Publications by authors named "Gangadhara Sundar"

77 Publications

Globe and Adnexal Trauma Terminology Survey.

JAMA Ophthalmol 2022 Jul 21. Epub 2022 Jul 21.

Lee Kong Chian School of Medicine, Singapore, Singapore.

Importance: Ocular trauma terminology should be periodically updated to enable comprehensive capturing and monitoring of ocular trauma in clinical and research settings.

Objective: To update terminology for globe and adnexal trauma.

Design, Setting, And Participants: A 2-round modified Delphi survey was conducted from January 1 to July 31, 2021, using an expert panel, including 69 ophthalmologists identified through their membership in ophthalmology (globe and adnexal trauma) societies. Consensus was defined as at least 67% expert agreement. A steering committee developed questions after identifying gaps in the current terminology via a targeted literature review. Round 1 sought consensus on existing and newly proposed terminology, and round 2 focused on unresolved questions from round 1. Experts included ophthalmologists who had managed, on average, 52 globe or adnexal trauma cases throughout their careers and/or published a total of 5 or more globe or adnexal trauma-related peer-reviewed articles.

Main Outcomes And Measures: Expert consensus on ocular and adnexal terms.

Results: A total of 69 experts participated in and completed round 1 of the survey. All 69 participants who completed round 1 were asked to complete round 2, and 58 responses were received. Consensus was reached for 18 of 25 questions (72%) in round 1 and 4 of 7 questions (57%) in round 2. Existing Birmingham Eye Trauma Terminology system terminology achieved consensus of 84% (58 of 69 experts) in round 1 and 97% (56 of 58 experts) in round 2. Experts agreed on the need for further refinement of the definition of zones of injury (55 of 69 [80%]), as the zone affected can have a substantial effect on visual and functional outcomes. There was consensus that the mechanism of injury (52 of 69 [75%]) and status of the lacrimal canaliculi (54 of 69 [78%]), nasolacrimal ducts (48 of 69 [69%]), lens (46 of 58 [80%]), retina (42 of 58 [73%]), and central and paracentral cornea (47 of 58 [81%]) be included in the revised terminology.

Conclusions And Relevance: There was consensus (defined as at least 67% expert agreement) on continued use of the existing Birmingham Eye Trauma Terminology system definitions and that additional terms are required to update the current ocular trauma terminology.
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http://dx.doi.org/10.1001/jamaophthalmol.2022.2594DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9305602PMC
July 2022

Prophylactic Intraoperative Nasolacrimal Duct Intubation in Surgical Treatment of Facial Fractures-Is There a Role?

Arch Plast Surg 2022 Mar 6;49(2):195-199. Epub 2022 Apr 6.

Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.

Nasolacrimal duct (NLD) damage is associated in the majority of type II and III naso-orbito-ethmoid (NOE) fractures. Our study aims to investigate the efficacy and safety of prophylactic NLD intubation in the setting of facial fractures, by comparing incidence of postoperative epiphora and wound infection. A retrospective matched control study was conducted on all patients with surgically treated facial fractures from 2008 to 2013 (  = 280) (IRB ref number: DSRB 2013/01198). Patients with the following fracture types were included: NOE (  = 16), frontal sinus (  = 2), Le Fort II/III (  = 8), and > 1 type (  = 48). All patients in this study were included with the intention to treat. The study group comprised patients who were intubated, while the control group patients were not intubated. Each group had 37 patients matched for age, gender, fracture type, and injury type. A single oculoplastic surgeon skilled in lacrimal surgery performed the procedure for all intubated patients. Patients with more severe and complex facial fractures were intubated with bicanalicular Crawford stents. Postoperative epiphora and infective complications (both facial wound and dacryocystitis) were assessed at 1, 3, 6, and 12 months. There was no significant difference in incidence of either postoperative epiphora (  = 0.152) or wound infection (  = 0.556) comparing both groups. Reduced incidence of postoperative epiphora in the study group is statistically not significant and does not support the need for prophylactic intubation. If radiographic evidence of NLD disruption or regurgitation seen on syringing on the NLD intraoperatively is present, intubation is safe and efficacious only if performed by an expert.
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http://dx.doi.org/10.1055/s-0042-1744407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9045536PMC
March 2022

Necrosis of uveal melanoma post-COVID-19 vaccination.

Indian J Ophthalmol 2022 05;70(5):1837-1840

Department of Ophthalmology, National University Hospital, National University of Singapore, Singapore.

A 49-year-old Indian male presented with rapidly progressive vision loss 1 day after receiving the second dose of BNT162b2 mRNA coronavirus disease 2019 (COVID-19) vaccine (Pfizer-BioNTech, NY, USA). The eye had secondary angle closure glaucoma, bullous retinal detachment, and massive intraocular hemorrhage. Ultrasound showed an ill-defined subretinal mass with moderate internal reflectivity. Magnetic resonance imaging (MRI) confirmed an enhancing heterogeneous subretinal mass. Histopathology showed a necrotic melanocytic lesion arising from the posterior edge of the ciliary body and choroid. Necrotic uveal melanoma was confirmed after expert histopathology opinion. Uveal melanomas can rarely present with tumor necrosis following mRNA COVID-19 vaccination.
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http://dx.doi.org/10.4103/ijo.IJO_3040_21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9333048PMC
May 2022

The application of clinical registries in ophthalmic trauma-the International Globe and Adnexal Trauma Epidemiology Study (IGATES).

Graefes Arch Clin Exp Ophthalmol 2022 Apr 23;260(4):1055-1067. Epub 2021 Nov 23.

Lee Kong Chian School of Medicine, Singapore, Singapore.

Ophthalmic trauma is a leading cause of preventable monocular blindness worldwide. The prevalence of ophthalmic trauma varies considerably based on geographic location, socio-economic status, age groups, occupation, and cultural practices such as firework celebrations. Clinical registries are known to be valuable in guiding the diagnosis, management, and prognostication of complex diseases. However, there is currently a lack of a centralized international data repository for ophthalmic trauma. We draw lessons from past and existing clinical registries related to ophthalmology and propose a new suitable international multicenter clinical registry for ophthalmic trauma: the International Globe and Adnexal Trauma Epidemiology Study (IGATES). IGATES is hosted on a secure web-based platform which exhibits user-friendly smart features, an integrated Ocular Trauma Score (OTS) prognosis calculator, efficient data collection points, and schematic graphical software. IGATES currently has 37 participating centers globally. The data collected through IGATES will be primarily used to develop a more robust and improved ophthalmic trauma prognostic classification system, the Ocular Trauma Score-2 (OTS-2), which builds on previous systems such as the Birmingham Eye Trauma Terminology System (BETTS) and Ocular Trauma Score (OTS). Furthermore, IGATES will act as a springboard for further research into the epidemiology, diagnosis, and management of ophthalmic trauma. Ultimately, IGATES serves to advance the field of ophthalmic trauma and improve the care that patients with ophthalmic trauma receive.
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http://dx.doi.org/10.1007/s00417-021-05493-6DOI Listing
April 2022

Prebending of Prefabricated Orbital Implants: Towards Improved Orbital Angle Symmetry Post Craniofacial Trauma Surgery.

J Craniofac Surg 2022 May 19;33(3):740-743. Epub 2021 Nov 19.

Department of Ophthalmology, National University Hospital Singapore.

Purpose: Reconstructive surgery after craniofacial trauma aim to restore orbital anatomy for function and aesthetic reasons. The purpose of this study is to improve postoperative orbital symmetry with the use of prebent prefabricated titanium implants.

Methods: In this retrospective study, patients with combined unilateral medial wall and floor fractures who underwent orbital reconstruction surgery were selected. The angle of inferomedial orbital strut (AIOS) was measured at 3 standard locations on preoperative facial computed tomography guided scans of the nonfractured orbit in the coronal view and used as a guide to bend the prefabricated titanium implants intraoperatively. The corresponding values were measured on the postoperative computed tomography and compared for symmetry.

Results: Out of 83 patients recruited for the study, 54 were in the prebent group while 29 were in the control group. All other demographics were similar among the 2 groups. Anterior AIOS has a difference of 4.9° between 2 orbits in the prebent group whereas a difference of 15.5° was noted in the nonprebent group. For middle AIOS, a difference of 4.7° was noted in the prebent group whereas nonprebent group had a difference of 14.1°. For posterior AIOS, the prebent group had a difference of 3.8° versus 14.1° in the nonprebent group. The difference in AIOS at all 3 points between the prebent and nonprebent group were significant.

Conclusions: Anatomical prefabricated titanium plates are versatile implants that facilitate orbital reconstruction. Prebending of these implants according to the fellow orbit can achieve better surgical outcomes in a cost-effective manner.
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http://dx.doi.org/10.1097/SCS.0000000000008107DOI Listing
May 2022

Intraocular Pressure and Glaucoma in Thyroid Eye Disease.

Ophthalmic Plast Reconstr Surg 2022 May-Jun 01;38(3):219-225. Epub 2021 Aug 17.

Orbit & Oculofacial Service, Department of Ophthalmology, National University Hospital, National University Health System, Singapore.

Purpose: Current literature lacks a summary of knowledge on intraocular pressure (IOP) elevation and glaucoma in thyroid eye disease (TED). This review aims to augment existing literature by providing such a summary. It qualitatively evaluates current knowledge on the pathogenesis, prevalence, and management of concomitant ocular hypertension or glaucoma in TED patients.

Methods: In this narrative review, relevant publications were identified through a computerized database search. Search results were screened for relevance. Correspondence, Editorials, and Letters to the Editors were excluded. References cited within the identified articles were used to further augment the search. Information extracted for qualitative analysis included epidemiologic data, methods of IOP assessment, management protocols, and response to treatment.

Results: Studies in current literature are relatively heterogenous, differing in country of origin, TED cohort sizes, and IOP measurement techniques. Further studies are required to elucidate the true epidemiologic relationship between TED and ocular hypertension or glaucoma. Proposed models of IOP elevation include elevation of episcleral venous pressure, mucopolysaccharide deposition within the trabecular meshwork, restrictive myopathy, steroid-induced glaucoma, and secondary glaucoma. IOP-reducing effects of TED treatment options are discussed.

Conclusions: While raised IOP in TED is a common phenomenon, the diagnosis of glaucoma in TED requires a high index of suspicion before any intervention.
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http://dx.doi.org/10.1097/IOP.0000000000002049DOI Listing
May 2022

Clinical application of "black bone" imaging in paediatric craniofacial disorders.

Br J Radiol 2021 Aug 8;94(1124):20200061. Epub 2021 Jul 8.

Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore.

For decades, CT has been the primary imaging modality for the diagnosis and surveillance of paediatric craniofacial disorders. However, the deleterious effects of ionising radiation in the paediatric population are well established and remain an ongoing concern. This is especially so in the head and neck region, which has relatively poor soft tissue shielding with many radiosensitive organs. The development of "black bone" imaging utilising low flip angles and short echo time (TE) has shown considerable promise in alleviating the use of ionising radiation in many cases of craniofacial disorders. In this review article, we share our experience of utilising "black bone" sequence in children with craniofacial pathologies, ranging from traumatic injuries to craniosynostosis and focal osseous/fibro-osseous lesions such as fibrous dysplasia and Langerhans cell histiocytosis (LCH). A detailed discussion on the technical aspects of "black bone" sequence, including its potential pitfalls and limitations, will also be included.
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http://dx.doi.org/10.1259/bjr.20200061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8764919PMC
August 2021

Epidemiology and outcomes of open globe injuries: the international globe and adnexal trauma epidemiology study (IGATES).

Graefes Arch Clin Exp Ophthalmol 2021 Nov 26;259(11):3485-3499. Epub 2021 Jun 26.

Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Novena, 308433, Singapore.

Purpose: To detail the methodology for a novel ocular trauma registry and utilize the registry to determine the demographics, nature of injury, and associations of severe visual loss for open globe injuries (OGI).

Methods: Thirteen hospitals in 7 countries used International Globe and Adnexal Trauma Epidemiology Study (IGATES) platform. Patients presenting between April 2009 and 2020 with OGI (with or without) adnexal involvement or intraocular foreign body (IOFB) were included.

Results: Analyses of presenting and final VA, using "severe vision loss" (VA ≤ 6/60) and "no severe loss" (VA > 6/60), were performed. Four hundred fifty-four (64%) patients had VA < 6/60 at presentation and 327 (44.8%) at final follow-up, with a highly significant association between presenting and final VA (p < 0.0001). From the cohort of 746 patients, 37 were missing VA at presentation and 16 at follow-up and complete clinical data was available for 354 patients. The male to female ratio is 6:1, and mean age 36.0 ± 20.0 years old. Relative afferent pupillary defect (RAPD), zone III injury, IOFB, and eyelid injury at presentation were recorded in 50 (6.7%), 55 (7.8%), 97 (13%), and 87 (11.7%) patients, respectively, and were significantly associated with VA < 6/60 at follow-up. Older age, ≥ 61 years, was associated with 3.39 times (95% CI: 1.95-5.89) higher risk than ≤20-year-old patients (p < 0.0001) and males 0.424 times (95% CI: 0.27-0.70) lower risk than female (p = 0.0001) of severe vision loss (SVL).

Conclusion: In OGIs from 13 hospitals, female gender, older age, zone III injury, eyelid injury, and IOFB were associated with higher risk of visual outcome of SVL.
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http://dx.doi.org/10.1007/s00417-021-05266-1DOI Listing
November 2021

Low-dose 'boom-boom' radiotherapy for ocular lymphoma arising from IgG4-related ophthalmic disease: Case report and literature review.

Eur J Ophthalmol 2021 May 24:11206721211018372. Epub 2021 May 24.

Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore.

Ocular adnexal extranodal marginal zone lymphoma (OA-EMZL) and immunoglobulin G4-related ophthalmic disease (IgG4-ROD) may exist on a continuum. Presence of immunoglobulin light-chain restriction and clonal gene rearrangement suggests presence of lymphoma; whereas bilateral, infraorbital nerve and systemic involvement accompanied by elevated serum IgG4 levels may indicate synchronous IgG4-ROD. Although steroids have been the mainstay for the treatment of IgG4-ROD, radiotherapy (RT) has been used occasionally. The reported RT doses range between 24 and 30 Gy, which can result in acute and late toxicities. A low-dose regimen of four Gy has not been previously described. We describe a patient with bilateral OA-EMZL arising from IgG4-ROD successfully treated with low dose 'boom-boom' radiotherapy. In addition, we review the literature for the association between these two conditions and the role of RT in their management.
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http://dx.doi.org/10.1177/11206721211018372DOI Listing
May 2021

Risk Factors of Thyroid Eye Disease.

Endocr Pract 2021 Mar 14;27(3):245-253. Epub 2020 Dec 14.

Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Medicine, National University Hospital, Singapore. Electronic address:

Objective: To examine risk factors that might be associated with thyroid eye disease (TED) in patients with Graves' disease (GD), which may guide physicians in the prevention and management of TED.

Methods: Medline and Embase were searched for articles discussing risk factors of TED. Comparisons were made between GD patients with and without TED, and between active and inactive TED GD patients. Weighted mean differences (WMDs) and odds ratios (ORs) were determined for continuous and dichotomous outcomes, respectively. Results were pooled with random effects using the DerSimonian and Laird model.

Results: Fifty-six articles were included in the analysis. Smoking, inclusive of current and previous smoking status, was a significant risk factor for TED (OR: 2.401; CI: 1.958-2.945; P < .001). Statistical significance was found upon meta-regression between male sex and the odds of smoking and TED (β = 1.195; SE = 0.436; P = .013). Other risk factors were also examined, and patients with TED were significantly older than those without TED (WMD: 1.350; CI: 0.328-2.372; P = .010). While both age (WMD: 5.546; CI: 3.075-8.017; P < .001) and male sex (OR: 1.819; CI: 1.178-2.808; P = .007) were found to be significant risk factors for active TED patients compared to inactive TED patients, no statistical significance was found for family history, thyroid status, cholesterol levels, or body mass index.

Conclusion: Factors such as smoking, sex, and age predispose GD patients to TED, and TED patients to active TED. A targeted approach in the management of GD and TED is required to reduce the modifiable risk factor of smoking.
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http://dx.doi.org/10.1016/j.eprac.2020.11.011DOI Listing
March 2021

Orbital Implants in Orbital Fracture Reconstruction: A Ten-Year Series.

Craniomaxillofac Trauma Reconstr 2021 Mar 11;14(1):56-63. Epub 2020 Aug 11.

Orbit & Oculofacial Surgery, Department of Ophthalmology, National University Hospital, National University of Singapore, Singapore.

Study Design: Retrospective comparative interventional series of all patients who had undergone orbital fracture repair by 2 senior orbital surgeons in a single tertiary trauma center from January 2005 to December 2014.

Objective: To compare the outcomes of different implants used for various types of orbital fractures.

Methods: Patients were evaluated by age, gender, etiology of fracture, clinical findings, type of fractures, and implant used. Main outcome measures included restoration of premorbid state without morbidity and complications including enophthalmos, diplopia, infraorbital hypoesthesia, and ocular motility restriction 1 year after fracture repair. Implant-related complications were collected for analysis.

Results: There were a total of 274 patients with 307 orbits reconstructed. Thirty-three (12.0%) patients sustained bilateral injuries; 58.0% ( = 178) of orbits had simple fractures (isolated orbital floor, medial wall, or combined floor and medial wall). The distribution of implants used were bioresorbable ( = 117, 38.1%) and prefabricated titanium plates ( = 98, 31.9%) depending upon the nature of fracture. Bioresorbables, titanium plate, and porous polyethylene were used significantly more than titanium mesh for simple fractures, and prefabricated anatomic titanium implants were used significantly more than the other implants for complex fractures. There was a statistically significant improvement in diplopia, enophthalmos, ocular motility, and infraorbital hypoesthesia (-value < 0.001) 1 year following orbital fracture reconstruction.

Conclusions: When used appropriately, diverse alloplastic materials used in orbital fracture repair tailored to the indication aid orbital reconstruction outcomes with each material having its own unique characteristics.
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http://dx.doi.org/10.1177/1943387520939032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868517PMC
March 2021

Three-Dimensional Planes of Reference for Orbital Fractures.

J Craniofac Surg 2021 Jun;32(4):1464-1466

Division of Plastic, Reconstructive & Aesthetic Surgery, National University Healthcare System.

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http://dx.doi.org/10.1097/SCS.0000000000007380DOI Listing
June 2021

Guidelines for the management of ocular trauma during the COVID-19 pandemic.

Indian J Ophthalmol 2020 Nov;68(11):2483-2485

Treasurer, All India Ophthalmological Society, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Madhya Pradesh, India.

As the COVID-19 pandemic rages on, India is recording a very high number of new cases daily; even as the country prepares to gradually "unlock", after months of lockdown. While elective eye surgeries such as uncomplicated cataract surgeries, blepharoplasty and eyelid procedures and refractive surgeries can be planned at a later date; emergency cases pertaining to ocular trauma cannot be deferred. This manuscript gives a brief overview of the general guidelines for the management of ocular trauma during the COVID-19 pandemic.
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http://dx.doi.org/10.4103/ijo.IJO_1892_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774135PMC
November 2020

Prevalence of thyroid eye disease in Graves' disease: A meta-analysis and systematic review.

Clin Endocrinol (Oxf) 2020 10 10;93(4):363-374. Epub 2020 Aug 10.

Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

Objective: Thyroid eye disease (TED) is a debilitating condition that frequently manifests in patients suffering from Graves' disease (GD). This study aims to analyse the prevalence of TED among GD patients, with a focus on geographical region-specific rates.

Methods: Medline and Embase were searched for articles examining TED prevalence on April 2020, and articles were retrieved and sieved. Statistical analysis was performed after Freeman-Tukey double arcsine transformation. Thereafter, results were pooled with random effects by DerSimonian and Laird model.

Results: Fifty-seven articles involving 26,804 patients were included in the review. The overall pooled prevalence of TED was 40% (CI: 0.32 to 0.48) and by continent was 38% (CI: 0.31 to 0.46) for Europe, 44% (CI: 0.32 to 0.56) for Asia, 27% (CI: 0.06 to 0.56) for North America and 58% (CI: 0.55 to 0.61) for Oceania. The prevalence of TED in Southeast Asia was 35% (CI: 0.24 to 0.47) and Middle East 48% (CI: 0.19 to 0.78). Subgroup analysis showed regions with predominantly Caucasians (37%; CI: 0.28 to 0.46) had a lower prevalence of TED compared to Asians (45%; CI: 0.33 to 0.58). The pooled prevalence of lid retraction was 57% (CI: 0.39 to 0.74), proptosis 57% (CI: 0.48 to 0.65), diplopia 36% (CI: 0.24 to 0.48) and ocular hypertension 13% (CI: 0.06 to 0.19).

Conclusion: A substantial proportion of patients with GD have TED and often manifest as lid retraction, proptosis and diplopia. Early detection through active screening might help to mitigate the progression of TED and its associated complications.
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http://dx.doi.org/10.1111/cen.14296DOI Listing
October 2020

Postoperative Quality of Life in Oculoplastic Patients.

Ophthalmic Plast Reconstr Surg 2021 Jan-Feb 01;37(1):12-17

Department of Ophthalmology, National University Hospital, Singapore.

Purpose: To conduct a literature review on postoperative quality of life in oculoplastic patients.

Methods: The authors conducted a database search to evaluate the evidence available for the change in quality of life after oculoplastic surgery.

Results: There was a wide disparity of evidence available for different oculoplastic conditions. Certain conditions, such as nasolacrimal duct obstruction, were well-researched while other conditions, such as epiblepharon, had little to no research supporting improvement in quality of life after surgery. The scales used to measure quality of life displayed heterogeneity.

Conclusion: There is a lack of published evidence concerning postoperative quality of life in patients with certain oculoplastic conditions such as brow ptosis, entropion, ectropion, epiblepharon, and orbital wall fracture. There is a need to standardize the quality of life data collection tools and scoring systems to allow better comparison and scrutiny of the current literature.
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http://dx.doi.org/10.1097/IOP.0000000000001681DOI Listing
April 2021

A Novel Method of CT Exophthalmometry in Patients With Thyroid Eye Disease.

Asia Pac J Ophthalmol (Phila) 2020 Jan-Feb;9(1):39-43

Department of Diagnostic Imaging, National University Hospital Singapore, Singapore.

Purpose: Conventional computed tomography (CT) exophthalmometry requires an intact lateral orbital wall and is therefore not feasible in patients who have undergone any form of lateral orbital wall surgery where the normal bony landmark may be lost or displaced. The purpose of our study is to validate an alternative method of CT exophthalmometry utilizing the posterior clinoid (PC) process as a new reference point that will allow for reproducible comparison of the anterior-posterior globe position in the preoperative and postoperative settings.

Design: Cohort study.

Methods: This is a retrospective study of 48 patients with clinically diagnosed thyroid eye disease who had undergone cross-sectional CT imaging in the pre- or postoperative settings. CT exophthalmometry was performed using both the conventional interzygomatic method and our proposed PC process method on all pre- and postoperative CT imaging by two independent observers. Interobserver variability analysis was performed with intraclass correlation coefficient. Correlation and agreement between the two methods were analyzed with Pearson correlation coefficient and linear regression method. All analyses were conducted at 5% level of significance with Stata MP V14.

Results: Interobserver variability analysis showed an intraclass correlation coefficient of >0.9 for both interzygomatic and PC methods. There is good correlation between the two different measurements observed in both the pre- and postoperative groups (r = 0.68 and r = 0.72, respectively, P < 0.001). Linear regression showed good agreement between the two different measurements with most of the points lying within the 95% limits.

Conclusions: Our new method agrees well with the conventional method and has the added benefit of being able to reliably assess the anterior-posterior globe position in patients who do not have intact lateral orbital walls after decompressive surgery.
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http://dx.doi.org/10.1097/01.APO.0000617908.29733.84DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7004459PMC
October 2020

Utilization of contrast-enhanced ultrasound in the evaluation of craniofacial osseous lesions: A case report.

Clin Imaging 2020 Mar 27;60(1):5-9. Epub 2019 Nov 27.

Department of Diagnostic Imaging, National University Hospital, 5 Lower Kent Ridge Rd, 119074, Singapore. Electronic address:

A 14-year-old boy undergoing brain MRI had an incidental avidly enhancing lobulated lesion in the left superolateral orbital rim with associated cortical erosion. Apart from Contrast-enhanced Magnetic Resonance Imaging (MRI), and Computed Tomography (CT), Contrast-Enhanced Ultrasound (CEUS) was obtained prior to a biopsy. It provided additional information about the microvasculature and an orbital biopsy was subsequently performed through an upper eyelid crease incision with minimal blood loss and no postoperative complications. Histopathological examination revealed features which were compatible with the diagnosis of LCH. The authors propose that CEUS may be considered as an adjunct and possibly alternative imaging modality for the evaluation of craniofacial osseous lesions, especially in the orbital region (due to the known radio-sensitivity of the eyes) and in pediatric patients, to minimize the risk of ionizing-radiation exposure.
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http://dx.doi.org/10.1016/j.clinimag.2019.10.018DOI Listing
March 2020

Vision loss associated with orbital surgery - a major review.

Orbit 2020 Jun 1;39(3):197-208. Epub 2019 Oct 1.

Department of Ophthalmology, National University Hospital, National University of Singapore, Singapore.

: Vision loss after orbital surgery is one of the most dreaded complications faced by the orbitofacial surgeon. This literature review was conducted in an attempt to determine the risk factors for severe vision loss and discuss the applied anatomy related to various types of orbital surgery - orbital tumor excisions, orbital decompression, and post-traumatic orbital reconstruction.: A literature search was conducted via PubMed and Google Scholar. All cases of vision loss following orbital tumor biopsy or excision, orbital decompression, and orbital trauma reconstruction were reviewed.: The incidence of postoperative blindness appears to be more after orbital tumor excisions (4.7%), compared to post-traumatic orbital reconstruction (2.08%) and orbital decompressions for thyroid orbitopathy (0.15%).The causes of vision loss include ischemic optic neuropathy, traumatic optic neuropathy, retinal and ophthalmic artery occlusions, and orbital compartment syndrome.: Apart from careful patient selection, proper counseling about the risk of postoperative blindness is of utmost importance. Detailed preoperative treatment planning, meticulous atraumatic intraoperative dissection under direct visualization, with attention to the danger zones and vital structures, close intraoperative and postoperative monitoring, and urgent management of potentially reversible compressive causes of vision loss can improve outcomes.
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http://dx.doi.org/10.1080/01676830.2019.1658790DOI Listing
June 2020

Quality of Life in Thyroid Eye Disease: A Systematic Review.

Ophthalmic Plast Reconstr Surg 2020 Mar/Apr;36(2):118-126

Orbit & Oculofacial Surgery, Department of Ophthalmology, National University Hospital, National University of Singapore, Singapore.

Purpose: The aim of this systematic review is to provide 1) an understanding of the components of quality of life (QOL) questionnaires and 2) an up-to-date insight of the types of QOL questionnaires available, strengths and limitations based on current literature.

Methods: A literature search was conducted from 18 to 21 of February 2019 using 6 major databases: Cochrane Library, Ovid Medline, PubMed, Scopus, Taylor and Francis, and Web of Science. All papers were skimmed by title and abstract to determine whether the paper fulfilled the screening criteria. In cases of uncertainty, the paper was read in totality to justify its inclusion. After that, duplicates were eliminated and the remainder was subjected to a second set of inclusion and exclusion criteria before finalizing the list of included studies.

Results: An initial search returned with 402 studies, which were subsequently filtered using prespecified criteria to 27 studies to collate information regarding questionnaires assessing QOL of thyroid eye disease patients.

Conclusions: The QOL of thyroid eye disease patients is best assessed using disease-specific questionnaires. Among the different types of questionnaires, the Graves Ophthalmopathy Quality of Life (GO-QOL) questionnaire is preferred due to its' ability to explore QOL in-depth and proven efficacy in many countries after cultural adaptation at the expense of time. Single-item questionnaires like the Thyroid Eye Disease Quality of Life (TED-QOL) are more suitable as screening tools in busy metropolitan settings while semi-structured interviews are important in developing new ways of assessing the QOL of thyroid eye disease patients.
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http://dx.doi.org/10.1097/IOP.0000000000001446DOI Listing
March 2021

Clinical spectrum, treatment and outcomes of uveal melanoma in a tertiary centre.

Singapore Med J 2019 Sep 14;60(9):474-478. Epub 2019 Jun 14.

Department of Ophthalmology, National University Hospital, National University of Singapore, Singapore.

Introduction: We aimed to describe the clinical characteristics, diagnostic challenges, treatment patterns and outcomes of uveal melanoma (UM) in a tertiary care centre.

Methods: This is a retrospective case series of 11 consecutive patients with UM who were managed in a tertiary referral centre between 2002 and 2017. Epidemiological, clinical, pathological and radiological characteristics were reviewed. Classification of choroidal melanoma as small, medium or large was based on the criteria established by the Collaborative Ocular Melanoma Study.

Results: Mean age at presentation was 42.9 (range 27‒67) years. In 7 (64%) patients, a definitive diagnosis of UM was made after a mean follow-up period of 6.4 (range 1‒17) months. There were one, six and four patients with small-, medium- and large-sized choroidal melanomas, respectively. Treatment was enucleation in 5 (45.5%) patients, plaque brachytherapy in 4 (36.4%) patients, transpupillary thermotherapy in 1 (9.1%) patient, and observation in 1 (9.1%) patient. Median follow-up was 29 months. Metastatic disease developed in 5 (45.5%) patients at the mean age of 46.6 (range 38‒56) years, with median overall survival of 20 months. Genetic mutations in three patients were monosomy 3 (n = 2), and gain of 3q and 8q (n = 1).

Conclusion: Our study supports the finding that UM in Chinese and Asian Indian patients presents at a younger age than in Caucasians. Although it is rare, ophthalmologists should remain mindful of this life-threatening disease. We propose establishing a national and regional registry for ocular tumours with genetic information to characterise the disease spectrum in Southeast Asia.
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http://dx.doi.org/10.11622/smedj.2019054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7911076PMC
September 2019

Sino-orbital desmoid tumor in a pediatric patient - Case report with review of literature.

Orbit 2019 Dec 27;38(6):477-485. Epub 2018 Dec 27.

Department of Pediatric Oncology, National University Health System , Singapore , Singapore.

We report a case of a 2-year-old female who presented with bilateral progressive proptosis, visual loss, nasal obstruction, and breathing difficulty. Magnetic resonance imaging revealed a large sino-orbital mass that was extending to the orbital apex and skull base. An initial diagnosis of rhabdomyosarcoma was made elsewhere on the basis of the presence of round and spindle cell tumor. Subsequent biopsy with immunohistochemical staining was positive for nuclear staining with β-catenin, shifting the diagnosis to a myofibroblastic tumor, favoring desmoid-type fibromatosis. With image guidance, near complete excision of tumor was performed by a multidisciplinary team, while respecting danger zones such as the skull base and the optic nerve. Following a recurrence over 2 months, additional excision was performed with a 6-month treatment of methotrexate and vinblastine. Desmoid tumor is a rare form of soft tissue tumor uncommonly seen in the orbital area. Although benign, it is known to be recurrent and infiltrative. Few data are known and further information will aid in the management of these tumors.
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http://dx.doi.org/10.1080/01676830.2018.1556306DOI Listing
December 2019

Efficacy and safety of pulsed intravenous methylprednisolone in early active thyroid eye disease.

Orbit 2019 Oct 12;38(5):362-369. Epub 2018 Dec 12.

Division of Orbit & Oculofacial Surgery, Department of Ophthalmology, National University Hospital , Singapore , Singapore.

: The mainstay of therapy for active inflammatory phase of thyroid eye disease (TED) is immunosuppression. Patients in our centre with early active TED are treated with pulsed intravenous methylprednisolone (IVMP). Two different protocols are offered in our centre: High dose (1g/day for 3 days, monthly for 6 months), or EUGOGO protocol (500 mg weekly for six weeks, followed by 250 mg weekly for the next 6 weeks). : A prospective cohort study of patients undergoing the two IVMP protocols was performed from January 2009 to May 2015. Main outcome measures were improvement of Clinical Activity Score (CAS) and International Thyroid Eye Disease (ITEDS) - VISA Inflammatory Index. : We had a total of 63 patients. Mean age was 43.1 ± 13.1years, females comprised 49.2% ( = 31), and 31 (49.2%) had a positive smoking history. Following IVMP, 65.0% ( = 41) had good response, 31.7% ( = 20) partial, and 3.3% ( = 2) poor. There were significant differences ( < 0.001) in CAS and ITEDS scores between pre-IVMP and post-IVMP visits, for both protocols. A higher proportion of patients receiving the modified EUGOGO protocol (58.3%) had persistent activity and required additional immunosuppression compared to those who underwent the high dose protocol (33.3%). Mild side effects were experienced by 5 (7.9%) and 3 (4.8%) patients at 3 and 6 months, respectively. There were no severe side effects, cardiovascular events or liver failure. : With adequate screening and follow-up, six repeated cycles of high dose pulsed IVMP is an effective treatment for TED and can significantly reduce the morbidity associated with this debilitating condition. None of the 51 patients from the high dose protocol met with any serious side effects.
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http://dx.doi.org/10.1080/01676830.2018.1553189DOI Listing
October 2019

Planes of Reference for Orbital Fractures: A Technique for Reproducible Measurements of the Orbit on Computed Tomography Scans.

J Craniofac Surg 2018 Oct;29(7):1817-1820

Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, National University Health System.

Purpose: Planes of reference for orbital fractures (PROF) was developed to standardize measurements made on orbital computed tomography scans. This study describes the use of PROF in determining the location along the orbital floor where the posterior ledge (PL) most commonly occurs. The transverse inclination and anterior-posterior inclination of the orbital floor will also be measured.

Methods: This study evaluates 104 patients with unilateral orbital fracture. Fifty-two patients had intact infra-orbital margin (IM) and 52 had fractured IM. Facial computed tomography scans were analyzed using Osirix Lite Digital Imaging and Communications in Medicine Viewer version 7.0.1 (Geneva, Switzerland). All skull positions were standardized by orientation according to Frankfurt and mid-sagittal planes. Measurements of distance of PL from IM were determined in the sagittal view. Measurements of the inclination of the orbital floor in the transverse and anterior-posterior sections were done on the coronal and sagittal views respectively.

Results: For patients with intact and fractured IM, the mean distances of PL from IM were 22.1 mm (95% CI: 21.2-23.0) and 21.1 mm (95% CI: 20.2-21.9) respectively. Mean transverse inclination was 19.4° (95% CI: 18.3-20.5). Mean anterior-posterior inclination was 15.5° (95% CI: 14.5-16.5).

Conclusion: Planes of reference for orbital fractures is a simple and effective method to acquire standardized measurements of the orbital cavity on computed tomography scans. Understanding the commonest location of PL and the orientation of the orbital floor in 3-dimensional space allows surgeons to perform dissection with greater precision.
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http://dx.doi.org/10.1097/SCS.0000000000005021DOI Listing
October 2018

Anophthalmic Sockets in Retinoblastoma: A Single Center Experience.

Asia Pac J Ophthalmol (Phila) 2018 Sep-Oct;7(5):307-311. Epub 2018 Aug 3.

Department of Ophthalmology, National University of Singapore, Singapore.

Purpose: To evaluate outcomes of anophthalmic sockets in retinoblastoma at a tertiary care center in Singapore.

Design: A retrospective study.

Methods: Patients who underwent enucleation as sole/part of treatment for retinoblastoma were reviewed at our center from 2005-2017. Details including demographics, grouping and staging, adjuvant therapy, surgery, implant, and complications were collected.

Results: Of 42 patients with retinoblastoma managed over the period, the anophthalmic sockets of 31 patients who underwent enucleation were analyzed. Mean age at enucleation was 2 years. Twenty-three enucleations were performed at our institution and 8 enucleations had been performed elsewhere. Seventeen patients (52%) had porous polypropylene, 9 patients (27%) had polymethylmethacrylate, 1 patient (3%) had glass implant, and 3 (9%) had dermis fat graft. The sizes of implants varied from 10 to 20 mm. Twelve patients had attempts at globe salvation before enucleation. Out of 28 patients with primary orbital implants, 3 had implant exposure. The rates of repeat surgery among patients with and without primary implant were 66.67% (2 out of 3) and 10.7% (3 out of 28), respectively. One patient had postenucleation socket syndrome with stock eye. Five patients referred for enucleation were conservatively managed.

Conclusions: Anophthalmic sockets in retinoblastoma have long-term implications if the primary procedure is not performed well. While the majority had good outcomes (structural and esthetic), a minority had complications requiring intervention. Ophthalmologists managing retinoblastoma must be aware of these. Primary implant had favorable outcome with minimal complications.
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http://dx.doi.org/10.22608/APO.201892DOI Listing
October 2018

A case report on dermal filler-related periorbital granuloma formation.

Orbit 2019 Apr 29;38(2):169-172. Epub 2018 May 29.

c Vasan Eye Care , Dubai , United Arab Emirates.

We report a case of a 49-year old East-Asian female who presented with delayed onset granuloma formation at the right medial lower eyelid area. The clinical and radiologic presentation with pathologic correlation following synthetic hyaluronic acid filler injection and its management are described along with a review of literature following dermal-filler injections types. Dermal-filler-related granuloma formation should be included in the differential diagnoses of periorbital inflammatory and mass lesions. It is recommended that clinicians who perform this procedure should discuss these risks and possible late complications with patients and provide them with the relevant product information of the injected filler for appropriate management should such early or late complications occur.
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http://dx.doi.org/10.1080/01676830.2018.1477806DOI Listing
April 2019

Permanent Versus Bioresorbable Implants in Orbital Floor Blowout Fractures.

Ophthalmic Plast Reconstr Surg 2018 Nov/Dec;34(6):536-543

Yong Loo Lin School of Medicine, National University of Singapore.

Purpose: To compare the outcomes of bioresorbable and permanent implants in the reconstruction of isolated orbital floor blowout fractures.

Methods: Retrospective series of all patients who had orbital floor fracture repair in a single tertiary trauma center from January 2005 to December 2014. The authors reviewed the case notes and CT scans of patients with orbital floor fracture repair with either bioresorbable or permanent implants. Main outcome measures were enophthalmos, diplopia, and ocular motility restriction 1.5 years after fracture repair. Implant-related complications were collected for analysis.

Results: There were a total of 88 patients in our study. Bioresorbable implants were used in 48 patients (54.5%) while 40 patients had permanent implants (45.5%). The authors analyzed the implants used in various sizes of orbital fractures: small (<13.3 mm), medium (13.3-20 mm), and large (>20 mm). One and a half years after fracture repair, both groups had comparable clinical outcomes (n = 2 and n = 0 for diplopia for permanent and bioresorbable implant groups, respectively, n = 0 for enophthalmos for both groups and n = 1 for ocular motility limitation for both groups) overall and across all fracture sizes.

Conclusion: Bioresorbable implants degrade after fracture healing through hydrolysis and promote the gradual transfer of functional forces to healing bone during its disintegration. The clinical outcomes of diplopia, enophthalmos, and ocular motility restriction associated with the use of resorbable implants are comparable to that of permanent implants for all fracture sizes. Their study shows that bioresorbable and permanent implants are equally safe and effective for the treatment of patients with isolated orbital floor blowout fractures.
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http://dx.doi.org/10.1097/IOP.0000000000001077DOI Listing
May 2019

Vascular lesions of the orbit: Conceptual approach and recent advances.

Indian J Ophthalmol 2018 01;66(1):3-6

Department of Ophthalmology, National University Hospital, National University of Singapore, 119077, Singapore.

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http://dx.doi.org/10.4103/ijo.IJO_1272_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778577PMC
January 2018

Surgical treatment outcome of medically refractory huge giant papillary conjunctivitis.

Am J Ophthalmol Case Rep 2017 Dec 18;8:22-24. Epub 2017 Sep 18.

Department of Ophthalmology, National University Hospital, Singapore.

Purpose: To compare the surgical outcome of excision of giant papillae with and without amniotic membrane in a patient with bilateral medically refractory giant papillary conjunctivitis (GPC).

Observations: 27-year-old Chinese lady presented with bilateral itchy eyes, discomfort and fullness of upper lids for past two years. She was a long-term contact lens user but stopped completely 2 years ago. Not a known atopic, she had unusually large giant papillae involving both upper tarsal conjunctiva. She had used topical olopatadine(0.1%), intermittent dexamethasone(0.1%) and also underwent intralesional injection of Triamcinolone (40mg/ml) twice on each side without any improvement in past two years. We decided to excise the papillae with amniotic membrane transplantation (AMT) in left eye and only excision in the right eye. The results were compared after 2 years. Giant papillae were excised in both eyes under regional anesthesia on separate occasions. The left eye received AMT in addition to excision. A symblepharon ring was applied and left in place for two weeks in both eyes. She was treated with topical Prednisolone acetate (1%) and Levofloxacin 4 times a day for a month. Postoperative period was unremarkable and she recovered well. In 2 years follow-up, the upper tarsal conjunctiva was smooth in both eyes and there was no evidence of any recurrences.

Conclusion And Importance: Excision of giant papillae is a treatment option for cases with refractory GPC. Additional AMT after excision may not be necessary as there was no difference in surgical outcome.
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http://dx.doi.org/10.1016/j.ajoc.2017.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5731670PMC
December 2017
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