Clinical Exposures: Palpebral reconstruction after entropion surgery in a dog

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Mar 01, 2010

A 9-year-old 46.2-lb (21-kg) spayed female mixed-breed dog was presented to the ophthalmology service at Colorado State University (CSU) for evaluation of incisional infection and delayed healing after bilateral entropion surgery.

HISTORY

The dog received a dental prophylaxis at its regular veterinarian's clinic nine days before presentation. While the dog was anesthetized, the veterinarian also performed bilateral blepharoplasties on the upper and lower eyelids. The dog recovered uneventfully, but a day after the surgery, it exhibited epiphora and blepharospasm and frequently vocalized.

The dog had been taken to an emergency clinic, and the emergency veterinarian prescribed a five-day course of tramadol for pain. The dog failed to improve and was re-presented to its regular veterinarian two days later. The veterinarian told the owner that the dog was progressing normally; however, the owner disagreed because the dog still had severe blepharospasm and had developed a greenish-yellow ocular discharge.

The owner had then taken the dog to a veterinary ophthalmologist for a second opinion. The ophthalmologist diagnosed septic blepharitis and removed the sutures to allow for better infection resolution and for second intention healing. In addition, the dog had received cephalexin (500 mg every eight hours) and triple antibiotic ophthalmic ointment (every eight hours in both eyes). The dog did not improve rapidly, so three days later it was presented to CSU.

PHYSICAL AND OPHTHALMIC EXAMINATION FINDINGS

A complete physical examination revealed that the abnormalities were confined to the dog's eyelids and eyes. Partially healed incisions extended the entire length of the upper and lower eyelids bilaterally.


1. The dog's left eye before reconstructive surgery. The medial canthus is on the left, and the nictitating membrane is elevated. Note the dehisced area at the medial canthus and inferior eyelid, the abnormal cilia (white arrow), and the excessive fibrous tissue (blue arrow).
On the left side, the incisions in the medial canthus and central part of the lower eyelid had pulled apart, and the subcutaneous tissue was exposed. The remainder of the left lower eyelid and the full length of the upper eyelid contained excessive granulation tissue. The right side appeared similar to the left, but no lesions were present at the medial canthus. In both eyes, short, abnormally directed cilia on both the upper and lower eyelids were growing toward and rubbing on the corneas. The initial incisions had split the eyelid margins just anterior to the meibomian glands, which resulted in eyelid thinning and contraction and exposure of the eyelash roots, causing them to grow abnormally (Figures 1 & 2). The conjunctivas were inflamed and the globes were retracted, leading to protrusion of the nictitating membranes.


2. The dog's right eye before reconstructive surgery. The medial canthus is on the right. Note the scar tissue, which had led to the rolling in of the lower eyelid at the lateral canthus. The dog was anesthetized, so the eyelids were relaxed and the entropion cannot be appreciated as well.
All other ophthalmic examination results were normal. The Schirmer tear test values were > 15 mm/30 sec in both eyes (normal > 15 mm/min). Intraocular pressures were 20 mm Hg in the right eye and 15 mm Hg in the left eye (normal = 15 to 20 mm Hg), and there was no fluorescein stain uptake.

PROBLEM LIST

The problem list included delayed healing of the eyelid incision sites due to infection and premature suture removal, excessive granulation tissue formation at the palpebral margins, misdirected cilia (iatrogenic distichiasis), conjunctivitis, and infectious blepharitis. The mechanical nature of these problems precluded resolution by medical therapy, so surgical intervention was necessary to remove the scar tissue and abnormal cilia and to reconstruct the eyelid margins to be as functionally normal and cosmetically acceptable as possible.