Thyroid Eye Disease – A New Look
Eye Surgery Centre at the NUH Medical Centre
03-04 Medical Spotlight • 05-13 Insight • 14-15 Treatment Room • 16-17 Doctor’s Heartbeat • 18-19 Medical Notes
Advances in Cataract Surgery
Medical Sp tlight
A/Prof Clement TanDepartment of Opthalmology
MédicoA quarterly publication of GP Liaison Centre, National University Hospital, Singapore. MCI(P) 151/07/2014
October to December 2014
About GPLCAt the National University Hospital (NUH), we recognise the pivotal role general practitioners (GPs) and family physicians play in providing and ensuring that the general public healthcare is of the highest quality and standard. As such, we believe that through closer partnerships, we can deliver more personalised, comprehensive, and efficient medical care for our mutual patients. The General Practitioner Liaison Centre (GPLC) aims to build rapport and facilitate collaboration among GPs, family physicians and our specialists. As a central coordinating point, we provide assistance in areas such as patient referrals, continuing medical education (CME) training, and general enquiries about our hospital's services.
Through building these important platforms of shared care and communication, we hope that our patients will be the greatest beneficiaries.
If we could be of any assistance to you, please feel free to contact our office from Mon - Fri : 0900-1200hrs, 1400-1800hrs at:
GP HotlineTel: +65 6772 2000Fax: +65 6777 8065
NUH Continuing Medical Education (CME) Events
At NUH, we strive to advance health by integrating excellent clinical care, research and education. As part of our mission, we are committed to provide regular Continuing Medical Education (CME) events for GPs and family physicians. These events aim to provide the latest and relevant clinical updates practical for your patient care.
Organised jointly by the GP Liaison Centre (GPLC) and the various departments, our specialists will present different topics in their own areas of specialties in these symposiums, which are held monthly.
For more information on our CME events, you can go to www.nuhcme.com.sg or scan the following QR code.
GP Appointment Hotline: +65 6772 2000
GPLCNUH GP Liaison Centre
2 • MEDICO OCT OBER - DECEMBER 2014
Dr Vivien LimAssociate Consultant,Department of Ophthalmology
Dr Vivien Lim is an Associate Consultant with the Department of Ophthalmology, National University Hospital. Dr Vivien Lim completed her medical training with the Faculty of Medicine, National University of Singapore (NUS) in 2004.
During her residency years in Ophthalmology from 2006 to 2012, Dr Lim has held various administrative appointments, including Chief Registrar in the Department of Ophthalmology, National University Hospital (NUH) from 2010 to 2011.
Dr Lim became a Member of the Royal College of Surgeons of Edinburgh and was awarded the Master of Medicine (Ophthalmology) by NUS in 2009. Upon completion of her residency in 2012, Dr Lim became a Fellow of the Academy of Medicine, Singapore (FAMS). Her practice interests include general ophthalmology, adult cataract surgery and refractive (LASIK/ Implantable Contact Lens) surgery.
Dr Lim has published scientific papers in respected peer-reviewed medical journals, and presented at numerous international and local conferences. Her research interests are in cataract and refractive surgery. She is active in teaching medical students and ophthalmology residents, and is a faculty member at the Yong Loo Lin School of Medicine, NUS.
Email: [email protected]
M EDIC AL S PO TL IGHT
Advances in Cataract Surgery
Traditional cataract surgery is one of the most frequently performed surgeries and considered as one of the safest and most effective procedures with predictable outcomes. Cataract surgery is estimated to be performed 19 million times annually. The World Health Organisation estimates this number will increase to 32 million by the year 2020.1,2 Femtosecond laser technology, introduced clinically for ophthalmic surgery in 2001 as a new technique for creating lamellar flaps in laser in situ keratomileusis (LASIK), has recently been developed into a tool for cataract surgery. At the National University Hospital (NUH), we obtained the CATALYST Femtosecond Laser Machine in 2012.
In traditional cataract surgery, the eye surgeon uses a hand-held metal or diamond blade to create an incision in the area where the sclera meets the cornea. The goal in creating this incision is to go a partial depth vertically, then go horizontally in the cornea about 2.5mm and then enter into the eye. The surgeon can then break-up and remove the cataract, which is located right behind the pupil. Next, an intraocular lens (IOL) is inserted and implanted, to replace the cloudy natural lens.
With the laser approach to cataract surgery, the surgeon creates a precise surgical plan with a sophisticated 3-D image of the eye called an OCT (Optical Coherence Tomography). Real time “live” OCT imaging function of the laser platform tracks progress of the procedure and gives real time feedback of eye images to the surgeon during the entire surgical process, providing an added level of safety to the patients.
The corneal incisionThe Femtosecond laser creates a corneal incision that is of an exact length and depth. This is important not only for accuracy, but also for increasing the likelihood that the incision will be self-sealing at the end of the procedure, which reduces the risk of infection. The capsulotomyThe eye’s natural lens is surrounded by a capsule that is very thin and very clear. In cataract surgery, the front portion of the capsule is removed in a step called the capsulotomy to gain access to the cataract. It is important that this capsule is not damaged during the cataract surgery because it must hold the artificial lens implant in place for the rest of the patient’s life.
In traditional cataract surgery, the surgeon creates the capsulotomy by using forceps to tear the capsule in a circular fashion. The laser machine is able to create a well-centred opening that is of a specific size. This allows for highly accurate positioning and centration of the artificial intraocular lens, reducing optical aberrations and refractive errors.
Removal of the cataractIn the traditional technique, after the capsulotomy, the surgeon uses the ultrasound machine to break-up and remove the cataract. Lens fragmentation by laser reduces the amount of ultrasound energy used during phacoemulsification, reducing risk of capsule complications and corneal injury.
Studies3 have shown that there is 99% reduction in ultrasound energy for cataracts of different grading, 25% less cornea edema, 47% less endothelial cell loss, and 19% less inflammation post-op. Femtosecond laser-assisted cataract surgery represents a paradigm shift in cataract surgery. Studies so far suggest that the use of the femtosecond laser precision will deliver superior outcomes, an improved safety profile for patients and thus pave the way for further advances in the field.
Types of intraocular lens availableArtificial intraocular lenses (IOLs) replace the eye’s natural lenses that are removed during cataract surgery. IOLs have been around since the mid-1960s, though the first FDA approval occurred in 1981. Before that, if you had cataracts removed, you had to wear very thick eyeglasses in order to see afterward since the natural lenses that had been removed were not replaced with artificial ones.
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Traditionally, a monofocal IOL is used. Cataract surgery with implantation of a traditional monofocal IOL, targeting distance vision, leaves most individuals dependent on some correction, usually spectacles, for near vision.
Having to frequently take reading glasses on and off is inconvenient for many people. With today’s advanced lens procedures, patients now have a choice in the type of lens that is implanted during cataract or clear lens extraction surgery. Unlike conventional “single vision” (monofocal) intraocular lenses (IOLs), multifocal IOLs are lens implants that are designed to help patients see at varying distances using different points of focus. The goal of a multifocal IOL is to provide functional vision at different distances to minimise the use of glasses. Although they might still prefer to wear glasses for prolonged reading, the vast majority of multifocal IOL patients experience freedom from glasses for tasks such as driving, watching TV, using their cell phone and computer, looking at photos, reading magazines, price tags, product labels, receipts, and menus. There are different manufacturers who make these lenses, such as AMO, Carl Zeiss and Alcon. The price differs, depending on the company and on the type of lens, with the most complicated being the most expensive.
How does a multifocal IOL work?With bifocal glasses, you look through the top part of the lens for distance and through the bottom area of the lens for near. A multifocal IOL, designed using advanced technology called diffractive and refractive optics, is entirely different, providing both a distance and near focus at all times. The brain will learn to automatically select the focus that is appropriate for the task at hand. There is a learning curve for using this new, advanced optical design. For example, patients often will have to learn the optimal distance for holding reading material as it will likely differ from what the patient was used to before surgery.
Depending on pupil size, the multifocal IOL patient may experience some halos, or rings around lights at night. These halos are different from and less problematic than those typically caused by cataracts. Fortunately, these halos become less noticeable and distracting over time as the brain learns to selectively ignore them through a process called neuroadaptation. This is the same process that allows us to ignore background noise such as traffic sounds or an air-conditioning fan. How quickly these adjustments are made by the brain varies for different individuals. Experience has shown that neuroadaptation is a gradual process that occurs over several months. Compared to their predecessors, the current generation multifocal IOLs have been engineered to significantly reduce the halo effect.
Multifocal toric lensesMultifocal toric lenses have the ability to correct astigmatic as well myopic or hyperopic refractive errors. This is a major advance as many patients who had astigmatism were previously unable to benefit from multifocal lens implantation because astigmatism will compromise the quality of vision that can be achieved in multifocal lenses.
Figure 1. Femtosecond laser Machine (Catalyst)
1) Trikha S, Turnbull AM, Morris RJ, Anderson DF, Hossain P. The journey to femtosecond laser-assisted cataract surgery: newbeginnings or false dawn? Eye 2013; 27:461–473
2) Brian G, Taylor H. Cataract blindness – challenges for the 21st century. Bull World Health Org 2001; 79:249–256.
3) Conrad-Hengerer et al, JCRS 2012; 38(11): 1888-94. Conrad-Hengerer et al, J Refract Surg 2012; 28(12):879-83
4) UCLA refractive centre www.uclaser.com
5) www.allaboutvision.com/conditions/laser-cataract-surgery.htmFigure 2. Docking system
Figure 3. Multifocal lens with diffraction rings
4 • MEDICO OCT OBER - DECEMBER 2014
I n s I g h t
Dr Ray ManotoshConsultant,Department of Ophthalmology
Dr Ray Manotosh is a Consultant with the Department of Ophthalmology, National University Hospital (NUH). He treats patients with eye conditions since 1997. His clinical interests are in general ophthalmology, and cornea and external eye diseases, including different forms of corneal and ophthalmic transplantations. Before coming to Singapore, Dr Ray completed his undergraduate training at the University of Calcutta in India. He underwent basic surgical training in Ophthalmology at the prestigious All India Institute of Medical Sciences (AIIMS) in New Delhi, India and his Doctor of Medicine in Ophthalmology in 1997. Subsequently, Dr Ray continued his advanced surgical training in the field of Cornea and External Diseases at AIIMS. In 1998, he became a Fellow in Ophthalmology from Royal College of Surgeons of Edinburgh, United Kingdom. With a passion in teaching, Dr Ray has contributed to clinical teaching in many different ways. He is not only an Assistant Professor and Undergraduate Education Director at the Department of Ophthalmology at the Yong Loo Lin School of Medicine, National University of Singapore (NUS), but he has also been very active in basic and advanced surgical training. In 2006, Dr Ray won the National Healthcare Group Excellence Award for Teaching. Active in research, Dr Ray Manotosh has published 25 research articles in various international journals and also contributed at least 14 chapters in books of Ophthalmology. His research interests include the cornea, ocular surface and anterior segment.
Email: [email protected]
Allergic conjunctival disease is defined as conjunctival inflammatory disease that is associated with some subjective and objective symptoms. This is essentially a Type I allergy when patient’s immune system overreacts to an allergen to which it has become sensitive. It is often a part of a larger systemic atopic condition and is usually associated with conjunctival injection, severe itching, lacrimation, photophobia and occasional visual loss in severe cases.
Allergic conjunctivitis may be divided into 5 major subcategories.
1. Acute allergic conjunctivitis • Seasonal allergic conjunctivitis • Perennial allergic conjunctivitis
2. Vernal keratoconjuctivitis 3. Atopic keratoconjunctivitis 4. Giant papillary conjunctivitis
Acute allergic conjunctivitis describes the abrupt and immediate response seen in sensitised individuals after exposure to a particular allergen or sensitising agent. This is a short-term condition that is more common during allergy seasons. There are two forms of acute allergic conjunctivitis: seasonal allergic conjunctivitis, which coincides with pollen blooms, and perennial allergic conjunctivitis, in which exposure may occur at any time throughout the year.
Seasonal allergic conjunctivitis (SAC)SAC is the most common type of ocular allergy. As the name suggests, this type of allergy is related to specific pollens that release spores in some specific seasons. Individuals with SAC typically have symptoms of acute allergic conjunctivitis, usually in spring when the predominant airborne allergen is plant pollens. Typically, the individuals with SAC are symptom-free in winter months because of decreased airborne transmission of these allergens (Figure 1).
Perennial allergic conjunctivitis (PAC)Perennial allergic conjunctivitis, in contrast, is a mild, chronic allergic conjunctivitis related to year-round environmental, mainly indoor, allergens
such as dust mite, animal dander and molds. Symptoms are similar to SAC but tend to be milder (Figure 2).
Vernal keratoconjunctivitis (VKC)VKC is a chronic bilateral inflammation of conjunctiva commonly associated with a history of atopy. It is characterised by conjunctival proliferative changes such as papillary hyperplasia of palpebral conjunctiva (Figure 3a) and or limbal gelatinous hyperplasia (Figure 3b). Majority of patients with VKC exhibit one or more atopic conditions such as eczema, asthma or allergic rhinitis. Various corneal lesions such as superficial punctate keratitis, shield ulcers and corneal plaque are commonly associated with VKC.
Atopic keratoconjunctivitis (AKC)AKC is a chronic inflammatory disease of the eye that occurs predominately between the late teenage years and the fifth decade of life. It is a chronic, bilateral disease that relapses and remits with no seasonal correlation. Atopic dermatitis is present in majority of cases. Periocular eczema is also almost always present and is one of the hallmark signs. In addition, various lid manifestations such as hypertrophy, crusting, cicatrising ectropion, and madarosis are common (Figure 4).
Palpebral conjunctivitis is characterised by micropapillae of the tarsal conjunctiva – primarily of the lower eyelid. Symblepharon, an adhesion of the palpebral conjunctiva to the bulbar conjunctiva, is not uncommon. Corneal neovascularisation related to stem cell deficiency occurs in approximately 60%
Allergic Conjunctivitis: Current Concept and
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of cases. Corneal ulcers and erosions are more common due to the poor epithelial adhesion and predispose to infectious keratitis, which can permanently scar the corneal stroma and occasionally may lead to corneal perforation.
Giant papillary conjunctivitis (GPC)GPC is an immune-mediated inflammatory disorder of the superior tarsal conjunctiva. As the name suggests, the primary sign is the presence of large papillae, which are typically greater than 0.3 mm in diameter (Figure 5). Proliferative changes in the upper palpebral conjunctiva are induced by mechanical irritation such as contact lenses, surgical sutures, extruded scleral buckle and ocular prosthesis. Clinically, GPC differs from VKC by absence of corneal involvement.
Clinical symptoms and signsThe allergic response classically involves several signs and symptoms, all of which may vary in intensity. Ocular itching remains the hallmark symptom; tearing is also an exceedingly common complaint, particularly after rubbing the eyes in response to itching. More severe reactions may prompt symptoms of ocular burning, foreign-body sensation or photophobia, although these are relatively rare. Clinical evaluation reveals variable conjunctival hyperemia and chemosis. Ocular discharge is watery, though mucus may accumulate in the fornices or collect on the lash margin in the form of “crusts”, especially during sleep. Eversion of the eyelids may reveal a fine papillary response, particularly along the upper tarsal plate. Externally, the eyelids may be red, swollen and edematous, with a pseudoptosis in pronounced cases. If questioned, the patient will often reveal a personal or family history of allergies. Concurrent symptoms of allergic rhinitis, post-nasal drip, or sinus congestion may be present, especially in SAC.
In addition, there are clinical signs related to the specific forms of allergic conjunctivitis as briefly mentioned above. Giant papillae, limbal proliferation (Horner-Trantas dot) and shield ulcer are highly specific of VKC. In contrast, giant
papillae sans corneal involvement are typical of GPC. AKC may affect eyelid skin and lid margin, conjunctiva, cornea, and lens. Skin of the eyelids may exhibit eczematous dermatitis with dry, scaly, and inflamed skin and the lid margins may show meibomian gland dysfunction and keratinisation. Conjunctiva may show chemosis and typically a papillary reaction, which is more prominent in the inferior tarsal conjunctiva, in contrast to that seen in vernal keratoconjunctivitis. Long-term chronic inflammation may result in fornix foreshortening, symblepharon and non-healing corneal epithelial defect. Premature cataract is a common association of AKC due to steroid dependency.
PathophysiologyThe allergic response is an overreaction of the body’s immune system to foreign substances known as immunogens or allergens. The response can be innate or acquired. The ocular allergic response is a cascade of events that is coordinated by mast cells. Beta chemokines such as eotaxin and MIP-1 alpha have been implicated in the priming and activation of mast cells in the ocular surface. When histamine is released from mast cells, it binds to H1 receptors on nerve endings and causes the ocular symptom of itching. Mast cell intermediaries cause an allergic inflammation and symptoms through the activation of inflammatory cells.
TreatmentAvoidance of the offending antigen, if known, is the primary behavioral modification recommended for all types of allergic conjunctivitis. In other respects, management of allergic conjunctivitis varies according to the specific subtypes.
• Avoid exposure to known allergens, if possible. • It is not advisable to wear contact
lenses (for CL users) until the allergic symptoms are relieved. Patient must abstain from wearing contact lenses from a few weeks to months if there is severe contact lens induced GPC.
• Try not to rub the eyes as this can cause inflammation.
• Frequent cold compress and usage of artificial tears may help to reduce allergic eye symptoms.
Seasonal and perennial allergic conjunctivitisTreatment may not be necessary in mild and self-limiting cases. However, pharmacologic interventions may be necessary to help alleviate the symptoms in more severe and symptomatic cases. Artificial tears help to dilute various allergens and inflammatory mediators that may be present on the ocular surface and help flush the ocular surface off these agents. Mast cell stabilisers such as sodium cromoglycate do not relieve existing symptoms immediately and are to be used on a prophylactic basis to prevent mast cell degranulation with subsequent exposure to the allergen. Therefore, they need to be used long term. Topical antihistamines may be prescribed to relieve acute symptoms. More potent treatments like steroid or immunosuppressant eye drops is rarely required in SAC and PAC.
Vernal keratoconjunctivitisThose with milder symptoms and no corneal involvement may be given mast cell stabilisers such as sodium cromoglycate or newer agents such as alomide. Topical antihistamines are effective as well. The mast cell stabilisers must be used regularly three to four times daily, even when there are no symptoms in order to stabilise the mast cells and prevent the release of histamine. They are of no value when used only when symptoms occur because their effect is not immediate. If well used, they can limit or stop the use of steroid drops. They do not have any of the side effects of steroids and can therefore be used for a prolonged period.
Those with more severe disease and presenting with corneal involvement should be managed at secondary and tertiary level where they may be treated
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with topical steroids (e.g. prednisolone, dexamethasone), the most effective available topical medication for severe vernal keratoconjunctivitis. Steroids should be used frequently initially and then tapered to a stop once the acute stage of the disease is stabilised (usually after a few weeks). A mast cell stabiliser should be started concurrently with topical steroids as their use requires monitoring because of the possible side effects including raised intraocular pressure. Topical cyclosporine (0.05%) may be tried as an alternative treatment option for steroid dependent cases without much adverse effects. Treatment of corneal shield ulcer may require antibiotic-steroid ointments.
Those who are not responding to conventional treatment may be managed by supratarsal injection of steroids. Both long-acting steroids such as triamcinolone and shorter-acting steroids (dexamethasone) have been found to be effective in bringing about resolution of the eye signs. Some studies suggest that the recurrence rate of the disease is lower following the use of longer-acting steroids like triamcinolone. These patients have to be monitored at a regular basis as theoretically, there is an increased risk of persistent elevation of intraocular
pressure with the long acting steroids. Severe cases of corneal shield ulcer may require superficial keratectomy to promote epithelial regeneration.
Atopic keratoconjunctivitisManagement of AKC, similar to that for VKC, consists of avoiding environmental allergens, and is aimed at decreasing the inflammatory response to alleviate symptoms. The majority of cases are co-managed with an allergist or dermatologist to provide guidance and follow-up of systemic therapy. In early disease, conservative management with combination topical mast cell stabilisers and anti-histamine drops, lubricants, cold compresses, and oral anti-histamines may keep the ocular disease under control. Systemic antihistamines have been found to be helpful. However, in more advanced cases, additional pharmacologic therapy is necessary. Pharmacologic therapy for these cases includes topical corticosteroid drops, cyclosporine drops, or tacrolimus ointment to the eyelid skin. When topical treatments fail to induce remission, systemic immunosuppressive such as oral prednisone, tacrolimus, or cyclosporine are the next treatment options. These are also useful for dermatologic manifestations of the
disease. Systemic cyclosporine, which has been shown to be effective in the treatment of atopic dermatitis, has also shown promise in controlling ocular inflammation in AKC. In the final stages of atopic keratoconjunctivitis where visual loss has occurred due to corneal opacification from stem cell deficiency, various keratoprosthesis may be used for visual rehabilitation with limited success in motivated patients.
Giant papillary conjunctivitisIf the underlying cause of the GPC is a foreign body such as a suture, prosthesis or exposed scleral buckle, removing the foreign bodies will often improve the symptoms. GPC due to contact lens use often requires changing the contact lens routine and reducing the wearing time to just a few hours a day. Switching to daily disposable lenses is helpful for more persistent cases of GPC. Rigid gas-permeable contact lenses may provide further relief from symptoms if disposable lenses do not provide adequate response. In more severe cases that do not respond to these measures, it may be necessary to stop wearing the contact lenses for a time. Pharmacologic treatment of GPC includes the use of mast cell stabilisers, topical corticosteroids, and antihistamines, in a manner similar to that of other forms of allergic conjunctivitis.
Figure 1. Seasonal allergic conjunctivitis Figure 2. Perennial allergic conjunctivitis Figure 3a. Vernal keratoconjunctvitis (palpebral type)
Figure 3b. Vernal keratoconjunctvitis (limbal type) Figure 4. Atopic keratoconjunctivitis Figure 5. Giant papillary conjunctivitis
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So, what is good about orbital fractures?
The bony orbits and paranasal sinuses are nature’s shock absorbers. If not for fractures of the orbit and the midface, the vital structures i.e., brain and globe, would suffer far more coup and contre-coup injuries and possible ruptures of the globe as well from blunt trauma. Despite the protection offered, in all such injuries, underlying brain and globe injury should be ruled and managed appropriately before managing the orbital fracture.
Orbital fractures are classified into either ‘blowout fractures’ (where the orbital rims are intact) (Figure 1) and complex
Figure 1. Blowout fracture of left orbital floor
Figure 2a. Zygomatico-maxillary complex fracture
Figure 2b. Naso-orbital ethmoidal fracture
Figure 2c. Le Fort III fracture
Dr Gangadhara SundarHead and Senior Consultant,Orbit and Oculofacial Surgery,Department of Ophthalmology
Dr Gangadhara Sundar is the Head and Senior Consultant of the Orbit & Oculofacial Surgery at the Department of Ophthalmology, National University Hospital (NUH), Singapore. Dr Sundar is also certified by the American Board of Ophthalmology. Dr Sundar graduated from Madras Medical College in Chennai, India. He obtained his residency training in Ophthalmology and a 2-year fellowship in Ophthalmic Plastic and Reconstructive Surgery from Henry Ford Hospital in Detroit, Michigan, United States.
His areas of training and expertise include diseases and surgery of the eyelid, tear duct system and orbit. His special interests include retinoblastoma, eyelid, lacrimal and orbital tumors, complex orbit and oculofacial fractures and deformities, as well as thyroid eye disease (Graves Orbitopathy). Aesthetic procedures performed include blepharoplasty, brow lift and midface lift. Techniques incorporated in his practice include minimally invasive surgery, computer assisted navigational surgery of the orbitofacial skeleton and balloon dacryoplasty. Active in furthering the cause of the subspecialty nationally, regionally and globally, Dr Gangadhara Sundar is actively involved in undergraduate and postgraduate education in Singapore and the region. He has trained several fellows from India, Singapore and around the world. He has been a Visiting Professor to several universities and hospitals globally including the Henry Ford Hospital in Detroit, United States and Universiti Sains Malaysia in Kelantan, Malaysia.
Email: [email protected]
I n s I g h t
Are fractures good or bad? Is there a downside to ‘active’ living? Did you think that the answer is straightforward and easy?
Orbital fractures are one of the most common forms of ophthalmic trauma seen by the Department of Ophthalmology at NUH. The causes of the condition that is as common in the young as the elderly, however, are varied. In children and young adults, the most common causes are sports related activities. In the elderly,
trips and falls either at home or outdoors are among the most common causes. The spectrum of sports and activities associated with orbital fractures include rugby, softball, ultimate Frisbee, silat, bicycling and jogging. For the rest, violence and occupational/industrial accidents are also quite common.
While minimally displaced fractures without extraocular muscle dysfunction can be observed, on the contrary, significantly displaced orbital walls and/or entrapment of one or more extraocular muscles are the most common indication for surgical intervention.
Orbital Fractures – Recent Advances
8 • MEDICO OCT OBER - DECEMBER 2014
fractures. Spectrum of complex orbital fractures includes the zygomatico-maxillary complex (ZMC) fractures, naso-orbital ethmoidal (NOE) fractures and the Le Fort II and III fractures (Figure 2a, b, c).
Most blowout fractures occur from moderate velocity injuries e.g., a fist punch or a trip and fall. In children and young adults it has significant consequences especially if the displacement of the orbital floor is minimal with entrapment of the inferior rectus muscle or intermuscular septum. If fact, such small trapdoor fractures may be missed by the inexperienced clinician and radiologist. The younger the patient, the earlier the intervention should be administered to prevent late consequences of intractable diplopia. Some of the most recent advances in the management of such fractures include direct transconjunctival scarless surgery and the increasing use of bioresorbable implants in children and adults (Figure 3a, b).
Complex orbital fractures are commonly co-managed with the Facial Plastic Surgery team (Figure 4). Numerous advances in technology and surgical techniques have greatly enhanced the outcomes while minimising the complications. Some of the advances include the increasing use of intraoperative navigation to verify accuracy of fracture localisation and implant placement (Figure 5), use of anatomical prefabricated orbital implants for large fractures involving multiple walls of the orbit (Fig 6a, b), as well as the use of 3-D printing technology to pre-bend orbital implants prior to placement within the orbit and endoscope assisted orbital surgery.
Figure 3a,b. Bioresorbable implant – preoperative and postoperative image showing well healed fracture with resorption of the implant
Figure 4. Combined surgery with Orbital and Facial Plastic Surgery teams
Figure 6 a, b. Pre and post-operative orbital CT scan with ‘preformed pre-bent anatomical’ titanium plates
Figure 5. Intraoperative navigation in orbital surgery
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Dr Gangadhara SundarHead and Senior Consultant, Orbit & Oculofacial Surgery,Department of Ophthalmology
Dr Gangadhara Sundar is the Head and Senior Consultant of the Orbit & Oculofacial Surgery at the Department of Ophthalmology, National University Hospital (NUH), Singapore. Dr Sundar is certified by the American Board of Ophthalmology.
Dr Sundar graduated from Madras Medical College in Chennai, India. He obtained his residency training in Ophthalmology and a 2-year fellowship in Ophthalmic Plastic and Reconstructive Surgery from Henry Ford Hospital in Detroit, Michigan, United States.His areas of training and expertise include diseases and surgery of the eyelid, tear duct system and orbit. His special interests include retinoblastoma, eyelid, lacrimal and orbital tumors, complex orbit and oculofacial fractures and deformities, as well as thyroid eye disease (Graves Orbitopathy). Aesthetic procedures performed include blepharoplasty, brow lift and midface lift. Techniques incorporated in his practice include minimally invasive surgery, computer assisted navigational surgery of the orbitofacial skeleton and balloon dacryoplasty.
Active in furthering the cause of the sub-specialty nationally, regionally and globally, Dr Gangadhara Sundar is actively involved in undergraduate and postgraduate education in Singapore and the region. He has trained several fellows from India, Singapore and around the world. He has been a Visiting Professor to several universities and hospitals globally including the Henry Ford Hospital in Detroit, United States and Universiti Sains Malaysia in Kelantan, Malaysia.
Email: [email protected]
I n s I g h t
Imagine waking up one fine morning to puffy, bulging, teary eyes only to progress to intermittent or permanent double vision, intolerance to the bright sun and inability to completely close the eyes. Worst case scenario, it gradually progresses to loss of vision in one or both eyes, intractable diplopia and corneal exposure with ulceration.
All these are symptoms and signs of a well-known but yet often poorly managed condition called Thyroid Eye Disease. This increasingly recognised and frequently diagnosed entity has not only medical, but economic, social and psychological consequences as well. Numerous advances in the understanding of the pathogenesis of the disease and management have helped us to turn around the condition, at least in most patients, especially if they are treated aggressively in the early stages.
At NUH, the Department of Ophthalmology conducts monthly Multidisciplinary Thyroid Eye Clinics that is run together by the ophthalmologists and
the endocrinologists. Patients thus get the benefits of advice and management for their orbital disease and systemic disease, thereby promoting a better understanding of the disease, increased compliance and better management of the various comorbidities. A close relationship with the immunologists also helps tailor immunological interventions for the refractory patients.
Thyroid Eye Disease – A New Look
Figure 2a. CT-Scan showing compression of optic nerve
Figure 1a. Inactive Moderate Orbitopathy
Figure 1b. Active Inflammatory Severe Disease
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With increased awareness by general practitioners and endocrinologists, thyroid eye disease, previously known as Graves Ophthalmopathy, is one of the most common inflammatory orbitopathy. Although typically seen in young adult females, it affects children as well as well as the middle aged and the elderly. Most patients present to their physicians or ophthalmologists with nonspecific symptoms of pressure sensation, redness, tearing or a ‘tight pressure’ sensation behind the eyes, especially upon waking up in the morning and a recent change in appearance. This has been often reported secondary to a recent stressful ‘trigger factor’. It is only over a course of weeks and months that the signs become obvious – unilateral or bilateral eyelid retraction with or without proptosis when physicians suspect the condition (Figure 1a, b).
Making a diagnosis This is primarily a clinical diagnosis, based on high suspicion. Classic and specific clinical features are an upper eyelid retraction with lateral flare with or without unilateral or bilateral exophthalmos. While two out of three patients may have concurrent or past history of hyperthyroidism which makes
diagnosis easier, the other third may have completely normal endocrinological parameters, resulting in confusion and misdiagnosis until the later stages. Likewise, imaging studies of the orbit are useful only in the later stages when the obvious signs of extraocular muscle infiltration (Figure 2a, b) are present. Therefore a high degree of clinical suspicion on part of the primary physician and ophthalmologist is recommended.
When and why should the patient be treated?The natural history of the disease is dictated by the Rundle’s curve where the patients go through a phase of active inflammation and edema for 12-18 months following gradual resolution with variable fibrosis. While most patients may improve spontaneously over 24-48 months, more often than not, residual morbidity of proptosis and eyelid retraction, and in extreme cases, disabling visual loss as well as exposure keratopathy (Figure 3) and diplopia are present. Current understanding of the disease therefore is aimed at medical intervention during the ACTIVE phase of the disease by various immunomodulation agents. It has also been shown that most vision threatening and disabling changes
occur during this stage and hence defining Threshold Activity using either the Mourits Clinical Activity Score (CAS) or the VISA_ITEDS inflammatory index is most crucial in identification and management at this stage. SEVERITY is defined by the degree of morbidity and disability caused by the active inflammatory (injection, edema, muscle enlargement) or secondary fibrosis of the extraocular muscles. While most patients may have aesthetic morbidity only, a significant proportion of patients have disabling pressure sensation behind the eyes, diplopia and even visual loss. Patients who are likely to do well are otherwise young healthy females, non-smokers and without systemic comorbidities. Risk factors for poor prognosis include middle aged males, smokers and those with systemic comorbidities like diabetes and hypertension. It is also now recognised that some of the affected patients may have other autoimmune disorders which may affect the management and the outcomes as well.
Figure 2b. MRI showing enlarged extraocular muscles
Investigations To diagnose and manage thyroid orbitopathy, a baseline thyroid screen (Free T3, T4 & TSH) with autoantibodies (TSH Receptor Antibody, Thyroid Stimulating Immunoglobulin) is recommended. Imaging of the orbit is considered only when the diagnosis is in doubt, surgery is being planned or in atypical presentations. If immunosuppression is being contemplated, complete systemic work up including for hypertension, diabetes mellitus, ruling out underlying cardiac and liver abnormalities, tuberculosis and hepatitis serology is warranted.
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ManagementBased on the current evidence, an outline of management of patients is shown above. Principles of management include observation with symptomatic treatment alone for both active and inactive mild disease, immunological intervention for ACTIVE (inflammatory phase) moderate to severe disease. Oral steroids are no longer recommended partly because of reduced effectiveness and more so because of the significant morbidity of weight gain, exacerbation of diabetes, osteoporosis, etc. from prolonged use. Moderate to
severe inactive disease may benefit from a spectrum of varied surgical interventions depending upon the presence of exposure keratopathy, eyelid retraction, residual proptosis or strabismus.
Medical management is begun with high dose of IV methyl prednisolone during the active and acute phases of the disease. While potential risks and complications can be severe, adequate screening and selection of patients with proper counselling and informed consent help to minimise complications and maximise
the benefits. While most patients respond to corticosteroids alone, a small proportion of patients with persistent inflammation may benefit from additional steroid-sparing immunological agents. Patients who are not responding to conventional medical treatment may require other measures including Rituximab, orbital radiation or even emergency orbital decompression. At NUH, the Outpatient Infusion Centre (OPIC) and its staff play a crucial role in counselling and administering most of the outpatient medical therapy during the Active phase of the disease.
Figure 4. General outline of management of Thyroid Eye Disease
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Surgical management remains the mainstay of treatment for residual morbidity of this potentially disfiguring and blinding disease. Orbital decompression of one, two, or three walls along with orbital fat decompression are indicated either for severe disfiguring proptosis or visual loss from compressive optic neuropathy (Figure 5a, b). The usages of minimally invasive and endoscopic approaches to the medial wall and intraoperative navigation have not only improved the outcomes, but
Figure 5b. Bone decompression
have also minimised the complications. Strabismus surgery, nowadays performed under topical anaesthesia, helps restore binocularity and functionality enabling single vision at least in primary, reading and down gaze. Finally, a blepharoplasty and eyelid retraction helps restore any residual asymmetry that may be present.
In summary, numerous advances in the understanding of the pathogenesis of Orbitopathy, the natural history of the disease, early recognition and medical
intervention, and surgical interventions when refractory have radically changed the outcome of the once-dreaded disfiguring and blinding disease. Multimodality, multidisciplinary approach to patients with complex medical and surgical conditions, specialised multidisciplinary clinics and collaboration with affiliated specialties of Orbital Surgeons, Endocrinologists, Immunologists, Strabismologists and Rhinologists have helped NUH to continue to be at the forefront of complex orbital disorders.
Figure 5a. Orbital fats
2014 OCT OBER - DECEMBER MED ICO • 13
Dr Dawn Lim Ka-AnnAssociate Consultant,Department of Ophthalmology
Dr Lim is an Associate Consultant with the Department of Ophthalmology, National University Hospital. She spent two years gaining further
experience in various fields of medicine including dermatology and rheumatology, which culminated in her admission as a member into the Royal College of Physicians (MRCP, UK) prior to commencing formal Ophthalmology training.
An awardee of the Ministry of Health training scholarship, Dr Lim proceeded to complete her advanced specialist training in Ophthalmology in mid-2014. During her training years, she held the administrative appointment of Chief Resident from 2011 to 2012, and has received research award, grant, co-authored scientific papers in peer-reviewed medical journals and presented her work at international/regional scientific conferences. Dr Lim has also co-authored several book chapters in Ophthalmology texts. Her clinical interests include visual problems in the elderly, ocular inflammatory disorders, glaucoma and advanced adult cataract surgery.
Her main research interests include visual issues related to functional aging and glaucoma.
Dr Lim is active in teaching and holds a joint appointment with the clinical faculty scheme of Yong Loo Lin School of Medicine, National University of Singapore.
Email: [email protected]
t r e a t m e n t r o o m
“ Roses are red, Violets are BlueA red eye can be a problemSo can be a blue one too……”
The red eye is one of the most common presentations in a primary care set-up.However, without the aid of a proper slit lamp biomicrosopic examination, confirming the diagnosis can often be challenging.
Causes of red eye seen in the local context can be classified generally as such:
1) Sclera/Episcleral- Episcleritis.
- Scleritis (Anterior or Posterior) (Figure 1).
2) Conjunctival - Subconjunctival haemorrhage.- Viral conjunctivitis.- Bacterial conjunctivitis. - Allergic conjunctivitis.
3) Cornea - Keratitis v Infective keratitis (contact lens or
non-contact lens related; bacterial, herpetic, fungal) (Figure 2).
v Marginal keratitis (Figure 3). v Peripheral ulcerative keratitis.
- Keratopathy v Exposure related - Following CNVII
nerve palsy from various causes with lagophthalmos.
v Neurotrophic.v Chronic irritation – lash
misdirection from various causes.
4) Uvea - Uveitis (anterior, intermediate,
5) Glaucoma-related - Acute angle closure.- Rubeotic glaucoma from causes of
proliferative retinopathy (including diabetic retinopathy, central retinal vein occlusion, ocular ischaemic syndrome).
6) Endophthalmitis (Endogenous or post-operative)/ Pandophthalmitis.
7) Orbital - Orbital cellulitis. - Active thyroid eye disease.
8) Trauma including industrial accidents - Corneal/Conjunctival abrasions.
- Blunt trauma.- Corneal/Conjunctival foreign body.- Chemical injury.- Intraocular foreign body.- Lid/Scleral/Corneal laceration with or
without canalicular involvement.
The following red flag indicators from the history in association with a red eye should prompt one to refer the patient for further evaluation in tertiary institutions. These include:Symptoms
• Laterality – Unilateral • Pain with or without eye movement• In association with headaches • Blurring of vision • Intermittent blurring of vision with
haloes (Intermittent angle closure or raised intraocular pressure)
• Photophobia (may suggest the presence of iritis)
• Double vision • Floaters • Copious mucopurulent discharge
Patient profile • Post-operative (endophthalmitis) • Contact-lens (CL) use (TRO CL-related
infective keratitis) • Female, Chinese, aged late 50s-60s
with a painful red eye and associated headache, nausea, vomiting (typical profile of an acute primary angle closure patient)
• Diabetic or multiple known vascular risk factors (rubeotic glaucoma)
• Trauma or industrial accident related presentations
• Associated autoimmune disorders e.g., rheumatoid arthritis, seronegative arthropathy, ankylosing spondylitis, Wegener’s granulomatosis (anterior uveitis, scleritis, peripheral ulcerative keratitis)
The Red Eye – What should I do?
14 • MEDICO OCT OBER - DECEMBER 2014
A word of caution on the use of topical steroids in the primary care settingTopical steroids have to be used with great caution, if at all, in the primary care setting, as this may lead to devastating consequences including corneal melt or perforation (Figure 4) in infective cases.
Mr A, is a 76-year-old gentleman, who had a history of cerebrovascular accident and was dependent on a caregiver for his activities of daily living. He was wheelchair ambulant when he presented to the Ophthalmology unit for complaints of left eye pain and copious mucopurulent discharge. He had been to three other clinics before this and was given oral and topical medications which included topical dextracin. He had a history of chronic retinal detachment in the left eye which rendered him with no light perception, hence did not notice any deterioration of vision that partly accounted for his
of topical dextracin instillation. He reported a rapid deterioration of vision following that which brought him to our unit. The same patient was found to have a large central corneal abscess with hypopyon and 90% corneal melt with impending perforation at presentation. The corneal melt rapidly progressed over the next five days, which led to the development of corneal perforation that necessitated a corneal transplant.
Other problems of steroid use include corticosteroid induced ocular hypertension. Studies have shown that when treated with topical steroids for
1) Tan AM, Loon SC, Chew PT. Outcomes following acute primary angle closure in an Asian population. Clin Experiment Ophthalmol. 2009 Jul;37(5):467-72.
2) Relief Jones III, Douglas J Rhee. Corticosteroid-induced ocular hypertension and glaucoma: a brief review and update of the literature. Curr Opin Ophthalmol 17:163-167.
3) Kwok AK, Lam DS, Ng JS, Fan DS, Chew SJ, Tso MO. Ocular-hypertensive response to topical steroids in children. Ophthalmology. 1997; 104(12):2112-2116.
late presentation. Examination of his left eye found him to have a large central corneal abscess and 80% corneal melt. As there was evidence of severe chemosis and limitation of eye movement, he underwent an imaging of the orbits which showed evidence of pandophthalmitis. He was managed with systemic, intravitreal, topical antibiotics, and subsequently underwent an enucleation of the left eye.
Mr Y, a 29-year-old construction worker, was seen elsewhere when he sustained a corneal foreign body at work 4 days prior to presentation. He reportedly had the foreign body removed and was prescribed dextracin eyedrops three times a day to the left eye. He revisited the former clinic when he did not improve symptomatically and was advised to increase the frequency
Figure 1. Anterior scleritis in a case of suspected ocular tuberculosis (TB); autoimmune screen was negative, the characteristic violet-bluish hue with scleral edema and dilatation typically observed in scleritis
Figure 3. Marginal keratitis
“Theories of its etiology include staphylococcal hypersensitivity. One distinct characteristic is the clear zone that lies between the infiltrate and the limbus. Treatment would include lid hygiene and topical steroids with topical antibiotic cover if there is an epithelial defect.”
4-6 weeks, up to 30% of the population demonstrated a rise in intraocular pressures of 6-15 mmHg. The incidence of corticosteroid response has been reported to be as high as 56% in children and up to 89% attained their peak intraocular pressure within 8 days. Risk factors for corticosteroid induced ocular hypertension include type and potency of the corticosteroid, primary open angle glaucoma patients, glaucoma suspects or a family history of primary open angle glaucoma. Hence, patients should ideally also receive intraocular pressure monitoring whilst on topical steroid eyedrops, which may not be always possible in a primary care set-up.
In summary, managing a red eye can be fraught with much difficulty. The first step to any treatment would be to clinch a diagnosis. If in doubt, it would be best to refer the patient for further evaluation by an Ophthalmologist.
Figure 4. Perforated corneal ulcer from chronic steroid use in a 15-year-old girl
Figure 2. Contact lens-related infective keratitis; a central corneal ulcer with hypoyon
2014 OCT OBER - DECEMBER MED ICO • 15
Clin A/Prof Caroline Chee Ka Lin
D OCT OR ’S H EAR TBEAT
Senior Consultant, Department of Ophthalmology
Specialist in Focus
Clinical Associate Professor Caroline Chee Ka Lin is a Senior Consultant at the National University Hospital in Singapore (NUH). She enjoys all aspect of retinal work, both medical and surgical.
A/Prof Chee graduated from the Medical Faculty of the National University of Singapore (NUS). She completed general ophthalmic and retinal training in Singapore before proceeding to retinal fellowships at Addenbrooke’s Hospital in Cambridge with John Scott and Declan Flanagan and Moorfields Eye Hospital in London with Alan Bird and Robert Cooling.
With her clinical interests in medical and surgical retinal diseases, A/Prof Chee is currently engaged in research on the Retina Implant for photoreceptor diseases, participates in several multicentre clinical trials, and initiated a Ministry of Health sponsored programme to enable patients with low vision. She sits on the review board of several journals.
She enjoys sharing her knowledge and experience with her younger peers, and is actively involved with training medical students and ophthalmology residents. She mentors both local and foreign retinal fellows. She is the Department Director for Postgraduate Education and still plays an active role in examining candidates for the MMed (Ophth) and Exit Examination in Singapore. She has also served as examiner in the Royal College of Surgeons of Edinburgh examinations, both locally and abroad.
Email: [email protected]
1Is there any particular reason as to why you chose to be in the Ophthalmology field?I enjoy using my hands and doing surgery, and I also enjoy the medical (non-surgical) side of patient management.
Ophthalmology is one of the few disciplines that allow a wide range of management options. It is also a discipline where you can make a big difference to patients’ lives, and that is always attractive to a physician.
Could you tell us more about your specialty, retinal disease, as well as the prevalence and relevance of the specialty in the region?A large proportion of the world’s blindness results from the two common
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retinal diseases. While diabetic eye disease is the most common cause of blindness in working age adults, age-related macular degeneration is the most common cause of blindness in the developed countries. The burden of these two diseases is greater in developed countries as the diabetes is reaching epidemic proportions world-wide. Singapore is no exception where both of these diseases are very common.
Our diabetic patients have access to adequate care, and thus could live long enough to develop diabetic retinopathy. Having said that, thanks to our excellent primary healthcare that has helped the patients to keep their diabetes under reasonable control, the severity of diabetic retinopathy has come down. An excellent screening programme, access to early treatment, and greater expertise in managing advanced diabetic retinopathy have also brought down the rate of diabetic blindness in Singapore. From the time I began training in Ophthalmology until now, I have seen the incidence of severe diabetic retinopathy and blindness from diabetic retinopathy dropped significantly.
Whilst the rate of diabetic retinopathy seems to have levelled off in Singapore, the incidence of age-related macular degeneration has ballooned, compared to when I began training. This is because we have one of the longest life expectancy in the world, thus our people are now living long enough to develop this disease of the elderly. It is also possible that the change in diet and lifestyle may have contributed to the increased incidence. Fortunately, therapy for this disease, in the form of anti-VEGF medication delivered directly into the eye, has become available in the past 8 years, which allows us to maintain vision in a large proportion of patients who may otherwise have become legally blind.
What are the challenges that you face in your practice?Despite great improvements in treatment, we still see patients that we cannot help,
such as patients who come with very advanced diseases (including advanced diabetic retinopathy and age-related macular degeneration).
Time management is always a challenge when one has to juggle between teaching and research commitments and the rapidly changing management options available to the patients. However, to me, all of these commitments are exciting challenges.
How do you see the treatment development of retinal disease in the next 10 years? The potential treatment options for genetic retinal diseases, which up to now were untreatable, are extremely exciting. We have been involved in research on the Retina Implant for patients who are blind from hereditary retinal disease, and this development should continue to improve and hopefully become available to this group of patients one day. Even before this group of patients become blind, there is a potential for gene therapy, stem cell transplants, or growth factors to maintain their vision. One of our consultants, Dr Mandeep Singh, is currently involved in this work overseas, and we are looking forward for him to bringing the expertise and continuing research back to NUH and NUHS.
For diabetic retinopathy and age-related macular degeneration, I look forward to new drugs and different treatment regimens to be developed to improve
the success of maintaining good vision. Currently, it may be considered a good result if these patients with advanced disease could move around by themselves. For the future, we hope to be able to maintain reading vision for these patients.
Do you have any tips to share with our primary care physician partners in managing patients who have common eye problems?Many elderlies do not realise that they
need reading glasses. If they can read well with reading glasses, no further treatment may be necessary.
However, elderly patients with reduced vision, despite changing their spectacles, should be referred to an eye specialist as they may have age-related macular degeneration, diabetic retinopathy, or glaucoma, which have to be treated early in order to maintain their visions. It should not be assumed that they have non-urgent cataracts.
Patients with age-related macular degeneration can benefit from oral supplements such as Ocuvite. However, there is no evidence that the numerous supplements for the eyes found on the market are useful for the eyes. The best advice is to maintain a healthy lifestyle, i.e. a healthy balanced diet with enough fruit and vegetables, adequate sleep and exercise, and good control of vascular risk factors (blood pressure, serum cholesterol and glucose).
Lastly, can you describe how a perfect Sunday afternoon will look like to you?A perfect Sunday afternoon: One where no one in the family has any work that has to be done that day or the next. I would spend it with family and friends. Begin with lunch, run some errands, and then followed by a walk by the water, a park, or Gardens by the Bay; a quick swim if there is enough time, and then look forward to dinner. One of the meals would be at an old favorite place, and the other would be exploring at a new place.
2014 OCT OBER - DECEMBER MED ICO • 17
Dr George ThomasResident,Department of Ophthalmology
Dr George Thomas is currently a Resident at the NUHS Ophthalmology Residency Programme, which has a strong focus on both general and specialist eye care as well as a proven track record in surgical training and academic medicine. He was trained at The University of Melbourne and his interests include research, education and outreach activities, particularly to those with reduced access to eye care in Singapore.
Email: [email protected]
M EDIC AL N O TES
The skyline of Kent Ridge has changed significantly after the development of the NUH Medical Centre, the latest state-of-the-art facility at the National University Hospital (NUH). Sitting directly atop Kent Ridge’s MRT station, the 19-storey medical centre contains over 190 specialist outpatient clinics, more than 200 procedure rooms, 10 operating theatres and clinical support services with facilities. Built to serve the outpatient population better, it also has dedicated space for teaching and clinical trials.
The Eye Surgery Centre is one of Singapore’s premier Ophthalmology tertiary referral centres with a focus on providing the highest levels of clinical and surgical care, backed by a strong portfolio of research and development, in conjunction with the National University of Singapore. Occupying the entire 17th floor, the additional facilities include procedure rooms that incorporate a Zeiss Operating Microscope for minor surgical procedures, as well as imaging and investigation tools, a LASIK and Refractive Surgery Centre, a Laser Surgery Suite and a comfortable waiting area for patients.
A dedicated team of doctors, nurses, patient care assistants and technical experts are on-site to provide prompt and quality care for patients, ensuring that the centre can cope with large volume of patients. The teaching facilities aide
Figure 2. Dedicated team of staff at the Eye Surgery Centre
Figure 1. The Eye Surgery Centre
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at the NUH Medical Centre
the on-going training and education programmes provided by the NUH Department of Ophthalmology in the fields of Family, Emergency and General Medicine. The Education Team trains hundreds of medical students a year and provides constant education to Eye Specialists in Singapore.
Strengths of the centre include being an integrated facility with medical and surgical eye care under one roof, while still having the support of all the other specialities in close proximity, making multidisciplinary clinic visits a more streamlined process. Having strong links with the National University of Singapore (NUS) has resulted in a strong academic focus of the Centre, with multiple research groups contributing to the research projects, clinical trials and the use of novel technology in Ophthalmology. Overall, the Eye Surgery Centre at NUH aims to be one of Singapore’s premier Ophthalmology Tertiary Referral Centres.Eye Surgery
Figure 4. Facilities in the procedure rooms, including a Zeiss Operating MicroscopeFigure 3. Nurses preparing for laser eye surgery
2014 OCT OBER - DECEMBER MED ICO • 19
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