be tried with icy poles, fluids and sandwiches before being allowed to leave the hospital, and must keep fluids down before being allowed to leave. If there is something you know your child LOVES to eat, bring it and show it to the nurse when the time comes.
" May be car sick on the way home. Be prepared.
" The patient should tolerate fluids at home. "Slurpee" is good - the cold crushed ice settles a nauseous tummy. If vomiting is still happening after 12 hours call Dr Kowal or Casualty Department (9929 8666) for advice.
8. The eye will have a feeling of sand or dust in the eye due to the cut edges and the very fine stitches on the surface.
9. There may be soreness over the muscles and it may hurt to move the eye in a particular direction.

Eye Drops:
In older children there are usually two bottles to be used for one week, antibiotic and cortisone.
In younger children, drops are usually "too hard" and only used if the eyes are particularly red or irritable, or if infection is suspected.
If drops have to be used in younger children, we try to limit them to once or twice a day. They can often be put in when the child is asleep (pry open the lids just a little and drop the drop onto the white of the eye).

Eye Rubbing after Surgery:
Parents are usually worried that if their child rubs the eyes after strabismus surgery something will go wrong. This fear is largely unwarranted. If your child rubs the eyes, s/he will always close the lids first so s/he cannot actually rub the eyeballs directly. But do your best to make sure his/her hands are clean!

The stitches holding the muscles in place are very deep and cannot be disturbed by eye rubbing. Some very superficial stitches might be disturbed by eye rubbing. At worst this can delay healing, keep the eye redder for longer, and necessitate some extra visits for check-ups over the first 2-3 weeks.

Post-operative course:
Each post-operative day should be better than the previous one. There should be progressively less redness and progressively less discomfort. A "turn for the worse" is potentially serious and you must call Dr Kowal quickly. Double vision is sometimes present. Ring Dr Kowal for advice if this occurs and has not been mentioned to you. There may also be some light sensitivity and blurred vision after surgery which is usually transient.

Here is some information dealing with complications following Strabismus sugery.

Post Operative Visit:

Dr Kowal will need to see your child within 48 hours of their operation. If he does not give you a time for your post-operative appointment, please call our rooms to make a suitable time. In the first 48 hours after surgery feel free to contact Dr Kowal at ANY time if you have any problems - his home number is 9827 7827, mobile 0414 793 687.

Patients who come a long way are seen day of, or day after surgery, and if okay can go home.  Email Dr Kowal a photo 2 days later. 

School: Plan to stay home from school for one week.

Swimming: Swimming can be resumed after a week. The eyes will be redder following exposure to chlorine.

Glasses:
If the patient usually wears glasses bring them to the hospital. The doctor will tell you when you go home if they are to be continued.

Post-Operative Scarring
Within a few weeks there is usually no redness or swelling at all. There is a purple dot sometimes seen for a few months until the knot holding the muscle in place dissolves completely.

After some months there is sometimes a faint line seen (if you get in just the right position, real close, and have just the right lighting) which was where the muscle used to be. Sometimes there can be a pale blue area just behind that line. These changes can be permanent.

A thickened red scar at the site of surgery is very rare in children.

Unfortunately no surgery is 100% reliable and 100% safe. You maximise your child's chances of success and minimise chances of problems by choosing a surgeon who is highly trained and specialised. Dr. Kowal is the only eye surgeon in Australia whose practice is restricted to strabismus. Dr. Kowal personally does over 10% of all the strabismus operations in Australia billed through Medicare.

Dr. Kowal does not suffer from any transmissible virus (HIV, Hep B, Hep C). Dr. Kowal reserves the right to ask if you do and to test you for this.

Dr. Kowal's Contact Details:

If you have any concerns during the initial post-operative course, Dr. Kowal's contact details are:

Home: 9827 7827
If you forget/misplace it, it's in the White pages.

Mobile: 0414 793 687
If you forget/misplace, call the hospital where you had the surgery and ask to be put through to Dr Kowal's mobile or call the office and the answering machine has the number.

Email: drkowal@privateeyeclinic.com
Sometimes Dr Kowal will want to see some day 1 or day 2 post-op photos. Take these with a camera; only use a phone if it produces large file photos (I-Phone is fine). A good way to communicate is:

1. Send photo and any comments by email.
2. Text a note to Dr Kowal's mobile asking him to check his email.

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This letter is protected by the laws of Copyright and must not be reprinted, copied or otherwise disclosed in whole or in part to any person without the written consent of Dr. Lionel Kowal.