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Eyelids & Adnexa Diseases & Surgery

David A. Wilkie DVM, MS, Diplomate ACVOProfessor Emeritus

The Ohio State UniversityWilkie.1@osu.edu

The Rule of Eyelid Surgeryn Kn In Sn S

The Rule of Eyelid Surgeryn KEEPn ITn SIMPLEn STUPID

Ophthalmic Surgeryn Gelatt KN:

Veterinary Ophthalmic Surgery 2011

Everyone has an opinion

Ophthalmic Surgeryn Pitfalls

n Failure to use magnification

n Failure to use appropriate instrumentation

n Inappropriate suture selection and/or placement

n Poor tissue handling

Chalazion clamp

Jaeger eyelid plate

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Jameson caliper

Castroveijo caliper

Magnification MagnificationGood

Bad

Surgeon Position for all microsurgery

n Surgical Positionn Seated

n Specialized chairs with armrests

n Arms resting on armrestn 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 entropionand 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/ectropionpatients 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

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EntropionEntropion

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

2 yr old Great DanePre-op

-Macroblepharon-Entropion-Ectropion-Scroll cartilage

Permanent Lateral Canthoplasty

41 mm

28 mm

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Modified Hotz-Celsus 2 yr old Great DaneImmediately Post-op41 mm

28 mm

Entropion

A combined HC and lateral canthal closure had a 99.21% success rate of resolving lower lid entropion

Why did this surgery fail?

Failed to correct macroblepharonFailed to correct collapsed canthusIncision too far from eyelid margin

Follow the rules….it works

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What options are there for this dog? Brow-Sling

Brow-Sling Brow-Sling

Pre-op Brow Sling Post-op

Rhytidectomy

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Rhytidectomy

Pre-op

Post-op

Rhytidectomy 4 month post-op

Rhytidectomy three years post-op

Focal Rhytidectomy plus lateral canthoplasty and modified-celsus (upper and lower eyelid)

Focal Rhytidectomy plus lateral canthoplasty and modified-celsus (upper and lower eyelid)

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Focal Rhytidectomy plus lateral canthoplasty and modified-celsus (upper and lower eyelid)

Pre-op

Post-op

Medial Canthal Entropion What is the #1 Question?

How old is this dog??

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5yr old and blind Shih Tzu with long soft hairs, no corneal damage

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

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Permanent Medial Canthoplasty

Preop

Postop

Ectropion

Entropion/Ectropion Kuhnt-Szymanowski

From: Projects by Dittmann J: http://www.delta-3.de/

Ectropion

The primary problem remains macroblepharon

Pre-op

46 mm

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EctropionKeepItSimpleStupid

Lateral Canthoplasty

Wedge excision

Agenesisn lack of development

of the upper eyelidn superior-temporal

50% of the eyelidn 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 Distichian Treatment:

n Epilating the hairs has only a short term effectn Cryosurgeryn Electroepilationn CO2 Laser

Cryosurgery

Nitrous Oxide -89oC

Liquid nitrogen -196oC

Distichia

CryosurgerySide effect is depigmentation

Ectopic cilia

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Ectopic Cilia Ectopic cilia

Ectopic cilia Eyelid Neoplasia

COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin

Canine Eyelid Neoplasian Canine

n commonn benign

(>90%)

Canine Eyelid Neoplasia

Histiocytoma Basal Cell

MelanomaAdenoma

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Canine Eyelid Neoplasm

Mast cellGranular cell

Feline Eyelid Neoplasian more aggressive than neoplasms of the

canine eyelid

Feline Eyelid Neoplasia

SCC SCC

Mast Cell Fibrosarcoma

Mast Cell Tumor

Eyelid Neoplasian Treatment:

n Dog vs. Catn Benign neglectn Surgery

n Excisional biopsyn Cryosurgeryn CO2 laser

n Chemotherapyn 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 closuren Conjunctiva: 6-0 absorbable suture in a continuous pattern

Two-layer closuren Conjunctiva: 6-0 absorbable suture in a continuous pattern

Two-layer closuren Skin: 6-0 non-

absorbable suturen cruciate suture

pattern at the eyelid margin , then simple interrupted

Two-layer closuren Skin: 6-0 non-

absorbable suturen cruciate suture

pattern at the eyelid margin , then simple interrupted

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Two-layer closuren Skin: 6-0 non-

absorbable suturen cruciate suture

pattern at the eyelid margin , then simple interrupted

http://youtu.be/95W0tRUd560

Wedge ResectionChalazion clamp

n Reconstruction of larger eyelid mass excisionsn H-plasty/Z-plastyn Semicircular flapn Split eyelid flapn Cross eyelid flapn Rhomboid graft flapn Lip to Lidn Axial pattern flap

n H-Plastyn Repair of larger

excisionsn Preserve as much

conjunctiva as possible

n 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 PostopZ-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

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

Axial Pattern 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

�Cherry� Eye

n Options:n Surgically replacen Leave alonen Excise

n All are at risk for KCSn Excise (48%) > Leave alone (43%) > Replace

(14%)*n Control (5%)

n Monitor STT for life*Morgan R: JAAHA1997

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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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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?