Revised from 6th edition of Veterinary Ophthalmology, Chapter 14: Diseases and Surgery of the Canine Eyelids, by Frans C. Stades and Alexandra Van der Woerdt Diseases of the eyelids of the dog represent another large clinical population that will confront the veterinarian. With nearly 250 different canine breeds, the size and shape of these dogs’ heads can predispose to certain eyelid diseases. In contrast to other ophthalmic structures, diseases of the canine eyelids are treated frequently with one or more of about 30 different types of surgeries. Some of these surgeries can be performed by the general and small animal practitioners, but others require the expertise and advanced training by veterinary ophthalmologists. The main goals of eyelid surgery are to provide continued protection of the eye, relieve or prevent pain, and restore cosmesis as much as possible. The primary function of the eyelids is the protection of the globe; they cover the orbit and globe, and surround the palpebral fissure through which the globe contacts the environment. It is normal for the lateral limbus and sclera to be exposed in the dog, and when the globe is deviated laterally, the medial sclera is seen. The hairless margins of the eyelids should be well aligned to the curvature of the cornea and should move smoothly across the globe. The inside of the lids is lined by very loose (except the area over the meibomian glands–tarsal plate) palpebral conjunctival mucosa connecting to the corneal limbus and allowing movements of the globe behind the lids. Eyelid diseases can be divided into congenital–developmental and hereditary, trauma, inflammatory, immune‐mediated and others, and neoplastic disorders. Clinical management of most of the eyelid diseases, except for the inflammatory and immune mediated types, is mostly surgical. The selection of the surgical technique for a particular condition may be influenced not only by the most effective procedure, but also by the experience of the surgeon, and other factors. In this chapter, the eyelid diseases and surgeries of the dog are presented; fundamental eyelid surgical techniques are emphasized. The eyelids are composed of outer skin, inner palpebral conjunctiva, and collagen, muscle, and glandular tissue (Figure 6.1). They are divided into the larger, 2–5 mm longer, and more mobile dorsal, superior, or upper eyelid; and the ventral, inferior, or lower eyelid. The circular muscle surrounding the palpebral fissure is the orbicularis oculi muscle. The eyelids do not close by circular contraction, but because of the subcutaneous tissues and a ligament in the medial canthus attached to the nasal bones and the retractor anguli lateralis muscle plus a lateral palpebral ligament at the lateral canthus, it narrows to a horizontal slit. The lateral ligament may contribute to eyelid distortion, particularly in mesocephalic breeds. The average length of the palpebral fissure when stretched by calipers is approximately 33 mm in most medium to large breeds of dogs. In breeds with distinct lack of contact of the lower lid to the globe, the palpebral fissure length measures often <39 mm. Figure 6.1 Cross section through the canine lid: (1) eyelash‐like hair on the lateral part of the upper lid; (2) Zeis/Moll glands; (3) meibomian gland; (4) mucus cells conjunctiva; (5) fornix; (6) scleral conjunctiva; (7) nictitating membrane gland; (8) orbicularis oculi muscle; and (9) tarsal plate. With its base anchored at the medial canthus, the orbicularis oculi muscle enables the closing phase of blinking, a movement in which the upper eyelid plays the most important part. During closure, there is a lateral‐to‐medial zipper‐like movement, bringing the tear surplus to the lacrimal puncta. The levator palpebrae muscle (innervated by the oculomotor nerve), levator anguli oculi medialis muscle (Müller’s muscle), and other superficial facial muscles help open the upper eyelid and the malaris muscle opens the lower eyelid (Figure 6.2) to maintain the precorneal or preocular tear film. The eyelids are thin pliable skin, enabling blinking and following the corneal surface smoothly. Fine and short hairs normally cover the eyelid skin. The transition of the “eyelash” hairs and regular hairs in the upper lid begins about 1 mm away from the free lid margin. In the lower lid, hairs start about 2 mm away from the free margin. This transition is important as it represents the site to position the eyelid sutures to rotate outward the lid margin (as to correct entropion). Cilia or eyelashes occur primarily on the lateral part of the upper eyelid, usually in two or four irregular rows. These cilia are usually the same color as the adjacent eyelid hair coat. Long tactile hairs (pili supraorbitales or vibrissae) appear as a tuft along the dorsomedial orbital margin. Figure 6.2 Muscles of the lids of the left eye of the dog: (1) orbicular oculi muscle; (2) lateral palpebral ligament or retractor anguli oculi lateralis; (3) medial palpebral ligament; (4) malaris muscle; (5) levator palpebrae muscle; and (6) levator anguli oculi medialis muscle. The free margins (margo intermarginales) of the eyelids are generally pigmented (usually nonpigmented if the skin around the eye is nonpigmented, e.g., in the area of a white spot around the eye), and they are hairless. Furthermore, the margins are smooth, glossy, and fatty, but dry. Thirty to forty orifices of the meibomian glands open into the posterior free lid margin in a fine groove, also named the “gray line,” an important surgical landmark used to appose the lid margins. Below the palpebral conjunctival surface starting at the eyelid margin, the meibomian glands are visible, below the palpebral conjunctiva, as 3–4 mm long, whitish yellow lines running perpendicular to the margin. Just outside the groove are the even smaller orifices of the glands of Zeis and Moll (modified sweat glands). The oily material secreted by these glands coats the margin of the lid with a lipid layer, preventing the tear fluid from flowing across it and forms the outer lipid component of the precorneal film. Meibometers have become available to measure the delivery rate of lipids on the lid margin, but their usefulness in dogs is still under investigation. The tarsal layer in humans consists of a distinct cartilaginous plate that provides internal support for the eyelids, but in dogs this tarsal plate consists of a thinner and more flexible fibrous tarsus resulting in a less rigid lid structure. Both canthi are composed of the lid margins converging together in the medial canthus, leaving 3–5 mm of skin, which continues into the conjunctiva in a minor eminence at the base of the nictitating membrane, called the “lacrimal caruncle.” The hair growth from the area is short and soft; excessive hair length promotes “wicking” and escape of tears onto the medial canthal surface. The lateral canthal ligament is relatively weak. It is supplemented by the retractor anguli lateralis muscle, but contributes to lateral canthal instability and eyelid abnormalities in medium and large breeds of dogs. The main sensation of the canine eyelids is provided by several branches of the trigeminal (V) nerve. Sensation of the lateral two‐thirds of the upper eyelids is provided by the ophthalmic branch of the trigeminal nerve. The sensation for the entire lower eyelid is provided by the maxillary division of the trigeminal nerve. The palpebral branch of the facial (VII) nerve innervates the majority of the muscles (e.g., orbicularis oculi) that control the palpebral fissure size, except for the levator palpebral superioris muscle, which is innervated by the oculomotor (III) cranial nerve. The levator anguli oculi medialis is under sympathetic control. Loss of sympathetic innervation results in ptosis of the medial upper lid. The blood supply to the eyelids primarily originates from the medial and lateral palpebral arteries. Additional blood supply to the lateral canthus and upper and lower eyelids is derived from branches from the external ethmoidal artery. The medial aspects of the canine eyelids are also supplied by branches of the malaris artery, a branch of the infraorbital artery, which anastomose with the inferior palpebral and transverse facial arteries and branches of the external ophthalmic artery. Limited blood supply to the eyelids originates from the deeper orbital blood vessels. The extensive blood supply to the eyelids provides nearly absolute protection and eliminates the need for surgical removal after traumatic injuries. The lymphatic drainage from the eyelids converges at both the medial and lateral canthal areas. Lymphatic drainage is mainly to the parotid lymph node. Some of the same areas also drain to the mandibular lymph nodes. There are several tests that can evaluate the eyelids and their functions (Box 6.1). These diagnostics are used in the preoperative evaluation, ophthalmic exam, and in the neuro‐ophthalmologic evaluations. In the preoperative evaluations before the different entropion, ectropion, and other lid deformities, the division of the real lid deformity from the additional effects of pain is critical to prevent the overcorrection of the lid defect. In general, sedation and local anesthesia are insufficient for lid surgery, especially because there should be sufficient muscle relaxation for the correct estimation of, e.g., the lid fissure length, the amount of tissue to be removed, or the amount of correction necessary. The lid skin is usually shaved or clipped by very small hair clippers. The last row of eyelash hairs may be cut by scissors with some ointment on the blades so that the cut hairs will stick to the ointment. Afterward, the conjunctival sac and the skin are washed copiously with hand‐warm saline. Diluted baby shampoo (1 part diluted with 20 parts water) can be used to clean the eyelids. The preferred method prepares the eyelid surface with 1:50 aqueous povidone–iodine solution, which is not toxic if corneoconjunctival contact occurs. If the standard alcohol‐based surgical povidone–iodine solution is used, the solution should not contact the conjunctival sac or the other eye. For lid surgery, the palpebral fissure has to be positioned more or less horizontally and the medial canthus lower than the forehead. The positioning of the head is best carried out by using a vacuum pillow. In lid surgery, the surgeon works in a sitting position, at the ventral side of the head, with the hands resting, as much as possible, on the animal’s head, or special adjustable arms on the surgeon’s chair, thus reducing the risk of uncontrolled movements. Special ocular drapes with an opening for the eye, or disposable drapes with a pre‐existing hole or a hole cut during surgery, are used. The drapes may be fixed by towel clamps. Any traction of these drapes during surgery should be avoided. Magnification (3–5×) is sufficient in most surgeries. Powerful, well‐focused operating lights, a head‐mounted light, or operating microscope lights are essential. The ophthalmic instruments for eyelid surgery are not numerous, and may include the Kalt, Arruga, strong modified (teeth shortened to 0.3 mm) Castroviejo’s forceps, calipers, ophthalmic needle holder, eye scissors for sutures, and chalazion or eyelid clamps. A source of cautery (Perma Tweez electroepilator™; most small animal cautery units result in excessive cauterization) and cryotherapy are also useful. Cutting using a pointed scalpel blade from the inside to the outside provides a more precise incision; however, cutting by scissors causes crushing of the tissues and nonperpendicular incisions edges. For eye (lid) surgery, atraumatic suture needles are always used. For lid skin, 10–16 mm, 3/8–1/2 circle, extra‐sharp‐pointed round, micropointed, or extra‐fine‐cutting needles are used. To avoid any corneal contact and injury, soft suture material such as silk is advised, but should be removed in 7–10 days. If strength is important, 5‐0 or 6‐0 monofilament nylon can be used. For difficult‐to‐handle animals, absorbable material, such as polyglactin 910 or polyglycol acid, can be used, eliminating the need for suture removal. Wound edges must be closed very precisely. Suture ends are left long to allow easy removal and thus hang downward, or else they are gathered together in the upper lid or canthi (Figure 6.3); short ends may “brush‐irritate” the cornea. If wounds are unequal in length (e.g., in Celsus–Hotz or Stades procedures), the longer wound edge has to be “smuggled” away over the total, thus preventing folding on either side of the wound. Special attention is necessary to appose the edges of eyelid margin defects. Hemostasis is usually achieved by direct pressure. Excessive hemorrhage can also be stopped by (bipolar) electrocoagulation. For hemorrhages of very fine vessels, special ophthalmic (battery) disposable microcautery units are available. Cautery of vessels will cause a local area of necrosis, and for this reason, cauterization should not be done too quickly or excessively. Good hemostasis should be achieved to prevent excessive lid swelling and distortions before the final closure of the wound, or a small drain must be placed, especially following extensive blepharoplasties. In cryosurgery, the destructive effect of freezing the intracellular water ruptures the cell membrane in unwanted tissues. In general, two cycles of rapid freezing and slow, spontaneous thawing are used. The tissues are frozen to at least −25 °C by the use of carbon dioxide or nitrous oxide. Cryosurgery is used for the destruction of hair follicles (as in distichia), the destruction of reactive granulation, or several types of neoplasia (especially in large animals). The main advantage of cryosurgery is the relative simplicity and repeatability of the method. Potential disadvantages are severe postoperative swelling; depigmentation, which may be permanent; and the unwanted loss of normal tissue. Figure 6.3 The ends of upper lid or lateral canthus sutures can be caught or linked together in an outer‐placed suture to prevent irritation of the cornea. During recovery from general anesthesia or later during uncontrolled moments, the patient may loosen or lose stitches, or worse, tissues. Routine use of an Elizabethan or E‐collar may prevent such complications; these collars should be long enough to prevent dogs from rubbing the surgical sites on the rugs or the floor, and should be in place as long as lid swelling and sutures are present. The canine palpebral fissure is sealed at birth. A pinhole‐sized patency at the medial canthus may be the earliest indication of the later separation. This period of natural ankyloblepharon is required in the dog because of the relative immaturity of the ocular and adnexal tissues at parturition. The bridge of tissue in the palpebral fissure between the already developed margins of the eyelid normally regresses at 10–14 days postpartum. Premature opening of the palpebral fissure is usually accompanied by exposure keratoconjunctivitis and severe corneal ulceration; globe perforation and uveitis are possible complications. In such cases, wetting ointments or gels must be used to protect the ocular surfaces. On occasion, temporary tarsorrhaphy with long and adjustable sutures may be necessary, particularly if the palpebral fissure opens within the first few days postpartum. Ankyloblepharon is delayed or complete failure of opening of the palpebral fissure. The anomaly occurs infrequently and is usually bilateral. Conjunctivitis or ophthalmia neonatorum must be considered in the differential diagnosis, but in this condition, the closed eyelids will bulge as a result of the inflammatory exudate that accumulates behind the adhered eyelids. This often staphylococcal keratoconjunctivitis may result from an intrauterine infection or from the dam’s genital tract during partum. The bacteria enter the conjunctival sac, presumably via the patent opening in the medial canthus (the nasolacrimal apparatus) resulting in a bead of purulent material at the medial canthus and the bulging lids (Figure 6.4). The lid fissure should be carefully opened without delay; otherwise, the lacrimal gland, cornea, and even the whole globe can be irreversibly damaged. The prognosis is usually favorable. There are no known means of preventing this condition. In aplasia palpebrae or lid agenesis, the lid margin and the lid itself are completely or partly undeveloped. This rare anomaly is congenital, possibly hereditary, usually bilateral, and in the canine affecting the lateral part of the lower eyelid; the condition is not infrequent in cats. Aplasia palpebrae is often associated with other congenital anomalies such as microphthalmia, persistent pupillary membrane, cataract, retinal dysplasia, and optic nerve head colobomata. Figure 6.4 Pathological ankyloblepharon. Delayed eyelid opening in a puppy has resulted in ophthalmic neonatorum with purulent exudate from the medial canthus. Dermoids or choristomas of the lids are ectopic and abnormally developed islands of skin in or at the margin of the eyelid, frequently associated with some dysplastic deformities of the adjacent conjunctiva. They are rare, possibly hereditary, anomalies, usually of the lower lid near the lateral canthus. Genetic predisposition exists in the German Shepherd, Dalmatian, and Saint Bernard, with the latter breed demonstrating a familial relationship between lower eyelid coloboma and dermoid formation. An island or fold of skin often disrupts the lid margin and is continuous with the conjunctiva. Blinking is abnormal, and long coarse hairs generally grow toward the cornea, causing chronic irritation and resulting in edema, neovascularization, and pigmentation. Treatment consists of removal of the abnormal parts of the eyelid and conjunctiva (especially the hair follicles). Distichiasis refers to single or multiple hairs arising from the free lid margin. They usually arise singly or with two or more hairs from the meibomian duct openings (Figure 6.5). In ectopic cilia, the follicle is located 4–6 mm behind the margin of the upper lid in the posterior distal tarsal plate, in or near the base of the meibomian glands. Most ectopic cilia affect the central upper eyelid. Meibomian glands are modified hair follicles, and distichia can develop from undifferentiated gland tissue. In dogs affected with soft distichia, directed away from the cornea, the condition appears to have limited clinical significance. However, stiff hairs that rub the cornea can irritate and cause injury. Irritation leads to increased lacrimation, blepharospasm, and epiphora. In more severe cases, corneal pigmentation, neovascularization, and even ulceration can result. Primary or secondary (from pain) entropion may be present, and distichia may cause severe irritation, resulting in a vicious circle. The simplest treatment is manual epilation by rounded‐tip epilation forceps at regular intervals (four to five weeks). The advantages of this method are that it determines the irritation is caused by the hairs, it needs no general anesthesia, and if there are only a few hairs, it can also be performed by skillful owners themselves. For permanent treatment, the distichia hair follicle is destructed, removed, or redirected (Table 6.1) and the eyelid margin remains intact. Cryosurgery is the most popular technique and it is performed through the conjunctival surface directly over the follicle, 3–4 mm behind the free margin of the lid. The lid margin is stabilized and everted, using a Von Graefe forceps or Desmarres eyelid clamp (Figure 6.6). A double freeze–thaw cycle using (nitrous oxide) specific probes produce a −25 °C freeze, which can destroy the follicles but spare the adjacent eyelid tissue. Because temperatures below −30 °C will easily produce necrosis and eyelid distortion, the use of thermocouple needles may ensure that tissue temperature does not fall below −25 °C. The immediate postoperative effect is considerable swelling of the cryosurgery site, sometimes so much that blinking is impaired. As a result, preoperative systemic nonsteroidals or postoperative topical treatment with corticosteroid–antibiotic eye ointment is helpful. The swelling usually lasts no more than two to four days. Depigmentation of the frozen areas occurs within 72 h. Repigmentation usually takes up to six months to complete. Permanent depigmentation, scarring, and distortion are possible complications. Figure 6.5 Distichiasis (hairs in or on the lid margin) emerging from the meibomian (1), Zeis, or Moll (2) gland openings; (3) tear film; and (4) cornea. Dogs with distichiasis are also predisposed to having ectopic cilia. The cilia emerge through the dorsal palpebral conjunctiva and impinge directly on the cornea, causing severe corneal irritation. They are usually pigmented in the same color as the rest of the hairs of the dog and located in a small, pigmented spot of mid dorsal conjunctiva several mm posterior to the eyelid margin (the upper lid must be everted to detect these cilia). Predisposed breeds are Flat‐Coated Retriever, Pekingese, Shih Tzu, Cavalier King Charles Spaniel, Boxer, English Bulldog, Poodle, and Jack Russell Terrier. The condition is usually in the young dog, accompanied by acute, intense blepharospasm and lacrimation, and may resemble a foreign body. It easily results in a superficial, rounded (no scratch) corneal defect, without undermined edges, and is accompanied by vessels. Table 6.1 Methods to treat distichiasis in the dog. Figure 6.6. (a) Cryodestruction of multiple distichiae in the conjunctiva–tarsal plate in a dog (b) Lid margin damage after distichiasis hair removal with excessive energy from electrocautery. The lid is everted by Von Graefe’s forceps, a chalazion, or an eyelid clamp. From the palpebral conjunctival surface, the assumed follicle area is excised “en bloc” by scalpel, dermal biopsy punch, or destroyed by cryosurgery. Aftercare consists of topical antibiotic ointment four times daily for seven days. Entropion is the inversion of all or part of the margin of the eyelid such that the outer skin contacts the conjunctival or corneal surface, or both, and is the most frequent eyelid abnormality in the dog. Entropion may be lateral, medial, angular, or total, and may affect the lower or upper lid, or both. Entropion can be divided into categories: primary, such as congenital or developmental entropion, and secondary or acquired, such as spastic and cicatricial entropion. Entropion is influenced by multiple conditions such as the length of the lid fissure, conformation of the skull, the orbital anatomy, gender, and the extensiveness of folds of the facial skin around the eyes. Primary, congenital, or developmental entropion is the most common lid disease in purebred dogs. In most cases, it is because of a hereditary defect, but the genetic basis is not well understood. In many breeds of dogs, the entropion has been demonstrated to affect specific areas of the eyelids (Table 6.2). Severe entropion of the entire lower lid often results in surgical correction, especially with secondary corneal ulceration, neovascularization, and pigmentation develop. In certain breeds, entropion is complicated further by the presence of the looseness of the circumorbital skin, the presence of loose facial folds, and the long and heavy ears contribute to upper lid distortion. Table 6.2 Site of entropion in selected breeds. Not all patients with entropion require surgical correction. Entropion may be secondary as a result of severe (corneal) pain, such as that occurs in primary corneal ulceration. It can also be secondary to a loss of lid support (e.g., in microphthalmos, phthisis bulbi, retrobulbar fat resorption, or muscle atrophy secondary to chronic myositis). However, in rare cases, conjunctival and skin scarring (caused by wounds or surgery) may cause traction to the lid margin and cause secondary cicatricial entropion, trichiasis, or both, and require surgery. The inverted position of the lid margin against the palpebral conjunctiva of the nictitating membrane and the bulbar conjunctiva and cornea results in irritation, excessive lacrimation, mucopurulent discharge, conjunctival hyperemia, and blepharospasm. Signs of chronic irritation of the cornea include edema, neovascularization, granulation, pigmentation, and even ulceration. Injury of the corneal surface in the area of the trichiasis from the entropion can be demonstrated with faint topical fluorescein and/or rose Bengal retention. Because of the trigeminal irritation, the patient will be in constant pain, resulting in excessive lacrimation, enophthalmos, a loss of support of the lid margin, and subsequently a further increase of the entropion. Diagnosis is based on clinical signs, history, and breed. The patient should be observed without restraint to determine the degree of entropion. After the evaluation has been done at a distance, during closer examination, the animal should not be held too tightly by the nape of the neck because the traction on the skin may evert the entropion. In dogs with single or multiple skin folds and/or long and heavy ears, elevating these areas can influence the extent of the entropion and suggest more extensive surgery. Instillation of topical anesthetics is another diagnostic method to differentiate the structural component from the secondary spastic or pain contribution of the entropion. In mild entropion, the cornea may be protected by a topical lubricant. It is usually best to postpone surgical correction until the head has grown to full size (1.5–2 years of age). However, if there are signs of distinct conjunctival or corneal irritation, surgical intervention is indicated, but may need repeating when the animal reaches maturity. In puppies (mainly Shar Pei and Chow Chow) less than 12 weeks old (when the general anesthesia risk is relatively high) with severe entropion, temporary retraction sutures (Figure 6.7) can be placed to gather up the skin of the lid and thereby evert the lid, thus preventing corneal lesions. Alternative staple or skin‐crushing methods are considered unpredictable, irritating, and animal‐unfriendly methods. Usually two to four, 4‐0 to 5‐0 nonabsorbable tacking sutures are placed adjacent to the involved lid margin. Simple, interrupted (needle direction: away from the cornea, thus less risk for corneal trauma) mattress sutures or interrupted, vertical mattress sutures are placed in the lower and less frequently in the upper eyelids. The “bites” are about 5 mm long to ensure adequate retraction and tissue holding occur. Often, the sutures are left long to permit multiple adjustments. When the sutures are removed (two to four weeks) or lost, the surrounding “scar tunnel” will remain, thus still causing correcting traction on the lid margin. In some cases, the entropion will not require further correction. Persistent entropion requires additional surgery. Figure 6.7 Entropion correction by retraction sutures (tacking). The sutures can be maintained for at least two to three weeks. The scar tissue “tube” formed around the suture material may result in moderate permanent correction. (a) Simple, interrupted sutures. (b) U‐figure suture, with the disadvantage that the needle points in the direction of the cornea during suturing. The Quickert–Rathbun technique can be used in dogs for lower lid entropion using fornix‐based sutures. This technique may be an alternate procedure to the tacking method in young puppies (especially those that recur after tacking) or may be employed in older dogs. In this procedure, double‐ended 4‐0 absorbable suture is positioned from the deep fornix to exit externally 1–2 mm from the eyelid margin, everting the lid margin and entropion. Many methods and variations are available for the correction of the different types of entropion (Table 6.3). Complicated entropion cases, such as combinations of upper and lower lid entropion, medial entropion, and combinations with severe corneal lesions (e.g., ulcer, corneal pigmentation), require more surgical skills and experience, and are best referred to a veterinary ophthalmologist. The Celsus–Hotz procedure and its modifications are currently the basic surgical techniques for the treatment of most types of entropion (Figure 6.8), and the most frequently performed entropion surgery worldwide. This procedure and its modifications provide consistent and beneficial results. Lid procedures in dogs must consider that this species lacks a tarsal plate and a well‐developed lateral canthal ligament that are present in humans. Often the presence of enophthalmos can further complicate the correction of entropion, as eyelid–cornea contact in the dog seems essential for lid function and shape. Table 6.3 Surgical procedures for canine entropion. The Celsus–Hotz procedure and its modifications have several characteristics that require consideration (Box 6.2). Surgical correction should be close to the eyelid margin to achieve the outer rotation of the eyelid margin so that the squamous transition of the outer lid margin ceases to contact the cornea. This remaining strip of eyelid margin must be wide enough to accommodate the sutures that secure apposition of the surgical wound. If the first incision is too far from the margin, the lid will not evert sufficiently, and the result will be less than anticipated. Overcorrection may cause ectropion, which may result in additional surgery. To estimate the size of the surgical wound (and amount of correction of the entropion), a simple rule‐of‐thumb technique is performed by placing digital pressure on the lid skin adjacent to the entropic margin and pulling down until the free lid margin is exposed. The second skin incision is made in an elliptical fashion joining the two ends of the primary incision. The skin incision opposite from the lid margin incision mirrors the amount and shape of the desired correction. Hence, some Celsus–Hotz procedures have elliptical wounds; others semielliptical shape, and even nearly separate circles near both canthi. Figure 6.8 The Celsus–Hotz procedure for the correction of severe lower lid entropion with corneal ulceration. (a) The skin is incised at about 2.5 mm (as near as possible to the margin for better prediction of the entropion correction but with enough space for skin suturing) from and parallel to the lid margin (b). (c) The skin and orbicularis muscle are excised (not deeper: canaliculus and [sub]conjunctival tissues should not be damaged). The lid margin should no longer show spontaneous intention of inward rolling. (d) The skin is sutured with material not exceeding 5‐0 (e.g., nonabsorbable silk or absorbable, especially in difficult‐to‐handle animals, mono‐ or polyfilament), using a fine, round‐body needle with or without a micropoint. Continuous sutures alone are not used because of the risk of rupture of the suture material when rubbed, resulting in dehiscence of the entire wound. The first sutures are placed at the medial and lateral ends, and the rest of the wound is closed by halving the intervals in the following order: 1, 2, 3, 4, and so on. The distance between sutures is 2–2.5 mm. Alternatively, the intervals of the simple interrupted sutures can be made at about 4 mm and thereafter the remaining wound intervals closed by a continuous suture. (e) Secondary upper eyelid trichiasis to the lower, caused by postoperative lower lid conjunctival swelling, can be prevented by tacking of the upper lid (5).
6
Canine Eyelids: Disease and Surgery
Introduction
Structure and Function
Skin and Cilia
Eyelid Margin
Canthus
Lid Sensation and Innervation
Blood Supply and Lymphatic Drainage
Diagnostics for Eyelids
Principles of Lid Surgery
Anesthesia
Preparation of the Operative Field
Positioning
Draping
Magnification and Illumination
Surgical Instruments
Suture Material
Suturing
Hemostasis
Cryosurgery
Postoperative Care
Congenital and Presumed Heredity Structural Abnormalities
Ankyloblepharon: Physiological
Ankyloblepharon: Pathological
Eyelid Aplasia or Coloboma
Dermoids and Dysplasia Palpebrae
Distichiasis and Conjunctival Ectopic Cilia
Treatment of Distichiasis
Ectopic Cilia
Method
Indications/results
Mechanical epilation
For few distichia; regrowth common (four to seven weeks). Can be used to confirm diagnosis
Celsus–Hotz resection
Produces mild ectropion and rotates the distichia from the conjunctival and/or corneal surface(s). Used when the entire eyelid is affected
Electrolysis
Limited to few distichia
Diathermy/electrocautery
Limited to few distichia
Eyelid splits
More difficult/for few distichia/use partial thickness technique
Partial resection of the distal tarsal plate
More difficult/for few distichia
Transpalpebral conjunctival dissection
More difficult/for few distichia
Cryotherapy
More swelling post freezing; lid margin depigmentation usually temporary. Because of its repeatability, has become most popular 
Therapy
Entropion
Epidemiology
Position of entropion
Breeds affected
Entire lower lid (lid often shorter)
Chow Chow, Shar Pei, Bouvier des Flandres, Rottweiler
Lateral 3/4 lower lid
Hunting breeds; German Pointer, Labrador Retriever, Golden Retriever
Lateral 1/2 lower lid and lateral canthus (lid may be too long)
Great Dane, Saint Bernard, Leonberger
Upper lid
Bloodhound, Chow Chow, Shar Pei, and older English Cocker Spaniel and Basset Hound
Medial lower lid
Toy and Miniature Poodle, Pekingese, Pug, Shih Tzu, English Bulldog, and Cavalier King Charles Spaniel
Clinical Signs
Diagnosis
Therapy
Tacking Lids or Stay Sutures
Quickert–Rathbun Procedure
Surgical Procedures
Surgical procedure
Type of entropion treated
Eyelid “tacking”
Puppy entropion; holds lid open to avoid conjunctiva and/or corneal contact (pain)
Quickert–Rathbun
Puppies; young dogs with lower entropion
Celsus–Hotz
Most cases of entropion involving lower, upper, medial, and lateral canthus. Can be easily modified
Wyman pedicle
For central lower entropion. Pedicle used with Celsus–Hotz modification
“Y” to “V” plasty (Wharton–Jones)
Mild central lower entropion
Celsus–Hotz modified
For medial entropion and secondary epiphora in toy and small breeds. A variable sized triangle of skin is excised. Alternatives: cryotherapy or electrocautery, and secondary fibrosis
Arrowhead
Modified Celsus–Hotz for lateral canthal entropion. Can be modified for micro‐ and macroblepharon
Wyman lateral canthoplasty
For 1/2 upper entropion and lower ectropion combined with lateral canthal entropion in large and giant breeds. Celsus–Hotz combined with myopedicle for new lateral canthus stability
Robertson
Lateral lower lid and canthal entropion in large and giant breeds. Transection of the lateral canthal ligament in lower lid
Gutbrod–Tietz
Lateral canthoplasty for lateral canthal entropion and macroblepharon in large and giant breeds. Shortens both eyelids
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