Article

Standing enucleation in the horse: A report of 5 cases

Christina A. Hewes, G. Curry Keoughan, Santiago Gutierrez–Nibeyro

Abstract — Enucleation was performed in 5 horses under local anesthesia and sedation with the horse standing.
Minimal hemorrhage occurred during the surgical procedure, and there were no other reported complications.
Standing enucleation is a surgery that is safe to perform in horses.

Résumé — Énucléation en position debout chez un cheval : rapport de 5 cas. L’énucléation a été réalisée chez
5 chevaux en position debout sous anesthésie locale et sédation. Une hémorragie minime est survenue pendant la
procédure chirurgicale et il n’y a pas eu de complications rapportées. L’énucléation debout est une chirurgie
sécuritaire chez le cheval.
(Traduit par Docteur André Blouin)
Can Vet J 2007;48:512–514

Introduction between March 1, 2005, and March 1, 2006, were reviewed to

E
determine whether the procedure had been performed under
nucleation, transpalpebral or subconjunctival, is the sur-
standing sedation or general anesthesia. Horses that received
gical removal of the globe, conjunctiva, and nictating
standing sedation for the enucleation were included and for
membrane. For transpalpebral enucleation, the eyelids are
them, the age, sex, breed, history, previous treatment of the
closed to prevent orbital contamination. It is performed when
eye, clinical findings, medical treatment, and outcome of the
severe ocular injury is present, such as severe corneal infection,
enucleation were recorded.
endophthalmitis, corneal or adnexal neoplasia, or severe corneal
All horses had been sedated with a single administration
lacerations (1–5). Enucleation is also performed in cases of
of xylazine hydrochloride (Anased; BenVenue Laboratories,
severe ocular trauma or in horses with a painful, blind eye (2).
Bedford, Ohio, USA), 0.3–0.4 mg/kg bodyweight (BW),
In subconjunctival enucleation, the globe is removed prior to
IV, and detomidine hydrochloride (Dormosedan, Pfizer,
removal of the eyelid margin, allowing for decreased surgical
New York, New York, USA), 0.01 mg/kg BW, IV, and then
time and hemorrhage, but increased contamination from the
placed in standing stocks. Additional doses of xylazine hydro-
globe than with the transpalpebral technique (1–5).
chloride, 0.2–0.3 mg/kg BW, and detomidine hydrochloride,
Although enucleation in the horse has been described as a
0.01 mg/kg BW, were administered, IV, as needed to keep the
surgery to be performed under general anesthesia, (7), surgery
patient sedated throughout the procedure. The horses received
under sedation and with local anesthesia to remove corneal for-
1 dose of flunixin meglumine (Vetagesic; Vedco, St. Joseph,
eign bodies, perform nictitans surgery, repair eyelids, or excise
Missouri, USA), 1.1 mg/kg BW, IV, preoperatively. One horse
tumors has been done with the horse standing (6).
received 1 dose of gentamicin sulfate (GentaVet100; Vedco),
A retrospective study was performed to document cases of
6.6 mg/kg, IV, prior to surgery.
standing transpalpebral enucleation in the horse. Our hypothesis
The periorbital area around the affected eye had the hair
was that enucleation could be performed safely in the standing,
removed with a #40 clipper blade before being aseptically pre-
sedated horse.
pared with chlorhexidine and sterile water. A nose twitch was
Materials and methods applied prior to the administration of local anesthesia and then
removed for the surgery.
The medical records of all horses requiring an enucleation at
Analgesia for the eye was provided by administration of local
the Marion DuPont Scott Equine Medical Center (MDSEMC)
anesthetic, mepivacaine hydrochloride (Carbocaine V (2%);
Pharmacia Upjohn, North Chicago, Illinois, USA), around the
Marion DuPont Scott Equine Medical Center, Virginia-
frontal nerve in the supraorbital foramen, around the lower lid
Maryland Regional College of Veterinary Medicine,
with a line block, and with a 4 point block along the dorsal,
PO BOX 1938, Leesburg, Virginia 20177, USA.
medial, ventral, and lateral aspects of the orbital rim to desen-
Address all correspondence to Dr. Hewes; e-mail: cahewes@ sitize the zygomatic nerve, lacrimal nerve, and infratrochlear
yahoo.com nerve, respectively (6). The frontal nerve was blocked by plac-
Dr. Hewes’ current address is Peninsula Equine, PO Box 7297, ing a 23 gauge, 2.5-cm long needle fully into the supraorbital
Menlo Park, California 94028, USA. foramen and injecting 3.5 mL there and 1.5 mL, SC, over the
Reprints will not be available from the authors. foramen. The lower lid was blocked with 5.0 to 10.0 mL by

512 CVJ / VOL 48 / MAY 2007

inserting a 23 gauge, 2.5-cm long needle at the lateral canthus Table 1.  Sedation amounts for surgery
and advancing it along the lower eyelid to the medial canthus. Preoperativea During surgery
For the 4 point block, an 18 gauge, 8.75-cm spinal needle was
Horse Zylazine Detomidine Xylazine Detomidine
slightly bent to curve around the shape of the globe. The needle
was placed at the midline of the dorsal orbital rim and then 1 150 mg 10 mg
2 150 mg 10 mg
guided along the orbital rim until the needle was two-thirds 3 150 mg 10 mg
of the distance around the globe; anesthetic was injected at 4 200 mg 10 mg 150 mg 10 mg

A R T I C LE
this location and as the needle was being removed for a total 5 200 mg 15 mg 150 mg
of 10.0–15.0 mL. This procedure was repeated at the midline a Preoperative — The period of being placed into the stocks and standing surgery
room, hair removal, surgical preparation, and local anesthetic administration
of the ventral orbital rim and at the medial and lateral canthi,
with 10.0–15.0 mL being injected at each site (8). If the upper ulceration (n = 2), severe uveitis with an anterior chamber
eyelid was not blocked with the supraorbital injection, a line infection (n = 1), phthisical eye (n = 1), and a ruptured globe
block was performed around the upper eyelids with a 23 gauge, from trauma (n = 1.)
2.5-cm long needle from the lateral canthus along the eyelid The horses required a nasal twitch for administration of the
margin to the medial canthus with 5.0 mL of anesthetic (this local anesthesia. Once the area had been anesthetized, that and
was performed in 1 horse due to swelling). the sedation maintained surgical analgesia throughout the pro-
The upper and lower eyelids were then apposed with pen- cedure and minimized response to surgical manipulation.Three
etrating towel clamps, and a routine enucleation performed (2). horses were sedated with 10 mg detomidine hydrochloride and
An elliptical incision was made through the skin 1 cm from the 150 mg xylazine hydrochloride prior to surgery, without addi-
margin of the eyelid with a #10 blade. The angularis oculi vein tional sedation being required during the procedure. One horse
was avoided near the medial canthus. Blunt and sharp SC dissec- received 10 mg detomidine hydrochloride and 200 mg xylazine
tion was performed with Metzenbaum scissors carefully around hydrochloride prior to surgery and an additional 10 mg detomi-
the conjunctival sac to avoid breaking into it. The medial and dine hydrochloride and 150 mg xylazine hydrochloride during
lateral canthal ligaments were transected with the Metzenbaum surgery. The 5th horse received 15 mg detomidine hydrochloride
scissors. The dissection was continued around the conjunctival and 200 mg xylazine hydrochloride prior to surgery and 150 mg
sac to remove the attachment of the extraocular muscles (dorsal xylazine hydrochloride during surgery (Table 1). The initial
rectus, ventral rectus, lateral rectus, medial rectus, dorsal oblique, response to sedation with the detomidine hydrochloride deter-
ventral oblique, and retractor bulbi) from the globe. When all mined the additional amounts and type of sedation. Xylazine
the muscular attachments had been transected from the globe, hydrochloride was administered as an additional sedative, if the
a gauze sponge soaked in mepivacaine hydrochloride (20 mL) surgery was almost complete, or if the horse became very sedate
was placed adjacent to the optic nerve for 3 min to provide with the detomidine hydrocholoride, or both. If the horse was
additional anesthesia. Care was taken to avoid traction on the less sensitive to the initial dose of the detomidine hydrochloride,
optic nerve. The optic nerve was transected with Metzenbaum a 2nd dose of detomidine was given.
scissors and another gauze sponge soaked in mepivacaine hydro- Minimal hemorrhage occurred during the dissection and
chloride (20 mL) was placed adjacent to the stump of the optic transection of the optic nerve and artery in all surgeries. None
nerve. The optic nerve was not clamped or ligated. The orbit of the horses developed blindness in the contralateral eye from
was rinsed with sterile saline (2). trauma to the optic nerve. No adverse effects were seen from
The deep fascia and SC tissue were apposed with 2-0 poly- the sedation used. Minimal swelling or hemorrhage was seen
galactin 910 (Vicryl; Ethicon, Somerville, New Jersey, USA) postoperatively.
(2 cases) or 2-0 poliglecaprone 25 (Monocryl; Ethicon) (3 cases) The horse with severe uveitis and an anterior chamber infec-
in a simple continuous pattern. The skin was apposed with tion and the horse with the ruptured globe received doxycycline,
2-0 nylon (Ethilon, Ethicon) in simple continuous pattern while the other 3 horses did not.
(2 cases) or in a cruciate pattern (3 cases.) Sterile gauze sponges None of the horses had signs of incisional problems. According
were placed over the incision and held in position with an elastic to the owners, the horses had minimal to no ocular pain after the
adhesive bandage (Elastikon; Ethicon). surgical procedure. Although the orbit had a sunken appearance
All horses were administered flunixin meglumine (Vetagesic; postoperatively, owners were pleased with the procedure.
Vedco), 1.1 mg/kg BW, PO, q12h for 5 d, and 2 horses received
the antibiotic doxycycline hyclate (Doxycycline Hyclate USP; Discussion
Westward Pharmaceutical, Eatontown, New Jersey, USA), The 2 main reasons for performing the surgery with the horse
10 mg/kg BW, PO, q12h for 5 d. standing were the risks to the horse of general anesthesia and
the financial costs associated with anesthesia. Since the horses in
Results the study were primarily older animals, the owners did not want
Records of 14 horses were reviewed; 5 adult horses the horse to undergo general anesthesia if it was not necessary.
(4 geldings and 1 mare, average age 20 y, reference range, Additionally, the cost of standing sedation is significantly less
4–33 y) met the criteria for the study: 2 American paint horses, than that of general anesthesia at MDSEMC. When a horse is
1 Thoroughbred-cross, 1 Tennessee walking horse, and 1 quar- being selected as a candidate for standing enucleation, it should
ter horse. Enucleation was performed due to severe corneal respond well to IV sedation and allow palpation of the area

CVJ / VOL 48 / MAY 2007 513

 around the affected eye once it has been sedated. If a horse does hydrochloride would have been a continuous IV infusion of
not allow palpation of the eye despite sedation and application detomidine, which has been shown to provide reliable sedation
of a nose twitch, the procedure should not be performed stand- in standing horses (11). Since continuous IV anesthesia is not
ing. This did not occur in any of our cases or potential cases. often used at MDSEMC, it was not used in these cases.
Anesthesia associated complications, such as movement Orbital implants were not placed in the horses in our study.
during surgery, transient hypertension, and poor recovery scores Orbital implants have previously been placed in horses requir-
have been reported with ocular surgeries, including enucleation ing enucleations (3,5,13,14). To prevent the sunken globe
A R T I C LE

(9). Parvianinen and Trim (9) reported that horses under­going appearance, an orbital implant, orbital implant beneath a cor-
an enucleation were 6.1 times more likely to move under anes- neoscleral shell, or a corneoscleral shell alone can be used (5).
thetic than were those undergoing other ocular surgeries, and In the standing procedure, the orbital implant could be placed
3.1 times more likely to move than were horses undergoing without the careful dissection required with the presence of a
splint bone excision (9). The use of a gas analyzer decreased the corneoscleral shell.
movement under anesthesia in horses undergoing ocular surgery Standing enucleation was a successful procedure in the
by facilitating adequate analgesia and anesthetic depth during 5 horses in this study. It is a good alternative for horses that
the surgery. Transient hypertension also occurred in horses on cannot undergo general anesthesia due to health problems or
which enucleation was performed. For horses on which ocular for other reasons. Since there was minimal hemorrhage with
surgery, including enucleation, was performed under anesthesia, the surgical procedure in the standing horse compared with the
the recovery score (based on agitation and the number of efforts recumbent horse, the dissection was simpler than in the anes-
to stand) was 4.4 times worse than the recovery score for horses thetized horse. Decreased hemorrhage is thought to be a result
with splint bone excision, as determined by the increased num- of enhanced venous return in the standing animal, similar to the
ber of efforts to stand and the agitation (9). Since horses move decreased hemorrhage seen with sinus surgery in the standing
under a lower plane of anesthesia and have inferior recoveries, horse versus the recumbent horse (15). Although there were
adequate pain control is necessary to perform enucleations. only 5 cases in this study, the authors will continue to perform
General anesthesia provides improved monitoring and treat- standing enucleations in future cases. Standing enucleation
ment of pain, but it involves incurring additional risks during should be considered a safe surgery for horses, although not all
recovery. Although recovery is not involved in the standing horses are safe candidates for “standing” surgery. CVJ

procedure, adequate analgesia is important.

To control pain in the standing surgical cases, desensitiza- References
tion of the frontal nerve, lacrimal nerve, zygomatic nerve, and   1. Hamor RE, Robert SM, Severin GA, Trawnik RW, Johnson RW,
Johnson WJ. Ocular cosmetic and prosthetic devices. Vet Clin North
infratrochlear nerve is important to anesthetize sensation in Am Large Anim Pract, 1992;8:637–654.
the upper and lower eyelids, lateral canthus, medial canthus,   2. Brooks, DE. The equine orbit. In: Auer JA, Stick JA, eds. Equine
nictating membrane, and lacrimal glands (6,8). In these cases, Surgery, 3rd ed. St. Louis: Saunders, 2006:760–762.
  3. Lavach, JD. Large Animal Ophthalmology. St. Louis: Mosby, 1990:
a supraorbital nerve block, a line block for the lower lid, and 289–298.
4 point block was performed and found to be adequate for   4. Lavach JD, Severin GA. Equine ocular cosmesis. Veterinary Clinics of
enucleation. An auriculopalpebral nerve block was not neces- North America, Large Animal Practice 1984;6:489–499.
  5. Michau T, Gilger BC. Cosmetic globe surgery. Vet Clin North Am,
sary to prevent motion of the upper eyelid, but a line block was Equine Pract 2004;20:467–484.
necessary in 1 case for upper lid anesthesia.   6. Robertson S. Standing sedation and pain management for ophthalmic
If required, further anesthesia for the globe can be provided patients. Vet Clin North Am, Equine Practice 2004;20:485–497.
  7. Irby, NL. Surgical disease of the eye in farm animals. In: Fubini SL,
with a retrobulbar block (10). Nonsteroidal anti-inflammatory Ducharme NG, eds. Farm Animal Surgery. St. Louis: Saunders, 2004:
medications are also necessary to alleviate ocular pain and mini- 436–440.
mize the inflammatory response to surgery (6). Nonsteroidal   8. Millichamp NJ. Principles of ophthalmic surgery. In: Auer JA, Stick JA,
eds. Equine Surgery, 3rd ed. St. Louis: Saunders, 2006:692–702.
anti-inflammatory medications were used preoperatively and   9. Parvianinen AKJ, Trim CM. Complications associated with anaesthesia
postoperatively. Additional analgesia could have been provided for ocular surgery: A retrospective study 1989–1996. Equine Vet J, 2000;
with butorphanol, morphine, or continuous IV infusion with 32:555–559.
10. Gilger BC, Davidson MG. How to prepare for ocular surgery in the
lidocaine (6). Systemic opioids were not used in this surgery standing horse. Proc Am Assoc Equine Pract, 2002:266–271.
due to the adverse effect of head jerking that can occur with 11. Wilson D, Bohart GV, Evans AT, Robertson S, Rondenay Y.
butorphanol. For additional pain control, continuous infusion Retrospective analysis of detomidine infustion for standing chemical
restraint in 51 horses. Vet Anaesth Analg, 2002;29:54–57.
of lidocaine should be considered in future cases (12). Systemic 12. Robertson SA, Sanchez LC, Merritt AM, Doherty TJ. Effect of systemic
lidocaine has not been used in ophthalmic cases during surgery, lidocaine on visceral and somatic nociception in conscious hourses.
during hospitalization, or for additional pain control at our Equine Vet J, 2005;37:122–127.
13. Gilger BC, Pizzirani S, Johnston LC, Urdiales NR. Use of a hydroxy-
hospital, and it has not been proven to control ophthalmic pain. apatite orbital implant in a cosmetic corneoscleral prosthesis after
To improve pain control, blood pressure and heart rate changes enucleation in a horse. J Am Vet Med Assoc, 2003;222:343–345.
could be monitored in future cases, although alpha 2 drugs can 14. Hamor RE, Roberts SM, Severin GA. Use of orbital implants after
enucleation in dogs, horses, and cats: 161 cases (1980–1990). J Am Vet
cause hypertension. Med Assoc, 1993;203:701–706.
The horses in this study received multiple IV injections 15. Quinn GC, Kidd JA, Lane JG. Modified frontonasal sinus flap surgery
for sedation during the surgical procedure. An alternative in standing horses: Surgical findings and outcomes of 60 cases. Equine
Vet J, 2005;37:138–142.
to repeated doses of xylazine hydrochloride or detomidine

514 CVJ / VOL 48 / MAY 2007