Marsupialization for the treatment of nictitating membrane cyst in a dog: case report

[Marsupialização para o tratamento de cisto em membrana nictitante de cão: relato de caso]

T.B. Lima T.B. Martins D.C. Gomes Junior R.A. Silva D.M.F. Sousa About the authors

ABSTRACT

This study aims to describe the first Brazilian report of a nictitating membrane cyst’s surgical treatment in a dog. A 6-month-old female French Bulldog presented at HOSVET-UNIME with a reddish mass-like structure in the medial canthus of both eyes, with a history of recurrent third eyelid gland prolapse previously treated with two surgeries performed at another clinic. Physical examination revealed a third eyelid gland prolapse in the right eye and a cyst in the left eye’s third eyelid. The animal was submitted to surgical correction of the right eye’s third eyelid prolapse using pocket technique and of the left eye’s third eyelid using marsupialization technique for the cyst’s treatment. 180 days after th1e surgical procedure no recurrence was observed. The marsupialization technique for the treatment of a third eyelid’s lacrimal cyst in a dog allowed the maintenance of its gland and prevented the formation of a new cystic cavity.

Keywords:
canine; conjunctival pocket; third eyelid gland prolapsed; ophthalmology

RESUMO

O objetivo do presente trabalho é descrever o primeiro relato no Brasil de tratamento cirúrgico de um cisto da membrana nictitante em um cão. Um Buldogue Francês, fêmea, seis meses, foi atendido no Hosvet-Unime, com queixa de aumento de volume avermelhado no canto medial de ambos os olhos, com histórico de recidiva de prolapso de glândula da terceira pálpebra, onde haviam sido realizadas duas cirurgias anteriormente em outro local. Ao exame físico, foi observado prolapso de glândula da terceira pálpebra no olho direito e a presença de um cisto na terceira pálpebra do olho esquerdo. O animal foi submetido ao procedimento cirúrgico de sepultamento de glândula da terceira pálpebra no olho direito e uma marsupialização na terceira pálpebra do olho esquerdo para o tratamento do cisto. Cento e oitenta dias após o procedimento cirúrgico, não foi observada recidiva. A técnica de marsupialização para tratamento de cisto lacrimal na terceira pálpebra em um cão possibilitou a manutenção da sua glândula e impediu a formação de nova cavidade cística.

Palavras-chave:
canino; pocket conjuntival; prolapso de glândula de terceira pálpebra; oftalmologia

INTRODUCTION

Nictitating gland prolapse is common in dogs and usually occurs due to a connective tissue fragility, which allows dorsal displacement and glandular exposure, with consequent inflammation (Hendrix, 2013HENDRIX, D. Diseases and surgery of the canine conjunctiva and nictitating membrane. In: GELATT, K.N.; GILGER, B.C.; KERN, T.J. (Eds.). Veterinary ophthalmology. 5.ed. ‎Hoboken: Wiley-Blackwell, 2013. v.2, p.945-75.). Surgical replacement should be performed early to avoid damage to lacrimal production. Several techniques have been reported, such as the conjunctival pocket technique and anchor sutures, which, when correctly performed following a good post-operative care, decreases the chances of complications (Peixoto and Galera, 2012PEIXOTO, R.V.; GALERA, P.D. Avaliação de 67 casos de protrusão da glândula da terceira pálpebra em cães (2005-2010). Arq. Bras. Med. Vet. Zootec., v.64, p.1151-1155, 2012.; Multari et al., 2016MULTARI, D.; PERAZZI, A.; CONTIERO, B. et al. Pocket technique or pocket technique combined with modified orbital rim anchorage for the replacement of a prolapsed gland of the third eyelid in dogs: 353 dogs. Vet. Ophthal., v.19, p.214-219, 2016.), such as suture dehiscence, recurrent gland prolapses, and, rarely, the development of cysts (Hendrix, 2013).

The cystic lesions involving lacrimal tissue may originate from the nictitating membrane’s superficial gland (Moore, 1999MOORE, C.P. Diseases and surgery of the lacrimal secretory system. In: GELLAT, K.N. (Ed). Veterinary ophthalmology. 3.ed. Baltimore: Wiley-Blackwell, 1999. p.569-607.), may be congenital (Lamagna et al., 2012LAMAGNA, B.; PERUCCIO, C.; GUARDASCIONE, A. et al. Conjunctival dacryops in two golden retrievers. Vet. Ophthalmol., v.15, p.194-199, 2012.) traumatic or inflammatory (Hendrix, 2013HENDRIX, D. Diseases and surgery of the canine conjunctiva and nictitating membrane. In: GELATT, K.N.; GILGER, B.C.; KERN, T.J. (Eds.). Veterinary ophthalmology. 5.ed. ‎Hoboken: Wiley-Blackwell, 2013. v.2, p.945-75.). The cyst distends the conjunctiva and protrudes into the palpebral fissure (Barbé et al., 2016).

Treatment options described in the literature include surgical excision of the cyst with the lacrimal gland (Playter and Adams, 1977PLAYTER, R.F.; ADAMS, L.G. Lacrimal cyst (dacryops) in 2 dogs. J. Am. Vet. Med. Assoc., v.171, p.736-737, 1977.), which would reduce quality and lacrimal production in dogs (Saito et al., 2001SAITO, A.; IZUMISAWA, Y.; YAMASHITA, K. et al. The effect of third eyelid gland removal on the ocular surface of dogs. Vet. Ophthal., v.4, p.13-18, 2001.). Therefore, the marsupialization technique consists of creating a communication between the cyst and the external environment, which has been reported in three dogs (Barbé et al., 2017BARBÉ, C.; RAYMOND‐LETRON, I.; MIAS, G.P. et al. Marsupialization of a cyst of the nictitating membrane in three dogs. Vet. Ophthal., v.20, p.181-188, 2017.). The present study aims to report the application of the marsupialization technique for the treatment of a nictitating membrane’s lacrimal cyst in a dog.

CASUISTRY

A 6-month-old female French Bulldog, 6.9kg, presented at the Veterinary Hospital of Unime - Bahia with a reddish mass-like structure in the medial canthus of both eyes, discomfort, and ocular secretion. The owner reported a two-time recurrent gland prolapse of the third eyelid in both eyes after surgeries performed previously for repositioning, with the last one performed two months ago. Based on the reported description, it was concluded that the technique performed was the pocket conjunctival technique in both attempts. The patient was being treated with diclofenac-based eye drops (Still®, Allergan, Brazil), twice a day in both eyes and antibiotic-based ointment with retinol acetate, amino acids and chloramphenicol (Regencel®, Latinofarma, Brazil), three times a day in both eyes.

Clinically the patient was in good condition and physiological parameters were within the normal range. Ophthalmic examination revealed a third eyelid gland prolapse on the right eye (Figure 1.A) and a cystic appearance mass on the eyelid surface of the third eyelid of the left eye (Figure 1B). In addition, a slight euryblepharon was noted, contributing to a larger exposure of the conjunctival surface in the medial canthus. Results of the Schirmer test were 19mm/min OS and 21mm/min OD. No other changes were noted in the other ocular and periocular structures.

Laboratory tests (hemogram, ALT, AP, urea and creatinine) and electrocardiogram were requested, which did not show any abnormalities. The patient was referred for surgical exploration and correction of the abnormalities. Cyst marsupialization (OS), pocket technique of the third eyelid gland (OD) and medial canthoplasty (OU) were used to correct the euryblepharon. Meperidine (Mytedom®), 4mg/kg/IM, was the pre-anesthetic medication used Cristalia, Brazil. The induction was performed with propofol (Propovan®, Cristalia, Brazil), 5mg/kg/IV and maintenance was conducted in a semi-open circuit with isoflurane (Isoforine® Cristalia, Brazil).

Trichotomy of the entire periocular surface was performed and the patient was placed into ventral decubitus position with maintenance of head elevation by padded support. Ocular surface antisepsis was performed with aqueous PVPI-I solution 0.5% (topical 10% Iodopovidone; Vic Pharma, Brazil) (1:20 dilution) and periocular surface antisepsis was carried out with PVP-I at 10%, followed by instillation of anesthetic eye drops composed of tetracaine and phenylephrine (Anestesico®; Allergan, Brazil).

After field cloths were placed, the left nictitating membrane was protracted by stay sutures, using 4-0 nylon (Nylon®, Procare, Medical Co. Ltd, China). The palpebral surface of the third eyelid was then exposed and the contents were drained with a 3ml syringe and a 21G needle. The cyst’s contents were sent for cytological evaluation. A small incision with a number 11 scalpel blade was performed over the cyst. Blunt dissection of the conjunctiva was followed, bordering the hyaline cartilage until the edge of the cyst was visualized. To avoid recurrence, marsupialization was performed, where the cavity edges were sutured to the third eyelid’s conjunctival epithelium of the palpebral surface, with GlycomerTM 631 6-0 (Biosyn, Medtronic, Brazil), in a simple interrupted pattern, in order to maintain a patent opening (Figure 1.C). Continuous, upper and lower lacrimal points were identified and cannulated, delimiting the palpebral margins that were excised. The tarsoconjunctival layer was positioned (medial canthoplasty) using simple interrupted suture with 5-0 nylon (Figure 1.D). The contralateral eye was prepared identically and a conjunctival pocket technique was performed (Morgan et al., 1993MORGAN, R.V.; DUDDY, J.M.; MCCLURG, K. Prolapse of the gland of the third eyelid in dogs: a retrospective study of 89 cases (1980 to 1990). J. Am. Anim. Hosp. Assoc., v.29, p.56-60, 1993.), also followed by medial cantoplasty.

The postoperative prescription consisted of oral 0.1mg/kg of meloxicam (Maxicam®; Ouro Fino Animal Health Ltda., Brazil) once a day for 5 days, tobramycin 0.3% (Tobrex®; Alcon, Brazil) eye drops three times a day for 7 days in the left eye, and ketorolac tromethamine (Acular®, Allergan, Brasil) eye drops four times a day for 7 days, in both eyes, and continuous use of the Elizabethan collar. The drained content was similar to tear due to its physical characteristics and crystallization on a glass blade with a dense lacrimal pattern, presenting several multi-branched crystals, with no empty spaces between them. There were still very rare intact neutrophils and anucleate keratinocytes. No microorganisms were isolated from the sample.

At one week postoperative evaluation the animal had no ocular discomfort or secretion and the surgery site did not present complications. After two weeks the sutures of the canthoplasty were removed and the nictitating membrane’s healing progressed well. At three weeks, the third eyelid remained unchanged. Schirmer test was 22mm/min OE and 21mm/min OD. Clinical evaluation at 180 days and at 1 year after the surgical procedure were performed. Marsupialization in the third eyelid of the left eye was maintained and no recurrence was noticed in both eyes (Figure 1.E).

Figure 1
A- Right eye demonstrating third eyelid gland prolapse. B- Left eye demonstrating a cyst in the third eyelid. C- Intraoperative appearance after marsupialization in the left eye. D- Final appearance of the left eye after the surgical procedures of marsupialization and medial canthoplasty. E- Aspect of both eyes one year after surgery.

DISCUSSION

Lacrimal cyst formation is rare in humans and animals and can occur in any portion containing tear producing glandular tissue (Moore, 1999MOORE, C.P. Diseases and surgery of the lacrimal secretory system. In: GELLAT, K.N. (Ed). Veterinary ophthalmology. 3.ed. Baltimore: Wiley-Blackwell, 1999. p.569-607.). Studies show that in 155 cases of nictating membrane gland prolapse in dogs there was only one report of cyst (Mazzucchelli et al., 2012MAZZUCCHELLI, S.; VAILLANT, M.D.; WÉVERBERG, F. et al. Retrospective study of 155 cases of prolapse of the nictitating membrane gland in dogs. Vet. Rec., v.170, p.443, 2012.). In Brazil, in a series of 67 cases of third eyelid gland prolapse, none observed cystic formation (Peixoto and Galera, 2012PEIXOTO, R.V.; GALERA, P.D. Avaliação de 67 casos de protrusão da glândula da terceira pálpebra em cães (2005-2010). Arq. Bras. Med. Vet. Zootec., v.64, p.1151-1155, 2012.).

Mazzucchelli et al. (2012MAZZUCCHELLI, S.; VAILLANT, M.D.; WÉVERBERG, F. et al. Retrospective study of 155 cases of prolapse of the nictitating membrane gland in dogs. Vet. Rec., v.170, p.443, 2012.) reported a higher occurrence of third eyelid gland prolapse in brachycephalic breeds, including Bulldogs. Of the three dogs that had third eyelid cyst described by Barbé et al. (2017BARBÉ, C.; RAYMOND‐LETRON, I.; MIAS, G.P. et al. Marsupialization of a cyst of the nictitating membrane in three dogs. Vet. Ophthal., v.20, p.181-188, 2017.) two of them were English Bulldogs and one was a French Bulldog, the same breed of the animal in this paper. This condition is mainly attributed to iatrogenic damage of the repositioning procedure of the third eyelid gland through conjunctival pocket technique (Hendrix, 2013HENDRIX, D. Diseases and surgery of the canine conjunctiva and nictitating membrane. In: GELATT, K.N.; GILGER, B.C.; KERN, T.J. (Eds.). Veterinary ophthalmology. 5.ed. ‎Hoboken: Wiley-Blackwell, 2013. v.2, p.945-75.).

It is believed that the higher casuistry of prolapse and relapse in these breeds is due to the their morphological (shallow orbit, euryblepharon and ectropion) and behavioral characteristics, which predispose this occurrence. Consequently, greater local manipulation in an attempt to reposition the gland contributes to cyst formation. However, it can also occur due to trauma caused by surgical dissection or duct inflammation during the postoperative wound healing process (Lamagna et al., 2012LAMAGNA, B.; PERUCCIO, C.; GUARDASCIONE, A. et al. Conjunctival dacryops in two golden retrievers. Vet. Ophthalmol., v.15, p.194-199, 2012.).

The clinical signs observed in the present report were notably ocular secretion, discomfort and a reddish mass-like structure in the medial eye canthus, cited by Barbé et al. (2017BARBÉ, C.; RAYMOND‐LETRON, I.; MIAS, G.P. et al. Marsupialization of a cyst of the nictitating membrane in three dogs. Vet. Ophthal., v.20, p.181-188, 2017.) in 3 dogs with third eyelid cyst. It should be noted that these are non-specific signs and should be evaluated in conjunction with other findings in ocular semiology. Presumptive cyst diagnosis was obtained through direct visualization of the affected eye, especially after third eyelid traction. Nevertheless differential diagnosis should be considered. Among them, epithelial, epidermoid or parasitic cyst, abscess, reaction to suture yarn and neoplasia, which are defined by tear analysis, culture and antibiogram, and histopathological examination (Barbé et al., 2017). Furthermore, history analysis and clinical presentation of a sterile crystallized liquid characteristic of tear marks the basis for a definitive diagnosis, as observed by Barbé et al. (2017).

Lacrimal cystic lesions in human’s conjunctiva can be removed en bloc without significant change in lacrimal quality (Playter and Adams, 1977PLAYTER, R.F.; ADAMS, L.G. Lacrimal cyst (dacryops) in 2 dogs. J. Am. Vet. Med. Assoc., v.171, p.736-737, 1977.). Unlike man, who has the main lacrimal gland and several other attachments arranged along the conjunctiva, lacrimal production in dogs is maintained by the main lacrimal gland (about 60%) and the third eyelid gland (about 40%) (Gelatt and Brooks, 2011GELATT, K.N.; BROOKS, D.E. Surgical procedures for the conjunctiva and the nictitating membrane. In: GELATT, K.N.; GELATT, J.P. (Eds.). Vet. Ophthal. Surg. Elsevier, v.1, p. 157-190, 2011.). Thus, cyst excision along the third eyelid gland can compromise the lacrimal quality in the medium and long term (Saito et al., 2001SAITO, A.; IZUMISAWA, Y.; YAMASHITA, K. et al. The effect of third eyelid gland removal on the ocular surface of dogs. Vet. Ophthal., v.4, p.13-18, 2001.), causing keratoconjunctivitis sicca (Pantaleoni et al., 1997PANTALEONI, F.B.; SPAGNOLO, S.; MARTINI, A et al. Argon laser photocoagulation in the treatment of the palpebral lobe cysts of the lacrimal gland (dacryops). Ophthalmic Surg. Lasers, v.28, p.690-692, 1997.). Therefore, the salvation technique described by Barbé et al., (2017BARBÉ, C.; RAYMOND‐LETRON, I.; MIAS, G.P. et al. Marsupialization of a cyst of the nictitating membrane in three dogs. Vet. Ophthal., v.20, p.181-188, 2017.) was used in this case for lacrimal gland preservation.

Drainage can be performed by aspiration using needle and syringe, with the administration of anti-inflammatory eye drops. However, recurrence is constant (Barbé et al., 2017BARBÉ, C.; RAYMOND‐LETRON, I.; MIAS, G.P. et al. Marsupialization of a cyst of the nictitating membrane in three dogs. Vet. Ophthal., v.20, p.181-188, 2017.). The definitive technique to avoid recurrence is marsupialization, which consists in creating a communication between the cyst and the external environment. This technique is already well described for the treatment of lachrymal cysts in humans with no need of en bloc resection (Playter and Adams, 1977PLAYTER, R.F.; ADAMS, L.G. Lacrimal cyst (dacryops) in 2 dogs. J. Am. Vet. Med. Assoc., v.171, p.736-737, 1977.; Salam et al., 2012SALAM, A.; BARRETT, A.W.; MALHOTRA, R. et al. Marsupialization for lacrimal ductular cysts (dacryops): a case series. Ophthal. Plast. Reconstr. Surg., v.28, p.57-62, 2012.), being described as having been performed in only three dogs to date by Barbé et al. (2017), with satisfactory results. Similarly, the technique used in this case showed great results regarding gland maintenance, lacrimal production and aesthetics, being the first report of this type in Brazil.

CONCLUSIONS

The marsupialization technique for the treatment of lacrimal cyst in the third eyelid in dogs allowed the maintenance of its gland and prevented the formation of a new cystic cavity.

REFERENCES

  • BARBÉ, C.; RAYMOND‐LETRON, I.; MIAS, G.P. et al. Marsupialization of a cyst of the nictitating membrane in three dogs. Vet. Ophthal., v.20, p.181-188, 2017.
  • GELATT, K.N.; BROOKS, D.E. Surgical procedures for the conjunctiva and the nictitating membrane. In: GELATT, K.N.; GELATT, J.P. (Eds.). Vet. Ophthal. Surg. Elsevier, v.1, p. 157-190, 2011.
  • HENDRIX, D. Diseases and surgery of the canine conjunctiva and nictitating membrane. In: GELATT, K.N.; GILGER, B.C.; KERN, T.J. (Eds.). Veterinary ophthalmology. 5.ed. ‎Hoboken: Wiley-Blackwell, 2013. v.2, p.945-75.
  • LAMAGNA, B.; PERUCCIO, C.; GUARDASCIONE, A. et al. Conjunctival dacryops in two golden retrievers. Vet. Ophthalmol., v.15, p.194-199, 2012.
  • MAZZUCCHELLI, S.; VAILLANT, M.D.; WÉVERBERG, F. et al. Retrospective study of 155 cases of prolapse of the nictitating membrane gland in dogs. Vet. Rec., v.170, p.443, 2012.
  • MOORE, C.P. Diseases and surgery of the lacrimal secretory system. In: GELLAT, K.N. (Ed). Veterinary ophthalmology. 3.ed. Baltimore: Wiley-Blackwell, 1999. p.569-607.
  • MORGAN, R.V.; DUDDY, J.M.; MCCLURG, K. Prolapse of the gland of the third eyelid in dogs: a retrospective study of 89 cases (1980 to 1990). J. Am. Anim. Hosp. Assoc., v.29, p.56-60, 1993.
  • MULTARI, D.; PERAZZI, A.; CONTIERO, B. et al. Pocket technique or pocket technique combined with modified orbital rim anchorage for the replacement of a prolapsed gland of the third eyelid in dogs: 353 dogs. Vet. Ophthal., v.19, p.214-219, 2016.
  • PANTALEONI, F.B.; SPAGNOLO, S.; MARTINI, A et al. Argon laser photocoagulation in the treatment of the palpebral lobe cysts of the lacrimal gland (dacryops). Ophthalmic Surg. Lasers, v.28, p.690-692, 1997.
  • PEIXOTO, R.V.; GALERA, P.D. Avaliação de 67 casos de protrusão da glândula da terceira pálpebra em cães (2005-2010). Arq. Bras. Med. Vet. Zootec., v.64, p.1151-1155, 2012.
  • PLAYTER, R.F.; ADAMS, L.G. Lacrimal cyst (dacryops) in 2 dogs. J. Am. Vet. Med. Assoc., v.171, p.736-737, 1977.
  • SAITO, A.; IZUMISAWA, Y.; YAMASHITA, K. et al. The effect of third eyelid gland removal on the ocular surface of dogs. Vet. Ophthal., v.4, p.13-18, 2001.
  • SALAM, A.; BARRETT, A.W.; MALHOTRA, R. et al. Marsupialization for lacrimal ductular cysts (dacryops): a case series. Ophthal. Plast. Reconstr. Surg., v.28, p.57-62, 2012.

Publication Dates

  • Publication in this collection
    06 July 2020
  • Date of issue
    May-Jun 2020

History

  • Received
    19 Sept 2018
  • Accepted
    07 Aug 2019
Universidade Federal de Minas Gerais, Escola de Veterinária Caixa Postal 567, 30123-970 Belo Horizonte MG - Brazil, Tel.: (55 31) 3409-2041, Tel.: (55 31) 3409-2042 - Belo Horizonte - MG - Brazil
E-mail: abmvz.artigo@abmvz.org.br