NESOS eMag 2nd issue

Volume 1, No. 2, July-December 2021

“ The wayward eyelids”

an Official biannual
e-Magazine by:



NESOS E-MAG

NESOS e-Mag is the official biannual electronic magazine of the Nepalese Society for
Oculoplastic Surgeons (NESOS). This e-Magazine will be a concoction of scientific publi-
cations such as articles, reviews, opinions, tips and tricks, interesting cases, and out-of-
the-track contents like interviews of eminent Nepalese oculoplastic surgeons, success
stories, photo gallery and oculoplastic news.

The aim of the e-Magazine is to provide a platform for the oculoplastic surgeons from
Nepal and abroad to discuss and engage on topics related to orbit, ophthalmic plastic and
reconstructive surgeries, oculofacial aesthetics and ophthalmic oncology. This will also
provide a platform for young oculoplastic surgeons and aspirants to learn from the expe-
rienced ones in the field. The e-Magazine also aims to disseminate important information
and messages regarding the NESOS activities including the news and events.

INFORMATION TO THE • Original research articles tion of 2–3 sentences related
AUTHORS: • Case report/ case series to the photograph and the
• Picture essay - Interesting name of the photographer.
Subscription information:
The e-Magazine is available oculoplastic pictures with Please note:
to download free of charge short explanation 1. This is not a peer reviewed
from www.nesosnepal.org.np,
& www.nesosemag.medium. 2. Word count: publication. Published ar-
com. While the word count is not ticle will not be counted as
rigid, it is advised that the academic achievement.
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mission: limit for their articles. the author to obtain ap-
• Major review and original propriate consent for the
1. Articles structured in appro- publication of the patient
priate academic English lan- research articles — maxi- details and patient photo-
guage and well referenced for mum 3000 words graphs.
factual data or claims should • Expert opinion, tips and 3. The articles need to be
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thor details and photograph to words referenced for any claims
[email protected] or as • Case report and series — or factual data presented
per the submission procedure maximum 1000 words in the article.
stated in the NESOS website • Picture essay — maximum 4. The opinions and any
(www.nesosnepal.org.np). 500 words claims made in the mag-
The articles can be one of the azine would be the liabil-
following: 3. Interesting photographs ity of the authors solely
• Reviews, expert opinion, related to oculoplasty, ocu- and NESOS or Editorial
loplasty surgery or surgeon, board would not bear any
history of surgery, and those depicting success responsibilities for any
tips/tricks stories in Oculoplasty are disputes arising thereof.
also welcomed. Photographs 5. The editorial committee
should have a brief descrip-

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 01

deserves the right to reject COPYRIGHTS:
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hibited.
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Department of Oculofacial
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NESOS e-Mag “The High-
way of Tears”
Year 1, Volume 1, Issue 2

02 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

EDITORIAL COMMITTEE

Dr Ben Limbu Dr Basant Raj Sharma Dr Rohit Saiju Dr Naresh Joshi
Patron Patron Patron Patron

Dr Aashish Raj Pant Dr Hom Bahadur Gurung

Editor Editor

Dr Triptesh Raj Pandey Dr Prerana Kansakar Dr Suresh Rasaily
Associate Editor
Associate Editor Associate Editor

Dr Aric Vaidya Dr Santosh Chaudhary
Associate Editor Graphic Designer

IN THIS ISSUE:

12. Anatomy of eyelid revisited

Nisha Shrestha

13. Clinical Case - Congenital ptosis in 3 siblings

Sabin Sahu

14. Tips and tricks - Choice of surgery for lower lid entropion

Aashish Raj Pant

16. Entropion surgeries

Ramita Kharel, Binita Bhattarai

21. Interview - Heart to heart with Dr. Naresh Joshi

26. Surgical pearls - Modified suture canthoplasty

Prerana Kansakar, Gangadhara Sundar

28. Oculoplasty Updates

Hom Bahadur Gurung, Aashish Raj Pant

32. NESOS newsdesk

33. NESOS members in action

37. Welcome to the fraternity - New NESOS members

38. The I-Stories: Oculoplasty in Photography

42. The video bouquet: Oculoplasty in Video

43. NESOS poll COVER PAGE STORY:

Courtesy - Aashish Raj Pant, MD, ChM

Picture 1 (top right) - Young female with bilateral lower lid epiblepharon;

Picture 2 (top left) - Capsulopalpebral fascia demonstrated during Jones procedure;

Picture 3 (bottom right) - Bilateral upper lid ptosis (right>left);

Picture 4 (bottom left) - Left eye cicactrical ectropion of both upper and lower eyelid

04 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

MESSAGE :
FROM THE PRESIDENT OF
NESOS

I would like to congratulate the NESOS eMag editorial BEN LIMBU, MD
committee led by Dr Aashish Raj Pant and Dr Hom
Bahadur Gurung for the successful launch of the sec- President
ond issue of the NESOS eMag entitled “The wayward Nepalese Society for
eyelids”. Oculoplastic Surgeon

NESOS eMag provides a platform for the members
of the NESOS to share and learn their knowledge and
experience regarding cases of oculoplasty and ocu-
lar oncology. Besides, the eMag also highlights the
activities carried out by the NESOS during the past 6
months.

I would also like to thank the sponsers for this issue
of the NESOS eMag - Vaishno Medisales, Biomed,
NPL, Jyoti eye hospital and Global eye hospital. We
hope for the continued support in the future.

My best wishes to the editorial team.

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 05

EDITORIAL

It is our great pleasure to bring forward the second issue of the “NESOS e-Mag”:
an official biannual e-Magazine of the Nepalese Society for Oculoplastic Surgeons
(NESOS). The first issue “The highway of tears” was well received by our readers
and we are thankful for the kind suggestions and warm appreciations made by the
esteemed readers for the maiden issue.

The theme for this issue is “The wayward eyelids”. The Oxford learners dictionary
defines wayward as “difficult to control”, thus, a wayward eyelid signifies a dystopic
eyelid which is difficult to control, unless an appropriate intervention is performed
by the oculoplastic surgeons. This issue is thus focussed on the common eyelid
conditions in oculoplasty such as entropion, ectropion and blepharoptosis.

This issue is our effort to make it a fun-to-read eMagazine and not just pages of
information. Apart from the review articles, opinions and, tips and tricks; we have
continued the Interview section - this time we have interviewed one of the globally
renowned pioneer of oculoplasty surgery from Nepal, Dr. Naresh Joshi. We have
also started an Oculoplasty update section where we have reviewed some impact-
ful articles published in the last 6 months in major oculoplasty and ocular oncology
journals. We have also started a section “Video Bouquet where we have provided
links for the oculoplasty videos of surgeries performed by the members of NESOS
and other pioneers of Oculoplasty. We have also continued providing an update on
activities conducted by NESOS while oculoplastic photostories have been covered
through the “I-stories”.

The objective behind the introduction of the e-Mag is to provide an ideal forum
for exchange of information on oculoplasty through research papers, reviews and,
case study/ series whilst retaining its character as an eMagazine with news, sto-
ries, photos and event coverages. We hope we are able to deliver that and promise
to keep continuing the same in the days ahead. We appreciate the efforts of all the
members of the NESOS executive committee, our esteemed authors, designers,
and the sponsors for the tremendous support.

Feedbacks and suggestions are always welcome. You can contact us at ne-
[email protected].

Hope you have a joyful reading.

06 NESOS E-Mag Volume 1, No. 2 (July - Dec, 2021)

REVIEW:

Clinical Anatomy of Eyelid Revisited

Nisha Shrestha
Lecturer, KIST Medical college

ABSTRACT
A sound knowledge of anatomy of eyelids is important for the successful outcome
of eyelid surgery and helps in minimising the complications in difficult cases and
maximising the outcomes. In this article, we revisit the clinical anatomy of eyelid
based on static and dynamic components.

INTRODUCTION Static eyelid anatomy: areolar tissue and aponeuro-
Eyelids are complex anatomic • Surface anatomy sis. The skin of forehead is the
structures and a sound knowl- • Lid margin thickest in the face and is trans-
edge of the eyelid anatomy • Anterior and posteri- versely oriented and forms a
(both form and function) is es- septae extending from the der-
sential to achieve good surgical or lamella mis to the frontalis.
outcome in ophthalmic plastic • Neuro-vascular-lym- The elevator of the forehead
and reconstructive surgery.1 and eyebrow is the frontalis
The eyelids not only act to pro- phatic supply muscle which originates from
tect the anterior surface of the the galea aponeurotica and it
globe from local injury but also Dynamic eyelid anat- merges with skin of eyelids and
aid in tear production (lipid omy: nose.
layer), tear film maintenance • Eyelid opening The depressors include pro-
and distribution, tear drainage • Eyelid closure cerus, corrugator supercilia.
(lacrimal pump), aesthetic and • Lid creases and folds Procerus is a triangular muscle
also to aid in light regulation. • Lid position originating from the fascia of
The anatomy of the eyelid can • Lacrimal pump nasal bone and inserting into
be divided into static or struc- the skin of glabella and fore-
tural and dynamic or function- mechanism head, between frontalis bellies.
al eyelid anatomy This muscle is responsible for
1. FOREHEAD the horizontal wrinkles over
It includes skin, connective
tissue, muscle, subcutaneous 07

Volume 1, No. 2 (July - Dec, 2021) NESOS E-Mag

nasal bridge; draws medial an- of lateral brow more. Retro Or- Applied anatomy of
gle downward. bicularis Oculi Fat pad (ROOF) eyelids:
Corrugator supercilia origi- is responsible for eyebrow vol- • Abnormalities of
nates from the nasal process of ume and mobility of the lateral
the frontal bone and extends eyebrow and eyelid. lashes: trichiasis,
obliquely over the supraorbital 3. EYELIDS: pseudo trichiasis, dis-
rim where it interdigitates with Eyelids are the pair of mobile, tichiasis, trichomeg-
fibers from the frontalis and flexible multilamellar struc- aly.
orbicularis muscles and inserts tures that cover the globe • Ectropion, Entropion
into the deep surface of the anteriorly. Eyelid skin is the • Blepharitis – anterior
skin. It pulls the forehead and thinnest due to attenuation of and posterior
eyebrow in an inferomedial di- dermis. They measure 30 mm • Chalazion, Hordeo-
rection giving frown lines, gla- horizontally. Lateral canthus is lum
bellar folds, rhytids. It is sup- 5-7 mm medial to orbital rim
plied by the buccal division of and 2mm above medial canthus line is an important structure
7th cranial nerve. and up to 5mm in mongoloids. in eyelid which corresponds to
Depressor supercilii originates In cases of antimongoloid slant muscle of Riolan. It separates
from the medial orbital rim, however the lateral canthus eyelid margin into anterior
near the lacrimal sac and in- lies below the medial canthus. and posterior lamella. Meibo-
serts into the medial aspect of Medial canthus is more obtuse
the bony orbit, inferior to the and moved away from globe Clinical aspects of an-
corrugators supracili. The mus- in Treacher Collins syndrome, terior lamella include:
cle acts as an accessory depres- mandibulofacial dysostosis.. • Stretching of skin
sor of brow. Lid margin
2. EYEBROWS: It is 2 mm wide and from an- with age provides
Male have straighter orienta- terior to posterior lies lash excess tissue available
tion of brows whereas female line, grey line, meibomian for reconstruction,
have more arched with apex gland opening and posterior dermatochalasis,
laterally. Medially it is angular mucocutaneous junction re- blepharoplasty.
and has lateralized cilia where- spectively. Lower lid margin • Full thickness skin
as laterally it is in a decreasing is distinct and is separated by graft uptake is good
degree. The upper end is direct- papillae lacrimalis containing due to rich vascular
ed downward and lateral from punctum (0.4-0.8 mm) into supply and no subcu-
the vertical plane whereas low- (1/6th) medial lacrimal part taneous fat.
er end is directed upward and & (5/6th) lateral ciliary part. • There is no vertical
lateral thus incisions need to There are 100 lashes in upper excess lower eyelid
be beveled to prevent lash fol- lid and 50 in lower lid. They skin so incisions
licles. In cases of Lateral brow originate from anterior lamella should be vertical
ptosis, frontalis contraction is in two or three irregular rows. in Lower lid, at lid
decreased, gravitational pull Several sebaceous Zeiss glands crease in upper lid.
from heavy cheek and lateral empty into each lash follicle • If thick graft is used,
facial tissues leads to elevation while Moll sweat glands are small bite should be
located between follicles. Grey taken at thick skin
and large bite at thin
skin.

08 NESOS E-Mag Volume 1, No. 2 (July - Dec, 2021)

mian gland line is an opening
of ducts of Meibomian glands.
They are approximately 25 in
upper lid and 20 in lower lid
and are vertically oriented.

Eyelid constitutes skin, sub- originates from upper and low- Surface anatomy of eyelid
cutaneous areolar tissue, mus- er margins of the medial can-
cles of protraction (striated), thal ligament and gets inserted Orbital septum applied
submuscular areolar tissue, lateral to the orbital rim on the anatomy
fibrous layer- orbital septum zygoma. It overlies the orbital • Age related herniation
and tarsus, retractors, conjunc- septum and orbital rim sepa-
tiva from anterior to posterior. rated by a fibrofatty layer the of orbital fat due to its
The balance of anterior and post orbicularis fascia. weakening, weakest at the
posterior lamella is integral for The orbital part originates medial part of lower lid -
normal lid architecture. An- from maxillary and frontal Dermatochalasis
terior lamella consists of skin bones and ends as medial can- • Barrier against the spread
and subcutaneous tissue. Skin thal ligament. It overrides the of infection
is thinnest and consists epider- orbital rims and inserts at the • Orbital cellulitis (behind
mis, attenuated dermis, seba- same location as the preseptal the septum) vs preseptal
ceous and sweat gland and mel- orbicularis. Orbital part is re- cellulitis (anterior to the
anocytes. It is slightly thicker at sponsible for the firm lid clo- septum)
infrabrow laterally. Subcutane- sure and squeezing of eyelids. gray line at lid margin. At the
ous tissue is a loose connective The action of the orbital part of anterior lamella it causes mei-
tissue containing no fat. the orbicularis is antagonized bomian gland discharge where-
Orbicularis oculi is the protrac- by occipitofrontalis. Palpebral as at posterior lamella it leads
tor of the eyelids. It is divided part causes gentle lid closure to lash position and movement.
into orbital and palpebral part. and involuntary eyelid move- Horner’s muscle (pars lacrima-
Palpebral part is further divid- ments (blinking). Its action is lis) is the deep pretarsal head of
ed into pretarsal and presep- antagonized by levator palpe- the orbicularis. Its contraction
tal part. The pretarsal part brae superioris. The muscle of pulls the eyelids medially and
contains superficial and deep Riolan is the ciliary portion of posteriorly which in turn com-
heads. Deep head originates orbicularis and corresponds to presses the canaliculi and lacri-
from posterior lacrimal crest mal ampullae pushing tears to-
and lacrimal fascia. Superficial ward the lacrimal sac. Paralysis
head originates from anterior
limb of the medial canthal ten-
don. The upper and lower eye-
lid segment fuse in lateral can-
thal area to become the lateral
canthal tendon and insert into
the lateral orbital tubercle. The
preseptal is also divided into
superficial and deep heads. It

Volume 1, No. 2 (July - Dec, 2021) NESOS E-Mag 09

Applied anatomy of fat pads Applied anatomy of
LPS
• Imparts fullness and smoothness to lids • Ptosis which may be
• Atrophy of the fat pads results in sunken looks, involu-
due to LPS muscle
tional enophthalmos, deep sulcus paralysis (3rd nerve
• Hypertrophy or prolapse of fat pads causes baggy eyes palsy) or LPS aponeu-
• Fullness of upper lateral part of the eyelids may be due rosis dehiscence/
detachment due to old
to lacrimal gland and not to be confused with fat pad age, surgery, trauma
• Identification of Levator aponeurosis and CPF during or inflammation.
• Lid crease – LPS
surgery is made easier by the fat pads detachment/ dehis-
• Contiguous with posterior orbital fat pad – upper cen- cence leads to absent
lid crea se. Asian
tral, lower all eyelids typically have
• Fat prolapse/ baggy eyelids may require blepharoplasty no lid crease. In these
cases, lid crease can
with fat reduction be formed by LPS
• Should not be directly cut due to the vasculature - cau- orbicularis suturing at
intended lid crease
terize and cut • Retracted eyelids –
• Inferior oblique muscle is located between inferior cen- patients with retracted
eyelids can be treated
tral and lateral pocket of fat pads by LPS weakening
by full thickness
or senile weakness of the mus- The inferior tarsus is smaller, blepharotomy
cle causes eye closure weak- thin, elliptical vertical diame- • Patients with Marcus
ness, ectropion and epiphora. ter of about 5 mm. Meibomian Gunn Jaw winking
Fibrous layer is formed by the glands are aligned vertically can be managed by
orbital septum which is a thin, within tarsus. Detachment of LPS
multilayered sheet of fibrous Upper eyelid retractors include and frontalis sling.
tissue. It arises from the perios- Levator palpebrae superioris
teum over the superior and in- and levator aponeurosis, su- Muscular part is 40 mm length
ferior orbital rims at the arcus perior tarsus muscle (Muller and aponeurosis is 14-20 mm
marginalis. Centrally it is con- muscle) and Whitnall’s liga- length. It is divided into ante-
tinuous with the tarsal plates. ment as support. Lower eyelid rior and posterior portion. An-
Laterally it is superficial and retractors include Capsulopal- terior portion is fine strands of
lies anterior to lateral palpebral pebral fascia (CPF), inferior aponeurosis and is attached to
ligament. Medially, it is behind tarsus muscle and Lockwood’s the pretarsal orbicularis muscle
lacrimal part of orbicularis oc- ligament as support. bundle and the skin. Posterior
uli. In the upper eyelid, it fuses Levator palpebrae superioris portion is firmly onto the an-
with the levator aponeurosis originates from the apex of terior surface of the lower half
2-5mm above the superior tar- the orbit from the periorbi- of the tarsus. Lateral Horn of
sal border whereas in the lower ta of lesser wing of sphenoid.
eyelid it fuses with the capsulo-
papebral fascia at or below the
inferior tarsal border.

10 NESOS E-Mag Volume 1, No. 2 (July - Dec, 2021)

the levator forms a prominent cle. Medial Horn of the levator palpebral artery branch of oph-
fibrous sheet that indents the blends with the intermediate thalmic Artery forms Marginal
posterior aspect of the lacrimal layer of the orbital septum and arcade, superficial branches of
gland, and so defines it’s orbital gets inserted into the posterior medial palpebral artery form
and palpebral lobes. It is insert- crus of the medial canthal ten- the Peripheral arcades and su-
ed into the lateral orbital tuber- don & the posterior lacrimal perficial temporal, transverse
crest. facial and infraorbital artery
Applied anatomy of Mullers muscle originates forms tarsal artery supplying
Mullers muscle from undersurface of levator the eyelids. Venous drainage is
• 1-2 mm ptosis which aponeurosis, 12-14 mm above through Ophthalmic and an-
the upper tarsal margin and gular vein and superficial tem-
is due to Lesion of the inserts into the superior tarsal poral vein from the medial and
cervical sympathetic margin. It helps in widening lateral part of eyelid respective-
chain with resultant palpebral fissure with resultant ly.
Muller muscle paral- 2mm elevation(approximate- NERVE SUPPLY: Upper eye-
ysis ly). lid is innervated by supra orbit-
• Horner’s syndrome Lower eyelid retractors: Cap- al nerve, supra trochlear nerve,
– a triad of Ptosis, sulopalpebral fascia originates infra trochlear nerve and Lac-
miosis and enophthal- as the capsulopalpebral head rimal nerve. Lower eyelid is
mos (Note: Ptosis + from attachments to the ter- innervated by Infra trochlear
mydriasis - 3rd nerve minal fibers of inferior rectus nerve and infra orbital nerve
palsy) muscle. Anterior to inferior LYMPHATIC DRAINAGE:
• The peripheral arterial oblique two portions of the Upper lid, lateral 1/3rd of low-
arcade –between the capsulopalpebral head fuse to er lid and lateral canthus drains
levator aponeurosis form the Lockwood suspenso- to preauricular lymph node
and muller muscle is a ry ligament and gets inserted and deep parotid nodes then to
useful surgical land- into the inferior tarsal border. cervical lymph nodes. Medial
mark to identify the Its functions are lid excursion part of upper lid, medial 2/3rd
muller muscle on downgaze - 3–5 mm, infe- of lower lid and medial canthus
rior fornix depth and white in- drains to internal jugular veins
Applied anatomy of fratarsal band. through submandibular nodes.
Capsulopalpebral fas- Palpebral conjunctiva is adher- DYNAMIC LID ANATOMY:
cia: ent to tarsal plate and forms Lid opening: Palpebral fissure
• CPF dehiscence/ the posterior layer of eyelids. It height at primary gaze is be-
is composed of non keratinised tween 9-10 mm and it is pri-
detachment leads to squamous epithelium and con- marily the function of levator
entropion tains mucin secreting goblet palpebrae superioris (LPS ac-
• Retractor reattach- cells and accessory glands of tion 14-17 mm). Other con-
ment, plication for Wolfring and Krause. tributing muscles are Muller
involutional entropion BLOOD SUPPLY: muscle (2mm lift) and low-
Arterial supply is through er eyelid retractors. Frontalis
vascular arcades. The lateral contraction also adds up to lid
palpebral Artery a branch of
lacrimal artery and the medial

Volume 1, No. 1 2 (July - Dec, 2021) NESOS E-Mag 11

opening. LPS-Superior rectus muscle complex to cortical connection. Diminution of sensitiv-
helps upper lid to follow globe in its movements. ity seen in contact lens wearer. Dazzle seen in
Anderson’s Myomectomy surgery for Blepharo- bright light facilitated by Optic nerve through
spasm changed concept who proposed a dynam- superior colliculus. Menace when there is sud-
ic classification of orbicularis oculi - extracan- den presence of near object. It is carried out by
thal and intracanthal orbicularis oculi. During optic nerve through cortical connection.
Myomectomy for blepharoplasty, intracanthal Lid crease could be dynamic/soft or hard/static.
portion is left intact due to lack of provocative
stimulation causing blepharospasm Lid position and movement:
Structural classification: Normal position of the upper eyelid is 1-2 mm
Pretarsal – spontaneous blink below superior limbus and lower lid at inf lim-
Preseptal – both bus. Upper lid is gently curved with highest
Orbital- forceful closure point nasal to the center of pupil. Lateral can-
Dynamic classification: thus sits 2 mm higher than medial canthus; it
Intracanthal: Maintenance of lower eyelid tone may be more in Asian.
and position, blinking, and the tear pump. This
part is supplied by the Buccal branch of facial Different types of Asian eyelids :
nerve • Single eyelid (no visible lid crease)
Extracanthal: Squeezing, animation, expression, • Low eyelid crease (low-seated, nasally
and ocular protection from flying objects. This
part is supplied by the zygomatic branch of fa- tapered, including hidden fold).
cial nerve • Double eyelid crease, infold type: the
Blinking:
Blinking could be Spontaneous blinking that height of the upper lid crease is lower
occurs at regular basis without an apparent ex- than the epicanthal fold.
ternal stimulus. It facilitates the drainage of tear • Double eyelid crease, on fold type:
film. It is present in blind as no retinal stimuli the height of the crease is right on the
are required. Reflex blinking can be due to var- epicanthal fold.
ious stimulus. Tactile as in corneal touch due • Double eyelid crease, outfold type: the
height of the crease is higher than the
Abnormalities of the lid position includes epicanthal fold (asterisk).
upper lid ptosis, retraction, lid lag or lower • Double eyelid crease, outfold type
lid ptosis and retraction. without an epicanthal fold

Abnormality of closure can be seen in REFERENCES
Facial nerve palsy, Ectropion of lower lid, 1. Clinton D McCord et. al. Concepts in eye-
Coma vigilance, Bells phenomenon and
inverse bells phenomenon. lid biomechanics with clinical implications.
Aesthetic Surgery Journal 33(2) 209–221
2. Brad B Bowling, Kanski’s Clinical Oph-
thalmology, 2016, Elsevier Inc
3. Khurana AK, Anatomy of eye and orbit
4. Yanoff and Duker, Textbook of Ophthal-
mology

12 NESOS E-Mag Volume 1, No. 2 (July - Dec, 2021)

Clinical case:

Congenital ptosis in three siblings!

Sabin Sahu, MD
Jyoti Eye Hospital, Janakpurdham, Nepal

Congenital Ptosis can have familial occurrence.
Three siblings presented with simple congenital
ptosis with poor levator functions since birth.
Eldest brother was 18 years old, younger brother
was 12 years old and youngest sister was 6 years
old. Ptosis correction with frontalis sling using
silicone rod was done in all three cases with ex-
cellent functional and cosmetic outcome.

Picture legends:
Top - Congenital ptosis with poor levator ac-

tion in three siblings
Bottom - Preoperative and postoperative pic-
tures of the patients after tarsofrontalis suspen-

sion surgery.

Volume 1, No. 2 (July - Dec, 2021) NESOS E-Mag 13

Tips and Tricks:

Choosing appropriate surgical technique
for lower lid involutional entropion

Aashish Raj Pant, MD, ChM

Department of Oculofacial plastic surgery,
Mechi Eye Hospital, Jhapa, Nepal

INTRODUCTION: such as undercorrection, over- cia for the lower eyelid.
Entropion is a common eyelid correction and recurrences. We 3. Overriding of preseptal
disorder with reported preva- firmly believe that the decision
lence of 2.1% over age 60 years, making for the choice of entro- orbicularis over pretarsal,
however, the impact this con- pion surgery should be guided which is the most directly
dition can have in one’s qual- by the predominant underlying attributable cause for en-
ity of life is tremendous, from mechanism for entropion and tropion.
foreign body sensation, water- thus preoperative evaluation 4. Others such as relative
ing and itching to corneal abra- for identifying the underlying enophthalmos, orbital fat
sions, corneal ulcers, scarring, mechanisms is of utmost sig- atrophy, etc.
and vision loss. Involutional nificance. Preoperative tests (See box below)
(age related or senile) entropi- MECHANISMS: CONCLUSION:
on of lower eyelid is the com- The main mechanisms under- The main idea is to correct the
monest one occurring due to lying the involutional entropi- underlying mechanism. So,
the stretching or overuse of the on are: wherever there is horizontal lid
eyelid retractors, tarsus or due 1. Horizontal Lid Laxity laxity, a lid shortening proce-
to overaction of orbicularis oc- dure is needed. When there is
uli muscle. Over 90% of involu- (HLL): This occurs due to not significant lid laxity, Wies
tional entropion occurs in low- the repetitive stretching of or Jones procedure may work
er eye lid and hence, our article the eyelid support struc- better. All in all, combined pro-
is focused on the lower eyelid tures such as medial and cedure act on multiple mecha-
entropion. There are plethora lateral canthal tendon. This nisms and are always the best
of surgical choices for invo- is the most commonly de- choice. Quickert procedure
lutional lower lid entropion. scribed underlying mech- seems to tick all the boxes for
Surgical decision making for anism for involutional en- the management of most im-
involutional entropion may be tropion. portant underlying mecha-
challenging sometimes as the 2. Vertical Lid Laxity (VLL): nisms however it is associated
underlying mechanisms may VLL occurs due to the in- with complexity of the proce-
be varied. “One size fits all” stability of the eyelid re- dure with lid margin repair and
may not be a good approach tractors such as dehiscence, increased surgical time.
and result in complications disinsertion or detachment Our recommended surgical
of the capsulopalpebral fas-

14 NESOS E-Mag Volume 1, No. 2 (July - Dec, 2021)

Preoperative checklist for lower eyelid entropion:
a) Vertical Lid Laxity
1) Eyelid resting position on primary gaze: MRD II - Inf. MLD -
2) Passive vertical eyelid distraction -
3) Inferior conjunctival fornix depth -
4) Lid excursion on down gaze -
5) Infratarsal band
6) Other-
b) Horizontal Lid Laxity:
Lid pulled away from globe, distance traversed in mm -
Snapback test ( Lid pulled downward & away from globe gently )
0 - returns immediately
I – returns in 2-3 s
II - returns in 4- 5 s
III – returns in >5 s –returns with blink
IV – does not return even on blink/ needs manually repositioning
MCT Laxity: (lid pulled laterally): Mobility in mm -
LCT Laxity: (lid pulled medially): Mobility in mm -
Appearance of lateral canthus -
c) Overriding of pretarsal by preseptal : (Upon lid closure; Upper border of tarsus moves
towards globe whereas lower border moves away from globe) Present/ absent

plan is as follows: REFERENCES
HLL<6 – Correct vertical laxity and/or orbicula-
ris overriding as evident with 1. Ansari, Z., Singh, R., Alabiad, C. and Galor, A., 2015.
HLL>6– Combined surgery with HLL correc- Prevalence, risk factors, and morbidity of eye lid laxity in
tion + either of VLL/orbicularis overriding a veteran population. Cornea, 34(1), p.32.

2. Bowling, B., 2016. Kanski’s clinical ophthalmology (pp.
45). Edinburgh: Elsevier.

3. Collin, J.R.O. and Rathbun, J.E., 1978. Involutional entro-
pion: a review with evaluation of a procedure. Archives of
Ophthalmology, 96(6), pp.1058-1064.

4. Danks, J.J. and Rose, G.E., 1998. Involutional lower lid
entropion: to shorten or not to shorten?. Ophthalmology,
105(11), pp.2065-2067.

5. Dresdner SC. 2012. Entropion. In: Black EH, Nesi FA,
Calvano CJ, Gladstone GJ, Levine MR editors. Smith and
Nesi’s Ophthalmic Plastic and Reconstructive Surgery.
3rd ed. New York (NY):Springer. p. 311-315.

6. Dryden, R.M., Leibsohn, J. and Wobig, J., 1978. Senile
entropion: pathogenesis and treatment. Archives of Oph-
thalmology, 96(10), pp.1883-1885.

7. Nishimoto, H., Takahashi, Y. and Kakizaki, H., 2013. Re-
lationship of horizontal lower eyelid laxity, involutional
entropion occurrence, and age of Asian patients. Ophthal-
mic Plastic & Reconstructive Surgery, 29(6), pp.492-496.

Volume 1, No. 2 (July - Dec, 2021) NESOS E-Mag 15

ARTICLE

Entropion surgery from classic to recent
approaches

Ramita Kharel, MD (Fellow - Oculoplastic surgery)
Binita Bhattarai, MD (Oculoplastic surgeon)

Lumbini Eye Institute, Bhairahawa, Nepal

INTRODUCTION: Non-invasive treatment: Rotational or everting sutures:
Entropion is a condition where Patients can achieve temporary Full-thickness eyelid sutures
the eyelid margin turns inward relief with taping of the lower lid (Quickert sutures) can be
against the globe, one of many to the malar eminence or with ap- placed at the bedside or in the
causes of eyelid malposition. En- plication of a cyanoacrylate liquid office as a quick procedure to
tropion or any eyelid malposition bandage to evert the lid margin. offer patients immediate relief
will affect the palpebral aperture These treatments are beneficial from entropion symptoms. A
and can affect the physiologic as temporizing measures until the double-armed 4-0 chromic or
integrity and clarity of the ocu- patient can have surgery for de- vicryl sutures is placed from
lar surface which are dependent finitive repair, or if the patient is the deep inferior fornix be-
on properly apposed eyelids and too ill to be a candidate for surgi- low the inferior tarsal border,
smooth eyelid margins. Thus, cal intervention. Temporary relief through the lower lid retrac-
early recognition and correction from involutional entropion can tors exitting through the skin
of eyelid entropion are critical to also be achieved with botulinum superior to the level of inser-
successful long-term health of the toxin injections to the preseptal tion. Exiting more superiorly
eyes procedure and surgical out- orbicularis, to combat override. causes more lid eversion. This
comes that are comparable to oth- Carbon dioxide laser skin resur- procedure indirectly tightens
er procedures. facing has been proposed as a the lower lid retractors and
conservative means of managing forms scarring between the re-
1. Involutional Entropion: involutional entropion. tractors, orbicularis and skin to
prevent override. Recurrence is
Involutional entropion is the most Surgical treatment: common.
common type of entropion. Man- General principles of manage- Horizontal Lid Tightening:
agement should be directed at the ment include either addressing This may be performed through
specific mechanical failures of one of the factors alone or when- a lateral canthototmy (Lateral
horizontal and vertical lid laxity, ever possible addressing the 2 Tarsal Strip) or through can-
lower lid retractor weakness, and main causative factors: lower thotomy sparing procedures
orbicularis oculi override. Ad- eyelid laxity and reattachment such as Modified suture can-
dressing more contributing factors of lower eyelid retractors. In the thoplasty/pexy with or without
has a greater chance at achieving elderly and debilitated patients, lateral canthal tendon release.
resolution. The approach depends minimally invasive and brief pro-
on disease severity, patient co- cedures may be attempted first
morbidities and goals of care. albeit with reduced success rates.

16 NESOS E-Mag Volume 1, No. 2 (July - Dec, 2021)

plane just below the inferior
tarsal border. The conjunctiva
and retractors are then sepa-
rated from the anterior lamella
to expose the orbital septum
overlying orbital fat.

Figure:Diagrammatic representation of Quickert sutures Transcutaneous approach:
More easily a subciliary inci-
A. Lateral Tarsal Strip suture (4-0 Maxon) may be sion with dissection below the
Horizontal lid laxity can be ad- placed through a scratch inci- pretarsal orbicularis oculi ex-
dressed surgically with a tar- sion with the double armed su- poses the orbital septum. Once
sal strip. A lateral canthotomy ture engaging the lateral tarsus, this layer is opened up, the
and inferior cantholysis is per- lateral canthal tendon which preaponeurotic fat of the lower
formed to release the lower lid. is then anchored to the super- eyelid helps identify the lower
The mucocutaneous junction otemporal orbital periosteum. eyelid retractors, aided by the
is removed from the lid mar- The upper eyelid wound is then patient being asked to look up
gin, and the anterior lamella closed. and down.The lower lid retrac-
is excised off the tarsus. Con- Lower lid retractor reinsertion: tor which is immediately pos-
junctiva is debrided from the Lower lid retractor disinser- terior to the fat compartments
posterior tarsus. A horizontal tion can be reversed surgically and adherent to the conjuncti-
incision through the superior with posterior advancement of va is identified with the patient
tarsal plate creates a strip that the retractors. This may be per- asked to look up and down.
is trimmed to achieve the de- formed through the posterior Regardless of approach above,
sired amount of tightening. The (transconjunctival) or anteri- a strip of orbicularis may be ex-
strip is attached to the internal or (transcutaneous) approach. cised or ablated inferior to the
aspect of the lateral orbital rim. These may be performed with tarsus, to reduce the preseptal
B. Modified Suture Canthop- or without a lateral canthoto- orbicularis override. The re-
lasty my. tractors may be separated from
A lateral upper eyelid incision Transconjuncitval approach: the conjunctiva with cautery,
may be employed to gain access An incision is made through and sharp dissection allows for
to the superotemporal orbital the conjunctiva and lower lid exposure of the anterior sur-
rim and overlying periosteum. retractors spanning from the face of the inferior tarsal plate.
The Lateral canthal tendon may lateral canthus to just lateral A single or multiple 6-0 vicryl
be released based on the degree to the inferior punctum, tak- sutures are then used to reatta-
of laxity and tightening desired. ing advantage of the bloodless che the lower eyelid retractor
A lateral lower eyelid margin to the anterior inferior tarsus
to evert the lid margin.
Combining tarsal strip with
retractor advancement takes
an average of 13 minutes more
than retractor advancement
alone, and gives a 96.7% suc-
cess rate.The dual procedure is
more effective in treating invo-

Volume 1, No. 2 (July - Dec, 2021) NESOS E-Mag 17

lutional entropion with hori-
zontal lid laxity than retractor
advancement alone.External
approach can be used if there is
absent lid laxity, significant fes-
toons or prominent lower lid
dermatochalasis.

Orbicularis override prevent- Figure:Diagrammatic representation of Right - Wies procedure and
ing procedures: Left - Jones procedure
A. Wies Procedure : After full
thickness incision ,sutures are
passed through the conjunc-
tiva and lower lid retractors
.Sutures are passed anterior to
the tarsal plate to exit inferior
to the lashes.
B. Jones procedure : Horizon-
tal Skin Incision is made ,the
lower border of the tarsal plate
is exposed , reflection of orbit-
al septum and the fat pad to
expose the lower lid retractors
and then tightening of retrac-
tors by plication .

2. Spastic Entropion:

Spastic entropion is thought by Figure:Spastic entropion due to corneal ulcer
some to be a subset of involu-
tional entropion often inter- described injecting 80% alco- ing pathologic condition when
mittent, and may be a precur- hol into the orbicularis oculi to present. Surgical technique de-
sor to persistent lower eyelid quell spasm with high rates of pends on the severity of disease
malposition. Muscle spasm of success. Presently, botulinum and etiology of symptoms.
the orbicularis can induced toxin injection to the orbicu- If there is mild disease with
by local irritation, infection laris and full thickness eyelid symptoms from lashes abrad-
or recent ocular surgery can sutures have been used. ing the corneal surface, skin
unmask asymptomatic involu- 3. Cicatricial Entropion: resection may be sufficient to
tional changes resulting in in- Treatment of cicatricial en- rotate the margin. If offending
termittent entropion. tropion should always include lashes are arranged in a sec-
Treatment medical control of the underly- toral pattern, eyelid margin
First line treatment is to relieve
the instigating condition by
treating underlying condition.
Hubbard and Kanski in 1973

18 NESOS E-Mag Volume 1, No. 1 (Jan-Jun, 2021)

Figure:Cicatricial entropion of upper lid secondary to trachoma Bilamellar Tarsal Rotation
(BLTR)
splitting with lash root, cry- from the globe. Everting su- The eyelid is fixed with waddle
otherapy may be considered. tures are placed to keep the lid type clamp of appropriate size
Lash follicle excision can also margin rotated anteriorly, and .The full thickness incision is
be considered for segmental the skin is closed. made through anterior and
lash malpositions. Follicle ex- Transverse blepharotomy and posterior lamella, parallel to
cision is achieved by splitting marginal rotation has also and 3 mm above the lid mar-
the lamella posterior to the been used to treat cicatricial gin .Three sutures are placed
lashes and excising the lashes entropion. In this procedure a to rotate externally and fix the
with sharp Westcott scissors. full-thickness incision is made eyelid.
The base of the lash follicles 4mm from the lid margin and For severe cicatricial disease,
may be cauterized to prevent 5-0 absorbable suture is passed the posterior lamella must be
regrowth. Functional success partial-thickness through the lengthened while releasing
of 90% has been demonstrated anterior tarsus and lower lid re- scar tissue and lid retractors.
with no return of trichiasis at tractors of the proximal lid and In these instances the posterior
6-24 months. then through the orbicularis lid retractors can be weakened
In moderate disease affecting and skin of the distal lid. The by recession or lysis with a
the upper lids, tarsal fracture suture is tied in horizontal mat- spacer. Hard palate graft, other
is a viable surgical option that tress fashion over a bolster near mucous membrane graft or al-
preserves the lashes with ac- the lash line, and skin is closed. lograft can be used to support
ceptable cosmesis. An exter- The sutures and bolster remain and bolster the posterior lamel-
nal partial tarsectomy is per- in place for 10 days. This pro- la. Graft choice is especially
formed through a lid crease cedure has an 85% success rate important when operating on
incision. A double-armed 6-0 for upper and lower lid cicatri- the upper lid, as the graft will
vicryl is placed partial thick- cial entropion repair. be in constant contact with the
ness through the tarsus and cornea. Free tarsoconjunctival
externalized. A full-thickness grafts may provide good re-
tarsotomy is then performed sults.
to direct the lid margin away 4. Congenital entropion:
Treatment include lubrication
to limit mechanical trauma,
taping the lower lid to the ma-
lar prominence, or injecting
low doses of botulinum toxin
into the orbicularis to weaken
the muscle and prevent over-
ride. Surgical therapy provides
definitive treatment.
COMPLICATIONS:
The most common complica-
tion following entropion repair
especially cicatricial entropion,

Volume 1, No. 1 (Jan-Jun, 2021) NESOS E-Mag 19

Figure:Congenital entropion during entropion repair , espe-
cially in recurrent cases, to pre-
vent necrosis at the lid margin.
Any full-thickness incisions
through the lid should be made
inferior to the inferior margin
of the tarsus, at least 4mm infe-
rior to the lid margin, to avoid
vascular compromise.
Overall, transconjunctival en-
tropion repair has a low rate of
complications, with Erb et al
noting a 4% rate: stitch abscess
and conjunctivochalasis 0.7%
each and lateral tarsal strip
dehiscence and lateral canthal
dystopia.

is recurrence. Transconjuncti- prevent induction of ectropion. CONCLUSION:
val involutional entropion re- Lid-splitting surgical ap- Entropion is a common eyelid
pair has a recurrence of 3.3% proaches risk fistula formation. condition with varied etiolo-
while involutional entropion If encountered, these should be gy, often multiple mechanisms
should be optimally corrected, excised and repaired. and management techniques.
recurrence in cicatrial entropi- The surgeon should be cog-
on may be minimized by aim- nizant of the marginal arcade
ing for mild overcorrection.
Excessive overcorrection may Suggested reading:
result in an ectropion however.
Ectropion can also result from 1. JRO Collins
repairs that attach the inferior 2. Myron yanoff and Jay S.Duker
lid retractors to the anterior 3. AAO-orbit, eyelid and lacrimal system anatomy
surface of the tarsus rather than 4. Nowinski TS. 2011. Entropion. In: Tse DT, editor. Color Atlas of Oc-
the inferior aspect especially
when lower eyelid laxity has uloplastic Surgery. 2nd ed. Philadelphia (PA): Lippincott Williams &
not been adequately addressed. Wilkins. p 44-53.
Overly aggressive shorten- 5. Tsang S, Yau GS, Lee JW, Chu AT, Yuen CY. Surgical outcome of invo-
ing of the lower lid retractors lutional lower eyelid entropion correction using transcutaneous everting
or excessive skin removal can sutures in Chines patients. Int Ophthalmol. 2014 Aug;34(4):865-8.
produce lower lid retraction 6. Jang SY, Choi SR, Jang JW, Kim SJ, Choi HS. Long-term surgical out-
and inferior scleral show. Using comes of Quickert sutures for involutional lower eyelid entropion. J Cra-
local anesthesia allows the sur- niomaxillofac Surg. 2014 May 14.
geon to assess lid height, mo- 7. Scheepers MA, Singh R, Ng J, Zuercher D, Gibson A, Bunce C, Fong K,
tility and contour during the Michaelides M, Olver J. A randomized controlled trial comparing evert-
procedure and make any nec- ing sutures and a lateral tarsal strip for involutional entropion. Ophthal-
essary adjustments promptly to mology. 2010 Feb;117(2):352-5.
8. Balaji K, Balaji V, Kummararaj G. The correction of involutional en-
tropion of eyelid by lateral strip procedure. J Surg Tech Case Rep. 2010
Jul;2(2):64-6.
9. Boboridis K, Bunce C. Interventions for involutional lower lid entropion.
Cochrane Database Syst Rev. 2002;(1):CD002221.

20 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

INTERVIEW

Heart to Heart with

Dr Naresh Joshi

Dr Naresh Joshi is an Oculoplas-
tic Surgeon based in London. An
astounding surgeon, a prolific
teacher and a great human being.
He was kind to record an inter-
view for NESOS emag despite his
busy schedule.

Synopsis of Interview by
Hom Bahadur gurung, MD

Namaste and good morn- competition involved and it’s Dr Naresh Joshi
ing, sir, very difficult to assess. But I tell DO, FRCOph
Dr. Naresh Joshi is a big them that I will always do my
name in oculoplastics all best for you. If I’m known in Consultant Oculoplastic
over the world. How was the world of ocular plastics, it’s surgeon at Chelsea and
your journey to being one of through some hard work, a lot
the best oculoplastic sur- of good luck, knowing a lot of Westminster Hospital
geons in the world? the right people, coming in on NHS Trust London
Well first of all, I would like to the scene at the right time. And
qualify that I’m a small person also, I hope because I’ve tried Honorary Consultant to
in the big game of oculoplas- my best to be the best that I can the Royal Marsden
tics. I happened to be fortunate be, and I really try to focus on
enough that I’m recognized by ensuring that my patients are Honorary Senior Lecturer
a few individuals, but I do not well cared for, and that I have in the Faculty of Med-
consider myself a big name in done my best for them. I hope icine, Imperial College
the world of oculoplastics. As that I’ve never compromised London
for being the best, I suppose care for any individual human
patients often turn up and say, being. In all our specialties, the Founder member of the
we hear you’re the best in your outcome really depends on the British Ophthalmic Plastic
field. And I always qualify by patient’s perception of, what is surgical Society (BOPSS)
saying, there’s no such thing perceived as the right thing.
as the best surgeon, there is no

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 21

How do you see the changes in oculoplas- OUTSIDE THE BOX
tic procedures when you started then, and
now? HOW DO YOU ENJOY YOUR LEISURE TIME?
Well, firstly surgery changes very little. And I think that my most fun is interacting with
what I have learned is that whenever you think other human beings.
you’ve come up with an amazing, innovative
new leap in surgery, if you look very carefully, LATEST NEPALI MOVIE, ANY NEPALI MOVIE
it’s been thought before, by decades, maybe even YOU’VE WATCHED?
by centuries. The human brain has just been dis- The first and only Nepali movie I watched is
covered for millennia. So, just look around, you the first Nepali movie “Ama” and the main ac-
might find that it has already been done. What tor was Shiva’s shankar. He was known to my
we are able to do is to make fine adjustments to family and he was our next-door neighbor.
the techniques that have been handed down.
We’ve had the privilege of learning from great WHAT IS Y OUR MANTRA TO SUCCESS?
teachers from before and so we make fine tun- Success is love. To be successful, you have to
ing. That’s what I’ve done. I hope I’ve fine-tuned love what you do. If you execute whatever you
some aspects of treatment, patient care (not just do, surgery or any other form of caring, with
the technical aspects) and thinking about their total passion for what you do and total care
perspective, which of course were hugely as- for them, then you’ll be a successful.
sisted by advances in technology. I think that is
what has really changed. I think we involve our QUOTES YOU LIVE BY?
patients a lot more in the decision-making. We as long as those around you are happy and
ensure that they and their families are enrolled you help them to be happy, whether it be your
in what is best for them, coming to a mutually patients, your friends, your children, your wife,
accepted decision. So, the changes I see in ocu- your anything else. If you can help them to be
loplastic as both in terms of the individual, try- happy, you will be happy yourself.
ing to be the best that they can and having the
assistance of amazing equipment that we have STRESS BUSTER?
around which assists us in surgery. It perhaps rarely stressed. I don’t think, I can’t remember
enhances our techniques of identification, of lo- when I was last stressed. maybe watching
calization, maybe even some of the aspects of the television or occasionally listen to music, but
surgeon itself is assisted, but ultimately, I think more watching than listening
90% is still us, the surgeons doing the work.
How would it change? Well, I say to all my train- TALENT, WE DO NOT KNOW ABOUT YOU?
ees and my fellows and some of my colleagues, I used to play the guitar a lot. I used to be a
of course, surgery is the most archaic form of very good tennis player and I’m very good at
treatment. It has changed little over thousands opening bottles of wine without damaging the
of years. And if you think that as a surgeon, you cork.
are the pinnacle of a patient’s treatment. That ac-
tually is not how the patient perceives it. I mean, PROCEDURE YOU LOVE TO DO?
of course, if you had any diseases or problems, I love to do every surgical procedure. I love
how you’d like to be treated is with a pill or an in- doing every procedure and I like to always
jection, the wave of the laser, but you don’t really push myself to do it to the best possible level
want to be cut and opened and stitched. That’s that I can.
such an old-fashioned way of doing things. So, if

22 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

you think as a surgeon, you are the ultimate but better everything that it did, work together co-
you’re actually the most old-fashioned. I would hesively and helped each other and had forums
like all my diseases to disappear with a tiny pill. where you could discuss your complications
Taken once a day for maybe a week. That’s how (which we inevitably will always have), without
I’d want my problem solved. I would like a cream fear, without a ridicule. I think that would be a
or an injection to get rid of my basal cell car- society I’d like to be part of. And I think NESOS
cinoma or my invasive sebaceous gland carci- will be. It has great leadership within and it has
noma. Consequently, not a disfiguring surgery, great young members and I’m sure that as the
which we consider with such bravado and with years go by, it will become a force, that will be
pride. So that’s what I like to see change in and recognized throughout. I know that there are
inevitably, it will change. many members within NESOS who are already
well recognized, and I’m sure that the young
Where do you see yourself in 10 years from people from the NESOS will grow in stature and
now? Future aspirations? on the world stage.
Well, actually I’m towards the end of my career.
I’m 59 years old. I will continue to operate for Any message you want to send to an aspir-
perhaps 10 years. We have worked abroad as ing oculoplastic surgeon in Nepal?
a group and that has been a great joy working I would say to any oculoplastic surgeon, any-
with other people, and learning and teaching to- where in the world, Work on anatomy, work on
gether. I hope my future will be more and more all the basics, to attend as many lectures, observe
working abroad, and working in centers to teach many surgeons, watch their behavior, watch
and learn from others in countries that need the techniques, read, subscribed to journals
me more. And that of course includes my own and watch YouTube videos. Do all those things
country. So that’s where I see myself in 10 years to really optimize your own potential/ability.
if I’m still healthy. And of course, if this present So, when you’ve gathered all that information,
situation of Corona and COVID, doesn’t sup- when you’ve gathered all your knowledge and
press our travel. you will have a core basis on which to go out, of
course, if you watch the great and the good it’s
You have been near to the Nepalese socie- like standing on the shoulder and seeing even
ty of oculoplastic surgeons (NESOS) since further, you don’t always have to start at the bot-
the birth of it, and also its life member. As tom. Those who have preceded you will help you
a founding member of British oculoplas- start at a higher position from their experience,
tic Surgery Society (BOPSS), you have a from their mistakes. I think most people would
lot of experience. How do you see NESOS love to teach. It’s inherent in medics to want to
growth? teach. Never be embarrassed about asking ques-
I think inevitably it’s a very young, very keen and tions. Ask even the most stupid questions, and
very dynamic society. It’s full of very enthusiastic sometimes you get wonderful answers that will
young people. Some societies have older mem- help you. What I’ve done is to constantly look at
bers who are in the top echelons of the member- myself, to praise myself, to reflect back on myself
ship. Of course, it’s relatively small in number, each year. At the end of the year, I look back at
which is always the case when you first start. all my cases in my operations, and I think what
But, it’s not so small for a small country. I think could I have done better? Where did I not do
it will grow and I hope it will focus on quality, as well as I could have done? I think that’s very
rather than quantity. I would rather be part of a important to really look into yourself and see
society that really looked hard at itself and try to how you can improve every aspect of your care.

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 23

From how you inject a patient Family reunion in time of Corona Nepal 2021 with Dr Narendra
to make the first cut, to do the and Mrs. Sarala Joshi
stitch, but also, how could you
be better in the whole journey tell you that surgical success is not dependent
of the patient? Not just the sur- on those three millimeters. If you have patients
gery. I mean, often surgeons with you throughout the journey. Then the three
think of the surgery, but for millimeters is less important. What you consid-
the patient, it’s the whole jour- er your failures might actually be success. So, I
ney from the beginning to the would say look hard at the whole journey as a
end, from the beginning, when young person reflect, constantly see how you
they first see you and they con- could be better at every phase, not just the sur-
sult you to when you discharge gery, the whole journey.
them. So, think how you can
improve each aspect of the
journey. When the patient first
turns up to your clinic, how
will you greet them, when they
walk into a room will you stand
up and smile and make them
feel at ease. All those things are
just as important because for
you, it might be the three-mil-
limeter ptosis correction. But
for the patient, it’s a lot more
than the three millimeters. It’s
that whole journey. And I can

Wedding reception 1996, Arts Club London UK How is Dr. Naresh Joshi as a family man?
I have a boy and a girl; Sarala and Naren and my
wife Anne. Sarala is now 24 and about to be a
doctor. She’s at Imperial college, London. Naren
is a medical student. He’s at Kings college Lon-
don. My wife is my total support and she has en-
sured that we as a family are cohesive and move
forward together. It really is not just one individ-
ual but the whole unit. The success of the unit is
dependent on the happiness of every individual.
We tried to ensure that the four of us are happy
together. I think, whatever your successes are,
certainly for many of us, our success will only be
defined by the success of our children and our
family. You will know that from all the lectures
that I gave, that I always show pictures of my

24 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

family, because everything that I am is because
of the family that I have.

Your childhood days? A regular family dinner outing 2018
I was born in Nepal, 1962, 1st of March. At an Hide Restaurant London
early age, my father, who was a pioneer in oph-
thalmology and many of you know him, left to maybe I did the right thing.
work in Brunei in 1965 which was very small
and relatively poor country in those days. He Few closing remarks to Readers
worked there for a considerable period of time. I I am a Nepali and proud to be one. And as I get
came back at about six years of age to Katmandu older, I become more Nepali. I have lived in Eng-
to study at St. Xavier’s boarding school initial- land since a very early age. I am married to an
ly at Jawlakhel and then to Godawari. When I English lady and we’ve been together for forever.
was about 11 years old or maybe 12, I left Nepal And I have two wonderful children. We have a
in 1973 and I went to boarding school in Eng- wonderful family and that at the end of the day
land to a school called Mill Hill school in Lon- is my success. I wish you all the very best. I know
don. There on, I went to Guy’s hospital, medical that there are many of you who aspire to be suc-
school in London, and then I did my training cessful, but look hard and think what success
thereafter. My childhood in Nepal was relatively is because some successes are rather empty. As
short actually having said that it’s the first dec- long as your family’s okay and you’re okay and
ade off and on between Nepal and Brunei, but it you have an adequate amount of money then
was mostly, American Jesuit school, in the Him- you’ll have a happy life.
alayas and the mountains, which was an amaz- Thank you.
ing school; brutal in its own way. But, put me in
the right path probably.

What would Dr. Naresh Joshi be if not an
ocular plastic surgeon?
I toyed with the idea of being a designer, a fash-
ion designer. I want to design cars. I want to de-
sign all sorts of things. I suppose, working with
my hands. I was good in painting. I won most
of the prizes in painting. my school pottery was
another forte of mine. I still, enjoy working with
my hands, but on people, as opposed to objects.
But I think I would’ve liked to being and I still
hope that I would one day do more designing.
I’ve designed most of the things in my house,
stack cases, tables, chairs, whatnot, so design
interests me hugely. Perhaps I would have been
an architect maybe, of course one assumes that
whatever you do, you would be the best at it. I
know that most architects have a tough time.
There are very few well-known whereas most
doctors I think do okay and earn a living. So

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 25

SURGICAL PEARLS

Modified suture canthoplasty

Prerana Kansakar, MD
Grande International Hospital

Gangadhara Sundar , DO, FRCSEd, FAMS
National University Hospital, Singapore

Lateral Canthal Angle Recon-
struction is an important compo-
nent in the rehabilitation of the
aging face. The lateral canthus
unites half of the upper eye-
lid-forehead continuum with the
lower eyelid-midface continuum.
Aesthetic reconstruction of the
canthal angle is hence crucial to
achieve a youthful outcome.

Indications of lateral canthal re- Figure: Lateral canthal tendon dehiscence
construction are as follows:
1. Horizontal lid laxity tion ity between the upper and lower
2. Entropion 5. Pseudoretraction of upper/ limbs of LCT which results in
3. Ectropion misalignment of the muco-cuta-
4. Lateral canthal dystopia lower eyelids neous junction.
5. Aesthetic rejuvenation fol- We hereby talk about Modified
Traditionally we have been doing Suture Canthoplasty which in-
lowing lower eyelid blepha- the Lateral Tarsal Strip Proce- volves tightening of the lateral
roplasty. dure to address this issue. It’s a canthus without shortening the
simple procedure which adresses eyelid and preserving the lateral
Features of Lateral Canthal Ten- both horizontal as well as vertical canthal angle.
don Dehiscense: lid laxity and has a fast recovery.
However, there is significant dis- Procedure:
1. Rounding and vertical dis- ruption of the lateral canthal angle 1. Local injection of lidocaine
placement of the lateral can- which can result in rounding of
thal angle on primary gaze the angle and web/scar formation. 2% with epinephrine.
There also occurs length dispar- 2. A limited lateral or standard
2. Loss of temporal scleral tri-
angle

3. Incomplete blink and clo-
sure in the absence of ante-
rior lamellar shortage

4. Temporal eyelid imbrica-

26 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

upper eyelid crease incision lateral aspect of the lower Figure:Sutures needed for the
is performed. A stab incision eyelid tarsus at the gray line. technique
is then made at the grey line 8. With appropriate tension on
in the lower eyelid near the the lower eyelid, the suture Figure:The 2 needles are both
lateral canthal angle. was then tied and the knot passed through the same spot in
3. Through the lateral extent tucked below the orbicularis the lateral aspect of the lower
of the upper eyelid incision, of the lateral eyelid crease in- eyelid tarsus at the gray line
blunt and sharp dissection, cision.
using Stevens scissors is done 9. This technique can be com-
to expose the lateral canthal bined with upper eyelid
tendon and orbital rim. blepharoplasty and direct
4. With one tip of the scissors browlifts.
in the orbit and the other out-
side, the lateral canthal ten- Advantages:
don fibers are dissected from • No disruption of lateral can-
their periosteal attachments.
5. A double armed, absorbable thal angle
suture (4-0 Maxon/ 4-0 Poly- • Aesthetically more predicta-
dioxanone) is used to reat-
tach the lateral canthus to the ble
Whitnall’s tubercle inside the • Decreases the risk of scarring/
orbital rim, at the appropriate
vertical height. malposition at the muco-cuta-
6. We modified this technique by neous junction
reinforcing the permanent su- • Better proctects the lymphatic
ture being used by tying mul- drainage and orbicularis oculi
tiple surgical knots in order to muscle.
prevent it from cheese-wiring
through the incision. Disadvantages:
7. The 2 needles are both passed • Cannot address severe hori-
through the same spot in the
zontal lid laxity
• Learning curve

REFERENCES

1. Taban, Mehryar M.D.*; Nakra, Tanuj M.D.†; Hwang, Catherine M.D.*;
Hoenig, Jonathan A. M.D.*; Douglas, Raymond S. M.D., Ph.D.*‡§;
Shorr, Norman M.D.*; Goldberg, Robert A. M.D.* Aesthetic Lateral
Canthoplasty, Ophthalmic Plastic & Reconstructive Surgery: May 2010
- Volume 26 - Issue 3 - p 190-194 doi: 10.1097/IOP.0b013e3181baa23f

2. Hesse RJ. The tarsal sandwich: a new technique in lateral canthoplasty.
Ophthal Plast Reconstr Surg 2000;16:39–41.

3. Fagien S. Algorithm for canthoplasty: the lateral retinacular suspension:
a simplified suture canthopexy. Plast Reconstr Surg1999;103:2042–58

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 27

Oculoplasty Updates

Snippets from the oculoplasty and ocular
oncology journals in the past 6 months

Science is beautiful because it is evolving. Journals are a way to keep up
to the change. In this section we serve you the recent articles related to our
profession.

Aashish Raj Pant, MD
Hom Bahadur Gurung, MD

Building your brand: Analysis of Success- Figure 1 3D printed plastic adapter (A) graphic de-
ful Oculoplastic Surgeons on social media sign, (B) photograph of the adapter holding a diver-
DOI: 10.1097/IOP.0000000000001654 gent lens with fabric straps attached to the side han-
Author: Sally S E Park, Sruti S Akella, Jee-Young dles (courtesy original article)
Moon, Bryan Zarrin, Sheel Patel, Hiten Doshi, Anne
Barmettler Sutureless Transconjunctival insertion of
Published in: Ophthalmic Plastic Reconstructive eyelid weights: A Novel Technique
Surgery 2020 Nov/Dec DOI:10.1097/IOP.0000000000002069
Highlight: Study analyzed successful Instagram ac- Authors: Elahi, Ebby, Afshin, Evan E., Guthrie, Ash-
counts of ASOPRS members. Social media is an ley J., Lo, Christopher
important communication and marketing tool, es- Published in: Ophthalmic Plastic and Reconstructive
pecially in esthetic fields like oculoplastics. The in- surgery 2022
fluence of social media is rapidly growing and can Highlights: This case series demonstrates that the
be strategically harnessed by oculoplastic surgeons transconjunctival approach for metal eyelid weight
to educate both patients and healthcare providers, insertion is practical, relatively easy to perform, and
collaborate with colleagues, and for referrals and associated with functional outcomes that are compa-
marketing. rable to those achieved with the traditional approach,
however, without external incision or placement of
A Novel method of video recording Oph- sutures.
thalmic surgical procedures.
DOI: https://doi.org/10.2147/OPTH.S267951
Authors: Kruger AD, Hendler K, Kruger JM
Published in: Clinical Ophthalmology 2020
Highlights: A divergent lens is suspended immedi-
ately below the objective of the microscope, thereby
increasing the microscope’s working distance. The
microscope can be suspended high above the pa-
tient, out of the surgeon’s field of view, yet still pro-
vide excellent video recording of the surgical proce-
dure who operate with surgical loupes.

28 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

Overall survival benefit with tebentafusp in of cases, and may present at an advanced stage in
metastatic uveal melanoma 46% of cases.
DOI: 10.1056/NEJMoa2103485
Authors: Nathan P, Hassel JC, Rutkowski P, et al Optical Coherence Tomography of Peri-Oc-
Published in: New England Journal of Medicine, ular Skin Cancers: An Optical Biopsy.
September 27, 2021 DOI: https://doi.org/10.1159/000511188
Highlights: Tebentafusp is a bispecific protein con- Authors: Bergeron S.• Arthurs B. • Sanft D.-M. •
sisting of an affinity-enhanced T-cell receptor fused Mastromonaco C.• Burnier Jr. M.N.
to an anti-CD3 effector that can redirect T cells to Published in: Ocular Oncology and Pathology 2021
target glycoprotein 100–positive cells. In this multi- Highlights: They have highlighted findings of basal
center, randomized, phase 3 trial, they compared te- cell carcinoma, squamous cell carcinoma and seba-
bentafusp with the investigator’s choice of treatment ceous carcinoma. They provide evidence supporting
as first-line systemic therapy in patients with meta- the use of OCT for the evaluation of peri-ocular can-
static uveal melanoma. Treatment with tebentafusp cers. OCT enables visualization of the skin layers in
resulted in longer overall survival than the control vivo, before biopsy. Their results show that certain
therapy among previously untreated patients with OCT features can contribute to include or exclude a
metastatic uveal melanoma. diagnosis of basal cell carcinoma. By integrating this
non-invasive imaging methodology into the routine
Nation- wide trends in incidence -based assessment of peri-ocular skin lesions, especially in
mortality of patients with ocular melanoma health care centers where access to specialists is lim-
in USA:2000 to 2018 ited, OCT imaging can increase clinical precision,
DOI:10.2147/IJGM.S299144 reduce delays in patient referral and enhance patient
Authors: Valasapalli S, Guddati AK care.
Published in: International Journal of General Med-
icine, August 5, 2021 Statins for graves orbitopathy (STAGO):
Highlights: The Surveillance, Epidemiology, and End A phase 2, open-label, adaptive, single
Results (SEER) database was queried to find the in- center, randomized clinical trial
cidence-based mortality for all patients diagnosed DOI: https://doi.org/10.1016/S2213-8587(21)00238-
with ocular and orbit melanoma for the years 2000 2
to 2018 in USA. Ocular melanoma and orbit mela- Authors: Lanzolla G, Sabini E, Leo M, et al
noma are rare entities that are predominantly seen Published in: The Lancet Diabetes & Endocrinology|
in Caucasian/White patients. This study shows that October 22, 2021
incidence-based mortality has been worsening for Highlights: The authors tried to assess the efficacy of
these patients in the past two decades. These entities the addition of a statin, atorvastatin, to intravenous
have a poor prognosis and have not been studied ex- glucocorticoids (ivGCs) on Graves’ orbitopathy out-
tensively in immunotherapy trials. comes in patients with hypercholesterolemia. A ran-
domized, open label, phase 2, adaptive, clinical trial
Retinoblastoma in children older than 6 was done. Addition of oral atorvastatin to an ivGC
years of age regimen improved Graves’ orbitopathy outcomes in
DOI: https://doi.org/10.1159/000509040 patients with moderate-to-severe, active eye disease
Authors: Meel R• Kashyap S. • Bakhshi S.• Singh Ba- who were hypercholesterolaemic. Future phase 3
jaj M. • Wadhwani M studies, which could potentially recruit patients re-
Published in: Ocular Oncology and Pathology 2020 gardless of low-density lipoprotein cholesterol con-
Highlights: This is a retrospective study of 48 pts centration, are required to confirm this association.
over 6 years old at presentation. This is the largest
study of older age retinoblastoma and shows that it
forms a significant percentage of retinoblastoma in
developing countries, is misdiagnosed in one-third

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 29

Teprotumumab and Hearing Loss: Case nation-wide centers for TED management.
Series and Proposal for Audiologic Moni-
toring Perioperative Prophylactic Antibiotics in
DOI:10.1097/IOP.0000000000001995 1,250 Orbital Surgeries
Authors: Irina Belinsky, Francis X Creighton Jr, DOI:10.1097/IOP.0000000000001565
Nicholas Mahoney, Carisa K Petris , Alison B Calla- Authors: Aaron Fay et al
han, Ashley A Campbell, Michael Kazim, H B Har- Published in: Ophthalmic Plastic and Reconstruc-
old Lee, Michael K Yoon, Lora R Dagi Glass tive surgery 2020
Published in: Ophthalmic Plastic and Reconstruc- Highlights: A prospective, nonrandomized compar-
tive surgery 2022 ative case series of all patients undergoing orbital
Highlights: Teprotumumab used for treating thyroid surgery with participating surgeons between Oc-
eye disease may cause a spectrum of potentially ir- tober 1, 2013, and March 1, 2015 was done. In this
reversible hearing loss ranging from mild to severe, large series, antibiotic prophylaxis did not appear to
likely resulting from the inhibition of the insulin-like have reduced the already low incidence of SSI follow-
growth factor-1 and the insulin-like growth factor-1 ing orbital surgery. Given the detriments of systemic
receptor pathway. Due to the novelty of teprotumum- antibiotics, the rarity of infections related to orbital
ab and the lack of a comprehensive understanding of surgery, and the efficacy of treating such infections
its effect on hearing, the authors endorse prospective should they occur, patients undergoing orbital sur-
investigations of hearing loss in the setting of tepro- gery should be educated to the early symptoms of
tumumab treatment. Until the results of such studies postoperative infection and followed closely, but do
are available, the authors think it prudent to adopt a not routinely require perioperative antibiotics
surveillance protocol to include an audiogram and
tympanometry before, during and after infusion, Rhino-orbital mucormycosis following
and when prompted by new symptoms of hearing COVID-19 in previously non-diabetic, im-
dysfunction. munocompetent patients.
DOI:10.1080/01676830.2021.1960382
Thyroid eye disease survey: An anony- Authors: Akshay Gopinathan Nair, Namrata G
mous web-based survey in the Indian sub- Adulkar , Lynn D’Cunha , Priyanka R Rao et al
continent. Published in: Orbit 2021
DOI:10.4103/ijo.IJO_1918_19 Highlights: They report a series of 13 immuno-
Authors: Pradhan, Anuradha; Ganguly, Anasua; competent patient who developed new onset un-
Naik, Milind N; Nair, Akshay Gopinathan; Desai, controlled diabeted mellitus following COVID 19
Savari; Rath, Suryasnata infection and presented as rhino-orbital mucormy-
Published in: Indian Journal of Ophthalmology au- cosis (ROM). They suggest that those involved in the
gust 2020 care of COVID-19 patients should be aware about
Highlights: The survey evaluated the current prac- the possibility of recent-onset DM, even in patients
tice patterns in the treatment of thyroid eye disease without a history of corticosteroid therapy. Rarely,
(TED) in Indian subcontinent through a web-based recent-onset DM following COVID-19 may present
survey of members of Oculoplastics Association of as rhino-orbital mucormycosis, which requires ag-
India (OPAI). Almost all favored a multidisciplinary gressive surgical and medical intervention.
approach. Grading severity and activity of TED was
the rule rather than exception in TED management. Rise of the phoenix: Mucormycosis in
While corticosteroids remained modalities of first COVID-19 times.
choice, more than half preferred immune-modu- DOI:10.4103/ijo.IJO_310_21
lators as the steroid-sparing agent for recalcitrant Authors: Ravani, Swati A; Agrawal, Garima A; Leu-
TED. Orbital radiotherapy was relatively an uncom- va, Parth A; Modi, Palak H; Amin, Krisha D
mon treatment choice. An increased awareness to- Published in: Indian Journal of Ophthalmology 2021
ward evidence-based disease-modifying treatment Highlights: retrospective, institutional cohort, inter-
modalities may help in the development of multiple

30 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

ventional study. 31 patients were seen. They recom- DOI:10.1097/IOP.0000000000002047
mend, a high index of suspicion of rhino-orbital mu- Authors: Meleha Ahmad, Jiawei Zhao, Mustafa Ift-
cormycosis in COVID-19 era in all patients referred ikhar, Joseph K Canner, Fatemeh Rajaii et al
or presenting to the ophthalmologist with ophthal- Published in: Ophthalmic Plastic and Reconstruc-
moplegia and diminution of vision with or without tive surgery 2021
history of concurrent uncontrolled diabetes mellitus. Highlights: The authors identified an estimated 4.2
The numbers may represent just the tip of the ice- million ED visits in the United States with oculoplas-
berg. Further studies need to be done to document tics-related primary diagnoses, of which pathology
management modality and risk factors. Rhino-orbit- was 80.8% eyelid/adnexal, 17.4% orbital, and 1.74%
al cerebral mucormycosis and HbA1c ≥8 mmol/mol lacrimal. Overall, 31.3% of the visits were deemed to
must be treated aggressively. be nonurgent. Orbital pathology was more likely to
be caused by trauma (70.6%), to be urgent (98.0%),
The first UK national blepharospasm pa- and to require a procedure (45.6%) (p < 0.001).
tient and public involvement day; identify-
ing priorities. The use of mobile devices in oculoplastic
DOI:10.1080/01676830.2019.1657469 and oral and maxillofacial surgery: A sys-
Authors: Fabiola R Murta, Jacob Waxman, Andi tematic review.
Skilton , Sadie Wickwar et al DOI:10.1016/j.amjoto.2021.103282
Published in: Orbit 2020 Authors: Haniah A Zaheer, Abdur Rahman Jabir,
Highlights: The authors innovative “Blepharospasm Kevin Yang, Sammy Othman et al
Day” in UK. Patient’s priorities for research were Published in: American journal of otolaryngology
identified, delegates understanding of blepharo- 2021
spasm increased and an independent blepharospasm Highlights: Mobile device use has become ubiquitous
patients-representatives’ group was established; a across cultures worldwide. The literature suggests
first in the UK. Furthermore, short-fallings identi- that mobile phone use in oculoplastic surgery and
fied in the Blepharospasm disability index tool high- OMFS may improve clinical practice in multiple set-
light the need for better severity-assessment tools. tings. Mobile phone applications have versatile func-
We demonstrate the benefits of the ‘patient and tions in ophthalmology, otolaryngology, and plastic
public involvement’ approach in the management of surgery, such as increasing patient engagement in
complex conditions such as blepharospasm treatment, decreasing no-shows to appointments,
and providing patient education, photography and
Cosmetic Filler Blindness: Recovery After medical references.
Repeated Hyaluronidase Injections.
DOI:10.1093/asj/sjab334 Gender and editorship in oculoplastics so-
Authors: Jennifer J Danks, James D Dalgliesh, Tom cietal publications.
Ayton DOI:10.1080/01676830.2021.1975771
Published in: Aesthetic Surgery Journal Authors: Edsel B Ing, Qinyuan Alis Xu, Bonnie He,
Highlights: complications of cosmetic injectables Stuti M Tanya, Nancy A Tucker
are seen with the rise of their use. The authors re- Published in: Orbit 2021
port a case which revived with immediate injection, Highlights: Women are underrepresented on the
followed by high dose intra-orbital and extra-orbital editorial boards of oculoplastic journals. Possible
injection of hyaluronidase. Recovery of vision was methods to improve gender balance include mul-
remarkable, from NPL to 6/6, documented at a ter- ticriteria objective decision-making criteria for ed-
tiary referral eye hospital. itor nominations, mentoring peer reviewers that are
women, and appointing a journal editor for equity,
Epidemiologic Trends in Oculoplastics-Re- diversity and inclusi
lated Emergency Department Visits in the
United States, 2006-2015.

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 31

NESOS newsdesk

Activities of the Nepalese Society for Ocu-
loplasty Surgeons (July-Dec, 2021)

ACTIVITIES: scientific chair while Dr Aash-
ish Raj Pant, oculoplasty sur-
1st NESOS International geon from Mechi Eye Hospi-
Webinar “The Highway of tal, took the responsibility as
Tears” - July 2021 scientific secretary.

The NESOS International We- 1st issue of NESOS eMag -
binar “The Highway of Tears” July 2021
(July 2021) was a hugely
successful event with acco- The maiden issue of “the Participation in DOS
lades from every corner of the NESOS e-Mag” – an official
country and abroad. The huge biannual eMagazine of the Dr. Aashish Raj Pant present-
number of participants- more NESOS was released by the ed on Eyelid entropion surger-
than 215 in the zoom webinar Editor-in-Chief of the NESOS ies on behalf of NESOS at the
streaming and more than 200 eMag, Dr. Jyoti B Shrestha DOS conference.
in the YouTube live streaming during the NESOS Internation-
(https://youtu.be/wESGmFHS- al webinar. It was released Participation in NOSCON
gNY) spoke volumes on the online via anyflip (https://an-
success of the webinar. This yflip.com/fpoyg/obiq/) and NESOS members presented
was due to a wide range of ex- the magazine was appreciat- and participated in the Annual
tremely knowledgeable speak- ed by all the panelists and the NOS conference held at Kath-
ers and panelists from Nepal, speakers. mandu.
India, Bangladesh, Thailand,
and the Philippines covering Participation in OPSSA or- MEETINGS:
nearly all aspects of lacrimal ganized by BOSS - Decem-
drainage disorders from ex- ber 2021 Due to the current COVID cri-
ternal DCR to endoscopic en- sis, regular 3-monthly physical
donasal, non-endoscopic en- A separate session for NE- meetings were replaced by vir-
donasal DCR, failed DCR and SOS was provided in the OPS- tual. A physical meeting was
canalicular trauma. SA virtual conference 2021 held during the annual NOS
“South Asian Trends in Ocu- conference.
Professor Reynaldo Javate loplastics” organised by the Virtual meetings – 3
was the chief guest speaker Bangladesh Oculoplastic Sur- Physical meeting - 1
for the event. Dr Prerna Arjy- geons Society (BOSS).
al Kafle, oculoplastic surgeon Six NESOS members gave
from Biratnagar Eye Hospital, their presentation relating to
took the responsibility of or- the theme.
ganizing the webinar as the

32 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

NESOS members in action

NESOS founder president and NOS president Prof Dr
Rohit Saiju inaugurating Jyoti Eye Hospital of NE-

SOS life member Dr Sabin Sahu at Ramanand Chowk,
Janakpurdham – 9, Madhesh Pradesh on 22nd Janu-
ary 2022.Our best wishes to Dr Sabin and his team

Congratulations and
welcome to new ocu-
loplastic surgeons in

NESOS -
Dr Anish Manandhar,
Dr Dikshya Bista and

Dr Varun Shrestha .

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 33

NESOS members in action

Jumbo NESOS team at Nepal Ophthalmic
Society Annual Conference (December 4,
2021)

Speakers posing for photograph after
NESOS session in the annual NOS an-

nual conference with token of love

Ramp walk cum fashion show co choreographed by NESOS member Dr Prerana and Lead by Dr Rohit
Saiju was the attraction of the day at the NOS Annual Conference

34 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

NESOS members in action

Dr Diwa Lamich-
hane started endo-
scopic
endonasal DCR
surgery at CHEERS
hospital, BP Eye
foundation.

Dr Naresh Joshi,
Oculoplastic surgeon
based in London always
makes time for NESOS
while he is in Nepal.
NESOS president Dr
Ben along with Member
Dr Sabita Palikhe and

Dr Varun Shrestha

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 35

NESOS members in action

Dr Sabin teaching Optometrist and
Ophthalmic assistant at his Jyoti
Eye hospital. He loves teaching
besides his clinical job.

Dr Hom giving lecture on eye safety and first aid to factory
workers at Hetauda.

36 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

Welcome to the fraternity
Newest members of the NESOS

Dr Anish Manandhar Dr Dikshya Bista Dr Varun Shrestha

Geta Eye Hospital, Kailali, Geta Eye Hospital, Kailali, Drishti Eye Care System
Dhangadi, Geta Dhangadi
I completed my MBBS from
I did my MBBS from Kathman- I completed my fellowship in Manipal (MCOMS, Pokhara) and
du Medical College and my MD Ludwig Maximilian Universi- MD from NEH. Post residency I
ty, Munich, Germany. I did my completed my Anterior segment
from BP Koirala Institute of MBBS from Kathmandu School of fellowship (EREC-P) and joined
Health Sciences, Dharan, Nepal. Medical Sciences and my MD from Drishti Eye Care, and pursued a
fellowship in Oculoplasty (TIO)
I completed my fellowship in BPKLCOS, TUTH.
Oculoplasty and ocular oncology During my residency days, I found thereafter.
from Tilganga Institute of Oph- orbital surgeries very challenging I always had a deep interest in
Oculoplasty as I felt the profound
thalmology. and always wanted to do such impact this field has on the life of
surgeries. I was immediately drawn the patient and also the aestheti-
I joined Oculoplasty due to towards the subspecialty as it gives cally pleasing end results of a well
the wide variety of surgeries in
oculoplasty and the immediate quick result and patient satisfac- performed procedure.
good outcome in some surgeries. tion. Regarding my aims in this field, it
Besides, there are very few ocu- is to slowly expand and improve
loplasty surgeons at peripheral I always wanted to give my patient my skills, learn from my seniors
happy faces so I joined Opthalmol- and peers and hopefully contrib-
eye hospitals. ogy to give immediate happiness of
vision after surgery. Oculoplastics ute in lessening the burden of
oculoplasty related problems.
not only help in regaining vision
but also wipe out tear in eyes(liter-
ally). The perfect reason to create

happiness.

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 37

The I-STORIES: Oculoplasty in Photography

Photography is an asset to any oculoplastic surgeon. The work of an oculoplastic sur-
geon is an art which needs to be documented. The I -stories: Oculoplasty in photography
section will feature the works of oculoplastic surgeons, their success stories and experi-
ences. Consent should be taken from the patient by the respective author.

Moderate Ptosis with nevus
(right); LPS advancement sur-
gery left upper lid (left)
Dr Puja Rajbhandari

Congenital ptosis in right
upper lid (right); Post fron-

talis sling surgery (left)
Dr Puja Rajbhandari

Lateral Tarsal Strip (LTS)
surgery for senile entropion
in Left lower lid. pre and
post-surgery.
Dr Devraj Bharati

38 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

The I-STORIES

Lateral Tarsal Strip (LTS) and post auricu- Blepharophimosis Syndrome. Post frontalis
lar skin graft for cicatricial ectropion. pre- sling surgery y- v plasty.
and post-surgery. Dr Prerna Arjyal kafle
Dr Devraj Bharati

Congenital ptosis pre and post frontalis sling LPS advancement surgery pre, on table and
surgery with silicon rod. post-surgery.
Dr Prerna Arjyal kafle Dr Prerna Arjyal kafle

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 39

The I-STORIES

Dr Tina Shrestha Dr Tina Shrestha

LTS surgery for bilateral lower lid ectro- Before: non epithelized tight skin all over-
pion face,complete loss of eyebrow, cicatricial

Dr Gaurav dhungana ectropion. After: extensive release of scar tissue,
postauricular graft plus LTS procedure.
Dr Suresh Rasaily

40 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

The I-STORIES

Aponeurotic ptosis
correction with LPS
Resection
Dr Suresh Rasaily
Aponeurotic ptosis
correction with LPS
advancement
Dr Suresh Rasaily

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag LPS resection for
mild ptosis.
Dr Koshal Shrestha

41

VIDEO BOUQUET

Surgical Video Links provided by the
NESOS members

Forehead flap lecture by Dr Naresh
Joshi at NESOS Nepal youtube chan-
nel
https://www.youtube.com/
watch?v=bqECYEBqC2s
Lower Lid Blepharoplasty . lecture
by Dr Naresh Joshi at NESOS Nepal
youtube channel.
https://www.youtube.com/watch?v=q-
j85kLFBODM

An approach to upper lid Blepharo-
plasty by Dr Naresh Joshi at NESOS
Nepal youtube channel
https://www.youtube.com/watch?v=-
4zwbaetc2Tg

42 NESOS E-Mag Volume 1, No. 2 (July-Dec, 2021)

NESOS POLL

NESOS e-mag poll for Eyelid malposition

Volume 1, No. 2 (July-Dec, 2021) NESOS E-Mag 43