Sankara Nethralaya: Clinical Practice Patterns in Ophthalmology Prema Padmanabhan, SS Badrinath
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Orbit and Oculoplasty1

  • Preoperative Evaluation
  • Evaluation and Management of Ptosis
  • Entropion
  • Ectropion
  • Trichiasis (Misdirected Lashes)
  • Lid Lesions (Benign/Malignant Growth)
  • Biopsy for Lid Pathologies
  • Eyelid and Adnexal Injuries
  • Thyroid Associated Ophthalmopathy
  • Orbital Injuries including Fractures
  • Orbital Fine Needle Aspiration Biopsy
  • Indications for Computed Tomography
  • Indications for Magnetic Resonance Imaging
  • Dacryocystitis
  • Dacryocystography
  • Endoscopy
  • Socket Evaluation
  • Ocular Prosthesis
  • Aesthetic Clinic2
 
PREOPERATIVE EVALUATION
Preoperative preparation of the patient is as important to the success of a plastic procedure as the actual technique.
 
EVALUATION IN THE OCULOPLASTY DEPARTMENT
 
Patient Assessment-Psychological Implications
  • The evaluation of a patient starts from the moment the patient steps into the consultation room till the entire course of his treatment.
  • The purpose is to determine if plastic surgery is appropriate for a particular patient at a particular time.
  • The motives, expectations and personality of the patient are to be assessed by observation and casual open-ended dialogue.
  • Give the patient an information pamphlet on plastic surgery procedures outlining realistic expectations, preoperative and postoperative condition and possible side effects.
  • Explain the available modalities of treatment for the particular condition with the risks and benefits of each.
  • Explain the surgical procedure and the complications which are likely to occur, if the surgery is to be done under local or general anesthesia.
  • Explain the realistic outcome of the surgery to the patient.
  • Explain the need for multiple procedures or a staged treatment plan in the case of a complicated condition and the reasons if any particular surgery is contraindicated.
  • Explain the need for taking grafts if required, the donor sites, the cosmetic implications, the postoperative 3care of the donor site as well as the primary surgical site.
  • Establishment of a positive relationship with the patient will pay well in the entire course of treatment of the patient.
 
MEDICOLEGAL IMPLICATIONS
 
Informed Consent
The modern standard of care requires the physician to inform the patient of the nature of the proposed treatment, alternate therapies including none, risks and reasonably expected benefits of each one and only then secure their consent.
 
Few Simple Rules
  • Be kind to the patient
  • Keep good records—essential for defense and is the best available evidence
  • Inform the patient of all the possibilities and ask if he understood the same
  • Never hesitate to get a second opinion if required
  • Photographic documentation is essential.
 
GENERAL PHYSICAL EXAMINATION
  • History of diabetes, hypertension, cardiovascular disorders, bronchial asthma
  • History of respiratory tract infections—upper and lower
  • History of bleeding diathesis
  • History of seizures
  • History of renal disorders—preoperative antibiotics, anesthetic medications
  • History of allergies, sensitivities to any drugs
  • Treatment history—intake of antiplatelet drugs, anticoagulants, etc.
  • Family history of bleeding disorders, atopy.4
 
In Case of a Child
  • History of being born of a consanguinous marriage
  • History of pregnancy-related complications—infections, drug intake
  • History of mode of delivery:
    • Forceps delivery
    • Prolonged labor
  • History of postnatal complications, milestones, vaccination, feeding habits.
 
INVESTIGATIONS
  • Baseline blood investigations:
    • Hematocrit, TLC, DLC
    • Blood sugar
    • ESR
    • Bleeding time, clotting time, prothrombin time, partial thromboplastin time
    • Blood grouping and Rh typing
    • Crossmatching in cases where blood loss is expected
  • Serum urea, creatinine
  • Urinalysis, serologic tests and electrolyte studies based on any supporting clinical signs
  • HIV, HBsAg, Hepatitis C
  • Chest X-ray
  • Baseline ECG a must in all patients above age of 40 years and echocardiogram if required
  • Rule out foci of infection—regional and distant
  • Ultrasonogram of the orbits
  • CT scan of the orbits, brain/MRI in necessary cases
  • Thyroid function tests—Free T3, T4, TSH, anti-thyroid antibodies
  • Metastatic work-up in case of suspected metastases to the orbit:
    • CXR, CT scan chest
    • USG abdomen
    • X-ray long bones, bone scan
    • CT scan brain
    • Liver and renal function tests.5
 
The Day Before Surgery
Anesthetist review: To explain the mode of anesthesia, proper premedication to be given, cardiovascular and respiratory assessment.
 
Surgeon's Review
  • Check for good preoperative photographs
  • Check for enucleation/evisceration/orbitotomy consent
  • Explaining about the procedure
    • Removal of the eyeball or its contents respectively which would mean total loss of vision in the operated site
    • Orbitotomy—impairment of vision, limitation of ocular motility, double vision, lid droop, squinting can occur
  • Check the donor graft site—hygiene and asepsis (Antiseptic mouthwash to be given in cases where buccal mucosal graft is planned).
 
On the Day of Surgery
  • Monitoring of blood sugar, blood pressure
  • Premedication, antibiotics, preparation of the patient.
 
Inside the Operation Theater
  • The surgeon should speak to the patient and make him relaxed before starting the surgery
  • Check the consent form
  • Check and cross-check the eye undergoing the surgery
  • Check the mode of anesthesia local/general anesthesia
  • Check the anesthetic drug if local anesthesia is planned expiry date, contamination if any
  • Check if the blood is ready as required
  • Check if X-ray lobby is ready6
  • Check the availability of headlights, microscope, magnifying loupes
  • Pathology department to be informed prior if frozen section is planned, things to be kept ready for imprint cytology
  • Check the availability of the instruments required for surgery and their sterilization, review the suture materials
  • Check the emergency department
  • Combination of preoperative photographs and CT/MRI scans, measurements should be in the operating room visible to the surgeon
  • Markings on the skin should be done prior to distorting the tissues by injection and without pull on these tissues by the head drapes.7
 
EVALUATION AND MANAGEMENT OF PTOSIS
 
HISTORY
  • Age of presentation: Since birth/Acquired later in life
  • Precipitating factor
  • Progression of the symptoms:
    • Worsening
    • Duration of stable ptosis
    • Diurnal variation
    • Presence of other neurological problems
  • History of trauma
  • History of any eyelid/ocular surgery
  • History of double vision
  • Review of old photographs, if available.
 
EXAMINATION OF PTOSIS
  • Facial asymmetry/dysmorphia
  • Abnormal head posture (AHP)
  • Periocular skin-scarring, mass lesions, dermato-chalasis
  • Visual acuity
  • Refraction
  • Hirschberg/cover test
  • Extraocular motility (EOM)
  • Pupillary evaluation
  • Slit-lamp evaluation—giant papillary conjunctivitis
  • Fundus
  • Measurements:
    • Palpebral fissure height (PFH)
    • Margin reflex distance (MRD 1 and 2)
    • Levator action (LPS)
    • Margin crease distance (MCD)
  • Lid lag
  • Lagophthalmos8
  • Bell's phenomenon
  • Marcus Gunn jaw winking/other synkinetic movements
  • Drooping of contralateral lid on manual ptosis correction
  • Fatiguability/Cogan lid twitch
  • Corneal sensation
  • Ancilliary tests:
    • Phenylephrine test
    • Schirmer's test
    • Ice test.
NB: It is important to eliminate frontalis overaction while taking ptosis measurements:
  1. Photographic documentation is a must showing the close-up of face with and without face turn or chin elevation in straight gaze—preferably postoperative and follow-up pictures with the same background.
  2. Parent/patient counseling especially to explain postoperative problems of lid lag and lagophthalmos, possible complications and need for revision procedures.
 
SURGICAL APPROACH
 
Congenital Ptosis
  • Early surgery is indicated if the ptosis is severe and the child is in the amblyogenic age group.
  • If the visual axis is spared surgery is to be performed when the child is round 3 to 5 years old provided the child is cooperative for the initial assessment and subsequent follow-up.
  • In the case of Marcus Gunn phenomenon with significant jaw wink.
    • LPS excision + Frontalis sling, early, if the child is within the amblyogenic age group and the ptosis is severe; preschool age if not.
  • Mild and moderate ptosis with fair-to-good function of the LPS—plan for LPS resection9
  • Severe ptosis and/or poor LPS action—plan for frontalis sling
  • Bilateral ptosis:
    • Same sitting if the ptosis is severe or symmetrical
    • Worse eye first if the ptosis is asymmetrical followed 6 months later by the fellow eye
  • In cases of vertical squint, referral to squint surgeon to improve pseudoptosis.
 
Aponeurotic Ptosis
  • Surgery is indicated for cosmetic or functional impairment
  • Procedure of choice is external approach with LPS reinsertion/advancement under local anesthesia.
 
Neurogenic Ptosis
  • Minimum 6 months of stable ptosis without further improvement is a must prior to surgery
  • Correct the squint prior to the ptosis
  • Options: Frontalis sling and occasionally LPS resection.
 
Myogenic Ptosis
  • Tensilon test, neurologist referral in cases of suspected myogenic ptosis
  • Crutch glasses can be prescribed in patients refusing surgery
  • Frontalis sling with silicon rods with undercorrection may be considered.
 
Traumatic Ptosis
  • Minimum 6 months stable period
  • Options include: Exploration ± reinsertion of the LPS aponeurosis or frontalis sling
  • Important to assess the adequacy of Bell's phenomenon and degree of extraocular muscle entrapment and restriction.10
 
POSTOPERATIVE MANAGEMENT
  • Look for epithelial defects (corneal status)
  • Wound integrity
  • Suture removal to be done on 5-7th postoperative day
  • Assessment of the procedure objectively by measuring the palpebral fissure width
  • Subjective assessment in terms of patient satisfaction
  • Look for complications
  • Final documentation with photographs to be made
  • Cycloplegic refraction in case of children at GA
  • Periodic annual evaluation is preferred.
 
REPEAT SURGERY
 
Overcorrection
Initial trial with lash traction/lid stretching. If not satisfactory by 3 to 6 weeks, then revision surgery. If overcorrection is causing exposure related problems, early release of sutures to be done.
 
Undercorrection
Repeat surgery after a minimum of 6 weeks. In case of persisting edema, preferable to wait until edema resolves.11
 
ENTROPION
 
DEFINITION
It is the condition where there is an inturning of the upper or lower eyelid with posterior migration/rounding of the posterior lid margin, eyelash contact against the cornea, etc. It may be partial or complete, intermittent or constant and symptomatic or asymptomatic.
 
EVALUATION
 
History
  • Symptoms (of present illness):
    • Irritation, FB sensation, redness
    • Tearing
    • Discharge
    • Light sensitivity
    • Visual loss
    • Interference with overall functioning and quality of life
    • Duration (intermittent or constant)
    • Aggravating or relieving factors.
  • Past history:
    • Chronic blepharoconjunctivitis
    • Glaucoma medications
    • Trachoma
    • Trauma/burns (thermal/chemical)
    • Ocular or eyelid surgery
    • Radiation
    • Stevens-Johnson's syndrome, ocular cicatricial pemphigoid, etc.
  • Medical history:
    • Diabetes mellitus
    • Systemic hypertension
    • Bleeding diathesis
    • Aspirin/anticoagulant intake
    • Anesthetic complications.12
  • Surgical history
  • Drug allergies.
 
EXAMINATION
  • General condition
  • Facies
  • Involutional changes of face—brows, upper eyelids, lower eyelids, dermatochalasis
  • Complete ophthalmic evaluation—with specific emphasis on corneal examination—corneal epithelium, sensation, scarring, tear film, etc.
  • Upper eyelid entropion:
    • Brow position
    • Vertical palpebral aperture
    • Margin reflex distance 1
    • Levator function
    • Superior lid crease
    • Lash position and direction
    • Posterior lid margin
    • Meibomian gland orifices—position, inspissation, distichiasis
    • Tarsal conjunctiva—shortening, scarring, integrity, thickening
    • Spontaneous eversion—floppy eyelid
  • Lower eyelid:
    • Position
    • Lid margin including retraction
    • Lash position and direction
    • Horizontal lid laxity—distraction test, snap back test
    • Medial canthal tendon integrity
    • Punctal position and patency
    • Capsulopalpebral fascia integrity
    • Conjunctival scarring
    • Dermatochalasis
    • Suborbicularis oculi fat/superficial musculo-aponeurotic system (SOOF/SMAS) descent
    • Precipitation on forced eyelid closure.13
  • Oral examination:
    • Labial mucosa
    • Buccal mucosa
    • Hard palate mucosa
    • Dental/gingival hygiene
 
INVESTIGATIONS
  • Tests for general fitness for surgery/anesthesia
  • Coagulation tests
  • Photographic documentation.
 
MANAGEMENT
  • Educate, counsel patient
  • Informed consent
  • Temporary procedures (lower eyelid)—taping, Botox injection, Quickert's sutures, etc.
  • Definitive surgery—lid tightening, eyelid retractor plication/reinsertion, margin rotation/tarsal fracture, spacer graft with MMG, etc.
  • Consider blepharoplasty when necessary.14
 
ECTROPION
 
DEFINITION
It is the condition where there is an outward turning of the upper or lower eyelid with anterior migration/rounding of the posterior lid margin, ectropion of the puncta, keratinization of the conjunctiva and shortening of the anterior lamella of the eyelid. It may be partial or complete, symptomatic or asymptomatic.
 
EVALUATION
 
History
  • Symptoms (of present illness):
    • Tearing
    • Irritation, redness
    • Discharge
    • Visual loss—intermittent blurring, permanent deficit
    • Interference with overall functioning and quality of life
    • Duration (intermittent or constant)
    • Aggravating or relieving factors.
  • Past history:
    • Chronic blepharoconjunctivitis
    • Trauma
    • Ocular, eyelid or facial surgery
    • Radiation, burns (thermal/chemical).
  • Medical history:
    • Cicatrizing dermatological conditions-ichthyosis, actinic keratosis, contact dermatitis
    • Diabetes mellitus
    • Systemic hypertension
    • Bleeding disorders
    • Aspirin/anticoagulant intake
    • Anesthetic complications
  • Surgical history
  • Drug allergies.15
 
EXAMINATION
  • General condition
  • Facies
  • Involutional changes of face—brows, upper eyelids, lower eyelids, dermatochalasis
  • Complete ophthalmic evaluation with specific emphasis on corneal examination—corneal epithelium, sensation, scarring, tear film, etc.
  • Upper eyelid ectropion:
    • Brow position
    • Vertical palpebral aperture
    • Margin reflex distance 1
    • Levator Function
    • Superior lid crease
    • Lash position and direction
    • Posterior lid margin, keratinization of conjunctiva
    • Meibomian gland orifices—position, inspissation, distichiasis
    • Tarsal conjunctiva—shortening, scarring, thickening
    • Spontaneous eversion—floppy eyelid
    • Scarring of the eyelid/eyebrow/forehead skin.
  • Lower eyelid:
    • Position
    • Lid margin including retraction
    • Lash position and direction
    • Horizontal lid laxity—distraction test, snap back test
    • Medial canthal tendon integrity
    • Punctal position and patency
    • Capsulopalpebral fascia integrity
    • Conjunctival scarring
    • Steatoblepharon
    • Dermatochalasis
    • SOOF/SMAS descent
    • Evaluation of the lacrimal secretory and drainage function16
  • Other:
    • Upper lid dermatochalasis-ipsilateral/contra-lateral eye
    • Retroauricular skin
    • Supraclavicular skin
    • Inner arm skin
    • Skin of anterior/medial thigh.
 
INVESTIGATIONS
  • Tests for general fitness for surgery/anesthesia
  • Coagulation tests
  • Photographic documentation.
 
MANAGEMENT INCLUDING PRINCIPLES
  • Educate, counsel patient
  • Dermatology consultation if indicated (Cicatricial ectropion)
  • Informed consent
  • Punctal eversion-punctal inversion sutures, punctoplasty
  • Involutional laxity—horizontal lid tightening— lateral tarsal strip, block excision, lateral canthal sling, etc.
  • Anterior lamellar cicatricial changes—scar release with full thickness skin graft
  • Tarsal ectropion—lid retractor reinsertion, tarso-conjunctival resection
  • Consider blepharoplasty at the same sitting.17
 
TRICHIASIS (MISDIRECTED LASHES)
 
HISTORY
  • Trachoma
  • History of drug ingestion of fever (Stevens-Johnson syndrome)
  • Trauma/Burns
  • Past history of treatment
 
EXAMINATION
  • Extent of misdirected lashes (diagrammatic representation is ideal)
  • Lid position
  • Vision
  • Puncta
  • Fornices (symblepharon)
  • Conjunctival scarring
  • Corneal status (staining—SPK, ulcer)
 
MANAGEMENT
  • Manual epilation (especially if there are very few misdirected lashes)
  • Argon laser epilation
  • Electroepilation
  • Cryotherapy—this may be combined with posterior lamellar advancement ± mucous membrane graft in cases with posterior lamellar shortening.18
 
LID LESIONS (BENIGN/MALIGNANT GROWTH)
 
HISTORY
  • Duration
  • Rate of growth, mode of onset (sudden/gradual), change of color, bleeding, ulceration
  • Any previous operation or biopsy—details if available including histopathology slides and paraffin blocks for review by our Ocular Pathology Department
  • Any swelling in the head and neck or elsewhere in the body
  • Associated ocular disease
  • Major systemic illness.
 
EXAMINATION
  • Detailed description of the eyelid lesion as in a general surgery examination (surface, consistency, etc.)
  • A simple diagrammatic description with measurements, arrows, etc.
  • Examine for condition of other lid, skin, eyelid margin (entropion, ectropion), lagophthalmos
  • Always evert the lids and examine the posterior surface
  • Examine the bulbar and palpebral conjunctiva and corneal surface in detail
  • Look for skin ulceration, blood-stained discharge, loss of cilia
  • Examine for preauricular and cervical lymph nodes
  • Examine the rest of the face, body where applicable
  • Inspection of other body areas for donor sites for planned reconstructive procedure (e.g. retro- auricular area, oral cavity).19
 
MANAGEMENT
  • To be examined and managed by Oculoplasty Consultant
  • Photographic documentation of all cases
  • In case of extensive lesions with possibility of orbital spread, USG orbit, CT scan orbit as applicable must be asked for
  • Histopathological examination (HPE) slide review, where available by Ocular Pathologist
  • Clinical diagnosis of benign/malignant lid lesion to be made in all cases with a detailed plan for management including technique of reconstruction
  • In a suspected chalazion, incision and curettege is done and the curetted material should be sent for HPE, especially, in cases of recurrent swelling and in an older patient
  • In small lesions, excision biopsy to be performed
  • In case of benign large lesions, excision biopsy with appropriate technique of eyelid reconstruction
  • In case of suspected malignant lesions, excision under frozen section control (Ocular Pathologist to be given advance notice of the same) with appropriate reconstruction
  • It is nearly always necessary to obtain tissue diagnosis prior to referral to Oncologist
  • In large tumors, incisional biopsy/exenteration as appropriate (arrange for blood transfusion as applicable)
  • In case of HPE diagnosis of a malignancy, appropriate referral to Oncologist with a case summary, copy of HPE reports and HPE slides or block as appropriate
  • Postoperative documentation in all cases
  • Video documentation (academic), where needed
 
FOLLOW-UP
  • As appropriate
  • Removal of sutures can be done in the OPD; general anesthesia may be needed for pediatric age group.20
 
BIOPSY FOR LID PATHOLOGIES
Features suggestive of malignancy and the necessity for biopsy:
  • Lesions which:
    • Bleed easily
    • Spontaneously ulcerate
    • Increase in size
    • Have localized loss of eye lashes
  • Any inflammatory lesion which pursues a relentless course.
  • Lesion which does not respond to the usual therapy.
  • Any growing lid lesion/recurrent stye/chronic rodent ulcer
  • Lesion which has:
    • Pearly telangiectatic changes in an area of cutaneous disturbance
    • An area of diffuse induration
    • A scirrhous retracted area
    • Loss of eyelid margin architecture
  • Involvement of regional lymph nodes.
    Choice of a biopsy technique is based on:
    1. Location of the lesion
    2. Suspected histological diagnosis
    3. Should minimize cosmetic defect
    4. Should interfere the least with further surgery
    The varied biopsy techniques are:
    1. Punch biopsy
    2. Shave biopsy
    3. Excision biopsy
    4. Incision biopsy
    The goal of biopsy: To remove tissue which is representative of the lesion.
    The requisites are:
    • The specimen should be of adequate size21
    • Should include some normal tissue for comparison
    • The specimen should be deep enough to include the base of the lesion
    • Use of sharp delicate instruments and gentle handling of tissue to prevent crushing artifacts
    • Orient the pathologist to the area by marking it or by drawing a simple diagram or pin the specimen with stainless steel pins or hypodermic needles.
 
Punch Biopsy
  • Gives a cylinder of tissue.
  • Different sizes of the punches are available with a circular sharp cutting edge
  • Sizes are varying from 2 to 8 mm
  • Most commonly used is 3 or 4 mm size punch
  • Unsuitable in globe and adnexal lesions because of close proximity to the globe.
 
Shave Biopsy
  • Gives a disc of tissue
  • Used for a lesion whose major component is protruding above the skin, i.e. only for superficial lesions; not for a melanoma.
 
Excision Biopsy
  • Simultaneous biopsy and excision of a tumor
  • The advantage is that it provides direct visualization and excellent tissue control
  • For best cosmetic results make an elliptical incision which incorporates the lesion and 1 to 2 mm of normal tissue
  • Mark the area initially, excise the skin ellipse with 15 blade, mark the temporal or nasal aspect of the lesion with suture followed by suturing the wound.
 
Incision Biopsy
  • To get a small but sufficient amount of tissue for diagnosis
  • An area of normal appearing tissue is also included22
  • The advantage is that it provides direct visualization and ensures adequate sample harvestation.
    In a patient with a suspicious lid lesion, determine if a biopsy is indicated and what type would be appropriate.
  • A probable benign lesion which is cosmetically unacceptable—shave biopsy
  • A benign large lesion—excision biopsy with appropriate technique of lid reconstruction
  • A probable malignant lesion which is small— primary excision with lid reconstruction
  • A probable malignant lesion which is large—an incision biopsy/a small trephine punch is ideal
  • Large malignant lesions—surgical removal under frozen section (pathologist informed beforehand) + extensive lid reconstruction
  • Malignant lesions with invasion of adjacent soft tissues—subtotal or total exenteration.23
 
EYELID AND ADNEXAL INJURIES
 
HISTORY
  • Details of mode of injury—exact detailed description to be obtained from patient, witnesses
  • Possibility of foreign body to be explored by detailed history
  • First aid, details of treatment taken earlier including Inj tetanus toxoid
  • Any associated injuries—head injuries, fractures, etc. to be specifically asked for
  • General condition—systemic disease.
 
EXAMINATION
  • Use disposable gloves when examining the patient
  • Evaluate the general condition of the patient and if sick or unstable, urgent evaluation by Physician/Anesthetist/Consultant in the emergency
  • If general condition is poor, a decision regarding shifting the patient out of Sankara Nethralaya and to an appropriate hospital may need to be taken urgently
  • All injuries to be examined and described in detail; a simple diagrammatic representation is appropriate
  • Remove any glass pieces, dirt or foreign material and clean the wound with saline/distilled water
  • Evaluate pupils and rule out relative afferent pupillary defect (RAPD) in all cases
  • In case of profuse bleeding, inform the trauma consultant urgently
  • In all cases look for associated orbital injuries— hematoma, fractures
  • Perform a complete ophthalmic examination in all cases and rule out associated globe injuries
  • CT scan of the orbit and brain may need to be done in case skull or orbit fractures are suspected.24
 
MANAGEMENT
  • Inj. TT 0.5 ml intramascular (if not already given)
  • Nil orally till further orders
  • Physician/Anesthetist opinion for fitness as appropriate
  • Trauma Consultant to be informed urgently
  • Arrange repair/reconstruction in MOT
  • Documentation of all cases is essential—to be done in Emergency/Ward/Operation theater
  • Urgent repair/reconstruction of eyelid injuries to be combined with any globe repair if present. If no associated globe injuries, lid surgery to be scheduled within 24 hours
  • Repair may necessitate specialized techniques, e.g. skin grafting in injuries with loss of tissue, eyelid burns. These may need to be arranged for
  • Postoperative evaluation and documentation at regular intervals.
 
GUIDELINES FOR DETAILED EXAMINATION OF MASS LESIONS OF THE ORBIT
 
Comprehensive History
  • Presenting complaint to be recorded in chronological order
  • Details of presenting symptoms and associated history
  • Progression of symptoms
  • Precipitating factors/events, e.g. trauma, physical straining
  • Past treatment if any
  • Response to treatment if any
  • Presence of any systemic mass lesions elsewhere
  • Visual compromise in terms of acuity, diplopia, blunting of colors
  • Personal history in terms of weight loss, appetite, smoking, exposure to pets
  • History of exposure STD if indicated
  • History of contact with TB.25
 
Evaluation of a Case of Proptosis
  • Visual acuity
  • Refraction
  • Color vision
  • Pupils
  • Extraocular Motility/Hirschberg/Cover test
  • Intraocular pressure (IOP)
  • Slit-lamp examination
  • Fundus
  • Facial asymmetry/dysmorphia
  • Exophthalmometry (Hertel's/Nafziger)
  • Globe displacement—horizontal and vertical (2 ruler test)
  • Eyelids:
    • Position (retraction, inf. scleral show, lateral flare)
    • Margin-reflex distance (MRD1)
    • Palpebral fissure height (PFH)
    • Lagophthalmos
  • Palpation:
    • Orbit
    • Thyroid
    • Regional lymph nodes
  • Globe retropulsion (RBR)
  • Pulsation/Thrill/Bruit
  • Valsalva
  • Cranial nerves examination (II, III, IV, V, VI)
  • Systemic: Skin, oral and nasal examination
  • Imaging: USG, CT, MRI.
6 Ps: Pain, Proptosis, Progression, Palpation, Pulsation, Periorbital changes.
 
Systemic Evaluation
  • Look for any masses in the body
  • Lymphadenopathy
  • Organomegaly
  • Evaluation by allied specialists.
 
Investigations
  • To be tailored to the nature of the presenting complaints26
  • Special investigations in view of planned surgery done
  • USG B-scan orbit
  • CT scan orbit (if the previous CT does not correlate with the current clinical findings or is more than a year old)
  • MRI to be reserved for specific situations only.
 
Surgical Approach
  • Informed special consent to be obtained in all cases regarding the risk for visual loss
  • Depending on the location of the tumor and the nature of the lesion medial, lateral, superior, inferior and anterior orbitotomy
  • Preference to be given to excisional biopsy for potentially resectable tumors
  • Incisional biopsy for extensive infiltrative lesions/debulking of the tumor
  • Frozen section to be reserved in special situations and lab to be informed in advance for the same
  • Intraoperatively both eyes to be prepared to enable pupillary evaluation
  • Six hours postoperative when patient is conscious and oriented, pupillary evaluation and gross visual acuity to be checked. Methylprednisolone may be indicated in certain cases
  • Drain to be removed when flow is minimal to nil (2–3 days)
  • Suture removal to be done on 6th to 7th day
  • Depending on biopsy report further line of management in terms of chemotherapy/radiotherapy/follow-up is to be planned.
 
FOLLOW-UP
  • At each visit, documentation of wound integrity, pupillary reaction, extra-ocular movement (EOM), Diplopia if any, visual acuity and Hertel's at six weeks postoperative
  • If residual mass lesion is present, follow-up frequency tailored according to type of the lesion, including evaluation by allied specialists.27
 
THYROID ASSOCIATED OPHTHALMOPATHY
 
DEFINITION
It is the condition where the eyeball and ocular adnexal structures (eyelid, extraocular muscles, orbital fat and optic nerve) are variably affected resulting in functional and cosmetic derangement of the patient related to autoimmune disease of the thyroid gland, sometimes with dysfunction of the thyroid gland.
 
EVALUATION
 
History
 
Ophthalmic
  • Prominence of the eyes
  • Wide eyed appearance
  • Redness, irritation, tearing
  • Blurred vision, blunting of colors
  • Double vision
  • Inability to close eyes
  • Are the symptoms present in one or both eyes, intermittent or persistent, duration. Impact on daily quality of life.
 
Systemic
  • Previous history of thyroid disease—hyper/hypo/euthyroid, thyroid swelling, surgery, radioactive or medical treatment, etc.
  • Weight loss, palpitation, heat intolerance, dysmenorrhea/menorrhagia, altered bowel habits, increased appetite, etc.
  • Diabetes mellitus—age of onset and nature of control
  • Severe anemia (Pernicious), vitiligo, other autoimmune disorders
  • Systemic hypertension
  • History of smoking—duration, frequency.28
 
Examination
See attached ITEDS/VISA forms.
 
Management Principles
  • Determine above parameters
  • Identify parameters for urgent/immediate intervention
    • Exposure keratopathy, optic neuropathy
  • Appropriate investigations
    • Perimetry, Ultrasound study of the orbit, CT/MRI scan of the orbit
  • Educate and counsel patient regarding natural course of disease including need for frequent follow-up and warning symptoms of visual compromise.
 
To Stop Smoking
  • Endocrinology referral and systemic management as indicated
  • Supportive therapy—lubricants, taping, punctual occlusion, moisture goggles, prisms in spectacles
  • Surgical
    • Acute—tarsorrhaphy/canthotomy/cantholysis, Orbital decompression
    • Residual disease
      • Severe disfiguring proptosis—Orbital decom-pression
      • Strabismus—strabismus surgery
      • Eyelid retraction—lid retraction repair +/- blepharoplasty
  • Ongoing ophthalmic and general medical care.29
 
ORBITAL INJURIES INCLUDING FRACTURES
 
HISTORY
  • Details of mode of injury—exact detailed description to be obtained from patient, witnesses
  • Possibility of foreign bodies (FBs) to be explored by detailed history
  • First aid, details of treatment taken earlier including Inj. Tetanus toxoid
  • Any associated injuries—head injuries, fractures, etc. to be specifically asked for
  • General condition—systemic disease
  • History of double vision, numbness or abnormal sensations over lower lid, cheek, or upper lid of affected side to be asked for
  • Difficulty in opening mouth, chewing, etc.
 
EXAMINATION
  • Use disposable gloves when examining the patient
  • Evaluate the general condition of the patient and if sick or unstable, urgent evaluation by Physician/Anesthetist/Consultant in the Emergency
  • If general condition is poor, a decision regarding shifting the patient out of Sankara Nethralaya and to an appropriate hospital may need to be taken urgently
  • All injuries to be examined and described in detail; a simple diagrammatic representation is appropriate
  • Rule out globe injury
  • Remove any glass pieces, dirt or foreign material and clean the wound with saline/distilled water
  • In case of profuse bleeding, inform the Oculoplasty/Trauma Consultant urgently
  • Evaluate pupils and rule out RAPD in all cases
  • In case of profuse bleeding, inform the Oculoplasty/Trauma Consultant urgently30
  • Look for and rule out proptosis/enophthalmos
  • Rule out subcutaneous emphysema by looking for crepitus
  • Gently palpate the orbital margins and facial bones for any point tenderness, irregularity or deformity
  • Evaluate ocular motility and look for double vision
  • Document double vision with Hess and diplopia charting whenever possible
  • Perform Hertel's exophthalmometry whenever required and possible
  • Rule out infraorbital nerve hypoesthesia.
 
MANAGEMENT
  • Photographic documentation of all cases
  • In case of proptosis, lubricant therapy, taping as applicable to prevent corneal exposure
  • Ultrasound examination of orbit to rule out hematoma, etc. when needed
  • X-ray orbits, CT scan orbit with axial and coronal cuts for documentation and to rule out fractures
  • Oral antibiotics, NSAIDs, etc. as appropriate
  • Use of icepacks in the early stages postinjury to reduce swelling, pain
  • Inj. TT 0.5 ml intramascular if not already given
  • Inform Trauma/Oculoplasty Consultant
  • Advise patient not to blow the nose, especially if fracture of the medial orbital wall is suspected
  • Conservative/surgical treatment on basis of extent of fractures, symptoms and signs. Surgical repair usually after 10 to 14 days
  • Serial Hess and diplopia charting to evaluate progress
  • Referral to Faciomaxillary Surgeon or Neurosurgeon when appropriate.31
 
ORBITAL FINE NEEDLE ASPIRATION BIOPSY
 
INDICATIONS
  • In tumors where histological confirmation is needed but primary treatment will not be surgical
  • Identification of unresectable orbital tumors especially epithelial lesions
  • Deep orbital lesion where surgery is risky with technical difficulty
  • Diagnosis of cavernous sinus syndrome lesions which enter the orbit
  • Metastatic tumors to the orbit
  • Optic nerve lesions are biopsied only when vision has progressed to blindness or near blindness
  • CT scan suggestive of lacrimal fossa malignancy or lymphoid lesions can be biopsied
  • Orbital abscesses
  • Aspiration of hematoma
  • Suspected antibiomas and pseudotumor
  • Debilitated or aged patients who are at risk for anesthesia or surgery.
 
PRE-REQUISITES
  • Availability of an expert Cytopathologist
  • Patient selection—fine needle aspiration biopsy (FNAB) gives only a small sample. Hence it is not as useful in patients for whom the differential diagnosis includes a choice between a benign and malignant tumor with similar microscopic features
  • Anticipate the potential complications. Hence, it should not be done if it will not affect the choice of treatment
  • The results are useful only if a positive result is obtained. False negative diagnoses also do occur because of sampling errors/fibrous tissue/carcinomas with large fibrous component or prominent inflammatory component32
  • CT and ultrasound be done prior to FNAB for tumor location, dimensions and relationship to the ocular structures
  • GA clearance for pediatric cases.
 
TECHNIQUE
  • Explain the procedure, implications, necessity for further surgery if FNAB is not diagnostic or gives a confusing picture
  • Ultrasound B-scan to locate the orbital mass and to guide the needle
  • Anesthesia is usually not required in adults but in children general anesthesia is required
  • A 3.75 cm/22 G Needle is taken on a 20 cc syringe mounted in a pistol grip holder. A one inch needle is used in children
  • Under ultrasound guidance one enters the orbit through the upper or lower lid in the appropriate quadrant. Avoid direct entry over or under the globe
  • No aspiration pressure is applied till the tumor is entered
  • Once the mass is entered negative suction is applied as the needle is advanced and retracted slightly with small changes in angulation within the tumor
  • Negative suction is released before the needle is withdrawn
  • Immediately prepare the specimen by fixing it in 95 percent alcohol or immediately transfer the contents into a test tube containing heparin solution for cytospin
  • Residual tissue in the needle if fixed in 4 percent formaldehyde and kept for cell block preparation and staining
  • Pressure patch is applied for an hour or longer if necessary.
 
COMPLICATIONS
  • Retrobulbar hemorrhage
  • Globe perforation
  • Vision loss33
  • Metastatic tumor seeding along the needle tract— very rare
  • Ptosis
  • Motility disturbances.
 
CONTRAINDICATIONS
  • Vascular tumors such as arteriovenous malformations, orbital varices and hemangiomas
  • Dermoids—leakage of cyst contents gives rise to intense inflammatory reaction
  • Benign lacrimal gland tumors are not usually biopsied.
 
CT SCAN GUIDED ORBITAL FINE NEEDLE ASPIRATION BIOPSY
 
Indications
  • For small lesions and posteriorly located lesions
  • In deeply located lesions where ultrasound cannot image
  • Lesions in the muscle cone especially optic nerve lesions in eyes which are nearly blind/are blind.
 
Technique
 
For Small and Posterior Lesions
  • Needle is inserted first unattached to the syringe and pistol grip while positioning the patient in the scanner
  • Check the location of the tip with scanner. If misplaced, reposition till it is within the mass
  • Then attach the syringe with the pistol grip and do the aspiration.
 
For Optic Nerve Lesions
  • Enter laterally through the lower lid and direct the needle up and medially
  • Engage the optic nerve with the needle with a characteristic feel and the globe retracts slightly. The globe moves with the needle movement
  • Evaluate the position and do the aspiration.34
 
INDICATIONS FOR COMPUTED TOMOGRAPHY
  • Proptosis
  • Suspected orbital mass—location, size, shape, involved structures, density, calcification, contrast enhancement, bony change
  • Unexplained optic neuropathy, visual field abnormalities, disc edema—contrast enhanced computed tomography (CT) of brain and orbits gives a picture of chiasma and retrochiasmal pathways for intracranial masses
  • Orbital and ocular trauma—orbital and nasoethmoidal fractures, intraorbital soft tissue trauma, intraocular or orbital foreign body.
  • Motility disorders—combined CT brain and orbits helps to localize lesions in cerebral cortex, brainstem, cerebellum, cranial nerves or extraocular muscles
  • Orbital inflammation or infection—specific signs help in delineation like multiple muscle enlargement of Grave's ophthalmopathy, diffuse or localized orbital soft tissue enhancement in pseudotumor, cellulitis with subperiosteal abscess and sinusitis
  • Pretreatment planning for radiotherapy
  • Preoperative planning for craniofacial reconstructive surgery
  • Pre-MR imaging evaluation to rule out orbital or ocular metallic foreign body (in certain selected areas)
  • Bony or ossifying lesions of the orbit.
 
THREE DIMENSIONAL CT
It uses volume-based computerized reconstructions of thin axial sections—1.5 mm slices or contour surface imaging.
 
Indications
  • In neurosurgery and craniofacial reconstructions especially in craniosynostosis and congenital 35craniofacial deformities—preoperative three dimensional viewing of bony anatomy, orbital morphology and volume, globe position, soft tissue volumes
  • To create orbitocranial prostheses which are used as models for tissue excision, as bone graft templates, as alloplastic implants
  • To evaluate post-traumatic enophthalmos after orbital fractures due to the accuracy of volume measurement with 3D-CT
  • Evaluation and management of orbital tumors—for evaluation of orbital osteomas, for detection of residual orbital neurofibroma, for reconstructive planning after extensive resection of orbitocranial malignant teratomas.
 
Advantages of CT
  • Excellent anatomical definition of bony and soft tissue anatomy
  • Cheaper and affordable than MRI
  • Good spatial resolution
  • Less sensitivity to patient motion—motion artifacts are lessened.
 
Disadvantages of CT
  • Radiation exposure approximately 2 to 3 rads
  • Allergic reactions to iodinated contrast dye
  • Poor contrast between some adjacent soft tissues which are isodense
  • Artifacts are produced by dense bone and metallic objects
  • Sagittal imaging is not possible.
  • Not indicated in pregnancy.
 
Disadvantages of Three Dimensional CT
  • Time investment for each study
  • Cost
  • Absolute necessity of strictly limiting patient movement
  • Increased radiation exposure with multiple thin slices.36
 
INDICATIONS FOR MAGNETIC RESONANCE IMAGING
 
INDICATIONS
  • Identification, localization and delineation of soft tissue lesions
  • Optic canal lesions and lesions around optic canal, to identify intracranial extension
  • Mass lesion surrounding the optic nerve.
 
ADVANTAGES
  • Can be done in pregnancy
  • Greater image resolution of central nervous system (CNS) and other soft tissues which are isodense on CT
  • Better detection of subtle pathologic changes
  • Less artifacts from metallic objects, dense bone, dental fill-ups
  • Allows imaging in multiple planes without patient repositioning or image reformatting
  • No risk of ionizing radiation
  • Better delineation of soft tissues in crowded bony regions as posterior fossa, optic canal, orbital apex due to less bony interference
  • Better for evaluation of intracranial extension of intraorbital lesions
  • Reveals excellent contrast between orbital fat, extraocular muscles and intraconal structures.
 
CONTRAINDICATIONS
  • Absolute—presence of ferromagnetic cerebral aneurysmal clips or cardiac pacemakers
  • Relative:
    • Iron foreign body in the eye or orbit
    • Claustrophobia37
    • Metallic prosthetic heart valves
    • Uncooperative patient.
 
DISADVANTAGES
  • Higher cost of equipment and site preparation
  • Slower scanning times
  • Greater sensitivity to movement artifact
  • Poorer imaging of bony structures
  • Poor spatial resolution—spatial blurring due to intense bright signals from orbital fat in T1 images degrades image quality.38
 
DACRYOCYSTITIS
 
CONGENITAL DACRYOSTENOSIS
 
History
  • Age of onset
  • Duration and severity of symptoms
  • Unilateral/bilateral
  • History of watering/wet looking eyes
  • History of discharge and matting of lashes
  • History of symptoms worsening with respiratory infection
  • History of application of eyedrops
  • History of massage and the technique
  • Details of any procedure done under anesthesia— probing
  • History of redness and swelling of the eyes
  • History of prematurity
  • History of trauma.
 
Clinical Examination
  • Mucoid/mucopurulent discharge in the medial canthal area
  • Dried mucoid discharge on the lashes
  • Increased tear meniscus
  • Skin maceration
  • Fixation and following of light
  • Corneal status
  • Digital tension
  • Extraocular movements
  • Fundus examination.
 
Examination in the Oculoplasty Department
  • Position of lids
  • Examination of puncta
  • Surface abnormalities
  • Medial canthal mass
  • Lacrimal—cutaneous fistula
  • ROPLAS sign—regurgitation on pressure over lacrimal sac region
  • Anterior segment examination.39
 
Management
The nature and course of the condition to be discussed in detail with the parents.
 
Conservative Treatment
  • Lid hygiene
  • Antibiotics - vanmycetin eyedrops 4 times/day x 2 weeks
  • Massage - Crigler's technique:
    • 20 strokes every time 3 times a day
    • Correct procedure is explained to the parents
This is done for two months up to the age of 6 months. If this fails probing and syringing is done.
 
Probing and Syringing of Lacrimal System
  • Ideal time is 6 to 9 months of age
  • General anesthesia with intubation is necessary
  • After punctal dilatation, Bowman's probe of adequate size is passed through puncta and maneuvered through the lacrimal system to reach the floor of the nose
  • Type of resistance (hard or membranous) and approximate level of the block/site of give-way is noted
  • Nasal endoscope is used to visualize probe in inferior meatus
  • Inferior turbinate infracture/intubation is done if needed
  • Syringing is done to confirm patency of the lacrimal system
  • Nature, site and percentage of regurtation, if present, is noted
  • Continue topical antibiotics and massage for 2 to 3 months
  • If this fails, probing is repeated after 3 months.
 
Persistence of Symptoms and Bony Block
  • Periodic follow-up is essential
  • Dacryocystorhinostomy at the age of 5 years or earlier if situation demands.40
 
ACUTE DACRYOCYSTITIS
 
History
  • History of watering and discharge—duration and severity
  • History of pain, redness, swelling in the medial part of the eye
  • History of fever
  • History of previous episodes
  • History of any treatment taken
  • History of sinusitis, nasal blockage.
 
Clinical Examination
  • Swelling, edema and erythema in the lacrimal sac region below the medial canthal region
  • Warmth and tenderness of lacrimal sac region
  • Tear stasis
  • Fistula formation
  • Visual functions-visual acuity
  • Pupillary reactions
  • Ocular motility evaluation.
 
Examination in the Oculoplasty Department
  • Examination of lids and puncta
  • Preseptal or orbital cellulitis
  • Evaluation of proptosis, if present.
 
Guidelines in the Management
  • Avoid probing and irrigation of canalicular system till infection subsides
  • Warm compresses
  • Topical antibiotics of limited value when stasis is there
  • Oral antibiotics of value in mild-to-moderate cases
  • Parenteral antibiotics for severe cases with cellulitis
  • Aspiration of lacrimal sac in a localized and pointing pyocele/mucocele - smear and cultures of the aspirate material and appropriate antibiotics41
  • Incision and drainage of a localized abscess and leaving the site open after packing the abscess cavity with antibiotics
  • Dacryocystitis with total nasolacrimal duct (NLD) obstruction—wait till resolution of symptoms for at least a month and proceed with dacryo-cystorhinostomy (DCR).
 
CHRONIC DACRYOCYSTITIS
 
History
  • History of recurrent episodes of watering with discharge
  • History of any treatment taken
  • History of previous lacrimal sac surgery
  • History of acute episode of pain or swelling
  • History of sinusitis, nasal obstruction
  • History of dryness, grittiness and burning of the eyes
  • History of drug intake
  • History of radiation therapy.
 
Clinical Examination
  • Swelling over the lacrimal sac region
  • Presence of fistula with discharging mucoid or mucopurulent material
  • Visual acuity
  • Extraocular motility.
 
Examination in the Oculoplasty Department
  • Position of the lids
  • Look for matted lashes
  • Tear film height
  • Examination of the puncta
  • ROPLAS test
  • Diagnostic probing and irrigation of the upper lacrimal system42
  • ENT evaluation:
    • Nasal septal deviation
    • Hypertrophied and swollen turbinates
    • Nasal polyps
    • Nasal mass
    • Atrophic rhinitis
    • Sinusitis
  • General health check up.
 
MANAGEMENT
External DCR/Endoscopic DCR.
 
Follow-up
  • Relief of symptoms
  • Wound integrity
  • Periodic syringing in the postoperative period
  • Suture removal generally on 5 to 7th postoperative day.43
 
DACRYOCYSTOGRAPHY
It is the technique of imaging of the lacrimal drainage system by the injection of contrast material into the passages.
 
INDICATIONS
 
Complete Obstruction
  • Determine exact location of obstruction
  • Delineate anatomy in post-trauma patients and when reconstruction surgery is planned following failed lacrimal surgery
  • When it is hard to differentiate between 'hard stop' and ‘soft stop’
  • Sac size determination for preoperative planning and prognosis estimation.
 
Incomplete Obstruction
  • In patients with symptomatic epiphora, despite patency on irrigation of the lacrimal system
  • Patients with suspected dacryoliths, lacrimal sac masses
  • In combination with additional intervention like balloon dacryoplasty.
 
CONTRAINDICATIONS
  • Contrast allergy
  • Uncooperative patient.
 
PROCEDURE
  • Detailed history including allergies to dye, etc. obtained
  • Procedure is explained to the patient and informed consent obtained
  • Patient asked to lie supine on a radiographic table
  • Lacrimal sac palpated to detect any mass lesion or express any fluid present44
  • Topical anesthetic applied into conjunctival sac as drops or on cotton applicator over the lower punctum/canaliculus
  • Lower punctum dilated
  • Plain X-ray of the nasolacrimal drainage system taken
  • Lower canaliculus cannulated with final metal/plastic cannula
  • 0.5 to 1.0 cc contrast injection
  • Radiographs usually taken at 0 minutes and 30 minutes.
 
Modifications
  • Macrodacryocystography
  • Digital subtraction dacryocystography
  • Dacryocystofluoroscopy.45
 
ENDOSCOPY
Endoscopy has diagnostic and therapeutic value in diseases of the lacrimal and orbital systems.
 
NASAL ENDOSCOPY
The patient's nostril should be packed with a nasal decongestant and topical anesthetic solution at least 15 minutes prior to the endoscopy.
It is mandatory prior to DCR surgery to assess for nasal pathology.
Presence of deviated nasal septum may be an indication for combined septoplasty if endoscopic DCR is planned.
Endoscopic DCR has the advantage of being more cosmetically appealing as it avoids an external scar and is recommended especially in young patients and in cases of lacrimal abscess.
Routine postoperative endoscopic examination with curettage and syringing is of importance in patients after endoscopic DCR. It is ideally done 1 week postoperatively and repeated after 6 weeks, and later as required.
Assessment of silastic tube within the nasal cavity can be done.
 
ENDOSCOPY IN ORBITAL SURGERY
It can be used for orbital decompression of the medial and inferior walls of the orbit (e.g. in cases of thyroid associated ophthalmopathy).46
 
SOCKET EVALUATION
 
INSPECTION
  • Presence of enophthalmos
  • Superior sulcus deformity
  • Eyelids:
    • Position
    • Lid laxity
    • Entropion, ectropion
    • Lagophthalmos
  • Palpebral fissure
  • Retention of prosthesis in the socket
  • Sunken socket
  • Prosthesis:
    • Scratches, roughened edges
    • Dried deposits
    • Motility
    • Cosmesis
  • Socket after removal of prosthesis
  • Health of the socket (conjunctival congestion or discharge)
  • Fornices - contracture (mild, moderate or severe)
  • Status of the orbital implant if present-whether well covered with conjunctiva or exposed, if exposed then amount of exposure to be noted.
 
PALPATION
  • Intactness of orbital rims
  • Any bony abnormality
  • Any abnormal palpable mass within the socket
  • Fitting of prosthesis.
    In children examination is done under anesthesia for evaluating the same.
 
MANAGEMENT
  • Adequate fornices - try fitting a larger conformer or shell47
  • Marked enophthalmos—consider secondary implant
  • Superior sulcus deformity—subperiosteal implantation is done
  • Conjunctival shortage—mucous membrane graft and fornix forming sutures
  • Severe contracture—dermis fat grafts, temporalis muscle transfer, etc.
    Pre-and postoperative photographic documentation is necessary.
 
COUNSELING
  • Take the patient into confidence
  • Find out the expectations of the patient
  • Emphasize the need for multiple surgeries for achieving the final outcome
  • Give a realistic outcome of the surgery to the patient.
 
OCULAR PROSTHETIC DEPARTMENT
The hospital runs a special clinic, since 2000 for one eyed patients to help them rehabilitate with artificial eye. The department deals with creating hand made artificial eye called custom-made prosthesis (CMP) and readymade prosthesis. The department is managed by a trained Ocularist, who is a skilled technician trained in the art of painting, modifying and fitting an ocular prosthesis. In addition to creating it, the Ocularist shows the patient ways of handling, cleaning and taking care of their prosthesis, and provides long-term care through periodic examinations of the socket and prosthesis.48
 
OCULAR PROSTHESIS
This is an artificial eye (shell) placed for cosmetic purposes.
The fitting of the prosthesis is done by the ocularist in conjunction with the oculoplasty department.
The prosthesis can be readymade (stock-eye) or custom-made.
Custom-made prosthesis gives the advantage of better cosmesis and motility as it tailor-made for the individual patient. Making of the prosthesis takes a minimum of three days and the patient is to be advised regarding the same. Measurements can also be taken in the operation theater, for example, when the patient is undergoing examination under GA. In these cases, the Ocularist is to informed the previous day.
 
Services Provided
 
Stock Shell
  • Custom-made prosthesis
  • Conformer
  • Scleral shell.
 
Indications
  • Enucleated eye
  • Eviscerated eye
  • Phthisical eye
  • Anophthalmic/Microphthalmic eye.
 
Stock or Custom Prosthesis
The patients are generally seen by the Oculoplasty department doctors and referred for the Prosthesis department. As per the need of the eye condition, the fitting of stock or custom eye prosthesis is decided.
“Stock” or “readymade” ocular prostheses - Drawbacks: low grade acrylic, not made for any particular person, poor color match, and restricted movement.49
“Custom” ocular prosthesis - high grade acrylic, biocompatible, better fit as it is hand-made, individualized for each person, good color match, better movement when compared with stock eye and allergies are unlikely.
 
Procedure
The impression of the socket is taken and a wax model is prepared.
Using the model, we determine the correct positioning of the iris, the outer curvature, and the extent to which the eyelids will open.
The wax model is then used to prepare a master mold which is filled with acrylic plastic to create a cast of the prosthesis.
The iris is hand painted from direct observation of the unaffected eye, including the sclera along with the blood vessels. It is then covered with a clear plastic protective coating and is cured once more. The prosthesis is now ready for a polishing to give it a perfectly smooth surface and wet-looking appearance.
 
Cleaning of Prosthesis
The stock shell is cleaned once a week and CMP once a month. Proper cleaning procedures should be followed. The proper way of cleaning the shell is washing with water and mild soap.
 
Complications
Watering of eyes, redness, discharge, pain, rotation of shell, itching can be avoided by following a proper cleaning schedule, decreasing frequency of handling of shell, and periodic polishing.
 
Follow-up
The ocular prosthesis needs to be polished regularly in order to restore the acrylic finish and ensure the health of the surrounding tissues. It is generally recommended that children between 3 to 9 years of age be seen every 6 months and all other patients at least once a year.50
 
AESTHETIC CLINIC
It is a super specialty clinic run by the hospital. The clinic focuses on aesthetic and reconstructive aspects of the eyelids, the brows and the face. The commonly performed procedures are the repair of droopy eyelids and brows and rejuvenation procedures such as eyelid lifts, brow lifts, removal of eyelid bags, face and mid face lifts, liposuction and facial fat transfer. The clinic specializes in the minimally invasive procedures such as botox, dermal fillers, chemical peels, micro-dermabrasion of the skin, radiofrequency skin tightening and cosmeceuticals to correct the lines of aging, periocular skin pigmentation, dark circles for the overall facial rejuvenation.
 
DERMATOCHALASIS
 
Definition
The upper eyelids consist of extremely thin skin. As the eyelid skin stretches, it may show the first signs of aging on the face. Droopy upper eyelid skin with the eyelid bags due to the prolapsed orbtial fat pads is called dermatochalasis.
 
Management
It is corrected by a surgical rejuvunation procedure that removes an ellipse of excess skin and sculpting of the orbtial fat called blepharoplasty.
 
Indications
  1. Dermatochalasis
  2. Blepharochalasis
 
Examination
Basic examination has to be performed as it is done in a case of blepharoptosis.51
Other parameters are:
  1. Measurement of upper eyelid skin (minimum upper lid skin should be 20 mm).
  2. Check for the elasticity of the skin.
  3. Grading of the prolapsed fat pads (medial and central in upper eyelids, medial, central and lateral in the lower eyelids).
  4. Eyelid laxity (distraction, snap test).
 
BROW PTOSIS
 
Definition
Aging changes in the brows can cause them to droop and lead to brow ptosis. It can be seen as tiredness, anger or sadness. The eyebrows can appear to sink or droop over time, due in part to stretching of skin and loss of fat that supports the brow. Brow droop can contribute to sagging of the upper eyelids called pseudodermatochalasis.
 
Management
The brow ptosis is corrected by the surgical procedure called brow ptosis repair. There are different types of repair and are tailored to the patients requirements and the amount of the brow ptosis present.
 
Indications
  1. Brow ptosis.
  2. Pseudodermatochalasis.
 
Examination
Basic examination has to be performed as it is done in a case of blepharoptosis and blepharoplasty.
Other parameters are:
Measurement of the brow ptosis (measured in mm by placing the ruler at 0 mark at the brow and the amount ptosis is measured by simulating the lift).52
 
FACE AND MIDFACE LIFT
 
Definition
A facelift, technically known as a rhytidectomy is a type of cosmetic surgery procedure used to give a more youthful appearance. It usually involves the removal of excess facial skin, with or without the tightening of underlying tissues, and the redraping of the skin on the patient's face and neck.
In the traditional facelift, an incision is made in front of the ear extending up into the hairline. The incision curves around the bottom of the ear and then behind it, usually ending near the hairline on the back of the neck. After the skin incision is made, the skin is separated from the deeper tissues with a scalpel or scissors (also called undermining) over the cheeks and neck. At this point, the deeper tissues (SMAS, the fascial suspension system of the face) can be tightened with sutures, with or without removing some of the excess deeper tissues. The skin is then redraped, and the amount of excess skin to be removed is determined by the surgeon's judgment and experience. The excess skin is then removed, and the skin incisions are closed with sutures and staples.
 
Indications
  1. Facial aging
  2. Facial nerve paralysis.
 
Examination
  1. Quality of the skin—texture, pigmentation and laxity.
  2. Dynamic and the static wrinkles (forehead lines, glabellar lines, crows feet, marionette lines).
  3. Facial folds (nasolabial folds).
  4. Cheek droop and the loss of malar fat pads.
  5. Jowls.
  6. Platysmal bands.
  7. Hairline.53
 
AUTOLOGOUS FAT TRANSFER
 
Definition
Fat transfer (medically, fat transplantation, also called fat injection or fat grafting) is a medical procedure that uses the patient's own fat tissue to increase the volume of fat in the subcutaneous area of the body- face.
Fat is withdrawn from the patient in one of two ways: with a syringe that has a large-bore needle or with a liposuction cannula. The fat is prepared according to the practitioner's preferred method and then injected into the patient's recipient site. The preparation process clears the donor fat of blood and other unwanted ingredients that could cause infections or other undesirable side effects.
 
Indications
  1. Facial aging and loss of facial fat.
  2. Facial paralysis.
  3. Enophthalmic sockets.
 
Examination
It is to be followed on same lines as in a patient for facelift.
 
BOTOX
 
Definition
Botox is a protein produced by the Clostridium botulinum. It is a nonsurgical treatment where it is injected directly into the muscles of facial expressions. It works by blocking nerve impulses to the injected muscles. This reduces muscle activity and smoothens the wrinkles/lines.
 
Indications
  1. Forehead lines.
  2. Glabellar lines.54
  3. Crows feet.
  4. Perioral lines/smoke lines.
  5. Marionette lines.
  6. Dimpling of chin.
  7. Platysmal bands.
  8. Functional- Blepharospasm, hemifacial spasm, reflex lacrimation, gustatory tears.
 
DERMAL FILLERS
 
Definition
Dermal fillers are basically a collagen material made of synthetic or natural substances and is used for injection in the dermis for purposes of augmenting soft tissues, hence the facial rejuvenation.
 
Indications
  1. Facial folds—nasolabial, tear trough deformity.
  2. Static wrinkles.
  3. Lips.
  4. Cheek droop.
  5. Scars and depressions.