The medical records of 23 dogs that underwent medial canthoplasty for treatment of epiphora were reviewed. The most prevalent breed encountered was the shih tzu. Other affected breeds included the Pekingese, Maltese, toy poodle, and pug. All dogs had epiphora associated with medial canthal trichiasis and/or entropion. Other ocular abnormalities included conjunctivitis, keratitis, pigmentary keratitis, corneal ulceration, globe prolapse, and nasal fold trichiasis. After medial canthoplasty, the epiphora resolved in all dogs.The authors thank the veterinarians who referred the dogs, and illustrator Un Gyu Lim for his drawing in the preparation of the illustration

Jeong, Man Bok

Kim, Min Su

Lim, Ji Hey

Nam, Tchi Chou

Park, Shin Ae

Seo, Kangmoon

Yi, Na Young

Journal of the American Animal Hospital Association

SNU Open Repository and Archive

Medial Canthoplasty for Epiphora in Dogs:A Retrospective Study of 23 CasesThe medical records of 23 dogs that underwent medial canthoplasty for treatment of epiphorawere reviewed. The most prevalent breed encountered was the shih tzu. Other affectedbreeds included the Pekingese, Maltese, toy poodle, and pug. All dogs had epiphora associated with medial canthal trichiasis and/or entropion. Other ocular abnormalities included conjunctivitis, keratitis, pigmentary keratitis, corneal ulceration, globe prolapse, and nasal fold trichiasis. After medial canthoplasty, the epiphora resolved in all dogs.J Am Anim Hosp Assoc 2006;42:435-439.Na Young Yi, DVMShin Ae Park, DVMMan Bok Jeong, MSMin Su Kim, DVMJi Hey Lim, DVMTchi Chou Nam, PhDKangmoon Seo, PhDIntroductionEpiphora is a common problem in small-breed dogs.1-3 The hairs andskin around the medial canthus may become stained and brown becauseof constant tearing. While tear staining is generally a cosmetic defect, afocal dermatitis may sometimes occur.3 Epiphora develops secondary toan impediment of the drainage of tears through the nasolacrimal systemor to an overproduction of tears.4 Certain anatomical features, such asmedial canthal entropion, excess hair growth at the medial canthus(trichiasis), a tight medial palpebral ligament, misplacement of the lowerpunctum, and close apposition of the eyelids to the globe may also pre-dispose the dog to epiphora.1,3 Problems associated with cilia, such astrichiasis and distichiasis, can irritate the conjunctiva and cornea and leadto excessive lacrimation.5Medial canthal trichiasis is common in some breeds, such as theTibetan spaniel, shih tzu, and Lhasa apso.6 The hairs growing from thecaruncle may cause epiphora, conjunctivitis, and pigmentary keratitis andmay be complicated by macropalpebral fissure, medial entropion, dis-tichiasis, and keratoconjunctivitis sicca.6,7 Cryotherapy has been advo-cated for the treatment of medial canthal trichiasis, where the conjunctivacontaining the hairs is frozen with liquid nitrogen using double freeze-thaw cycles.8Medial lower eyelid entropion causes ventral displacement and func-tional closure of the lower lacrimal punctum and canaliculus, with sub-sequent impairment of tear drainage.1 To treat medial canthal entropion,a modified Hotz-Celsus resection may be performed.5 In this procedure,a triangular piece of skin is excised with the apex of the triangle posi-tioned opposite the lower lacrimal punctum. The wound is then closedwith nonabsorbable suture. A tight medial palpebral ligament displacesthe medial canthus ventrally, which allows for the overflow of tears ontothe face.1 Medial canthoplasty has been used to correct canthal entropi-on and trichiasis, as well as tight medial palpebral ligaments.1 Medialcanthoplasty can also be used to reduce the palpebral fissure size inbrachycephalic dogs.9RSJOURNAL of the American Animal Hospital Association 435From the Department of Veterinary Ophthalmology,College of Veterinary Medicine,Seoul National University,San 56-1, Sillim 9-dong, Gwanak-gu,151-742 Seoul, Korea.Address all correspondence to Dr. Seo.The purpose of this study was to evaluate the surgicaloutcomes and complications of medial canthoplasty in dogswith epiphora.Materials and MethodsMedical records of dogs that underwent a medial cantho-plasty for treatment of epiphora from October 2002 to May2005 were reviewed. All dogs included in the study had noprior surgical treatments for epiphora. Any dogs thatreceived prior electroepilation for distichiasis or nasal foldresection for nasal fold trichiasis were excluded from thestudy. Complete ophthalmic examinations, including aSchirmer tear test (STT),a slit-lamp biomicroscopy,b appla-nation tonometry,c fluorescein dye test,d and an indirectophthalmoscopy,e were performed. Epiphora was diagnosedif a dog had an overflow of tears onto the skin near themedial canthus, with a normal STT value. The breed, age,sex, causes of epiphora, and concurrent ocular diseases wereinvestigated. The surgical outcomes and complications werealso reviewed. Follow-up clinical evaluations were donepostoperatively in all dogs, and owners were also inter-viewed by telephone.Surgical TechniqueIn all cases, anesthesia was induced with propofolf andmaintained with isofluraneg in oxygen. Each dog was posi-tioned in dorsal recumbency, and the head was stabilizedwith a vacuum pack.h The surgical procedure was per-formed with an operating microscopei using 10-power mag-nification. The superior and inferior canaliculi werecannulated with 24-gauge polyethylene catheters,j whichallowed preservation of both lacrimal puncta. A no. 15scalpel bladek was used to make an incision that ran fromthe center of the medial canthus to the upper lacrimal punc-tum along the eyelid margin, superficial to the meibomiangland openings [Figure 1A]. A second incision was made onthe lower eyelid in the same fashion. The superficial part ofthe medial palpebral ligament was cut with tenotomy scis-sors,l and the circumscribed skin was undermined to free itfrom its orbital attachment. An arrow-shaped wedge of skinnear the medial canthus was removed. The hair-bearingmucosa of the caruncle was also removed, and care wastaken to preserve the lacrimal puncta and canaliculi [Figure1B]. The resulting skin wound was closed with 6-0polyglactin 910,m employing a figure-of-eight pattern[Figure 1C]. One or two simple interrupted sutures werealso applied medial to the figure-of-eight suture to enhanceskin closure [Figure 1D]. Postoperatively, all dogs receiveddexamethasone/neomycin/polymyxin B dropsn in the oper-ated eyes q 8 hours for 14 days; carprofeno 2.2 mg/kg oral-ly q 12 hours for 7 days; and cephalexinp 30 mg/kg orally q12 hours for 7 days. The sutures were removed 10 to 14days after surgery.ResultsMedial canthoplasty was performed on both eyes of 23 dogswith epiphora. The dogs’ ages ranged from 1 to 10 years(mean 5.1 years). The genders of the animals included fourmales, nine castrated males, nine females, and one spayedfemale. The most prevalent breed was the shih tzu (n=15).Other affected breeds included the Pekingese (n=4),Maltese (n=2), toy poodle (n=1), and pug (n=1).A review of the medical records revealed that all dogsdeveloped epiphora at a young age. The causes of epiphorawere primarily medial canthal trichiasis and/or entropion.Other ocular abnormalities were found, such as conjunctivi-tis or conjunctival hyperemia (n=16), keratitis (n=12), pig-mentary keratitis (n=9), corneal ulceration (n=4), globeprolapse (n=4), and nasal fold trichiasis (n=1) [Table].Examination of the cornea revealed corneal pigmentation(20 eyes), neovascularization (20 eyes), and edema (12eyes). These corneal changes were found predominantly inthe nasal/inferior quadrant near the medial canthus, adjacentto the hairs growing at the caruncle and/or on the eyelids atthe medial canthus. Four dogs had a history of globe pro-lapse associated with macropalpebral fissure. One dog hadtwo eyelid masses near the medial canthus, which wereexcised and diagnosed as meibomian gland adenomas on436 JOURNAL of the American Animal Hospital Association November/December 2006, Vol. 42TableOcular Findings in 23 Dogs With EpiphoraTreated by Medial CanthoplastyReasons for Epiphora No. of Dogs (%)Medial canthal trichiasis 21 (91.3)Medial canthal entropion 19 (82.6)Ocular Abnormalities No. of Dogs (%)Conjunctivitis, 16 (69.6)conjunctival hyperemiaKeratitis 12 (52.2)Pigmentary keratitis 9 (39.1)Corneal ulceration 4 (17.4)Globe prolapse 4 (17.4)Nasal fold trichiasis 1 (4.3)Eyelid neoplasm 1 (4.3)Anterior uveitis 1 (4.3)Glaucoma 1 (4.3)Retinal detachment 1 (4.3)histopathology. Anterior uveitis was noted in one dog, andthis dog later developed glaucoma. Retinal detachment wasfound in one shih tzu.After medial canthoplasty, all dogs developed moderateto severe chemosis that resolved by the time of sutureremoval. At the time of suture removal (10 to 14 days), thetearing onto the skin near the medial canthus and tear stain-ing had resolved in all dogs. Recheck examinations wereperformed for up to 16 weeks (mean 8 weeks) after surgeryin all dogs. All corneal ulcers and conjunctivitis resolvedwithin 2 weeks after surgery. Most corneal neovasculariza-tion and edema regressed within 1 month after surgery;however, corneal pigmentation showed little improvementduring the 16-week observation period. As a result of themedial canthoplasty, the palpebral fissure was shortenedapproximately 3 to 4 mm in all dogs. By closing the medialcanthus, nasal fold trichiasis resolved in one dog withoutresection of the nasal fold. Although the operated eyesappeared to be smaller and rounder than before surgery[Figure 2A], 22 (96%) of the 23 clients whose dogs wererechecked within 3 months were satisfied with the results ofmedial canthoplasty. Seventeen of the 18 clients who werecontacted by telephone (5 to 24 months after surgery; mean12 months) were satisfied with the cosmetic results of theoperation. During the follow-up period, epiphora did notrecur in any dog.DiscussionBreed predisposition for the dogs with medial canthal trichi-asis in this study was similar to a previous report.6 Medialcanthal trichiasis occurred predominantly in brachycephalicbreeds.In 1973, medial conjunctivoplasty was first reported as atreatment for epiphora in 11 dogs.10 The procedure involvedNovember/December 2006, Vol. 42 Medial Canthoplasty Technique 437ABCDFigures 1A-1D—Schematic diagram showing the medial canthoplasty technique used in the 23 dogs of this study. (A) Anincision is made from the center of the medial canthus to the lacrimal punctum along the eyelid margin, superficial to themeibomian gland openings (black dots). (B) An arrow-shaped piece of skin is resected, and the haired mucosa of thecaruncle is also removed. The lacrimal puncta have been cannulated in this image. (C) The wound is closed with a figure-of-eight suture and additional simple interrupted sutures in the skin. (D) The completed medial canthoplasty, with shorten-ing of the palpebral fissure.the removal of aberrant dermis, which reduced the epipho-ra; however, only six of 11 dogs were permanently cured. In1979, Jensen described a medial canthoplasty technique thatnarrowed the palpebral fissure.11 The medial canthoplastytechnique described in the current study preserves thelacrimal puncta better than the Jensen technique, which sac-rifices the upper punctum. The medial canthoplastydescribed here also appears to be a simpler method than theJensen technique.The canthoplasty technique reported here simultaneous-ly removes the excess hair in the caruncle and corrects anymedial canthal entropion. The lower eyelid is also loosenedby partial resection of the medial palpebral ligament, whichmay impair tear drainage through the lacrimal punctum. Aone-layer skin closure was performed in this study in orderto create an empty area by leaving the conjunctival woundopen. It was hoped that this open area would provide a largerspace for tears to collect and reduce the overflow of tears.Polyglactin 910 was used for the skin closure, because it issoft and less likely to cause corneal irritation.Another advantage of medial canthoplasty is the shorten-ing of the palpebral fissure, which protects the globe andprovides better cosmesis by making any exotropia lessnoticeable.8 Despite the smaller appearance of the eye aftersurgery, most owners were satisfied with the results. In thisstudy, medial canthoplasty alone prevented nasal fold trichi-asis in one dog by eliminating the contact between thecornea and nasal folds by shortening the palpebral fissure.In the event that both macropalpebral fissure and nasal foldtrichiasis are present in a dog, medial canthoplasty may beconsidered if the owner is reluctant to have a nasal foldresection performed.ConclusionMedial canthoplasty was performed in 23 dogs with epipho-ra. Epiphora resolved in all dogs, and many ancillarycorneal changes also improved. The medial canthoplastytechnique described here is an effective procedure for thecorrection of epiphora in toy and brachycephalic dogs.a Schirmer Tear Test; Schering-Plough Animal Health, Kenilworth, NJ07033b SHIN-NIPPON No. 1320884; SHIN-NIPPON Co., Inc., Tokyo, Japanc Tono-Pen XL; Medtronic, Minneapolis, MN 55432d Fluorets; Chauvin Pharmaceuticals Ltd, London, Englande Vantage Indirect Ophthalmoscope; Keeler, Berkshire, United Kingdomf Anepol; Hana Pharm Co., Ltd, Seoul, Koreag Isoflurane; Rhodia, Bristol, United Kingdomh Vacu support (BUSTER); AlfaMedic Ltd, Hong Kong, Chinai Leica M 651; Leica Microsystems GmbH, Wetzlar, Germanyj BD IV catheter; Becton Dickinson & Co., Helsingborg, Swedenk Ailee surgical blade; Ailee, Busan, Koreal Stevens tenotomy scissors; Bausch & Lomb, San Dimas, CA 91773m Vicryl; Johnson & Johnson, St-Stevens-Woluwe, Belgiumn Maxitrol; S.A. Alcon-couvreur N.V., Puurs, Belgiumo Rimadyl; Pfizer Animal Health, New York, NY 10017p Cephalexin; Dongkoo Pharm Co., Ltd, Seoul, KoreaAcknowledgmentsThe authors thank the veterinarians who referred the dogs,and illustrator Un Gyu Lim for his drawing in the prepara-tion of the illustrations.References11. Crispin S. The lacrimal system. In: Petersen-Jones S, Crispin S, eds.Brit Small Anim Vet Assoc Manual of Small Animal Ophthalmology.2nd ed. Quedgeley: Brit Small Anim Vet Assoc, 2002:115-116.12. Olivero DK. Epiphora. In: Riis RC, ed. Small AnimalOphthalmology Secrets. Philadelphia: Hanley & Belfus, 2002:147-152.13. Slatter D. Fundamentals of Veterinary Ophthalmology. 3rd ed.Philadelphia: WB Saunders, 2001:245-249.14. Grahn BH. Diseases and surgery of the canine nasolacrimal system.In: Gelatt KN, ed. Veterinary Ophthalmology. 2nd ed. Baltimore:Lippincott Williams & Wilkins, 1999:570-573.438 JOURNAL of the American Animal Hospital Association November/December 2006, Vol. 42ABFigures 2A, 2B—Photographs taken 14 days after a medi-al canthoplasty was performed in a 5-year-old, male shihtzu. (A) Right eye; the medial canthal area looks rounder,and the palpebral fissure is shorter. (B) Left eye; thehealed incision at the medial canthus is hairless, and thereis no overflow of tears onto the skin.15. Bedford PG. Diseases and surgery of the canine eyelids. In: GelattKN, ed. Veterinary Ophthalmology. 2nd ed. Baltimore: LippincottWilliams & Wilkins, 1999:542-558.16. Petersen-Jones S. The eyelids and nictitating membrane. In:Petersen-Jones S, Crispin S, eds. Brit Small Anim Vet Assoc Manualof Small Animal Ophthalmology. 2nd ed. Quedgeley: Brit SmallAnim Vet Assoc, 2002:90-91.17. Maggs DJ. Conjunctiva. In: Slatter D, ed. Textbook of Small AnimalSurgery. 3rd ed. Philadelphia: Elsevier Science, 2003:1346-1347.18. Munger RJ. Blepharoplastic procedures. In: Riis RC, ed. SmallAnimal Ophthalmology Secrets. Philadelphia: Hanley & Belfus,2002:163-165.19. Stades FC, Wyman M, Boevé MH, et al. Ophthalmology for theVeterinary Practitioner. Honover: Schlütersche GmbH & Co,1998:74-75.10. Carter JD. Medial conjunctivoplasty for aberrant dermis of the Lhasaapso. J Am Anim Hosp Assoc 1973;9:242-244.11. Jensen HE. Canthal closure. Compend Contin Educ Pract Vet1979;1:735-741.November/December 2006, Vol. 42 Medial Canthoplasty Technique 439

Medial canthoplasty for epiphora in dogs: A retrospective study of 23 cases

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Medial canthoplasty for epiphora in dogs: A retrospective study of 23 cases

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