Doc, My Child has this Swelling Since Birth !

In the previous blog, the patient presented with an inflammed orbital cyst in adulthood. However, most cases are brought to the attention of ophthalmologists because of parental concern.

Below was a typical case in a 3 year-old boy. The cyst presented as a slow-growing, painless, subcutaneous mass. Intense inflammation may occur if the cyst ruptures spontaneously or because of trauma. Excision resulted in complete resolution.

Swellling of the left upper eyelid below the eyebrow.

Feature typical of an orbital dermoid.

Marking was done below the eyebrow to hide

the scar.

Incision was made below the eyebrow.

The dermoid was exposed via blunt dissection.

The cyst was removed intact to avoid leaving behind

any remnants which may cause inflammation.

The cyst measured 1.5cm in diameter.

Cheesy content inside the cyst.

The wound was closed with 6/0 vicryl.

Appearance at 6 days post-operative, the scar will fade

with time and become inconspicuous as it is hidden

by the eyebrow.

Doc, I Got a Big Lump in My Upper Lid !

This young man who had had a small lump in the right upper eyelid since young. Recently, the lump suddenly ballooned with pain. The location of the lump was classical for dermoid cyst and the sudden increase in size meant the cyst has become inflammed possibly due to trauma or spontaneous ruptured of the cyst.

Dermoid cyst is a developmental abnormality in which a bit of skin has been pinched off from the surface and comes to lie in areas where they are not usually found. The most common site for dermoid cyst on the face is below the lateral side of the eyebrow. This cyst can continue to grow because of secretion from the component. It is advisable to remove the dermoid cyst when the patient is young to prevent its continous growth or inflammation as a result of trauma.

The cyst in this patient showed transillumination indicating the cyst is filled with fluid.

About 4 ml of yellowish-green fluid was aspirated from the cyst. The aspiration was done to reduce the pain from distension and also help with surgery so that the wound created does not have to be too big.

To make the scar less conspicuous, the incision was made below the eyebrow.

The whole lump was removed completely so that there is no remnant to cause future inflammation or reaccumulation of the fluid.

The flaccid cyst measured 1.5cm across.

The cyst has thickened wall and contained some cheesy materials secreted by the inner surface of the cyst.

The wound was closed with 6/0 nylon suture and he had no recurrence at 6 months follow-up.

Allergy to Tapes for Double Eyelids

There are several non-surgical methods of creating double eyelids to make the eyes bigger. The most common ones are using glues and tapes. However, no everybody finds these methods satisfactory for several reasons: a. time consuming; b. failure to form double eyelids in those with excessive skin or puffy upper eyelids and c. contact dermatitis (skin allergy to the glues or tapes).

This young girl had been using tapes for years to create double eyelids. Recently, she started to develop itchy eyelids whenever she used tapes despite switching to different brands.

Sore and red skin from glue and tape application.

Examination shows inflammation and excoriations as a result of contact dermatitis.

Contact dermatitis made obvious after

removing eye make-up.

As the patient finds it difficult not to use eye make-up because of her profession as a beautician, double eyelids were created using the incision technique.

One-week post eyelid surgery.

Modified Technique for Double Eyelid Surgery - Partial Incision Technique

The two main techniques for creating double eyelids  are incisional technique and suture technique. Several modified techniques have been developed for the incisional technique in order to achieve the desirable results with faster recovery. These techniques include partial incision technique and mini-incision technique.  While these techniques sound exciting they are not suitable for all patients.  Those who have excess skin or very full upper eyelids (meaning fat removals are needed), the conventional incisional technique is still preferrable.

In the case of partial incisional technique, only the middle third of the lid is incised. This has the advantages of faster recovery and less scarring.

Comparing the incision for conventional

and partial incision.

During the operation, the tarsal plate or the levator muscle (the muscle that opens the eye)  is exposed. The muscle under the skin nearest to the eyelashes is then sutured to either the tarsal plate or the levator musclefter,  the skin is then closed.

Muscle sutured to the tarsal plate.

Muscle sutured to the levator.

A patient before and after partial incision.

The scar only scans 1/3 of the upper eyelid.

17 years of low self-esteem gone in 20 minutes.

Right droopy eyelid before and after surgery.

Ptosis refers to droopy eyelids and it is usually caused by weak muscle that open the eyelid. Most cases occur in older patients but it can also occur at birth in which case it is known as congenital ptosis. Ptosis needs special attention as it can cause lazy eye and further more children with significant ptosis often suffer from emotional stresses as they are soft targets for bullying. This girl had significant ptosis since birth but her parents did not seek help believing this was only a small blemish. However, the significant ptosis had produced poor vision in the right eye and she had low self-esteem and was socially withdrawn. On examination, she had very poor muscle function and so the best option to treat her ptosis was with frontalis suspension in which the forehead muscle was recruited to lift the eyelid. The technique is as shown in the series of picture below and took between 15 to 20 minutes to complete.

Public Talk in Penang

Everybody welcomed.

Oculoplastic Surgeons Must be Experts in Jigsaw Puzzles

One of the common referrals to oculoplastic surgeons is severe eyelid trauma needing meticulous repair. The defect may be partial or full thickness and careful inspection usually reveals that slowly piecing the remnants together like a jigsaw puzzle will correct the repair. Failure to put the pieces together can lead not only to poor cosmesis but affect the proper functions of the eyes such as causing watering eyes and pain from eye exposure.

The pictures below show eyelids that had been badly repaired by doctors who were definitely not good jigsaw puzzle players.



Poorly repaired lower eyelid trauma referred

for reconstruction.

Another poorly repaired eyelid trauma. The left eye

was removed because the globe was badly

ruptured during an explosion accident.

The following cases show how traumatic eyelids should be pieced together like jigsaw puzzles to give reasonable to good cosmetic and functional results.



Severe eyelid trauma from fall.

The left upper eyelid was avulsed.

Immediately after repair.

Facial appearance at one month.

Repair of eyelid trauma from

road traffic accident.