Skip the Padding Protocol? Rethinking Postoperative Care for Strabismus Patients

This investigation was published in the Indian Journal of Ophthalmology in May 2025

While routine, the physiological benefit of padding under general anesthesia (GA) remains unproven, as it may counterproductively increase pain by trapping heat and triggering inflammatory mediators. Consequently, this study led by Amit Kumar of the Department of Ophthalmology, All India Institute of Medical Sciences (AIIMS), Patna, Bihar, India, and colleagues compared postoperative pain and physiological markers between padded and unpadded eyes to establish more effective recovery protocols.

The prospective, observer-masked study followed 100 children undergoing bilateral strabismus surgery, comparing recovery markers between randomly padded and unpadded eyes over a four-week follow-up period. Researchers evaluated primary endpoints—including lid edema (LO), conjunctival chemosis (CC), subconjunctival hemorrhage (SH), and pain via the Numeric Pain Scale (NPS) and Faces Pain Scale-Revised (FPS-R)—while excluding patients with pre-existing ocular or neurological pathologies.

Key Clinical Findings of Study:

• Improved Postoperative Comfort: On the first postoperative day, patients experienced significantly higher levels of pain in padded eyes (mean score 3.39 ± 0.87) compared to unpadded eyes (mean score 2.82 ± 0.88), suggesting that omitting the pad enhances early comfort (P < 0.001).
• Reduced Inflammatory Congestion: Conjunctival congestion was significantly more severe in the padded group on day one (mean score 4.40 ± 1.44) compared to the unpadded group (mean score 3.94 ± 1.26), with this disparity remaining statistically significant at the one-week follow-up (P = 0.001).
• Muscle-Specific Pain Severity: The most significant pain was observed in surgeries involving the Inferior Oblique (IO) muscle, where padded eyes had a mean pain score of 4.03 ± 0.74 compared to 3.21 ± 1.00 in unpadded eyes, followed by Medial Rectus (MR) recession with 3.10 ± 0.62 versus 2.52 ± 0.63 respectively (P < 0.01).
• Safety and Physiological Markers: There were no significant differences in the rates of LO (7% in padded vs. 4% in unpadded) or CC (34% in padded vs. 24% in unpadded), and no instances of suture breakage (SB), infection, or wound gaping were recorded in either group (P > 0.05).
• Resolution of Clinical Signs: While SH and congestion were initially higher in padded eyes, all minor physiological differences resolved completely in both groups by the one-month mark, indicating no long-term benefit or harm from padding.

The results conclude that routine padding after strabismus surgery significantly increases postoperative pain (3.39 ± 0.87 vs. 2.82 ± 0.88; P < 0.001) and conjunctival congestion (P = 0.001) without providing any measurable protective advantages. Consequently, the authors recommend a no-padding approach for procedures performed under GA to ensure a more comfortable recovery and avoid unnecessary inflammatory distress.

Clinicians should adopt a no-padding approach following strabismus surgery performed under GA to significantly enhance patient comfort and minimize early inflammatory distress. Forgoing the routine use of eye pads effectively reduces pain and redness without compromising surgical safety or increasing the risk of infection.

Reference

Kumar A, Saxena R, Sharma M, Sinha R, Phuljhele S, Tandon R, et al. Comparative evaluation of effect of postoperative padding versus no padding after strabismus surgery. Indian J Ophthalmol 2025;73:754-7