Eyelids.pptx from University of Pretoria

Eyelids.pptx from University of Pretoria

1. Dr Izak Venter [email protected] FB DVOSVETS 0833089237 Ophthalmology SAS 410 [2023] Eyelids

2. Why have eyelids ? Main function is protection of the eyes Blink reflex Contribute to the outer lipid layer of the precorneal tear film Distribution of the tear film by lid movement Removal of the tear film When the eyelids are closed, they provide oxygen for the cornea Exclusion of light

3. Eyelids - Anatomy Septum / Tarsal plate Orbicularis oculi Closing eyelids Levator palpebrae Lifting upper eyelid Muller’s muscle Smooth muscle Tone

4. Expectations !!!

5. Distichiasis Definition Cilia emerging from the Meibomian gland openings Tarsal glands normal Hair follicle is situated in the connective tissue surrounding the gland Predisposed animals Soft distichia Poodles, golden retrievers, and cocker spaniels Stiff short distichia with ocular irritation English bulldog, Bull Mastiff and Ridgeback Distichiasis rarely affects cats

6. Clinical signs A single hair (distichia) or multiple hairs ( distichiae ) visible along the eyelid margins Blepharospasm Epiphora Tear staining Conjunctival hyperemia Corneal ulcers Superficial corneal vascularization

7. Clinical significance & Diagnosis Very fine distichia clinically insignificant Large numbers of distichia or coarse distichia Discomfort Keratitis Visualize the hair / hairs Magnification

8. Treatment Epilation Provide transient relief Electrolysis Treatment of small number of hair follicles Less reliable and efficient than cryoepilation Cryosurgery Two fast-freeze, slow-thaw cycles at −80°C Postoperative swelling Perioperative use of a systemically administered corticosteroid or NSAID Depigmentation of the eyelid margin

9. Prognosis Very good Regrowth of the hairs possible Repeat procedure

10. Ectopic cilia Definition Cilia arise from the meibomian glands Emerge from the palpebral conjunctiva 12 ‘o clock position of the upper eyelid Predisposed animals Young dogs Rare in cats Distichia Ectopic cilia

11. Clinical signs & diagnosis Epiphora Visualization of the abnormal cilia Blepharospasm Corneal ulcers (dorsal cornea) Conjunctivitis

12. Ectopic cilia - Treatment Surgical excision Electro epilation of the cilium Cryosurgery

13. TRICHIASIS Hairs growing from normally placed follicles leading to irritation Entropion Facial skin folds Nasal skin folds Eyelid agenesis [cats]

14. Clinical signs Hairs arise from a normal location but are in contact with the ocular surface Blepharospasm Epiphora Tear staining Conjunctival hyperaemia Superficial corneal vascularization Pigmentary keratitis Corneal ulceration

15. Eyelid agenesis (NB) Congenital absence of a portion of the eyelid Barely perceptible to the entire length Bilateral Dorso lateral eyelid typically affected Eyelid coloboma Feral cats ?

16. Treatment Depends on the amount of eyelid affected Small defects without corneal disease No therapy may be required Small defects with mild corneal disease Topical lubricants Electro / cryo-epilation Defects involving less than 25% of the eyelid length Excision of the colobomatous region Primary apposition

17. Treatment Severe colobomas aims of treatment Provide outer layer of skin Middle layer of muscle and support Inner layer mucus membrane Advancement and rotational flaps Lip to eyelid transposition Veteriankey

18. Lip to lid graft

19. Nasal skinfolds Absorbable 6/0 suture Simple interrupted pattern Post op NSAIDS

20. Entropion Entropion is the inversion of part or the entire eyelid margin Etiology Inherited Spastic Cicatrical Alteration in globe position Enophthalmos Phthisis or microphthalmos

21. Predisposed animals Common dogs / rare cats Conformational entropion dogs Shar Pei, Labrador retriever, Golden retriever, English bulldog, Chow chow , Bull Mastiff Feline entropion Usually cicatricial FHV-1–induced keratoconjunctivitis

22. Clinical signs Rolling in of the eyelid Epiphora or mucoid discharge Conjunctival hyperaemia Blepharospasm Corneal ulceration Corneal vascularization Pigmentary keratitis is common in medial canthal entropion

23. Inherited / conformational entropion Typically, bilateral Most cases the lower eyelid is affected Upper eyelid entropion - very heavy brows Shar-pei and chow chow In brachycephalic animals Medial canthus Clinically evident later in life www.animalwised.com

24. Spastic entropion Spasm of the orbicularis oculi muscle Painful ocular conditions Corneal erosions, corneal ulcers and uveitis Spastic entropion is a component of all cases of entropion Rottweilers “spontaneous”

25. Entropion - approach Schirmer tear test Examination of the patient before and after the application of a topical anesthetic Examination with magnification Fluorescein staining Aqueous flare NB treat any underlying condition prior to surgical correction of entropion

26. Entropion - treatment Spastic entropion - treat the underlying cause Eyelid tacking Rottweilers 10 – 15 units of Botox is injected into orbicularis oculi muscle 4 – 5 areas

27. Entropion - treatment Eyelid tacking Mattress sutures 4/0 Nylon 3-5 weeks

28. Entropion- Surgical principles Eliminate other causes of spastic entropion Correct for the “conformational” or “anatomic” component only Rather under correct Minimize surgical tissue trauma Do not remove the orbicularis oculi muscle 6/0 Vicryl with swaged on cutting needle Simple interrupted suture pattern Elizabethan collar for 10 days Postoperative analgesia for 5 – 7 days

29. Hotz–Celsus procedure for entropion Most practical and commonly used surgical techniques Entropion of the entire lower lid, the upper eyelid, and, with modification entropion extending around the lateral canthus

30. Hotz–Celsus procedure for entropion Distance from eyelid margin 2 mm

31. CHALAZION Retention of inspissated Meibomian gland secretions within the eyelid Accompanied by eyelid inflammation Meibum accumulates may leak out of the glands Lipogranuloma formation

32. CHALAZION Treatment Incise and curette Systemic Prednisolone Doxycycline

33. Blepharitis Inflammation of the eyelids Predisposed individuals Dogs and cats of any breed, age, or sex Clinical signs Hyperemia Swelling Pruritis Allopechia Epiphora Crusting of the skin along the eyelid margins Ulceration of the eyelid skin Chemosis

34. Blepharitis - causes Idiopathic Immune-mediated disease Atopic dermatitis Pemphigus foliaceus Uveodermatologic syndrome Infectious Bacterial dermatitis Demodicosis Sarcops Neoplasia Meibomian adenoma Squamous cell carcinoma Mast cell tumor Trauma Solar

35. Diagnosis Cytology Identification of bacteria, fungi/yeast Neoplasia Culture and sensitivity Skin scraping Histopathology Wedge resection Indicated when cytology, skin scrapings are not conclusive

36. Treatment Underlying cause Eyelid inflammation Corticosteroid ophthalmic ointment mild cases Oral corticosteroids most cases Prednisone / prednisolone Oral NSAIDs Infectious disease Corticosteroid contraindicated Oral tetracycline [Immune modulating] Hot / cold packs

37. Solar blepharitis Ultraviolet [UV] light radiation UVA rays penetrate the skin by about 1.5mm and cause increased stimulation of the melanocytes UVB causes intense damage to the epidermis [possible SCC] UVC absorbed in the ozone layer around the earth

38. Solar blepharitis / SCC Three definite stages Dermatitis characterized by a raised red, inflamed area of skin Carcinoma in situ, which is also red, raised and ulcerated Biopsy - damage to the dermis True squamous cell carcinoma

39. Solar blepharitis Erythema Ulcerations of the eyelid margin Epiphora Please give me tattoo !!!!

40. Solar blepharitis - treatment Sunscreen Try to keep animals indoors Topical cortisone will relief inflammation Eyelid tattooing

41. Tattooing Protective effect of black pigment in the dermis Ultraviolet absorption by black tattoo pigment below the epidermis Reduction of backscattered radiation Reducing the extent of SCC formation

42. Eyelid neoplasia Most common ocular tumor Species differences Dog: Meibomian adenoma, melanoma, histiocytoma, papilloma Cat: Squamous cell carcinoma, feline multiple apocrine hidrocystoma Dog in general Locally minimally invasive Respond to conservative surgical procedures Distinct metastasis from eyelid has not been reported Upper lid is affected slightly more often Cats SCC highly infiltrative

43. Treatment - general principles dogs Typically surgically removed Adjunctive therapy may be required. Should be removed early Histopathological examination < 1/3 full-thickness wedge Larger tumors resection with blepharoplastic procedure

44. Treatment - general principles dogs Larger tumors resection with blepharoplastic procedure Complications Trichiasis Exposure keratitis Removal orbicularis oculi muscle

45. Early removal recommended !

46. Meibomian gland adenomas The most common eyelid neoplasm in dogs Originate in the meibomian glands May grow rapidly Invariably clinically benign

47. Meibomian gland adenomas – clinical appearance Blepharospasm Epiphora Conjunctival hyperemia Corneal vascularization Pigmentary keratitis Dr Piyush Dubey

48. Eyelid melanomas Common eyelid tumors in dogs Usually benign Prognosis is good after removal Firm black firm, usually slow growing and localized Surgical excision www.acvo.org

49. Squamous cell carcinoma [SCC] All species Common in poorly pigmented areas of the eyelids in horses, cattle, and cats Dogs not common Very infiltrative May metastasize to regional lymph nodes Prevention rather than cure !

50. Squamous cell carcinoma [SCC] Chronic exposure to ultraviolet light White cats Actinic keratoses

51. Squamous cell carcinoma [SCC] Characteristic appearance Slightly raised or depressed ulcerative lesion Crusted surface On or adjacent to the eyelid margin Metastasis Late in the disease Extensive local invasion

52. SCC - Treatment Imiquimod Immune system modulator Potent antiviral and antitumor activity Directly by inducing apoptosis Topical 5% imiquimod Three times per week for up to 12 weeks

53. SCC - Treatment Wide surgical excision L imited eyelid skin available Early detection and treatment

54. Lip to lid graft

55. SCC - Treatment Radiation Cryosurgery

56. SCC - Treatment Electrochemotherapy Improving the efficacy of chemotherapy agents Bleomycin or cisplatin Efficacy limited by diffusion through the cell membrane’s lipid bilayer Uptake can be increased 700-fold after electroporation

57. Eyelid lacerations

58. Eyelid laceration: Considerations Rich blood supply Rapid healing Susceptible to severe edema and distortion Thorough examination for any concurrent injuries Cornea Sclera Nasolacrimal puncta / duct Flickr

59. Eyelid laceration: Considerations Medial canthal region Identify and cannulate nasolacrimal puncta Time since injury <24 h repaired immediately >24 h treat as an open wound until gross infection, if present, is controlled Prevent self-mutilation Elizabethan collar Sedation or tranquilization if indicated

60. Eyelid lacerations: Principles for closure General anesthesia Direct closure and healing by primary intention Minimal debridement

61. Eyelid lacerations: Principles for closure Eyelid margin not involved Treat as a simple skin laceration Avoid tension on the lid margins Avoid sutures that penetrate through the conjunctiva Restoration of the eyelid margin Figure of 8 suture pattern Extensive lacerations Reconstructive surgical

62. Questions ?