CHERRY EYE
The nictitans gland is positioned at the base of the third eyelid in the medial canthus ca nthus and envelops the base of the upright u pright T cartilage skeleton of the third eyelid (Figure 1). Glandular secretions are emptied into the conjunctival sac via many small ductules that open on the bulbar surface of the third eyelid in an area rich in lymphoid tissue. A prolapse of the nictitans gland is a common problem in several breeds o f dog such as the cocker spaniel and bulldog. t occurs much less commonly in cats. !hen the nictitans gland prolapses it passes bet"een the third eyelid and the globe to appear over the free border of the third eyelid. The prolapsed gland results in a pink#colored mass at the medial canthus$ hence the descriptive term %cherry eye.& 'nce prolapsed$ mild inflammation and venous congestion of the gland can develop and the presence of the prolapsed gland disrupts the normal anatomical relationship bet"een the third eyelid and cornea. The condition has a characteristic appearance and usually additional diagnostics are not reuired. everal techniues have been developed over the years for replacing the prolapsed nictitans gland. The pocketing techniue as suggested by *oore (1+,-) and modified by *organ et al (1++-) generally "orks "ell. nictitans gland lymphoid follicles on bulbar surface site of secretory ductule openings 250
Figure /. 0ocketing techniue for replacing prolapsed nictitans gland uipment reuired2 *agnification nstrumentation o yelid speculum o calpel 314 blade "ith 35 handle '6 7eaver blades 38+ o cissors Tenotomy scissors o Forceps 7ishop#9arman o :eedle holders ;astroviejo T"o curved mosuito artery forceps o T"o utures ilk o tay suture e.g. <#= ilk >icryl (thicon) e.g. ?<+/G o 8#= >icryl After preparing the eye for surgery (dilute povidone#iodine solution to prepare conjunctival sac and periocular skin)$ stay sutures are placed through the nictitans close to the 1. tay sutures are used to manipulate the nictitans. T"o T"o curved incisions are made through the th e bulbar conjunctiva of the nictitans$ one bet"een the prolapsed gland and the free border of the nictitans and the other ventromedial to the prolapsed gland. /. The cut edges of conjunctiva are mobili@ed and pulled over the surface of the gland by suturing the
t"o cut edges. This buries the gland and overlying conjunctiva in a %pocket&. Gaps are left at the ends of the incision to allo" secretions to escape. The knots are made on the outer surface of the third eyelid so they do not irritate the ocular surface. 8#= >icryl (thicon. ?<+/G) is used. -. The gland has been buried in a pocket on the bulbar surface of the nictitans. %pocketed& nictitans gland
uipment reuired2 *agnification nstrumentation o yelid speculum o calpel 314 blade "ith 35 handle '6 7eaver blades 38+ o cissors Tenotomy scissors o Forceps 7ishop#9arman o :eedle holders ;astroviejo o T"o curved mosuito artery forceps utures o tay suture e.g. <#= ilk o 8#= >icryl (thicon) e.g. ?<+/G
After preparing the eye for surgery (dilute povidone#iodine solution to prepare conjunctival sac and periocular skin)$ stay sutures are placed through the nictitans close to the free#border to allo" manipulation. The third eyelid is everted and t"o conjunctival incisions are made on the posterior surface of the third eyelid. The proimal incision is approimately parallel to the free border of the nictitans but curves a"ay from it at either end flanking the prolapsed gland. This incision should not be too close to the free border of the nictitans "here the conjunctiva is very closely apposed to the cartilage. The second incision is a mirror image of the first and is made distal to the gland in the sooth conjunctiva just beyond the lymphoid tissue that
is on the bulbar conjunctival surface of the gland. The conjunctiva is gently undermined to mobili@e the more distal conjunctiva and the t"o furthest apart cut conjunctival surfaces are then sutured together. This creates the pocket by pulling the conjunctiva over the gland and acts to force the gland into a more natural position. The 8#= >icryl suture is anchored to the conjunctiva on the outside (palpebral surface) of the nictitans (so the knot cannot contact the ocular surface). The needle is passed though the third eyelid to emerge through the conjunctival incision. A simple continuous suture pattern is used to oppose the t"o outer cut conjunctival surfaces over the top of the surface of the gland. After completing the suture pattern and ensuring the loops are pulled tight the needle is again passed through the nictitans to the outer surface again$ and a bite of conjunctiva used to tie a finishing suture. !hen using this techniue care should be taken to ensure the conjunctival pocket does not create a complete seal over the gland$ preventing escape of the secretions$ other"ise a cyst could result. To prevent this possibility the t"o conjunctival incisions do not completely mee t so after the cut conjunctival edges are sutured together a small gap remains at both ends. 0ost#operatively dogs are fitted "ith an li@abethan collar (for about 1= days) to prevent any self trauma and a broad spectrum antibiotic is given - to < times daily (e.g. Triple antibiotic ophthalmic ointment). f the gland "as s"ollen an antibioticBsteroid combination can be used$ so long as there is no corneal epithelial defects. Complications ;oncomitant scrolling of the cartilage of the nictitans (this may reuire that the scrolled portion of the cartilage is ecised to allo" the gland to sit in a normal position). 6eprolapse of the gland due to suture breakdo"n or leaving too large a gap at the ends of the incisions. A reprolapse rate of 4C has been suggested in the literature ;yst formation due to not leaving draining gaps at the ends of the suture line.
Cherry Eye Kenneth L.Abrams, DVM, Diplomate ACVO,Veterinary Ophthalmology Services, Inc,ar!ic", #ho$e Islan$
Profile DEFINITION ;herry eye is clinically defined as a prolapsed gland of the third eyelid. The term cherry eye "as coined because the prolapsed gland looks like a cherry located near the medial canthus. The gland$ "hich under normal circumstances hugs the base of the T#cartilage in the third eyelid and sits adjacent to the orbital rim$ becomes obvious to the o"ner after prolapse. SIGNALMENT Breed and Age. ;herry eye can occur in many breeds of dogs but is most common in young cocker spaniels$ Dhasa apsos$ hih T@us$ bulldogs$ mastiffs$ beagles$ sharpeis 0ekingese$ 7oston terriers$ and t. 7ernards.1 t is much less common in cats$ but it occasionally occurs in 7urmese$ iamese$ and 0ersians. Although the problem can occur at an y age$ it is most common
in animals / years of age or younger and can be unilateral or bilateral at initial presentation. >ery young puppies often present "ith a prolapsed gland. Geneti I!"liation#. Although the precise mechanism by "hich cherry eye is inherited is unkno"n$ the breed predisposition implies some type of genetic mechanism. The ;anine ye 6egistration Foundation$ the national purebred eye registry$ does not define the genetics of the problem and advises %breeder option& for breeding purposes$ meaning that the actual inherited mechanism is unkno"n$ but that the problem freuently occurs in that particular breed. As it occurs almost eclusively in 7urmese$ iamese$ and 0ersian cats$ th e problem is probably genetic in cats as "ell. PATHOPHYSIOLOGY The anatomical structures that anchor the gland of the third eyelid in its normal position and the pathogenesis of their failure are poorly understood. The gland is classified as seromucoid in dogs and contributes an estimated -=C to 45C to aueous tear production.1$/ t has recently been sho"n that removal of the gland or leaving the prolapsed gland in situ predisposes the patient to E;$ a common complication associated "ith cherry eye.- E; reuires lifelong treatment$ usually "ith topical cyclosporine$ corticosteroids$ and ocular lubricants. CLINICAL SIGNS Appearance of a round$ smooth$ red mass near the medial canthus of a young dog$ especially in high#risk breeds$ is highly suggestive of a prolapsed gland of the third eyelid (Fig$re %). nflammation of the gland "ith s"elling and redness may b e present$ but often the gland looks relatively normal$ "ith a smooth$ pink conjunctival surface. As the gland remains prolapsed for an etended period (months to years)$ the eposed conjunctiva overlying the gland often becomes pigmented$ but there is no evidence of ocular pain. The gland usually remains prolapsed but occasionally repositions itself naturally or "ith gentle digital massaging. ven after repositioning$ prolapse tends to recur. Diagno#i# chirmer tear tests should be done on both eyes to assess refle tear production and to determine if tear production has decreased or if the patient has developed E;. After clearing a"ay any significant buildup of mucus "ith a dry tissue$ the test is done as follo"s2 0lace the chirmer tear test strip on the nonanestheti@ed eye before instillation of any solutions. 9old the strip in place for 8= seconds. Any value greater than 14 mm of "etting per minute is considered normal. Fluorescein staining should also be done to evaluate the effect of decreased tear production on the corneal surface. DIFFERENTIAL DIAGNOSIS ;herry eye can be confused "ith everted cartilage of the third e yelid. verted cartilage also occurs in many breeds but is overrepresented in German shepherds$ Great anes$ shar# peis$!eimaraners$ German shorthaired pointers$ and other large breeds. Great anes$ shar#peis$ and mastiffs present "ith both problems. 9o"ever$ careful observation allo"s differentiation bet"een bent$ everted cartilage and a prolapsed gland. 'ther differential diagnoses include follicular conjunctivitis$ plasmoma$ and neoplasia. Treat!ent HISTORY The proper "ay to manage cherry eye "as controversial for many years until it "as determined that the gland is responsible for a significant amount of tear production in dogs. For years$ practitioners either removed the gland or allo"ed the gland to remain prolapsed$ but these
approaches resulted in a high rate of E;.- urgical replacement of the gland is no " the overriding management strategy. MANAGEMENT PHILOSOPHY 0ersonal clinical eperience "ith cherry eye has resulted in the follo"ing management approach2 >ery young puppies (birth to about - months) presenting "ith unilateral cherry eye for a short duration that have no complications are not immediately treated because the gland in the other eye is likely to prolapse in the near future. f or "hen the other gland prolapses$ surgical repair (see belo") can be done as soon as the surgeon feels comfortable anestheti@ing the small patient and handling the patients tissue.!atchful "aiting can also be used to manage older pu ppies and adults that have had unilateral prolapse for a short duration (less than about a month)$ but if prolapse occurred more than a month previously$ surgery is recommended. 7ilateral prolapses are al"ays surgically repaired at the same time. S&RGERY Three basic surgical techniues have been described$ but many variations have been reported. The basic methods include orbital rim anchoringH scleral anchoringH and$ most recently described$ the pocket method.-8 The method chosen is largely a matter of personal preference$ but in a series of surgical corrections of 1/4 cases of cherry eye$ the pocket method "as the most successful (+icryl$ is used by most ophthalmic surgeonsH ho"ever$ 8#= suture is more appropriate for cats$ puppies$ and small dogs. ome surgeons recommend a second ro" of sutures$ suggesting a higher success rate. ome ophthalmologists suggest leaving the t"o ends of the incision open to allo" tears to escape more easily from the created pocket. 0ostoperative triple antibiotic ointment is applied t"o to three times daily for / to - "eeks. Follo)*&" PATIENT MONITORING An li@abethan collar should remain in place. The patient is eamined / "eeks after surgery to ensure proper healing "ithout corneal ulceration. PROGNOSIS *organ and colleagues reported that only 1=C of eyes in "hich the gland "as repositioned developed E;$ "hereas a total of ,4C of patients "ith glands that "ere ecised or that remained prolapsed developed E;.- The o"ner should be "arned that recurrence is the most common complication of surgery. ;orneal ulceration from suture abrasion can also occur$ and the o"ner should observe the patient for postoperative suinting and discharge. Although there has been no report of the success rate of surgical procedures according to breed$ large#breed dogs and dogs "ith preoperative inflammation of the gland seem to be most likely to have recurrence (Fig$re +). ;ases of cherry eye in bulldogs and mastiffs seem to be most difficult to manage$ and the surgeon may elect to pretreat the inflamed gland "ith topical corticosteroids to improve success. CONCL&SION 0rolapsed gland of the third eyelidIcherry e yeIis most common in certain purebred dogs and cats$ either as unilateral or bilateral disease. ince the gland is responsible for a significant
amount of tear production$ the gland should be surgically re#placed to prevent development of E;$ a disease reuiring lifelong treatment. J
rim anchoring % Scleral anchoring % &oc"et metho$' ( Ma"e parallel incisions anterior an$ posterior to glan$ along b)lbar aspect o* the thir$ eyeli$ con+)nctiva. ( )c" glan$ into poc"et )sing $ry, cottontippe$ applicator. ( Close )sing contin)o)s s)t)re pattern -(/ Vicryl0 1(/ *or cats, p)ppies, small $ogs20 tie "nots on palpebral s)r*ace to avoi$ corneal abrasion. ( Apply postoperative triple(antibiotic ointment 3 4(56 7 *or 6 to 8 !"0 Eli9abethan collar . (E:amine patient 6 !ee"s a*ter s)rgery to ens)re proper healing;no corneal )lceration.
PROLAPSE OF THE GLAND 0rolapse of the :* gland (or %cherry eye&) is the most common primary disorder of the :* (Fig. 15./8). The pathogenesis of this disorder has not been determinedH ho"ever$ it is thought to result from "eakness in the connective tissue attachment bet"een the :* ventrum and the periorbital tissues (everin$ 1++8). This "eakness allo"s the gland$ "hich normally is located ventrally$ to flip up dorsally to protrude above the leading edge of the :*$ "here it then becomes enlarged and inflamed from chronic eposure. 0rolapse of the :* gland can be either unilateral or bilateral$ and it generally occurs before / years of age (ugan et al.$ 1++/H *organ et al.$ 1++-). 0rolapse of the :* gland is common in the American ;ocker paniel$ Dhasa Apso$ 0ekingese$ 7eagle$ and nglish 7ulldog (*organ et al.$ 1++-H everin$ 1++8). The prolapsed gland appears as a smooth$ red mass protruding from behind the leading edge of the :*. f uncorrected$ chronic conjunctivitis and ocular discharge occur (ugan et al.$ 1++/). The reduction in tear production seen "ith ecised glands or glands surgically repositioned "as not clinically important in a 8#month study (ugan et al.$ 1++/). 9o"ever$ a long#term study sho"ed that do gs treated "ith surgical replacement of the gland had a lo"er incidence of E; later in life than dogs that "ere not treated or had the prolapsed gland ecised (*organ et al.$ 1++-).
Surgical Repositioning !hen the importance of the :* gland in tear production became apparent$ surgical repositioning of the gland$ rather than ecision$ became "idely recommended (;hang K Din$ 1+,=H 9elper et al.$ 1+5<). !hile many modifications of repositioning techniues have been published$ the surgical techniues can be divided into methods that anchor the gland and methods that create a pocket for the gland. n the original anchoring techniue described by 7logg$ the prolapsed gland is sutured to the inferior episcleral tissue (7logg$ 1+,=). Follo"ing
a posterior conjunctival incision$ a suture of -#= polyglycolic acid is placed into the deep episcleral tissues on the inferonasal aspect of the globe. The suture is then passed through the ventral aspect of the gland and pulled tight$ thus retracting the gland. Gross modified this techniue by anchoring the gland to the inferior sclera "ith 4#= chromic gut rather than to the episcleral tissues (Gross$ 1+,-). Albert et al. (1+,/) anchored the proimal end of the cartilaginous :* shaft to the origin of the ventral obliue muscle in t"o cats "ith eversion of the :* cartilage. 0resumably$ this techniue could also be used to reposition prolapsed :* glands in dogs. A perilimbal incision is made in the bulbar conjunctiva < mm from the inferonasal limbus$ and the episcleral tissues are dissected a"ay$ thus eposing the inferior obliue muscle. A second conjunctival incision is made perpendicular to the first$ thus eposing the gland. A 4#= silk suture is passed through the ventrum of the gland and then through the tendinous origin of the muscle$ thus tucking the gland into its natural position. Theori@ing that the approaches from the posterior aspect of the :* used in these anchoring techniues could damage the ecretory ductules of the gland$ Eas"an and *artin sutured the gland to the periosteum of the ventral orbital rim using an anterior approach (Fig. 15./5) (Eas"an K *artin$ 1+,4). A modification of this techniue$ "hich facilitates the approach to the orbital periosteum$ has been described by tanley and Eas"an (tanley K Eas"an$ 1++<). 0lummer et al. described a techniue that anchors the gland to the cartilage of the :* allo"ing mobility. For this procedure$ a <#= nylon suture is passed from the anterior surface of the third eyelid through the base of the cartilage to the posterior aspect and then tunneled circumferentially beneath the conjunctiva over and around the prolapsed gland. The suture is then passed through the cartilage again to the anterior face of the third eyelid. The gland returns to its normal position as the suture is slo"ly tightened and then tied on the anterior aspect of the :* (0lummer et al.$ /==,). 6ather than anchoring the gland$ some advocate burying it in a pocket created by conjunctiva on the anterior or posterior surface of the :* (*oore$ 1+,-$ 1++=H *organ et al.$ 1++-H T"itchell$ 1+,<). n the T"itchell techniue$ an incision is made in the conjunctiva on the palpebral surface of the :*$ and a pocket is created by dissection of subconjunctival tissues (T"itchell$ 1+,<). The gland is then reduced into the pocket and sutured anteriorly "ith 4#= absorbable suture material. *oore described resection of the posterior conjunctiva from over the prolapsed gland and then imbrication of it "ith t"o simple$ interrupted sutures of 5#= absorbable suture material (*oore$ 1+,-). A later modification did not involve conjunctival resection (but suggested light scarification) and used a single purse#string suture (*oore$ 1++=). The *organ techniue may be the most commonly used pocket techniue (Fig. 15./,A$ 7) (*organ et al.$ 1++-). The choice of repositioning techniue is a matter of personal preference. The pocket techniues of *oore and *organ may be the easiest to learn$ but the anchoring techniues$ once
mastered$ are simple and uick to perform. :o systematic studies have compared effects on tear production and reprolapse rates among all the described techniues. Tear produc# nt h eo r b i t a lr i ma nc ho r i n gt e ch ni q ueofKa swa n& Figure 1!2! I Mar t i n( 1985)t ot r eat“ c her r ye y e”i nt h edog,ani nc i s i onpar al l el t ot h e o r b i t a lr i mi sma dei nt h ea nt e r i o rc o nj u nc t i v an ea rt h ev e nt r u mo ft h eNM, a nd40no na bs or b ab l emo no fil a me nts ut u r emat e r i a li si n se r t e di n t ot h e me di al e xt e nto ft her e sul t i n gc onj unc t i v al po ck etanddi r ec t edt owar dt h e or bi t al r i m.Abl i ndbi t ei st a k eni nt ot heper i os t eal t i s suesanddi r ec t edout oft hepoc ketati t sl at er al e xt ent ;t hi sbi t ec anal s obet ak enf r om l at er al t o me di a l .Ad eq ua t ep ur c h as ei n t ot h ep er i o s t e al t i s s u ess ho ul db ec o nfi r me d b yfi r ml yt u gg i n ga tt h es ut u r ebe f o r epr o ce ed i n g.Ap ur s es t r i n gi st h en pl ac edt oe nc i r c l et hegl an db yr e i ns er t i n gt hes ut ur eate ac he xi tpo i nt , an dt hes ut ur ei spu l l e dt i ght ,t husan chor i ngt hegl an dt ot heor b i t al r i m. Th ec on j u nc t i v ac anb el e f t e i t h ero p eno rc l o se dwi t h6 0po l y gl a ct i n9 10 s ut ur emat er i a li nas i mpl e,c ont i n uou sp at t er n.( Re pr i nt edwi t hpe r mi s si on f r om Gel at t ,K. N.&Gel at t ,J . P .( 2 011)Veterinary Ophthalmic Surgery , Ed i n bu r g h :El s e v i e r Sa un de r s ,1 5 7– 19 0. )
tion follo"ing both anchoring and pocket techniues$ ho"ever$ is superior to that follo"ing gland ecision$ and *oore et al. demonstrated that neither posterior pocket techniue alters tear production or morphology of the :* gland ecretory ductules (ugan et al.$ 1++/H *oore et al.$ 1++
PROTR"S#ON 0rimary protrusion of the :* "ithout prolapse of the gland can occur in several large breeds (0eruccio$ 1+,1). Though principally a cosmetic problem$ the protrusion sometimes causes conjunctivitis and epiphora. The :* can be shortened surgically to return it to a more normal position (0eruccio$ 1+,1). 0rotrusion can also occur secondary to enophthalmos$ microphthalmos$ and space#occupying retrobulbar lesions (7arnett$ 1+5,). f the primary problem can be resolved$ the :* often returns to its normal position. 0rotrusion may also occur in 9orners syndrome$ dysautonomia$ cannabis intoication$ tetanus$ and rabies (7agley et al.$ 1++alentine$ 1++/H !ise K Dappin$ 1+,+). n animals "ith one pigmented and one nonpigmented :* margin$ an optical illusion makes the nonpigmented
:* appear to protrude abnormally (7arnett$ 1+5,). n most instances$ no problems result from lack of pigmentation$ and no treatment is necessary. 'ccasionally$ ho"ever$ solar conjunctivitis occurs$ "hich can be treated "ith topical antiinflammatory drugs (7romberg$ 1+,=).
NEOPLAS#A :eoplasia of the :*$ like neoplasia in the rest of the conjunctiva$ is uncommon in the dog. *elanomas$ adenocarcinomas$ suamous cell carcinomas$ mastocytomas$ papillomas$ hemangiomas$ hemangiosarcomas$ angiokeratomas$ and lymphosarcoma have all been reported (7uyukmihci K tannard$ 1+,1H ;ollier K ;ollins$ 1++
