Surgical eye procedures

Meredyth L. Jones, DVM, MS, DACVIM

Oklahoma State University, Stillwater, OK 74078
Large Animal Consulting & Education, Perkins, OK 74059

Abstract employed and are fully described in the manuscript, Local

Anesthetic Techniques of the Eye and Foot, located elsewhere
Membrana nictitans excision, H-plasty, and exentera- in this issue.
tion are common surgical procedures used in cattle as part of
the management of ocular squamous cell carcinoma, trauma, Third Eyelid Resection (Membrana Nictitans Excision)
and infectious diseases of the eye. These procedures may
be performed using local anesthesia in field settings and OSCC of the third eyelid can be aggressively locally
can result in full resection of primary tumors, extending the invasive, making early detection and resection critical to
productive life and protecting the welfare of the animal. animal longevity. Early lesions can be subtle, and I encourage
clients to watch eyes as cattle come through the chute for any
Key words: bovine, surgery, eye, squamous cell, carcinoma reason. I similarly watch eyes when pregnancy checking and
as part of bull evaluation.
Résumé Lesions typically start in the center of the margin of the
third eyelid and progress dorsally, ventrally, and medially.
L’excision de la membrane nictitante, la plastie en T This facilitates removal early because it is possible to incise
et l’exentération sont des procédures chirurgicales utilisées ahead of the lesion and achieve full excision.
fréquemment chez les bovins dans le cadre de la gestion du Third eyelid resection should be performed after local
carcinome des cellules squameuses oculaires, des trauma- anesthesia is provided, with or without sedation. There are
tismes et des maladies infectieuses de l’œil. Ces procédures several possible approaches using 2% lidocaine, including
peuvent être faites avec un analgésique local sur le terrain a Peterson Eye Block, 4-Point Block with auriculopalpebral
et peuvent entraîner la résection complète des tumeurs n. block, or combination auriculopalpebral nerve (n.) block
principales prolongeant la vie en production et protégeant with local infusion into the third eyelid. The Peterson and
le bien-être de l’animal. 4-Point Blocks are generally more than is necessary for a
simple lid resection. After the auriculopalpebral n. has been
Introduction blocked and blinking is inhibited, a pair of thumb forceps may
be used to extend the third eyelid, slightly separating it from
Ocular squamous cell carcinoma (OSCC) is the most the cornea. Using a 20-gauge needle, 1 mL of 2% lidocaine is
common indication for ophthalmic surgical intervention in infused within the layers of the third eyelid.
cattle. Infectious diseases and trauma may also result in le- After anesthesia is attained (5 to 10 minutes) 2 pairs
sions requiring surgical intervention. Ocular squamous cell of Kelly forceps are used to isolate the mass. An assistant
carcinoma most often affects the lower lid, lateral limbus and should support the weight of the forceps to prevent trauma
the third eyelid (nictitating membrane). Selection of resection to the cornea or tearing of the third eyelid. The free portion
procedures should be based on the location of the mass and of the mass is grasped with thumb forceps and a #10 scalpel
extent of tissue invasion, including regional lymph nodes, as blade is used to excise the mass, following along the border
well as productive/reproductive status of the animal and any created by the Kelly forceps (Figure 1). The mass is removed
current drug withdrawals. Patient age, physiologic status, and and the Kelly forceps are left in place, while being supported.
behavior are important considerations for restraint for ocular After 2 to 3 minutes the forceps can be removed. Hemostasis
procedures. Most can be performed with chute restraint with is partially achieved with this additional crimping time, but
a halter holding the head in position for the target eye. Head some hemorrhage may still occur. This generally occurs at an
tables are ideal for eye procedures if available, but present acceptable level and care should be taken not to wipe across
a choking hazard, particularly as animals fatigue from long the incision with gauze which will damage forming clots. Fly
procedures or under sedation, and their posture should be spray should be sprayed on the face while the eye is covered.
monitored closely throughout. Standing sedation may be Supportive and aftercare treatments include systemic
used for fractious or anxious animals. Drug combinations anti-inflammatory administration and continued fly control.
that include an opiod result in the animal planting their feet In uncomplicated removals where concurrent infection is
and standing squarely and reliably. Regardless of the selected not present, systemic antimicrobial therapy is not indicated.
method of restraint, local anesthesia techniques should be

264 AABP PROCEEDINGS — VOL. 52 — NO. 2 — SEPTEMBER 2019

 Figure 2. Schematic of an OSCC of the ventral eyelid with initial incisions
for H-plasty.

Next, 2 more vertical incisions are made as exten-

sions ventrally of the initial vertical incisions. These should
be equal or slightly greater in length to the height of the
removed flap. At the ventral corners of the removed flap, 2
equilateral triangles are created (Figure 3). These triangles
of skin should be dissected and removed. Now, the lower flap
to be advanced has been created. It should be undermined
and advanced dorsally until it creates the new eyelid margin
Figure 1. Kelly hemostats isolating an OSCC of the third eyelid for without tension.
removal by scalpel blade. Each new skin junction is then apposed using simple
interrupted sutures, except along the eyelid margin, where

H-Plasty

H-Plasty is a specialized resection technique for OSCC

lesions affecting the central portion of the margin of the
lower eyelid. This technique allows for removal of the tumor
along with the creation of a new eyelid margin, giving a more
functional and cosmetically appealing result.
H-Plasty is performed after an auriculopalpebral block
along with either a Peterson Eye Block or 4-Point Block,
providing both sensory and motor blockade to the eye and
adenexa. The area is surgically clipped and aseptically pre-
pared, using care to protect the cornea.
The initial incisions are made vertically, medial and
lateral of the mass. The incisions should be full thickness
through the skin and enter into the conjunctiva and subcu-
taneous tissues, so that the skin containing the mass may
be freed and removed later. The vertical incisions are then
connected ventrally by a horizontal incision (Figure 2). The
ventral portion of this created, but attached, flap is then
grasped with thumb forceps and elevated to allow sharp
dissection from subcutaneous tissues. At the level of the Figure 3. H-plasty procedure where the skin containing the mass has
conjunctiva (lid margin), the flap is removed. This results in been removed (rectangle) and triangular incisions have been created
a square or rectangular void in the lower eyelid. to allow advancement of the lower flap.

SEPTEMBER 2019 — VOL. 52 — NO. 2 — AABP PROCEEDINGS 265

 margin in parallel. This incision should extend medial to
the medial canthus and lateral canthus and initially be full
thickness through the skin. The second incision is similarly
made parallel to the upper eyelid margin, connecting to the
lower incision (Figure 5). These incision locations should
be altered based on the location and invasion of any OSCC
or other mass, with careful planning to ensure that the final
incision can be closed without tension.
Blunt and sharp dissection are used to dissect the soft
tissues away from the bony orbit. A sharp pair of curved
Mayo scissors follow along the curve of the orbit nicely for
this dissection. The medial and lateral ligaments support-
ing the eye are thick and dense, making a scalpel blade the
tool of choice at least for this portion. The towel clamps are
used to manipulate the tissue to be removed to allow for
dissection along the orbit. Care should be taken not to place
excessive traction on the eye, which may damage the brain
via the optic nerve. The dissection continues until the orbit is
completely evacuated, which is a lengthy process (Figure 6).
Figure 4. Final positioning of the H-plasty flap to create a new eyelid
margin.

simple continuous is preferred. #1 polyglactin 910 or catgut

may be used. This prevents suture tails from contacting the
cornea. Interrupted sutures may be used here, but attention
should be paid to how each suture tail lays.
Supportive and aftercare treatments include systemic
anti-inflammatory administration (generally 3 to 5 days of
therapy) and fly control. Systemic antimicrobial therapy
(extralabel) may be considered based on the procedure and
environment. Generally, beta lactam and specifically cepha-
losporins are appropriate, but extralabel, choices for control
of incisional infections. Suture removal is not required where
polyglactin 910 or catgut are used.

Exenteration Figure 5. Transpalpebral towel clamp placement with initial dorsal and
ventral incisions made parallel to the eyelid margins.
Exenteration, specifically, is the most common form of
eye removal in cattle. It is often referred to as enucleation,
which is removal of the globe. However, removal of the
globe and the surrounding adenexa is more commonly in-
dicated and performed, which is exenteration. Exenteration
is indicated when OSCC has invaded the adenexa of the eye,
where there has been penetrating trauma, or when infec-
tious disease has caused the tissues within the orbit to be
irreparably damaged.
Exenteration is performed after an auriculopalpebral
n. block along with either a Peterson Eye Block or 4-Point
Block, providing both sensory and motor blockade to the eye
and adenexa. A wide area is surgically clipped and asepti-
cally prepared. A tarsorrhaphy is initially performed, which
may be done by lid closure with simple continuous suture,
however, placement of 4 to 5 transpalpebral towel clamps
achieves this more quickly. The initial incision is made about
1 to 2 cm ventral to the lower eyelid margin, following its Figure 6. Exenteration with complete evacuation of the orbit.

266 AABP PROCEEDINGS — VOL. 52 — NO. 2 — SEPTEMBER 2019

As the optic nerve and blood supply are approached behind Additionally, an assistant may lavage the orbit with saline
the eye, many sources will encourage the placement of a during closure. The hemorrhage will result in a very large
ligature around these structures to control hemorrhage. This hematoma at the surgical site, which often becomes softball-
is extremely challenging and often is not retained well due to sized. This will be resorbed over the course of days, giving
the thickness of the tissue ligated. Alternatively, prepare the a more asthetically pleasing result. It is not recommended
skin suture ahead and begin suturing skin immediately after to place any antimicrobials or other therapies into the orbit
those structures are incised and the tissue bundle removed. behind the closure. The use of a trampoline suture across the
A rapidly-placed Ford Interlocking or other continuous pat- bony orbit to provide a more cosmetic result is contraindi-
tern across the incision seals the skin (Figure 7). The ocular cated in cases where infection or neoplasia are present, and
vessels will bleed and fill the socket with blood, which will this technique is rarely performed in cattle.
begin to clot and place pressure on the cut vessel ends. #1 or Supportive and aftercare treatments include systemic
#2 polyamide pseudomonofilament non-absorbable suture is anti-inflammatory administration (generally 3 to 5 days of
suitable for this purpose, and a single-layer closure is used. therapy), systemic antimicrobial therapy, and fly control.
The orbit may be packed temporarily during closure, but Generally, beta lactam and specifically cephalosporins are
gauze should be removed gently to minimize clot disturbance. appropriate, but extralabel, choices for control of incisional
infections. The sutures should be removed at 14 days. Cli-
ents should be made aware that cattle with impaired vision
may develop behavioral changes due to impaired ability to
monitor their environment and should be handled with care.

Suggested Readings

1. Schulz K. Field surgery of the eye and para-orbital tissues. Vet Clin
North Am Food Anim Pract 2008;24:527-534.
2. Schulz KL, Anderson DE. Bovine enucleation: A retrospective study
of 53 cases (1998-2006). Can Vet J 2010;51:611-614.

Figure 7. Ford interlocking suture pattern used for closure of the

exenteration site.

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