1. Disease

Squint, either uni- or bilateral

Muscle Recession - muscle (often medial rectus) is weakened by transection or moving its insertion more posteriorly.

Muscle Resection - the action of the muscle is enhanced by tightening through either resecting a piece of muscle or pleating of the muscle belly.

Transposition - The action of the muscle is altered by cutting its insertion from the eyeball and reattaching it at a new location

Adjustable suture - occasionally in older children, or repeat surgery. The muscle is reattached to eyeball with stay sutures, which are adjusted and tied once the patient is awake and able to sit up and focus on an object in the distance.

2. Anaesthetic problems

Most are idiopathic but is more frequent in exprems and those with neurological disorders (eg cerebral palsy, Down syndrome)

Oculo-cardiac reflex during traction on the extra- ocular muscles

Post-operative vomiting leading to admission or re-admission

3. Assessment

Routine pre-operative assessment

Often day surgery

4. Preparation

Pre-medication: paracetamol 20 mg/kg oral ± midazolam

5. Preparation of theatre

Routine: as elective surgery

6. Induction

Gaseous (O2 /N2O/sevoflurane) or I.V. as indicated

Spontaneous ventilation

Armoured laryngeal mask, or intubation under deep volatile or relaxant

7. Maintenance

Spontaneous ventilation of O2 /±N2O/volatile

Some would advocate TIVA maintenance in older children

Alternatively- IPPV

analgesia – fentanyl 1mcg/kg

atropine - 20mcg/kg drawn up ready, not as prophylaxis

anti-emetic – prophylaxis 0.1mg/kg tropisetron (max 2mg) with 0.15mg/kg dexamethasone (max 8mg)

Monitoring - pulse oximetry, ECG, NIBP, capnography, FIO2

8. Homeostasis

Guided by monitoring, no special measures, IV fluids 20ml/kg

9. Emergence

Extubate deep unless contra-indicated

10. Recovery

Routine observations

Fentanyl Pain protocol

Return to ward when consciousness regained, observations stable and any vomiting controlled

Prescribe rescue anti-emesis such as metoclopramide or droperidol

11. Post-operative management

Analgesia - paracetamol orally

Oral fluids as tolerated

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