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Prolapsed Gland of the Third Eyelid
Cherry Eye

 
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Frequently Asked Questions

Subject: Help! - Prolapsed third eyelid

My 4 and 1/2 months old Labrador Retriever recently came up with a prolapsed third eyelid ("cherry eye"). I have taken her to two different vets and spoken to three others - each has given me a somewhat different opinion and I still have not been able to decide what to do. Basically, the three main options that have been presented to me are:

  1. Have an Ophthalmalogist do what amounts to a "tuck" and stitch
    PRO: No possibility of Keratoconjunctivitis sicca (KCS) or "dry eye"
    CON: VERY expensive and only a 50% rate of success
  2. Cut and cauterize the part that is sticking out
    PRO: Success rate is higher for less of an expense
    CON: Slight possibility of "dry eye", some difference in facial expression could result
  3. Do nothing for now and see if it changes as she gets a little bit older.
    PRO: Not sure
    CON:Not sure

In addition to providing me with your opinion on the pros and cons of the above three options, can you please give me a little more detail on the following questions:

  1. Is this condition just a cosmetic thing or is it absolutely necessary to treat?
  2. How common is this condition in Labs? (I know that some breeds are more prone to it) Does it have any significance?
  3. How likely is it that she may develop dry eye if I go with option (2)?
  4. Can it be "popped" back in (I suppose that would be option (4))?

Thank you very much for your help!
Sean

Sean,

A prolapsed gland of the third eyelid (or "cherry eye") is thought to be associated with a laxity of a small ligament which holds the gland in a normal position behind the third eyelid. The gland is a tear producing gland, and produces about 30% of the tears, while the main orbital lacrimal gland produces the rest. Dogs that have had the gland of the third eyelid surgically excised have a greater risk of development of a dry eye (KCS ) than dogs with intact third eyelid glands. It is thought that should the main orbital lacrimal gland be damaged later in life that there is no "back-up" for tear production. Dry eye is a serious eye condition that is difficult to treat, and requires lifelong treatment which may be costly. If the chance of the development of a dry eye can be lessened by tacking the gland back into a normal position so that it stays functional, then this is the most desirable way of handling "cherry eye". The tacking surgery, done by a experienced practitioner or a veterinary ophthalmologist has a re-occurrence rate of only 5 to 10%. I have great success with my tacking procedure. The tacking surgery is certainly more expensive than surgery to excise the gland, but I can assure you that the cost of treating a dry eye in consultations and medication is much higher.

(a) Is this condition just a cosmetic thing or is it absolutely necessary to treat?

Yes, the condition needs to be treated. The longer the gland sits in an abnormal position the greater risk that the gland will undergo damage, and not be fully functional when it is tacked back into place.

(b) How common is this condition in Labs? (I know that some breeds are more prone to it) Does it have any significance?

While the Cocker Spaniel, the Beagle and the Shih Tzu are the most frequently affected breeds, I have certainly seen the condition in the Labrador before.

(c) How likely is it that she may develop dry eye if I go with option (2) Excision?

This cannot be predicted. Dry eye develops later in life when some damage occurs to the main orbital lacrimal gland. This damage is usually associated with an immune system dysfunction, and no one can predict that.

(d) Can it be "popped" back in (I suppose that would be option (4))?

The gland can be manipulated back into a normal position using a topical anesthetic and a sterile swab, but since there is nothing to hold the gland in the normal position, re-prolapse will occur in a day or so, and sometimes within minutes.

My recommendation: Option #

There are several methods of tacking a prolapsed gland of the third eyelid back into a normal position.

The techniques fall into three basic groups:

  • Tacking to the periorbital tissue
  • Tacking to the periosteum of the oribital rim
  • Imbrication techniques.

My personal preference is to tack to the orbital rim, as I feel that this restores the anatomy to the most natural state, and does not disturb the conjunctiva overlying the gland thus potentially disrupting the fine duct system of the gland. Many general practitioners who do surgery to correct "cherry eye" do an imbrication technique. The imbrication techniques are the easiest to learn, and many general practitioners become skilled at this procedure. The best success rate with these procedures comes with experience.

Imbrication Technique

also called the pouch or pocket technique

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Graphic 1 - Prolapsed Nictitans Gland

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Graphic 2:

If the third eyelid cartilage is bent, the cartilage is cut via a small incision on the palpebral conjunctival side of the third eyelid.

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Graphic 3:

Two conjunctival incisions are made in the conjunctiva on the bulbar surface of the third eyelid. The incisions are slightly proximal and slightly distal to the prolapsed gland.

IMPORTANT: The incisions should not join.

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Graphic 4:

Using a small forceps (Bishop Harmon or Colibri) to secure the conjunctiva at the distal incison, a small blunt-blunt ophthalmic scissor (a Steven's tenotomy scissor is perfect) is used to bluntly dissect a "pocket".

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Graphic 5:

I recommend using 6-0 vicryl. The suture is anchored on the palpebral surface of the third eyelid, passed through the third eyelid, and a continuous suture pattern is used to close the conjunctiva. As you imbricate the conjunctiva over the gland, the gland is repositioned into the pocket. The suture is then again passed through the third eyelid and anchored on the palpebral surface. When tying, don't pull too tightly or else the third eyelid will "accordion" on itself.

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Graphic 6:

Final appearance.

Postoperatively I give 5 days of antibiotic, and an elizabethan collar.

ORBITAL RIM ANCHORAGE TECHNIQUE

Zigler's (minor) modification of Stanley's modification of the original Kaswan Martin technique

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  1. The incision over the orbital rim
  2. The suture (I use 4-0 Prolene) is passed through the periosteum of the orbital rim
  3. I usually take some of the bend out of the needle at this point and then direct the needle into the incision and up and through the gland being careful not to allow the suture to come out in the conjunctival sac in front the the third eyelid. The suture must be completely buried.
  4. The needle is directed into the exit hole on the gland and a bite is taken across the gland.
  5. The needle is again directed into its own exit hole and the suture is passed down through the gland, again carefully ensuring that you don't exit in the conjunctival sac, until the needle comes out the original incision.
  6. The suture is tied SNUGLY but do not wrench down on the first tie too tightly or else you can cut through the periosteum, strangulate the gland, or provide a tractional force on the third eyelid which results in a very prominant position of the third eyelid. The suture is tied with six throws to reduce the risk of unravelling, and then the suture is cut leaving quite short ends so that the suture tips don't erode through the conjunctival sac creating a draining sinus.

Question

I repaired a prolapsed gland of the third eyelid on an 11 week old beagle puppy belonging to one of our technicians today. Would there be any benefit on doing a prophylactic "tacking" procedure on the normal eye in pups this age with unilateral disease? If it would be a benefit to the patient, it sure would reduce costs as opposed to having to repeat the procedure on the other eye if it were to prolapse at a later date.

Answer

Once the dog is anesthetized, I will attempt to manually prolapse the gland of the unaffected eye. If I can, this suggests that the connective tissue attachments in this eye are also weak and I will tack the second eye prophylactically.