DR. RAGHURAJ HEGDE

Which one is the real eye?

Only one of the eyes in the above photo is a real one. Look at both eyes and decide on your answer. You can scroll down to know the answer.

A #Customized ocular prosthesis (prosthetic eye) 👁️ surgery is considered when we have to remove an #eye due to one of the following reasons:

1. Eye Cancer (for example Retinoblastoma in children)
2. Irreparable eye injury due to trauma (children & adults)
3. Cosmetically disfigured eyeball with no hope of visual rehabilitation and which may or may not be painful.

There are two stages in achieving great outcomes.

Stage 1- #Surgery performed by an #oculoplastic surgeon. The surgery involves #Enucleation (eyeball being removed)/#Eviceration (the contents of the eyeball removed retaining the outer white scleral shell) and globe volume is then replaced with an appropriately sized #orbital #implant.

Stage 2- After the eye socket heals which takes about 6 weeks, an #ocularist (a professional who fabricates prosthetic eyes) then fabricates a customised ocular prosthesis which fits perfectly in the patient’s socket. This prosthetic eye looks similar to the other eye including co-ordinated movements making it look natural.

This young patient had suffered trauma to one of his eyes in childhood and wanted a cosmetic artificial eye which looked just like his other seeing eye. He underwent a customised ocular prosthesis surgery. Needless to say he was very happy with the outcome.

For details of this surgery and for appointments

⏲Surgery time: 45 mins
💉Anaesthesia: Done under Local/Sedation
🗓️Downtime: 6 weeks
📈Duration of effect: Long term
📠 Phone: +91 80 2502 3257
📩 E-mail:dr.raghuraj.hegde@raghurajhegde
🖥️ Website: www.drraghurajhegde.com

Not all masses are tumours!

This was a 13 year old teen who presented with a mass under her left eye pushing the eyeball up.

The CT scan showed a multi-cystic mass encasing the lower part of the globe. Three cysts were dicernated in the scan.

**CT Scan showing the mass encasing the eyeball**

She was taken up for surgery. Exploratory Orbitotomy with excision biopsy of the mass in toto was done. It turned out to be an interesting case. It was a multi-cystic mass as observed in the CT scan. The anterior-most cyst was infected and purulent discharge oozed out of a small defect in the cyst. The purulent discharge was due to a super added infection by Klebsiella bacterium.

The histopathology of the mass turned out to be characteristic of tissue infected with Mycobacterium Tuberculosis. In the sub-continent, tuberculosis (TB) is always a differential even when tests for TB turn out to be negative. Histopathology is gold standard for diagnosing TB. Orbital TB though not always a top clinical diagnosis it is not uncommon.

Since the complete mass was excised completely without any residual lesion left behind, decision was made to not treat the patient further with any anti-TB medications and to observe with close follow up.

There has been no recurrence 1 year since surgery.

Before and After surgery
Note that there is no visible scar of the incision where the mass was removed from in the after surgery picture.

Exploratory Orbitotomy with Excision Biopsy of mass:
⏲Surgery time: 45-60 mins depending on the size of the eyelid mass.
💉Anaesthesia: Done under General anaesthesia
🗓️Downtime: 2 weeks
📈Duration of effect: Permanent.
📠 Phone: +91 80 2502 3257
📩 E-mail:dr.raghuraj.hegde@gmail.com
🖥️ Website: www.drraghurajhegde.com

Cancer Cancer go away! Don’t come another day!

Ocular Surface Squamous Neoplasia (OSSN) – Cancer on the surface of the eye!

Ocular Surface Squamous Neoplasia (OSSN) is a spectrum of pre-cancerous and cancerous lesions of the conjunctival epithelium (transparent coat covering the surface of the eye).

This condition can be diagnosed clinically and if promptly treated can achieve complete cure-as in this case. The after surgery photo of the eye seems as if she was never had any disease in the eye. If not operated on time, the cancer will invade into the eye can cause vision loss and can become fatal.

⏲Surgery time: 30-45 mins
💉Anaesthesia: Done under Local
🗓️Downtime: 3-4 weeks
📈Duration of effect: Long term
📠 Phone: +91 80 2502 3257
📩 E-mail:dr.raghuraj.hegde@gmail.com
🖥️ Website: www.drraghurajhegde.com

The keratin deposits on the lesion with feeder vessels leading up the lesion is pathognomic of OSSN.

See below the same lesion staining with Lissamine green dye thus confirming the clinical diagnosis of OSSN.

Cancer can indeed go away!

Surgery:

A no touch technique is used to excise the lesion with 4mm margins, alcohol keratectomy to excise involved corneal epithelium-followed by double freeze-thaw cryotherapy of conjunctival edges. The ocular surface reconstruction is done using Conjunctivo-Limbal Auto-Graft (CLAG) and Amniotic Membrane Grafting (AMG) gives best outcomes without complications.

Growing out of a Crack!

This 22yr old young man came to the clinic with a slowly growing mass near the left eyebrow which was present since birth. At present the mass was causing a drooping of the left eyelid with the disfiguring mass protruding out under the eyebrow. It was affecting the young man’s confidence as he had just joined his first job.

Given the history, location of the mass and examination, it was clinically diagnosed as dermoid cyst and MRI scan ordered.

Surgery was done using an eyelid crease incision which would ensure an aesthetically hidden scar.

The picture above shows the before and after surgery comparitive photos.

MRI scan showing the entire exent of the tumour.

Dermoid cysts have excellent prognosis after surgery when completely removed in toto without rupturing the cyst. If someone you know suffers from this easily treatable condition consult your nearest oculoplastic surgeon.

⏲Surgery time: 45-60 mins depending on the size of the eyelid mass.
💉Anaesthesia: Done under local or general anaesthesia
🗓️Downtime: 2 weeks
📈Duration of effect: Permanent
📠 Phone: +91 80 2502 3257
📩 E-mail:dr.raghuraj.hegde@raghurajhegde
🖥️ Website: www.drraghurajhegde.com

Dermoid cyst (also known as choristoma) is a benign tumor growing out of a embryonic suture line. The tumour consists of normal cells occurring in an abnormal location. It is usually diagnosed in children when it is first visible but it is not uncommon to have adults coming to the clinic to know if it can be removed.

Dermoid cysts contain keratinized stratified squamous epithelium with dermal appendages and adnexal structures, including hair follicles, sebaceous glands, sweat glands, smooth muscle, and fibroadipose tissue.

The Eye of Thyroid!

This lady walked into my clinic wondering what’s wrong with her right eye. It had gradually started protruding forward, she wasn’t able to close her right eye fully and she had double vision in all gazes.

The diagnosis was quite straightforward. She was suffering from the after effects of a disease called Thyroid Eye Disease (TED). It is an auto-immune disease where antibodies cause sometimes severe inflammation in Thyroid as well as the eyes causing both short and long term sequelae to the eyes and thyroid. As my mentor would say to his TED patients, “Your Thyroid and the Eyes are the victims of the same disease”.

CT Imaging revealed a Muscle dominant Thyroid Orbitopathy.

The severe ones are fairly easy to diagnose but still challenging to treat. In nearly a third of the cases of TED, there is an almost sub-clinical course of the active phase of the disease and only recognised by the after effects of TED like in this lady. She presented with Right Eye Proptosis, upper and lower eyelid retraction

A right orbital 3 wall decompression was done via bone removal from medial, lateral and floor of the right orbit with conjunctival and eyelid crease incision thereby providing nearly symmetrical outcome.

**Shows the before and after surgery photos**

Comparison betweek Pre and post operative CT Imaging revealed good and adequate correction

The picture below documents the patient’s journey from before TED to after Surgery

Isn’t this transformational?

⏲Surgery time: 90 mins
💉Anaesthesia: General Anaesthesia
🗓️Downtime: 4 weeks
📈Duration of effect: Permanent
📠 Phone: +91 80 2502 3257
📩 E-mail:dr.raghuraj.hegde@gmail.com
🖥️ Website: www.drraghurajhegde.com

The patient chose not to go ahead with correction of right lower lid retraction as she was thrilled with the outcome already!

While acute symptoms have debilitating morbidity with sight threatening features, the after effects of TED can have long lasting eye abnormalities like protruding eyeballs, squint, staring look and inability to close eyes causing eye dryness. Surgery can take care of many of these after effects.

Consult an oculoplastic surgeon if you or anyone you know has this condition.

An Eye for an Eye!

This beautiful lady came to us with complaints of Right droopy eyelid or Right Upper eyelid ptosis. She was investigated extensively for Myasthenia Gravis by a neurologist elsewhere with multiple tests- all of which ruled out myasthenia. She came to us for a second opinion.

On clinical examination, the cause of the ptosis was quite clear- Aponeurotic- that is the muscle lifting the right upper eyelid was stretched and was not as efficient as the opposite eyelid.

So right eyelid ptosis correction surgery was performed and the Levator Palpebral Superioris (LPS) muscle was tightened to correct the right upper eyelid ptosis.

However, her left upper eyelid began to droop after correction of the right upper lid ptosis. This is an uncommon possibility post unilateral ptosis correction explained by Hering’s Law. With experience of operating on many droopy eyelids over the years, one knows how to predict this phenomenon ahead of surgery. This patient was warned of this possibility before surgery as hering’s response was elicited before it was easier to counsel for ptosis correction of the left upper eyelid.

**Hering’s response elicited ahead of first surgery where the left upper eyelid droops on temporary correction of right upper eyelid ptosis using a probe.**

Hering’s Law for the eyelids: There is reflexive descent of the contralateral upper eyelid after the ipsilateral surgical correction of unilateral ptosis. Hering’s law is explained by considering the two eyes as paired organs and it follows that the muscles moving it will work in co-ordination. The co-ordination of eyelid opening muscles- LPS is controlled by a common central caudal sub-nucleus of the oculomotor complex which innervates both LPS. So second surgery on the left upper eyelid was performed which ensured symmetry of the eyelid position.

**Surgical stages- At presentation (top), after 1st Surgery (middle) and after 2nd surgery (bottom)**

This is the before and after photo collage of the final correction with a very happy patient.

**Patient at presentation with right upper lid ptosis (above) and (below) after both serial ptosis correction surgeries to both upper eyelids**

If you or someone you know are suffering from this easily correctable condition, consult your nearest Oculoplastic Surgeon.

©All patient photos are being used with the express consent of the patient. These cannot be shared or reproduced elsewhere.

Need an Eyelid Please!

A 13 day old baby boy presented to us last month with a right eyelid coloboma as a part of #Goldenhar syndrome. Unfortunately the large eyelid coloboma at birth made the right eye susceptible to exposure keratitis leading to a large corneal abscess on the verge of a corneal perforation.

**At Birth, At Presentation at 13 days & Two weeks Post Surgery**

The photos above show the baby at birth, at presentation and finally 2 weeks post surgery.

Goldenhar syndrome is characterized by craniofacial anomalies in association with spine, heart, kidneys and brain deficits. Goldenhar Syndrome is usually accompanied by a triad of anomalies comprising epibulbar dermoid, accessory auricular appendages, and aural fistula. The eye manifestations can be microphthalmia, epibulbar or limbal dermoids, lipodermoids, and coloboma. Coloboma can present with eyelid coloboma, iris coloboma or choroidal coloboma, a combination of the three or all three. Eyelid colobomas part of goldenhar syndrome is usually in the upper eyelid, resulting incomplete closure resulting in exposure keratopathy which can then turn into a corneal ulcer as in our case.

Thanks to our excellent Neonatology and Anaesthesia teams we could mobilise the small baby weighing less than 2kilos to the operating table within 24 hours of presentation. I could reconstruct the right upper eyelid using a rotational flap and enough of the conjunctiva was present to be mobilised into the reconstruction.

Post surgery, with good closure of the eye and with extensive topical antibiotic treatment of the corneal ulcer by our cornea specialist, the corneal abscess started healing, reduced in size and finally became a residual central corneal scar. The baby is awaiting a corneal transplant as soon as we can get a good quality cornea in our eye bank.

So happy to see a good outcome for this baby! Hope he is lucky enough to be able to see from that eye soon.

Hugging the Optic Nerve!

This 67yr old man presented with complaints of protrusion of right eye (Proptosis), Double vision (Diplopia) and diminution of vision in the right eye since a couple of years.

The MRI scan showed a large intraconal well defined mass sitting right next to the optic nerve causing mass effect which in turn was causing diminution of vision. My working differentials going into surgery- based on location and imaging was Cavernous Hemangioma, Fibrous Histiocytoma, Dermoid cyst, Schwannoma among others.

The mass was removed via lateral orbitotomy with a bone window to make space for the tumour (which was bigger than the eyeball) to come out of the orbit.

Swipe ➡️ in the insta link below to see a short video montage of the surgery followed by the collage of the surgery. He made an uneventful recovery from the surgery while his proptosis resolved and vision improved dramatically post surgery.

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A post shared by Dr. Raghuraj Hegde (@eye_plastix.raghuraj_hegde)

The Histopathological examination gave a tissue diagnosis of Schwannoma. It was an unusual location for a schwannoma but not entirely unknown to be at that location.

For details of such types of surgeries and for appointments
📠 Phone: +91 80 2502 3257
📩 E-mail:dr.raghuraj.hegde@gmail.com
🖥️ Website: www.drraghurajhegde.com

©All patient photos are being used with the express consent of the patient. These cannot be shared or reproduced elsewhere.

Murdered in a Pandemic

The cost of human life is so low
That governments won’t even count you if you are dead,
Lest they be accountable to the public for your health.
In any case,
You won’t be voting anymore after you are dead!

Every body cremated or buried was once a life valued.
Each of them may be a statistic in the newspapers (or not)
But for their family it is someone who was part of their lives yesterday,
but today is not
In any case,
You won’t be laughing or crying at this since you would have died!

You may struggle to breathe in a desolate hospital ward,
Or your family and friends struggling to find you a bed in
an overwhelmed health system, while you are too tired to breathe.
In any case,
You will be loved or hated in equal measure for dying too soon!

You are gasping for breath because there is no oxygen supply,
You are told to breathe less, because it is somehow your fault.
You try your best to do so, until you are breathing no more.
In any case,
The dead don’t breathe at all.

Crowds gather at the election rallies and religious gatherings.
Politicians showing their hypocrisy by encouraging both,
While demonizing you for getting afflicted.
In any case,
You were not killed by a virus but murdered by the state!

Dr. Raghuraj Hegde

(Eye)Lid off with Canal(iculus) in tow!

Canalicular lacerations are missed quite often during evaluation of periocular injuries due to Road traffic accidents, assaults and animal bites in busy emergency rooms.

At the same time, surgical repair of canalicular laceration can be very frustrating experience as the distal end of the lacerated canaliculi can become very illusive to locate. After locating the distal end, it is treated by using a monocanalicular silicone stent to act as a scaffold between the two ends of the affected canaliculi.

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Repair of canalicular injuries are important to keep the tear drainage intact as well as maintain the contour of the eyelids. It is ideal if an oculoplastic surgeon repairs these type of laceration to obtain best outcomes.

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A post shared by Dr. Raghuraj Hegde (@eye_plastix.raghuraj_hegde)

As an example, this lady came with her right lower lid avulsed in a road traffic accident. Her lower canaliculus was torn along with the lower lid.

A timely eyelid and canalicular repair using a mono-canalicular silicone stent which acts as a scaffold for the reattached canaliculus while it heals and gets back to its original anatomical position. The outcome after surgery shows the benefits of meticulous early repair of the canaliculus. This maintains eyelid contour while keeping the tear drainage into the nose intact thus serving both aesthetic and functional issues for the patient. The eyelid sits snugly aagainst the globe with hardly any residual evidence that there was a trauma to the eyelid earlier.

©All patient photos are being used with the express consent of the patient. These cannot be shared or reproduced elsewhere.