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An Eye for an Eye – Customized Ocular Prosthesis Surgery! This 48 year old patient had a painful blind right eye for which he wanted resolution with the best aesthetic outcome. Seen in the picture is the Before surgery (above) and After customised Prosthesis fitting (below) of the Right eye. . . . 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 like in this case. 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. Swipe ➡️ to see the schematic diagram of how the prosthetic eye (Stage 2) sits on the eye socket prepared with surgery (Stage 1). For details of this surgery 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.

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OSSN- Cancer of 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). The good news is that, this type of cancer can be completely cured by surgery and/or chemotherapy eye drops if diagnosed before it becomes an invasive Squamous Cell Carcinoma. Here is a case of a large OSSN which was picked up just in nick of time before it became an invasive tumour and he went on to have a complete cure. Picture legends below. Swipe left to see other photos. (viewer discretion advised) Pic 1 : Photo at presentation (above) and 3 months after surgery showing complete cure. The keratin deposits on the pigmented lesion is pathognomic of OSSN. Pic 2: Steps of OSSN surgery- Excision Biopsy + Alcohol Corneal Epithelectomy + Double Freeze-Thaw Cryotherapy + Ocular Surface reconstruction with Amniotic Membrane Grafting Pic 3: Histopathology of OSSN. The microscopic picture shows Carcinoma in Situ which has still not breached the basement Membrane. Pic 4: A Comprehensive Review article on Management of OSSN. For details of this surgery 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.

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Ocular Surface Squamous Neoplasia
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The rodent that dug into the eyelid! This 70 year old lady presented in the clinic with an ulcerated ring shaped pigmented lesion in the lateral canthus (outer corner of the eyes) of the left eye. A provisional diagnosis of Basal cell carcinoma was made due to the typical appearance of the lesion. Basal Cell Carcinoma (BCC) also known as the “rodent ulcer” because the lesion appears as if a rodent burrowed a hole in to the skin. 🐀 Excision Biopsy of the lesion with frozen section margin control was done along with reconstruction of the resultant defect in the same sitting. If surgery is done early in this disease, #BCC is curable and can have an aesthetically pleasing outcome as in this case. Pic 1: Picture at presentation with the planned margins marked in Red (Above)and Picture after 1 year after surgery (Below) showing excellent outcome of the reconstruction. The patient had no recurrence of the malignancy till the last visit- 3 years after surgery. A regular follow up with a physician is important in these patients as those with BCC are more prone to have BCC elsewhere in the body. Pic 2: (viewer discretion advised). Swipe ➡️ to see the steps of the surgery including the reconstruction of the lateral canthus. The defect involved 1/2 and 1/4th of the lateral lower and upper lid respectively. The upper lid defect was closed by direct closure fixing it to the periosteum of the lateral orbital rim. A wide periosteal flap was raised from the outer side of the lateral orbital rim and fixed it to the residual tarsus of the lower lid to reconstruct the posterior lamellae of the lower lid. An advancement skin flap was fashioned from the temple area and divided unequally to cover the anterior lamellar skin defect. The flap was fixed to the lateral canthus with a non-absorbable suture to fix it to form a new lateral canthal angle. For details of this surgery 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.

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Tumour Behind the eye! This 40 year old lady started noticing her left eye becoming more prominent since about a year and increasing. On examination she was found to have proptosis (protrusion) of the left eye. A CT Scan showed a well defined intra-conal mass behind the eye (Supero-medial orbit). A left trans-conjunctival orbitotomy was performed thereby avoiding an external scar. The mass was found to be a vascular benign tumour or malformation called cavernous hemangioma or cavernous venous malformation. #Orbitotomy is one of my favourite surgical procedures. A tumour behind the eye can be removed by a single short surgery with a small incision and low morbidity to the patients. #CavernousHemangioma is the commonest benign orbital tumour in adults In an earlier era, these tumours would be removed via a craniotomy (brain surgery) by neurosurgeons or a disfiguring open surgery sometimes causing the loss of vision in the involved eye by other surgeons- too much morbidity for a benign tumour. But with the advent of modern day techniques and skilled oculoplastic surgeons performing orbitotomy today to remove such tumours, this surgery’s risks and complications is very low with the added advantage of a #ScarLess as well as without even having to remove #Bone followed by a mostly uneventful recovery period Swipe ➡️ away to see more radiological details of the tumour as well as to see how the tumour looks intraoperatively and finally the microscopic picture. Pic 1: Photos at presentation (above) and 6 weeks after surgery. Surgery was done without an external skin incision by using a trans-conjunctival, retro-caruncular approach from the supero- medial fornix. Pic 2: Pre-operative CT images with clinical correlation. Shows a well defined supero-medial orbital mass indicating cavernous hemangioma as a top differential. Pic 3 : Intra-operative mass exposure confirms our pre-operative diagnosis. The image shows the bluish red solid tumour- #CavernousHemangioma in relation to the globe. Pic 4 : Histopathology of the tumour: The microscopic picture shows large dilated vessels with thin walls consistent with the diagnosis of cavernous hemangioma.

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The #COVID19 lockdown was a period when we had stopped elective surgery and were prioritising semi-urgent surgeries and emergencies. But some surgeries can’t wait even if not life threatening. Like this girl who fell down the stairs to have an orbital (eye socket) fracture. The walls of the bony socket holding the eye were broken entrapping the eye muscles- which causes double vision and also making the eye sunken (enophthalmos). This needed early intervention hence a semi-urgent surgery. Pic 1: Photos at presentation (above) and 6 weeks after surgery(below). Surgery was done without an external skin incision by using a trans-conjunctival approach to the fracture site. The large orbital medial and floor blowout fracture was repaired using a titanium pre-fabricated implant. Both issues of diplopia and enophthalmos was resolved. Pic 2: Pre-operative CT images with clinical correlation. The medial wall and floor fracture is clinically translated to enophthalmos seen in the left eye. The axial CT slices shows medial rectus entraped causing the diplopia. The sagittal CT slices shows the trapdoor nature of floor fracture. Pic 3 : Pre and post operative CT Scans for comparison- The titanium implant is in position sitting very nicely on the posterior ledge (palatine bone). The entrapment and volume issues caused by the orbital blowout fracture taken care of. For details of this surgery 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. #RaghurajHegde #EyePlastix #oculoplastic #OphthalmicPlasticSurgery #OrbitalFracture #ScarLess #TraumaSurgery #Ophthalmology

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Orbital Fracture Repair
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Why I love what I do? I wasn’t a natural at being a doctor and struggled a little bit in medical school. Medical school was sometimes confusing and intimidating. I picked up empathy along the way and learnt to be compassionate to other people. I found out that I loved the difference that I bought to others and got better at doing my job. A lot of what I love about my job today, I discovered while being a doctor. If I hadn’t taken up medicine I would have never found out how much I would enjoy it. Once I started residency, I took to Ophthalmology like a fish to water. It seemed to tick off all the right boxes for me. Ophthalmology is an awesome subject and it had the good mix of medical and surgical management. As I got deeper into the subject, the more I began loving it. I discovered that surgery gave me the high I had never experienced before in my life which prompted me to try to become a better surgeon every day. I learnt that there is a lot of suffering between life and death- and there was something I could do about it. I did well in ophthalmology and in time my surgical prowess improved too. I had wonderful teachers who provided me the best platform to be a skilled surgeon that made me so confident that I always carried a chip on my shoulders-maybe even now! I found an interest in a niche sub-specialty called Ophthalmic Plastic Surgery. The tipping point of my residency when I decided for sure that Oculoplasty was my calling was when I assisted my then boss in a surgery called Lateral orbitotomy-where he was removing a tumour from the back of the eye cutting through bone. While delivering the tumour out, I remember saying to myself then, “that is something I want to do for a living!” . To cut a long story short I eventually managed to get into a fellowship that fed into my obsession. It was a coveted fellowship and my dream come true. I learnt to be pretty good at Oculoplasty- mostly because of the excellent training by my mentors in fellowship and equally too because I loved what I did so much. #OphthalmicPlasticSurgery #OphthalmicOncology #Ophthalmology #RaghurajHegde

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Why I love what I do?

Manipal Hospital Appointments
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Eyebags of Worry! 👀 Trans-conjunctival Lower lid Blepharoplasty This young woman turned up at my clinic 10 weeks before her wedding wanting something done for her eyebags which was giving her a tired look and making her seem much older than she really was. Given the tight deadline, I suggested injectables as a possible short term solution. However she was motivated for a long term solution to her problem and she had done her homework on what it would entail. I performed a Bilateral Trans-conjunctival Lower lid Blepharoplasty with fat repositioning. This involves repositioning of prolapsed orbital fat on both sides by draping the fat to the orbital rim area- which gives an aesthetically better appearance. This technique is done with an incision on the inside of the eyelid without a skin incision making the surgery “scarless”. In this technique there is minimal loss of existing fat- using the patient’s own fat for contouring the shape of the eyelid. This technique is especially suited for our younger patients who do not need skin excision but can also be used in older patients who need a small excision of eyelid skin. Lower lid blepharoplasty is an orbital surgery for an eyelid condition- so requires good knowledge of orbital anatomy which is the strength of an Oculoplastic surgeon. An Oculoplastic surgeon deals specifically with conditions of eyelids, eye socket (Orbit) and Lacrimal apparatus- hence combining the micro-surgical skills with intimate knowledge of anatomy. The before and after photos this surgery shows excellent outcomes. I am glad that I could pull off this outcome despite the tight timeline. Photos sent by the patient- hence the difference in the lighting of the photos. Needless to say, I was invited for the wedding😊 ⏲Surgery time: 45 mins each eyelid 💉Anaesthesia: Done under Local 🗓️Downtime: 4-6 weeks for final outcome 📈Duration of effect: Long term till age related changes start to appear over time. 📠 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.

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Opening the Eyes! This 22 year old school teacher was born with a condition called #BlepharophimosisSyndrome. It is a rare congenital condition where the eyelids are not fully developed. It is characterised by #Blepharophimosis- shortened vertical and horizontal palpebral fissures (eyelid openings), low/flat nasal bridge, #Telecanthus (increased distance between the inner corners of the eyes making the eyes spaced widely apart), #Ptosis (droopy eyelids). This condition is challenging to treat but amenable to treatment by surgery. Treatment involves a two stage surgery. Stage 1 is the correction of the Telecanthus followed about 4 weeks later with stage 2- Ptosis correction. In this case, Stage 1- Bilateral Telecanthus correction was done using a newer technique of medial epicanthoplasty described by Dr. Kim Yoon-Duck from Korea which I found superior to the traditional Mustarde’s double Z plasty and other techniques with multiple small flaps. This technique reduces the incidence of scarring due to lower number of incision lines. The stage 2- Bilateral Ptosis correction was a levator resection as the patient had moderate function of the levator palpebrae superioris (muscle which lifts the eyes). The picture shows top to down at presentation(top), after stage 1 (middle) and final outcome (bottom). The end result is a wonderful outcome both functionally as well as cosmetically. Needless to say that the patient was happy as well as confident when she went to teach her class after the summer holidays. 😊 A big thank you to @eyeplastics_sg who suggested the new technique for medial epicanthoplasty to me. We oculoplastic surgeons discuss challenging cases among ourselves using our collective experience to get the best outcomes for our patients. For details of this surgery 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.

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The Dog and the Eyebrow! This 50 yr old man’s pet dog decided to have this man’s eyebrow for breakfast. A large chunk of his left eyebrow was bitten off and swallowed by the dog. This poor guy landed at the hospital along with his very loved dog. The tissue was obviously lost but the man had no ill feelings for the dog. 🐶 The #Eyebrow is a unique facial aesthetic unit and it’s importance to the face is apparent only when it is disfigured with loss of the hair bearing #skin like in this case. Likewise, #reconstruction of the eyebrow is challenging because the thickness and direction of the eyebrow hair which is unique and not easy to replicate with #HairTransplants from other hair bearing areas. Fortunately for this patient we could achieve an optimum result. Pic 1- The patient at presentation (above) and 6 months later (below). With close follow up, good post-operative scar-management and lots of hand-holding- an aesthetically beautiful outcome was achieved. The patient is happy, the dog is still the darling of the family and the surgeon is super thrilled to this day. 🧔🐕👨‍⚕️ Pic 2: Swipe ➡️ to see the steps of the #ReconstructionSurgery (viewer discretion advised) On careful examination of the wound site, the lateral end of the hairy eyebrow was remaining. I used a surgical technique called “island flap” to mobilise the hair bearing skin medially. The island flap involves the base of the flap being attached- thus maintaining blood supply to the flap while covering the middle portion of the eyebrow with hair bearing skin. Two advancement flaps one medially and one superiorly to supplement the island flap was done to complete the reconstruction. For details of this surgery 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.

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Radiology Saves an Eye One of my rare opportunities to be a hero in an emergency. In Oculoplastics, there are not too many life threatening or sight threatening emergencies one can boast of and even when they happen, it’s not too often. This 12 year old kid hit the back of a truck and presented to our hospital with left eye sudden vision decrease, proptosis (protrusion of the eye), diplopia (double vision) and a clinical sign called relative afferent pupillary defect (RAPD) which indicated optic nerve compromise. Time was running out. An emergency CT scan showed a well defined collection in the supero-medial quadrant of the left orbit (eye socket) pushing the intra-orbital contents outward and downwards. This collection was putting pressure on the optic nerve. All this explained the proptosis, diplopia and reducing vision. My Radiologist colleague @raghupatil18 confirmed that the collection was a hematoma. An emergency aspiration of the hematoma was done under general anaesthesia using a large gauge needle and syringe. Slide left to see the CT scan images and video of aspiration (viewer discretion advised). The explanation legends are below. Pic 1: Photo at presentation (Above) and Photo two weeks after procedure(Below) with resolution of Proptosis, diplopia and complete return of vision. Pic 2: CT Scan showing a supero-medial isolated classical dome shaped collection limited by the orbital wall periosteum with no communication to the sinuses- diagnostic of a sub-periosteal hematoma (SPH). Pic 3 : The clincher in the radiological diagnosis was @raghupatil18 confirming that the collection had a Hounsfield Units (HU) value of +63 indicating that the collection was definitely a hematoma. Pic 4: A time lapse video of the aspiration of the SPH with on table resolution of the proptosis and RAPD. About 20ml of blood was aspirated out of the orbit. For context- an adult orbit has a total volume of 30ml. By the following day, the vision had improved significantly and reached 20/20 in the left eye in a week’s time. #Eyes #Vision #Eye

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Sub-periosteal Hematoma
AIOS-OPAI Consensus guidelines for oculoplastic and lacrimal surgery during COVID-19 pandemic

The Alina Project-TVM’s first steps in Vietnam

Taken during my fellowship in National University Hospital, Singapore where I first started my journey in Ophthalmic Plastics and Ophthalmic Oncology. Quite the journey it has been.

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