Ophthalmic Plastic and Reconstructive Surgery

Inviting those who are attending Asia Pacific Academy of Ophthalmology (APAO) Congress 2024 in Bali Indonesia later this week, to our instruction course.

Looking forward to meeting and learning from colleagues in the region. Hoping to have a fruitful meeting.

A good day in the office, very satisfying one to boot!

This 8 year old child had a very severe Ptosis with almost nil levator function was operated with Frontalis Flap Suspension technique providing an aesthetic pleasing and symmetric ptosis correction with a good lid crease formation.

⏲Surgery time: 30-45 mins
💉Anaesthesia: General Anaesthesia in children/ Local anaesthesia in adults
🗓️Downtime: 3-4 weeks
📈Duration of effect: Long term
📠 Phone: +91 80 2502 3257
📩 E-mail:[email protected]
🖥️ Website: www.drraghurajhegde.com

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

Extremely privileged to be part of The WSBF Diploma course last month. This Skull Base Cadaver dissection course was a 11 day course where 1 full day was dedicated for orbital approaches to skull base.

We demonstrated how we could give great access to the anterior and lateral skull base via the orbit- what has been termed as “Trans-Orbital Neuro-Endoscopic Surgery”. Along with Dr. Gaurav Medikeri ( ) - my partner in crime, we shared our experience with TONES over the last 3 years along with the dissection on the fresh wet cadaver.

Would like to thank who invited me as faculty for this superlative course. WSBF stands for World Skull Base Foundation helmed by Dr. Sampath Chandra Rao

A very Happy New Year!

A very Happy post to start the year with.

Steroids are not the answer!
Orbital Inflammatory Disease (OID) is a very challenging entity to treat in ophthalmology. Any Orbital specialist would testify how frustrating it is to treat. This patient presented to us a little less than a year back with severe right orbital inflammation with painful proptosis, a mass in the orbit (Eye Socket) and a frozen orbit (right eye not being able to move). She was treated earlier during similar acute episodes with oral steroids only for it to recur with more severity. We did an Orbitotomy with multi-layered incision biopsy which revealed that the inflammation to due to a condition known as SARCOIDOSIS.

Post-operatively she treated with a tapering steroid dosage along with long term immuno-modulatory treatment since the diagnosis was established. The long term immuno-modulation was started and treatment monitored by our very capable Immunologist. This is the same patient today- the orbital inflammation fully in remission and no acute episodes since we started her on treatment. She is indeed going to have a great 2024!

Swipe ➡️ to see the MRI Scan at presentation.

A special mention to .mk Consultant-Ophthalmic Pathologist and Dr. Abhishek Patil - Consultant- Rheumatology & Immunology. Both of them are very instrumental in getting best outcomes for our OID patients.

If you have something similar and you are repeatedly being treated by oral steroids every time, it is time to consult with an oculoplastic surgeon ASAP!

For Appointments
📠 Phone: +91 80 2502 3257
📩 E-mail: [email protected]
🖥️ Website: www.drraghurajhegde.com

Following up on the previous post of white eyed orbital blowout fracture (WeBoF), this above is the intra-operative picture of the floor fracture in another patient.
Swipe ➡️ To see the CT scan showing the fracture in left orbital floor in sagittal & coronal cuts.
Swipe ➡️ ➡️ to see the barrier bioresorbable implant which dissolves in 18-24 months replaced by that time with bone.

📠 Phone: +91 80 2502 3257
📩 E-mail: [email protected]
🖥️ Website: www.drraghurajhegde.com

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

He’s white eyed, but there’s a fracture!

Managing Orbital fractures in kids are challenging stuff. Sometimes diagnosing a fracture in children can get just as challenging. Like the white eyed orbital blowout fracture (WeBoF) case above.

With no external signs to to go by and the child not able to verbalise symptoms, we often have to depend on the perceptive parents to realise something is wrong and get them to the hospital.

WeBoF is caused by direct trauma to eyeball causing increase in intra orbital pressure, causing a crack in the orbital (eye socket) floor which then entraps the inferior re**us muscle (muscle for eye movement)- Causing restriction in upward movement of the affected eye
Swipe ➡️ to see the CT scan showing the entrapment of the inferior re**us in the fracture.

As you can see from the post operative photos we have a happy child at the end of it.

📠 Phone: +91 80 2502 3257
📩 E-mail: [email protected]
🖥️ Website: www.drraghurajhegde.com

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

Just back from Oculoplastics Association of India Annual Conference . It was great fun catching up with friends, colleagues & mentors. Also managed to do a bit of teaching what little I know to the new and upcoming oculoplastic surgeons. The workshops in orbital plating & navigation guided surgery were a hit!

Glad to be part of this Orbito-Facial Trauma Meeting and Plating Workshop as expert faculty. This focussed meeting is at Dr. Shroff’s Charity Eye Hospital, New Delhi on 16th & 17th September, 2023.

Special Interest meetings are very important for new surgeons in practice to learn about the latest in management protocols and new technologies.

There is still time to register for the meeting and hands on workshop. Slots for the workshop are limited and are apparently filling up fast.

This nearly 1 year old infant presented to me with swelling in the right lower lid which became bigger in size when the child was crying or during viral illness like common cold. Clinically the lesion appeared like a Veno-lymphatic malformation (VLM). Sure enough on MRI imaging (Swipe ➡️ to see, the lesion turned out to be a well defined slow filling vascular malformation. Unfortunately, dynamic and post contrast sequences was not done in the child, so it was not possible to zone in the accurate diagnosis. However, one thing was sure that if it was indeed a VLM, it was slow filling and microcystic. Sclerotherapy in micro-cystic VLMs have sub-optimal outcomes compared to macrocystic ones. The child was advised surgery as first option as it was relatively well defined lesion and it was possible to excise it in toto. The parents were also offerred sclerotherapy in case they didn't want to go ahead with surgery. After a couple of months of thinking over the options the parents decided to go ahead with the surgery.

Swipe ➡️ to see the surgery collage: Excision was done using a small sub-ciliary incision, exposing the tumour layer by layer to finally exposing the bright red tumour which was eased out of the orbit using blunt dissection. Our ocular pathologist .mk had the final say in the diagnosis- a mixed harmartoma with capillary dominance. So parts of the tumour was VLM and parts of it were other types of vascular malformations.

After surgery, the child made an uneventful recovery and if one sees the after surgery photo (swipe ⬅️back to the first photo) you wouldn't notice the small incision that we used to excise the tumour nor can we see any residual mass pushing the right lower lid. It's like this problem didn't ever exist!

⏲Surgery time: 1 hour
💉Anaesthesia: usually under general anaesthesia especially in children
🗓️Downtime: 2-3 weeks
📈Duration of effect: Long term
📠 Phone: +91 80 2502 3257
📩 E-mail: [email protected]
🖥️ Website: www.drraghurajhegde.com
©All patient photos are being used with the express consent of the patient. These cannot be shared or reproduced elsewhere.

This 75yr old was an avid 🚴‍♀️ , swimmer 🏊‍♀️ and Yoga 🧘 practitioner. He has been severely restricted from regular activities due to his bilateral ptosis. He was suffering from CPEO. It is a genetic condition that affects patients mainly in the second half of their lives. His two elder brothers too suffered ptosis without getting it corrected and passed on without relief.

Surgical correction of Neurogenic Ptosis like in CPEO is challenging as conventional methods cannot tackle this condition with safely as both opening and closure of eyelids is compromised.

However, this gentleman proved to be luckier than his elder brothers. When he approached me, I told him about the technique I was experimenting with which was having acceptable results- Tarsal Switch technique for correction of severe myogenic ptosis. I agreed to go ahead despite explaining that there might be chances it may not work in everyone who has CPEO. He told me, “he had nothing to lose, even if I have a 50% chance I’ll accept it”.

Post surgery, the surgery was a success-as can be seen by the photo collage above. We were able to achieve clearance of the central visual field. The patient is thrilled at the results and is back to his previous quite active lifestyle 🧘🚴‍♀️🏊‍♂️.

My experience over the past 2 years with this technique has been gratifying and have made some modifications to the techniques described in the literature. I’m surprised why this techique is not being offered more frequently.

⏲Surgery time: 45mins per side
💉Anaesthesia: Done under Local with or without sedation
🗓️Downtime: 3-4 weeks
📈Duration of effect: Long term
📠 Phone: +91 80 2502 3257
📩 E-mail: [email protected]
🖥️ Website: www.drraghurajhegde.com

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

The best part about attending an international sub-specialty conference is the exchanging of notes with colleagues across the world and sometimes long after the conference is over! This mail brought a smile to my face today!

My Workstation!

This is my workstation at my hospital. Right from reading CT/MRI images from the hospital PACS system to designing and approving Patient Specific Implants (PSI) lot of back end work goes on long after seeing the patient at the clinic. This includes planning for the surgery looking at the radiological scans and sometimes having to design patient specific implants before the patient is on the table. We today have a lot of tech that supports us in getting the best outcomes for our patients. So a surgeon’s table sometimes resembles a coder’s table!

Speaking at this Twitter Space tomorrow. Tune in at 5.30pm on Twitter space. Link in comments.

Excited to have on the same panel. Looking forward.

Which eye is it?

Can you guess which side this patient suffered trauma?

When this patient turned up at our emergency room several months ago, one side of the face was a mess from the road traffic accident he had just suffered. In fact upper and lower eyelids on that side was un-recognisable with multiple lacerations including ripping off of the both canaliculi and detachment of the levator muscle (which opens the eyelid).

Swipe ➡️ to find out which eye was affected and also the pre and post surgery pictures

Swipe ➡️ once more to see the steps of the repair.

The eyelids were meticulously repaired like a jigsaw puzzle and since both canaliculi were lacerated, a Dacryocystorhinostomy with bicanalicular intubation was performed primarily.

The end result of good post- operative scar care is an excellent outcome where you would struggle to guess if he actually had an accident.

For trauma related queries, you can call up our emergency number : +91 99455 26889 which is active 24/7

For non-emergent appointments:
📠 Phone: +91 80 2502 3257
📩 E-mail:[email protected]
🖥️ Website: www.drraghurajhegde.com

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

Delighted to see our Chapter on Orbital Interventions in Rhino-Orbit-Cerebral Mucormycosis in the textbook Invasive Skull Base Mucormycosis -New Perspectives.

We’ve included all the new perspectives we learnt and the latest studies resulting from the unprecedented Covid-19 Associated Mucormycosis (CAM) epidemic in 2021 including the natural history of this dreaded disease.

Kudos to my partner in crime Dr. Akshay Nair (.akshaynair.eyeplastics )for co-writing this chapter with me.

A big thank you to the editors in chief Dr. Sampath Chandra Prasad Rao ( )& Dr. Janakiraman for the opportunity to contribute to this massive undertaking.

I was in the audience listening to the keynote address by the guest speaker Infectious Diseases Specialist, Dr. Ayesha Sunavala. Was pleasantly surprised and honoured to see her quote my paper in one of her slides.

So glad I ended up finishing this paper in no small part because my mentor who is the co-author was pushing me to get it done.

Always a reminder that one’s work lives on beyond us if it’s part of the literature.

Just back from Mumbai where EyeWitness 2022 -the annual meeting of OculoPlastics Association of India (OPAI). My talk on Trans-Orbital Neuro-Endoscopic Surgery (TONES) was well received. I got so many questions &queries even from international faculty that it made my day.

#2022

Old Trauma can make your eyes tear!😢

This patient had a trauma to the right side of the nose years ago damaging a small little passage called “Naso-lacrimal duct”. This duct drains the tear fluid of the eyes into the nose. When the formerly partial block of this duct became a full block, the tears started collecting in the lacrimal sac above the duct and got infected apart from causing tearing (epiphora) in the right eye.

She presented with acute dacryocystitis- secondary infection of the lacrimal sac-which progressed to abscess formation as seen in the picture (Before Surgery). After treating the acute infection with drainage of the muco-purulent contents of the sac and systemic antibiotics she was taken up for definitive surgery- Dacryocystorhinostomy. This is a lacrimal sac bypass surgery where an anastomosis is created between the lacrimal sac & Nasal mucosa so that drainage of tears happens into the middle meatus of the nose.

There two equally good approaches to this surgery- endoscopic & external. We chose the external approach here as there was a pre-existing scar on the nose. As can be seen the post operative result is aesthetically good and presently even the old scar is well hidden.

✂️ Surgery : External Dacryocystorhinostomy
⏲Surgery time: 45 mins
💉Anaesthesia: Done under Local
🗓️Downtime: 2 weeks
📈Duration of effect: Long term
📠 Phone: +91 80 2502 3257
📩 E-mail:[email protected]
🖥️ Website: www.drraghurajhegde.com

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

Have not been posting here lately since my wife and I were on a holiday to the west coast of US.

Most people visit Los Angeles for Hollywood and a chance meeting with celebrities. We did do Hollywood but next to it is Jules Stein Eye Institute where the celebrities in my field work or worked. I did manage to catch a few celebrity stars- Pallavi and Dan in between their very busy OT schedule.

Wish I could have spent more time in the beautiful UCLA campus and in the star studded oculoplastics department.

Was impressed to learn Jules Stein was an Ophthalmologist who retired from medicine to found a music industry in LA. His persona fitting in well with the pioneering surgeons in the institute that bear his name.

Fresh off the press!

This mega collaboration is finally published! This ICMR-NIE helmed case-control study involving 20 major institutes which were firefighting the epidemic of Mucormycosis within the COVID-19 pandemic.

I’m privileged to be part of this landmark paper which shines light on the part of puzzle that COVID-19 Associated Mucormycosis (CAM) was!

I’ll be in a different role in this conference. I’ll be representing describing it’s work around the globe at Singapore Odisha Ophthalmic Meet (SOOM) 2022. Never thought I will be speaking in a community Ophthalmology Session.

SOOM 2022 is being organised by -formerly an annual event is back again after a gap of 3 years.

#2022

Nice to get back to in person conferences with a room full of real people.

Spoke about Orbital Trauma in the BOS SUMMIT 2022!

It was great to meet colleagues and old friends after gap of nearly 3 years.

#2022

Dial Eyelid Surgeon for Ptosis!

Droopy Eyelid Surgery or Ptosis correction surgery is more art than science. More so when it is a congenital Ptosis as in this case of a 5 yr old girl. In the above picture, you can see the before and after surgery picture of left upper eyelid Ptosis Correction Surgery. She can now go to school next year confident and without anyone outside family knowing any surgery was done.

I first diagnosed her when she was 2 yrs old after an unpleasant experience of being over-tested to rule out myasthenia gravis. An early consult with an oculoplastic surgeon would have made the diagnosis of "left upper eyelid congenital ptosis" faster and with less friction. Since it was a mild grade ptosis not covering the visual axis of the left eye, Ptosis correction surgery was deferred to when the child was older. The timing is important in congenital ptosis when the child's eyes & eyelids have sufficiently grown and before the child starts school to prevent other kids pointing out the droopy eyelids (Kids can be cruel!).

Oculoplastic surgeons are able to get the best outcomes for Ptosis correction surgery since they are best skilled to correct this condition with micro-surgery when compared to general plastic surgeons who also sometimes offer to operate this.
If you or someone you know have a child suffering from this easily correctable condition, consult your nearest Oculoplastic Surgeon.

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

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

Today was an interesting day. Hospital was celebrating doctor’s day and the mood was festive with everyone from non-doctor staff to our patients wishing us their best. Got lots of chocolates from hospital and patients. Felt like I was back to children’s day in school.

Happy Doctors Day to all my physician colleagues and friends. I think we earned this one fair and square! 😁

This sweet 84yr old lady came to us with a painful blind left eye. We advised eye removal (evisceration) with orbital implant followed by customized ocular prosthesis. She had been resisting this surgery the past 5 years when the blind eye of 20yrs started becoming painful. We finally managed to convince her for the surgery and went ahead with the surgery. Our talented ocularist put in incredible work in making the customised prosthesis for her post surgery.

After the prosthesis fitting, when I showed the lady and her daughter the pre-operative photos, the daughter broke down in tears and told me "You've given back my mother after 20yrs".

Small things we do for our patients mean so much for them personally. ❤️

A ocular prosthesis (prosthetic eye) 👁️ surgery is considered when we have to remove an 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- performed by an surgeon. The surgery involves (eyeball being removed)/ (the contents of the eyeball removed retaining the outer white scleral shell) and globe volume is then replaced with an appropriately sized .
Stage 2- After the eye socket heals which takes about 6 weeks, an (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.

For details of this surgery and for appointments
⏲Surgery time: 45 mins
💉Anaesthesia: Done under Local/Sedation
🗓️Downtime: 6 weeks
📈Duration of effect: Long term
📠 Phone: +91 80 2502 3257
📩 E-mail:[email protected]
🖥️ Website: www.drraghurajhegde.com

Enrol for this fantastic course for surgeons to learn about - Trans-Orbital Neuro-Endoscopic Surgery. TONES will be a sub-module in the larger two day skull base cadaver dissection workshop. The course is being conducted in the state of the art anatomy lab with wet cadavers.

Honoured to be faculty for the TONES module.

Will be part of this panel discussion on . This is a new discussion format for me but seems exciting.

Looking forward to learn more from interacting with the stalwarts around the world.

Tune in to on Twitter at 830pm IST tonight.

In these gloomy times, something to pick us up. Treating kids is a special kind of joy.