Kiełbowicz Zdzisław, Paczuska Joanna
Department of Surgery, Faculty of Veterinary Medicine, Wrocław Univeristy of Environmental and Life Sciences, 50-366, Wrocław, Poland
An eight-month old female American Staffordshire Terrier was referred to the Department of Surgery at the Faculty of Veterinary Medicine, Wroclaw University of Environmental and Life Sciences. Initial ophthalmic examination revealed bilateral distichiasis. Multiple cilia were removed with CO laser by follicle ablation in the non-contact mode. CO2 laser distichiasis ablation is an interesting alternative to conventional methods of treatment, allowing fast cilia removal with minimal traumatization of the eyelid margin and good tolerance by the patient.
The presence of extra cilia or eyelashes is a common condition that occurs in dogs, rarely observed in cats. In distichiasis the cilia emerge from the area of meibomian or tarsal glands. More commonly affected breeds are American and English Cocker Spaniel, English Bulldog, Toy and Miniature Poodles, Boxer, St Bernard, Golden Retriever, Long-haired Miniature Dachshund, Alsatian, Bedlington Terrier, Shetland Sheepdog, Yorkshire Terrier, Staffordshire Bull Terrier [3,5,7]. Clinical signs are related to prolonged irritation of the eye bulb by abnormal cilia. Lacrimation, epiphora, blepharospasm and conjunctival hyperemia can be observed. Other clinical signs like eyelid swelling or corneal injuries are related to excessive scratching of the irritated eye. In some cases distichiasis is irrelevant and will not lead to clinical symptoms [3,5,8]. Diagnosis is based on clinical examination under bright light and at magnification, examination with fluorescein can be also a valuable test for cilia highlighting. Clinically relevant distichiasis should be treated as a temporary solution by a manual epilation or a permanent destruction of the follicle [3,5,7]. Available methods of treatment like cryotherapy or electrolysis can be ineffective when most of the eyelid margin is affected. In those cases surgical excision using a wedge resection is recommended, however it can lead to scar formation or ectropion.
An eight-month old female American Staffordshire Terrier was referred to the Department of Surgery at the Faculty of Veterinary Medicine, Wroclaw University of Environmental and Life Sciences. The owner reported that the dog had had wet and itchy eyes for approximately one month and had been treated for conjunctivitis by the referring veterinarian with topical gentamycin drops applied 4 times daily for 10 days with no improvement noted.
Clinical examination revealed conjunctival hyperemia in both eyes and blepharospasm in the left eye. The examination of adnexa under focused light revealed multiple distichiae in the upper and lower eyelids in both eyes (Fig 1).
Irritation of the corneal surface was observed especially due to cilia growing from the right upper eyelid canthus. The examination of corneal surface with fluorescein didn’t reveal ulceration. Surgical removal of the distichiasis was recommended.
Preanesthetic sedation was obtained with medetomidine 10µg/kg body weight with butorphanol 0.1mg/kg injected intramuscularly (IM). Anesthesia was obtained by intravenous (IV) injection of propofol in 4 mg/kg dose. Analgesia was obtained by metamisolum 30mg/kg IV and meloxicam 0.2mg/kg IM. The cornea and the eye bulb were covered with carbomer gel and moistened gauze. The distichiae were removed with CO2 laser with Flexible Fiber Waveguide beam delivery (Aesculight). Distichia ablation was performed in the non-contact mode – perpendicular to the eyelid margin (Fig. 2)
Using a 0.4 mm spot diameter tip and single pulse mode – 200 mSec and 4W power output. For each cilia 3 single pulses were applied. No bleeding or swelling was observed (Fig. 3, Fig. 4).
Oxytetracycline with hydrocortisone acetate ointment was recommended for 6 days, three times daily.
A postsurgical check was performed after 10 days. Complete incisional healing with areas of depigmentation was found. No blepharospasm, hyperemia or deformations of an eyelid margin were observed. The owner did not notice any discomfort, mild discharge was reported during the first two days after surgery. The animal did not attempt to scratch the wounded area.
One year after the surgery the owner noticed that the dog started scratching the right eye; mild hyperemia was observed. Ophthalmic examination revealed areas of hypopigmentation and recurrence of distichiasis in both eyes, no deformities of the eyelid margin were found. The same surgical procedure was repeated. No recurrence of distichiasis was observed 4 months after the surgery.
Ophthalmology was one of the first fields in which laser treatment was applied. In 1961 Charles J. Campbell treated the first clinical patient using a ruby laser in advanced retinal angiomatosis . Since then technology advancements have resulted in many laser systems development with different light waves and therefore different fields of its applications in ophthalmology . Therefore CO2laser enables precise cutting and ablation of eyelids and conjunctiva and is used mainly in extraocular surgical procedures. No difference is seen in the long-term results between CO2 laser and scalpel incisional blepharoplasty, additionally the use of laser results in less bleeding and ecchymosis and less swelling .
Distichiasis is still a problematic condition to treat. Time consuming surgical procedures can result in eyelid deformation or recurrence in a relatively short time from the surgery. The most commonly used techniques in the treatment of distichiasis are cryoepilation and electrolysis, however both techniques can be ineffective in the case of multiple cilia along the eyelid [3,6,8]. Less postoperative inflammation after CO2 treatment compared with cryosurgery, less bleeding and swelling than with scalpel incision, along with the possibility of multiple cilia ablation refer this tool as a promising alternative to conventional methods of distichiasis treatment . Multiple distichiasis observed in the presented case was the reason for the decision about CO2 laser ablation of the cilia. It should be noted that the healing process and cosmetic effect after CO2 laser treatment always depends on proper surgical technique as excessive power densities will result in collateral thermal damage, edema, fibrosis and/or eyelid contour abnormality. Although recurrence has occurred, the time of clinical sings reappearance was longer compared to other methods in which recurrence usually occurs after 4-6 weeks. In conclusion CO2 laser distichiasis treatment is an interesting alternative to conventional methods of treatment, allowing fast cilia removal with minimal traumatization of the eyelid margin and good tolerance by the patient.
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