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.
The following medical conditions and aesthetic treatments are commonly managed in our clinic.
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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.
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.
Surgeries including:
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:
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 are the treatments available?
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.
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 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.
ECTROPION
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?
What are the treatment options?
Brochures
Common Eyelid Problems
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, 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 can be done for thyroid eye disease?
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.
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
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.
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.
Fig. 1 Leukoria (white coloured pupillary reflex) is present in the right eye due to retinoblastoma
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.
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.
Various treatment modalities are available in the management of a retinoblastoma.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Fig.1 This photo shows a large basal cell cancer with central ulceration
Fig. 2 Surgical removal of the basal cell carcinoma was performed.
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.
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.
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.
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.
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.
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.
It is a highly malignant disease that can spread to the lymph nodes or other organs such as the liver, lung, brain and bones.
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.
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.
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.
