eyelids & adnexa 1.5hr - buffalo academy of veterinary ... · diseases & surgery david a....
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Eyelids & Adnexa Diseases & Surgery
David A. Wilkie DVM, MS, Diplomate ACVO
Professor Department Chair
The Ohio State University [email protected]
The Rule of Eyelid Surgery ! K ! I ! S ! S
The Rule of Eyelid Surgery ! KEEP ! IT ! SIMPLE ! STUPID
Ophthalmic Surgery ! Gelatt KN:
Veterinary Ophthalmic Surgery 2011
Everyone has an opinion
Ophthalmic Surgery ! Pitfalls
! Failure to use magnification
! Failure to use appropriate instrumentation
! Inappropriate suture selection and/or placement
! Poor tissue handling
Chalazion clamp
Jaeger eyelid plate
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Jameson caliper
Castroveijo caliper
Magnification Magnification Good
Bad
Surgeon Position for all microsurgery
! Surgical Position ! Seated
! Specialized chairs with armrests
! Arms resting on armrest ! Essential for fine motor
control
The Eyelids serve the Cornea
16 mm
23-25 mm
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They come in all sizes, but……Most corneas are the SAME size!
We breed them to look different, but corneas remain the same
Macroblepharon
This is the underlying cause of almost all entropion and ectropion
Eyelid length is determined under anesthesia and is the “stretched” maximum canthus to canthus length
Most normal canine eyelids measure 24-26mm when stretched
24-26 mm
Size Does Matter
12 month old labrador retriever
Cornea 16mm
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Macroblepharon
All entropion/ectropion patients have abnormalities of eyelid length
Eyelids 33 mm
12 month old labrador retriever
33 mm pre-op
25 mm post-op
12 month old labrador retriever
Jameson caliper
Bishop harmon tissue forceps
Tenotomy scissors
Needle holder
Permanent Lateral Canthoplasty Permanent Lateral Canthoplasty
6-0 to 7-0 absorbable
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Permanent Lateral Canthoplasty
6-0 non-absorbable, monofilament
Cruciate pattern
Permanent Lateral Canthoplasty
Tuck the ends so they direct away from the cornea
Lateral Canthal Entropion
http://youtu.be/TBHSIoEk8iw
Look where the canthus collapses and also for “notching” at the fold
Permanent Lateral Canthoplasty
http://youtu.be/y-vg-5DaiFQ
Entropion
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Entropion Temporary Tacking
5-0 to 6-0 non-absorbable monofilament
Young dog, mild entropion
Jaeger Eyelid Plate
Bishop harmon tissue forceps
Tenotomy scissors
Needle holder
Scalpel For a more permanent correction we use the Modified Hotz-Celsus
Where is 2mm???
2 mm
Modified Hotz-Celsus
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6-0 Surgilene
Modified Hotz-Celsus Entropion
http://youtu.be/zMG4ckCgjf0
Entropion and Macroblepharon
Modified Hotz-Celsus
http://youtu.be/gBBpummV08M
Lateral canthoplasty and Modified Celsus
2 yr old Great DanePre-op
-Macroblepharon-Entropion-Ectropion-Scroll cartilage
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Permanent Lateral Canthoplasty
41 mm
28 mm
Modified Hotz-Celsus
2 yr old Great DaneImmediately Post-op41 mm
28 mm
2 yr old Great Dane2 wk Post-op41 mm
28 mm
Entropion
A combined HC and lateral canthal closure had a 99.21% success rate of resolving lower lid entropion
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Why did this surgery fail?
Failed to correct macroblepharonFailed to correct collapsed canthusIncision too far from eyelid margin
Follow the rules….it works
What options are there for this dog? Brow-Sling
Brow-Sling Brow-Sling
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Pre-op Brow Sling Post-op
Rhytidectomy
Rhytidectomy
Pre-op
Post-op
Rhytidectomy 4 month post-op
Rhytidectomy three years post-op
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Focal Rhytidectomy plus lateral canthoplasty and modified-celsus (upper and lower eyelid)
Focal Rhytidectomy plus lateral canthoplasty and modified-celsus (upper and lower eyelid)
Focal Rhytidectomy plus lateral canthoplasty and modified-celsus (upper and lower eyelid)
Pre-op
Post-op
Stades Technique
From: Projects by Dittmann J: http://www.delta-3.de/
Stades FC. A new method for surgical correction of upper eyelid trichiasis–entropion: operation method. JAHA 1987; 23: 603–606
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Medial Canthal Entropion What is the #1 Question?
How old is this dog??
5yr old and blind Shih Tzu with long soft hairs, no corneal damage
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2 yr old pug with short stiff hairs and pigmentary keratitis
This is NOT the result of the nasal fold!
Permanent Medial Canthoplasty
Tissue to be excised
Caruncle
Permanent Medial Canthoplasty
http://youtu.be/Tq8mFUGncS4
Intraop
Postop
Permanent Medial Canthoplasty
Preop
Postop
Ectropion
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Entropion/Ectropion Kuhnt-Szymanowski
From: Projects by Dittmann J: http://www.delta-3.de/
Munger RJ, Carter JD. A further modification of the Kuhnt– Szymanowski procedure for correction of atonic ectropion in dogs. JAHA 1984; 20: 651– 656
Ectropion
The primary problem remains macroblepharon
Pre-op
46 mm
Ectropion KeepItSimpleStupid
Lateral Canthoplasty
Wedge excision
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Agenesis ! lack of development
of the upper eyelid ! superior-temporal
50% of the eyelid ! usually bilateral
Dziezyc/Millichamp modification
What is wrong with this image?
What the books tell you to do
Dziezyc/Millichamp modification
What is wrong with this image?
What the books tell you to do
Lip to Lid
Whittaker CJG, Wilkie DA, et al: Lip commissure to eyelidtransposition for repair of feline eyelid agenesis. Vet Ophth 13:173-178, 2010
Agenesis
Rotational Graft
Lip to Lid
From: Popesko P: Atlas of topographical anatomy of the domestic animals
Parotid duct
Facial v.Facial n. dorsal and ventral buccal branch
Orbicularis oris
Bucinnator
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Parotid Duct
Oral Mucosa
Bridge incisionBridge incision
Conjunctiva to oral mucosa8-0 vicryl simple continuous
Parotid Duct
Parotid Duct
Immediately Post-op Immediately Post-op
2 months Post-op
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Distichia Distichia ! Treatment:
! Epilating the hairs has only a short term effect ! Cryosurgery ! Electroepilation ! CO2 Laser
Cryosurgery
Nitrous Oxide -89oC
Liquid nitrogen -196oC
Distichia
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Cryosurgery Side effect is depigmentation
Ectopic cilia
! originates from tarsal/meibomian gland exits from palpebral conjunctiva
! difficult to diagnose (need magnification)
! Usually at the 12 o'clock position ! Common in Shih Tzu
Ectopic cilia
Ectopic cilia Ectopic Cilia
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Ectopic cilia Ectopic cilia
Eyelid Neoplasia
COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin
Canine Eyelid Neoplasia
! Canine ! common ! benign
(>90%)
Canine Eyelid Neoplasia
Histiocytoma Basal Cell
MelanomaAdenoma
Canine Eyelid Neoplasm
Mast cellGranular cell
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Feline Eyelid Neoplasia ! more aggressive than neoplasms of the
canine eyelid
Feline Eyelid Neoplasia
SCC SCC
Mast Cell Fibrosarcoma
Mast Cell Tumor
Results All periocular CMCTs were restricted to the eyelids. In addition to surgical excision, three cats were treated with adjunctive therapy (strontium-90 irradiation or cryotherapy) intraoperatively. Local tumor control was achieved in 22/23 cats with a minimum follow-up of 30 days (median follow-up time of 711 days); one cat developed disseminated CMCTs but no local recurrence. Cats with periocular CMCTs had a median survival time of 945 days. Metastatic disease involving peripheral lymph nodes or abdominal viscera was not detected in any cat at any time during the study. All periocular CMCTs were classified as low-grade based on histopathology, and complete excision was achieved in approximately 50% of cases.
Conclusions Surgical excision of periocular CMCTs in cats is an effective treatment option with rare local recurrence and metastases, even following incomplete surgical excision.
Eyelid Neoplasia ! Treatment:
! Dog vs. Cat ! Benign neglect
! Surgery ! Excisional biopsy ! Cryosurgery ! CO2 laser
! Chemotherapy ! Radiation
How much can I remove?
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1/3<1/3 <1/3
How much can I remove?
Wedge Resection
Two-layer closure ! Conjunctiva: 6-0 absorbable suture in a continuous pattern
Two-layer closure ! Conjunctiva: 6-0 absorbable suture in a continuous pattern
Two-layer closure ! Skin: 6-0 non-
absorbable suture ! cruciate suture
pattern at the eyelid margin , then simple interrupted
Two-layer closure ! Skin: 6-0 non-
absorbable suture ! cruciate suture
pattern at the eyelid margin , then simple interrupted
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Two-layer closure ! Skin: 6-0 non-
absorbable suture ! cruciate suture
pattern at the eyelid margin , then simple interrupted
http://youtu.be/95W0tRUd560
Wedge ResectionChalazion clamp
! Reconstruction of larger eyelid mass excisions ! H-plasty/Z-plasty ! Semicircular flap ! Split eyelid flap ! Cross eyelid flap ! Rhomboid graft flap ! Lip to Lid ! Axial pattern flap
! H-Plasty ! Repair of larger
excisions ! Preserve as much
conjunctiva as possible
! Diverging incisions
From: Projects by Dittmann J: http://www.delta-3.de/
ab
b = 120% a
Excised
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Diverging incisions
Preserve Conjunctiva
6-0 surgilene cruciate
6-0 vicryl continuous
48hr Postop
1 month Postop 3 month Postop
3 month Postop Fibrosarcoma
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Mast cell tumor Postop
Z-Plasty -for lateral canthus
From: Projects by Dittmann J: http://www.delta-3.de/
Feline Mast Cell Tumor
Z-Plasty Z-Plasty
Post-op
Suture Removal
Axial Pattern Flap
Jacobi S, Stanley BJ et al: Use of an axial pattern flap and nictitans to reconstruct medial eyelids and canthus in a dog. Vet Ophthalmol 11:395-400, 2008
One step procedure for medial canthal reconstruction
Axial Pattern Flaps incorporatea cutaneous artery and vein vs a subdermal plexus flap
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Axial Pattern Flap
Jacobi S, Stanley BJ et al: Use of an axial pattern flap and nictitans to reconstruct medial eyelids and canthus in a dog. Vet Ophthalmol 11:395-400, 2008
Feline SCC Axial Pattern Flap
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Cryosurgery Intralesional Chemotherapy
Radiation Conjunctival Neoplasm
COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin
Conjunctival Neoplasm Squamous papilloma
Conjunctival Neoplasm HemangiomaHemangiosarcoma
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Canine Conjunctival Melanoma
Conjunctival Melanoma- 5% mortality
Canine amelanotic melanoma
Feline conjunctival melanoma
Conjunctival Melanoma- 55% mortality
Feline conjunctival melanoma
55% mortality
Third Eyelid Neoplasia
K9 adenocarcinoma K9 adenocarcinoma
Papilloma
SCC
K9 adenocarcinoma
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“Cherry” Eye
! Options: ! Surgically replace ! Leave alone ! Excise
! All are at risk for KCS ! Excise (48%) > Leave alone (43%) > Replace (14%)*
! Control (5%) ! Monitor STT for life
*Morgan R: JAAHA1997
Morgan RV, Duddy JM, McClurg K. Prolapse of the gland of the third eyelid in dogs: a retrospective study of 89 cases (1980–1990). Journal of the American Animal Hospital Association 1993; 29: 56–60
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https://www.youtube.com/watch?v=uBmCpekwpcc
Power set to lowest coagulation energy setting and gradually increased to effect. Typically a setting of Cut 0 and Coag 2..
Allbaugh RA, Stuhr CM: Thermal cautery of the canine third eyelid for treatment of cartilage eversion. Vet Ophth 16:392-395, 2013
Thermal Cautery
QUESTIONS?