eyelids & adnexa thailand - apvcapvc.ca/notes/2019notes/wilkie2-vet.pdf · ophthalmic surgery n...
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Eyelids & Adnexa Diseases & Surgery
David A. Wilkie DVM, MS, Diplomate ACVOProfessor Emeritus
The Ohio State [email protected]
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?