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Everted third eyelid cartilage in a cat: A case report and literature review

Article  in  Veterinary Ophthalmology · October 2011

DOI: 10.1111/j.1463-5224.2011.00945.x · Source: PubMed

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Veterinary Ophthalmology (2012) 15, 2, 123–127 DOI:10.1111/j.1463-5224.2011.00945.x

CASE REPORT

Everted third eyelid cartilage in a cat: a case report and literature

review
David Williams,* Sheldon Middleton† and Adele Caldwell‡
*Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES UK; †Acorn House Veterinary Practice, Linnet Way,
Bedford MK41 7HN, UK; and ‡Ark House Veterinary Clinic, 22 Hockliffe Street, Leighton Buzzard LU7 1HJ, UK

Address communications to: Abstract

D. Williams An 8-year-old neutered female British Blue cat was presented with a presumed
Tel.: 07939 074682
diagnosis of a prolapsed nictitans gland and associated ocular irritation and epiphora.
Fax: 01223 232977 However, during surgery, the apparent nictitans gland protrusion was determined to
e-mail: dlw33@cam.ac.uk be an everted cartilage of the nictitating membrane. The scrolled portion of the
cartilage was removed through an incision through the conjunctiva on the bulbar
aspect of the third eyelid, as previously described in the dog. This operation resolved
the ocular irritation occurring, and the third eyelid returned to its anatomically
correct position.
Key Words: cat, eversion, nictitating membrane, surgery

INTRODUCTION CASE REPORT

Third eyelid pathology reported in the cat has included pro- An 8-year-old female neutered British Blue cat was referred
trusion in Horner’s syndrome,1,2 protrusion associated with with a presumptive diagnosis of prolapsed nictitans gland
dehydration,3 and protrusion in Torovirus infection.4 Con- and associated ocular irritation and epiphora (Fig. 1). The
junctivitis regularly involves the nictitating membrane. condition had been present for 3 weeks without a previous
Neoplastic changes reported have included conjunctival history of trauma or other ocular pathology. The Schirmer
squamous cell carcinoma,5 lymphoma,6 mast cell tumor,7 tear test in the unaffected eye was 14 mm/min, while in the
hemangiosarcoma,8 fibrosarcoma,9 and adenocarcinoma.10 affected eye, it reached 26 mm/min with a significantly
Prolapse of the gland of the third eyelid is less common in increased tear lake.
the cat than in the dog but has been reported in several pub- On closer examination under general anesthesia, the pro-
lications,11–13 particularly being seen in the Burmese truding mass was found to be an everted third eyelid carti-
breed.14,15 Scrolling of the third eyelid cartilage has also lage rather than prolapsed glandular tissue. The adjoining
been noted in one report concurrent with gland prolapse in conjunctiva was seen to be pleated (Fig. 2), demonstrating
the Burmese14 and has been reported anecdotally as being that the everted cartilage was causing protrusion of the third
rare in the cat,16,17 but surgical repair does not appear, until eyelid conjunctiva away from the ocular surface, on which it
now, to have been documented in the domestic cat.18,19 would normally follow the curvature of the ocular surface.
Here, we report a case of everted third eyelid cartilage in a On everting the third eyelid, the scrolled cartilage could
cat and its correction using a technique similar to that clearly be seen (Fig. 3).
employed in the equivalent condition in the dog.20,21 Two The cartilage was partly removed through an incision in
principle methods of removal involve dissection of the the bulbar conjunctival surface, initially attempting to sepa-
scrolled portion of cartilage through a bulbar approach and rate the conjunctiva from the underlying cartilage as is read-
a palpebral approach. The former, in the dog as least, has ily achieved in the dog. In this cat, however, the conjunctiva
the advantage that dissection is easier with less adhesion of was considerably more adherent to the underlying cartilage
the cartilage to overlying conjunctiva, but the latter may be than these authors have previously experienced during simi-
beneficial in reducing the possibility of traumatic corneal lar surgeries in the dog. As the conjunctiva of the palpebral
scarring in the postoperative period. surface of the third eyelid was much less adherent to the

 2011 American College of Veterinary Ophthalmologists

124 w i l l i a m s , m i d d l e t o n a n d c a l d w e l l

Figure 1. Appearance at presentation.

Figure 4. Dissection of cartilage from underlying conjunctiva.

Figure 2. Pleated conjunctiva next to the third eyelid elevated from

the ocular surface by the everted cartilage.

Figure 5. Undermining of cartilage appendix prior to complete

removal.

cartilage, it was separated with ease, and the scrolled portion

of the cartilage and the overlying conjunctiva of the bulbar
side were removed together (Figs 4–6).
The everted portion of cartilage, once removed, was
indeed seen to be scrolled in an analogous manner to that
Figure 3. The everted cartilage demarcated by arrows. seen in the dog (Figs 7 and 8). The third eyelid returned to

 2011 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 15, 123–127

 everted third eyelid cartilage in a cat 125

Figure 9. The eye restored to normal appearance immediately post-

operatively.

its anatomically correct position after removal of the

Figure 6. Removal of cartilage appendix. deformed section of cartilage (Fig. 9), and the irritation
resolved henceforth. No suturing of the conjunctiva was
attempted, and the animal was discharged with topical
gentamicin antibiotic in a hypromellose base (Clinagel;
CEVA, Chesham, UK). No complications were noted on
re-examination 10 days later nor in the period following
surgery, now reaching 8-month follow-up.

DISCUSSION

The nictitating membrane, a prominent semilunar fold of

conjunctiva at the medial canthus, is supported by a T-
shaped cartilage described anatomically22 and histologically
in several species. The cartilage in the cat comprises, as
described by Schlegel et al., ‘an appendix which is broader in
the proximal end as compared to the dog…[and] initially has
a paddle-like shape, becomes thinner over a small distance
and extends to a triangular plate in the distal direction’. The
cartilage of dog and cat are compared in Fig. 10, these taken
with kind acknowledgement from Schlegel et al.’s mono-
Figure 7. The everted cartilage ex vivo. graph.22 These workers concluded that the cartilage in the

Figure 8. Histological image of cartilage: fixation has uncurled the cartilage. Line = 100 lm.

 2011 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 15, 123–127

126 w i l l i a m s , m i d d l e t o n a n d c a l d w e l l

(a) (b) ference between surgeons being whether the cartilage is

approached from the palpebral or bulbar aspects of the third
eyelid. The bulbar aspect provides in most cases an easier dis-
section of the cartilage from the conjunctiva and so has been
preferred in previous cases by the current authors. Stades
et al.30 in their pictorial representation suggest that corneal
damage may occur from resulting scarring if approach
through the bulbar aspect is chosen, although in over 50 cor-
Figure 10. Nictitating membrane cartilages of (a) the dog and (b) the rective surgeries in the dog, we have not found this to be a
cat, from the study of Schlegel et al. The cartilage of the third eyelid: a problem because suturing of the conjunctival incision is not
comparative macroscopical and histological study in domestic animals. necessary (D.L. Williams, unpublished observations). In the
Annals of Anatomy 2001; 183: 165–169, with kind permission. case reported herein, an approach from the palpebral aspect
was found more beneficial than from the bulbar, and thus,
cat was elastic, with fibers originating from adjacent connec- risk of possible corneal damage was avoided in any case.
tive tissue and continuing into the perichondrium. While restoration of the third eyelid is relatively straight-
Leibrich23 reported the cartilage to be hyaline in horses forward, questions regarding the etiopathogenesis of carti-
and pigs and elastic in cats, while other researchers consid- lage scrolling are much more difficult to answer. Martin19
ered the cartilage to be elastic in horses, pigs, and cats.24,25 suggested that abnormal differential growth of the anterior
Others considered it to have a mixed character in pigs and and posterior portions of the cartilage results in cartilage in-
cats with some elastic and some hyaline components.26 or out-turning. The fact that fixation straightened the carti-
These anatomical and histological differences between cat lage in this cat suggests that it is a tension across the depth of
and dog third eyelid cartilages may explain the lack of the cartilage rather than an anatomical abnormal growth
reports of everted or scrolled cartilage in the cat compared that resulted in scrolling/eversion of the nictitating mem-
with the numerous papers describing third eyelid cartilage brane, but clearly, this is a subject requiring further investi-
eversion or scrolling in the dog.16–19 Nevertheless, apart gation in both the cat and the dog.
from the considerable adhesion between the bulbar conjunc-
tiva and the cartilage, which somewhat complicated removal
CONCLUSION
of the cartilage in this report, the everted cartilage described
in this cat and its removal were very similar to those in the This case report documents scrolling of the third eyelid car-
dog in all other respects. However, as a single case, the tilage in a cat and the surgical correction of this condition.
authors are aware that the findings here may not be repli- Removal of the deformed portion of cartilage resolves the
cated in other cases of the condition in cats. deformation while still allowing full function of the nictitat-
The function of the third eyelid in the companion animals ing membrane.
has been described as protecting the globe, clearing debris
from the ocular surface27 and providing a sizeable propor-
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 2011 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 15, 123–127

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