Surgery of the Eyelids

TOPICAL REVIEW

Surgery of the Eyelids Susette M. Aquino, DVM, DACVO Eyelid fit and function are important for maintaining ocular surface health. Some common conditions, which affect these parameters, include abnormal cilia, inappropriate eyelid conformation, eyelid trauma, and neoplasia. When these conditions are associated with discomfort and compromised corneal health, surgical intervention is indicated. The following article reviews common eyelid conditions and recommended surgical techniques for addressing these problems. © 2008 Elsevier Inc. All rights reserved. Keywords: eyelid, distichiasis, ectopic cilia, trichiasis, entropion, eyelid agenesis, neoplasia, third eyelid

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ommonly encountered eyelid conditions that may adversely affect the ocular surface health include ciliary abnormalities, conformational abnormalities, trauma, and neoplasia. Ciliary abnormalities include distichiasis, ectopic cilia, and trichiasis. Conformational abnormalities refer to conditions characterized by alterations in the eyelid fit. Entropion in the dog and eyelid agenesis in the cat are two such conditions that affect ocular surface health due to resultant mechanical irritation and exposure, respectively. In brachycephalic dogs, ciliary and conformational abnormalities are often present concurrently. Surgical intervention can be useful for alleviating discomfort and preserving corneal clarity in the face of these conditions. Other common presenting eyelid problems include eyelid lacerations and neoplasia. When eyelid lacerations involve the eyelid margin, realignment of the margin is essential for restoring proper eyelid function. Eyelid neoplasia, although often benign, may be problematic if the mass becomes sizable as ocular surface irritation and even corneal ulceration may occur. Common surgical problems involving the third eyelid include prolapsed gland of the nictitans and, less commonly, neoplasia. The former may be effectively corrected using the conjunctival pocket technique to reposition the gland. Neoplasia of the third eyelid is an indication for amputation of the nictitans. This article reviews basic surgical techniques for treatment of common eyelid problems. The readers are referred to an article elsewhere in this issue for recommendations for appropriate ophthalmic surgical instrumentation.

Animal Medical Center, New York, NY. Address reprint requests to: Susette M. Aquino, DVM, DACVO, Animal Medical Center, 510 E. 62nd Street, New York, NY 10022. e-mail: [email protected]. © 2008 Elsevier Inc. All rights reserved. 1527-3369/06/0604-0171\.00/0 doi:10.1053/j.ctsap.2007.12.003

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Ocular Surgical Preparation For cleansing of the eyelids before surgery, use 1:50 dilute betadine solution.1 The area is scrubbed at least three times or until scrub pads are visibly clean. The area is then rinsed thoroughly with 0.9% sterile saline. Alcohol should not be used in the ocular region as contact with the cornea and conjunctiva may occur causing marked irritation.1

Surgical Instrumentation Eyelid surgery is facilitated by the use of appropriate instrumentation. Typically the tissues in this region are delicate and the dimensions are smaller than what is encountered with many other soft-tissue surgeries elsewhere in the body. Surgical instruments that are useful for performing extraocular surgery are discussed elsewhere in this issue.

Ciliary Abnormalities Distichiae are cilia that arise from meibomian gland openings.2 They are most commonly seen in younger dogs. Breed predispositions include American and English Cocker Spaniel, English Bulldog, toy and miniature poodle, Boxer, St. Bernard, Golden Retriever, and Shih Tzu among others.2 Distichiae are rarely seen in cats. They are identifiable with the naked eye. Not all distichiae are associated with clinical signs of irritation. However, in some cases they cause trigeminal irritation evidenced by increased blink rate or blepharospasm, epiphora, eyelid swelling, conjunctival hyperemia, and keratitis.3 If the dog is symptomatic, surgical removal is indicated to restore comfort. Electroepilation may be used to destroy individual follicles and permanently remove the offending cilia.1,2 This technique is tedious and is typically used for treatment when there are only a limited number of distichiasis. To perform this technique, the eyelid is stabilized with nontraumatic forceps and a fine electrode is inserted into the follicle. Electrical current of 3 to 5 mA is applied for 15 to 30 seconds.1 Disadvantages to electroepilation include focal destruction of the meibomian gland and possible survival of the follicle despite epilation of the cilia.4 Electroepi-

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Figure 1. Medial canthoplasty. (A) Lacrimal puncta are cannulated to mark position. Triangular incision is made excising the medial canthus including the caruncle. Minimally, the inferior punctum is spared. (B) Conjunctiva is closed with a simple continuous suture pattern. (C) Skin is closed with simple interrupted suture pattern. Figure-eight suture may be used to reform the medial canthus. (Color version of figure is available online.)

lation is of limited use when multiple distichiae are present in the same opening.1 Focal depigmentation and notching may occur if overzealous electrical impulse is administered.4 Cryoepilation is the more commonly used method for removal of distichiae as this technique allows treatment of a large number of cilia more efficiently. Cryotherapy may be performed with liquid nitrogen or nitrous oxide and the appropriate administrative instrumentation. A double freezethaw cycle is used to ensure follicular destruction.1,3,5,6 Optimal therapeutic temperature is ⫺25°C.5,6 Temperature below ⫺30°C will cause necrosis of the eyelid. A chalazion clamp (Bausch & Lomb, San Dimas, CA) is placed on the eyelid to stabilize the lid and reduce local blood flow.1 The cryoprobe is placed on the palpebral conjunctiva approximately 3 to 4 mm caudal to the eyelid margin overlying the distichiasis follicles. The initial freeze of approximately 45 to 60 seconds is followed by a slow thaw period and then a second freeze of 20 to 30 seconds.1,2,6,7 Decreased freeze time may be indicated in smaller breeds and young dogs with

excessively thin eyelids to avoid over-freezing and necrosis. Use of thermocouple needles is optimal to monitor temperature. Immediately postoperatively, marked swelling is expected. Resolution is expected in 2 to 4 days postoperatively,2,8,9 although this may take up to a week. Permanent depigmentation and distortion are possible complications.1,2 Owners should be forewarned of these possible sequelae. Ectopic cilia are hairs that emerge from the palpebral conjunctiva.10-12 The location and direction of these cilia are problematic in that there is marked corneal contact and irritation. Predisposition is noted for the Flat-Coated Retriever, Pekingese, Shih Tzu, English Cocker Spaniel, Boxer, English Bulldog, Poodle, and Jack Russell Terrier.2 Ectopic ciliae are most commonly found at the 12 o’clock position in the upper eyelid. Therefore, a frequent clinical presentation is a dog with dorsal paraxial ulceration, which is nonhealing due to the ongoing mechanical irritation. Careful examination with magnification is indicated whenever an ulcer is found to be nonhealing. Sedation may be necessary as well. Oftentimes a

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Figure 2. Cross lid flap. (A) Initial incision in the donor eyelid. (B) Rotation of the pedicle into the defect. (C) Trimming of the pedicle to reform the eyelid margin. (D) Single pedicle advancement graft for closure of the donor site. (Color version of figure is available online.)

small raised spot of conjunctiva where the cilia emerges is identifiable even before the cilia is visualized particularly if the cilia is nonpigmented. En-bloc excision is simple and effective.1 This is done by stabilization and eversion of the eyelid with a chalazion clamp or nontraumatic forceps. A simple wedge resection around the cilia and including follicle is performed. No closure is necessary. Hemostasis with topical 2.5% phenylephrine and direct pressure should suffice. Excision may be facilitated with use of a 2- to 3-mm punch biopsy.13 The eyelid is stabilized as above. The punch biopsy is centered over the cilia and light pressure and rotational force is applied. The central plug is excised with a tenotomy scissors. Care should be taken not to create a full-thickness defect, although the follicle is often quite deep and incision up to ¾ of the eyelid thickness is recommended to ensure full excision of the follicle.13 Again, no suture is needed and may only create an increased risk for ongoing mechanical trauma. Trichiasis is a condition in which hairs that originate from normal follicles deviate to contact the ocular surface. They may cause clinical signs similar to that described with other

cilia abnormalities. Choice of surgical technique for treatment of trichiasis is determined by the area being treated and the presence of any associated eyelid abnormalities. In dogs, medial caruncular trichiasis is commonly noted in breeds with shallow orbits and prominent nasal folds such as Shih Tzus, Pekingese, and Lhaso Apso among others.2 These dogs often have some degree of inferior medial entropion and euryblepharon as concurrent conformational abnormalities. Additionally, prominent nasal folds may also be a source of further hair– corneal contact. A simple medial canthoplasty will address this entire constellation of problems. By resecting the medial canthus and caruncle, the palpebral fissure is shortened, caruncular trichiasis is removed, risk of proptosis is reduced, lagophthalmos is diminished, globe contact with nasal fold trichiasis is decreased, and medial inferior entropion is corrected.2 Before performing a medial canthoplasty, the lacrimal puncta are cannulated with a large suture to mark their location for preservation (Fig. 1A). Minimally, the inferior punctum must be preserved to prevent epiphora postoperatively.2,4,14 A full-thickness arrowhead-shaped re-

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Figure 3. Bucket handle technique. (A) Lower eyelid full-thickness incisions are made for preparation of the graft. Note that the lower eyelid margin remains intact. (B) Advancement of the flap into the upper eyelid defect. Temporary tarsorrhaphy is performed to limit motility during graft healing (14 to 21 days). (C) Second stage of the procedure. The graft is trimmed to 0.5 to 1.0 mm beyond the upper eyelid margin. The inferior eyelid is reformed. (Color version of figure is available online.)

gion is excised from the medial canthal region with the widest portion encompassing the medial most eyelid margins (medial and superficial to the lacrimal cannaliculi) and the caruncle (Fig. 1A). The conjunctiva is closed with 5-0 or 6-0 absorbable suture in a simple continuous manner with buried knots (Fig. 1B). The skin is closed with 4-0 or 5-0 nonabsorbable suture in a simple interrupted pattern (Fig. 1C). A figureeight suture may be used at the lateral end to ensure alignment of the new medial canthal eyelid margin. The Jensen technique, also referred to as the “pocket technique,” is an alternative method for medial canthoplasty in which superior and inferior skin-conjunctival pockets are created and a section of superior conjunctiva is placed into the inferior pocket.14 This technique may offer a stronger closure as there is more adhesion formation in the pocketed region than can be achieved with apposition of incised surfaces in the simple canthoplasty procedure. This technique is detailed elsewhere.14 A medial temporary tarsorrhaphy may be placed at the completion of surgery to decrease motion of the eyelids

and resultant tension on the incision during healing. This is accomplished with placement of a single horizontal mattress suture using 4-0 nonabsorbable suture. For trichiasis arising from prominent nasal folds, nasal folds resection may be indicated. This is easily accomplished by surgical reduction or excision of the folds. The fold is clamped before excision with a mayo scissors. The wound is closed directly with a simple interrupted or simple continuous pattern using 4-0 or 5-0 nonabsorbable suture.1 In some cases of eyelid agenesis in the cat where trichiasis from the adjacent periocular region is the predominant source of irritation, cryoepilation may be used to ablate the follicles in the offending region. As for cryotherapy for distichiasis, a double freeze-thaw cycle is used. The probe is placed over the region of concern. Freezing to ⫺25°C is needed for follicular destruction. If the degree of agenesis is more severe such that there is inadequate eyelid closure and coverage over a large portion of the cornea, eyelid reconstructive techniques should be considered. The cross lid (Fig. 2) and bridge flap techniques (Fig. 3)

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Figure 4. Temporary tacking suture. (A) Inferior lateral entropion. (B) Vertical mattress sutures placed with first bite close to the eyelid margin and the second bite sufficient distance ventrally to create eversion when sutures were tied. (C) Eversion of entropion with tacking sutures in place. (Color version of figure is available online.)

have been used effectively for correction of feline eyelid agenesis.15,16 Both of these procedures are two-stage techniques that limit the vision during healing and require a second anesthetic event. However, structural and cosmetic results are good with both of these techniques. These techniques are detailed elsewhere.15,16 In brief, cross lid flap is performed by sharp dissection of a full-thickness pedicle graft from the inferior lateral eyelid (Fig. 2A). This is rotated into the upper eyelid defect and sewn in place with a two-layer closure (Fig. 2B). After 2 to 3 weeks, the base of the graft is transected just ventral to the superior eyelid margin (Fig. 2C). The lower eyelid defect is repaired with a single sliding pedicle graft (Fig. 2D). The bridge flap also utilizes a full-thickness flap harvested from the inferior eyelid. In this case the eyelid margin is let intact. The graft is taken just ventral to this and advanced under the eyelid margin and into the superior defect (Fig. 3A). The graft is sutured in place in a two-layer pattern (Fig. 3B). After 2 to 3 weeks, the graft is trimmed similar to the cross lid flap. The inferior defect is repaired with a sliding graft as for the cross lid flap (Fig. 3C). The disadvantage to

both of these techniques is that trichiasis may occur in the region of the transposed graft. Cryotherapy of the area is then required as an additional procedure.15,16 An alternative method for treatment of eyelid colobomas is the injection of subdermal collagen in the area of the defect and treatment of any trichiasis by performing a Stades procedure.17 This is also a two-step procedure, but it is less invasive than other reconstructive techniques.

Entropion The position of the eyelid margins can affect the distribution of the tear film as well as cause mechanical irritation if haired surfaces are contacting the corneal surface. Entropion, or the inward rotation of the eyelid margin, is frequently associated with clinical signs that range from mild epiphora to active keratitis. Mixed ectropion and entropion is seen in breeds with elongated palpebral fissures or “diamond-eyed” dogs.2 Surgical correction is indicated when clinical signs of discomfort and/or associated corneal changes are noted. Surgical

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Figure 5. Modified Hotz–Celsus. (A) Inferior lateral entropion. (B) Partial thickness, crescent-shaped, skin-muscle incision. Outlined area excised before closure. (C) Skin closure with simple interrupted suture pattern. (Color version of figure is available online.)

intervention should be delayed if possible for puppies younger than 6 months to allow for full development of the head and face area before permanent correction.2,4 Temporary tacking sutures may be used before this time.18 Two to three simple vertical mattress sutures may be placed using 4-0 to 5-0 nonabsorbable suture (Fig. 4A-C). To effect good eversion, the initial “bite” is taken close to the eyelid margin and the second “bite” is placed caudal to this (Fig. 4B). The distance between the suture “bites” is determined by the amount of desired eversion. Sutures may be kept in place until permanent correction is possible. In some cases, correction of the entropion is permanent after removal of the sutures. For cases that show recurrence of the entropion, surgical correction is warranted. For simple entropion that does not involve either canthus, a modified Hotz–Celsus technique is effective. To perform this technique, the eyelid is stabilized using a Jaeger lid plate (Bausch & Lomb, San Dimas, CA). An incision the length of the affected area is made parallel to and approximately 2 mm dorsal (superior eyelid) or ventral (inferior eyelid) to the eyelid margin using

a number 15 Bard-Parker blade (Fig. 5A). A second incision is made ventral (for inferior eyelid) or dorsal (superior eyelid) to the first incision to create a crescent-shaped area (Fig. 5B). The width of the crescent is determined by the amount of skin that needs to be excised to correct the entropion. Slight undercorrection is advised to account for further rotation with subsequent healing and contraction.2,4 The crescent of skin, subcutis, and periocular muscle in this region is excised. The defect is closed with 5-0 or 6-0 nonabsorbable suture in a simple interrupted pattern (Fig. 5C). The initial suture should be placed at the center of the incised area to help ensure proper alignment.4 The two sides of the incision may be further bisected if the incision is excessive in length or sutures may simply be placed in an interrupted fashion. If entropion is associated with laxity of the lateral canthus or excessive length of the eyelids as can be seen with many “diamond” eye dogs, techniques that shorten the palpebral fissure, evert the eyelid margin, and support the lateral canthus may be more appropriate.1,2,4 The modified Kuhnt–Szymanowski or a combined modified Hotz–Celsus and wedge resection proce-

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Figure 6. Kuhnt–Szymanowski. (A) Triangular-shaped, partial thickness incision extending length of the affected area and beyond lateral canthus. Skin-muscle flap liberated with blunt and sharp dissection. (B) Tarsoconjunctival wedge excised. (C) Conjunctiva closed with simple continuous pattern. Skin-muscle flap advanced laterally and trimmed. (D) Skin sutured with simple interrupted pattern. (Color version of figure is available online.)

dures are effective surgical options.19,20 Both procedures shorten the eyelid length. The Kuhnt–Szymanowski technique also calls for lateral advancement of the skin and subcutis from the affected region creating increased lateral support. The modified Kuhnt–Szymanowski procedure is performed by incising parallel to and 2 to 3 mm ventral to the eyelid margin.19 This incision should extend upward and away from the lateral canthus (Fig. 6A). The incision should be long enough to encompass the problematic region and extend laterally approximately two times the predetermined excessive eyelid length. A vertical incision is made at the distal end of this incision extending ventrally to create a triangular skin incision (Fig. 6A). The incised area is undermined thus splitting skin and muscle from underlying tarsoconjunctival tissue medially. Laterally, the skin and subcutis are dissected from muscle and fascia layers. A wedge of tarsoconjunctiva is removed approximately 5 to 6 mm from the lateral canthus (Fig. 6B). The width at the widest point is determined by the amount of shortening desired. The skin

and muscular layer is advanced laterally to tighten the flap over the shortened underlying layer. The distal flap is trimmed to fit the underlying defect (Fig. 6C). The tarsoconjunctival incision is closed with 6-0 Vicryl in a simple continuous pattern with buried knots (Fig. 6C). The skin is closed with 4-0 to 5-0 nonabsorbable suture. The initial suture is placed in the tip of the skin and muscle flap laterally. The horizontal and vertical incisions are bisected with placement of a single interrupted suture to ensure proper alignment. The remaining incisions are closed, continuing with a simple interrupted pattern (Fig. 6D).19 The combination wedge resection and modified Hotz–Celsus shortens the eyelid and corrects the entropion as well.20 This is performed by excising a full-thickness wedge adjacent to the lateral canthus. The width is determined by the amount of shortening desired. Medial to this area, a half-crescent incision is made as if to perform a modified Hotz–Celsus but truncated at the medial edge of the wedge incision as entropion lateral to this is already corrected and excised (Fig. 7B).

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Figure 7. Lateral wedge and Hotz—Celsus. (A) Inferior lateral entropion. (B) Full-thickness wedge resection laterally. Partial thickness, truncated Hotz–Celsus incision medially. (C) Conjunctiva closed simple interrupted pattern. Skin close simple interrupted pattern. (D) Skin–muscle incision in region of wedge excision closed simple interrupted pattern. (Color version of figure is available online.)

The wedge resection is closed in two layers as described above (Fig. 7C). The modified Hotz–Celsus is closed in a single layer as described above for skin closure (Fig. 7D).20 In some breeds, lateral canthal ligament tension results in inversion of the entire canthal region. Resection of the ligament will aid in restoring proper alignment in this region.21 The lateral canthal palpebral conjunctiva is incised with tenotomy scissors. Blunt and sharp dissection are used to locate and transect the lateral canthal ligament. An obvious release in tension is detected when transaction is successfully completed. A small wedge of transected ligament and conjunctiva is excised. No closure is necessary. This techniques is recommended for Rottweilers, Mastiffs, English Bulldogs, Chow Chows, as well as other dogs with similar head and face conformation.21

Eyelid Laceration Eyelids are very vascular. In the event of eyelid trauma, minimal debridement should be performed initially until it is clear what

tissues are viable. Excessive inflammation and contamination at the time of injury and presentation may preclude immediate primary closure. Medical therapy with topical and systemic antibiotics and systemic anti-inflammatories may be indicated short term. Constant lubrication of the eye with antibiotic or artificial tear ointment is important in the interim. When tissues are less inflamed, debridement and primary closure should be performed immediately to restore alignment and function of the eyelid. Wound edges should be freshened. The defect should be closed in two layers as for other eyelid surgeries involving full thickness incisions (Fig. 8).1,22,23 A simple continuous suture pattern using 5-0 or 6-0 absorbable suture is used for conjunctival closure moving from the fornix to the eyelid margin (Fig. 8 B). Suture knots should be buried to prevent ocular surface irritation and possible corneal ulceration. The skin is closed with 4-0 or 5-0 nonabsorbable suture. A figure-eight suture is recommended for closure of the eyelid margin (Fig. 8C).1,22,23 The suture should be equidistant from the incisional margins and should exit at the eyelid margin where meibomian gland

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Figure 8. Two-layer closure for an eyelid defect. (A) Upper eyelid full-thickness defect after excision of an eyelid mass. (B) The conjunctiva is closed with a simple interrupted suture pattern. (C) The eyelid margin is aligned and apposed with a figure-eight suture. (D) The remaining skin incision is closed in a simple continuous suture pattern. (Color version of figure is available online.)

Figure 9. (A) Full-thickness wedge resection for removal of an eyelid mass. A Jaeger lid plate can be placed under the eyelid to stabilize the tissue for scalpel incisions. (B) Four-sided or “house incision” for excision masses with maximal preservation of the eyelid margin. (Color version of figure is available online.)

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Figure 10. Pedicle advancement graft. (A) Vertical incisions should be at least twice as long as the defect. (B) Burrow’s triangles are excised at the base of the pedicle to facilitate closure without puckering after advancement. They are equilateral triangles with the legs being 20% greater in length than the depth of the defect. (Color version of figure is available online.)

openings are visualized (gray line). This ensures alignment of the eyelid margin without notching. Suture ends may be left long and held caudally by incorporating the ligature ends into subsequent sutures to prevent suture and corneal contact.

Eyelid Neoplasia Eyelid neoplasia is a common occurrence in the canine species. It is less frequently encountered in the feline species. According to retrospective studies, the majority of canine eyelid tumors are benign.24-26 Eyelid neoplasms are uncommon in the feline population. They occur most frequently in cats over 10 years of age.27 Preservation of eyelid structure and function is an important consideration when choosing treatment of choice for eyelid neoplasms. If the structure and

function of the eyelid is significantly altered, corneal exposure, irritation, and ulceration may result. In general, up to one-third of the eyelid margin may be excised without significant alteration in the resulting eyelid structure.1,4,28 This may vary with breed and conformation. For simple excisions, a wedge or rectangular “house-shaped” excision may be performed (Fig. 9A and B).1,22 For wedge resection, a lid plate is inserted under the eyelid or a chalazion clamp is placed over the mass to help stabilize the area and protect the globe. A “V”-shaped incision is made using a 15 blade. The incisions should be perpendicular to the eyelid margin 2 to 3 mm away from the mass and angle dorsally or ventrally to meet at a point 2 to 3 mm beyond the mass (Fig. 9A). The defect is closed in two layers as described above.1,22,23

Figure 11. Semicircular flap technique. (A) An incision is made lateral to the defect extending down and away from the lateral canthus. The lateral canthus is freed and the flap undermined superficially to avoid injury to nerves and vessels. (B) The flap is advanced medially with normal eyelid margin reconstructed centrally. (Color version of figure is available online.)

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Figure 12. Conjunctival pocket technique for repositioning prolapsed third eyelid gland. (A) Prolapsed gland of the third eyelid (TEL). (B) Incision on both sides of gland. (C) Conjunctival pocket partially closed with simple continuous pattern. (D) Palpebral side of the TEL showing placement of initial and final suture knot to prevent corneal contact. (Color version of figure is available online.)

The rectangular “house-shaped” excision allows for resection with adequate margins on a larger mass with maximal preservation of the eyelid margin (Fig. 9B).1,4,29 Parallel incisions are made perpendicular to the eyelid margin 2 to 3 mm away from the mass extending just beyond the dorsal (ventral) extent of the tumor. Converging incisions are then made from the end of the parallel incision to a point dorsal (ventral) to and 1 to 2 mm beyond the mass. A two-layer closure is performed. The vertical pedicle advancement is an easily performed technique for advancement of skin into a large eyelid defect in which direct apposition would result in excessive shortening of the eyelid. This is a partial thickness graft and conjunctival transposition is needed to line the graft and create a smooth hairless eyelid margin. Conjunctiva may be translocated from adjacent eyelid, the third eyelid as a rotational graft, or from oral mucosa.23,30-32 For preparation of the pedicle, parallel diverging incisions are made ventral (dorsal) to the defect. Incisions should be approximately two times the length of the depth of the defect. Burrow’s triangles may

be excised at the base of the incision as needed to prevent dog-ears (Fig. 10A). The base of the triangle should be at least 20% longer than the depth of the defect. The skin is undermined to free the graft from subcutaneous attachments. The graft is advanced into the defect with the leading edge 0.5 to 1.0 mm above the eyelid margin to account for postoperative contraction.4,22 Simple interrupted nonabsorbable sutures are placed first at the eyelid margin to maintain alignment in this crucial area and then along the incisional lines to complete the closure (Fig. 10B). Conjunctiva should be advanced from an adjacent palpebral or conjunctival region or transposed from more distant sites to line the graft. The conjunctiva should be sutured to the eyelid margin without tension to allow for contraction with healing and to prevent cicatricial entropion. If excision of the mass requires more extensive resection of the eyelid margin, a restoration procedure is needed. Reconstructive procedures for the eyelid optimally restore both the dermal and the conjunctival surfaces.1,4 Various advance-

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Volume 23, Number 1, February 2008 ment and rotational grafts have been successfully used for reconstruction of the eyelids.1,4,15,16,22,30,32-35 The semicircular flap is a simple rotational and sliding graft, which is liberated from the lateral periocular region. It can be used for closure of lateral eyelid defects that involve up to 60% of eyelid margin. It is a one-stage procedure, which has the advantage of replacement of the central eyelid region with normal marginal tissue.34 It is performed by incising a semicircle extending ventral (dorsal) and away from the lateral extent of the defect (Fig. 11A). The length of the incision should be approximately the length of the eyelid. The lateral canthus is freed and the flap is undermined with care taken to remain in a superficial plane to avoid damage to the palpebral nerves and vessels. The flap is then advanced into the defect and medially a two-layer closure is performed (Fig. 11B). The lateral canthus is reformed making sure to place the graft such that there is minimal tension in the lateral direction. Subcutaneous and skin closures are performed with 4-0 or 5-0 absorbable suture in simple continuous pattern and 4-0 or 5-0 nonabsorbable suture in simple interrupted pattern, respectively. A number of procedures that use the opposite eyelid for reconstruction of large defects have been described. For more medial defects, the bucket handle or bridge flap may be useful. This technique utilizes a full-thickness conjunctival and skin flap from the opposite eyelid while preserving the normal eyelid margin of the donor lid.16 For superior, lateral eyelid reconstruction, the cross-lid flap can be used. This procedure restores the eyelid margin with normal tissue by rotating a lower eyelid flap into the defect.15 As discussed above, these are two-stage procedures that require a second anesthetic event. They do provide good reconstructive results.

Prolapsed Gland of the Third Eyelid Prolapse of the third eyelid gland is the most common surgical problem involving the nictitating membrane. There is a predisposition for English Bulldogs, Beagles, American Cocker Spaniels, Pekingese, and Lhasa Apsos and it typically occurs in dogs less than 2 years old.36 It is occasionally seen in the feline patient.37-41 Studies on the effects of third eyelid gland removal support the recommendation of surgical repositioning verses amputation for treatment of a prolapsed gland.36,42,43 Multiple techniques for replacement of the gland have been described.44-49 The conjunctival pocket technique has been utilized for dogs and cats.36 It is easy to perform and has a low re-prolapse rate. To perform the conjunctival pocket procedure, an atraumatic forceps is used to hold and evert the third eyelid. An incision is made on both sides of the gland in the conjunctiva on the bulbar side of the third eyelid (Fig. 12B). Fine dissection undermining the conjunctiva dorsal and ventral to the gland creates a pocket into which the gland may be repositioned. An initial suture bite is taken of the conjunctiva on the palpebral side of the third eyelid overlying the medial or lateral end of the incision. The needle is then passed through the third eyelid. The gland is repositioned into the “pocket.” The conjunctival edges are

apposed over the gland with 4-0 to 5-0 absorbable suture in a simple continuous pattern (Fig. 12C). The distal ends of the incision are left open 3 to 4 mm on either side to prevent cyst formation (Fig. 12C).36 To complete the closure, the needle is passed once more through the third eyelid exiting on the palpebral side. A small conjunctival bite is taken and the final knot is placed (Fig. 12D). This will prevent suture rubbing and potential injury to the cornea. Third eyelid tumors in the dog and the cat are uncommon and usually malignant.1,50-52 They occur in older animals and may arise from the conjunctival or glandular tissues. Neoplasia of the third eyelid is an indication for amputation of the nictitans membrane and gland.1,28,50 Amputation of the third eyelid is performed by extension of the third eyelid, placement of double curved hemostats at the base of the membrane, and sharp excision with Metzenbaum scissors (George Tiemann & Co., Hauppauge, NY). Alternatively, the gland may be excised without use of hemostats and hemostasis may be achieved with cautery and vessel ligation.1 The entire cartilage and gland should be removed. Conjunctiva and deeper layers should be closed with 4-0 to 6-0 absorbable suture to help prevent orbital fat prolapse and maintain normal globe position.50 Knots should be buried so they do not rub on the cornea. If complete excision with at least 5- to 10-mm margin of normal appearing tissue is not possible due to caudal extension of the mass, adjunctive therapy such as cryotherapy, hyperthermia, or radiation therapy may be used to prevent recurrence.51,53 If local invasion is extensive, exenteration should be considered.28

Postoperative Treatment Postoperative care for eyelid procedures is typically minimal. Topical antibiotic ointment should be applied to the affected areas three times daily for a minimum of 1 week. An Elizabethan collar should be placed until incisions are healed and sutures are removed. In the case of cryoepilation, topical steroid and systemic nonsteroidal anti-inflammatory therapy will aid in resolution of the expected postsurgical inflammation and discomfort.

References 1. Stades FC, Gelatt KN: Disease and surgery of the canine eyelid, in Gelatt KN (ed): Veterinary Ophthalmology. Ames, IA, Blackwell Publishing Professionals, 2007, pp 563-617 2. Bedford PGC: Eyelashes and adventitious cilia as causes of corneal irritation. J Small Anim Pract 12:11-17, 1971 3. Gelatt KN, Gelatt JP: Surgery of the eyelids, in Gelatt KN, Gelatt JP (eds). Small Animal Ophthalmic Surgery, vol 1. Extraocular Procedures. Pergamon Veterinary Handbook Series, 1994, pp 60-125 4. Bedford PGC: Disease and surgery of the canine eyelid, in Gelatt KN (ed): Veterinary Ophthalmology. Baltimore, MD, Lippincott Williams & Wilkins, 1991, pp 535-568 5. Withrow SJ: General principles of cryosurgical technique. Vet Clin North Am 10:779-801, 1980 6. Wheeler A, Severin A: Cryosurgical epilation for the treatment

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