ADVAnCEs In REFRACTIVE SuRGERY

Transcription

Médico
A quarterly publication of GP Liaison Centre, National University Hospital.
MICA (P) No. 016/08/2011
March-May
2012
Aesthetic & Functional
Eyelid Surgery
Red Eyes Is it acute glaucoma?
Medical Sp
tlight
Advances in
Refractive Surgery
1-5
Medical Spotlight
A member of the NUHS
6
Medical Notes
7 - 12
Treatment Room
13 - 24
Insight
25 - 26
Doctor's Heartbeat
Medical Spotlight
Advances in Refractive Surgery
Dr Anna Tan, Consultant, Department of Ophthalmology
Introduction
Table 1
Laser in situ keratomileusis (LASIK) has become a widely
accepted and commonly performed surgical refractive
procedure since its introduction in the 1990s. The success of
LASIK is attributed to its efficacy, predictability and stability.
LASIK can be used for the treatment of myopia (up to 15
dioptres), hyperopia (up to 6 dioptres) and astigmatism (up
to 6 dioptres).
In brief, LASIK consists of 3 main steps.
Intra-operative flap complications
Incomplete flap
Buttonhole in flap
Irregular flap
Free cap (entire flap sliced off from underlying cornea,
including the hinge)
Corneal epithelial defects
Post-operative flap complications
Flap striae/ folds
Flap displacement/ slippage
Flap melt
Interface issues, including debris, infection, haze
Epithelial ingrowth (under the flap, into the interface)
1.
2.
In the case of an intra-operative flap complication, most
surgeons would abort the procedure, carefully replace the
flap as precisely as possible and apply a contact lens on the
cornea surface to act as a bandage. The patient has to wait
for about 6 months for healing to occur before a re-attempt
at LASIK is possible.
3.
1. A cornea flap is first created with a blade (microkeratome).
This flap has a hinge, either nasally or superiorly, to
allow the surgeon to reflect the flap over the hinge and
thus exposing the underlying stroma bed.
2.An excimer laser is then used to ablate the exposed
stroma bed based on the desired correction.
3. The flap is then repositioned back to its original position.
Complications
Though safe, LASIK is not a risk-free procedure. It comes
with its own set of complications, including those associated
with flap creation and corneal ectasia (progressive thinning
and bulging of the weakened cornea).
Flap complications (Table 1) range from 0.1% to 0.3% and
can happen both during the surgery and post-operatively.
1
The femtosecond laser LASIK (all-laser or bladeless
LASIK)
Since its commercial availability in 2000, the femtosecond
laser has led to a paradigm shift in refractive surgery. It was
revolutionary as it eliminated the need for a blade to create
the LASIK flap.
The femtosecond laser uses a neodymium laser that achieves
tissue dissection at a specified level within the corneal
stroma. It has greatly improved the safety and precision of
flap creation compared to microkeratomes (blade LASIK).
Medical Spotlight
A true single laser LASIK – ReLEx SMILE
Figure 1 - illustrates the difference between a flap created with
a blade (in red) and that by a femtosecond laser (in green).
The femtosecond laser creates very uniform and thinner
flaps that preserve much of the corneas’ biomechanical
strength. These flaps have also better adherence to the
underlying stroma and are much less likely to displace or
slip after surgery. What this translates to is a significantly
lowered intra and post-operative flap complication rate with
the femtosecond laser.
Other advantages of femtosecond laser LASIK (also known
as “all-laser LASIK” or bladeless LASIK) is a lowered risk of
cornea ectasia and dry eye symptoms as less cornea nerves
are disrupted. Better contrast sensitivity and better visual
outcomes compared to traditional blade LASIK have been
reported with femtosecond laser LASIK.
This became a reality when a new application known as
ReLEx SMILE was introduced in April 2010. This is a allin-one laser technique where only the femtosecond laser
is used to perform the refractive surgery. The femtosecond
laser is programmed to create a lens-shaped piece of
cornea tissue (lenticule) within the cornea stroma; the exact
profile of the lenticule is based on the refractive correction
desired. This lenticule is then removed physically, either from
the stromal bed after the flap is raised or through a small
key-hole incision in the peripheral cornea.
The ReLEx SMILE application actually comprises of 2
separate and slightly different techniques known as FLEx
and SMILE.
The FLEx procedure (figure 2) consists of four steps:
1. The refractive surgeon uses the femtosecond laser to cut
a small lens-shaped segment of tissue (lenticule) within
the cornea.
2. The surgeon then makes a flap in the anterior cornea
with the laser — similar to the flap created in all-laser LASIK.
3. The flap is lifted and the lenticule is removed from the
underlying stroma bed.
4. The flap is then repositioned, as in LASIK
Due to the much improved safety profile and better
visual outcomes, there has been a wide adoption of the
femtosecond technology by refractive surgeons in NUH.
The disadvantage of this new technology is mainly financial.
This setup requires the purchase of two laser machines, the
femtosecond laser (to create the flap) and an excimer laser
(for the actual refractive correction). This twin-laser setup
adds to the overall cost and maintenance and requires
additional floor space in the laser suite. Furthermore, the
patient needs to be moved from one laser to the other
to complete the procedure, adding to the overall surgical
time. It would be beneficial if an all-laser LASIK could be
performed with a single laser.
1.
2.
3.
4.
Figure 2
2
Medical Spotlight
SMILE (figure 3) takes this whole process a step further.
Instead of making a complete flap cut, only a small side
incision is created, and the lenticule is extracted from within
the cornea through this small key-hole incision.
Figure 3
1.
Unlike existing all-laser LASIK treatments, ReLEx SMILE
requires an 80% smaller surface incision in the cornea.
The biomechanical stability of the vital upper layers of the
cornea remains largely intact. For the patient, this means a
gentle, minimally invasive operation. Due to the minimised
severance of nerve pathways, this technique may result in
an even lower occurrence of dry eye syndrome which is a
common side effect of conventional blade LASIK.
Also, with the femtosecond laser (VisuMax), the suction
pressure on the eye during the laser procedure is much
gentler as compared to conventional blade LASIK. This
translates to significantly less discomfort both during and
after the surgery for patients. In conventional blade LASIK,
patients often complain of a complete “black-out” in their
vision when the aiming beam of light they were told to focus
on disappears when high suction pressure is applied to the
eye. This “black-out” does not occur with the gentle suction
pressure with the VisuMax machine and is more comfortable
for patients.
2.
3.
Since no flap is created, this eliminates all possible intraoperative as well as post-operative flap complications like
flap displacement and dislocation with trauma. The main
differences in ReLEx, femtosecond LASIK and conventional
blade LASIK is summarised in table 2.
As the treatment involves physical tissue removal and
not ablation on an exposed corneal bed, ReLEx is more
independent of intra-operative ambient conditions. At the
same time, the predictability of the results is better, which
is particularly beneficial with high refraction corrections
up to -10 diopters. Since the entire refractive correction
Table 2
3
ReLEx SMILE
Femtosecond LASIK (“all-laser” LASIK)
Conventional LASIK (Blade LASIK)
No flap created no flap complications
Less flap complications
0.1 – 0.3% flap complications;
can occur intra and post operative
Gentle suction pressure less discomfort, no more
“black-out” during surgery
Same as ReLEx SMILE
Higher suction pressure more discomfort, “black-out” common
during surgery
Can correct higher
degrees of myopia
with greater accuracy
Can correct higher degrees of myopia,
visual outcomes better
than conventional LASIK
More variability in results especially for
high degrees of correction
Fast procedure,
under 10 minutes per eye
2 staged procedure slower
2 staged procedure slower
Medical Spotlight
takes place on the femtosecond laser machine, the patient
does not have to be moved to another laser system. This
minimises stress and increases convenience.
and leave the other eye slightly myopic (usually about -1.50
dioptres) to read. This can be done using glasses, contact
lenses or LASIK.
Recent studies conducted showed that both FLEx and SMILE
compared favorably with LASIK in terms of effectiveness,
predictability and stability. About 85 % of patients achieved
uncorrected visual acuity of 6/6 or better on the first postoperative day. At 6 months after the surgery, 95% of eyes
were within 1 dioptre of the intended correction.
Not everyone can tolerate monovision; the brain has to adapt
to seeing 2 different images from the two eyes. The depth
of field is small and there is a blur middle zone (intermediate
distance like reading a desk top). According to published
reports, only 45% to 60% of people can tolerate monovision.
Myopic patients, in general, tend to be more tolerant. People
with long-sightedness (hyperopes) or pure presbyopia (i.e.
no power for distance and only require reading glasses; also
known as emmetropes) may find monovision confusing and
difficult to adapt to.
The all-in-one femtosecond laser refractive surgery promises
to change the way refractive surgery is performed. It is
advantageous to both the patients as well as the surgeons.
For patients, ReLEx SMILE means a fast and safe surgery
with excellent visual outcomes; for the surgeon, it translates
to less cost, less hassle, greater predictability and most
importantly, better safety.
LASIK for presbyopia
Presbyopia, or the inability to focus and read due to
ageing, remains the greatest challenge to overcome in
Ophthalmology. While LASIK is highly successful in restoring
spectacle independence to young patients, LASIK for
presbyopia has seen much less success.
The traditional way for presbyopia correction was to do
monovision correction. Monovision refers to the correction
of one eye (usually the dominant eye) for distance vision and
the other eye for reading. What this really means is to fully
correct the refractive error in one eye (for distance vision)
Laser Blended Vision – “micro-monovision” for all
Another treatment option for the correction of presbyopia is
Laser Blended Vision. This procedure uses a special LASIK
protocol to correct the dominant eye mainly for distance
vision and the non-dominant eye mainly for near vision, while
the depth of field (i.e. the range of distances at which the
image is in focus) of each eye is increased. As a result of the
increased depth of field, the brain merges the two images,
creating a blend zone, i.e. a zone which is in focus for both
eyes. This allows the patient to see near, intermediate and
far without glasses. Recent literature shows that >95% of
patients adapt readily to laser blended vision and over time,
many report that they are unaware that one eye is out of
focus. Table 3 summarises the key differences between
laser blended vision and traditional monovision.
Table 3
Traditional monovision
Laser Blended Vision
Two different images seen by each eye
Overlapping blend zone for intermediate distance with clear
binocular distance & near images
Blur middle zone
Clear middle zone
Small depth of field
Larger depth of field
Tolerance rate 45% - 60%
Tolerance rate >95%
More suitable for myopes
Suitable for myopes, hyperopes & emmetropes
4
Medical Spotlight
Figure 4 – illustration of blend zone in laser blended vision
Dr Anna Tan
near
near
Dr Anna Tan is a Consultant in Refractive Surgery
Service as well as Corneal and External Eye
Diseases, National University Hospital and an
Instructor in Ophthalmology in National University
of Singapore.
intermediate
intermediate
far
far
Besides comprehensive Ophthalmology, Dr Tan
is also experienced in laser refractive surgery,
including bladeless LASIK and the latest flapless
LASIK.
Her other area of interest is in the treatment of glaucoma. She is
the key investigator for the use of micropulse laser transscleral
cyclophotocoagulation in the treatment of refractory glaucoma. This novel
technique is currently under world-wide patent and due for a multi-centre
randomised controlled trial.
Email address: [email protected]
Due to the excellent adaptability and high satisfaction of
patients to laser blended vision, the author now offers this
as a routine to all patients with presbyopia who want to be
independent of wearing spectacles.
Summary
Laser Refractive Surgery has had rapid evolutions in the
recent decade. The safety, efficacy and predictability of LASIK
have greatly increased, especially with the development of
femtosecond laser LASIK (“all laser” LASIK).
ReLEx SMILE, the truly single laser procedure, promises
an even safer, minimally invasive refractive correction that
is flapless.
For those with presbyopia, laser blended vision offers clear
binocular distance, intermediate and near vision and a
restoration of spectacle independence.
5
*All figures courtesy of Carl Zeiss Meditec*
Medical Notes
Preventing falls amongst the older persons
– Collaborations to provide a holistic care
Dr Kamun Tong, Associate Consultant, Division of General Medicine, University Medicine Cluster and Ms Eng Jia Yen, Senior Occupational Therapist,
Department of Rehabilitation Medicine
About 30 per cent to 40 per cent of people who are aged
65 and above sustain a fall each year which results in
injuries ranging from bruises to fractures. This can lead
to multiple complications, and mortality. The quality of life
can also be affected due to the injuries sustained or even
from the fear of falling again.
The Division of General Medicine and the Department of
Rehabilitation started a new arrangement at the Falls Free
Living Clinic. The new arrangement aims to holistically
provide care, assess the causes of falls and reduce falls
risks among the elderly patients. A multi-disciplinary
team, comprising geriatricians, nurses, physiotherapists,
and occupational therapists, sees patients who are above
65-year-old and have had more than two falls within a
year.
At the Falls Free Living Clinic, the geriatric nurse will first do
a thorough assessment on the patient’s medical and social
history, while the geriatrician will assess and examine the
patient, and review the causes of the falls to determine the
necessary management plan and investigations required.
If there is a need for rehabilitation services, the geriatrician
will refer the patient to a physiotherapist for assessments
to objectively quantify the patient’s fall risk. On the same
day, an occupational therapist will carry out an interview
with the patient and his or her caregiver to identify the
potential factors contributing to falls at home, and will
share specific home modification advice to help ensure
a safer home environment for the patients. A structured
therapy, including tailored home modification advice, falls
prevention advice and assistive aids will be offered and
implemented by the team.
The multi-disciplinary team works together, with regular
communication and feedback sessions, to offer the most
appropriate care for the patients depending on their
conditions.
Patients who have attended the holistic falls free clinic
sessions have responded positively. They shared that
they are now able to walk with more confidence and a
more stable footing. Patients have also shared that they
are impressed by the care and thorough assessments
provided by the team.
Occupational therapy falls prevention tips for the elderly
in the community and at home:
1. Avoid walking on uneven ground surfaces
2. Wear covered shoes or sandals with a heel strap,
and ensure that soles are non-slip.
3. Avoid going out on rainy days or during peak hours
when buses and trains are crowded.
4. Place non-slip mats beneath loose rugs in the home.
If possible, remove loose rugs in the home.
5. Install grab bars, if necessary, in the toilet for shower and toileting needs.
For more information and appointments, please contact:
Sukinah Bte Alwee
Medicine Clinic D
6772 6461
With this new arrangement, the patients and family
members are now more aware of the fall risks, the need for
rehabilitation sessions, and the importance of having an
exercise regime which they have to continuously practice
to help in the prevention of falls. The team stresses on
educating and empowering the patients and caregivers
on falls prevention, which in turn increases personal
responsibility and improves compliance rate as compared
to the previous paternalistic patient-doctor model.
6
Treatment Room
Flashes and Floaters
Dr Lingam Gopal, Senior Consultant, Department of Ophthalmology
Flashes and floaters are important symptoms of potential retinal disease. It is important to
understand that these symptoms do not necessarily mean that there is a definite retinal pathology,
or is the treatment aimed at ameliorating the symptoms.
Flashes
Flashes are subjective symptoms that are usually described
by patients as streaks of light. The symptoms are better
appreciated in night time.
Floaters
Floaters (also known as muscaevolitantes) are common
symptoms characterised by subjective appreciation of
floating obstructions to vision.
Origin of flashes
Flashes are usually caused by tugging on the retina by
the vitreous. The vitreous is a transparent gel that fills the
posterior two-thirds of the eyeball. Normally the vitreous is
in close proximity to the retina posteriorly. Normal vitreous
firmly adheres to the retina around the optic disc, at the
macula, around major blood vessels and near the vitreous
base – which is a circumferential zone located anteriorly and
straddling the oraserrata. The firmest attachment is at the
vitreous base.
Origin of floaters
Floaters can be caused by any opacity in the vitreous cavity
that throws a shadow on the retina. Hence, it is totally nonspecific and by itself does not indicate any specific disease
process. There are several causes of floaters.
However, vitreous can be adherent to some abnormal areas
such as lattice degeneration, snail track degeneration,
areas of inflammatory or traumatic scars, etc. With age, the
vitreous also undergoes synerisis. This is a process where
the vitreous liquefies in pockets and the residual collagen
collapses. This precipitates a separation of the vitreous from
the retina- a process called “posterior vitreous detachment”.
This act of separation of the vitreous from the retina can
result in acute symptoms of flashes of light.
Flashes have also been described in association with
migraine. The migraine related flashes are different however,
and are usually associated with other features of migraine
such as a scintillating scotoma, and headache.
Transient flashes for a fraction of a second are a common
occurrence - especially if one rubs the eye violently.
Significance
When the vitreous gel separates, it proceeds from posteriorly
towards the vitreous base. In most cases, the process is
clean, resulting in no untoward complications. However, in
a few cases the retina can develop tears because of the
pull on the retina by the vitreous. This happens when there
are abnormally strong vitreo-retinal adhesions, or, when the
retina is thin and degenerated as in lattice degeneration,
high myopia, etc.
Retinal tears can be the harbinger of retinal detachment that
has potential to cause significant vision loss and requiring
surgical management. Unfortunately, the type of flashes
and their location do not give any clue as to whether or
not a retinal tear has occurred. It is only by a diligent eye
examination (fundus examination with dilated pupils) that
one can diagnose or exclude such an eventuality.
7
The commonest cause is age-related condensation of the
vitreous collagen. Typically, this produces very fine thread
like floaters that shift with change of position of the eye.
They usually do not produce vision loss and are of no great
significance. Although some patients are bothered by their
presence, most learn to ignore the same. In high myopia,
these floaters can occur at an early age since vitreous
degeneration and condensation occur earlier in life in these
patients.
Bleeding into the eye can cause a shower of black spots.
The symptom is more dramatic and it is unlikely that any
patient will miss this symptom. Since the bleeding mostly
trickles down due to gravity, the patients appreciate the
shower in the upward direction. Very quickly however, the
discrete spots are replaced by a generalised haze once the
blood diffuses. Depending on the extent of the bleed, the
vision may be affected greatly, or not at all. The cause of
such a bleed can be multitude – e.g. diabetic retinopathy,
branch vein occlusion, retinal tear formation, etc.
A combination of a shower of black spots (due to vitreous
bleed) and flashes of light is more suggestive of a retinal
tear formation. Hence any patient with this combination of
symptoms merits a very detailed retinal evaluation to try and
detect the retinal tears so that they can be treated with laser
photocoagulation before they can cause retinal detachment.
It must be understood that all flashes or floaters are not
associated with retinal tears. Vitreous detachment can
also cause bleeding by pulling on the retinal blood vessels
without actually tearing the retina.
Floaters are also caused by entry of other cellular elements
such as white blood cells into the vitreous cavity or anterior
chamber. This occurs in eyes with acute inflammation of the
eye (uveitis).
Occasionally, patients with asteroid hyalosis (calcium soaps
in the vitreous cavity) complain of floaters. More often than
not, however, they are completely unaware of the presence
Treatment Room
of these discrete opacities in the vitreous cavity. It is only
when there is significant increase in their number, or, if there is
occurrence of posterior vitreous detachment (which crowds
the opacities together), that they become symptomatic.
Floaters are also experienced by a patient in whom an intra
vitreal injection of opaque material (such as triamcinolone
acetonide) is performed. This is to be expected and the
patients should be warned before the procedure.
The optics of the vitreous floaters
From the patient’s perspective, the floater is appreciated as a
moving shadow on the retina. Floaters are best appreciated
against a bright background such as a brightly lit sky. The
variables involved are the density and size of the vitreous
opacity, their number and the location (near the anterior or
posterior vitreous).
The closer the vitreous opacity is to the retina, the more
defined is the shadow caused. Hence the ring opacity
caused by the posterior vitreous detachment (Weiss ring)
causes a disturbing shadow to start with but becomes less
of a bother over a period of time as the vitreous further
detaches and the ring opacity is brought forward (away from
the retina). Shadows caused by membranes in gel vitreous
tend to move with eye movement but come roughly back to
the same location once the eye movement stops.
Multiple fine opacities such as red blood cells and white
blood cells do not cause discrete shadows but produce a
diffuse haze and reduce the vision depending on the density.
Although floaters caused by vitreous membranes (as in agerelated vitreous condensation, and high myopia) tend to be
a permanent feature, patients learn to ignore them over time.
Management
1. Observation: As was alluded to in the beginning paragraph, the treatment in most situations is aimed
at the disease causing the symptom of flashes or floaters
and not to remove these symptoms. Most patients with
flashes may not have any treatable retinal tear and hence
need only assurance. However, the patients may
have to be called back to the clinic for a re-evaluation in
2 weeks time, to make sure that no retinal tears
have formed afterwards or have been missed in the first
examination.
2.
Laser photocoagulation: Laser photocoagulation
is performed if a retinal tear is observed. It must be
re-emphasised that the treatment is not aimed at
reducing the flashes but to seal the retinal tear and reduce
the risk of retinal detachment. Treatment of retinal tears
can also be done with cryo therapy if laser is not possible
for any reason. It must be communicated to the patient
that the flashes may sometimes remain despite adequate
treatment of the retinal tears.
3.
Rest and restricted physical activity: In patients
with vitreous bleed, the first step of treatment is aimed
at reducing the medial haze by allowing the blood to settle
down. The patient is advised to keep the head propped
up while sleeping (with 2 pillows). It is important that
one should not persist with this approach for too
long lest it causes neck pain. In most cases, the vitreous
haemorrhage is not severe and tends to clear in a few
days to enable detailed retinal evaluation and identification
of the retinal tear.
4. Surgical management: If the vitreous haemorrhage
does not clear, it would require vitrectomy to clear
the media and also to attend to the primary cause of the
haemorrhage. Most cases of vitreous haemorrhage
secondary to retinal tear formation clear with bed rest
enough to enable visualisation of the retinal tear. Once
the tear is identified, and if the media is not clear enough
for laser photocoagulation of the tear, one can perform
cryo therapy. Asteroid hyalosis is only very rarely an
indication for surgery in the form of vitrectomy.
5. Other treatment modalities are steroids when the
floaters are caused by inflammation (uveitis).
Conclusion
Flashes and floaters are rather common symptoms with
which a patient can present. Although the symptoms can be
caused by significant pathologies like retinal tears, diabetic
retinopathy, etc, in a majority it may be caused by innocuous
problems such as age-related vitreous degeneration. In the
presence of these symptoms, the patients are encouraged
to have a detailed eye examination, including dilated
fundus evaluation, to exclude any pathology that may need
intervention.
Dr Lingam Gopal
Dr Lingam Gopal is a Senior Consultant at the
Department of Ophthalmology, National University
Hospital, Singapore. He graduated from Andhra
Medical College, India, and did his post-graduation
in Ophthalmology from the Post Graduate Institute
of Medical Education and Research at Chandigarh,
India.
He subsequently did his FRCS, Edinburgh. He
has been trained in vitreo-retinal surgery from the
Medical Research Foundation, Chennai, and has
served the same institution in various capacities for 27 years.
In addition to clinical practice involving the surgical and medical
management of vitreo-retinal diseases, he is actively involved in teaching
trainees in ophthalmology, and fellows in vitreo-retinal surgery.
He was also involved in ophthalmic research, both as principal investigator
as well as Director, Research.
8
Treatment Room
Red Eyes – Is it Acute Glaucoma?
Dr Loon Seng Chee, Head and Consultant, Glaucoma Unit, Departament of Ophthalmology
• Inflammation
· Iritis
· Episcleritis /scleritis
• Glaucoma (acute)
• Subconjunctival haemorrhage
In Clinical Practice
In differentiating the various conditions, it is important to try
to elicit a history from patients.
In the history, look out for symptoms of itch, pain, headache
or vomiting.
Red eyes are one of the most common issues that we see
in the Ophthalmology clinic and also in many general clinics.
Although red eyes can be benign in most cases, we would like
to share some information to provide certain basic guidelines,
which would in turn prevent severe conditions from being
missed.
Many of the simple causes of red eyes can be examined
without the aid of sophisticated ophthalmic equipment; and
following simple check-lists of things to be examined with a
simple penlight will help to sieve out conditions which can
be treated by the family physician and those which require
referral to a specialist:
It is important to remember that red eyes do occur commonly,
and we should anticipate these conditions, and be familiar
with treating them, so that if it falls outside of these conditions,
we can recognise it and then refer more serious cases to an
ophthalmologist.
1. Visual acuity
2. Conjunctiva
3. Any discharge? What’s the nature of the discharge?
4. Cornea – look for opacities, examine the epithelium
5. Anterior chamber - depth, hypopyon (pus in the anterior
chamber)
6. Pupils: are they dilated, and do they react to light?
Most of these common causes can be diagnosed and
examined with simple equipment that a typical family practice
will have:
Table 2 – Differentiating what is Benign and Serious
Table 1 – Basic Examination Equipment
VA
Normal,
minimal reduction
Reduced
RAPD
None
Maybe
Pain
Minimal
Significant
Discharge
Mucoid
Purulent
Remarks
Penlight
General examination
Direct ophthalmoscope
More detailed examination,
or under higher magnification
Flourescein strip
For staining the cornea
Involvement
Bilateral
Unilateral
Snellen’s chart
For checking visual acuity
Cornea
Clear
Hazy, opacity,
ulcer
IOP
Normal
Raised
Anterior
chamber
Deep
Shallow,
hypopyon
• Allergy
9
Serious
Equipment
Common conditions are as listed below:
“Benign”
• Infection (viral / bacterial)
· Blepharitis
· Preseptal /orbital cellulitis
· Conjunctivitis
· Keratitis
· Endophthalmitis
Treatment Room
Allergies
The common causes for allergies are seasonal allergens,
atopy and contact lenses. The most common symptom
is itch and on examination, you should invert the lids to
look for papillae and also look out for shield ulcers on
the cornea.
Treatment involves the use of mast cell stabilisers, antihistamines and lubricants, as well as general allergen
avoidance of systemic anti-histamines. If the allergy
warrants the use of topical steroids, it is best to refer the
patient for management by an ophthalmologist.
Children and the elderly tend to be affected more; and in
particular, in children, the orbital septum is not well-formed
yet, so it is important to observe them more closely for
spread beyond the superficial layers of the skin.
Cellulitis can be caused by external causes such as
trauma, or spread from surrounding sinusitis.
• Preseptal Cellulitis
In preseptal cellulitis, the characteristics are:
•
•
•
•
•
•
infection is mainly confined to lids
conjunctiva is not primarily injected
full range of ocular movements
no or minimal visual loss
no relative afferent pupil defect (RAPD), and
treatment is with oral and topical antibiotics
• Orbital Cellulitis
Characteristics of this condition are:
Figure 1 – Cornea Ulcer
Infection (viral / bacterial)
Blepharitis
This is a condition where there is infection or inflammation
of the lids, which can result from a build-up of oils at the
lid margins with subsequent inflammation and infection
with Staphylococcus. Clinically you may see inflamed lids
and lid-margins with crusting, and conjunctival injection. If
left untreated, it can result in severe irritation and can lead
to marginal keratitis.
Treatment is essentially centred on good lid hygiene,
with warm compress, lid cleaning and then treatment of
infection, if any.
Chronic cases should be referred to an Ophthalmologist.
Cellulitis
Cellulitis is an infection of the skin and the fascia beneath,
and is typically caused by bacteria. It is classified into:
preseptal, septal and intra-orbital involvement.
•
•
•
•
•
•
limited, painful eye movements
severe chemosis, injection and proptosis
significant visual loss
relative afferent pupil defect (RAPD)
the patient is likely to have a fever and appear toxicated
the patient requires admission and intravenous
antibiotics with further investigations
Conjunctivitis
This is the most common cause of red eyes which a
family physician will face and typically, there is a series
of cases with a similar presentation. What is important
is to differentiate what can be safely treated at the family
clinic, and what needs a referral for further investigation
and treatment.
Table 3 – Triaging Conjunctivitis
What’s safe
(treat and watch)
What’s not
(refer early / immediately)
Viral
Bacterial
Typical history
(contact, URTI, tearing)
Atypical history,
Contact lens users
Little pain, good vision (6/12),
bilateral, watery discharge,
conjunctival injection
Only Conjunctival chemosis
Short duration
Pain, poor vision, purulent
discharge (bacteria)
Corneal involvement
Prolonged course
– more than 1 week
10
Treatment Room
Keratitis
This is an infection of the cornea and it can be either viral
or bacterial, and it is hard to diagnose, especially the viral
type without using a slit-lamp. Vision is usually affected,
and it is worse in bacterial cases, as there is more pain
with bacterial keratitis.
In young patients, there is a history of contact lens
use and trauma. In the elderly, who may be immunocompromised, viral infections are more common. There
may also be a past history of ocular surgery.
Clinically, there can be a cornea ulcer, or a herpetic ulcer
that can be associated with a loss of cornea sensation.
An urgent referral to see an ophthalmologist is required.
Endophthalmitis
Enopthalmitis can be endogenous, such as in a patient
with sepsis, or exogenous, such as in cases of postoperative infections. There is usually severe loss of vision,
pain and a past history of surgical intervention if the cause
is exogenous. You may also see a hyopyon in the anterior
chamber.
This condition is an emergency and requires immediate
referral to see an ophthalmologist.
Clinical examination will reveal ciliary injection, possible
hypopyon (pus in the anterior chamber of the eye) and
posterior synechiae.
• Scleritis and Episcleritis
These two related conditions are sub-sets of inflammation
of the eye, and can be idiopathic or related to other
systemic inflammations, such as auto-immune conditions.
The eye can feel very painful and vision may be reduced.
Episcleritis tends to have less severe symptoms and signs
than scleritis.
Glaucoma
The type of glaucoma which presents acutely is typically
the narrow angle glaucoma. Symptoms will include:
• Severe pain
• Nausea and vomiting
• Reduced vision
On clinical examination:
•
•
•
•
Hazy cornea
Mid-dilated pupil
Shallow anterior chamber
High IOP (eye feels hard)
Inflammation of the eye
Inflammation of the eye can affect only the anterior aspect
of the eye, a certain component, such as the iris (iritis), or
the sclera (scleritis) or the entire globe.
• Iritis
This is one condition which commonly presents as
persistent red eyes, which initially can mimic conjunctivitis.
However, after giving the usual treatment for conjunctivitis,
the patient does not get better. This is when we should
consider referring the patient.
Typically, the eye is not as red, and there is less discharge
compared with conjunctivitis but the vision often worsens.
The pain is described as throbbing and there may be
photophobia, and haloes.
Figure 2 – Acute Angle Closure Glaucoma
11
Treatment Room
This condition is also an emergency and requires
immediate referral to a hospital to see an ophthalmologist.
Using a penlight, we can often identify patients with
narrow anterior chambers that can potentially develop
into acute glaucoma. Simply take a penlight and shine
from the lateral aspect, and see if there is a shadow cast
on the nasal aspect of the iris. This is what we call the
“eclipse” sign.
Figure 4 – An example of subconjunctival hemorrhage
Dr Loon Seng Chee
Dr Loon is an Eye surgeon with sub-specialist
training in Glaucoma. He is currently the Head of the
Glaucoma unit in the Department of Ophthalmology
at NUH, and the assistant director of research as
well as the IT chairman of the Department.
He has special interests in clinical epidemiology
and the imaging of the eye in glaucoma, and in
particular, the optic nerve. Dr Loon specialises in
performing laser and surgery for glaucoma as well as cataract surgery.
Figure 3 – How to identify a narrow angle with a penlight
Subconjunctival hemorrhage
This results from a damaged blood vessel, which allows
blood to exude into the subconjunctival space. It is usually
benign and is typically caused by sneezing, coughing,
straining, vomiting, trauma and can be associated with
systemic conditions like high blood pressure, diabetes
and sometimes from certain blood disorders.
Dr Loon has a gold medal in Ophthalmology as a student, and has received
grants for his research. During his fellowship in Sydney, Australia, he
undertook a second Masters - Masters in Clinical Epidemiology – and was
given a Merit Award.
Dr Loon also has interests in medical outreach and has led numerous trips
to perform eye surgery in Bangladesh, China, Nepal and Indonesia. He has
also taught doctors in the Asian region.
No real treatment except assurance of the patient is
needed, but if it recurs very often, the patient should be
sent for a blood workup.
12
Insight
Aesthetic & Functional Eyelid Surgery
Dr Gangadhara Sundar, Head & Senior Consultant, Orbit & Oculofacial Surgery, Department of Ophthalmology
Her eyes, her lips, her cheeks, her shapes, her features seem to be
drawn by love’s own hand; by love Himself in love.
− Dryden
Ophthalmic Plastic & Reconstructive Surgery is one
of the youngest yet rapidly advancing subspecialty of
Ophthalmology which deals with both functional and
aesthetic needs of children and adults worldwide. Traditional
oculoplastic surgery deals with the diseases and surgery of
the eyelids, lacrimal system, orbit, anophthalmic sockets,
thyroid ophthalmopathy and facial palsy with ophthalmic
consequences with a significant overlap between functional
and aesthetic implications.
With the incorporation of conventional and microscopic
techniques, cross pollination between major related
surgical specialties, adoption of newer technology like the
use of image-guided navigational surgery, bioresorbable
implants and minimally invasive techniques, and a greater
acceptance within the community from enhanced outcomes
with minimal recovery period have all greatly enhanced the
quality of life1.
Diseases and pathology of the eyelids are common in all
age groups and has immense functional, cosmetic and
psycho-social consequences. It has special implication in
children as obscuration of the visual axis, if uncorrected,
may result in significant amblyopia with life-long blindness.
With increased awareness and globalisation, cosmetic
eyelid surgery such as Asian Blepharoplasty (Double Eyelid
Surgery) and Cosmetic Blepharoplasty are commonly
performed amongst the middle-aged and elderly.
13
However the greatest challenge in eyelid surgery is not just
delivering good results but also ensuring symmetry in height,
contour with patient and societal acceptance. Some of the
common eyelid disorders are listed below.
Table 1 – Common eyelid disorders
Etiology
Examples
Developmental
Blepharoptosis, Epiblepharon
Traumatic
Lid lacerations with or without
canalicular involvement
Inflammatory
Chalazia, preseptal cellulitis
Neoplastic
Benign: nevi, seborrheic ke ratosis,
Malignant: Basal cell carcinoma,
Squamous cell carcinoma, Sebaceous
gland carcinoma
Structural
Entropion, ectropion, lid retraction
Vascular
Capillary hemangioma, pyogenic
granuloma
Degenerative
Dermatochalasis, Xanthelasmata
Blepharoptosis: contact lens induced,
age related,etc
Ptosis of the eyelid is common in children and adults and
of varied etiology. Common causes by incidence include
dehiscence of levator aponeurosis (contact lens wearers, old
age, previous ocular surgery, chronic allergies), neurogenic
(congenital synkinetic ptosis, oculomotor nerve – Cranial
N III palsy), mechanical (inflammations, tumors, severe
dermatochalasis) and finally myopathic (levator muscle
dysgenesis, myasthenia gravis, etc).
Insight
A comprehensive medical history with detailed examination
often helps confirm the diagnosis and plan treatment
accordingly. An outline of various causes of paediatric ptosis
is shown below (Figure 1).
Paediatric
Ptosis
Pseudoptosis
Once a definitive diagnosis is made, treatment is often
tailored to the patient with proper informed consent.
Various modalities of ptosis correction include various
forms of levator shortening procedures (levator aponeurosis
advancement or resection), combined Muller’s musclelevator shortening procedures for minimal ptosis and
frontalis suspension procedures. Most procedures in older
teens and adults are performed as day-surgery procedures
under local anaesthesia. An important component of droopy
eyelid correction is reformation of the eyelid crease.
True
Blepharoptosis
Facial asymmetry
Microphthalmos/
Anophthalmos
Contralateral eyelid
retraction
Enophthalmos
Congenital
Figure 2 – Congenital ptosis before (left) and 2 years after frontalis
suspension (right).
Acquired
Figure 3 – Adult ptosis before (left) and after levator
Simple (Typical,
Uncomplicated)
Congenital Ptosis
Levator muscle dysgenesis
Complex (Atypical)
Congenital Ptosis
Congenital Horner’s syndrome
Double elevator palsy
Congenital III nerve palsy
Marcus Gunn Jaw winking
Congenital fibrosis of extraocular
muscles (CFEOM) phenomenon
Duane’s eyelid syndrome
Blepharophimosis (congenital
eyelid) syndrome Others
Neurogenic
Acquired III Nerve palsy
Horner’s syndrome
(Traumatic, Cervical
Neuroblastoma,
Cystic Hygroma)
Aponeurotic
Post-traumatic
Post-operative
Myogenic Myasthenia
gravis Mitochondrial
Cysticercosis
myopathy
advancement with lid crease formation (right).
One of the most common eyelid procedures performed in
children is Epiblepharon correction3. An epiblepharon is a
developmental condition of the eyelids, typically seen in
those of Chinese descent (Chinese, Japanese and Koreans),
where there is an overhanging of the eyelid skin over the
eyelid margin with resultant in-turning of the eyelashes
against the cornea and conjunctiva. While asymptomatic
in infants, it usually becomes symptomatic with protean
manifestations of redness, tearing, irritation resulting in
children rubbing their eyes, etc, all of which may result in
misdiagnosis of allergic conjunctivitis.
Mechanical
Benign (Chalazion,
neurofibromatosis)
Malignant
(Rhabdomyosarcoma)
Traumatic
(multifactorial)
Figure 1 – Causes and management of Pediatric Blepharoptosis2
14
Insight
Evaluation demonstrates the presence of the skin fold
with eyelash signs and when stained with Fluorescein,
demonstrates varying degrees of keratopathy (Figure 4).
While some children indeed improve as they grow older,
they may not be in children with high BMI, absent upper
eyelid crease, etc, and if keratopathy persists despite
lubricants, epiblepharon correction is often indicated3.
Current techniques deliver good outcomes without visible
scars except in the upper eyelid where an eyelid skin crease
(double eyelid) is created.
Figure 4 – Epiblepharon with keratopathy
Lid lacerations are common in children and adults due to
varied causes. These include animal bites, human bites,
road traffic accidents, assaults and in association with
other facial injuries from industrial accidents. Principles of
evaluation and management include a detailed assessment
of the vital structures, e.g. the underlying globe and thus
vision, lacrimal drainage structures, extraocular muscles
including levator aponeurosis and the canthal tendons.
Meticulous wound closure addressing the vital structures
often produces excellent results with minimal compromise
in structure and function (Figure 5). When underlying lacrimal
injury is present, stenting of the lacrimal system is performed
for 3-6 months to ensure good tear drainage.
A common and sometimes recurrent problem in children
and adults is chalazia. These are lipogranulomata from
extravasation of the oily meibomian secretions in susceptible
children and adults, often resulting from varying degrees of
meibomian gland dysfunction. This is also more common
in patients with acne rosaceae when a combination of
systemic and topical treatment may be indicated.
Most lesions are treated with a combination of systemic
antibiotics with warm compresses. However, a minority, if not
resolved within 6 weeks, may require incision and curettage
of the granulomata, again performed as an outpatient
procedure. Long term management of meibomian gland
dysfunction often requires courses of Doxycycline with good
lid hygiene, warm compresses and massages to minimise
recurrences.
Tumours of the eyelid are not uncommon and most benign
lesions only require observation and reassurance for the
patients. Disfiguring benign tumours and suspicious lesions
often require biopsy performed either as an incisional or
excisional procedure. Although uncommon, malignant eyelid
tumours are not infrequently encountered and sometimes in
late stages owing either to patient or physician neglect. It
is for this reason that all atypical (persistent) inflammatory
or ulcerative lesions should be biopsied and wide excision
with reconstruction performed to ensure optimal results.
Of particular note is the relatively increased incidence
of sebaceous gland carcinoma amongst Asians which
may present as a chronic blepharoconjunctivits which, if
neglected, may result in systemic metastasis and death
(Figure 6).
(a)
Figure 5 – Monkey bite injury in a newborn – before (left) and 2
(c)
years after surgery (right).
Figure 6 – (a) Basal cell carcinoma, (b) Sebaceous gland
carcinoma, (c) Merkel cell carcinoma
15
(b)
Insight
A common presentation of Graves disease (autoimmune
hyperthyroidism) is eyelid retraction, which may be unilateral
or bilateral. While in most patients this is purely of cosmetic
significance, not infrequently it may be associated with active
underlying orbitopathy or significant lagopthalmos with
keratopathy. In such patients when conservative measures
of lubricants, goggle protection, etc. fail, eyelid retraction
repair using minimally invasive techniques help restore
structure, function and appearance as well (Figure 7).
Figure 7 – Graves disease before (left) and after eyelid retraction
repair (right).
Finally, with greater literacy, better or improved healthcare
and longer life expectancy, people are more conscious of
their appearance, especially because of extended life in the
workforce, and many thus feel the need to appear wellrested and youthful. It is in this context that aesthetic eyelid
surgeries (Periorbital and facial rejuvenation), sometimes
in combination of brow-lift and mid-face lift, is one of the
emerging fields in Ophthalmology. Common procedures
performed are listed below.
Ageing is inevitable and its effects are most obvious and
presents early in the Periorbital area, in the form of dynamic
rhytids (wrinkles). Neuromodulation with Botulinum toxin
injection (Botox cosmetic, Dysport) is commonly performed
for the laugh lines, glabellar frown lines and forehead wrinkles
(Figure 8).
With our current understanding of ageing changes on the
face and the role of fat atrophy and fat descent resulting
in troughs and hollows, tissue filler injection (temporary or
semipermanent) with non-animal source hyaluronic acids
(NASHA) have minimised the need for surgical procedures,
especially in younger patients. Both procedures of botulinum
toxin injections and tissue filler injections may sometimes
be combined, performed as outpatient procedures with
minimal down time and without disruption of work-life
schedule. When changes such as static rhytids are present ,
various forms of skin resurfacing may also be performed as
an outpatient procedure.
Table 2 – Common periorbital rejuvenation procedures
Non-invasive /Minimally
invasive procedures
Invasive
procedures
• Neuromodulation, e.g.
Botulinum toxin injection
• Blepharoplasty
– upper / lower
• Tissue filler injection,
e.g. NASHA
• Brow-lift
• Resurfacing: radiofrequency skin
tightening, chemical peels, lasers, etc.
• Mid-face lift
Figure 8 – Periorbital rhytids
However, when established ageing changes are present
with true loss of elasticity, redundant skin folds with descent,
various forms of surgical rhytidectomy are indicated.
The most common procedures are upper and lower
blepharoplasty, performed through existing crease lines
or transconjunctivally without visible scars and with good
outcomes. Not infrequently these may be combined with
upper facial rejuvenation (forehead/brow lift) or mid-facial
rejuvenation. The specific technique is tailored to the individual
based on various tissue and hairline characteristics4.
16
Insight
Younger patients of East-Asian descent who are desirous of
an eyelid crease and a more awake and alert appearance, or
experience increased fatigue from underlying eyelash ptosis,
often benefit from Asian Blepharoplasty (Double eyelid
surgery). These are performed as day-surgery procedures.
While there are numerous techniques, such as closed suture
technique, open surgical technique, etc. most oculoplastic
surgeons prefer the open surgical technique (Figure 9),
owing to their predictability and permanency.
REFERENCES
1. Cahill KV et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. 2011 Dec; 118(12):2510-7.
2. Sundar G. Pediatric ptosis - Pearls and pitfalls. A Review. Journal of Tamilnadu Ophthal Assoc. 2010 Jun 48(2): 84-90.
3. Sundar G, Young SM, Tara S, Tan AM, Amrith S. Epiblepharon in East Asian patients – The Singapore experience. Ophthalmology 2010 Jan 117(1):184-9.
4. Almousa R, Amrith S, Sundar G. Browlift – A South-east Asian experience.
Orbit 2009; 28(6) 347-53.
Dr Gangadhara Sundar
Figure 8 – Periorbital rhytids
It should be remembered that while most patients benefit
from all of the above procedures, each has its own risks and
complications; and hence, the need for a clear understanding
of the indications and outcomes with realistic expectations
are paramount, underscoring the need for a fully informed
consent.
In summary, eyelid and oculofacial surgery has evolved from
either observation or invasive techniques, with varied and
unpredictable outcomes, to minimally invasive techniques
with more predictability and early recovery, thus resulting
in enhanced functional, social, psychological, and in the
modern era of extended productivity, economical outcomes
as well.
17
Having graduated from the Madras Medical
College and received his basic Ophthalmic training
in Chennai, Dr Gangadhara Sundar went on to
pursue his residency training in Ophthalmology
and a 2-year fellowship in Ophthalmic Plastic &
Reconstructive Surgery & Ocular Oncology from
Henry Ford Hospital in Detroit.
His areas of training and expertise include
functional and reconstructive ophthalmic plastic surgery, aesthetic oculofacial surgery and Ocular Oncology, and he is certified by the American
Board of Ophthalmology.
Dr Ganga is also active in furthering the cause of the subspecialty in the
South and East-Asian region and is actively involved in undergraduate
and postgraduate education in Singapore and the region. He has been a
Visiting Professor to various universities internationally and is an examiner
in Singapore and regional universities.
His special interests include aesthetic and functional reconstructive surgery
of the upper and mid-face, orbital reconstruction, anophthalmic sockets,
thyroid eye disease and paediatric oculoplastics.
Insight
Minimally Invasive Surgery in O&G - Diagnostic
and Therapeutic Applications
Dr Fong Yoke Fai, Head & Senior Consultant, and Dr Ng Ying Woo, Associate Consultant, Division of Benign Gynaecology, Department of Obstetrics & Gynaecology
One of the most significant transformations within the
history of surgery has been the paradigmatic shift from
open surgery to the realm of operative video-laparoscopy,
an approach that truly captured all that minimally invasive
surgery was meant to mean.
In the last 20 years, gynaecological laparoscopy has
evolved from a limited surgical procedure used only for
diagnosis to become a major surgical tool used to treat a
multitude of gynaecological indications. Through a few small
abdominal wounds and the use of specialised laparoscopic
instruments, laparoscopic surgeons are able to achieve the
traditional surgical goals that were usually accomplished by
open laparotomy.
Combining advanced technology with patient care has also
allowed minimally invasive surgeons to do more with less.
Patients who undergo minimally invasive surgery enjoy the
numerous advantages of laparoscopy over laparotomy,
such as reduced post-operative pain, smaller surgical scars,
shorter hospital stay, and faster return to normal activities.
We can truly hail the advancement of operative videolaparoscopy as a "revolutionary" change to surgery in this
century as the development of anaesthesia was in the last
century.
The History of Laparoscopy
Laparoscopy was first discovered by Dr George Kelling,
who performed his procedure, koelioskopie, on the dogs.
Subsequently, numerous great surgeons such as Dr Hans
Christian Jacobeus, Dr Bertram M. Bernheim, and Dr
Janos Veress and others, contributed to the development
of this surgical approach. In the early part of the century,
laparoscopy was limited to diagnostic procedures, used by
a few surgeons and with substantial complications. It was
not until the 1970s that operative laparoscopy was initiated
and tubal ligations for contraception using laparoscopy were
performed in women.
The development of solid state video camera and optic fibre
technology in the 1980s further transformed this surgical
approach into our modern operative video-laparoscopy.
With that, operative laparoscopy approach was extended
to complicated gynaecological procedures including
hysterectomy, adnexal surgery and uterine myomectomy.
Today, laparoscopic surgery has become an essential part
of surgical treatment for gynaecological diseases, including
gynaecological cancers. The 21st century looks set to further
extrapolate this great surgical discovery into the realms of
robotic surgery and single-port technology.
What Can We Do with Laparoscopy Nowadays?
Traditionally, the use of laparoscopy in gynaecology had
been mainly limited to diagnostic purposes in chronic pelvic
pain and infertility procedures. Thereafter, its use widened to
include various forms of sterilisation. Nowadays, laparoscopy
is the gold standard in the diagnosis and treatment of ectopic
pregnancy. With its increasing popularity, laparoscopy has
also become the treatment of choice for endometriosis,
ovarian cysts and fibroids.
Diagnostic laparoscopy
Frequently, surgeons need to assess the pelvis for acute
or chronic pain, infertility, ectopic pregnancy, ovarian cysts,
or other pelvic pathology. Laparoscopy is an excellent
approach to achieve the diagnosis. The use of optics and
electronic visualisation equipment has provided highlymagnified images of surgical anatomy and pathology that
make subsequent surgery more precise and accurate.
Tubal surgery
Laparoscopic tubal ligation has been shown to be highly
effective in preventing pregnancy. Instead of making a large
abdominal incision, laparoscopy has allowed the surgeon to
tie the fallopian tube via small "keyholes" in the abdomen.
Laparoscopy has transformed tubal sterilisation into a highly
cost-effective procedure that has had great impact in the lives
of many women. On the other hand, it is possible to perform
tubal microsurgery which can enhance fertility. Tuboplasty or
reanastomosis is performed for damaged tubes when there
is a further desire for spontaneous pregnancy.
Treatment of endometriosis
Treatment of endometriosis may be potentially complicated
with involvement of the surrounding organs such as bowels
and bladder. Laparoscopy provides superior magnified
images of the disease and facilitates haemostasis. This is
especially critical in the treatment of endometriosis, as it
18
Insight
helps the surgeon to completely resect or ablate the disease.
Laparoscopic treatment of endometriosis has been shown
to improve fertility and decrease pelvic pain in multiple welldesigned studies.
Recently, two approaches have been introduced into the
arenas of minimally invasive surgery, aiming to alleviate
these weaknesses. They are the robotic surgery platform
and single-port laparoscopic surgery (SPLS).
Treatment of ectopic pregnancy
Robotic surgery has many advantages such as
3-dimensional view, wrist-like motion of the robotic arm
and improved ergonomics for the surgeon, allowing him or
her greater precision and the ability to tackle more complex
cases. Scientific data has also demonstrated the feasibility
of robotic surgery in gynaecological oncology. In the near
future, we will see greater miniaturisation of the robot as it
integrates into mainstream surgery. Cost reduction in robotic
surgery will kick in as the demand increases.
Laparoscopy is the gold standard treatment for ectopic
pregnancy. Besides helping the surgeon to clinch the
diagnosis, treatment can also be instituted in the same
setting. A salpingostomy or salpingectomy may be
performed to remove the embryo and gestational sac.
Treatment of ovarian pathology
Ovarian pathology such as cysts, torsion or mass can be
effectively managed using laparoscopy. Laparoscopic
cystectomy, adnexectomy or de-torsion can be performed
via laparoscopic approach with excellent surgical outcomes.
Treatment of fibroids
Uterine fibroids are benign tumours on the muscular wall
of the uterus, commonly found in women of reproductive
age. Uterine fibroids may be associated with painful and
distressing symptoms, including heavy menstrual periods,
abdominal cramping, and even infertility. Nowadays,
laparoscopy is effectively employed in both myomectomy
and hysterectomy, with a much quicker recovery for the
patients.
Others
With increasing experience in laparoscopy, minimal access
surgery is now being conducted for more complicated
gynaecological procedures such as gynaecological cancers,
urinary incontinence, microsurgery for fertility and pelvic
organ prolapse. The most telling of these developments
has been the use of laparoscopic access for pelvic and
para-aortic lymphadenectomy and radical hysterectomy for
gynaecological malignancy.
What’s New?
Progress in medicine often follows innovation and
improvement in technology. For laparoscopic surgery, it is
becoming a technically easier and less invasive procedure.
Despite several advantages of laparoscopic surgery,
weaknesses of conventional laparoscopy – such as the
limited mobility of straight laparoscopic instruments, poor
quality two-dimensional imaging, less cosmesis associated
with multiple incisions and a steep learning curve for
surgeons – still remain.
19
While SPLS has several benefits including reduced
postoperative pain, and better cosmetic results as compared
to conventional laparoscopy, technical difficulties and
limitation of the laparoscopic instruments are the current
barriers to its further development. An increasing number
of clinical trials indicate the feasibility of using SPLS in
gynaecological surgery, however, further studies are needed
to demonstrate its potential benefits over the conventional
laparoscopy.
In the next few years, we will probably be witnessing these
two innovations taking the lead in the development of
minimally invasive surgery, thereby improving the quality of
care for our patients.
Conclusion
Neither the use of minimal access nor technical feasibility is
an indication for surgical intervention. A surgical procedure
is undertaken solely to benefit the patient. Hence, there is
also a need to increase public awareness and education
on laparoscopic procedures, so that the advantages of
laparoscopy and its potential benefits can be fully realised.
Both robotic surgery and SPLS are currently in their infancy
stage, and greater strides in the existing technology are
needed if this technology is to become a commonplace
for the general gynaecologist. Nevertheless, we are seeing
a growing body of literature demonstrating the feasibility
of these approaches with several added advantages. As
the technology advances, we will eventually arrive at our
promises offered to our patients of being truly "minimally
invasive".
Insight
The Gynae-Endoscopic Surgical Team at the National University Hospital, Singapore
Our team at the National University Hospital (NUH) has continually strived for excellence in the field of minimally invasive surgery.
Besides offering expertise in the traditional laparoscopic surgical treatment of ectopic pregnancy, fibroids, ovarian cyst and
endometriosis, we were among the first in the region to perform single-port laparoscopic surgery (SPLS) in 2009. We have also
worked with our oncology colleagues (A/Prof Jeffrey Low, Dr Joseph Ng) under the umbrella of the GRACES (Gynaecological
Robotic Assisted Cancer and Endoscopic Surgery) project, to perform the first robotic-assisted surgery for endometrial cancer
and cervical cancer in the region. These minimally invasive approaches are accomplishing traditional surgical goals with less
pain, faster recovery and lower wound complication rates. Our team is committed to excellent patient care through research,
education and clinical expertise.
The laparoscopy team from the Department of Obstetrics & Gynaecology.
From left to right: Dr Ng Ying Woo, Associate Consultant; Dr Anupriya Agarwal, Consultant;
Dr Fong Yoke Fai, Senior Consultant and Dr Stephen Chew, Senior Consultant.
Dr Fong Yoke Fai
Dr Ng Ying Woo
Dr Fong Yoke Fai is Senior Consultant and Head
of the Division of Benign Gynaecology, at the
Department of Obstetrics and Gynaecology in
NUH. He completed his MBBS degree at the
National University of Singapore, and obtained
his postgraduate qualifications in Obstetrics and
Gynaecology from the UK College, and Royal
Australian and New Zealand College. Dr Fong has
also spent one year training under world-renowned laparoscopic surgeon
Alan Lam in Sydney before returning to NUH. Dr Fong’s current interest
is in the treatment of various gynaecological conditions and the use of
microsurgical techniques.
Dr Ng Ying Woo is Associate Consultant in the
Division of Benign Gynaecology, at the Department
of Obstetrics and Gynaecology in NUH. Dr Ng
obtained his basic MBBS degree and completed
his specialist training at the National University of
Singapore (NUS). Dr Ng has a special interest in
the areas of minimally invasive surgery. He has just
completed one year of training at the distinguished International Centre
for Endoscopic Surgery (CICE) in Clermont Ferrand, France. He is also a
clinical tutor for the medical students at NUS.
20
Insight
Managing Urinary Stone Disease
Dr Heng Chin Tiong, Senior Consultant, Department of Urology, University Surgical Cluster
Urinary stone disease is one of the commonest urological
conditions seen. This remains so even as the disease
patterns change in Singapore with increasing affluence and
standard of living. Most of the stones seen now are small,
and are managed as far as possible, non-invasively or
minimally invasive.
However, there remains a significant proportion of stones
which are larger or even staghorn. Many of these stones
are asymptomatic and are picked up on imaging for other
reasons, such as with ultrasound of the hepatobiliary system
for Hepatitis B follow-up, or on MRI of the spine for back
pain.
Traditionally, staghorn stones were thought to be related
more to infections. However, many of these stones are found
to be of a combined mineral content, with areas of calcium
oxalate, calcium phosphate and ammonium-magnesium
phosphate. The specific mineral crystalline structure also
has bearing on the hardness of the stones, which influence
the success of the various modalities of treatment.
counseling can be given on their relative options and
consequences.
As presented in the accompanying case study, some patients
may wish to have ESWL even though the ideal treatment
is a more invasive procedure. If the patient has realistic
expectations, and is willing to comply with instructions to
minimise complications, then even large stones can be
treated this way.
Indeed, our experience with ESWL also extend to treating
certain biliary and pancreatic stones, although this has to
be done in conjunction with the gastroenterologist, as
endoscopic procedures such as an ERCP or nasobiliary
drains are usually performed as an auxiliary procedure to
assist in the removal of the stone fragments.
Family physicians may refer patients for the investigation
and management of urinary stone conditions by calling up
the Urology Centre at NUH. (Biliary and pancreatic stones
should be referred first to the gastroenterologist).
Treatment
Case study
Urinary stones can be treated in a variety of ways. This can
run the whole gamut of invasiveness, from observation and
regular follow up, to non-invasive procedures such as an
extracorporeal shockwave lithotripsy (ESWL), to endoscopic
procedures such as an ureteroscopy and laser lithotripsy,
to minimally invasive procedures such as a percutaneous
nephrolithotripsy (PCNL) and laparoscopic ureterolithotomy.
This patient is a 40-year-old male who has recurrent urinary
stone disease. Illustrated in Figure 1 is a large renal pelvis
stone with fragments in the lower pole calyx. Ideally, the
stone should be treated with a PCNL, which is invasive and
requires general anaesthesia. The average length of stay
after such a procedure is about 3 to 4 days, with a transient
nephrostomy tube inserted.
One major consideration in stone management is the
preservation of renal function, and in this regard, we
sometimes employ drainage procedures such as a double-J
stenting or percutaneous nephrostomy.
In patients with recurrent stones or complex stones, the
management will also include the assessment of metabolic
risk factors such as hypercalcaemia, hypercalciuria or
hypocitraturia.
Management at the NUH Urology Centre
The NUH Urology Centre provides patients with a
comprehensive range of treatments and management for
their stone disease. Patients are investigated and reviewed
before the most appropriate course of action is advised. In
those patients who are risk-averse to surgery, appropriate
21
Figure 1 – Before treatment
Insight
The patient declined this and, having done his own research,
was keen for ESWL. He was aware that multiple sessions of
ESWL will be needed, and that there is a risk of “steinstrasse”
or “stone street”, where the fragments form a column of
stones in the mid- to distal ureter, causing obstruction. He
was willing to have a stent placed should any obstruction be
persistent.
A total of two treatments were administered, 2 weeks apart.
Figure 2 illustrates the fluoroscopy picture seen during one
of the ESWL treatments.
Figure 4 – Stone fragments
This case demonstrates that even large stones can be
treated with ESWL. However, it must be emphasised that
this is not the usual mode advised, and is really suitable only
in highly-motivated individuals who are aware of the risks
and potential complications. Most patients will still ideally be
treated with a PCNL.
Figure 2 – During ESWL
The patient did indeed have fragments dropping down the
ureter, causing transient obstruction and hydronephrosis.
He came back to the clinic twice a week for an assessment,
and continued to pass many fragments. After another 3
weeks, the fragments eventually all passed out. Figure 3
illustrates the x-ray picture after treatment, while Figure 4 is
a picture of the large amount of fragments that he managed
to retrieve.
Dr Heng Chin Tiong
Dr Heng Chin Tiong is a Fellow of the Royal
College of Surgeons (Edinburgh) and member of
the Chapter of Urologists, College of Surgeons,
Singapore. His interests are in laparoscopic surgery,
shockwave lithotripsy and computer modeling of
the bladder and voiding. He leads the team which
manages and performs surgeries in patients with
complicated urinary stone disease. He is also a
key member of the prostate high-dose brachytherapy programme, with
NUH being one of the few centres in the region that offers this modality of
treatment for prostate cancer.
Dr Heng also oversees the Year 3 Medical Undergraduate programme of
the Yong Loo Lin School of Medicine, NUS. He coordinates the teaching
of the students in their first full-year of clinical rotations, as well as the
summative barrier examinations.
His training includes a year's fellowship with the Department of Urology
in Westmead Hospital, Australia. He has been actively involved in the
development of laparoscopic urologic surgery for the past decade, in both
his previous hospital and in NUH. He has trained many young urologists in
Endo-laparoscopic Urological Surgery. He is also an applications specialist
for the Siemens Modularis and Variostar Shockwave Lithotripsy systems,
and has performed on-site training in many centres regionally, including
Indonesia, Malaysia, Thailand, Bangladesh and Taiwan.
Figure 3 – After treatment
22
Insight
Age-related hearing loss and hearing aids
Ms Shirley Chong Sheue Lih, Audiologist and Ms Lynne Tan Zhilin, Speech Language Therapist/Auditory Verbal Therapist, Centre of Hearing Intervention and
Learning Development (CHILD), Department of Otolaryngology – Head & Neck Surgery
Hearing loss is the third most chronic health condition
affecting older adults. Age-related hearing loss, also known
as presbycusis, is gradual loss of hearing, as people get
older. It is part of the ageing process, which affects about
one third of adults between the ages of 65 and 75, and
over half of people aged 75 and older. Since presbycusis
is progressive and develops slowly, some people might be
unaware that their hearing is diminishing.
Symptoms of age-related hearing loss
Presbycusis commonly occurs in both ears. It is usually slow
in progress and gets worse in high frequencies. Since the
higher pitched consonants, which are important for speech
intelligibility, are missing or distorted, elderly with presbycusis
may experience difficulty understanding speech, especially
from women and children’s voices. They may also find
speech muffled or slurred during conversations, especially
in the presence of background noises. Their inability to
understand speech clearly is usually disproportionate to
their elevation of hearing threshold.
Although degree of audibility strongly influences speech
comprehension, some seniors seem to face more hurdles
than would be expected based solely upon their audiometric
configurations (Martin & Jerger, 2005). It is not abnormal to
have two individuals with comparable age and degree of
hearing loss to report great difference in perceived hearing
handicap.
People with hearing loss are also likely to report symptoms
of depression, dissatisfaction in life, reduced functional
health and withdrawal from social activities. If hearing loss
is left untreated in elderly, the impact is pronounced to both
the patients as well as his or her family. Recent studies also
found that hearing loss is associated with dementia. Treatments for hearing loss
Age-related hearing loss is incurable. The current treatment is
focused on improving patient’s every day functions. Patients
will either be fitted with hearing aids or recommended for a
cochlear implant, depending on the severity of the hearing
loss. Most of the time, patients will be fitted with hearing aids,
as cochlear implants will only be involved if the hearing aid
is no longer strong enough to provide sound amplification.
Hearing Aids
A hearing aid is an electroacoustic device which typically fits
in or behind a person's ear. It is to amplify sounds so that the
user can hear better.
Hearing aids are usually categorised based on their size and
manner of placement. There are four types of hearing aids
in the market – which are Behind-the-Ear (BTE), In-the-Ear
(ITE), In-the-Canal (ITC) and Completely-in-the-Canal (CIC)
hearing aids.
Behind-the-Ear hearing aids can be further divided into
Conventional BTE, Open Fit BTE and Receiver-in-the-Canal
23
(RIC) BTE. A BTE hearing aid suits all degree of hearing loss
while CIC hearing aid is only for those who have mild to
moderate hearing loss. Generally, the smaller the hearing aid,
the less gain and maximum output it has. All the hearing aids
available in the market now are digital hearing aids although
some patients are keeping their old analog or programmable
hearing aids.
Different type of hearing aids.
Factors that may influence the acceptance of hearing
aids
Although it is well-documented that hearing aid use can
improve quality of life for those with hearing impairment (E
TsakiropoulouI et.al, 2007), the adoption rate of hearing aids
remains low. Research in US showed that three out of four
people who could benefit from hearing aids actually use
them (Kochkin, 2010). Reasons could be, certain individuals
are unwilling to accept the fact of hearing loss, or they believe
nothing can be done to help. Another survey reviewed that
two-thirds of the respondents who did not use hearing aids
stated that their hearing losses were not “bad enough to get
a hearing aid”.
A lack of motivation towards using hearing aids is a result
of negative beliefs such as hearing aids causing headache,
or that hearing aids could further damage hearing. Cost
is another important factor that may contribute to the low
hearing aid adoption rate. The price of a unit of digital
hearing aid ranged from SGD1000 to SGD6000. Some
patients may find it too expensive to own one. Also, many
Asians reject hearing aids as they are concerned with the
stigma of hearing loss.
However, once patients understand the benefits of having
hearing aids and how they will improve their daily wellbeing, those concerns that they have previously may not
be a setback anymore. This explains the importance of
public awareness and setting up of convenient hearing care
services to change people’s perception of wearing hearing
aids.
Hearing aid selection
Hearing aid selection will be influenced by several factors,
such as the type and the extent of hearing loss, manual
dexterity, cognitive abilities, patient’s personal preference
and the cost of hearing aids. Often, BTE hearing aids or
Insight
ITE aids are selected for elderly due to manual dexterity
issues. Some automatic features like auto-phone and autoprogramme switches that change sound levels automatically
in various listening situations, make hearing aids more
elderly-friendly.
Binaural fitting is reported to produce better speech
understanding especially in noise, has better sound quality
and better sound localisation (Kochkin.S, 2000). However,
factors such as patient’s cognitive abilities, manual dexterity
or cost may still influence a patient’s decision in getting
hearing aids for both ears.
Post-fitting Interventions
Hearing aids aren’t perfect! They can’t restore one’s hearing
to normal. Despite advances in digital signal processing,
hearing aid success may be limited as a function of the extent
of sensory cell loss, specifically inner hair cells and spiral
ganglion cells. Hearing aid users may still face difficulties
understanding speech in the presence of background noise
or multiple talkers, or in highly reverberant environments
(Abrams. H, 2009). Conventional amplification addresses
the issue of audibility but may not compensate for deficits
in impaired temporal processing occurring within the central
auditory system. (Martin & Jerger, 2005)
New users may also need time adjusting to the hearing
aids. Factors that will affect the period of adjustment include
the individual’s motivation, degree of hearing loss and its
duration, age of the individual and his or her manipulation
skills. Research showed that individuals older than 70 years
would take a longer time to adapt to a hearing aid when
issued with one for the first time as compared to younger
people (Brooks. D.N, 1996). Thus, early referral of hearingimpaired individuals for hearing assessments is vital.
Audiologists will follow up with their patients to ensure
optimal use of hearing aids. Regular post-fitting follow-up
is especially important among elderly hearing aid users.
They are more likely to forget information given during the
hearing aid fitting such as ear mould insertion, hearing aid
maintenance, battery changing, programme switch and
volume control manipulation. Often times, family members
are encouraged to sit in the sessions so that they can help
out should patients have difficulties subsequently.
During follow-up sessions, the audiologist will further finetune the hearing aids based on patient’s feedback and
needs. Hearing aid verification will need to be conducted
as well to ensure the aid provides adequate gain and
proper loudness comfort. Apart from this, the audiologist
will also provide communication tips, and strategies such
as identifying the sources of every day communication
difficulties, suggestions for controlling the communication
environment to reduce listening difficulties, and ways of
repairing communication breakdowns (Kricos.P, 2006).
Research has shown that with hearing aids alone, it is
insufficient to provide optimal listening benefits to individuals
with hearing loss. Hearing aid users continue to experience
difficulties in discriminating between words that are similar
sounding, hearing speech in noisy environments and talking
on the phone. A common feedback from many hearing aid
users is that it is noisy and uncomfortable to hear with.
Auditory training by auditory-verbal therapists is aimed at
helping working adults and the elderly population in the
3 areas of deficits that are still present after hearing aids
have been prescribed. Auditory training is individualised
and tailored according to the listening skills and functional
needs of the patient. Listening tasks are designed for the
patient, from easier ones at their skill level, with step-wise
increments to more difficult listening conditions.
Hearing loss is an invisible disability that can potentially
threaten the quality of life for those at their ‘golden years’.
Hearing loss is irreversible, but they can be prevented from
living in a world of silence.
REFERENCES
Abrams, H. (2009). Audiologic Management of the Older Patient. The ASHA
Leader.1 Sept 2009
Brooks DN. (1996) The time course of adaptation to hearing aid use. Br J Audiol 1996;
30: 55-62.
E TsakiropoulouI et.al (2007) Hearing aids: Quality of life and socio-economic aspects.
Hippokratia.2007 Oct-Dec; 11(4) pp 183-186
Kochkin, S. (2000) Binaural Hearing Aids: The Fitting of Choice for Bilateral Loss Subjects.
Knowles Electronics: Itasca, Ill (2000). A tutorial for Audiologists, dispensers and
physicians; includes 15 reasons why binaural hearing aids are effective.
Kochkin, S. (2010) MarkeTrak VIII: Consumer satisfaction with hearing aids is slowly
increasing. Hearing Journal. Jan 2010Vol 63(1) pp19-32
Kricos.P (2006) Audiologic Rehabilitation with the Geriatric Population.
http://www.audiologyonline.com/articles/article_detail.asp?article_id=1673
Martin.S & Jerger. J (2005) Some effects of aging on central auditory processing.
Journal of rehab research and development,Vol42,no4 pg25-44
Ms Shirley Chong Sheue Lih
Shirley
graduated
from
the
University
of Kebangsaan Malaysia (UKM) with a Bachelor
of Audiology (Honours). Having 3 years of
experience, she specialises in seeing adult patients
for hearing aids, cochlear implant management and
auditory processing disorder testing.
Ms Lynne Tan Zhilin
Lynne graduated from the Masters in Speech
Language Pathology, MSc (SLP) program at the
National University of Singapore in 2008. Prior
to the Masters program, Lynne was managing
children with hearing impairment using the Auditory
Verbal approach. She has also been actively
involved in the local Deaf community. She has a
keen interest in rehabilitating persons, young and
old, with hearing loss. She believes strongly that
with appropriate rehabilitation, persons with hearing loss will be able to
benefit fully from their hearing devices and in turn enjoy improved quality
of life.
24
Doctor’s Heartbeat
Specialist in Focus
Dr Cheng Jin Fong
Consultant
Department of Ophthalmology, NUH
Dr Cheng graduated from the University of Manchester in the United Kingdom and completed her
ophthalmology training in Singapore.
She has interests in general ophthalmologic problems and is a skilled cataract surgeon.
She also has interests in various eye-lid diseases, tearing problems, orbital pathologies and injuries,
cosmetic surgeries for sagging eyebrows and baggy upper and lower eyelids.
The eye is one of the five organs in the human sensory
system which allows for vision.
Scientific experiments have shown that humans can
discriminate between very subtle differences in color, and
estimates of the number of colors we can see range as high
as 10 million 1.
Though a small part of the entire human body, it is intriguingly
complex with many different parts. Having good vision helps
us to see beauty in all that life has to offer.
Diseases, disorders and age-related changes, however,
affect the eyes, and our ability to see. Specifically, the earliest
signs of aging usually occur around the eyes – such as
sagging of the forehead, the eyebrow, eyelids, etc. Drooping
eye-lids and forehead tissues may affect our field of vision
and thus affect visual function.
In addition, with increasing societal consciousness of wanting
to present and look our best, oculoplastic procedures, which
include improving both the function and appearance of the
eyes, definitely have their place in medicine.
In this issue, we have a chat with Dr Cheng Jin Fong, a
doctor who sub-specialises in oculoplastic surgery.
1) What, or, who inspired you to be an Ophthalmologist?
Vision is a sensory function that is essential to every day
living. Without it, many of the activities of daily living would
be very difficult. I find restoring good vision for my patients
very rewarding. It really makes my day when patients thank
me for helping them see well again. There is also the surgical
aspect of ophthalmology, which I find very exciting.
2) If you weren't a doctor, what would be your dream
alternate career?
When I was in secondary school, my diabetic grandfather
was often ill and was frequently in and out of hospital.
Whenever I visited him, he would tell me how thankful he
was for his kind and compassionate doctors. Seeing them
whiz around the wards attending to patients, with an “allimportant air” around them, looked very impressive to a
teenager at that time. I was determined to be like them.
During my medical school days, I saw a different side to
doctoring. I remember a tag-on call with my medical officer.
It was a cold winter night and we had completed our night
rounds and were just sitting down for dinner when we were
called to see a breathless patient. I turned instantly from a
hungry, tired and lethargic person to a dynamo, running to
the ward to see the patient. There was a mysterious force
that energised me; I realised that helping someone in need
was what I wanted to do with my life.
I am a very determined person, if I did not get into medical
school at university, I would just keep trying.
3) What motivated you to sub-specialise in Oculoplastics
amongst all other aspects of Ophthalmology?
I found oculoplastics very challenging because of the wide
variety of conditions that we see and operate on. Some of
the diseases I get to see in my clinic include: elderly patients
with eyelid problems, thyroid eye disease, tearing problems,
trauma and patients wanting cosmetic eyelid procedures.
1. Judd, Deane B.; Wyszecki, Günter (1975). Color in Business, Science and Industry. Wiley Series in Pure and Applied Optics (third edition ed.). New York: WileyInterscience. p. 388. ISBN 0471452122.
25
Doctor’s Heartbeat
With so many different types of patients, each would require
different treatments. Hence, I will not get bored.
4) Who has had the biggest influence on your career?
Why?
I’m grateful to all my teachers and mentors who have
taught me through the years. They have shown me both the
academic aspects of medicine as well as the importance of
compassion towards patients.
5) What are some of the newer and exciting developments
that you think have resulted in better treatment for
patients?
There are many advances in the field of oculoplastics – for
example, the safe and effective use of propranolol to treat
patients with capillary haemangiomas.
Conventional dacryocystorhinostomy done for tearing
leaves a visible scar on the face of patients. However, with
new endo-nasal techniques, this is no longer the case.
satisfaction when I get a good surgical outcome for my
patients, or, when they are happy with the final cosmetic
appearance.
8) Any personal heroes? Who are they?
I admire Stephen Hawkins. He is able to overcome physical
impairment and make great contributions to the world
of physics. He is well known for his humour, humility and
courage, and is an example of the amazing human spirit and
a drive to live life to the fullest.
9) What do you enjoy doing in your free time? Any
hobbies or passions?
I like to read novels, anything from Chinese sword fighting
serials to Jane Austin. I like to dream about the places and
people that are described in novels. My favourite holiday is
to buy a good book and sit by the beach reading all day.
However, with three young boys at home now, making time
for pleasure reading is a real luxury.
There are also the advances in surgery with better implants,
fillers, laser and surgical techniques to provide safer and
more predictable outcome for patients.
6) What are the most common injuries caused to the
eye seen in your sub-specialty? And how to prevent
them?
I have seen many foreign workers with industrial accidents
causing blunt or sharp trauma to the eye. If patients had
been wearing the appropriate eyewear, many of them could
have been prevented.
Some patients were not aware of the dangers around their
work place, while others were briefed but chose to ignore
the warnings. They refuse to wear eye protection because
they felt that it was inconvenient.
There also might be language barriers between the workers
and their superiors, and hence, the workers did not fully
understand the importance of safety goggles. Better
education and communication with workers can help
prevent these injuries.
7) Could you share with us personal reflections some
as a doctor?
There are many memorable experiences during my career
– some have happy endings while others not so.
I am always very disturbed when young children lose their
vision due to tumours or other congenital processes, and
there is nothing I can do about it. Fortunately, this does not
happen often in my practice.
But I love talking to my patients; I am particularly happy
when I can make a difference in their lives. It gives me great
Dr Cheng with he
r young sons.
26
Médico
Upcoming Events
NUH GP CME Programme 2012
Please refer to our GPLC website for online registration.
Date
Clinical Specialty / Topic
24Mar
Obstetrics & Gynaecology
7 Apr
Cardiac
21 Apr
28 Apr
Endometriosis and Menstrual Disorders
Interpreting the ECG Without Fear
Psychological Medicine
Anxiety Disorder Associated With Other Medical Disorders
Surgery
Facial Paralysis: Current Management in Diagnosis,
Treatment and Reconstruction
19 May
Common Conditions in Children
26 May
Palliative Care for GPs: What I can do in the clinic and at home
25-27
May
Paediatrics and Hand & Reconstructive Microsurgery
Medicine
Obstetrics & Gynaecology
University Obstetrics & Gynaecology Congress 2012
For more info, please visit: www.obgyn2012.com
*Event information listed is correct at time of print.
While every attempt will be made to ensure that all events will take place as scheduled,
the organisers reserve the rights to make appropriate changes should the need arises.
Please refer to our events calendar at www.nuh.com.sg/nuh_gplc/index/index.htm
for more updates and information.
A Publication of NUH GP Liaison Centre (GPLC)
Advisors A/Prof Goh Lee Gan
Editor Esther Lim
Editorial Team Lisa Ang
We will love to hear your feedback on Médico.
Please direct all feedback to:
The Editor, Médico
National University Hospital,
1E Kent Ridge Road, NUHS Tower Block, Level 6, Singapore 119228
Tel: 6772 2151 Fax: 6777 8065
Email: [email protected] Website: www.nuh.com.sg/nuh_gplc/index/index.htm
Co. Reg. No. 198500843R
The information in this publication is meant for educational purposes and should not be used as a substitute, or relied solely upon, for medical diagnosis or treatment. Please seek further medical
advice if you have questions related to any medical condition. Although great effort has been made in compiling and checking the accuracy of the information given in this publication, the authors,
publisher and National University Hospital shall not be responsible, or in any way liable, for the continued currency of the information, or for any errors, omissions or inaccuracies, whether arising from
negligence or otherwise, or for any consequences arising therefrom. Contents in this newsletter are not to be quoted or reproduced in any form without the prior permission of National University
Hospital.

ADVAnCEs In REFRACTIVE SuRGERY

Transcription

Similar documents

SoundWaves-September-2013 - Canadian Hard of Hearing

972-258-6400 | TYLOCK.COM

Laser Engraving - Source International

to the Neon end-user brochure

sh MiracleEar profile

SASLOW`S

HARTFORD`S FINEST

hartford`s finest - Proactive Resources

OVER 8 YEARS - Asaadi Plastic Surgery

Abdominal Sacrocolpopexy with possible removal of ovaries