Eyelids Flashcards
Belpharospasm
squinting
Blepharitis
swelling of the eyelids
lagophthalmos
inability or incomplete blinking
where the upper and lower lids meet (nasal and lateral)
canthus
blinking upon stimulation of the face, particularly near the canthi
palpebral reflex
the region under the eyelid where the palpebral conjuctiva lines eyelid bends back to become bulbar conjunctiva (where foreign bodies get trapped)
fornix
excessive tearing
epiphora
Why might a patient have Lagophthalmos
1) Exophthalmos - physically cant get lid over eyelid
2) Nerve problems (ex: Facial nerve VI)
It can numb the eye during an eye surgery or procedure
Proparacaine
Epiphora
excessive tearing
swelling of eyelids
Blepharitis
What are the functions of eyelids
1) General ocular protection
2) Spread tear film, prevent evaporation
3) Clean debris from the eye and push tears down the nasolacrimal duct
4) Produce portions of tear film
What makes the lipid component of the tear film
meibomian glands
What makes the mucin component of tear film
conjunctiva
What makes the aqueous portion of the tears
lacrimal gland
70% lacrimal gland (above globe)
30% gland of the third eyelid
How much of the eyelid can you remove
remove up to 1/3 of the eyelid without having to perform specialized flap/ grafting surgery
upper lid form and function is more vital than the lower
Is the function of the upper lid or lower lid more vital
Upper lid (need to get good apposition during surgery)
lower lid, dont necessarily need to get perfect apposition
controls the muscles to the face, allows us to blink
provies parasympathetic stimulation of the lacrimal glands
CN VII
Facial Nerve Paralysis Clinical signs
1) patients will have lagophthalmos (absent palpebral reflex and menace) but intact facial sensation
-may learn to blink with Abducens (VI)
2) some may have keratoconjunctivitis sicca (neurogenic dry eye)
3) Drooping of face on affected side
How can a patient have facial nerve paralysis with normal tear production
depends on where the lesion is
parasympathetic branch of VII breaks off early and runs with CN V for majority of pathway
similarly, you can have neurogenic KCS with an intact palpebral
Patients with facial nerve paralysis may learn to blink with ___________
Abducens (CN VI)
T/F: you can see lagophthalmos without neurogenic dry eye (keratoconjunctivitis sicca)
True- parasympathetic branch of VII breaks off early and runs with CN V for majority of pathway
T/F: you can see neurogenic dry eye without lagopthalmos
true- just damage to the parasympathetic branch of CN VII - breaks off early
What test would you to do rule out neurogenic dry eye
Schirmer tear test
What would you expect the Schirmer tear test results to be in a dog with neurogenic dry eye from facial nerve paralysis
No tear production
In a dog with facial nerve paralysis characterized by neurogenic dry eye, what would you expect their nose to look like
completely dry nasal planam - split down the middle
Xeromycteria
Xeromycteria
deficient parasympathetic innervation of the lateral nasal gland
from facial nerve paralysis
results in completely dry nasal planum, split down the middle
Facial nerve paralysis is typically unilateral or bilateral
unilateral
What causes facial nerve paralysis
1) Idiopathic (likely only singular nerve)
2) Trauma
3) Neoplasia
4) Infectious (inner ear infection causing swelling and pressure on nerve)
5) Iatrogenic (surgery- TECABO)
6) Rarely- hypothyroidism &
nasopharyngeal polyps in cats
What is a potential consequence of Total Ear Canal Ablation and Bulla Osteotomy (TECA-BO)
facial nerve paralysis
What should you do to diagnose dermatitis of the eyelid skin
consider culture, cytology, aspirates, biopsy to obtain a diagnosis
1) Parasitic
2) Bacterial
3) Fungal
4) Immune mediated
5) Neoplastic
What is Immune Mediated Belpharitis
also called Staphylococcal Blepharitis
-inflammation targets meibomian glands
-bilateral: upper lids more often affected than lower
-severe thickening and dermal ulceration can develop
-Primarily immune mediated (although bacteria is a component)
Tx:
oral steroid - 1mg/kg/day and tapered slowly over weeks to months
oral antibiotic (cephalosporines for 1-2 weeks)
T/F: topical steroids and antibiotics are important in treating Immune Mediated Belpharitis
False- need oral steroid and oral antibiotic
What bacteria is associated with Immune Mediated Belpharitis
Staphylococcus
although majority of it is immune mediated (overproduction of bad staph or immune reaction to good staph)
In Immune Mediated Belpharitis, what does the inflammation target
meibomian glands
Immune Mediated Belpharitis, what eyelids are worse?
Upper lids
Immune Mediated Belpharitis is unilateral or bilateral?
bilateral (upper lids often more affected than lower)
What is seen with Immune Mediated Belpharitis
severe thickening and dermal ulceration can develop
normal hairs in contact with the corneal surface
Trichiasis
How do you treat Immune Mediated Belpharitis
1) Oral steroid started at 1mg/kg/day and tapered slowly over weeks to months
2) Oral antibiotic (cephalosporins for 1-2 weeks)
*Topical medications do not help *
What is a good oral antibiotic for Immune Mediated Belpharitis
cephalosporings 1-2 weeks
Trichiasis
normal hairs in contact with the corneal surface
can have variable impact on comfort
may lead to keratitis (vascular, pigmentary and/or fibrotic
treatment: lubrication, cryotherapy, belpharoplasty surgery
What might trichiasis lead to
keratitis (vascular, pigmentary and/or fibrotic)
can have variable impact on comfort
How do you treat trichiasis
1) lubrication
2) cryotherapy
3) blepharoplasty surgery to change conformation of how eyelids come together
Why are the meibomian glands a good surgical landmark
you do not want your suture close to them otherwise it is going to rub on the surface of the eye
What serves as a source of distichia
meibomian glands - they are modified hair follicles
T/F: meibomian glands are modified hair follicles
true - they serve as a source of distichia
Distichia
an eyelash that arises from an abnormal part of the eyelid.
grow straight up or down from the lid margins
most dogs with distichia are not clinical
T/F: not all dogs with distichia and trichiasis are clinical
true- some dogs arent bothered by it
T/F: ectopic cilia is subclinical
False- they are massively irritating
Most are very irritated and often have associated corneal ulceration
Where does ectopic cilia grow
grow through the palpebral conjunctiva pointing directly at the eye
-very irritating
-95% of these will be between 11 and 1 o’clock on dorsal lid
-most will be <1.5 years of age
-Most are very irritated and often have associated corneal ulceration
Most dogs with ectopic cilia will be ______ years of age
<1.5 years of age
What lid does ectopic cilia commonly occur on
-95% of these will be between 11 and 1 o’clock on dorsal lid
grow through the palpebral conjunctiva pointing directly at the eye
How do you treat distichia and ectopic cilia
1) Manual Epilation: they will grow back
2) Cryosurgery- can result in damage to lids/ meinomian glands
3) Radiofrequency epilation- requires an operating microscope - fries the hair follicles
4) Surgical excision- best option for ectopic cilia
What is the best treatment option for ectopic cilia
Surgical excision
What should you consider when doing manual epilation for distichia and ectopic cilia treatment
they will grow back
Radiofrequency Epilation
requires an operating microscope - fries the hair follicles - treatment of distichia and ectopic cilia
very well toleratio.
normal tissue in an abnormal location
can affect the eyelid, conjunctiva and.or cornea
developmental problem
requires surgical removal- be sure to remove all hair follicles
Dermoid
How do you treat a dermoid
surgical removal
-be sure to remove all hair follicles
-will not regrow
Where does dermoid typically develop
eyelid, conjunctiva, and/or cornea
Entropion
condition where the eyelid rolls in
With Entropion, typically the ___________ lid is affected
lower lateral lid
almost every bulldog has what kind of entropion
lower nasal canthal entropion
what breed commonly get entropion
bulldogs
What are the causes of entropion
1) Congenital/ Inherited - skin elasticity, muscle strength, eye position, etc.
2) Spastic (due to squinting e.g corneal ulcer) - squinting causing lid to roll over
3) Cicatrical
4) Fat loss/atrophy- especially in older cats - less support
How do you treat entropion causes by spastic/ squinting from pain (ie corneal ulcer)
proparacaine for pain
T/F: you should treat cats entropion due to weight loss with surgical methods
False - it will reoccur
How do you treat entropion
1) Temporary tacking - vertical mattress sutures placed perpendicular to lid, place 3 (assume one will fail and a single suture wont hold the lid)
2) Hyaluronic acid lid filler injection- excellent for young dogs and all cats
3) Surgery (typically wait until fully grown)
-Hotz Celsus
-Wedge resection
-Stades (upper lid)
How should you suture temporary tacking in entropion treatment
vertical mattress sutures placed perpendicular to lid, place 3 (assume one will fail and a single suture wont hold the lid)
What is a good non-surgical method for entropion treatment
Hyaluronic acid lid filler injection- excellent for young dogs and all cats
What entropion treatment is good for young dogs and cats
Hyaluronic acid lid filler injection- excellent for young dogs and all cats
For entropion treatment, the Hotz Celsus and Wedge resection can be done on __________ eylids and the stades can be done on _______
Hotz Celsus and Wedge Resection: both lids
Stades: upper lid only
Surgical approach for entropion where eyelid is narrowed down to prevent it from folding
Wedge resection
Surgical approach for entropion where a huge amount of skin of the upperlid is taken out and kept open to allow granulation
Belpharoplasty- Stades
Surgical approach for entropion where
a crescent-shaped piece of skin and the underlying orbicularis oculi muscle are excised, and the wound is then sutured
Hotz-celsus
what is the result of ectropion
because the eyelid rolls out- leads to exposure, increased trapping and poor clearing of debirs
What might cause ectropion
1) Breed related (large breeds)
2) cicatricial
How do you treat ectropion
1) Wedge resection to remove redundant lid length
2) V to Y plasty
Is entropion or ectropion more irritating
entropion
What species is eyelid agenesis typically seen in
cats- congenital defect
-affects the dorsal lateral lid to varying degrees
What eyelid is commonly affected by eyelid agenesis in cats
dorsal lateral lid
How do you treat eyelid agenesis in cats
1) Lubricating drops
2) Cryotherapy
3) Robert-Bishner sx: eyelid skin from below is flipped up
4) Lip to Lid Blepharoplasty : lip margin skin is brought up
Robert-Bishner surgery is for
eyelid agenesis in cats
procedure involves creating a rotating skin flap that includes the lip commissure to replace the missing eyelid
What is the word for swollen eyelid
Blepharitis
in patients with immune mediated blepharitis, what dose of steroids do you start them on?
immunosuppressive dosage
1mg/kg/day and tapered slowly over weeks to months
what part of the tear film is produced by the meibomian glands
lipid layer
what part of the tear film is produced by the conjunctival goblet cells
mucins
what part of the tear film is produced by the lacrimal gland and gland of third eyelid
aqueous
What examination technique can you use to distinguish cataract from lenticular sclerosis
Transillumination
-also fundic exam (cataracts = you cant see the fundus)
What drug do we use to dilate the eye for a fundic exam
Tropicamide (lasts 2-3 hours)
You should not use tropicamide if
-Risk of glaucoma
-Risk of lens luxation
-4th years (if there are vision or PLR abnormalities)
What are the 4 classifications of cataracts
1) Incipient (localized)
2) Immature (15-90+%)
3) Mature (>90%)
4) Hypermature (sometimes the lesion will dissolve)
What are 5 possible causes for facial nerve paralysis
1) Idiopathic
2) Trauma
3) Neoplasia
4) Infectious (inner ear infection causing swelling and pressure on the nerve)
5) Iatrogenic (surgery- TECABO)
rarely- hypoT4 and nasopharyngeal polyps in cats
What rarely causes facial nerve paralysis
hypoT4 (dogs) nasopharyngeal polyps (cats)
What are common canine eyelid masses
1) Meibomian gland adenoma (most common)
2) Papilloma
3) Melanoma / Melanocytoma
4) Mast cell tumor
5) SCC
irregular, papilloma like projections from/near a meibomian gland
Meibomian gland adenoma
Meibomian gland adenoma
irregular, papilloma like projections from/near a meibomian gland
eyelid may be swollen, often insipissated
upper or lower lid (patient may have more than one location)
slow growth
can ulcerate and bleed
irritating if it rubs cornea
does not metastasize, but can be locally invasive
What is the most common canine eyelid mass
Meibomian gland adenoma
do you need to be concerned about eyelid mast cell tumor
no- most are more benign
excise the mass, shouldnt recur
T/F: Meibomian gland adenomas grow quickly
false- they grow slow
What is a consequence of Meibomian gland adenoma
-can ulcerate and bleed
-eyelid can be swollen, often inspissated
-irritating as it rubs the cornea
-doesnt metastasize
T/F: Meibomian gland adenoma can metastasize
False- they are just locally invasive
What looks similar to Meibomian gland adenoma
papilloma
-same treatment options
-same benign behavior
T/F: papillomas of the eyelid are just locally invasive and do not metastasize
Trie
Eyelid melanoma / melanocytomas are common in what dog breeds
Vizsla, Weimaraner and dogs with a liver coat color
Eyelid melanoma / melanocytomas are benign or malignant?
Benign (as long as its on the lid margin
Can be malignant if it’s developing from the conjunctiva or dermis
Eyelid melanoma / melanocytomas can be malignant if
they develop from the conjunctiva or dermis
otherwise they are benign if it acts on lid margin
How do you treat meibomian gland adenoma, eyelid papillomas, and eyelid melanoma / melanocytomas
1) Debulk with crytosurgery
-most common tx for meibomian gland adema
can be done awake with/without light sedation
-local anesthesia
2) Wedge resection- good option after regrowth or for larger or more ingrained tumors
How do you treat meibomian gland adenoma
1) Debulk with crytosurgery
-most common tx for meibomian gland adema
can be done awake with/without light sedation
-local anesthesia
2) Wedge resection- good option after regrowth or for larger or more ingrained tumors
How do you treat eyelid papilloma
1) Debulk with crytosurgery
-most common tx for meibomian gland adema
can be done awake with/without light sedation
-local anesthesia
2) Wedge resection- good option after regrowth or for larger or more ingrained tumors
How do you treat eyelid melanoma / melanocytomas
1) Debulk with crytosurgery
-most common tx for meibomian gland adema
can be done awake with/without light sedation
-local anesthesia
2) Wedge resection- good option after regrowth or for larger or more ingrained tumors
What are comon feline eyelid masses
1) SCC
2) Fibrosarcoma
3) MCT
4) Lymphoma (primary and secondary)
5) Basal cell carcinoma
6) Apocrine Hydrocystoma
*tend to be more malignant/locally invasive
T/F: eyelid masses tend to be more malignant/locally invasive in cats
True
How should you address feline eyelid masses
take a biopsy and then proceed
What are common equine eyelid masses
1) SCC (appaloosa, paint, draft)
2) Sarcoid
3) Melanoma
4) Fibrosarcoma
5) Lymphoma (secondary)
What breeds of horse commonly get eyelid SCC
appaloosa, paint, draft
fibroblastic cutaneous tumors that can occur on the equine eyelid
metastasis is rare but is locally invasive
Sarcoid
Do eyelid sarcoids typically metasize?
Not typically
metastasis is rare but is locally invasive
How do you treat equine eyelid sarcoid
High risk of recurrence
-Surgery
-Immunotherapy
-Radiation
-Cryotherapy
most methods directed towards triggering immune response to attack the equine sarcoids, needs multiple injections
Equine eyelid sarcoid typically occur in what horses
Younger horses (3-6 years)
Appaloosa, QH, Arabians
lower risk: standardbreds
Wht is the most common eyelid neoplasia in bovines
Squamous cell carcinoma (cancer eye)
Eyelid Neoplasia (bovine)
-Typically squamous cell carcinoma
-huge economic loss
-75% limbal
-25% eyelid and third eyelid
-starts with thickening of eyelid skin
-progresses to proliferative mass
-will metastasize later in life
T/FL eyelid squamous cell carcinoma in cattle will metastasize
yes will eventually later in life
solar damage (actinic change) starts with thickening of eyelid skin
progresses to proliferative mass
Eyelid neoplasia in bovines typically affect what cows?
typically older animals
female predisposition
Bos taurus (especially hereford) > Bos indicus
lack of periocular pigmentation
UV exposure
Nutritional status High > Low
What factors predipose cows to getting eyelid squamous cell carcinoma
1) Older
2) Female
3) Breed: Bos taurus (especially hereford)
4) Lack of periocular pigmentation
5) UV exposure
6) Nutrtional status (high > Low)
What is the most common eyelid mass in feline, equine, and bovine species
Squamous cell carcinoma
SCC of the eyelid typically develops on
exposed surfaces
-lower eyelid, third eyelid, lateral limbus
How do you treat SCC in cats, horses, and cattle
-Surgery
-Radiation
-Cryotherapy
-Immunotherapy
-Intralesional Chemotherapy
-Photodynamic therapy: material absorbed and light applied
How do you treat a wedge resection for removing a tumor or an eyelid laceration
1) Debride (if needed) to freshen edges
2) 2-layer closure for lacerations
SQ (using 4-0 or 6-0 absorbable braided suture) : be sure no knots are exposed to conjuctival side
Skin: careful alignment of margin (use 4-0 to 5-0 Nylon suture) simple interrupted or cruciates to close remainder of incision
direct suture tags away from eye
3) Identification, canulation of NL systemi if necessary
4) Systemic topical antibitoics
5) Systemic anti-inflammatories
How do you close an eyelid laceration or wedge resection for mass removal?
2-layer closure for lacerations
1) SQ (using 4-0 or 6-0 absorbable braided suture) : be sure no knots are exposed to conjunctival side
2) Skin: careful alignment of margin (use 4-0 to 5-0 Nylon suture) simple interrupted or cruciates to close remainder of incision
direct suture tags away from eye
How should you place your suture for lid margin repair
figure-8 (similar to cruciate)
take a bite into the skin and out SQ then cut across and up to lid margins
second bite is taken coming out anterior to meibomian glands
third bite on other site
fourth bite down
symmetry is very important, bites needs to be even
when doing lid margin repair, bites should be take ________ to the meibomian glands
anterior
What are the 7 causes third eyelid elevation
1) Enopthalmos
2) Exopthalmos
3) Decreased eye size
4) Orbital (retrobulbar) mass
5) Deformity of orbit
6) Idiopathic- Haw’s syndrome in cats (bilateral) - evaluate for intestinal parasites
7) Horner’s syndrome
Haw’s syndrome
in cats that causes the third eyelid, also known as the nictitating membrane, to elevate in both eyes
evaluate for gastrointestinal diseases
follicular conjunctivitis
occurs in young dogs (<1.5years)
typically self limiting
occurs as the immune system figures out the local environment
if there is irritation or significant discharge: treat with NeoPolyDex TID
You should only treat follicular conjunctivitis if
there is irritation of significant discharge
treat with NeoPolyDexTID
How do you treat follicular conjunctivitis if there is irritation and signficiant discharge
NeoPolyDex TID
T/F: dogs dont get infectious conjunctivitis unlike cats and humans
Follicular conjunctivitis occurs as
the immune sustem is figuring out the local environment
typically in young dogs <1.5 years
Atypical pannus is also called
Plasmoma of third eye lit
Plasmoma (Atypical Pannus) occurs in what breeds
shepherd breeds
grey hounds
dogs with Plasmoma (Atypical Pannus) of the third eyelid may or may not have
concurrent “typical” pannus affecting the cornea
How do you treat Plasmoma (Atypical Pannus)
if itchy = topical steroid or cyclosporine if itchy
Prolapsed gland of the third eyelid is often unilateral or bilateral
bilateral, but there may be a delay between eyes
T/F: Plasmoma (Atypical Pannus) is harder to treat than corneal pannus but rarely bothers the patient
True
Prolapsed gland of the third eyelid typically occurs in what dogs
young brachycephalic dogs
-but any breed can develop these
Prolapsed gland of the third eyelid is also called
“Cherry eye”
How do you treat Prolapsed gland of the third eyelid
-If minor, with little exposure or inflammation (pink) can be left alone
Bulldogs will likely need to go to surgery
-Replace them surgically if red/irritated (Morgan Pocket Technique)
Do not cut them out -> dry eye
cutting out the Prolapsed gland of the third eyelid should only be done
if its a last resort, still no corrections
Dont cut them out!
The Morgan Pocket Technique is for
Prolapsed gland of the third eyelid
What is the Morgan Pocket Technique
a surgery for fixing a Prolapsed gland of the third eyelid.
1) make parallel (not connected incisions above and below the gland, give yourself room to suture
2) Dissect a “pocket” under the globe through the proximal most incision
3) Tie a suture knot on the anterior surface of the 3rd eyelid and pass the suture through the third eyelid avoid knot rubbing (small suture 5-0 or 6-0)
4) Suture the proximal part of the proximal incision to the distal part of the distal incision in two layers
-Simple continuous first
-horizontal mattress second
5) Pass the suture back thorugh the third eyelid and tie off on the original knot
What is scrolled cartilage of the third eyelid
occurs younger giant breeds
can be the vertical or horizontal part of the T cartilage
look for the leading edge to distinguish from cartilage
tx:
removal of bent cartilage
thermocautery (heating) of the cartilage to bend it back into place
both treatment options carry risk leading to cherry eye
How do you treat scrolled cartilage of the third eyelid
1) Removal of Bent Cartilage * then morgan pocket
2) thermocautery (heating) of the cartilage to bend it back into place
both treatment options carry risk leading to cherry eye (do morgan pocket to prevent)
Removal of scrolled cartilage and thermocautery can potentially lead to
cherry eye
scrolled cartilage of the third eyelid typically occurs in
younger giant breeds
What neoplasias occur on the third eyelid
1) SCC
2) Hemangioma (conjunctival- can also develop on the lateral bulbar conjunctiva)
3) Adenoma of the gland of the third eyelid
4) Lymphoma
tx: surgical excision is often curative for all these as long as you get good margins
How do you treat neoplasms of the third eyelid
surgical excision is often curative for all these as long as you get good margins
What is a normal Schirmer Tear test result
15 mm in 1 minute
Should you do a schirmer tear test in cats?
NO
a patient presents with a history of a thickened irregular third eyelid.
the dog is not irritated by it. What is the diagnosis
atypical pannus
What are the 4 uses for a florescein in the ophthalmic exam
1) Evaluate for corneal ulcerations
2) Evaluate health of tear film
3) Jones Test
4) Seidels Test
diagnostic procedure that detects leakage of aqueous humor from the eye’s anterior chamber through cornea
Siedels Test
What ocular muscles are controlled by CN VI
Lateral rectus
Retractor bulbi
Which cranial nerve is responsible for Horner’s Syndrome
None- it is loss of sympathetic tone
What is the purpose of the frontal nerve block
block sensation to the upper lid and cornea
What is the purpose of the auriculopalpebral block
block motor to the upper eye lid
