Disorders of the eye

and associated surgical techniques

Begede AC
Anatomy of the eye
Ocular anatomy
• Surgical conditions commonly managed by general practitioners
include emergency procedures (i.e., traumatic proptosis, eyelid
lacerations, and corneal ulcers)
• and entropion or ectropion repair, tumour removal, and enucleation

• Complicated or severe periocular diseases, corneal problems and

intraocular procedures should be performed by persons with
specialized training in veterinary ophthalmology
Definition of terms
• Proptosis is outward displacement of the eye from its normal position
in the orbit.
• Enucleation is removal of the globe, nictitating membrane, orbital
glands, and eyelid margins.
• Exenteration is removal of the globe, nictitating membrane, orbital
contents, and eyelid margins.
• Entropion is inversion or inward turning of the edge of the eyelid.
• Ectropion is eversion or outward turning of the edge of the eyelid
Eyelid lacerations
• commonly associated with traumatic injuries such as
bite wounds and automobile injuries.
• They should be repaired as soon as possible to protect
the cornea and maintain an effective blink reflex.
• Healing of lid lacerations by secondary intention may
result in considerable fibrosis and distortion of the
eyelids and lid margin, and secondary scarring of the
corneal surface.
• Direct re-apposition is possible if one-third or less of
the lid margin is missing.
• More extensive injuries require advancement flaps or
grafts for repair.
Conjunctival and corneal lacerations
• Superficial conjunctival lacerations without eyelid lacerations rarely
require surgical repair because they heal rapidly.

• They are allowed to heal by secondary intention after debris has been
removed and topical antibiotics applied.

• Deep corneal lacerations (>50% corneal stromal thickness) and

perforations are surgical emergencies
Conjunctival flaps
• Conjunctival flaps are used to treat deep corneal ulcers,
descemetoceles, and small sealed corneal perforations.

• Conjunctival flaps typically are harvested from the bulbar conjunctiva

and are integrated into the cornea with healing over a few weeks;

• They provide a protective covering that brings blood vessels and

fibroblasts to facilitate healing.
Third eyelid flap
• serve as physiologic bandages to support and protect the cornea
after trauma (superficial corneal lacerations and ulcers)

• should not be used on deep corneal ulcers, descemetoceles or

corneal perforations, which usually are fragile and require visual
monitoring to direct aggressive medication management

• main disadvantage of the third eyelid flap is to monitor progress or

worsening of the lesions
Protrusion of third eyelid gland ( Cherry eye)
• caused by defects in the attachments between the third eyelid gland and
periorbita

• More common in dogs than cats

• Owners notice a third eyelid mass, ocular discharge (serous or mucoid),

and/or conjunctivitis

• The condition usually begins unilaterally but eventually may become

bilateral.
• Presenting signs include an obvious reddish mass protruding from
behind the third eyelid near the medial canthus, conjunctivitis,
epiphora, and local irritation
• Although both removal and replacement techniques have been used,
replacement is recommended to reduce the incidence of
keratoconjunctivitis sicca (KCS) later in life.
• Goals of surgical treatment include replacing the protruding gland
behind the leading margin of the nictitans, maintaining nictitans
mobility, and preserving glandular tissue and excretory ducts.
• Common techniques include anchoring the nictitans to oblique
muscles, equatorial sclera, periorbital fascia, or periorbital rim, or
creating an envelope or pocket in adjacent conjunctiva and covering it
with or without scarification of the surface.
Enucleation
• probably the most common orbital surgical procedure performed in
small animal practice.

• Common indications for enucleation include:

- irreparable corneal or intraocular injury,
- intraocular neoplasia,
- severe proptosis, and
- intractable uveitis.
• An additional indication might include painful end-stage glaucoma
Exenteration
• Exenteration is performed much like enucleation, except that it begins
by suturing the eyelids together and then excising their margins and
conjunctiva, together with the globe, extraocular muscles, lacrimal
gland
• Surgical dissection is performed along the orbital walls, external to
the extraocular muscles.
• In animals in which wide excision is necessary to remove all diseased
tissue (i.e., neoplasia), creation of skin flaps may be necessary to
allow primary wound closure.
• The main indication for exenteration is orbital disease extending
outside of the globe but limited to soft tissues in the orbit that cannot
be resolved by other means.

• Examples of such causes include neoplasia or infection involving both

globe and orbit, and penetrating globe injury involving the orbit (e.g.,
migrating foreign bodies such as wood or porcupine quills)
Traumatic ocular proptosis
• defined as forward displacement of the eye by a traumatic episode
with entrapment of the eyelids behind the eye.
• Aetiology includes:
- Blunt head trauma,
- bite wound,
- retrobulbar hemorrhage,
- orbital fracture,
- or excessive restraint of animals with large palpebral fissures and
shallow orbits
P.E findings
• Assess for shock and life threatening injuries
• Auscultate the chest
• Perform a complete ophthalmic exam:
- If the optic nerve is torn, the posterior pole of the globe is clearly
visible, or a large perforation of the eye wall is present = grave
prognosis for globe salvage => enucleation
- If three or more extraocular muscles are torn, the orbit is fractured,
or the pupil is not visible = the prognosis for saving vision is poor, but
globe itself may be salvageable
• Positive prognostic indicators include:
- a brachycephalic dog signalment,
- intact PLR,
- intact vision
- short duration of proptosis

• The prognosis for vision in proptosed globes is guarded to poor

Entropion
• Entropion is inward rolling of the eyelid margin
• it may be conformational, developmental, spastic, or cicatricial.
• may affect the entire length of the eyelid margin or may be limited to
one area
• Hair may rub on the cornea, causing irritation, epiphora,
blepharospasm, conjunctivitis, corneal ulceration
• Clinical signs may include blepharospasm, serous or mucopurulent
ocular discharge, eyelid discoloration, etc
Eyelid tacking
• Done in the neonate or young animal (up to 20 weeks of age),
especially Shar-Pei puppies
• by application of a drop of tissue adhesive to glue adjacent skin
surfaces together, thereby rolling the eyelid margin outward,
• or by placement of skin staples or inverting Lembert sutures
• maintenance of a normal position for 10 to 20 days may effectively
resolve the inversion
• Hotz-Celsus technique:
Ectropion
• Ectropion is eversion of the lower eyelid.
• may be a developmental condition or may be acquired secondary to
scar tissue formation or fatigue of the orbicularis oculi muscle.
Temporary
tarsorrhaphy
• may be performed after correction of
entropion, ectropion, eyelid
lacerations, or eyelid mass removal, to
help prevent wound contracture
during healing.
• Tarsorraphies are also indicated when
the patient cannot blink, but should be
avoided for deep corneal ulcers, deep
corneal lacerations, or corneal
perforations
Special considerations
• Absorbable and non-absorbable small-gauge, soft-suture material (4-0
to 9-0) with swaged-on needles is used for most procedures.
• Use 4-0 to 6-0 soft pliable sutures such as Vicryl or silk for eyelids, 6-0
to 8-0 Vicryl for conjunctiva, and 6-0 to 9-0 Vicryl for cornea.
• Spatula or reverse cutting micropoint needles are recommended for
corneal suturing.
• Ophthalmic scalpel blades, forceps, scissors, needle holders, and
retractors (specula) are also recommended because they are specially
designed for delicate procedures, with fine tips and unique curves for
specific purposes.
Post-op care
• Recovery should be slow, calm, and smooth to prevent vocalizing, head
thrashing, and rubbing or scratching of the surgical site
• Prevention of self-trauma by the patient is critical = E.collar
• Analgesics are essential to prevent pain and pruritus that might
encourage the patient to rub and scratch the eye
• Topical ocular medications (e.g., antibiotics) should be administered at
least four times a day.
• Systemic antibiotics should be used for eyelid disease or intraocular
involvement such as corneal perforation or enucleations
• Remove sutures at 10 to 14 days.