Entropion and disorders of dogs eyelids

Chalazion or Tarsal Gland Adenoma

Question: Dear Dr. Mike: Lucy has a round, raised growth of some sort form on the inside of her upper eyelid which is dark brown, almost black in color (about 1/8" in diameter). There is also something like a skin tag (black in color like the edge of her eyelid) which is very small, but can be seen from the outside - it almost seems to be an extension of this growth. All of this appears to be rubbing on her eye causing irritation and redness to the sclera. She also has some milky/yellow discharge. She was seen by our vet about 1 1/2 weeks ago and he felt that she has a chalazion, although a bump is not visible when looking at the exterior of her eyelid. He gave her an eye ointment containing neomycin and polymyxin B sulfates and dexamethasone. We applied this twice a day for 5 days. Some of the redness and the discharge had lessened, but as of today, it`s still present, just less severe. We discussed this with our vet last week and he said that we should stop using the ointment. He said that he felt that it should be surgically removed, however he`s apprehensive about surgery (as am I) because of her long-standing elevated liver values associated with Cushings, in addition to the fact that she is now 12-years-old. Her liver is severely enlarged. Her Alk Phos is 4,000-5,000 (extremely elevated), her ALT is somewhere around 450. He said that we could monitor the growth and see if it enlarges or becomes more irritating and abrasive. His concern is that it could scratch the cornea or cause an ulcerated cornea. My questions to you are: 1) Does a chalazion look like this on the underside of the eyelid (brownish-black)? If this is not how it typically looks, what else could it be? 2) Can a chalazion cause any serious problems to the eye? How serious can they be? 3) Do they tend to get bigger? 4) Are they normally surgically removed or do they go away on their own? 5) What is your knowledge of experience of risks of surgery (anesthesia) due to elevated liver enzymes and enlargement of the liver? What would be the risks or complications? Are they common? What could lessen the risks? 6) Do you feel that it would not be advisable to perform surgery because of the issues with her liver? 7) What are some alternatives to surgery (because of the anesthesia)? Thank you once again, Karen

Answer: A chalazion is a painless, hard consistency, white to yellow in color when viewed through the pink tissue of the inside of the eyelid. They usually are a few millimeters in diameter and do not grow. They are treated by making an incision into the swelling and scooping out the contents. They usually don`t grow in size after they get hard. They can usually be ignored without too much consequence but sometimes they do seem to irritate the cornea. I think that it is more likely from your description that Lucy has a tarsal gland adenoma. These are the most common eyelid tumors in dogs and they look more like what you are describing. Tarsal adenomas tend to keep growing, often appear to be growing right through the eyelid (so they are visible on the inner and outer surfaces) and are more likely to form a lump of tissue that irritates the eyelid. Other tumors grow on the eyelids sometimes, too. Squamous cell carcinomas, melanomas, and sebaceous hyperplasia can occur on the eyelids. These are less likely to be the problem, just based on occurrence rates, though. Sometimes there are tarsal adenocarcinomas, which are a malignant tumor similar to the more common benign tarsal adenomas. Tarsal adenomas often grow slowly but they aren`t going to go away in most cases so it is best to remove them when they are irritating the cornea. I`d try to be sure that this was the case and that there wasn`t another contributing problem, like deficient tear production, before making a decision to do surgery in a case like Lucy`s where there are complicating factors, though. I do think that the high liver values are reason for concern when anticipating a surgical procedure. It is usually possible to anesthetize patients successfully even when the liver isn`t functioning very well if the anesthetic agents are carefully chosen. I think that I`d want to try to find out what was causing the rises in liver enzymes. First I`d ask about medications that might be in use that might be causing rises in liver enzyme levels (cortisones and anti-seizure medications are the prime suspects). If I wasn`t comfortable doing a biopsy and X-rays were relatively normal, I think I might refer a patient for ultrasound examination, perhaps with an ultrasound guided biopsy if that seemed feasible during the US exam. I might try doing a bile acid response test prior to referral for ultrasound, on the theory that if the bile acid response test was normal there was adequate liver function to proceed with surgery -- in which case I might be willing to try to obtain a surgical biopsy sample. We do a blood clotting test prior to doing surgery when the liver function is questionable since liver disease can interfere with blood clotting (this is especially true if we intend to do a liver biopsy). If liver function seemed OK on the bile acid test I think I`d test for Cushing`s disease just to be sure it wasn`t the cause of the elevations in liver enzymes. If Cushing`s disease wasn`t present I`d be a lot more likely to want to have some sort of diagnostic test of the liver -- the ultrasound exam, some sort of biopsy, possibly surgical exploration combined with a biopsy. Eyelid surgery is usually a very quick procedure once a surgeon learns the basic techniques for doing surgery on eyelids. If it was possible (surgeon and ultrasound at the same place -- or a plan to do surgical biopsy from the start) I would be comfortable combining the diagnostic procedures for the liver with the eyelid surgery but not all vets would be. It is sometimes possible to freeze eyelid tumors (cryosurgery) but it is still necessary to have a sort duration of anesthesia, I think -- or an extremely cooperative patient. I have some clients who choose not to try to make a diagnosis on a liver problem but still want me to do surgery to correct things that are causing disability or discomfort. I am willing to do this most of the time (judgment call) and we have good success getting through surgical procedures despite known liver impairment. I`m a lot more comfortable when I know what is wrong with the liver, though. Mike Richards, DVM 10/15/2002

Entropion surgery recovery

Question: I picked up a stray with eyes swollen almost shut up a week ago Friday. The vet`s diagnosis was Entropion for which he prescribed salve until I could bring her in for surgery last Thursday (3 days ago). One eye looks pretty good but I`m afraid my vet may have over corrected on the other. Do you think there is still swelling that may go away and if a correction is needed, what is the usual procedure? She is due to go back to have the stitches out next Thu. or Fri. and I guess we`ll know then. She`s a little Chow mix about 15 months old. The vet even mentioned he hoped he did not correct too much when I took her in Friday (the day after surgery) to look at her. Thank you for your kind attention, Dixie

Video: Canine Entropion Surgery, "Mama" the homeless dog

Answer: Dixie- For the first week or so after entropion surgery there can be enough swelling to make it difficult to decide how well the surgery worked. After that it takes a little while for the eyelid healing to reach its greatest strength. It is usually best to wait at least three or four weeks before deciding that entropion surgery didn`t work or to worry about over correction problems. Good luck with this. The odds are pretty good that it will turn out OK. Mike Richards, DVM 6/19/2000

Entropion

Q: Dear Dr. Mike, I`ve read all I can find about canine entropion on the Internet, but I haven`t found much. I want to get as complete an understanding as possible of the causes and effects of, and the remedies for, entropion. Would you explain, please, what causes the eye lids to turn inward in the first place? It`s easy to see that if the lashes rake across the eyes, they`ll irritate and eventually wreck the patient`s corneas. But does it also work the other way? -- does the irritation also tend to worsen the entropion? If so, how, exactly? What causes the cornael pigmentation sometimes seen with entropion, how is it treated, and what`s the likelihood for eliminating it? What are the surgical options for treating entropion, including "tacking"? Benefits and risks of each? I`d be very grateful to receive your answers to these questions or to have a pointer to a thorough on-line paper on this important health issue. Best regards, A. D. Thailand

Video: Dog Eyelids Comparison

A: A.D. The causes of entropion vary somewhat by the breed of dog (or cat) affected by the condition. In shar pei dogs, the weight of the folds and tissues around the eyes leads to entropion. This may also be the problem for chows. In other breeds the problem is thought to be insufficient muscle mass (improper development) of the muscles in the lid, leading to weakness and the tendency to roll inward. Obesity, scarring from injury and skin infections and probably other stuff all can cause entropion. We have seen it a couple of times as a sequelae to temporomandibular myositis, too. In cats, most of the entropion problems we have seen have occurred after severe viral ocular infections (rhinotracheitis usually). Corneal pigmentation seems to be a defense mechanism against chronic irritation. I am not sure why this occurs but it happens in skin as well as eyes. If you look at dogs with chronic skin disease most of them have increased skin pigment, too. I suppose that it is a general "all purpose" response to chronic irritation. It does not always clear up but there can be considerable improvement with correction of the entropion. Using corticosteroid eye drops AFTER making sure the problem is corrected and the cornea is not ulcerated can speed up the recovery process. I think that irritation does tend to worsen the entropion because it makes the lid thicker due to inflammation, which can make the problem worse. Once in a while we have dogs and cats with very mild entropion who do OK as long as we use anti-inflammatory eye medications occasionally. This doesn`t happen often enough that anyone can count on it working, though. The only times in which tacking is very successful are in puppies of the breeds in which lid and facial fold thickness lead to the entropion formation. If the eyelids are tacked into proper position early there is a good chance of avoiding entropion. This works for sheep, too. It is conceivable that this might help in some trauma situations but I haven`t had the opportunity to try this, or at least I don`t remember trying it. Surgical correction of entropion is a simple surgical procedure. Unfortunately, there is a fair amount of "art" in this surgery, despite the relative ease of the surgery itself. There are several surgical approaches to the condition, depending on the position of the entropion and severity of the entropion. In the most common procedures a small amount of the lid is removed and the skin and subcutaneous tissues sutured to shorten the lid. This produces a proper orientation of the lid if done well. Estimating how much skin to remove is the tricky part. It is generally accepted that it is better to remove too little and do surgery twice than to remove too much and then try to fix the problem of ectropion (a lid that tilts outward). Surgery is by far the best solution to most cases of entropion. Surgical treatment also entails anesthetic risk. This is not a surgery that requires great depth of anesthesia, so it is a little safer than some surgeries, in that regard. The other option is medical treatment of the irritation. But this is a never ending process since there is an underlying cause that is not being corrected. There has to be a really good reason not to consider surgery for this to be a reasonable option. If you tell me the breed of your dog or cat and can tell whether the upper lid, the lower lid, or both lids, are affected, I can probably give you additional information that is more specific. Mike Richards, DVM 9/25/99

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