Um animal da espécie canina, macho, de 3 anos de idade, com botulismo e descemetocele bilateral foi submetido à ceratoplastia lamelar com cápsula renal eqüina preservada em glicerina no olho direito, e enxerto conjuntival pediculado no olho esquerdo. Ambos os olhos mostraram evolução satisfatória porém, o olho receptor da cápsula renal eqüina apresentou transparência corneana mais evidente.   __________________________________________________________________________________________ ABSTRACTA 3-year-old, male mixed breed dog with botulism and bilateral descemetocele was submitted to lamellar keratoplasty with equine renal capsule preserved in glycerin in the right eye and conjunctival pedicle graft in the left eye. The evolution was satisfactory in both eyes, but better in the eye receiving the equine renal capsule, because the corneal transparence was more evident in that eye. On the other hand, the surgical period was more quickly in the eye receiving the equine renal capsule because the preparation of the conjunctival pedicle before the keratoplasty was not necessary

Andrade, Alexandre Lima de

Cavassani, Marluce de Macedo

Galera, Paula Diniz

Laus, José Luiz

Schocken-Iturrino, Ruben Pablo

Repositório Institucional da Universidade de Brasília

Ciência Rural, Santa Maria, v. 29, n. 2, p. 355-359, 1999ISSN 0103-8478Recebido para publicação em 22.06.98.   Aprovado em 04.11.98355BILATERAL LAMELLAR KERATOPLASTY IN DESCEMETOCELETREATMENT IN DOG WITH BOTULISM BY USE OF EQUINERENAL CAPSULE AND CONJUNCTIVAL PEDICLE GRAFTEMPREGO DE CERATOPLASTIA LAMELAR BILATERAL NO TRATAMENTO DEDESCEMETOCELE EM CÃO COM BOTULISMO, UTILIZANDO-SE CÁPSULARENAL EQÜINA E ENXERTO CONJUNTIVAL PEDICULADOJosé Luiz Laus1   Paula Diniz Galera2   Ruben Pablo Schocken-Iturrino1Marluce de Macedo Cavassani3   Alexandre Lima de Andrade4CASE REPORT                                                       1Professor DVM PhD, Veterinary College, UNESP, Jaboticabal, SP. Brasil, Rodovia Carlos Tonanni, km5, 14870-000, Fax-(016)3224275. E.mail-jllaus@fcav.unesp.br. Author for correspondence.2Professor DVM - Veterinary College - UNIC, Cuiabá, MT. Brasil.3Professor DVM - Veterinary College - UNESP, Araçatuba, SP. Brasil.4Graduate Student - Veterinary College - UNESP, Jaboticabal, SP. Brasil.SUMMARYA 3-year-old, male mixed breed dog with botulismand bilateral descemetocele was submitted to lamellar kerato-plasty with equine renal capsule preserved in glycerin in the righteye and conjunctival pedicle graft in the left eye. The evolutionwas satisfactory in both eyes, but better in the eye receiving theequine renal capsule, because the corneal transparence was moreevident in that eye. On the other hand, the surgical period wasmore quickly in the eye receiving the equine renal capsule becau-se the preparation of the conjunctival pedicle before the kerato-plasty was not necessary.Key words: keratoplasty, cornea, descemetocele, botulism.RESUMOUm animal da espécie canina, macho, de 3 anos deidade, com botulismo e descemetocele bilateral foi submetido àceratoplastia lamelar com cápsula renal eqüina preservada emglicerina no olho direito, e enxerto conjuntival pediculado noolho esquerdo. Ambos os olhos mostraram evolução satisfatóriaporém, o olho receptor da cápsula renal eqüina apresentoutransparência corneana mais evidente.Palavras-chave: ceratoplastia, córnea, descemetocele, botulis-mo.INTRODUCTIONA neurotoxin produced by Clostridiumbotulinum, which is an anaerobic gram-positive rod,is responsible for a non-contagious disease known asbotulism. The main symptom of the disease is aneuronal inferior motor disturbance, which mayresult into a picture of total flaccid paralysis. Thealteration of the activity of cranial nerves may de-crease the palpebral and pupilary reflexes(SWANGO et al., 1992). The interference of themotor enervation of the eyelids may result into acorneal drying with a severe damage to the cornea(SLATTER et at., 1990).The cornea represents an important ocularbarrier against external traumas. It also representsthe fore and transparent portion of the eye. It has avariable thickness according to the species and theanatomic area (SAMUELSON, 1991); being about0.6 and 0.95mm in dogs (HELPER, 1989). Amongits functions, the maintenance of the eye shape andthe light convergence, are highlighted (DYCE et al.,1990). In domestic species, 80% of the total eyeLaus et al.Ciência Rural, v. 29, n. 2, 1999.356convergence power is developed by the cornea(WARING, 1984; HELPER, 1989). Its nerves origi-nate from ciliar nerve, which is derived from theophthalmic nerve (DYCE et al., 1990).Among the diseases commonly found inthe cornea, the ulcerative keratitis is the most im-portant one due to the risks it offers to the eye func-tion. The treatment for that disease is accomplishedby clinical and surgical procedures. Among thesurgical ones, the keratoplasties are the most fre-quently employed.The first reports on these techniques aredated from XVIII century. However, moresuccessful techniques were presented from the se-cond half of the present century on. Procedures withauto and homografts were conducted successfully byGUNDERSEN (1958), JENSEN  (1963), DICE etal. (1973), THOFT (1977), THOFT (1982),STARTUP (1984), NASISSE (1985),BRIGHTMAN et al. (1989), PORTNOY et al.(1989), KERN (1990), SLATTER (1990), HACKER(1991), MISHRA & REDDY (1991).Superficial keratectomies in dogs havebeen repaired with equine pericardium by BARROSet al. (1990), with equine renal capsule byANDRADE (1994), with homologous peritoneumby GARCIA et al. (1996) and sardine scales byLAUS (1994). LAUS et al. (1996) and MORALESet al. (1996) studied the corneal and both conjuncti-val pedicle and non-pedicle grafts, and could obser-ve that the pedicle grafts were better, since theyprovided with an immediate blood supply, thoughbeing indicated in deep corneal ulcers. Non-pedicleconjunctival grafts and corneal grafts were incorpo-rated more quickly by the cornea; however, thistechnique would be bettered indicated for less deepulcers.CASE REPORTA male dog, aging 3 years old, mixed bre-ed with a diagnosis of botulism, was assisted at theOphthalmogical Section of Veterinary College ofSão Paulo State University, UNESP, Jaboticabal-SP/Brazil. This animal presented, as a consequence ofbotulism, a flaccid paralysis of the eyelids, followedby a deep bilateral corneal ulcer, with descemetoce-le. This case, due the severity, demanded the car-rying out of a surgical treatment which under such acondition, suggested the treatment with lamellarkeratoplasty.The animal, following the routine preli-minary procedures for a surgery like that, was thentaken into the surgical center, being so, submitted toinhalatory anesthesia, with Halothane®, in a closedcircuit. The surgical procedure was done with theuse of a surgical microscope.The conjunctival pedicle graft is well-known technique, as being highly efficient in caseslike that, and it was then employed by taking asbasis, what had been described by SLATTER(1990). Lamellar keratoplasty with equine renalcapsule was admitted, as we have mentioned before,had already been experimentally tested by our team,according to original publishing by ANDRADE(1994). As both eyes presented an ulceration, wethen decided that the choice for which eye wouldreceive what graft, should be randomized. This way,the left eye received the conjunctival pedicle graft,and the right eye, the equine renal capsule preservedin glycerin. The post-operative treatment was doneby the use of chloranphenicol ophthalmic creamemploying Epitezan®, at intervals of 06 hours for 20days, and also Atropine eyedrops at 1%, every 24 hfor 4 days.The comparison between both employedtechniques was made by comparing the surgicalperiod spent on each of them, and also the evolutionof cicatrization of the corneas receiving the surgicalprocedures. For the study of cicatrization evolution,photophobia, ocular discharge, oedema, neovascula-rization, pigmentation and transparence a slit-lampwas employed, as well as the fluoresceine test whichwas used with the same objectives. The utilizedmethod for that comparing evaluation, was based ongraduation (Nihil: absent; discreet: +; moderate: ++;intense: +++).Along the first fifteen days, blepharos-pasm, mucous-discharge, oedema and neovasculari-zation were observed in both eyes, and according tothe adopted criteria, these were moderate (++). Thefluoresceine test was negative at this time in bothcorneas. In the right eye, more than in the left one, agranulation tissue could be noticed in the graftedarea. Elapsed thirty days, it could be observed thatthe equine renal capsule, began to be incorporatedby the cornea, and the transparence in the graft areastarted to appear gradually. In the eye receiving theconjunctival pedicle graft, it could be verified thatthere was no transparence, and the graft showed tobe still very crystallized. Fifty days later, the corneareceiving the equine renal capsule, already presenteditself as more transparent, whereas in the other eye,the picture was similar to what we had observed atthirty days. Four months of post-operative, the cor-nea receiving equine renal capsule presented to befully repaired, the graft was no longer seen, due toits total incorporation by the cornea, and the areawhere it was applied presented to be much moretransparent, comparing with the other cornea.Bilateral lamellar keratoplasty in descemetocele treatment in dog with botulism by use of equine renal capsule...Ciência Rural, v. 29, n. 2, 1999.357Otherwise, in the eye receiving conjunctival pediclegraft there is small anterior synechiae. (figures. 1and 2).RESULTS AND DISCUSSIONThe ulcerative keratitis are one the mostimportant ocular diseases. The treatment for thesediseases, frequently require the utilization of surgicalmethods known as keratoplasties.In the last few decades, innovating te-chniques have been proposed. Among them, wecould highlight the employment of biological mem-branes. In our work, we tried to assess the results ofa keratoplasty with the employment of an equinerenal capsule preserved in glycerin, by comparingthem with a traditional procedure, such as conjuncti-val pedicle graft. In relation to the pedicle graft,many have been the researcherswho have presented the advanta-ges and merits of the technique(PFEIFFER et al., 1977;THOFT, 1982; HAKAN-SON,et al.,1988). These authors des-cribed that patients who hadbeen treated with that technique,evoluted fairly well. In spite ofthat, they could observe that inthe first fifteen days after thesurgery, the patients presentedblepharospasm, photophobia,ocular discharge and hyperemia.MORALES et al.(1996), described that thosefindings were common and didoccur indistinctively in all pati-ents. The same author also re-ported that, thirty days after thesurgery, the pedicle graft becamevery outlined and a granulationtissue could be observed in thegrafted areas. As usual, thesefindings maintained themselvesfor up to fifty days, when thenthe cornea started to regain itstransparence.In relation to biologi-cal membranes, BARROS et al.(1990) showed good results withthe employment of equine peri-cardium preserved in glycerin.The authors also have reportedthat, besides the found habitualphenomena, there was a depositof pigments in the cornea, whichhad been operated. GARCIA etal. (1996) studied the homolo-gous peritoneum and describedsimilar results as the ones oncepresented by BARROS et al.(1990). Besides those works, wecould bring to light the utilizati-on of sardine scales by LAUS(1994), in which the authorsFigura 1 - The eye receiving the equine renal capsule 4 months after surgery. Notice that thereare few vessels, there is no pigmentation and the graft can no longer be seen. Thecorneal transparence is not perfect, but it is better than the eye receiving the conjunc-tival pedicle graft.Figura 2 - The eye receiving the conjunctival pedicle graft 4 months after surgery. Notice thatcorneal transparence has not been damaged by the graft. There are new vesselsaround the graft and pigmentation.Laus et al.Ciência Rural, v. 29, n. 2, 1999.358showed the occurrence of new vessels and pigments,even after having a long period of post operativebeen elapsed.Generally speaking, all the authors agreethat lamellar keratoplasties result into a partial lossof transparence in the sites where the grafts are im-planted, due to the neo-vascular formation and pig-mentation.About this present work, whose resultsare being discussed, it is relevant to state at first that,it is meant to be the very first work in which clini-cally, the equine renal capsule was tested, becauseuntil then, it had only been experimentally tested byANDRADE (1994).Since the ulcers were very similar in botheyes, we decided for utilizing this case to compare atraditional surgical procedure (conjunctival pediclegraft) with lamellar keratoplasty by employing anequine renal capsule preserved in glycerin, which upto that moment, had only been tested experimentally,showing fair results. It is worth mentioning that, thiscomparison was only possible, because the animal´sowner allowed such a procedure.In relation to the comparison with con-junctival pedicle graft, the post operative assessmentshowed that in the first fifty days, blepharospasm,ocular discharge, hyperemia and oedema were evi-dent for both techniques. From thirty days after thepost operative, the differences between both techni-ques began to appear. It could be observed that theequine renal capsule was incorporated by the corneawith the reduction of oedema and vascularization. Inthe eye receiving conjunctival pedicle graft, a vita-lity of the graft could be observed, which had beenexpected since it was a pedicle graft, according toMORALES et al. (1996).At fifty days, the equine renal capsulecould already be found totally incorporated by thecornea and the oedema was now very small. Theseremarks are in agreement with the ones byANDRADE (1994). In that period, the conjunctivalpedicle graft could be found still vitalized, accordingto MORALES et al. (1996).Forty months after the surgery the corneareceiving renal capsule, showed a transparence de-gree fairly well whereas the other cornea still main-tained the conjunctival graft well vitalized. It isworth mentioning that, due the severity of ulcerati-on, we decided toward not cutting the pedicle,Finally, by the comparative analysis onecan assume that both methods were efficient. Howe-ver, advantages can be granted to renal capsule. It issaid for this statement, some situations or conditionsin which the conjunctiva cannot be utilized as forexample, in the bacterial infections of this structure,in cases in which it had been used but there was adehiscence, and also when the ulcer occurs in equinespecies animals, because namely in this species theconjunctiva does not represent a fair material for theaccomplishment of pedicle graft. Still about theadvantages of renal capsule, we could mention agreater transparence of cornea, and the shorter timeused for the accomplishment of keratoplasty. Inrelation to this time mentioned, it is easy to unders-tand why it is shorter, because by using renal cap-sule, we do not spend any time at all on the prepara-tion of conjunctival pedicle before the keratoplasty.AKNOWLEDGEMENTSResearch supported by FAPESP - Proc 98/03153-0,Fort Dodge and Ethicon.REFERENCESANDRADE, A.L. Emprego experimental da cápsula renalxenógena, conservada em glicerina, no reparo deceratectomias superficiais em cães (Canis familiaris,LINNAEUS, 1758): Avaliação clínica e morfológica.Jaboticabal, 1996. 74p. Tese (Mestrado em Veterinária) -Faculdade de Ciências Agrárias e Veterinárias, UniversidadeEstadual Paulista, 1996.BARROS, P.S.M. Reparação cirúrgica da córnea de cães usandopericárdio de eqüino conservado em glicerina. In:CONGRESSO BRASILEIRO DA ANCLIVEPA, 13, 1990,Gramado. Resumos... Gramado: ANCLIVEPA, 1990, p. 11.BRIGHTMAN, A.H., MCLAUGHLIN, S.A., BROGDON, J.D.Autogenous lamellar corneal grafting in dogs. J Am Vet MedAssoc, Schaumburg, v. 195, n. 4, p. 469-475, 1989.DICE, P.F., SEVERIN, G.A., LUMB, W.V. Experimentalautogenous and homologous corneal transplantation in thedog. J Am Anim Hosp Assoc, Mishawaka, v. 9, p. 245-269,1973.ZYCE, K.M., SACK, W.O., WENSING, C.J.G. Tratado deAnatomia Veterinária. Rio de Janeiro: Guanabara Koogan,1990. Os órgãos dos sentidos, p. 225-235.GARCIA, J.A., BARROS, P.S.M., LAUS, J.L., et al. Implante deperitônio homólogo conservado após ceratectomia lamelar emcães. Braz J Vet Res and Anim Sci., São Paulo, v. 33, supl.,p. 290-294, 1996.GUNDERSEN, T. Conjuntival flaps in the treatment of cornealdisease with reference to a new technique of application.Arch Ophthalmol, Chicago, v. 60, p. 880-888, 1958.HACKER, D.V. Frozen corneal grafts in dogs and cats: a reporton 19 cases. J Am Anim Hosp Assoc, Mishawaka, v. 27, p.387-398, 1991HAKANSON, N., LORIMER, D., MERIDETH, R.E. Furthercomments on conjunctival pedicle grafting in the treatment ofcorneal ulcers in the dog and cat. J Am Anim Hosp Assoc, v.24, p. 602-605, 1988.Bilateral lamellar keratoplasty in descemetocele treatment in dog with botulism by use of equine renal capsule...Ciência Rural, v. 29, n. 2, 1999.359HELPER, L.C. Magrane’s canine ophthalmology. 4. ed.Philadelphia: Lea & Febiger, 1989. Diseases and surgery ofthe cornea and sclera, p. 102-149.JENSEN, E.C. Experimental corneal transplantation in the dog. JAm Vet Med Assoc, Chicago, v. 142, p. 11-22, 1963.KERN, T.J. Ulcerative keratitis. Vet Clin North Am SmallAnim Pract, Philadelphia, v. 20, n. 3, p. 643-666, 1990.LAUS, J.L. 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Infecçõesbacterianas, riquetsiais, protozoais, e outras. In: ETTINGER,S.J. Tratado de medicina interna veterinária. 3. ed. SãoPaulo. Manole, 1992, p. 286-287THOFT, R.A. Conjunctival transplantation. Arch Ophthalmol,Chicago, v. 95, p. 1425-1427, 1977.THOFT, R.A., Indications for conjunctival transplantation.Ophthalmology, Philadelphia, v. 89, n. 4, p. 335-339, 1982.WARING, G.O. Corneal structure and pathophysiology. In:LEIBOWITZ, H. Corneal disorders: clinical diagnosis andmanagement. Philadelphia: Saunders, 1984, p. 3-25.

Emprego de ceratoplastia lamelar bilateral no tratamento de descemetocele em cão com botulismo, utilizando-se cápsula renal eqüina e enxerto conjuntival pediculado

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Emprego de ceratoplastia lamelar bilateral no tratamento de descemetocele em cão com botulismo, utilizando-se cápsula renal eqüina e enxerto conjuntival pediculado

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