Eyelids & Adnexa Diseases & Surgery

Transcription

1 The Rule of Eyelid Surgery Eyelids & Adnexa Diseases & Surgery! K! I! S! S David A. Wilkie DVM, MS, Diplomate ACVO Professor Department Chair The Ohio State University Wilkie.1@osu.edu The Rule of Eyelid Surgery! KEEP! IT! SIMPLE! STUPID Ophthalmic Surgery! Gelatt KN: Veterinary Ophthalmic Surgery 2011 Everyone has an opinion Ophthalmic Surgery Chalazion clamp! Pitfalls! Failure to use magnification! Failure to use appropriate instrumentation! Inappropriate suture selection and/or placement! Poor tissue handling Jaeger eyelid plate 1

2 Jameson caliper Castroveijo caliper Magnification Magnification Good Bad Surgeon Position for all microsurgery The Eyelids serve the Cornea mm! Surgical Position! Seated! Specialized chairs with armrests! Arms resting on armrest! Essential for fine motor control 16 mm 2

3 They come in all sizes, but Most corneas are the SAME size! We breed them to look 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 mm 12 month old labrador retriever 3

4 Macroblepharon All entropion/ ectropion patients have abnormalities of eyelid length Eyelids 33 mm 12 month old labrador retriever 33 mm pre-op Jameson caliper Tenotomy scissors 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

5 Permanent Lateral Canthoplasty Permanent Lateral Canthoplasty Cruciate pattern 6-0 non-absorbable, monofilament Tuck the ends so they direct away from the cornea Lateral Canthal Entropion Look where the canthus collapses and also for notching at the fold Permanent Lateral Canthoplasty Entropion 5

6 Entropion Temporary Tacking Young dog, mild entropion 5-0 to 6-0 non-absorbable monofilament 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

7 Modified Hotz-Celsus Entropion 6-0 Surgilene Entropion and Macroblepharon Modified Hotz-Celsus 2 yr old Great Dane Pre-op -Macroblepharon -Entropion -Ectropion -Scroll cartilage Lateral canthoplasty and Modified Celsus 7

8 Permanent Lateral Canthoplasty Modified Hotz-Celsus 41 mm The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again. 28 mm 41 mm 2 yr old Great Dane Immediately Post-op 41 mm 2 yr old Great Dane 2 wk Post-op 28 mm 28 mm Entropion A combined HC and lateral canthal closure had a 99.21% success rate of resolving lower lid entropion 8

9 Why did this surgery fail? Follow the rules.it works Failed to correct macroblepharon Failed to correct collapsed canthus Incision too far from eyelid margin What options are there for this dog? Brow-Sling Brow-Sling Brow-Sling 9

10 Rhytidectomy Pre-op Brow Sling Post-op Rhytidectomy Pre-op Post-op Rhytidectomy three years post-op Rhytidectomy 4 month post-op 10

11 Focal Rhytidectomy plus lateral canthoplasty and modified-celsus (upper and lower eyelid) Focal Rhytidectomy plus lateral canthoplasty and modified-celsus (upper and lower eyelid) Focal Rhytidectomy plus lateral canthoplasty and modified-celsus (upper and lower eyelid) Pre-op Post-op Stades Technique From: Projects by Dittmann J: Stades FC. A new method for surgical correction of upper eyelid trichiasis entropion: operation method. JAHA 1987; 23:

12 Medial Canthal Entropion What is the #1 Question? How old is this dog?? 5yr old and blind Shih Tzu with long soft hairs, no corneal damage 12

13 2 yr old pug with short stiff hairs and pigmentary keratitis Permanent Medial Canthoplasty This is NOT the result of the nasal fold! Caruncle Tissue to be excised Permanent Medial Canthoplasty Intraop Postop Permanent Medial Canthoplasty Ectropion Preop Postop 13

14 Entropion/Ectropion Kuhnt-Szymanowski From: Projects by Dittmann J: Ectropion Munger RJ, Carter JD. A further modification of the Kuhnt Szymanowski procedure for correction of atonic ectropion in dogs. JAHA 1984; 20: The primary problem remains macroblepharon Pre-op 46 mm Lateral Canthoplasty Ectropion Keep It Simple Stupid Wedge excision 14

15 ! lack of development of the upper eyelid! superior-temporal 50% of the eyelid! usually bilateral Agenesis Dziezyc/Millichamp modification Dziezyc/Millichamp modification What the books tell you to do What is wrong with this image? What the books tell you to do What is wrong with this image? Agenesis Lip to Lid Facial v. Lip to Lid Facial n. dorsal and ventral buccal branch Orbicularis oris Rotational Graft Parotid duct Bucinnator Whittaker CJG, Wilkie DA, et al: Lip commissure to eyelid transposition for repair of feline eyelid agenesis. Vet Ophth 13: , 2010 From: Popesko P: Atlas of topographical anatomy of the domestic animals 15

16 Bridge incision Bridge incision Parotid Duct Conjunctiva to oral mucosa 8-0 vicryl simple continuous Oral Mucosa Parotid Duct Parotid Duct Immediately Post-op Immediately Post-op 2 months Post-op 16

17 Distichia! Treatment:! Epilating the hairs has only a short term effect! Cryosurgery! Electroepilation! CO2 Laser Distichia Cryosurgery Distichia Nitrous Oxide -89 o C Liquid nitrogen -196 o C 17

18 Cryosurgery Side effect is depigmentation Ectopic cilia Ectopic cilia! originates from tarsal/meibomian gland exits from palpebral conjunctiva! difficult to diagnose (need magnification)! Usually at the 12 o'clock position! Common in Shih Tzu Ectopic cilia Ectopic Cilia 18

19 Ectopic cilia Ectopic cilia Eyelid Neoplasia Canine Eyelid Neoplasia! Canine! common! benign (>90%) COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin Canine Eyelid Neoplasia Canine Eyelid Neoplasm Histiocytoma Adenoma Basal Cell Melanoma Mast cell Granular cell 19

20 Feline Eyelid Neoplasia Feline Eyelid Neoplasia! more aggressive than neoplasms of the canine eyelid SCC SCC Mast Cell Fibrosarcoma Mast Cell Tumor Results All periocular CMCTs were restricted to the eyelids. In addition to surgical excision, three cats were treated with adjunctive therapy (strontium-90 irradiation or cryotherapy) intraoperatively. Local tumor control was achieved in 22/23 cats with a minimum follow-up of 30 days (median follow-up time of 711 days); one cat developed disseminated CMCTs but no local recurrence. Cats with periocular CMCTs had a median survival time of 945 days. Metastatic disease involving peripheral lymph nodes or abdominal viscera was not detected in any cat at any time during the study. All periocular CMCTs were classified as low-grade based on histopathology, and complete excision was achieved in approximately 50% of cases. Conclusions Surgical excision of periocular CMCTs in cats is an effective treatment option with rare local recurrence and metastases, even following incomplete surgical excision. Eyelid Neoplasia! Treatment:! Dog vs. Cat! Benign neglect! Surgery! Excisional biopsy! Cryosurgery! CO2 laser! Chemotherapy! Radiation How much can I remove? 20

21 <1/3 1/3 <1/3 Wedge Resection How much can I remove?! Conjunctiva: 6-0 absorbable suture in a continuous pattern Two-layer closure! Conjunctiva: 6-0 absorbable suture in a continuous pattern Two-layer closure Two-layer closure! Skin: 6-0 nonabsorbable suture! cruciate suture pattern at the eyelid margin, then simple interrupted Two-layer closure! Skin: 6-0 nonabsorbable suture! cruciate suture pattern at the eyelid margin, then simple interrupted 21

22 Two-layer closure Chalazion clamp Wedge Resection! Skin: 6-0 nonabsorbable suture! cruciate suture pattern at the eyelid margin, then simple interrupted Reconstruction of larger eyelid mass excisions! H-plasty/Z-plasty! Semicircular flap! Split eyelid flap! Cross eyelid flap! Rhomboid graft flap! Lip to Lid! Axial pattern flap a b! H-Plasty! Repair of larger excisions! Preserve as much conjunctiva as possible! Diverging incisions Excised b = 120% a From: Projects by Dittmann J:

23 Diverging incisions 48hr Postop 6-0 surgilene cruciate Preserve Conjunctiva 6-0 vicryl continuous 1 month Postop 3 month Postop 3 month Postop Fibrosarcoma 23

24 Mast cell tumor Postop Z-Plasty -for lateral canthus From: Projects by Dittmann J: Z-Plasty Z-Plasty Feline Mast Cell Tumor Post-op Axial Pattern Flap Suture Removal 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: ,

25 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: , 2008 Feline SCC Axial Pattern Flap 25

26 Cryosurgery Intralesional Chemotherapy Radiation Conjunctival Neoplasm COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin Squamous papilloma Conjunctival Neoplasm Hemangioma Hemangiosarcoma Conjunctival Neoplasm 26

27 Canine Conjunctival Melanoma Canine amelanotic melanoma Conjunctival Melanoma - 5% mortality Conjunctival Melanoma - 55% mortality Feline conjunctival melanoma Feline conjunctival melanoma 55% mortality Third Eyelid Neoplasia Papilloma SCC K9 adenocarcinoma K9 adenocarcinoma K9 adenocarcinoma 27

28 Cherry Eye! Options:! Surgically replace! Leave alone! Excise! All are at risk for KCS! Excise (48%) > Leave alone (43%) > Replace (14%)*! Control (5%)! Monitor STT for life *Morgan R: JAAHA1997 Morgan RV, Duddy JM, McClurg K. Prolapse of the gland of the third eyelid in dogs: a retrospective study of 89 cases ( ). Journal of the American Animal Hospital Association 1993; 29:

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30 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: , 2013 QUESTIONS? 30