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.