Health Resources

Oculoplastic and Facial Aesthetic

What is Oculoplastic & Facial Aesthetic

Oculoplastic surgeons are highly trained ophthalmologists with sub-specialisation in oculoplastic surgery, which focuses on the orbit (eye socket), eyelids, tear ducts and the surrounding structures.

Combining the microsurgical precision of ophthalmology with the aesthetic concepts of facial plastic surgery, we provide a comprehensive range of aesthetic and medical services for the orbit, eyelids and lacrimal (tearing) system for both paediatric and adult patients.  

Oculoplastic surgery covers a wide range of procedures, including:

  • Eyelid surgery, including blepharoplasty and eyelid reconstruction, for ptosis (droopy eyelids), entropion, ectropion, and eyelid tumours
  • Tear duct surgery to manage tearing from blocked tear drainage systems
  • Orbital surgery to manage thyroid and eye disorders, tumours, and trauma
  • Paediatric oculoplastic surgery to correct congenital defects and manage eye disorders in children
  • Eyebrow and forehead lifts
  • Facial rejuvenation (e.g. lower eyebags surgery, midface lift)
  • Non-surgical treatments performed by oculoplastic surgeons, including:
    • Skin rejuvenation 
    • Botox injections to reduce wrinkles and involuntary muscle spasms
    • Facial filler injections to reduce wrinkles, tear troughs and improve facial volume
Additionally, our specialised services extend to the management of eye tumours like retinoblastoma, and the fabrication and fitting of ocular prosthesis (artificial eye) to restore the appearance of patients who have lost an eye due to disease or injury. 
Clinical Services
Clinical Services

The following medical conditions and aesthetic treatments are commonly managed in our clinic.

EyelidOrbitLacrimal system
  • Ptosis/droopy lids or brows
  • Eyelid malposition (e.g. entropion [eyelid turned in] and ectropion [eyelid turned out])
  • Eyelid lumps/tumours
  • Eyelid/facial spasms
  • Thyroid eye disease
  • Orbital fractures from trauma
  • Orbital tumours around the eye
  • Tearing from dry eyes
  • Tearing from tear duct blockage or narrowing
  • Tear duct infections
  • Lower lid eyebag surgery
  • Double eyelid surgery
  • Cosmetic brow lift
  • Botox and filler injections
  • Skin tightening with radio frequency
  • Orbital decompression for cosmetic purpose
  • PreLASIK punctal closure for dry eyes
A Multidisciplinary Approach to Oculoplastics

Our commitment to comprehensive patient care is reflected in our collaborative, multidisciplinary approach to oculoplastics.

Lacrimal Clinics

We conduct monthly lacrimal clinics in collaboration with Ear, Nose, Throat (ENT) specialists. This joint effort allows us to co-manage lacrimal and nasal disorders and ensures optimal care for our post-surgery patients.

Thyroid Eye Clinics

Every first Friday of the month, we hold clinics with Endocrinology specialists to manage patients with Thyroid Eye Disease. This approach ensures both systemic and ophthalmic optimization for individuals with this condition.

Plastic, Reconstructive and Aesthetic Surgery

Our close collaboration with Plastic Surgery colleagues is evident in cases involving trauma and the need for reconstructive surgery, addressing fractures and soft tissue injuries. We extend our services to patients with complex orbital and facial conditions, including tumours (benign and malignant), and congenital or acquired deformities that require major reconstruction.

Retinoblastoma Service

As a tertiary referral centre for Retinoblastoma patients regionally and globally, we pride ourselves on working collaboratively with esteemed colleagues from National University Children's Medical Institute (NUHKids) in Pediatric Oncology, Vitreo Retinal Surgery, Paediatric Ophthalmology, and Interventional Radiology. This collaboration ensures top-quality and individualized treatment for paediatric patients with Retinoblastoma.

Aesthetic Eyes and Facial Treatment

Recognising that the eyes often reveal the earliest signs of aging, such as freckles, crow’s feet, and sagging eyelids, our expertise extends to addressing facial aging, including creases on the forehead, around the eyes (crow’s feet or laugh lines) and other areas of the face and mouth.


Oculoplastics allows for the application of minimally invasive techniques in enhancing the aesthetics of an individual. The use of modern techniques permits safe and predictable outcomes with minimal down time. 

At NUH Eye Surgery Centre, our Oculoplastics surgeons are specialised in various techniques of eyelid and facial rejuvenation, including:
  • Botulinum toxin injections (Botox)
  • Tissue fillers 
  • Skin rejuvenation with chemical peels and lasers

Surgeries including: 

    • Brow lift
    • Upper and lower blepharoplasty (cosmetic eyelid surgery)
    • Mid-face lift
We combine these modern surgical techniques to achieve comprehensive facial rejuvenation, restoring a more youthful, vibrant and well-rested appearance for patients seeking total facial enhancement.


Aesthetic Eye-facial Treatments

Botulinum (Botox) Treatment 
  • Relax muscles to visibly soften and minimise lines (frown lines, crow's feet and laugh lines).
Tissue fillers 
  • Fill up grooves and depressions on the face to achieve a modest “face lift” effect
  • Improves under eye dark circles, tear troughs and eyebags
Brow Lifts
  • Elevate sagging brows and minimise appearance of forehead wrinkles 
Upper and Lower Blepharoplasty (Cosmetic Eyelid Surgery)
  • Address droopy eyelids and appearance of sagging skin by removing excess skin/fat in the upper lid
  • Improves lower lid eye bags or under-eye hollows
  • Creates a more distinct upper lid crease for a larger eye effect
  • Reduce heaviness of eyelids 
Mid-Face Lift
  • Improves facial lines and minimise the cheek descent
For more details, please contact your Ophthalmologist or Eye Plastic Surgeon who can discuss your requirements and tailor them to your needs.


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Cosmetic Eyelid Surgery – Upper & Lower Blepharoplasty 
Periorbital Rejuvenation with Botox 
Periorbital Rejuvenation with Fillers 
Common Eyelid Problems

Eyelids protect the eyes from dust and dirt, and keep the eyes covered during sleep and periods of involuntary blink and voluntary closure. Additionally, eyelids aid in preventing dryness by distributing tears across the eye surface, ensuring clear vision. Common eyelid conditions include:
Droopy Eyelids/Ptosis
  • What is ptosis?
    • The term "ptosis" is the shortened form for "blepharoptosis" which refers to drooping of the eyelid.
  • Why does ageing cause ptosis? What are other causes of ptosis?
    • Ageing contributes to a specific type of ptosis known as "senile ptosis," a form of aponeurotic ptosis. In this scenario, the tendon connecting the levator muscle (the primary eyelid lifter) to the tarsus (the primary structural support) weakens over time, leading to eyelid drooping. 

    • Other causes of aponeurotic ptosis include intraocular procedures like  cataract surgery, long-term contact lens use or chronic rubbing of the eyes. These activities result in the stretching and weakening of the levator muscle tendon, affecting its attachment to the eyelid.

    • Apart from aponeurotic ptosis, other causes include congenital weakness, trauma and neurologic disease (cranial nerve palsy, myasthenia gravis, etc.).

    What happens if ptosis is left untreated?
    • Senile ptosis usually does not improve with time. If left untreated, it may progress to obscure part of the visual field of the person, interfering with daily activities. Some individuals may be unhappy with the way ptosis changes their appearance, especially if there is asymmetry between both sides or when both eyelids exhibit drooping, imparting a sleepy or haughty appearance.
    When should we seek help?
  • Individuals who is bothered by their droopy lids should promptly seek help as ptosis can be easily treated.

What are the treatments available?

  • Treatment for ptosis is personalized based on the underlying cause.
  • Senile ptosis can be corrected surgically and usually involves tightening the levator muscle to elevate the eyelid. 

Other forms include a brow suspension (frontalis sling) or surgery on the muscle on the inside of the lid (conjunctivomullerectomy), but the specific method will depend on the type and severity of the ptosis. 

The surgeon will conduct tests to determine the most suitable correction for each patient. 

The goal is to elevate the eyelid to permit a full field of vision and to achieve good height, contour and symmetry with the opposite upper eyelid.

Baggy eyes/Dermatochalasis

Commonly observed in older adults as an age-related change in both upper and lower eyelids, the primary cause is the progressive stretching of tissues and loss of elasticity. Blepharoplasty, a day surgery procedure, enhances the appearance and functionality of the eyelids. It may include the creation of an eyelid crease (double eyelid) if desired for aesthetic reasons. A comprehensive assessment by your Eye Plastic Surgeon will determine if it is medically necessary or aesthetically desired. It is often combined with ptosis surgery when co-existing droopy eyelids are present.

What is Upper Blepharoplasty?

Upper blepharoplasty is eyelid surgery of the upper lid. As we age there is excess skin and fat that may hang over the eyes, causing them to have a tired appearance, or even affecting our vision. 

Upper blepharoplasty removes this excess skin and fat, to give the eyes a more open, lifted and youthful appearance. 

In younger patients who seek to enhance their eyes by creating “double eyelids”, upper blepharoplasty can be used to make the eyes larger and create a more distinct crease that enhances the beautiful Asian eye.

What is Lower Blepharoplasty?

Lower blepharoplasty is eyelid surgery of the lower lid. As we age, the eyelid skin stretches, the fat bulges, and the muscles weaken. These may give rise to prolapse of fat in the lower lids, causing a puffy appearance. 

In some cases, fat may shrink, creating a prematurely aged look with increased hollows and dark circle.

Lower blepharoplasty addresses these issues by removing excess fat and redistributing them to fill the hollows where necessary.

How is blepharoplasty done and how long does it take?

Both upper and lower blepharoplasty can be performed alone or in combination, usually under local anaesthesia. 

Incision cuts are hidden in the natural lines of the eyes to minimise visible scarring. Excess fat and skin are removed to give the eyes a rejuvenated appearance. 

Both upper and lower blepharoplasty are day surgery procedures, lasting one to two hours, depending on the extent of the surgery.

Entropion and Ectropion

Entropion refers to the inward-turning of the eyelid, while Ectropion describes the outward-turning of the eyelid. These conditions are frequently associated with ageing, leading to irritation, tearing and, in rare cases, corneal damage that may result in blindness. The primary causes involve the stretching and weakening of eyelid structures. Correction typically entails the tightening of the eyelids to improve both their form and function.



What causes entropion?

    • With age, the skin, muscles and tendons of the lower eyelid can sag and droop.  Additionally, the surrounding fat may bulge forward, resulting in the lower lid turning inward with lashes rubbing against the eyeball.

    • This can lead to tearing, eye redness, mucous discharge (mattering), crusting of the eyelashes and scratching of the cornea.

What is a lower lid entropion repair?

    • Repair of a lower lid entropion is typically done as an outpatient procedure. The patient usually receives a local anaesthetic injection and sedation, although deeper anaesthesia can be administered, if needed.  

    • The procedure involves tightening the inferior retractors of the lower lid to correct its position, preventing it from turning inward. Sutures are often used to tighten the tendons of the eyelid in the corners of the eye through small incisions, tailored to each patient's needs. 

How will entropion repair affect my symptoms or appearance?

    • The outcomes of entropion repair depend on factors such as the patient's symptoms, unique anatomy, appearance goals  and ability to adapt to changes. 

    • While entropion repair primarily addresses droopiness and sagginess, it is not considered a cosmetic procedure. The surgery typically improves tearing, mucous discharge, and the foreign body sensation caused by lashes rubbing against the eye.  

    • Since saggy, in-turned eyelids are typically associated with ageing, most patients find that entropion repair improves their appearance and alleviates issues such as persistent redness in the eyes.



What causes ectropion?

    • With age, the skin, muscles and tendons of the lower eyelid can sag and droop.  Additionally, the surrounding fat may bulge forward, causing the lower lid to evert and turn inside out. 

    • It may also occur in patients with facial palsy, which results in a paralytic form of ectropion.

    • These changes can lead to tearing, eye redness, mucous discharge, crusting of the eyelashes and skin irritation.  Excess skin and fat also create what many feel is an unattractive, aged appearance in the lower lids ("bags under the eyes").  

What is a lower lid ectropion repair?

Repair of a lower lid entropion is typically done as an outpatient procedure. The patient usually receives a local anaesthetic injection and sedation, although deeper anaesthesia can be administered, if needed.  

The procedure involves tightening the inferior retractors of the lower lid to correct its position, preventing it from turning inward. Sutures are often used to tighten the tendons of the eyelid in the corners of the eye through small incisions, tailored to each patient's needs.  

Some patients may opt for cosmetic "add-on" procedures performed at the same time as functional (insurance) surgery, such as the removal of lower lid fat bags removed, knowing that this is NOT covered by insurance.

How will ectropion repair affect my symptoms and appearance?

    • The outcomes of ectropion repair depend upon the patient's symptoms, unique anatomy, appearance goals, and ability to adapt to changes. While entropion repair primarily addresses droopiness and sagginess, it is not considered a cosmetic procedure. The surgery typically improves tearing and mucous discharge, alleviating associated symptoms.  



Often seen in children and young adults of East Asian origin, including Chinese, Japanese and Koreans, eyelash inversion occurs when the lower and sometimes upper eyelashes turn inwards. This can lead to corneal irritation, redness, watering and irritation. While the condition is generally mild and improves over time with lubrication, surgical correction may be required to alleviate the symptoms to provide permanent relief.

What is epiblepharon?

Extra horizontal fold of skin that stretches across the border of the eyelid

Anterior part of eyelid overrides posterior part

Abundant orbicularis muscle

Lashes brushing against eye

May result in scratches on the cornea

Some have reported association with astigmatism

What are the common symptoms?

  • Rubbing eyes
  • Irritation
  • Itchiness
  • Discomfort
  • Tearing

What are the treatment options?

  • Observation
    • Some improve spontaneously with age
  • Lubricant eyedrops
  • Non-incisional method
    • Suture correction (may have higher recurrence rate)
  • Incisional
    • Modified Hotz procedure (lower lid)
    • Cilia rotational suture (lower lid)
    • Asian blepharoplasty (upper lid)


Common Eyelid Problems

Diseases of the Eye Sockets
What Are Orbits?
Orbits refer to the bony structures supporting the eyeballs and other vital structures that enable the eye to see, feel, move and absorb impact. These structures include for eye movement, nerves for sensation and movement, and fat facilitating free sliding and impact absorption by the eyeball and its muscles. Diseases of the orbit may affect this variety of structures, affecting eyeball function and vision.

Orbital Trauma and Fractures

Orbital trauma and fractures are commonly seen in both adults and children and may present as an isolated fracture, usually as a result of road traffic accidents and assaults. It is also commonly associated with other facial, intracranial and systemic injuries. 

Orbital trauma and fractures

Children may sustain orbital fractures without evident external signs of injury. If not promptly diagnosed and treated surgically as an emergency, there is a risk of permanent dysfunction in eye movements.

Newer concepts in the management of fractures include reparation through scarless, minimally invasive approaches and the use of absorbable implants. These strategies enable shorter hospital stay and early rehabilitation. The orbital surgeon may work in collaboration with the Facial Plastic team or Neurosurgical team for total management and optimal care.

Thyroid Eye Disease

Thyroid eye disease, a condition associated with thyroid hormone dysfunction, is often seen among the middle-aged and elderly. It is the most common cause of a prominent, wide-eyed staring appearance and, in severe cases, can lead to the inability to close the eyes during sleep. This pronounced protrusion, giving rise to a 'bug-eyed' appearance, is accompanied by constant pressure, pain, and the potential to impact the optic nerve, leading to blindness. Beyond visual impairment, the resulting disfigurement may have profound psychological and social repercussions for the patient.

In the early active phases of the disease lasting 1-2 years, conservative management can alleviate most symptoms, although the appearance remains the same. When vision is threatened, steroid or immunosuppressant therapy may be considered. For residual deformities, various forms of eyelids, eye muscles and orbital surgery usually help restore a more normal appearance.

The Thyroid Eye Clinic at NUH brings together Orbital Surgeons, Neuro-ophthalmologists and Thyroid specialists to evaluate patients and optimise medical treatment before surgical rehabilitation is used to restore a comfortable, pre-morbid normal state.

What is thyroid eye disease and why does it happen?
  • Thyroid eye disease (TED) is an autoimmune disease mainly associated with an over-active thyroid due to Graves' disease, although it may  occur in individuals with an under-active or normally functioning thyroid. 
  • The eyes are particularly vulnerable to Graves' eye disease because the autoimmune response often targets the eye muscles and connective tissues within the orbital socket. This is likely due to the presence of proteins in orbital tissues resembling those in the thyroid gland. 
  • Consequently, inflammation in the eye muscles and fatty tissue behind the eyes can lead to eye protrusion and upward-pulled eyelids, resulting in a 'staring' or 'bulging' appearance.
  • During the active phase or chronic phase, patients may experience pain, tightness, and swelling of the eyes and eyelids. TED rarely causes blindness from pressure on the optic nerve (compressive neuropathy or exposure keratopathy).
Is my thyroid eye disease mild, moderate or severe?
  • Apart from activity, TED is classified based on severity (mild, moderate or severe).
  • In mild cases of TED, patients may complain of sensitive and dry eyes, often accompanied by increased tearing. Some mild cases may have associated lid signs, such as lid retraction and lid lag. 
  • In moderate TED, patients usually has worsening of soft tissue signs, with greater lid retraction and exophthalmos. Patients may also experience diplopia (double vision) beyond 30 degrees of primary gaze.
  • In severe TED, patients may experience severe exposure keratopathy resistance to conservative management, compressive optic neuropathy or diplopia within 30 degrees of primary gaze.

What can be done for thyroid eye disease? 

  • For patients with TED, the following measures may help to prevent disease progression:
    • Symptomatic treatment of dry eyes, including topical lubricants, sunglasses in bright sunlight or temporary punctal plugs.
    • Quit smoking, both active and passive, to reduce the severity, duration of activity, degree of scarring and risk of optic nerve involvement.
    • Collaboration with an endocrinologist to ensure well-controlled thyroid disease.
  • Classifying the patient into active or inactive disease is very important for appropriate management.  
    • Active disease requires immunosuppression, with intravenous methylprednisolone being the treatment of choice. 
    • Steroid sparing immunosuppressant therapy, administered in collaboration with the Rheumatology team, is considered for their steroid sparing effects, especially in cases of persistent inflammation. 
    • External beam radiotherapy, provided by radiation oncologists, may also be considered in patients who have contraindications or intolerance to various forms of corticosteroid/steroid sparing agents. It is  generally avoided both in the young and the elderly, as well as in those with diabetes.
  • Surgical management for TED includes:
    • Orbital decompression for several indications, including:
      • Protrusion of the eyes
      • Persistent congestion after immunosuppression
      • Compressive optic neuropathy
      • As a staging procedure, in preparation for strabismus or eyelid surgery
    • Strabismus surgery on the extraocular muscles is performed to correct the misalignment of the eyes.
    • Eyelid surgery, which may include procedures to correct: 
      • Upper or lower lid retraction
      • Upper or lower blepharoplasty (to remove excess skin and fat)

Thyroid eye disease, while posing clinical and therapeutic challenges, has become more manageable with advancing understanding and treatment options. Early identification and a patient-cantered, multidisciplinary approach are crucial for effective care. The goal is to halt and reverse the active inflammatory process, ensuring optimal outcomes and improved quality of life for patients dealing with TED.

Tumors of the eye socket (Orbital tumors)

Tumours of the eye socket, or orbital tumours, are relatively rare in the general population. However, they can sometimes indicate underlying systemic diseases and pose potential life-threatening risks. Timely and accurate evaluation, diagnosis, and appropriate management, whether through surgery or other treatments, are crucial for optimizing visual outcomes and ensuring a return to normal life.

Orbital tumours

  • The orbit is the bony socket in which the eye is located. It consists of a floor, roof and walls on either side. 
  • Tumours can develop in the space between the eye and the surrounding bones.
  • These tumours vary in severity, ranging from benign, observable lumps to malignant tumours requiring complex treatment plans.
  • They can be either congenital or acquired and may extend beyond the orbit, affecting areas such as the sinuses or even the brain.
  • Orbital tumours can originate from different tissue types found in the orbit, including blood vessels, nervous tissue, bone, and lymphoid tissue.

Anophthalmic Sockets

The loss of an eye, often a result of surgical removal following an irreparable injury or disease, is a visually and psychologically devastating experience. While visual restoration may not be possible, a two-step procedure involving orbital implant placement (socket surgery) followed by artificial eye fitting (ocular prosthesis) can restore a normal appearance. This, in turn, aids patients in resuming a regular social and psychological profile. An ocularist plays a crucial role in fitting a customised eye prosthesis and provides guidance on maintaining the eye socket and prosthesis.


Thyroid Eye Disease
What is a Retinoblastoma?

Retinoblastoma is the most common eye cancer in children globally. Affecting 1 in every 12,000 to 15,000 children, it typically manifests around 2 years of age. However, instances have been noted as early.

Retinoblastoma is a tumour that originates in the retina, which is the inner lining in the back of the eye responsible for vision. Retinoblastomas are the most common primary paediatric ocular neoplasm in children.

Left untreated, the disease often progresses beyond the eye, infiltrating the eye socket, the brain, and eventually other parts of the body, leading to fatalities. Thus, it is not only sight-threatening but also life-threatening.

Who Manages Retinoblastoma at NUH? 

At NUH, Retinoblastoma is primarily managed by a team of experienced specialists including paediatric ophthalmologists, retinal specialists, and eye plastic surgeons. This collaborative effort forms the core of our ocular oncology team. The multidisciplinary approach extends to include geneticists, ocularists (specialists in artificial eyes), interventional radiologists, radiation oncologists, and pathologists.

With over two decades of experience, we annually manage 8-10 new Retinoblastoma cases, providing extensive, long-term follow-up care for both seeing and surviving children. The disease is thoroughly staged through appropriate investigations, and individualised treatment plans are crafted. Long-term monitoring involves the joint efforts of ophthalmologists and oncologists, with additional genetic counselling provided by Geneticists.

Is Retinoblastoma Deadly?

Early diagnosis and intervention contribute to a remarkable survival rate of over 90-95%. Children who receive timely treatment lead normal lives, attending school and engaging in regular activities. However, when left untreated or poorly treated, almost all confirmed retinoblastoma  cases spread beyond the eye(s) into the eye socket or the brain, and eventually to other parts of the body resulting in death.

What Are the Signs / Symptoms of a Retinoblastoma?

It is most commonly presented as an altered light reflex in the affected eye (white reflex, or leucocoria) typically seen in flash photographs of a child in the first 1-2 years of life (Fig. 1). Other manifestations include a new onset of 'cross eye' ('squint', strabismus), a non-responsive red eye to treatment, vision impairment, or late-stage manifestations such as eye enlargement or bulging. Advanced cases may present with systemic symptoms like irritability, failure to thrive, seizures, or swelling in other body parts due to metastasis. Parents who notice any of the early signs should promptly consult an eye specialist or paediatrician.

Fig. 1 Leukoria (white coloured pupillary reflex) is present in the right eye due to retinoblastoma

How Is Retinoblastoma Diagnosed?

When signs indicative of Retinoblastoma are observed, the initial evaluation involves a thorough examination by an eye specialist. This examination is often followed by a more detailed assessment under anaesthesia or sedation. Diagnosis primarily relies on clinical examination, assessing the tumour's appearance and characteristics. Additionally, ultrasound scan is commonly used to identify calcifications and measure the tumour's size and potential spread beyond the eye. The use of a specialised fundus camera (RetcamR) aids in documentation, family education, communication with specialists and seeking second opinions when necessary.

In cases where the disease is suspected to extend beyond the eye or affects both eyes, imaging of the orbit (eye socket) and brain is conducted to rule out extraneous spread and assess the presence of a rare third tumour in the brain (pinealoblastoma).

For patients presenting late with evident spread outside the eye, procedures such as lumbar puncture for cerebrospinal fluid analysis and bone marrow examination may be performed to confirm disease spread.

Note: This is one of the very few cancers where diagnosis is made and treatment is started without first performing a biopsy.

Newer Forms of Treatments Options

Recent years have witnessed the introduction of various advanced treatment options for Retinoblastoma, with some available at NUH. These include plaque brachytherapy (local radiation), intra-arterial chemotherapy (administered through blood vessels accessed via thigh blood vessels), intra-vitreal chemotherapy (direct injections into the eye, but it is not yet considered a primary treatment), and Autologous Stem Cell Rescue (ASCR)/Bone Marrow Transplantation (BMT) for late-stage metastatic disease. 

How Is Retinoblastoma Treated? 

The primary goal in the treatment of retinoblastoma entails the preservation of life, followed by the eye and subsequently, vision. Close teamwork within a multidisciplinary team comprising ophthalmologists, paediatric oncologists, geneticists, interventional radiologists and pathologists is essential to achieving those objectives. At present, retinoblastoma is one of the most curable paediatric cancers.  

Staging the disease

To determine the most suitable treatment, a thorough evaluation to stage the disease has to be performed. In young children, who may not cooperate with awake eye examination, assessment is usually done under sedation or anaesthesia. The pupils are dilated so the entire retina can be examined to determine whether there is one or more retinoblastomas. The examining doctor will also assess for seeding into the vitreous or front chamber of the eye.

An ultrasound of the eye (Fig. 1) is performed to evaluate for characteristic features for the tumour like calcification, and to measure the size of the tumour. agnetic resonance imaging (MRI) of the brain and orbit (Fig. 2) is conducted to explore potential tumor spread outside the eye or into the brain. Importantly, both ultrasound and MRI procedures involve no exposure to radiation, ensuring a safe diagnostic process. 

Fig. 1 This is an ultrasound scan that demonstrates the tumour (arrow), which is in close proximity to the optic nerve (orange asterisk).

Fig. 2 This is an MRI scan that demonstrates the tumour (red arrow) in the right eye. The MRI is useful to assess for extension of the tumour outside the eye, and intra-cranial involvement of the disease.

Treatment options

Various treatment modalities are available in the management of a retinoblastoma.

  • Photocoagulation or cryotherapy can be used for the treatment of small tumours.  
  • For medium to large tumours with no systemic spread, enucleation is an established treatment. While this ensures the elimination of the tumor, it results in the complete loss of visual potential in the affected eye. Enucleation remains the treatment of choice for advanced unilateral disease with no prospect of functional vision.
  • In situations where the disease is less severe, and there is potential for vision in the affected eye, several globe salvage treatments are available. These include:

Intra-arterial chemotherapy. NUH is the only institution in Singapore and the region to offer state-of-the-art Selective Intraarterial Chemotherapy for Retinoblastoma, performed by a neurointerventional radiologist. This is complemented by intraocular laser therapy, cryotherapy, and intravitreal chemotherapy administered by our Ophthalmologists. Additionally, systemic chemoreduction provided by our pediatric oncologists ensures a comprehensive, multimodal, and multidisciplinary approach to managing Retinoblastoma.

This treatment involves the super-selective infusion of chemotherapy into the ophthalmic artery—the blood vessel that delivers blood to the eye. This maximises the bioavailability of the drug in the targeted ocular structure, while minimising systemic drug exposure.

The current chemotherapeutic regimen used in intraocular chemotherapy comprises single or combined use of these three agents: melphalan (most commonly), topotecan or carboplatin. Introduced in 2006, this treatment has proven effective, especially in cases classified as advanced group D or E disease. A review comparing this method to primary enucleation showed no increased risk of orbital recurrence, metastatic disease or death.

While generally safe, there are potential side effects associated with intra-arterial chemotherapy. Transient effects, typically resolving within six months, may include eyelid swelling, eyelid drooping, loss of lashes, skin redness over the forehead, and temporary limitations in eye movements. More serious potential side effects involve occlusion of the retinal artery or vein and choroidal atrophy, which may result in visual loss. Systemic side effects also include low white blood cell counts, risk of stroke and allergic reactions.

    • Intra-vitreal chemotherapy involves the injection of medication directly into the vitreous cavity of the eye to treat refractory and recurrent seeding of the tumour into the vitreous. Reported complications include cataract formation, bleeding in the vitreous cavity, retinal haemorrhage and low eye pressures. There is also a risk of introducing infection into the eye, potentially leading to a loss of vision. Additionally, it carries a theoretical risk of tumour cells spreading through the needle track. Techniques used to minimize this risk include applying cryotherapy to the injection site before removing the needle, or using distilled water to wash the eye after needle removal. Distilled water has been shown to be effective in killing retinoblastoma cells in culture within a few minutes.

    • Systemic chemotherapy is another option to achieve globe salvage, often preserving useful vision. However, it comes with potential risks, including an increased likelihood of secondary tumours such as leukaemia, low blood counts, kidney toxicity, and hearing loss. However, in cases with metastatic disease, multiple-agent intensive systemic chemotherapy is utilized to target tumour cells that have disseminated to other parts of the body.
    • Radiotherapy has generally fallen out of favour because of the subsequent risk of second cancers, prompting a shift towards more efficacious and safer treatment options


The electroretinogram (ERG) is an objective and non-invasive method for evaluating the visual pathway (Fig. 3).  This diagnostic technique involves recording electrical signals produced by the retina in response to a brief flash of light. A reduction in ERG amplitude has been correlated with the degree of retinal disruption or toxicity. At our centre, ERGs are routinely conducted before each intra-arterial chemotherapy session to monitor retinal function.

Following successful treatment with regression of the tumour, surveillance has to be continued due to the potential for recurrence of disease or development of additional eye tumours.

ERG (landscape).png
Fig. 3 (a) This is the recording of the electrical activity in a normal eye
(b) This is the recording of the electrical activity in an eye affected by a retinoblastoma.  There is reduced amplitudes and loss of the normal sinusoidal pattern.
(c)This is the recording of the electrical activity of the eye shown in (b), after 2 cycles of intra-arterial chemotherapy. There is improvement in the amplitudes and more semblance to the normal sinusoidal pattern.

Will the Eyes Be Taken Out?

Overall, the need for removal of the eye to treat Retinoblastoma has diminished substantially. Once a primary intervention, eye removal is now considered only after exhausting all other eye-preserving option, such as systemic or intraarterial chemotherapy. It is predominantly recommended for older children (above 2 years) with advanced cancer in a single eye, providing a fast and effective therapeutic approach while minimising potential complications associated with alternative treatments.

Note: An eye is usually removed only when absolutely necessary and is no longer the primary treatment option.

Will My Child Appear Normal After Removal of the Eye?

Despite undergoing eye removal, most children can be successfully rehabilitated to appear and function normally. After the eye is removed and any residual tumour in the eye socket is cleared, an "orbital implant" is inserted during the initial surgery. This implant is connected to the child's eye muscles to ensure adequate volume and reasonable movement. While the child recovers from the surgery, a temporary 'artificial eye', a customized iris painted conformer, is placed until a definitive customised 'artificial eye' (prosthesis) is fitted after 6-8 weeks, when most of the swelling from the surgery has subsided. 

Can My Child Go to School Once Treated?

All children who have been treated are advised to wear protective spectacles with polycarbonate lenses, preferably tinted. These spectacles serve a dual purpose by not only shielding the eye(s) but also concealing subtle differences in appearance between the eyes. This precautionary measure ensures that children can engage in their daily activities, including physical exercises and studies, with a sense of normalcy. For children wearing a prosthesis (artificial eye), it is advised to wear protective goggles during swimming and contact sport. However, extra caution should be taken to prevent any injury to the normal eye.

Once Treated, How Long Should My Child Be Followed Up?

Once treated and completely rehabilitated, most children require regular and close follow-up until the age 5 years, and subsequently every 6-12 months until the age of 10. Thereafter, annual follow-ups with their eye specialists and paediatricians may be needed throughout their lifetime.

Is This A Genetic Disease? Why Should We Consider Genetic Testing? 

Retinoblastoma is the first cancer with an identifiable genetic mutation. Approximately 15-20% of children with retinoblastoma in one eye and all children with the condition in both eyes are likely to possess an identifiable genetic mutation. Once identified, this mutation can be used to screen siblings and parents for similar mutation. Such insights not only guide parental counselling but also identify other children susceptible to the disease. Furthermore, this approach diminishes the risk of transmitting the mutation to subsequent generations when these children reach adulthood. For children without the mutation, this approach minimizes the need for aggressive, repeated examinations under anesthesia, easing parental concerns. 

How Is Genetic Testing Done?

Most children are referred to the paediatric geneticist and counselled based on the family history and presentation. With informed consent, blood samples are collected and sent to national or international referral centres for genetic mutation analysis. In specific cases where the eye is removed prior to chemotherapy, tumour samples may also be used to identify genetic mutations.

Where Do NUH’s Retinoblastoma Patients Come From?

Apart from treating Retinoblastoma patients in Singapore (averaging 2-3 per year), our patients come from Indonesia, Vietnam, Malaysia, Myanmar, Sri Lanka and Russia.
Ocular Prosthesis (Prosthetic Eye)
A prosthetic eye (artificial eye) is used to restore the appearance of individuals who have lost an eye due to disease or injury. In normal circumstances, the removal of an eye causes not only an immediate loss of function and disfiguration to the patient, but also leads to devastating psychological effect. An ocular prosthesis or prosthetic eye implant is therefore an ideal form of rehabilitation, offering patients the opportunity to regain their confidence.

Customised Ocular Prosthesis

We offer custom-made prosthetic eyes that are moulded and designed by our skilled Ocularists to seamlessly fit the patient's socket. In contrast to stock (ready-made) prosthetic eyes, customised eye prostheses are known to minimise discomfort, discharge and other potential complications, allowing for extended wear.  

Each prosthetic eye undergoes meticulous fabrication in our laboratory, featuring hand-painted details that replicate the natural eye of the patient. Integrating modern techniques with a high standard of workmanship, every intricate detail—ranging from shape and size to the colour of the iris and blood vessels—is painstakingly recreated to achieve an accurate and lifelike result.

What Is A Prosthetic Eye Made Of?

Contrary to the common reference as a "glass eye," modern prosthetic eyes are crafted from high-quality cross-linked acrylic rather than glass. Taking the form of a convex shell, it is skillfully fitted over an orbital implant beneath the eye.

Making of a Customised Ocular Prosthesis

Your ophthalmologist will refer you to an ocularist, a specialist trained to create customised artificial eyes.

Steps of the procedure include:
  • Initial evaluation and counselling
  • Impression molding
  • Prosthetic model fitting
  • Iris and sclera painting
  • Fitting of completed prosthesis

Ocular Prosthesis Brochure 
Tearing Disorders
Tearing Disorders

Where Do Tears Come from and Where Do They Go?

Tears are produced constantly by the lacrimal gland, located under the upper eyelid. 

Tears play a crucial role in maintaining eye health, continuously produced by the lacrimal gland beneath the upper eyelid. These tears create a delicate film that prevents the eye's front surface from drying out. A sophisticated network of channels, known as the lacrimal drainage system, facilitates the efficient drainage of tears from the eye. These channels lead from the inner corners of the eyelids and direct tears into the nose.

What Causes Excessive Tearing? 

Any emotional stress or eye irritation can trigger an overproduction of tears. Blockage of the lacrimal drainage system is a major cause of excessive tearing, often observed in older individuals. This blockage is typically associated with age-related changes in the nasolacrimal duct. 

How Do You Treat a Blocked Lacrimal Drainage System?

Acute infection of the system must be treated with antibiotics. The next step is to determine the degree of obstruction and the site of blockage. This is simply done in the clinic by flushing the tear ducts with saline. While this may provide temporary relief, symptoms often recur. 

Surgery (dacryocystorhinostomy, or DCR), is necessary in cases of severe obstruction of the tear ducts, or in those with repeated infections of the system. 

Severe tear duct infection


What is a dacryocystorhinostomy?
  • It is a procedure performed for the treatment of tearing (epiphora) due to blockage of the nasolacrimal duct. 
  • It creates an ostium between the tear sac and the nasal cavity by removing the mucosa and bone layers between them.
  • There are two main approaches: External and Endoscopic
    • The external approach requires a skin incision.
    • The endoscopic approach creates the ostium from within the nose without the need for a skin incision.
    • Both have similar success rates, with each approach coming with its own set of advantages and disadvantages.

While external and endoscopic DCR remain the gold standard for nasolacrimal duct obstruction. However, contemporary surgical landscape is evolving towards minimally invasive techniques and lacrimal surgery is no exception. A notable development is the advent of Natural Orifice Transluminal Endoscopic Surgery (NOTES), especially in disciplines beyond lacrimal procedures.

Meanwhile, endoscopic lacrimal duct recanalization (ELDR) provides an alternative approach to the treatment of obstructive epiphora. ELDR is currently the least invasive procedure designed for primary acquired nasolacrimal duct obstruction (pando). ELDR restores the integrity of natural lacrimal drainage system, and avoids the necessity of making new bony openings. 

NUH Oculoplastics is the first hospital in Singapore to offer ELDR as the treatment of choice for nasolacrimal duct obstruction. 

Tearing in Newborns

Newborns may present with a "wet" eye, usually surfacing at one to two weeks of age. Occasionally, there may be associated mucopurulent discharge due to a membrane blocking the drainage system of tears into the nose. This blockage generally resolves spontaneously within four to six weeks, and massaging the inner corner of the eyelids may expedite the opening of the blockage. 

However, if tearing persists despite massage, flushing and probing of the drainage system can be done to perforate the membranous blockage. This is usually performed before one year of age, and maybe repeated if tearing is still not resolved. Should tearing persist despite initial interventions, surgical procedures become a viable option to alleviate the obstruction. 

Tearing disorders may be due to irritation of the eye or disorder of the drainage system. This cause can be determined by an eye doctor through simple tests.

Tumours of the Eye
Tumours of the Eye

Large basal cell cancer with central ulceration
Fig.1 This photo shows a large basal cell cancer with central ulceration

Surgical removal of the basal cell carcinoma
Fig. 2 Surgical removal of the basal cell carcinoma was performed.


What Is a Basal Cell Carcinoma?

BCC is a type of skin cancer that usually develops on sun-exposed areas (Fig. 1), and is the most common malignant eyelid tumour. 

Is a Basal Cell Carcinoma Dangerous?

For BCCs located on the lower eye lid near the inner corners of the eye, invasion of the tear drainage system can lead to deeper spread into the orbit. In more seevre cases, rxtension to the brain may occur.

What Are the Signs of a Basal Cell Carcinoma? 

The most common appearance is a pearly nodule. Central ulceration may be present, earning it the moniker of "rodent ulcer". A less common but more aggressive form of this tumour has a firm and flat appearance with indistinct borders. Loss of lashes can be another indicative sign in either form of the tumor.

How Can Basal Cell Carcinomas Be Treated?

The treatment of choice is surgical removal of the tumour, with various surgical techniques available. During surgery, margins are sent for pathological examination to confirm complete tumour removal. Radiotherapy or cryotherapy are alternatives for those ineligible for surgery, although with a higher recurrence rate compared to surgical excision.

Please make an appointment for consultation with a doctor if you notice any concerning signs or symptoms.


What is Sebaceous Gland Carcinoma?

Sebaceous gland carcinoma is the second most common malignancy of the eyelid. These tumours usually arise from the Meibomian gland, which plays a role in producing the lipid layer of the tear film. The characteristic yellow appearance of the tumor is attributed to the presence of lipid material.


Sebaceous gland carcinoma

Fig.1 This patient had a sebaceous gland carcinoma affecting the left lower eyelid. A yellow-coloured lump can be seen at the centre of the lid margin. The entire lower lid also has a thickened appearance.

Is a Sebaceous Gland Carcinoma Dangerous?

This is a highly malignant disease that is locally invasive, and can spread to the lymph node or other parts of the body. SGC is a potentially fatal disease due to metastatic spread of the tumour.

What Are Signs of a Sebaceous Gland Carcinoma?

This tumour is notorious for masquerading as more benign conditions, such as a chalazion or chronic eyelid inflammation, often resulting in delayed diagnosis. Another sign that may be present is the loss of lashes.

How Can Sgcs Be Treated?

This disease should be managed in conjunction with an oncologist. Systemic evaluation should be performed to evaluate for spread to the lymph nodes or other organs. In general, complete surgical removal should be performed when possible. Wide excision of the tumour is undertaken. During the surgery, the margins are sent to the pathologist, to ensure that the entire tumour has been removed successfully. In patients with advanced disease, orbital exenteration may be necessary. Radiotherapy for palliative purposes is an alternative for patient who are unable to undergo surgery.

Please make an appointment for consultation with a doctor if you have any signs or symptoms that worry you.

Is a Sebaceous Gland Carcinoma (SGC) Dangerous?

SGC is a highly malignant disease that is locally invasive and has the potential to spread to the lymph nodes or other parts of the body. The metastatic spread of the tumour renders sebaceous gland carcinoma a potentially fatal condition.

What Are Signs of a Sebaceous Gland Carcinoma?

This tumour is notorious for masquerading as a more benign condition, such as a chalazion or chronic eyelid inflammation, often resulting in delayed diagnosis. Another notable sign is the loss of lashes.

How Can SGC Be Treated?

Collaborative management with an oncologist is essential for addressing sebaceous gland carcinoma. Systemic evaluation is conducted to assess potential spread to lymph nodes or other organs. Surgical intervention, specifically wide excision of the tumour, is generally recommended when feasible. During surgery, the margins are sent for pathological examination to ensure that the entire tumour has been removed. In cases of advanced disease, orbital exenteration may be necessary. Radiotherapy for palliative purposes is an alternative for patients who are unable to undergo surgery.

Please make an appointment for consultation with a doctor if you have any concerning signs or symptoms.


What is a Melanoma?

A melanoma is a tumour that arises due to the malignant transformation of melanocytes. Melanocytes produce melanin, and can be found in the skin. In the eye, melanocytes can also be found on the conjunctiva, the iris, ciliary body, and choroid. As such, melanomas can be develop on the eyelid, the conjunctiva, or inside the eye. 

Is a Melanoma Dangerous?

It is a highly malignant disease that can spread to the lymph nodes or other organs such as the liver, lung, brain and bones. 

What Are the Signs of a Melanoma? 

  • Melanoma on the eyelid: features are suggestive of an acquired pigmented lesion, which include irregular borders, increasing size, ulceration, bleeding or a change in colours. In some cases, melanoma may be depigmented.
  • Iris melanoma: shows a range of appearances, from amelanotic to dark brown lesions. In some cases, diffuse lesions can alter the iris colour, and bleeding within the front chamber of the eye (hyphema) and secondary glaucoma may occur.
  • Ciliary body or choroidal melanoma: Early stages may be asymptomatic, but symptoms such as vision loss or flashes of light (photopsia) can develop. Complications may include cataracts, glaucoma, or retinal detachment.

How Can Melanomas Be Treated?

This disease should be managed in conjunction with an oncologist. Systemic evaluation should be performed to evaluate for spread to the lymph nodes, or other organs. 

For tumours arising on the eyelid, complete surgical removal is generally recommended, with wide excision of the tumor. Prognosis correlates with tumor thickness. During surgery, the margins are sent for pathological examination to ensure that the entire tumour has been removed.

For patients with intraocular melanoma, several factors need to be taken into consideration. This includes the size and extent of the affected eye, the visual prognosis of the eye and the state of the fellow eye. The general health of the patient also needs to be assessed before deciding on the most suitable therapeutic option.

Options include transpupillary thermotherapy for small tumors, radiotherapy, or enucleation for medium-sized tumors. Enucleation is often the choice for large tumors, optic nerve invasion, or poorly-seeing and painful eyes. 

Please make an appointment for consultation with a doctor if you have any concerning signs or symptoms.


Signs and Symptoms of an Orbital Tumour

  • Proptosis (Fig. 4) occurs as the tumour exerts s a mass effect.
  • Displacement of the globe (Fig. 5) causing double vision (diplopia).
  • Loss of vision due to compression or infiltration of the optic nerve.
  • Limitation in eye movement.

Protrusion of the right eye was due to a tumour behind the globe
Fig. 4
(a) This patient has marked protrusion of his right eye (proptosis).
(b) Protrusion of the right eye was due to a tumour behind the globe.

Inferior displacement of right globe, proptosis and fullness in right upper lid
Fig. 5
(a) This patient has inferior displacement of his right globe, proptosis and fullness in his right upper lid.
(b) MRI revealed a mass arising above the globe.

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