Opthalmic Surgery Flashcards
T/F: Alcohol and detergents are used on the cornea and conjunctiva
False
– alcohol and detergents damage the cornea and conjunctiva
How does the surgical prep of the eye differ from standard surgical procedures:
- delicate thin skinned eyelids
- cornea and conjunctiva are damaged by alcohol and detergents
- -bacterial flora present on ocular surfaces
- deep conjunctiva and 3rd eyelid harbors hairs and pathogens
What is placed in the eye before clipping
Lube ( KY jelly or ocular ointment) – prevents hair entering the conjunctival sac.
9 Steps for ocular surgical prep
- Place lube before clipping
- Clip periorbital hair and trim cilia
- clip eyelids gently if eyelid sx
- gently scrub periocular area with 1:50 (0.2%) iodine/ saline solution.
- clean conjunctiva and nictating membrane with cotton swab
- irrigate cornea with the same solution
- routine draping with animal placed in sternal (both eyes) or lateral (one eye) position
- Surgeon seated with armrests & Magnification.
What dilution of iodine/saline solution is used for ophthalmic sx:
1:50 (0.2%) iodine/ saline solution — VERY DILUTE
What ophthalmic instrument is used to place under the lower & upper lid to hold them open and allow examination of the cornea & conjunctival tissue.
Barraquer eyelid speculum
What ophthalmic instrument slips between the eyelid and the globe (protects the globe) and flattens out the eyelid to facilitate the procedure
Jaegar eyelid plate
What ophthalmic instrument acts as delicate forceps but can be used to grab conjunctival tissue
Bishop - Harmon Forceps
What ophthalmic instrument is used to hold small needle used on the eye. Regular needle drivers for other procedures would not secure the needle well enough due to how small the needle is for ophthalmic procedures
Derf needle holder
What ophthalmic instrument can be used to cut & resect skin of the eye. This instrument should only be used in ophthalmic procures because they need to be kept sharp & pointed.
Stevons Tenotomy Scissors
What are some methods in maintaining hemostasis of the eye:
- Direct pressure with cotton tip applicators
- Wedge shaped cellulose sponges
- 4 x 4 sponges
- . Hand held cautery
- Phenylephrine
- 1:10,000 epinephrine
What is a disadvantage of using 4x4 sponges or cotton tip applicators
They shed fibers that can irritate the cornea post-op
What tool can be used to control hemostasis without shedding fibers
Wedge shaped Cellulose sponges
What is the dilution of epinephrine used to control hemostasis in the eye:
1:10,000 epi
Eyelid lacerations are most often caused by:
Sharp trauma
Usually lacerations start ______ to the commissure of the eyelid then transverse ______
Usually lacerations start perpendicula to the commissure of the eyelid then transverse _parallel__
– lacerations can be full or partial thickness
What is important to look for when dealing with eyelid lacerations:
ALWAYS examine globe
– looking for any evidence of corneal ulceration which is very common to find with eyelid lacerations.
When repairing an eyelid laceration what is ESSENTIAL:
Meticulous anatomic apposition is essential for repairing eyelid lacerations.
– cosmetic & function
Meticulous anatomic apposition is essential for eyelid lacerations, for what 2 reasons:
- Cosmetic
- Function – failure to have proper occlusion of those commisures results in chronic problems with exposure to debri and dry eye (KCS)
Eyelid lacerations are closed in __ layers
2 layer closure
Describe the 2 layer closure for eyelid lacerations:
- Deep layer (muscle & fibrous tissue)
2. Skin layer (ensures apposition)
What patterns are used for eyelid lacerations for the 2 layer closure:
- -Deep layer = Simple continuous
- - Skin layer = Figure 8
In what direction is the bites placed for the first layer (deep layer) of an eyelid laceration closure:
Bites perpendicular to eyelid
- very important that bites are not so deep that they penetrate the conjunctival tissue.
- avoid conjunctiva
Which layer of the 2 layer closure for eyelid laceration ensure apposition:
2nd layer (skin layer) using the figure 8 pattern.
- helps to provide anatomical alignment by placing one of the throws right on top of that eyelid commissure where the lacerations occurred.
- it also helps bring the suture tags down lower (about 4-5 mm away from the commissure) so it is less likely your suture tags can come up and irritate the cornea.
What orientation is need when placing the knots for closing the skin layer for eyelid laceration repair:
Place knots away from cornea (use figure 8 pattern)
- start 4mm from eyelid
- exit 1 mm from margin
- 5/0 or 6/0 Vicroyl
What small, soft, braided suture is used in the figure 8 pattern to achieve apposition with the skin layer closure for eyelid laceration repair
5/0 or 6/0 Vicroyl
For repairing eyelid tumors, if the mass is _____ of eyelid margin then treat like a laceration (primary removal).
For repairing eyelid tumors, if the mass is _<1/3__ of eyelid margin then treat like a laceration (primary removal).
For repairing eyelid tumors, if the mass is >1/3 of eyelid margin then do a _____ resection of that tumor in 0.5 to 1 mm margins because they are not malignant
V resection: used for non-malignant tumors effecting >1/3 of the eyelid margin
What % of canine eyelid tumors are benign:
73% are benign
What is the most common canine eyelid tumor:
Meibomian Gland Adenoma
3 unique characteristics for Meibomian gland adenoma:
1.
2.
3.
3 unique characteristics for Meibomian gland adenoma:
- Exophytic
- Pendunculated
- Cauliflower
What does Exophytic mean:
Growing outward from the skin
What type of scissors are used for canine eyelid tumors:
Iris scissors
if the tumor is starting to approach <1/3 of the eyelid margin, what type of resection is used:
H resection
- make incision in the shape of a house
- allows less lid margin resection: preserves & helps to decrease the chance of having to do an eyelid reconstruction technique.
When dealing with eyelid tumors, which resection will take less lid margin.
H resection
If the tumor is >1/3 of the eyelid commissure, then what surgical technique is indicated:
Eyelid reconstruction
What are the 2 common malignant eyelid tumors that often result in eyelid reconstruction due to being <1/3 of eyelid margins.
- Adenocarcinoma
2. Melanoma
What can be done if there is an eyelid tumor that does not have the unique characteristics of a Meibomian gland Adenoma :
- FNA
- Punch biopsy
- FNA used for non characteristic M gland adenoma
- this will tell you if wide margins are indicated based on aspirate or biopsy results.
Name 4 Eyelid reconstruction procedures:
Name 4 eyelid reconstruction procedures:
- Single pedicle advancement flap
- Lip to lid flap
- Single pedicle advancement flap + conjunctival graft
- Semicircular Flap
Reconstructive technique used on both upper & lower eyelids when partial thickness is indicated:
Single pedicle advancement flap
SPA flap = partial thickness
Lip to lid = full thickness
T/F: it is important to cut the triangles BEFORE making the flap on the SPA flap reconstruction.
FALSE
– wait to cut the triangles until the flap is made to see how big the triangles need to be in order to relieve tension.
Reconstructive technique used for FULL thickness on the lower lateral side:
Lip to Lid flap
- creates a mucocutaneous flap from the oral cavity.
- take wide base, make bridging incision where eyelid defect would be, bring flap to the defect, suture closed the secondary defect that was created by the lip.
Reconstructive procedure that harvest the conjunctiva from the opposite eyelid of the defect:
Single pedicle advancement flap with conjunctival graft
– temporary tarsorrhaphy for 1-2 weeks until the conjunctival graft takes
Reconstructive technique used for LATERAL defects of both upper & lower lid by taking skin from the side of the face, pulling it over creating more skin to close the eyelid defect.
Semicircular Flap
- use triangle to create more skin to slide into the defect
Most common feline eyelid tumor:
SCC
- associated with light skin cats & sun exposure
- prognosis guarded
What is difficult with treatment of SCC in cats
Tumors in cats tend to be more aggressive
– harder to get wide enough margins to avoid recurrence.
T/F: Eyelid agenesis is more common in dogs than cats.
False – eyelid agenesis is more common in felines
T/F: Eyelid agenesis is most commonly associated with the MEDIAL side of the eye.
FALSE– upper lateral or lower central eyelid
** Important: it looks like it would be medial in all pictures but most common is LATERAL or lower CENTRAL eyelid
Most common area for Eyelid agenesis to occur:
Upper LATERAL
Small eyelid agenesis defects are treated _______
Large eyelid agenesis defects are treated _______
Small eyelid agenesis defects are treated = MEDICALLY ( Eye lubricants & Anti-inflammatories)
Large eyelid agenesis defects are treated = SURGICALLY ( Dziezye Milichamp Mucocutaneous Pedicle graft )
Condition that is a congenital abnormality where they no longer have proper eyelid closure which predisposes them to dry eye (KCS) keratitis, corneal ulceration, blindness.
Eyelid agenesis
– congenital abnorm where part of their eye is voided.
T/F: Surgical repair of eyelid agenesis is recommended in all cases after >4 months of age..
FALSE
- Dziezye Millichamp procedure does NOT have a high success rate.
- treat medically if option
If the patient has a large defect of eyelid agenesis where the cornea is being exposed all the time, what is the method of treatment in this patient
Treat Surgically after >4 months of age
– Dziezye millichamp
A 3 month old puppy is in the hospital for eyelid agenesis. The eyelid agenesis is worsening. What is the treatment of choice.
Keep patient on eye lubricants, anti-inflammatories, +/- temporary tarsorrhaphy for a month until the puppy is over 4 months of age. Then perform a Dzieyze Millichamp procedure.
– waiting until >4 months ensures mature facial folds so you will not have to repeat the procedure again.
How long must you wait until performing a Dziezye Millichamp on a patient with eyelid agenesis.
> 4 months
What type of graft is Dziezye Millichamp
Mucocutaneous Pedicle Graft
Inward turning of the eyelid margin
Entropion
T/F: Some patients with entropion can be asymptomatic
True
Clinical signs of entropion include:
CS of entropion
- Asymptomatic
- Ocular discomfort
- Epiphora (increased tearing)
- Self trauma
- Corneal erosion, ulceration, and visual deficits
Epiphora definition? cause?
Epiphora= Increased tearing
Cause = eyelid cilia rubbing against the cornea
T/F: Congenital entropion is often unilateral while acquired entropion is often bilateral
FALSE
- Congential = Bilateral
- Acquired = Unilateral
Congenital form of entropion is more common in cats or dogs
Dogs
Most common area of the lid that is effected by congenital entropion
lower LATERAL lid
You can perform a Dziezye millichamp procedure when the patient is ____ months of age. When can you perform surgery for congenital entropion?
Dziezye Millichamp = > 4 months
Congenital entropion sx = >8 months
It differs because congenital entropion is often seen at < 6 months of age.
List the predisposing factors for congenital entropion: 1. 2. 3. 4.
List the predisposing factors for congenital entropion:
- Globe size
- Globe position in orbit
- Palpebral fissure length
- Orbicularis oculi m. tone
List predisposed breeds for congenital entropion:
1.
2.
3.
List predisposed breeds for congenital entropion:
- Chow chow
- Shar-pei
- Saint Bernard
What is the acquired form of entropion associated with:
Lid spasm (spastic)
- corneal ulcers
- KCS
- -FB
Acquired entropion occurs in only adult dogs:
FALSE
– acquired entropion can occur at ALL ages.
Acquired entropion is often hard to correct. This is because it is often associated with a secondary condition so you do not know how much entropion needs to be corrected. What method can be used in treating acquired entropion:
Treat the secondary condition FIRST and then re-examine the entropion.
– Tx secondary condition = Temporary Eyelid Tacking & Lubricants
Acquired entropion is treated by temporary tarsorrhaphy
FALSE
– Eyelid tacking
T/F: often congenital and spastic (acquired) entropion are combined
TRUE
4 surgical procedures used for entroption:
4 surgical procedures used for entroption:
- Eyelid tacking
- Hotz Celsus
- Modified Hotz Celsus
- Arrowhead resection
Suture used for temporary Eyelid tacking:
3/0 -5/0 PDS = Eyelid Tacking
— 5/0 or 6/0 Vicroyl = Figure 8 pattern for lacerations
Pattern used for Eyelid tacking
Multiple Interrupted Lembert pattern is used for eyelid tacking along with 3/0-5/0 suture
T/F: In some cases, eyelid tacking may resolve some cases of entopion
True – in mild cases
– After leaving in for 1-2 weeks it can create enough adhesion that it can permanently correct entropion.
Length of time that eyelid tacks are left in:
Leave in for 4 week or until of age for surgery.
Most common surgical procedure used to treat entropion:
Hotz Celsus = Most common tx for entropion
Suture used in Hotz Celsus procedure:
5/0 PDS
Name 2 techniques of the Hotz Celsus procedure
- Hemostat technique
2. Incision method
List the steps for Hemostat technique when performing a hotz Celsus procedure
Steps of hemostat technique:
- Place hemostats on skin to be removed
- leave for 30 seconds
- remove hemostats & remove skin w/ scissors
- Suture defect with 5/0 PDS
Which technique (hemostat or incision method) of the hotz celsus procedure uses jaegar lid plate to create crescent shaped incision 2 mm from the lid margin & suture in same fashion.
Incision method
Suture pattern preferred in incision method (of hotz celsus procedure):
Simple continuous – allows you to cut tag on each of the ends really short to minimize the change or irritation to cornea.
What area of the eye is the modified Hotz Celsus used for:
Medial canthal entroption = modified hotz celsus
remember MM
Name which area of the eye is associated with each procedure:
- Eyelid Tacking =
- Hotz Celsus =
- Modified Hotz Celsus =
- Arrowhead resection =
Name which area of the eye is associated with each procedure:
- Eyelid Tacking = Temporary
- Hotz Celsus = Lateral entropion
- Modified Hotz Celsus = Medial canthal entropion
- Arrowhead resection = Lateral entropion (concurrent upper & lower)
“Hotz on Loser” – Hotz for lateral entropion
“MM”- Modified for medial
“Arrow has a peak laterally on BOTH sides”
What procedure to fix entropion is done by isolating the lacrimal puncta:
Modified Hotz celsus
- Caution: if disrupt lacrimal apparatus then the tear drainage is altered.
- create triangle with ventral apex and suture
What landmark is used when isolating the lacrimal puncta in Modified hotz celsus procedure:
Orbicularis oculi muscle – do NOT go deeper than this muscle.
What procedure may decrease epiphora in some patients
Modified Hotz celsus
– often brachycephalic breeds have entropion in the medial aspect so if fix the entropion you increase the caniculi opening resulting in more tear drainage.
Which procedure is used for concurrent upper and lower LATERAL canthal entropion
Arrowhead resection
What must be resected during a arrow head resection to fix entropion:
Lateral canthal ligament transection
– allows better retraction of the skin when correcting the entropion defect
Eversion of the eyelid
Ectropion
Ectropion usually effects which lid
usually only Lower lid
Congential ectropion mainly effects which 2 breeds:
Ectropion breeds:
- Saint Bernards
- Blood hounds
What breed is predisposed to BOTH entropion AND ectropion
Saint Bernard!
How is ectropion acquired?
Contraction of scar tissue
Overcorrection of entropion
T/F: Most ectropion patients will not require treatment
TRUE
– only tx if causing signs because this is a desirable trait in some dogs.
When do you treat ectropion:
ONLY when CS develop such as:
- Keratitis
- Conjuncitivitis
Surgical treatment for ectropion:
- -Wedge resection (V-like resection) of loose tissue and resecting it back together.
- V-Y blepharoplasty
Clinical signs associated with the Nasolacrimal system:
Nasolacrimal system CS:
- Epiphora
- Periorital alopecia & tear staining
- Mucopurulent ocular discharge / conjuncitivits
Most common clinical signs associated with nasolacrimal system:
Epiphora – most common
Name 4 diagnostic test used for the nasolacrimal system:
Nasolacrimal system Diagnostics:
- Jones 1 Test
- Nasolacrimal Flushing
- Dacryocystorhinography
- CT,MRI
Diagnostic test that uses fluorescent dye to place (wait 3-5 min) then uses a woods lamp to see if patient has a patent nasolacrimal system
Jones 1 Test – shows dye coming from the nose on the same side the dye was placed in the eye.
Which test for the nasolacrimal system can be used as a therapeutic and diagnostic tool:
Nasolacrimal Flushing
– use cannula or 22 G catheter to use a saline flush n the caniculi while occluding other caniculi so it does not come out. If you do not see the saline coming out of the nose then the duct is clogged. if feel resistance then no resistance you just unclogged the duct.
Test that uses radiopaque dye when looking for cyst or neoplasia that is causing occlusions somewhere in the bony structures where the nasolacrimal system runs through.
Dacrocystorhinography
Most common reported congenital anomaly of the drainage system in dogs
**
Puncta Aplasia
- associated breeds:
1. golden retrievers
2. cockers
3. poodles
- associated breeds:
What disease of the nasolacrimal system can cause a membrane over one of the punctas
And what is the CS
Punta aplasia
– CS: epiphora & tear staining
How to confirm puncta aplasia:
To confirm puncta aplasia
- Find unaffected puncta and inject saline in
- you will see a bulge at the level of the puncta
- Snip bulge of the membrane with iris scissors to correct the problem
Treatment of puncta aplasia
Snip bulged membrane
– sometimes the membrane will grow back, then catheterize with a 2/0 stiff suture like an ethylone and allow to heal
Term used to describe abnormally small puncta
Micropunctum
- take tip of iris scissors, place them in small puncta, then snip to create a bigger orifice to increase tear drainage.
- feed suture all the way down through nose to avoid them to heal closed
- remove suture after one week
4 common diseases associated with Nasolacrimal system:
- Punctal aplasia
- Micropunctum
- Trauma & scarring
- KCS
How do you know if trauma & scarring is associated with the Nasolacrimal system:
BUBBLE TEST
- inject air into puncta & look for bubbles. This will determine site of trauma/laceration.
- attempt to canulated both sides of laceration : catheterize both ends with 2/0 suture and then tie to the side of the face and allow it to heal by second intention.
- leave in for 3 weeks
What structure is involved with the functions below:
- Tear production
- Protects globe
- Remove debris from cornea
Nictitating membrane
3 Surgical disease involving the nictitating membrane:
- Everting Nictitating membrane
- Prolapsed nictitating membrane (cherry eye)
- Neoplasia
What surgical disease of the nictitating membrane is common in large breed dogs less than 1 year of age.
Everting Nictitating membranes = Everting of cartilage
- anterior fold of cartilage
- chronic conjunctivitis
- surgical excision & allow to heal
Tx for everting nictitating membrane:
Surgical excision and allow to heal
– under general anesthesia, you can grasp this cartilage and gently resect the cartilage out bc they don’t need it for anything and basically by removing it, it solves the problem and you do not have to suture anything
What is cherry eye
Prolapsed Nictitating membrane
– gland flips up dorsally above leading edge
Most common disorder of the 3rd eyelid
PROLAPSED NICTITATING MEMBRANE ( aka cherry eye)
– often cherry eye is bilateral
Predisposed breeds for cherry eye:
predisposed breeds for cherry eye:
- cockers
- Pekingese
- bulldogs
- Beagles
Clinical signs associated with cherry eye
Ocular discharge and conjunctivitis
– which predisposes them to KCS and mucopurulent discharge of the eye
Surgical options for cherry eye:
Surgical options for cherry eye:
- Excision of the nictitating membrane
- Orbital rim anchoring technique
- Pocket technique
T/F: Excision of the nictitating membrane is NOT recommended
TRUE
- important for tear production
- can lead to KCS so it is NOT recommended
T/F: the orbital rim anchoring technique is the easiest technique to learn for cherry eye.
FALSE
- Orbital rim anchoring technique = more technically difficult
- Pocket Technique = Easier to learn
Describe the technique used for cherry eye that creates a small incision in the anterior conjunctiva (gland of 3rd eyelid), anchoring suture down with 4/0 suture passed through the hole and engaged by periosteum, and then use a purse string suture around the gland to tie off.
Anchoring technique – Kaswan and Martin
Morgan Pocket Technique uses perpendicular or parallel incision into bulbar conjunctiva?
Parallel incisions in bulbar conjunctiva
Morgan Pocket technique – parallel incision in bulbar conjunctiva (incisions on both sides of the gland)
- do NOT connect incisions bc tear production
- reduce and suture with 6/0 simple continuous
- oversewn with cushing sans place knots on anterior aspect
Suture and pattern used in the morgan pocket technique
6/0 and simple continuous pattern
T/F: evidence shows that the morgan pocket has a better success rate than the orbital rim technique
FALSE – No evidence that one technique is better than the other
