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Eyelids & Adnexa 1.5HR Short Version 9/10/19 The Rule of Eyelid Surgery 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? 25.
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