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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. Email address: [email protected] 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. Email address: [email protected] 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. Email address: [email protected] 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. Email address: [email protected] Email address: [email protected] 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. Email address: [email protected] 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. Email address: [email protected] 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. Email address: [email protected] 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.