The eyelids

image of The eyelids
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This chapters considers the eyelids and their development during the embryology phase, their anatomy and physiology; investigation of disease; canine and feline conditions.

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9.1 Cross-section of the eyelid viewed from the posterior aspect of the medial canthus. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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9.2 Gross anatomy of the eyelids of the dog. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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9.3 The meibomian gland orifices can be visualized along the eyelid margins in a shallow groove in this 2-year-old male Samoyed.
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9.4 The vertically aligned meibomian glands in this 5-year-old Shih Tzu bitch can be visualized through the palpebral conjunctiva perpendicular to the eyelid margin.
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9.5 A 2-year-old male Clumber Spaniel with discharge adherent to the upper eyelashes, which is an indication that these lashes are contacting the cornea or lower conjunctival fornix at times of low head carriage. The white line demonstrates the difference in the horizontal position of the medial and lateral canthi, indicating lateral canthal instability.
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9.6 Distichiasis in a 1-year-old Staffordshire Bull Terrier bitch. The extra lashes are highlighted by fluorescein application.
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9.7 Bilateral eyelid dermoids in a 5-month-old male Labrador Retriever. Left eye. Lower left eyelid everted to demonstrate the extent of the dermoid. Right eye. (Courtesy of S Monclin)
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9.8 Macropalpebral fissure in a Clumber Spaniel (same dog as in Figure 9.5 ).
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9.9 Macropalpebral fissure in a 1-year-old male Neapolitan Mastiff with lower eyelid ectropion, lateral lower eyelid entropion and upper eyelid ptosis, resulting in the upper eyelid cilia contacting the exposed lower conjunctival fornix.
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9.10 Macropalpebral fissure in a 9-year-old Shih Tzu with associated axial exposure keratitis. There is also medial canthal entropion and caruncular trichiasis with medial ulcerative keratitis.
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9.11 Axial corneal stromal ulceration in the right eye of a 5-year-old male neutered Pug due to lagophthalmos and exposure. Front view. Side view.
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9.12 Cross-section of an eyelid showing the location of an abnormally situated eyelash shaft within the meibomian gland. (Courtesy of J Green)
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9.13 Distichiasis contributing to corneal ulceration in an 11-month-old Jack Russell Terrier bitch.
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9.14 Districhiasis (multiple hairs emerging from one meibomian gland) contributing to corneal ulceration in a 5-year-old male Pug. Management of corneal disease in this dog should address not only the districhiasis but also the macropalpebral fissure and medial lower eyelid entropion.
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9.15 Multiple fine eyelashes in an 18-month-old Boxer bitch, which are unlikely to be clinically significant.
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9.16 Eversion of the eyelid using a chalazion clamp prior to cryosurgical treatment for long curly ectopic cilia and distichiasis in an 8-month-old Toy Poodle bitch.
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9.17 Eyelid depigmentation 10 days following cryosurgery (same dog as in Figure 9.16 ).
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9.18 Eyelid distortion and persistence of distichiasis following attempted subconjunctival surgical resection in a 4-year-old Labrador Retriever bitch. Right eye. Left eye.
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9.19 Cross-section of an eyelid showing an ectopic cilium arising within a meibomian gland and emerging through the palpebral conjunctiva to contact the corneal surface. (Courtesy of J Green)
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9.20 Superior corneal neovascularization and ulceration associated with an ectopic cilium in a 5-year-old Shih Tzu bitch. Note the tendency towards nasal fold trichiasis. A non-pigmented ectopic cilium was identified within a raised, slightly discoloured area in the middle of the upper palpebral conjunctiva (arrowed).
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9.21 Ectopic cilia (arrowed) in the upper palpebral conjunctiva of a 2-year-old Pug. Note that the meibomian gland openings are also visible. Clump of ectopic cilia in the upper palpebral conjunctiva of a 4-year-old Flat-coated Retriever.
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9.22 Right and left eye in a 2-year-old male Siberian Husky with bilateral distichiasis but only right-sided ocular discomfort and corneal disease (see distorted specular reflection), indicating the likelihood of an ectopic cilium. A short stumpy ectopic cilium (solid white arrow) and a long fine ectopic cilium (dashed white arrow) are visible in the lower eyelid conjunctiva.
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9.23 Excision of an ectopic cilium. A chalazion clamp is applied to the affected eyelid to immobilize and evert it. A biopsy punch or No. 11 scalpel blade is used to excise the cilium and its follicle.
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9.24 Upper eyelid trichiasis with associated keratitis in a 13-year-old English Cocker Spaniel bitch. (Courtesy of S Monclin)
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9.25 Nasal fold trichiasis causing medial corneal scarring and pigmentation in a 9-year-old male Pekingese.
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9.26 Nasal fold trichiasis causing deep stromal ulcerative keratitis in an 8-year-old Pekingese. (Courtesy of Willows Referral Service)
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9.27 Descemetocele in a Shih Tzu associated with contact from matted facial hair.
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9.28 A 6-year-old male Chow Chow with overlong lower eyelid and lateral lower eyelid entropion (manually everted in this case, but the location can still be seen as a region of depigmentation on the lower eyelid skin), as well as trichiasis from the medial upper eyelid prominence. The distribution of the pathology suggests that corneal irritation has occurred as a result of both areas of trichiasis and both require surgical correction.
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9.29 Temporary eversion of the eyelids to treat lower eyelid entropion. The lower eyelid is exhibiting entropion. Three or four temporary everting sutures of an interrupted Lembert pattern are pre-placed in the eyelid skin before tightening sufficiently to correct the eyelid deformity. This procedure can also be applied to the upper eyelids and multiple rows of sutures can be placed if indicated (e.g. in Shar Pei puppies).
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9.30 Temporary partial tarsorrhaphy. Sufficient mattress or simple interrupted sutures are placed to close the required length of the eyelid. The sutures are placed so that they enter through the haired eyelid and exit through the eyelid margin in the area of the meibomian gland openings. The needle then enters the opposing eyelid through the eyelid margin and exits through the haired eyelid before the suture is tied. When the suture is tied, the eyelid margins abut. Sutures placed in this position should not be able to contact and damage the cornea. This technique may also be useful in the management of proptosis and corneal exposure. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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9.31 Hotz–Celsus correction for lower eyelid entropion. The degree of correction is assessed in the conscious and non-sedated patient. A lid plate is positioned in the conjunctival sac to support the eyelid and a No. 15 blade is used to incise the strip of skin to be removed. The first incision is parallel to, and 2 mm from, the eyelid margin. A piece of skin the required width and length is excised. The defect is closed with simple interrupted sutures of 6/0 (0.7 metric) polyglactin, with each suture placed to bisect the wound. The knots are positioned away from the eyelid margin. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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9.33 Lower lateral eyelid entropion in an Italian Spinone. Manual eversion reveals that the eyelid is overlong. Deposits and slight depigmentation can be seen on the eyelid margin consistent with it being chronically wet. (Courtesy of Willows Referral Service)
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9.34 Lower lateral eyelid entropion in a 6-year-old Chow Chow combined with trichiasis from the medial upper eyelid prominence (same dog as in Figure 9.28 ). Eversion revealed that the eyelid was overlong.
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9.35 V-shaped and four-sided eyelid resection for eyelid shortening or tumour removal. The resultant defect is closed in two layers using a figure-of-eight suture to re-appose the eyelid margins (see text).
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9.36 modification of the Kühnt–Szymanowski procedure for eyelid shortening and correction of lower eyelid ectropion. A skin incision is made 3 mm from and parallel to the eyelid margin along the lateral one-half to three-quarters of the lower eyelid. The incision is extended dorsolaterally to 1 cm beyond the lateral canthus. From the lateral end of the incision, a 10–20 mm incision is made vertically in a ventral direction. The resulting skin–cutaneous muscle flap is undermined and mobilized. A triangular wedge of tarsoconjunctiva is resected. The width of the triangle base is equal to the length by which the eyelid is to be shortened. The defect created in the tarsoconjunctival half of the lower eyelid is sutured using 6/0 (0.7 metric) polyglactin, burying the knots. The skin flap is slid laterally and a triangle removed from the lateral end of it. This is a similar size to the triangle removed from the tarsoconjunctiva. The skin flap is sutured into its transposed position. The result is eyelid shortening with a double-layered staggered wound. In addition, the lateral eyelid is drawn upwards and laterally.
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9.37 The lateral canthal tendon (LCT) is a poorly defined musculofibrous band that connects the orbicularis oculi muscle fibres at the lateral commissure to the orbital ligament. It lies immediately adjacent to the palpebral conjunctiva and stabilizes the lateral canthus. In dolichocephalic dog breeds (left-hand side), the line of traction provided by the lateral canthal tendon is parallel to the skin, resulting in normal close eyelid/globe apposition. In certain mesaticephalic breeds with broad skulls and redundant facial skin (right-hand side), traction on the lateral canthal tendon occurs at an angle, resulting in lateral canthal inversion. Associated ocular discomfort results in globe retraction, exacerbating the problem. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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9.38 Nasal fold excision. Once the facial hair has been clipped, it is very obvious where to incise in order to resect the nasal fold. Following a skin incision with a No. 15 blade, the nasal fold is then excised with strong sharp scissors and the skin wound is closed routinely.
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9.39 Medial lower eyelid entropion and resultant medial corneal pathology associated with brachycephalic conformation and prominent nasal folds in a Pug. (Courtesy of Willows Referral Service)
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9.40 Medial upper and lower eyelid entropion associated with brachycephalic conformation and prominent nasal folds in an 11-month-old male Pug. The medial corneal neovascularization and pigmentation are made obvious by retro-illumination. The pupil has been pharmacologically dilated as part of the treatment for an unrelated traumatic laceration in the temporal cornea (fluorescein stained).
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9.41 Bilateral caruncular trichiasis and medial lower eyelid entropion in a Shih Tzu (same dog as in Figure 9.27 ), which was previously obscured by nasal trichiasis. This dog had bilateral corneal perforations as a result of the trichiasis, which were repaired with Biosist and a conjunctival pedicle graft in the right eye and a corneo-conjunctival transposition in the left eye. This case illustrates the importance of identifying the underlying aetiology in corneal ulceration because eyelid surgery should be recommended in such cases to prevent recurrence or worsening of corneal disease.
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9.42 Modified Hotz–Celsus procedure to address medial lower eyelid entropion/trichiasis in brachycephalic breeds. A triangular piece of skin (rather than a crescent) is removed. This helps to reduce the potential for recurrence of entropion associated with the excess skin still present in the nasal fold. Closure is routine using simple interrupted sutures of 6/0 (0.7 metric) polyglactin.
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9.43 Medial canthoplasty to shorten the eyelids of brachycephalic dogs. The degree of eyelid shortening required should be assessed preoperatively. The length of medial eyelid that can be removed is somewhat limited by the position of the lacrimal puncta and canaliculi, which should ideally be preserved. However, realistically, these patients often have concurrent dry eye or poor tear distribution. It also allows alignment of the eyelid margins with a tougher tarsal plate, which reduces the tendency for postoperative stretching of the eyelid repair. An additional benefit of increased shortening is that the medial canthus is displaced laterally, which may prevent the nasal hairs from coming into contact with the nasal cornea and avoid the need for concurrent nasal fold excision. Following a skin incision with a No. 15 blade or Beaver blade, the medial eyelid margins are excised, continuing around the medial canthus to ensure that all the hair-bearing caruncular tissue is included in the excised tissue. The tissue has been removed. The defect is closed in two layers with a figure-of-eight suture used to realign the eyelid margins. The conjunctival layer is closed with a continuous suture, ensuring that the suture/needle does not penetrate the underlying conjunctiva and that the knots are directed outwards. The skin is closed with simple interrupted sutures. The suture closest to the figure-of-eight suture can also catch the ends of the margin suture to ensure that they are directed away from the corneal surface. Horizontal mattress sutures are also placed across the wound to relieve tension on the repair. All sutures are of 6/0 (0.7 metric) polyglactin. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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9.44 Postoperative appearance of the eye shown in Figure 9.10 following medial canthoplasty (and conjunctival pedicle grafting). The palpebral fissure is reduced in size, eyelid closure has improved (as indicated by the sharp corneal reflex and lustrous cornea) and the medial caruncular trichiasis has been removed.
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9.45 Postoperative appearance of the eye shown in Figure 9.39 following combined medial canthoplasty and modified lower eyelid Hotz–Celsus skin resection. The palpebral fissure is reduced in size and the medial lower eyelid entropion has been corrected. (Courtesy of Willows Referral Service)
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9.46 Facial droop in a 5-year-old English Cocker Spaniel bitch. (Courtesy of Willows Referral Service)
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9.47 Correction of upper entropion/trichiasis using a Stades procedure. A skin incision is made 1 mm superior to the meibomian gland openings so that all cilia can be removed from the upper eyelid. The incision should be made 3–4 mm from the medial canthus and extended 5–10 mm past the lateral canthus. A second incision (arc shaped) should be made with the superior margin at the level of the orbital rim such that a 15–20 mm wide strip of skin is removed. Any hair follicles remaining in this area need to be excised. The upper skin edge is then mobilized and sutured about half-way across the wound, leaving the lower half to head by secondary intention. It is important to suture the skin to the tarsal plate, just behind the meibomian gland bases. The upper skin edge is sutured with cardinal simple interrupted sutures and, once positioned, secured with continuous sutures using 6/0 (0.7 metric) polyglactin. Healing by secondary intention results in eversion of the upper lid margin and a tough, bald strip remains above the eyelid margin, making recurrence of the entropion/trichiasis unlikely. Incompletely removed follicles with produce hairs following surgery, but they are not usually a problem because the position of the eyelid has been improved.
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9.48 Appearance immediately following a Stades procedure on a 13-year-old English Cocker Spaniel bitch (same case as in Figure 9.24 ). The upper skin edge is sutured half-way across the wound, leaving the second half to heal by secondary intention. The owners of the dog should be warned in advance of the presence of an open granulating wound following surgery. By 13 days following the surgery, the wound has epithelialized, leaving a hairless area above the eyelid. (Courtesy of S Monclin)
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9.49 Side view and front view of the dog in Figure 9.46 following a coronal rhytidectomy (face lift). Eyelid surgery was not necessary. (Courtesy of Willows Referral Service)
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9.50 Modified Wyman canthoplasty coupled with eyelid shortening for the treatment of ‘diamond eye’. A horizontal skin incision is made from the lateral canthus to the zygomatic arch. Full-thickness wedge resections are performed in both the upper and lower eyelids, which are closed in two layers with a figure-of-eight suture at the eyelid margins. The zygomatic arch is exposed by blunt dissection. One or two 2/0 (3.0 metric) nylon sutures are used to anchor the lateral canthus permanently to the zygomatic arch. The nylon suture is then tied in such a position that it provides sufficient tension to create a palpebral fissure of reasonably normal size and shape. The lateral canthal skin incision is closed routinely. (Courtesy of J Green)
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9.51 V-to-Y plasty for the correction of cicatricial ectropion. Converging skin incisions are made commencing 1–2 mm from the eyelid margin. A V-shaped skin flap is separated from the subcutaneous tissues and the cicatricial tissue is excised. The V flap is advanced to correct the eyelid eversion and the resulting Y-shaped wound is closed with simple interrupted sutures of 6/0 (0.7 metric) polyglactin. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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9.52 Multiple chalazia visible through the palpebral conjunctiva. Solitary chalazion visible through the upper eyelid skin.
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9.53 External hordeolum in the lateral upper eyelid of a 3-year-old male German Shorthaired Pointer.
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9.54 Granulomatous inflammation erupting through both the eyelid and conjunctival surfaces in a 6-year-old Shih Tzu bitch with presumptive hordeola.
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9.55 Prominent meibomian gland orifices in a dog with meibomianitis. (Courtesy of Willows Referral Service)
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9.56 Mucocutaneous pyoderma.
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9.57 Diffuse eyelid swelling with ulceration of the eyelid margins and periocular skin in a 4-year-old male Cocker Spaniel. The condition was bilateral and involved only the eyelids. The blepharitis responded to systemic antibiotics alone.
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9.58 Granulomatous blepharitis in a 5-year-old German Shepherd Dog bitch. The inflammatory disease process was confirmed on biopsy and complete resolution occurred following systemic corticosteroid and antibiotic administration. (Courtesy of Willows Referral Service)
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9.59 Periocular alopecia in a dog with demodicosis. (Courtesy of Dr S Shaw)
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9.60 Periocular atopic blepharitis. (Courtesy of Dr S Shaw)
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9.62 Medial canthus ulceration and plasma cell infiltration of the third eyelid in a German Shepherd Dog.
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9.63 Poliosis and vitiligo of the periocular skin and muzzle/nasal planum of a Japanese Akita with uveodermatological syndrome. (Courtesy of Willows Referral Service)
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9.64 Pemphigus foliaceus. (Courtesy of Dr S Shaw)
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9.65 Juvenile cellulitis. (Courtesy of Dr S Shaw)
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9.66 Zinc-responsive dermatosis in a Siberian Husky. (Courtesy of P Sands)
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9.67 Sebaceous adenoma affecting the upper eyelid. Eversion of the eyelid reveals the extent of the tumour. (Courtesy of S Crispin)
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9.68 Histiocytoma in a 10-year-old male Jack Russell Terrier. The diagnosis was confirmed by fine-needle aspiration of the mass. The same lesion following spontaneous regression.
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9.69 Bilateral ulceration of the eyelid margins of both the right and left eye as a result of epitheliotropic lymphoma. Note the subconjunctival haemorrhage in the right eye, indicating possible paraneoplastic disease.
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9.70 Sliding lateral canthoplasty. A large tumour is excised from the eyelid, requiring removal of more than one-third of the eyelid length. An incision is made at the lateral canthus, extending laterally in a direction that appears as a continuation of the eyelid that is being lengthened (the upper eyelid in this case). The incision is made through the full thickness of the eyelid and continues into the adjacent skin. A triangle of skin is excised at the lateral end of the skin incision, which allows the skin to be slid medially to lengthen the upper eyelid. The resulting defect is sutured. The direction of the lateral incision and excised triangle of skin is reversed if elongation of the lower eyelid is required.
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9.71 Mustardé technique. This is a two-stage procedure in which the upper eyelid is repaired using a pedicle of eyelid transposed from the lower eyelid. There are several variations on this technique, which involve repairing the defect in the lower eyelid using an H-plasty or a lip-to-lid graft. However, it is much simpler to transpose a pedicle of eyelid that is shorter than the defect, leaving a sufficient length of lower eyelid to be closed directly. The result is that both the upper and lower eyelids are slightly shorter, but this procedure avoids the potential for trichiasis associated with H-plasty or the need for another complicated grafting technique. A flap of skin and lower eyelid is dissected, leaving a pedicle of attachment at one end. The flap is rotated into the defect in the upper eyelid, which has been prepared to accept it. The flap is sutured into position and the defect at the donor site is closed. Once healed, the donor pedicle is resected and the lid margins are repaired using small wedge resections. (Courtesy of J Green)
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9.72 Lip-to-lid graft (mucocutaneous subdermal plexus flap). Rotation of a graft fashioned from the upper lip can be used to replace the lower eyelid. A portion of oral mucosa is included with the flap to replace the lower palpebral conjunctiva and the oral mucocutaneous junction mimics the eyelid margin. There is a large defect in the lower eyelid. A full-thickness dissection of the lip has been started. The lip flap only includes oral mucosa to a sufficient depth to mimic the depth of the eyelid itself. The dissection is then continued to separate the skin and subdermal plexus from the deeper structures over a sufficient length to allow the flap to be rotated to reach the eyelid defect. The skin ventral to the eyelid defect is incised and the edges are separated sufficiently to accommodate the rotated flap. The oral mucosa of the lip flap is sutured to the conjunctiva in the fornix. The lip skin is sutured to the edges of the eyelid defect and the separated edges of the skin incision ventral to the lid defect. The defect in the oral mucosa and lip skin is closed. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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9.73 Eyelid laceration following a dog fight. Primary repair and temporary tarsorrhaphy. Postoperative appearance showing satisfactory eyelid reconstruction, although the dog subsequently developed keratoconjunctivitis sicca. (Courtesy of R Grundon)
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9.74 Ophthalmia neonatorum in a kitten. (Courtesy of Willows Referral Service)
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9.75 Agenesis of the lateral portion of the upper eyelid of a cat. The periocular hair has been clipped in preparation for surgical reconstruction. (Courtesy of R Grundon)
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9.76 Right and left eyes showing lagophthalmos and exposure keratitis with sequestrum formation in a 5-year-old female Persian. The right inferior cornea has developed stromal ulceration. The distribution of corneal pathology, corresponding to the region of the palpebral fissure, is highly suggestive of exposure keratitis, keratitis due to facial paralysis or keratitis due to lack of corneal sensation.
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9.77 Superionasal corneal ulceration (arrowhead) secondary to an ectopic cilium (arrowed) in a 3-year-old female Burmese.
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9.78 Poxvirus infection causing medial canthal ulceration in a 2-year-old male neutered Domestic Shorthaired Cat. (Courtesy of P Sands)
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9.79 Lipogranulomatous conjunctivitis. (Courtesy of A Read)
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9.80 Unusual presentation of lipogranulomatous conjunctivitis, which was present bilaterally in an elderly cat. The aggregations of creamy inspissated meibomian secretions can be seen through the upper eyelid skin. The adjacent conjunctiva is chemotic and appears to contain small foci of lipid.
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9.81 Idiopathic facial dermatitis in a 2-year-old female Persian. Fluorescein application confirmed significant epiphora, which was contributing to the ulceration in the facial fold. Modified medial lower eyelid Hotz–Celsus skin resections were performed to correct the entropion and improve the lacrimal lake, in order to reduce the epiphora. This was combined with facial fold resection, which partially improved the dermatitis. Characteristic deposits of black waxy material, exudation and ulceration persisted around the eyelids.
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9.82 Squamous cell carcinoma in the lateral lower eyelid of a 10-year-old male neutered white Domestic Shorthaired Cat. Appearance 3 months following surgical debulking and cryotherapy.
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9.83 Squamous cell carcinoma in the non-pigmented medial lower eyelid of an 8-year-old male neutered Domestic Shorthaired Cat. The patient was initially treated with cryotherapy, but the residual lid defect required reconstructive surgery and a lip-to-lid procedure was performed.
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9.84 Apocrine hidrocystomas in a Persian cat.
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9.85 Fibrosarcoma in a Domestic Shorthaired Cat.
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