9/10/19
n K Eyelids & Adnexa n I n S Diseases & Surgery n S David A. Wilkie DVM, MS, Diplomate ACVO Professor Emeritus The Ohio State University [email protected]
The Rule of Eyelid Surgery Ophthalmic Surgery n KEEP n Gelatt KN: n IT Veterinary Ophthalmic Surgery n SIMPLE 2011 n STUPID
Everyone has an opinion
Ophthalmic Surgery Chalazion clamp n Pitfalls n Failure to use magnification n Failure to use appropriate instrumentation Jaeger eyelid plate n Inappropriate suture selection and/or placement n Poor tissue handling
1 9/10/19
Jameson caliper
Castroveijo caliper
Magnification Magnification
Good
Bad
The Eyelids serve the Cornea Surgeon Position for all microsurgery
23-25 mm n Surgical Position n Seated 16 mm n Specialized chairs with armrests n Arms resting on armrest
n Essential for fine motor control
2 9/10/19
They come in all sizes, but…… We breed them to look Most corneas are the SAME size! different, but corneas remain the same
Macroblepharon Eyelid length is determined under anesthesia and is the “stretched” maximum canthus to canthus length
This is the underlying cause of almost all entropion and ectropion
Size Does Matter
Cornea 16mm
Most normal canine eyelids measure 24- 26mm when stretched 24-26 mm
12 month old labrador retriever
3 9/10/19
Macroblepharon
Eyelids 33 mm All entropion/ectropion patients have abnormalities of eyelid length
12 month old labrador retriever
Jameson caliper Tenotomy scissors 33 mm pre-op
Bishop harmon tissue forceps Needle holder
25 mm post-op
12 month old labrador retriever
Permanent Lateral Canthoplasty Permanent Lateral Canthoplasty
6-0 to 7-0 absorbable
4 9/10/19
Permanent Lateral Canthoplasty Permanent Lateral Canthoplasty
Cruciate pattern
Tuck the ends so they direct away 6-0 non-absorbable, monofilament from the cornea
Lateral Canthal Entropion Look where the canthus collapses and also for “notching” at the fold
http://youtu.be/TBHSIoEk8iw
Permanent Lateral Canthoplasty
http://youtu.be/y-vg-5DaiFQ
5 9/10/19
Entropion Entropion
Jaeger Eyelid Plate Scalpel For a more permanent correction we use the Modified Hotz-Celsus
Tenotomy scissors
Bishop harmon tissue forceps Needle holder
Where is 2mm??? Modified Hotz-Celsus
2 mm
6 9/10/19
Modified Hotz-Celsus Entropion
6-0 Surgilene
http://youtu.be/zMG4ckCgjf0
Entropion and Modified Hotz-Celsus Macroblepharon
http://youtu.be/gBBpummV08M
2 yr old Great Dane Permanent Lateral Canthoplasty Pre-op -Macroblepharon -Entropion -Ectropion -Scroll cartilage
41 mm
28 mm
7 9/10/19
Modified Hotz-Celsus 2 yr old Great Dane 41 mm Immediately Post-op
28 mm
Entropion
A combined HC and lateral canthal closure had a 99.21% success rate of resolving lower lid entropion
Why did this Follow the rules….it works surgery fail?
Failed to correct macroblepharon Failed to correct collapsed canthus Incision too far from eyelid margin
8 9/10/19
What options are there for this dog? Brow-Sling
Brow-Sling Brow-Sling
Rhytidectomy
Pre-op Brow Sling Post-op
9 9/10/19
Rhytidectomy
Pre-op
Post-op
Rhytidectomy three years post-op
Rhytidectomy 4 month post-op
Focal Rhytidectomy plus Focal Rhytidectomy plus lateral canthoplasty and lateral canthoplasty and modified-celsus (upper and modified-celsus (upper and lower eyelid) lower eyelid)
10 9/10/19
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??
11 9/10/19
5yr old and blind Shih Tzu with long soft hairs, no corneal damage
2 yr old pug with short stiff hairs and pigmentary keratitis Permanent Medial Canthoplasty
Caruncle This is NOT the result of the nasal fold!
Tissue to be excised
Permanent Medial Canthoplasty Intraop
Postop
http://youtu.be/Tq8mFUGncS4
12 9/10/19
Permanent Medial Canthoplasty Ectropion
Preop
Postop
Entropion/Ectropion Kuhnt-Szymanowski
From: Projects by Dittmann J: http://www.delta-3.de/
Ectropion Pre-op
46 mm
The primary problem remains macroblepharon
13 9/10/19
Ectropion Lateral Canthoplasty Agenesis Keep It n lack of development Simple of the upper eyelid Stupid n superior-temporal 50% of the eyelid n usually bilateral
Wedge excision
Dziezyc/Millichamp modification Dziezyc/Millichamp modification
What the books tell you to do What the books tell you to do
What is What is wrong with wrong with this image? this image?
Agenesis Lip to Lid Bridge incision
Parotid Duct
Rotational Oral Mucosa Graft
Whittaker CJG, Wilkie DA, et al: Lip commissure to eyelid transposition for repair of feline eyelid agenesis. Vet Ophth 13:173-178, 2010
14 9/10/19
Bridge incision
Conjunctiva to oral mucosa 8-0 vicryl simple continuous
Parotid Duct
Immediately Post-op
Parotid Duct
Immediately Post-op Distichia
2 months Post-op
15 9/10/19
Distichia Cryosurgery n Treatment: n Epilating the hairs has only a short term effect n Cryosurgery n Electroepilation n CO2 Laser Nitrous Oxide -89oC
Liquid nitrogen - 196oC
Distichia Cryosurgery Side effect is depigmentation
Ectopic cilia Ectopic Cilia
16 9/10/19
Ectopic cilia Ectopic cilia
Eyelid Neoplasia Canine Eyelid Neoplasia
n Canine n common n benign (>90%)
COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin
Canine Eyelid Neoplasia Canine Eyelid Neoplasm
Histiocytoma Basal Cell Mast cell Melanoma Granular cell Adenoma
17 9/10/19
Feline Eyelid Neoplasia Feline Eyelid Neoplasia n more aggressive than neoplasms of the canine eyelid
SCC SCC
Mast Cell Fibrosarcoma
Mast Cell Tumor Eyelid Neoplasia n Treatment: n Dog vs. Cat n Benign neglect n Surgery
n Excisional biopsy n Cryosurgery n CO2 laser n Chemotherapy n Radiation
<1/3 1/3 <1/3 How much can I remove?
How much can I remove?
18 9/10/19
Wedge Resection Two-layer closure
n Conjunctiva: 6-0 absorbable suture in a continuous pattern
Two-layer closure Two-layer closure n Conjunctiva: 6-0 n Skin: 6-0 non- absorbable suture absorbable suture in a continuous n cruciate suture pattern pattern at the eyelid margin , then simple interrupted
Two-layer closure Two-layer closure
n Skin: 6-0 non- absorbable suture n Skin: 6-0 non- absorbable suture n cruciate suture pattern at the n cruciate suture eyelid margin , pattern at the then simple eyelid margin , interrupted then simple interrupted
19 9/10/19
Chalazion clamp Wedge Resection
http://youtu.be/95W0tRUd560
n H-Plasty n Repair of larger excisions n Preserve as much n Reconstruction of larger eyelid mass excisions a conjunctiva as b possible n H-plasty/Z-plasty n Diverging incisions n Semicircular flap b = 120% a n Split eyelid flap n Cross eyelid flap n Rhomboid graft flap From: Projects by n Lip to Lid Dittmann J: http://www.delta-3.de/ n Axial pattern flap
Excised Diverging incisions
Preserve Conjunctiva
20 9/10/19
48hr Postop 1 month Postop
6-0 surgilene cruciate
6-0 vicryl continuous
3 month Postop 3 month Postop
Fibrosarcoma Mast cell tumor Postop
21 9/10/19
Z-Plasty Z-Plasty -for lateral canthus Feline Mast Cell Tumor
From: Projects by Dittmann J: http://www.delta-3.de/
Z-Plasty Post-op
Suture Removal
Axial Pattern Flap Axial Pattern Flap
One step procedure for medial canthal reconstruction
Axial Pattern Flaps incorporate a cutaneous artery and vein vs a subdermal plexus 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
22 9/10/19
Feline SCC 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
“Cherry” Eye
n Options: n Surgically replace n Leave alone n Excise n All are at risk for KCS n Excise (48%) > Leave alone (43%) > Replace (14%)* n Control (5%) n Monitor STT for life Morgan RV, Duddy JM, McClurg K. Prolapse of the gland of the third eyelid in dogs: a retrospective *Morgan R: JAAHA1997 study of 89 cases (1980–1990). Journal of the American Animal Hospital Association 1993; 29: 56– 60
23 9/10/19
24 9/10/19
Thermal Cautery
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
QUESTIONS?
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