Volume 9, Issue 1 October 2010

®

A Quarterly Publication for the Veterinary Community from Eye Care for Animals

When Hairs Meet the Eye

become shortened the facial skin has sequestra. In some dogs we see corneal not correspondingly been reduced - this vascularization and medial corneal results in the formation of large nasal pigmentation as a result of the chronic folds of haired skin. Hair on the nasal cilia irritation. This pathology is often folds may impinge on the eye and cause compounded by the abnormally large problems in some dogs. As the facial palpebral fissure (macroblepharon), the skin is pushed towards the eye there is shallow orbit which limits the extent to a tendency for the lower to roll which the eye can be retracted and the against the eye (). This is lids closed over the , the extreme usually compounded by tight attachment rounded (rather than elliptical) shape of the medial canthus (the location where of the upper and lower around the upper and lower eyelids join on the the medial canthus which may reduce nasal side of the face) to the underlying the effective medial corneal coverage bone via the medial palpebral ligament. during blinking, and in some dogs Nicholas J. Millichamp, The net result is a rolling of the medial reduced tear secretion from the lacrimal BVetMed, PhD, DVOphthal, DECVO, part of the lower (and occasionally glands (keratoconjunctivitis sicca). All MRCVS, DACVO upper) eyelid such that normal eyelid of these factors (and probably some that Eye Care for Animals cilia contact the conjunctiva or cornea. In we don’t yet understand) contribute to addition many affected animals have cilia the development of keratitis. In dogs In this article we look at the effects which grow from the anterior surface with good tear production the corneal that two common eyelid abnormalities of the medial palpebral conjunctiva changes (vascularization, scarring and have on the eye - one due to an (this area in people is referred to as the pigmentation) may be limited to the abnormal eyelid conformation, the conjunctival caruncle although a discrete medial cornea where cilia contact the other due to abnormal hair growth in structure is rarely evident in animals). eye. In dogs additionally affected with what may otherwise be normal lids. These cilia also contribute to medial low tear production, reduced corneal Unfortunately many of the conditions we corneal irritation in many dogs. sensitivity and reduced coverage of the see in domestic species and especially eye when blinking, the corneal pathology in dogs are due to years of selective is more diffuse – often resulting in breeding for a variety of traits considered widespread corneal pigmentation even desirable for a particular breed - one at an early age. unintentional consequence of which is the development of conformational (continued on page 2) abnormalities or inherited abnormalities of the eyelids which can negatively impact ocular structure and function. INSIDE THIS ISSUE: Medial Canthal Entropion Scientific Article...... Pg 1-3 and (MCET) The effect of this irritation on the eye News & Events...... Pg 4 Many of the eyelid and cilia varies from animal to animal. In cats CERF Corner...... Pg 5 abnormalities in dogs and cats stem irritation from the lower eyelid cilia may Memo to Managers...... Pg 6 from breeding for an extreme form contribute to the formation of chronic of brachycephalism. As the skull has ulceration and formation of corneal

Eye Care for Animals One THE OCULAR OUTLOOK cells (especially polymorphonuclear Celsus) types of excision often are leukocytes entering the tear film difficult to perform in a way that in response to infection) as well as actually corrects the problem at bacteria and degenerating corneal this location. The most effective epithelial cells causes rapid breakdown approach is one in which the lid of the corneal tissue (keratomalacia) margins are incised just medial to and in extreme cases perforation of the nasolacrimal puncta and a strip the eye. of lid margin is excised, continuing The treatment of medial canthal the incision in an arrowhead shape Some dogs may go their entire trichiasis and entropion depends medial to the medial canthus. This life without any significant signs (at on how severely the lids are dissection is necessarily performed least as perceived by the owners) of deformed and the extent of corneal with high magnification under the ocular discomfort or development pathology. In any of these cases, operating microscope in order to of more severe corneal lesions. It medical treatment for any identified identify the areas with hair follicles is likely that the chronic reactive reduction in tear production with which need to be excised and in order scarring and pigmentation “protect” corneal desiccation is important. to avoid damage to the nasolacrimal the cornea against development Medical treatment involves use of puncta (especially lower) and the of more severe corneal pathology cyclosporine or tacrolimus to increase underlying nasolacrimal duct. If the (ulceration) in many animals and tear production, antibiotics to control medial palpebral ligament is very reduce the sensitivity of the medial bacterial infection and application of tight it may be necessary to relieve cornea. However some dogs and cats artificial tear preparations to moisten the tension slightly - this has to be develop more severe ocular lesions the corneal surface. Corticosteroids done with extreme care to avoid due to cilia contact medially. I have should be used very cautiously or not damage to the nasolacrimal duct. seen dogs and cats of all ages with at all so long as cilia are abrading the Hair extending onto the conjunctiva at severe corneal ulceration associated corneal surface. Surgical treatment the medial canthus or arising from the with medial canthal entropion and can be divided into efforts to reduce palpebral surface of the third eyelid trichiasis. the cilia contacting the ocular medially are also excised. The upper structures and correction of the and lower eyelids are then re-apposed eyelid malformation itself. In mild just medial to the puncta – a medial cases of medial trichiasis, the eyelid tarsorrhaphy. hairs can be treated with cryothermy – a double freeze thaw cycle with a 3-4mm ophthalmic cryoprobe applied over the palpebral conjunctiva to destroy hair follicles. This also results in eyelid depigmentation, although repigmentation occurs over Chronic irritation of the cornea a few months. damages the corneal epithelial surface Various surgical techniques have layer. If erosions and superficial ulcers been described which aim to correct occur, bacteria may proliferate in the the medial eyelid entropion and In some extreme cases of deeper corneal stromal tissue - the remove the cilia which contact the macroblepharon a partial lateral release of enzymes from inflammatory eye. The usual elliptical (Hotz- tarsorrhaphy may also be created to reduce overall corneal exposure. Editor’s box Modifications have also been described to increase support during healing which involve creating a bridge of palpebral conjunctiva from Ocular Outlook the lower eyelid which is sutured Editor: Sara Calvarese, DVM, DACVO into a pocket created in the upper Managing Editor: Julie Gamarano lid between the skin and orbicularis muscle and tarsoconjunctival inner Eye Care for Animals welcomes your comments on the Ocular Outlook. lining of the lid. Depending on Please e-mail your feedback to [email protected] the extent of the correction, in or call Julie at (480) 682-6911. some cases, the upper nasolacrimal For electronic subscription please visit www.eyecareforanimals.com punctum may be occluded as part of this – rarely would this be

Two Eye Care for Animals THE OCULAR OUTLOOK a problem since the upper punctum With more firm and stout cilia, a breed commonly affected with a contributes less than the lower the hairs may cause conjunctival multiplicity of eyelid cilia disorders. punctum to tear drainage. Because and cornea irritation or ulceration. Treatment of distichia is most many brachycephalic dogs with Treatment of these hairs by cutting effectively performed with medial entropion also have low or plucking is not recommended in cryothermy to destroy the follicle tear production and increased tear most cases due to their tendency to at the base of the Meibomian gland. evaporation, any reduction of tear re-grow from the remaining follicle. When viewed under the operating drainage might actually be beneficial. Each time distichia are trimmed microscope the location of the cilia In more extreme cases the medial there is a tendency for them to regrow can easily be seen and a double blepharoplasty is combined with as thicker and more troublesome freeze thaw cycle applied with a surgical removal of part or the entire hairs with resultant corneal disease. fine ophthalmic cryoprobe over the nasal fold when either the fold is The irritation from the hairs causes follicle at the base of the gland. Cilia contributing to the medial lower increased lacrimation, conjunctivitis eyelid entropion or nasal fold cilia are and in some cases corneal ulceration also rubbing on the corneal surface. (which may be compounded due to Since owners are often concerned self trauma). In some breeds (for about the cosmetic alteration when instance the shown removing the fold I usually try to below) the cilia often present as remove only the anterior half of the numerous short stout hairs along fold in order to preserve some of the a considerable length of the eyelid brachycephalic facial appearance. margin. Cilia abnormalities may can then be epilated at the time of The incisions are sutured in such a be seen at any age but are usually surgery or a few days later. way that the nasal fold is rolled away present in young animals and will Ectopic cilia can be treated with from the lower eyelid which directs persist unless treated appropriately. a combination of local excision cilia on the fold further away from the (using high magnification to identify corneal surface. cilia coiled beneath or protruding through the conjunctival surface) Distichiasis and Ectopic Cilia and cryothermy. I find that reliable Cilia which arise from the identification of these cilia almost Meibomian glands are referred to invariably requires examination of the as distichia when they emerge from lids under the operating microscope the openings of the gland at the eyelid -- even the magnification provided margin or ectopic cilia when they by a slit lamp biomicroscope in emerge through the conjunctiva on the posterior surface of the eyelid. Ectopic cilia may coil in the conscious animal may fail to We see these conditions commonly the Meibomian gland and identify some ectopic cilia. Various in many breeds of dog (where subconjunctival tissue and be other surgical approaches have been presumably they are inherited), and associated with accumulations recommended for treating distchia with slightly less frequency in cats of lipid in the sebaceous glands. and ectopic cilia - many of them are and horses. In each case the cilia more traumatic and less effective have a follicle located near the base than cryothermy and some may of the meibomian gland. Distichia result in considerable scarring of the may arise as fine hairs from the eyelid eyelids and permanent damage and margin and float in the tear film. In destruction of the eyelid sebaceous some breeds this appearance is very glands. Laser treatment seems to common (for instance the Cocker Spaniel). If the hairs are very fine and offer little advantage (and is more not numerous they may cause few costly) than cryothermy. clinical signs (possibly only slightly increased tearing). If the hairs begin to protrude through the conjunctival surface they usually cause severe corneal irritation and development of chronic non- healing corneal ulcers which may become deep or form exuberant granulation a the corneal surface. These are always very painful. Shih Tzus are

Eye Care for Animals Three THE OCULAR OUTLOOK What’s new at Eye Care for Animals?

Congratulations!

Dr. Christin Chapman Dr. Tina Fife Dr. Stacy Ivins Dr. Lynsey Smith

for attaining diplomate status in the American College of Veterinary Ophthalmologists.

Upcoming Continuing Education Lectures

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Round Rock, Texas Reno, Nevada Eye Care for Animals beginning Nov 1st Eye Care for Animals will merge with Located in: Dr. Dan Lavach, DACVO at Heart of Texas Veterinary Specialty Center Eye Clinic for Animals in November 115 East Old Settlers Blvd. 9720 S. Virginia Street, Unit D Round Rock, TX 78664 Reno, NV 89521 Southern Arizona Veterinary Medical Association CE Phone: (512) 335-EYES (3937) Phone: (775) 852-1155 Speaker: Reuben Merideth, DVM, DACVO Fax: (512) 835-0227 Fax: (775) 852-1146 Topic: Glaucoma...What’s brand spanking new in diagnosis, medical Toll Free: (877) PETSEYES (738-7393) management and surgery Location: Radisson Suites 6555 E Speedway Blvd, Tucson, AZ October 20, 2010 Dinner 6:00pm Lecture 6:45-8:45pm Please contact Julie Gamarano for further information at 480-682-6911 [email protected]

Four Eye Care for Animals THE OCULAR OUTLOOK

CERF CORNER

Prolapse of the Gland of the Third Eyelid

The gland of the third eyelid contributes approximately one third of the total tear production. Prolapse of this gland is the most common condition affecting the third eyelid. It is most likely to occur in Cocker Spaniels, Lhasa Apsos, Pekingese, and English Bulldogs. Although Sara Calvarese the pathogenesis of this disorder is not fully understood, it is believed DVM, DACVO to be the result of weak connective tissue attachments between the Eye Care for Animals gland of the third eyelid and the periorbital tissues. Prolapse of the gland of the third eyelid usually occurs in young dogs (<2 years) and occasionally in cats. It can be either unilateral or bilateral and is diagnosed by its characteristic clinical appearance, which has led to the name “cherry eye.”

Surgical repositioning of the gland is the recommended treatment. Studies have shown that dogs treated with excision of the gland or those that remained untreated were more likely to develop keratoconjunctivitis sicca (KCS) than those that underwent surgical repositioning of the gland. However, some breeds predisposed to prolapse of the gland of the third eyelid are also breeds predisposed to KCS, so repositioning of the gland does not guarantee that the dog will not develop KCS in the future. Surgical repositioning of the gland has a 90-95% success rate, with re-prolapse occurring more commonly in cases with concurrent bent third eyelid cartilage, more severe inflammation and/or vascular congestion and swelling of the gland pre-operatively.

The Morgan pocket technique is probably the most popular repositioning technique, although other types of anchoring procedures may be performed on more difficult cases. Care must be exercised to avoid placing suture material, and especially suture knots, on the bulbar surface of the third eyelid in a manner that will lead to corneal ulceration. Small, absorbable suture material, magnification, and post-operative use of an Elizabethan collar are recommended for most procedures and referral to a specialist should be considered for more complicated cases or cases of re-prolapse. Complications can include re-prolapse of the gland, wound dehiscence, infection of the surgical site, and/or corneal ulcerations.

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