Saving Little Nemo - the Clown Fish with Big Problem

Mr Sam Lee of Birmingham Medical School alerted me to this piece of interesting news from Hong Kong. The news related a clown fish being operated on by a vet in Ocean Park. I think the news tied in nicely with my previous post and showed that it is not just human beings but fish that the place you live determines if you get proper health care.

The clow fish which was 4cm in length lived in Hong Kong Ocean Park and recently developed a large tumour in the right eye  (in human term it is like having tumour the size of an orange growing inside a pserson's orbit). The tumour caused the fish to lose its balance and problem swimming. The in-house vet decided to carry out a biopsy to determine the nature of the tumour. The fish was first anaesthetized  in a small tank containing anaesthetic solution before being taken out of the water. A small tube connected to the fish tank with constant water infusion was used to intubate the fish. The orbital region of the fish was explored and tissues were removed for histology. Postoperatively, the fish was given an injection of anaesthesia to control postoperative pain. According to the vet, if the result showed benign growth the tumour will be excised but if the tumour showed cancerous growth euthanasia would be carried out.

The blue arrows show the tumour of the right eye.

Once anaesthetized, the fish was intubated using

a fine tube connected to the fish tank.

A cutting diathermy was used to explore the right eye.

Anaesthesia was injected into the fish to reduce

postoperative pain.

A Young Kayan Woman with a Massive Eye Tumour.

While going through my collections of more than 2000 clinical pictures, I came across this newspaper cutting from last year about a younKayan woman our team operated on.

The case shows how fortunate are people who lived in big towns and cities in Sarawak where they can gain easy access to health care. The natives in Sarawak often live in sparsely inland areas who have to relie on Charity Organizations for medical health. This patient lived in a remote part of Sarawak near the border with Kalimantan (the Borneo part of Indonesia) and developed a slowly progressive swelling below the left eye for the past 9 years. She was seen once in Miri about 4 or 5 years ago but the surgeon who saw her attempted to aspirate the mass by sticking a needle. However, nothing was apirated and the patient returned to her village and didnot return for follow-up due to financial constrains. Unfortunately, the mass continued to grow with time resulting in severe disfigurement with her left globe pushed out of position. She avoided seeing people and always covered her left face with her long hair. It was not until March 2009 was she re-referred to Miri General Hospital where she was seen by Dr. Chieng, Consultant Ophthalmologist. A scan done in Miri showed a solid tumour extending to the back of the orbit. Dr. Chieng referred her to our Eye Department in Sarawak General Hospital, Kuching for further management. While in Kuching, she was also found to have ventricular septal defect which was medically managed by Prof Dr Sim of the Cardiology Department.

A massive white gelatinous mass was removed from the orbit and the tumour measured 9cm in length. Histology showed this to be a myxoma, an unusual tumour but not malignant ie. cancerous. She made a good recovery and we recommended further surgery at a later date to reconstruct her eyelids to make the two sides symmetrical. However, she did not return from follow-up after one year. The tumour rarely recurred and hopefully she is now leading a normal life in her village.

Eyelid problem is not unique to human being.

The 5 eyelid operations went well today and finished before 12:00 noon so I had plenty of time to surf the web for up-to-date articles on eyelid surgery. One interesting news caught my eye about a breed of dog with its origin in China called Shar-Pei (沙皮 or sandy skin in Chinese).

This dog has numerous wrinkles which make them look cute or ugly depending on the beholders. As the dog was regarded as rare and when it was introduced to the US, interbreeding was rift to satisfy the demands. The rushed breeding resulted in many health problems and one which was excessive loose skin and wrinkles in the upper eyelids of the dog causing entropions (inturning of the eyelids). The inturned eyelids cause the eyelashes to rub on the eyes giving rise to painful eye conditions and unless treated the dogs would go blind. One of the unfortunate victim of this breeding is Molly, a female puppy born in the UK. Molly was unable to open her eyes because of entropion, fortunately her sight was restored by vet following two operations to remove the offending skin and stitch it to the back of her head. The pictures below show the pictures before and after the operation.

What to do when you lose all your eyelids?

I have 5 eye operations today: one excision of multiple papilloma, three ptoses (one bilateral senile ptosis, one left ptosis and one congenital ptosis) and one lagophthalmos (for gold weight implantation). While reading oculoplastic books to update myself, I come across a chapter on reconstruction of both eyelids (in which the patients lose both eyelids) in the book Repair and Reconstruction in the Orbital Region by John Clark Mustarde and thought to myself that this is one operation I am unlikely to need to do in my practise. Most of us are fortunate to like in countries where war injuries resulting in severe facial disfigurements are rare. The majority of facial injuries we encountered are caused by accidents or assaults and most do not come near to the severity of war injuries. Total loss of eyelid would necessitate prolonged operation using skin tissues from undamaged parts of the body and this usually comes from the head region.

I google for pictures on total eyelid reconstruction and come across this fascinating series of pictures belong to a World War I victim called Walter Ernest O'Neil Yeo. He was reported as the first patient to undergo successful advanced skin grafts (I suppose the emphasis here is advanced which I take to mean extensive otherwise many patients before him would have undergone small skin grafts with success). In 1917 he was treated by Sir Harold Gillies - the first man to use skin grafts from undamaged areas on the body - and know as 'the father of plastic surgery'. The operation involved skin graft from neck using tubular pedicle. The skin removed from the neck was attached to the face and to ensure survival of the grafts, the remaining skin was rolled up and remained attached to the blood supply of the neck.

Although the postoperative picture appeared not better than the preoperative one, the patient's eyes are not protected by the new eyelids. Otherwise he would go blind from exposure of the eyes to the environment.

Final twist to the story relates to the surgeon not the victim.

Sir Gillies found that his operation with tubular pedicle (green arrows)was so successful that he later used it to reconstruct penis in his practise in Harley Street for women who want to undergo sex change to become men! Of course the penis was created with the skin from the abdoman and not from the neck. The moral of the story is that a bit of lateral thinking can be healthy for your bank account ;).

Which operation to do? and the Balloon Debate.

A 73 year-old woman with dementia was brought by her son to see me because of severe left ptosis occluding her vision. She had not been able to walk about at home unaided or pick up food at the table. She had had left cataract operation and implant 15 years ago using ECCE (which involved making a big cut to the eye and suturing). On examination, she had severe left droopy eyelid blocking the vision and with the eyelid lifted the vision was about 6/60 (with difficulty of communication) without glasses, refraction shows she need +2.00/-4.50X180.

The right eye had a dense cataract that reduce the vision to hand movement. The son wanted me to lift the left eyelid, however, I suggested to him that it would be better to do a right cataract because of 3 reasons:

a. After lifting the left eyelid, there is a possibility that the lid may droop over the next few years;

b. In order to see well even after lifting the eyelid, she would still need gasses to see well and with he dementia she may have problem wearing the glasses and the high astigmatism may be uncomfortable for her and

c. It would take only about 10 minutes and without injectioin and at least 20 minutes to lift the eyelid and injection will be needed into the skin.

I would do the ptosis later if the family is concerned about her appearance but as the family's main concern is to improve her vision a right cataract shoul be done first. The son agreeded with my assessment and she underwent a successful cataract operation three weeks ago.

Although it is difficult to assess her postoperative vision, she is now able to find her way and feed herself. The family is happy to leave the droopy eyelid.

The moral of this case is to decide what is the most important that the patient or the patient's family wanting to achieve instead of making a knee jerk decision. I think this type of knee jerk decision is common amongst many doctors (me not excluded as I sometimes regret the decision I made but hopefully experience and time will continue to improve my skills).

Although the connection is oblique, I thought I will share with you the balloon debate which I read recently in Wikipedia. A balloon debate is a debate in which a number of speakers attempt to win the approval of an audience. The audience is invited to imagine that the speakers are flying in a hot-air balloon which is sinking and that someone must be thrown out if everyone is not to die. Each speaker has to make the case why they should not be thrown out of the balloon to save the remainder. Typically each participant speaks on behalf of a famous person, profession, fictional character, etc.

Assumming the balloon contained Maggie Thatcher, Josef Stalin and Adolf Hitler which person would you throw out?

Before you answer this question, assuming the balloon contained this three sumo wrestlers, which one would you throw out?

Any right minded person would throw out the female sumo in the middle as she is the heaviest . So before your knee jerk reaction to throw out Maggie Thatcher, you should decide who is the heaviest amongest the three

Woman who shed black tear !

My colleague Dr Ngo showed me this interesting piece of news in a local Chinese newspaper about a Hong Kong woman who shed black tear.

全球第3宗眼皮发霉 港女流黑泪

（香港26日综合电）香港出现全球第3宗罕见流黑色眼泪个案。眼科医院一名44岁女病人，眼睛受到会分泌黑色素的霉菌感染，导致眼皮底下发霉，黑色的霉菌群随泪水流出，变成黑眼泪，并有十多粒黑色的霉菌积聚物，最大一粒近两毫米

 I think the picture in the newspaper (shown above)  is an artist impression. I can't help noticing that the patients have parallel skin creases (double eyelids) which don't join at the nasal part of the eyes ie not a tapering type of double eyelid (will talk about this later in later blog) typical of Chinese with double eyelids. This type of double eyelids are uncommon amongst Chinese and are most often surgically created or one of the parents is non-Chinese (may be Caucasian, Indian or any South-East Asian natives).

Anyway,  I am wondering what the condition was and decided to google under "Hong kong woman black tear" However, there was no news under these keywords but on the web search the newspaper report was actually taken from Archives of Ophthalmology. And the full report is as follow:

Subconjunctival Mycetoma as an Unusual Cause of Tears With Black Deposits

Ocular mycosis is a rare condition that is usually related to ocular trauma, preexisting ocular disease, or immunocompromised states. We report a case of subconjunctival mycetoma secondary to Exophiala dermatitidis in a healthy middle-aged woman with recalcitrant ocular inflammation and black deposits in her tears.

Report of a Case.

A 44-year-old woman had recurrent discharge from her right eye and black deposits in her tears for 2 years. Her symptoms persisted despite the use of topical antibiotics, steroids, and antihistamine. She was otherwise healthy and was not receiving any systemic or other topical medication. She denied any history of ocular trauma or surgery. She did not use contact lenses or eye makeup. On examination, her general condition was excellent. Her visual acuity, intraocular pressure, and fundi were all normal. There was no eyelid swelling or erythema.Oneverting the right upper eyelid, some subconjunctival black deposits were noted . During biopsy, the conjunctiva was incised and multiple black, mulberry-like concretions extruded with mucoid discharge. Topical chloramphenicol, 0.5%, with dexamethasone sodium phosphate, 0.1%, eyedrops were prescribed postoperatively. Histopathological evaluation of these concretions showed large amounts of fungal hyphae with chronic inflammation over the conjunctiva. The diagnosis was subconjunctival mycetoma. Initial culture results for fungal growth were negative, but further evaluation with 28S ribosomalRNAgene sequencing identified the causative organism as E dermatitidis. At subsequent follow-up visits, the patient had complete resolution of symptoms. Topical antifungal treatment was not given as she was asymptomatic and there was no recurrence of mycetoma at month 3 after de´bridement.

Comment.

Tears with black deposits are extremely rare. In our case, we initially thought the black deposits were either foreign bodies or adrenochrome deposits, but they proved to be shedding from the subconjunctival mycetoma. Patients with tears with black deposits should therefore be evaluated for the presence of subconjunctival mycetoma. Asimilar clinical entity termed melanodacryorrhea (black tears) is caused by extraocular extension of uveal melanoma.

In immunocompetent subjects, fungal infection can remain superficial and localized as illustrated in our case. Subconjunctival mycetoma has been reported after subtenon corticosteroid injection in an immunocompromised host and in an immunocompetent woman with no risk factors, similar to our patient. The Exophiala species are dematiaceous mold commonly recovered from soil, plants, water, and decaying wood materials. This strain of black yeasts has been reported to cause deep infection (especially in the lung), cutaneous infection involving skin and mucous membranes, and subcutaneous infection manifested as mycetoma.4 E dermatitidis has been described as the causative agent in fungal keratitis that occurred after keratoplasty5 and laser in situ keratomileusis, 6 but to our knowledge it has not been reported to cause subconjunctival mycetoma.

Treatments described for subconjunctival mycetoma are diverse, ranging from aggressive topical and systemic antifungal treatments following surgical intervention2 to surgical de´bridement alone. A study by Zeng et al4 evaluated the activity of amphotericin B, itraconazole, voriconazole, and posaconazole against E dermatitidis and reported that all 4 antifungal agents have low minimum inhibitory concentrations (range, 0.03-0.5). However, data on correlation between in vitro and in vivo susceptibility are unavailable.

In summary, we describe an immunocompetent woman with tears with black deposits caused by subconjunctival mycetoma, the causative fungus having been identified as E dermatitidis.

Emmy Y. Li, MRCSEd

Hunter K. Yuen, MRCSEd
David C. Lung, MRCPCH (UK)

Double eyelid for an 83 year-old !

An 83 year-old woman came to see me 5 weeks ago because she was not keen to travel to Kuching for cataract operation as suggested by her private doctor. From the examination, her cataracts were not so dense and the main problem was her excess eyelid skin (dematochalasis) that cover her vision. Her visual acuities were 6/36 but when the eyelids were lifted  the vision improved to 6/18. If I were to perform just cataract surgery, the droopy eyelids will still block the vision so I recommended to her and the grand-daughter who accompanied her that the eyelids should first be lifted and only if the vision still bothered her would I perform cataract operation. It must be the way I explained to the grand-daughter that made me received a phone call from the old woman's son asking for clarification. "Doctor do you seriously think that my mum need a double eyelid surgery? She is not concerned about her look you know?" Well, I had to explain at length over the phone that the main purpose of the operation is to remove the excess skin that cover her vision and creation of the double eyelid (skin crease) was not to make her attractive (which is an added bonus if it does at not extra cost) but to create a barrier to prevent the remainin skin from coming down to block the vision. Now I must be more careful about using the term "double eyelid" when counselling the elderly with droopy eyelids as the term appear to be associated with vanity or seduction in the mind of some patients. Anyway, post-operativelythe patient was happy with her vision and her grand-daughter thought she looks younger and less tired (the added bonus without extra cost)!

A Round Trip Back to Kuching

This man had problems opening his eyes after cataract surgery 8 years ago (which sometimes happens if there is persisent inflammation causing the muscles that open the eyes to weaken). Unfortunately, his surgeon was unable to do the surgery and so he consulted another private eye surgeon who told him that there are no surgeons in Sarawak who can do this type of surgery and ask him to consult an oculoplastic surgeon in Kuala Lumpur. He went to Kuala Lumpur last month and was surprised to be told by the oculplastic surgeon there that the correction can be done in Kuching and referred him to me. Below shows pictures of his progression. The procedure that I did was levator advancment which involves reattaching the detached muscles and as he had excess skin (dermatochalasis) so I also removed the excess skin at the same time.

Surgery to restore one's ethnicity.

In my last post, I mention the importance of not radically alternating the shape of a Chinese eyes to make them lose their ethnicity. However, there are occasions when I got requests from patients who want to change the shape of their eyes so that they can blend in with their racial group. The requests usually come from young Malay girls who are born with indistintive skin creases so that they appear Chinese (some of them have one parent Chinese). They are often mistaken as Chinese unless they wear their Tudongs. Of course some well-known celebrities use their exotic (Eurasian) looks to their career advantages but for a lof of people they prefer to blend in with their cultural background and are unhappy to appear racially ambiguous.

Below are some of the celebrities benefited from their exotic looks.

This Malay girl was unhappy to be constantly mistaken for Chinese and spoken to in Chinese. So I perform a double eyelid surgery to restore her Malay identity.

Is Asian blepharoplasty (double eyelid surgery) similiar to Westernization of the eyelids?

In Malaysia, double eyelid surgery or Asian blepharoplasty is the most common cosmetic  eyelid surgery performed amongst  people of Chinese descents. The purpose of the procedure is to make the eyes appear bigger and more animated without losing their ethnic identity. Consequently, it is a misnomer to call double eyelid surgery Westernization of the eyelids otherwise the results would be disasters as the end results will make the patient appear neither Chinese nor Caucasians because the shape of the eyes are the most distinctive parts of  Chinese faces. Westernization of the eyelids will make the skin creases too high and the eyes sunken. Using my basic photoshop skills, I use three famous actresses/singer to illustrate the points. Lucy Liu has the so called single eyelids and if she were to undergo double eyelid surgery, the surgeon who thought she want her eyes westernized may create double eyelids in the shape of Angelina Jolie. From the photoshop result, the result would be a disaster as she would appear weird with Caucasian eye and yet Chinese nose, cheek and mouth. On the other hand, a considerate and experienced surgeon will make her eyes appear bigger says in the shape of Wang Fei. The photoshop result shows she would retain her Chinese looks despite the double eyelids.

Unfortunately, some western surgeons who thought their Chinese patients want their eyelids to resemble that of Caucasians and may even display their results in textbooks as "successful" results. The pictures below are taken from two American textbooks on eyelid surgery under the chapters Asian Blepharoplasty. To most potential Chinese patients who wish to undergo double eyelid surgery, any surgeons who show these results are most unlikely to get any patients.

I will disuss more on double eyelid surgery later and show how I do the operation (with pictures).

The importance of retaining the Chinese features (at least in Malaysia) after double eyelid surgery will make or break the name of any surgeons. I think the same can be said about creating fuller lips with fillers. Most people would prefer fuller lips without ones that resemble Africans (Africanization of the lips), unfortunately some cosmetic surgeons give their patients the lips of Naomi Campbell!

Eyelid tumour

Eye surgeons who also specialize in eyelid surgry are called oculoplastic surgeons. Many people think that oculoplastic surgeons only perform cosmetic eyelid surgery such as double eyelid (Asian blepharoplasty a bit more of this later in the blog), in actual fact, we also operate on potential life threatening or disfiguring conditions (again more cases will be shown later in this blog) such as eyelid tumours. Here is a 78 year-old patient whom I saw 10 weeks ago with a large tumour eating away the lower eyelid. This tumour is basal cell carcinoma and if untreated can slowly eat away the whole eye. I excised the tumour and after making sure the tumour is completely removed, the eyelid was recontructed using the skin and muscle (myocutaneous flap) to cover the defect. 10 weeks later apart from the scar which would disappear with time, the eyelid is free of tumour and is functionaing well.

 

Eyelid Surgery

We all know the cliche that the eye is the window of the soul. However, no matter how good your vision is if the eyelids that house the eyes are in bad shape, the soul may not given a fair chance to free itself. Some of the eyelid problems are congenital and some acquired either through accident, sickness or old age. Either ways badly shaped eyelid may distort the ways public perceive you. The badly shaped may include ptosis (droopy or sleepy eyes), eyebags, dermatochalasis (excess eyelid skin) or eyelid distortion from injuries.

You may think looks are only important to actresses and actors, however, an article by American research workers (Social implications of blepharoptosis and dermatochalasis. Warwar RE, Bullock JD, Markert RJ, Marciniszyn SL, Bienenfeld DG. Ophthal Plast Reconstr Surg. 2001 Jul;17(4):234-40.) show that social attitudes may lead to unjust bias toward patients with badly shaped eyelids and surgical correction probably provides benefits beyond improved visual function.

The two patients show dramatic changes to their faces immediately after eyelid surgery. The face not only appear younger but more animated. This is not surprisingly because the skin of the eyes are the thinnest of the body and therefore is the first to show signs of ageing. Picture A belongs to a 55 year-old man taken before the operation to correct excess upper eyelid skin (dermatochalasis) and picture B was taken one week later. Picture C belongs to a 47 year-old woman before surgery to correct dermatochalasis and removal of eyebags and D was taken 10 days after the procedure.

If you have any questions regarding eyelid surgery, you can email me at chuaoxford@hotmail.com and better still if you could send me a picture of your upper face for a discussion. Your pictures may be put on the blog for discussion so if you not willing to do so please state that in your email. You can also visit my website at http://www.eyelidsurgery.my/ for more pictures of surgery and contact details.