Inject in Haste, Repent at Leisure - Part 2

The following showed the improvement of the facial disfigurement after surgical excision. However, all her problems could have been avoided if she did not have the injection in the first place by unlicensed practitioner. Let this be the cautionary tale for anybody who are remotely tempted to have any injections in beauty saloons.

Before the surgery.

Three days after the surgery.

Three weeks after the surgery

Six weeks after the surgery.

Inject in Haste, Repent at Leisure - Part 1

Some sensible persons may never think twice when the beauticians tell them their faces can be enhanced with special injections. Unfortunately, many faces are ruined due to injections of harmful substances chiefly silicone. The best advice to those who want to have injections done in beauty saloon is "Don't" as these places are unlicensed for invasive procedure and one never know what are in those injections.

This young professional underwent bilateral cheek injections in a beauty saloon three years ago and since then developed bilateral cheek swellings with discoloration resembling festoons seen in older patients. She had sought various treatment including hyalurodinase injection, steroid injection and laser resurfacing but with little effect. 

Bilateral cheek swellings and discoloration after injection 

of unknown substances in a beauty saloon. 

Festoon seen in an older patient.

After discussing with the patients and pros and cons of surgical treatment, the offending parts of the cheeks were surgically removed. During the operations, the subcutaneous tissues were noted to contain multiple small shiny droplets. When pricked, the droplets contained sticky substances which may be silicone oil.

Marking of areas to be excised.

Shiny droplets in the subcutaneous tissues.

Three days post-excision.

Ptosis Day

Another good day, saw 25 patients in the morning followed by three eyelid surgery and one silicone oil removal. The eyelid surgery included a doctor with bilateral ptosis (droopy eyelids).

Both ptosis were corrected with conjunctivomullerectomy 

with buried sutures.

Not Something an Oculoplastic Surgeon Likes to See - Part 4

The patient discussed earlier was advised to return for prosthesis fitting but defaulted. Below was another patient who underwent exenteration 2 years earlier. He also suffered from conjunctival squamous cell carcinoma and was treated with radiotherapy on the recommendation of another ophthalmologist. However, the tumour continued to spread and CT scans showed invasion of the orbital content including the extraocular muscles and optic nerve. He was referred to the oculoplastic clinic for further management and a decision was made for exenteration. He was fitted with a reasonable prosthesis at 18 months with the help of the dental department. 

Left invasive squamous cell carcinoma. 

CT scans showing orbital invasion. 

Exenteration of all orbital contents. 

One day post-exenteration. 

5 month post-exenteration. 

18 month post-exenteration. 

Prosthesis for post-exenteration socket. 

Anterior view of the prosthesis. 

Posterior view of the prosthesis. 

Not Something an Oculoplastic Surgeon Likes to See - Part 3

The patient stayed in the hospital and received daily dressing. He was discharged two weeks later and followed up in the eye department of another town.

    

First day post-exenteration.

First day post-exenteration.

   

One week post-exenteration.

Two week post-exenteration. Granulation was progressing well 

and the wound was clean. 

Not Something an Oculoplastic Surgeon Likes to See - Part 2

The patient was initially reluctant to undergo any treatments but after much persuasion from the family members,  he relented.  The exenteration was performed under general anaesthesia. The wound was dressed daily and allow to granulate spontaneously without skin graft so that any recurrence can be detected early. 

Picture before and immediately after exenteration. 

Figure a - h. Steps showing the procedure of exenteration in which the whole orbital content 

including the periosteum was removed. 

A Fruitful Day :)

A fruitful day, 7 eyelid cases on the list in SGH today. Did three biopsies and two eyelid reconstructions, left epiblepharon and syringing and probing to the junior. One cataract surgery in the pm on a 83 year-old, a bit of struggle as patient had pseudoexfoliation syndrome with small pupil and subluxated lens but the end all ended well. 

Not Something an Oculoplastic Surgeon Likes to See - Part 1

Two of the many advantages of being an ophthalmologists are: 1. one can usually guarantee a good night sleep and 2. rarely do one need to face with life-and-dead decision. And being an oculoplastic surgeon, there is the added advantage that most procedures can be planned ahead for optimal outcomes. However, one occasionally see extreme gross pathology in patients who neglect their conditions necessitating big unpleasant but life-saving procedure. 

This man had a growth in his right eye about three years ago, an ophthalmologist in another town did a biopsy and confirmed the diagnosis of conjunctival squamous cell carcinoma. The man refused further treatments and did not return for follow-up. When he was eventually bought to the clinic by concerned relative because of foul smell emitting from the right eye, his whole eye and its surrounding tissues have been destroyed by the fungating tumour. 

To prevent the spread of tumour into the brain which could kill the patient, the only procedure of choice is orbital exenteration. The procedure involves removal of all eye socket contents, including muscles, the lacrimal gland system, the optic nerve as well as varying parts of the bone of the orbit. 

Front view of the fungating tumour that destroyed 

all the orbital contents and eyelids.

Side view of the tumour.

When Less is More

A young woman from a remote village is referred because of a right shrunken globe. She sustained an accidental injury as a child when a stick entered her eye at the playground. The referring eye doctor requested that her damaged eye to be removed (enucleated) so that an implant can be inserted and had her fitted with an ocular prosthesis. Examination reveals there is no visual function in the right eye.
Instead of performing enucleation as suggested, in which the patient needs many returned visits and may later cause post-enucleation syndrome (in which the disturbance of the orbital vasculature can lead to orbital volume loss; superior sulcus deformity, ptosis and lower lid laxity) which requires more surgical revisions, she was fitted with an ocular prosthesis over the blind eye. The result is reasonable and she is happy.

Right shrunken globe. 

Prosthetic eyes. 

Poor cosmetic result as the prosthesis is too big.

Poor cosmetic result as the prosthesis is not centred.

Good cosmetic result.

Good lid closure with the prosthesis in-situ

Another patient with a left shrunken globe from childhood injury. The eye was fitted with a prosthetic eye  without removing the damaged globe.

Left shrunken globe before and after insertion of a prosthetic eye. 

Doc, can Anything be Done to My Eye? Part 5

The following pictures show the patient's recovery after the second stage of reconstruction. There is ptosis as expected and this can be corrected later using frontalis suspension. The patient may also benefit from eyebrow reconstruction using scalp hair later. 

Appearance at 2 weeks post 2nd stage procedure.

Appearance at 2 months post 2nd stage procedure.

Appearance at 4 months post 2nd stage procedure.

Doc, can Anything be Done to My Eye? Part 4

The second stage of procedure was done two months after the first stage. The lower lid was used to form the upper eyelid and the lower lid defect was closed with Tenzel's flap as shown in the pictures below. 

The pictures show the steps used in the second stage of upper lid 

formation in this patient with cryptophthalmos.

Doc, can Anything be Done about My Eye? Part 3

The patient's recovery was uneventful, despite some wound breakdown at the follow-up. There was no signs of tissue ischaemia.

Post-operative appearance at 24-hour (a) and two week (b)

Medial wound breakdown at 6 week follow-up but the switched 

lid appear viable. 

Doc, can Anything be Done about My Eye? Part 2

There are several ways of reconstructing the upper eyelid, some methods give a more natural looking result than others. The three commonly used methods are shown here.

Cutler-Beard technique. This is often used following a large upper eyelid tumour excision. 

The disadvantages are the absence of eyelashes in the reconstructed part and 

some distortion of the lower eyelid.

In this method, the posterior lamella is first formed by using either 

the tarsus from the lower or hard palate, the anterior lamella is formed 

by using glabellar flap. The main disadvantage is that the skin of the forehead 

is thick and give the upper lid a rigid appearance.

Lower lid switch. This method has the advantage of giving a more natural looking 

eyelid as the eyelashes are transferred together with the flap to the upper lid defect.

For this patient, the best approach is the lid switch procedure. However, there is the problem of locating the levator muscle to allow the new upper eyelid from moving normally. This is also explained to the patient. 

Lid switch procedure for partial cryptophthalmos. a. Before the start of the procedure; b. the upper part 

of the eye where the upper eyelid is to be reconstructed is prepared to received the lower lid switch; 

c. and d. Buccal mucosa is harvested to cover the raw surface of the upper eyeball and three 6/0 prolenes 

are used to attach the upper end of the mucosa to form upper fornix. e. The lower lid switch is fashioned 

and f. and attached to the upper part of the eye. This is left for two months to allow the upper part of 

the eye from taking up the lower eyelid through formation of new vessels.

(to be continued)

Doc, can Anything be Done about My Eye? Part 1

This patient was born with a left absent upper eyelid and eyebrow and the eyeball was covered by a thin layer of skin. The left eye has no light perception but the right eye has normal vision. Her family asks if anything could be done about her condition.

Absent left upper eyelid and the eye covered by a thin layer of skin. 

A left partial cryptophthalmos.

This is a case of partial cryophthalmos in which there is a failure of upper eyelid formation. The structure of the eyeball is often malformed and therefore any surgical procedure to try and restore the vision invariably fail. However, in this case the creation of an upper eyelid may be attempted to restore some semblance of upper eyelid. After explaining to the patient the need to undergo two separate length procedures, the patient agrees to the procedures. 

A child born with complete cryptophthalmos. 

Note absence of any eyelids and eyelashes.

What the Nurse Really Means when She Says All Surgeons are the Same

I overheard a conversation between a nurse and a patient at the cataract clinic.

Patient:” Nurse, are you sure the surgeon who is going to operate on me next week is good? Can you ask a good one to operate on me?”

Nurse: “All the eye doctors here are the same, they are equally good. No to make choices!”

I looked across the room and noticed it was the same nurse who asked me to operate on her father several years ago. Her father was scheduled to be operated by a senior surgeon but two days before the surgery the senior surgeon fell sick and took a one-week sick leave. Her father was rescheduled to be operated by a different surgeon.

Nurse:” Doc, could you go into the theatre tomorrow to operate on my father?”

I:”I thought doctor X is going to do the operation!”

Nurse:”But I am scared that the result would be bad.”

I:”How do you know?”

Nurse: “I have seen his operations, he is very rough with the patients and has lots of complications.”

I:”But I would upset him if I went in during his list, I am sure you can find some excuses to delay the operation until the senior surgeon returns.”

The nurse duly informed the doctor in-charge of the operating list that her father had persistent cough and could not have operation the next day.

Lessons:

1. Not all surgeons are the same, the nurses know best even if they don’t want to say it.

2. While it is complimentary to be regarded as a better surgeon, never upset your colleague by taking away his/her patient.

3. For elective surgery, there is no need to compromise on outcomes by subjecting your loved one to less able hands.

Doc, can you do anything to my son's eyes to stop the bullying ?

Children are cruel and often like to bully their classmates who have facial imperfection despite the threat of punishments from school authorities. This boy had been bullied for many years because of his droopy eyelids and right squinting eye (he has an exotropia in which the eye turns out). 

Bilateral droopy eyelis and a right eye that turns out.

His mother noticed that his school performance has been deteriorating steadily due to the bullying. She enquired if anything could be done to correct the defects. Examination revealed normal vision in both eyes and the right eye was able to take up fixation rapidly when the left eye was covered. Both eyelids had good functions. Surgery was perfromed under general anaesthesia to correct the squint, droopy eyelids (ptosis) and simultaneous creation of double eyelids. Post-operatively, the boy regained his confidence and the bullying stopped.

The right squint was corrected vai right lateral rectus recession and left medial 

rectus resection. The ptosis and double eyelids were corrected by posterior approach

 conjunctivomullerectomy and suture techniques respectively.  

Before and 2-month post surgery.