Thank you very much for that warm introductions, Bruce. Welcome everyone to tonight's seminar about eyelid surgery. My contract with the webinar vet stipulates that I may disclose any conflicts I have, so lawyers would call this disclosure, I just call it shameless advertising.

But lots of the pictures that I will be showing today are taken from the book mentioned by, Bruce Slatter's Fundamentals of Veteranphthalmology, which I'm honoured to co-author. The latest edition came out some 6 months ago, a chapter about eyelids and chapter about salic surgery, and lots of the pictures will be seeing today, are from this book. I know anatomy is no one's favourite topic, so just one slide to remind us about the anatomy of the eyelid, so we know, we'll be familiar with the tissue that we're cutting.

So really an eyelid is composed of four layers. We have the skin here as the outermost layer. Then we've got a muscle layer beneath it, the orbicularis oculi muscle that we use for lining for shutting our eye.

Behind the orbicularis oculi muscle, we've got a tarsal plate you can see here in brown, that's a very dense connective tissue that helps you keep the eyelid in shape, maintain its shape, otherwise it will just be a flaccid piece of skin really. And the innermost aspect of the eyelid is the palpiro conjunctiva. So those are the four layers we'll be looking at today, the skin, the muscle, the tarsus, and the innermost conjunct.

Right, the first problem I want to discuss is entropion, probably one of the more common eyelid procedures you'll be doing, and we can see here a case of entropion inversion of the lower eyelid, causing eyelashes and facial hair to come in contact with the ocular surface. The inversion that defines entropion, may be anything from mild to severe ranging from 45 degrees all the way to 180 degrees as you can see here, and the degree of inversion, the degree of entropion is really influenced by the length of the eyelid, fissure, orbital anatomy, skull conformation, facial skin folds will be. Touching on all of these topics and for those of you who are interested in mechanisms, then really the cause of entropion is difference in tension between the malarious muscle muscle shown here and the orbicularis oculi muscle shown here and C and the difference in tension between the two causes the inversion.

Entropion may be secondary and when we're talking about secondary entropion, we're talking about either spastic entropion, we'll come back to spastic entropion later but it's really sort of a snowball effect, you squint. Because something is irritating your eye, you squint really hard. Some of the eyelids starts enrolling just a bit, and then you have eyelashes irritating the cornea, so you squint even harder and it becomes more and more severe again or a snowball effect that will come back later, maybe be caused by Scarring, a cat claw that injured the eyelid and, the eyelid doesn't heal properly.

The scar tissue will cause entropion, but in dogs it is usually an inherited disease, though the extent and location vary with breed, . As you can see here, we can have entropion affecting the entire lower eyelid in some breeds, the lateral part of the eyelid in other breeds, the medial part of the eyelid, especially in brachycephalic. Breeds, that's a point we'll come back to later.

Lower lead, upper lead. You can see, as I said earlier, that the extent of the entropion is affected by the lead fissure length by the skull conformation, and that's what you are seeing here, the effect of breed on the type of entropion that you are presented with. What would be the clinical signs of entropion?

Well, obviously it's a very painful condition. Any of us who had, one eyelash rub our cornea know how painful it can be. So obviously a whole row of eyelashes will cause pain, which is what we're seeing here.

You can see the rolling of the lower eyelid. You can see the hairs coming in contact with. Ocular surface.

As a reaction to that, we have retraction of the globe, what we call an ophthalmus. The third eyelid comes up passively to protect the cornea and as you can see, as a result, the cornea is protected, but the third eyelid is highly, highly irritated. So leftrospasm and secondary enophthalmus in this picture on the left.

Obviously, you will have lots of corneal irritation, ulceration or inflammation. We can see all of that here. We can see edoema, we can see vascularization, we can see a big ulcer, and here in the lower eyelid, we can see the sutures that were used to correct the entropion, the surgical correctment of entropion that caused all of these corneal pathology that we're seeing here.

Obviously there is pira, there is tearing cause there are, the hair is irritating the eye and we get a secondary tearing. We may have inflammatory discharge, and if the eyelid is rolled enough, it rolled in for a long, long time, then you'll even have discoloration of the lid just from the constant irritation of the skin, such as the picture you are seeing on the right. I mentioned the iphora here, the secretions that we see in entropion.

This may be more severe in all of the miniature dogs, ni breed dogs, and I'm sure you're all familiar with this presentation of a tear stain in miniature breed dogs, and here really the tearing is caused by two mechanisms. First, there is the irritation of the cornea by the facial hair, but also, these breeds suffer, as I mentioned earlier, from a medial entropion of the lower eyelids. The medial part of the eyelid is where the lower puncta, the nasolacrimal puncta, is located.

So really when you have a nasal entropion, you, the dog is, hit with two, is facing two problems. Number one, Hair is irritating the cornea. Number 2, the lower poncta is obstructed because it is rolled inwards.

It's not draining any tears and therefore you get the excess tears that are produced are not drained to the nasal lamo that. They are staining the face and the presentation. So how do we treat these guys?

Well, if it's a young dog, then really temporary attacking may be the solution that you wanna exercise and when you have such a little of sharp pace coming into your clinic, I think you can already, you're already confident that you won't have to worry about mortgage payment at the end of the month, but really for this bunch of sharp pace, temporary tech would be the way to go. You don't want to start removing skin and taking them into surgery, until they've completed their growth and you know the final status of their skull con confirmation, eyelid confirmation, etc. Etc.

So especially in sharp pas, especially in chows, we would go with temporary attacking using either staples such as you're seeing in this picture here or vertical mattresses without or with tension relief as it says here, this will delay the surgery . Because the dog is no longer painful and you can delay the surgery until it completes its growth and you know the final anatomy and disposition of the eyelids and sometimes it may even resolve the problem and here I come back to what I mentioned earlier, that part of the entropion is spastic. So if you Resolve the spastic component of the entropion with this temporary tacking, sometimes it may resolve the problem if I may go back to these 6 sharp pace that you're seeing here, they come into your clinic, you do temporary tacking for all 6 of them.

They'll come back probably in 4 to 6 weeks because they will grow, their skin will stretch and the staples or the sutures that you place will have fallen out, but when they come back, maybe. One or two of them outgrew their entropion and maybe they will not need further surgical intervention because it sold the spastic component, the dog continued growing and the lids maintained regained their proper anatomy, so you re-tack only 4 of them, they'll come back in another 6 weeks, maybe 1 or 2 more resolved, and you'll end up doing a. The definitive surgery just one or two dogs.

So yes, tacking may delay surgery because it removes the pain or it may resolve the problem. If you didn't resolve the problem, then you have to go into the permanent repair and the permanent repair is most commonly used by people is the modified hot cells' technique. The aim of which is to restore the eyelid from its inverted position to the proper anatomy of alignment between the eyelid margin and the corneal surface.

And really the most critical part of the surgery, is to decide beforehand how much to cut, how much skin am I going to remove. And for that, again, I, go back to a point I made earlier that whenever you're looking at roon, you are really looking at the growth entropion. To it.

When you are seeing it ron, it is really composed both of the original atomical component, the hereditary component, if you will, and it also has aplastic component overriding it cause, when, as I said earlier, when the dog squints, you will have more severe pain and more enrolling as a reaction. Obviously our aim in surgery is to resolve only the anatomical entropion. If you resolve the entire gross entropion that you're seeing, then you will be really creating overcorrection or tropion such as you are seeing here.

So really our first challenge when looking at the dog with entropion such as this guy here is to differentiate between the anatomical component of the entropion which I want to correct and this passive component which is secondary and which will resolve itself once we've corrected the anatomical one. So, and the easiest way to do it is applying topical anaesthesia to enhance. Sedated patients so that you see the real anatomy, you apply topical anaesthesia, neutralise the special component, and once you've applied it, then you're really left just with the anatomical component that is what you are going to correct.

Other techniques to help you evaluate how much skin to remove is just to roll the lid outwards. You'll see it in the next slide to, rolling the lid out to see how much aversion is needed to restore, the al to its correct anatomy. The amount of li discoloration that I mentioned earlier will also help you in evaluation.

Obviously this shows you exactly the. Of the entropion in this sky. And remember, if you're not Not sure it's always better to undercorrect, rather than overcorrect, for two reasons.

Number one, undercorrect, there will be some additional correction due some additional inversion due to secondary retraction and if you didn't correct enough, it's easier to go back in again and correct an entropion rather than an entropion that you are seeing here. So how much to cut? We've placed anaesthesia, we can roll out the lid using our fingers to see how much lead are we rolling out to restore the proper anatomy.

And when I say proper anatomy, I mean to restore the alignment of the eyelid margin too. The ocular surface to the corneal surface, you can grasp the excess folds with your Alice forceps or even use what we call blood staining. Make the first incision, let the entropion roll back in and see how much of it is stained with blood that will tell you where to make the.

And on all of these methods are valid to estimating the amount of entropion you are going to correct. I said that estimating how much skin to remove is the most critical part of the surgery. There is actually one more important part, and that's where are you going to place your first incision and the answer is 2 to 2.

5 millimetres from the lead margin. You don't want to place it too close to the lead margin because then you won't have enough skin to pass your needle through, so you want to leave at least 2 2.5 millimetres, but you don't want to place the Incision too far because if you make the first incision here, for example, and then a second one even further down, then suturing the two will not cause a version of the eyelid margin, which is our aim in surgery.

So not too far, not too near, 2 to 2.5 millimetres, use a Jager lead plate, both to protect the eye, the. Cornea and the ocular surface and to give you tension so you can cut and the upper lip pate and then you make a second incision in the shape of a banana or a crescent and the distance between the first and the second incision is your original estimate of the anatomical hereditary component of the entrochial.

We extend the incision 1 millimetre medially and laterally to the extent of the entropion. Remember I said that not all entropions will necessarily involve the entire length of the eyelid. They may be lateral, they may be medial, so you just want to correct that part of the eyelid that is affected plus 1 millimetre on both sides and We remove the skin and the subcutaneous tissue, it's an open debate whether or not you want to remove muscle tissue or not.

It doesn't, if there hasn't been any scarring, this is probably er. So these are, this is what your two incisions would look like in a drawing again, 2.5 millimetres from the eyelid margin that you can see here, just enough to pass your needle, and this is what it actually looks like in a dog.

And then it's time to suture, two ways to go about it. Either the halving method shown here, place the first suture in the middle and then halving the distances, or, the second method, proposed by Franztade, I'll mention him again, a very respected eyelid surgeon. From Utrecht in the Netherlands, he proposes that you first place the two, extreme sutures on the medial and on the lateral side just to define the edges of your surgical field and to avoid misalignment and gaps later and then use the half.

Silk is often used in eyelid surgery, simply because it is very soft, we can fold it. It is very soft, it gets into the eye, it is far less irritating than nylon. And you can also fold it away and extend it away from the cornea to make sure that it doesn't come in contact with the cornea.

So you'll find many ophthalmologists using silk to suit your eyelids. To the horror of many of our soft tissue surgeons, and this is what the final result would look like. And again, as I said, the silk is pliable.

You can turn it away from the eye from the eyelid margin, and it will stay away. Right, so that's entropion and the opposite of entropion is entropion, . Entropion was inversion of the eyelid margin.

Ectropion is inversion rolling out of the eyelid margin, and we can tell that this dog would have an ectropion because we can actually see orifices of the my bone gland open of the myboin glands, which we don't normally see, and the result is. And exposed quantum type sack as you can see here, this is dead space for accumulation of debris, so we will have inflammation, we'll obviously have interference with the blinking and with tear and tear film and highly function. So maybe not as painful and damaging to the cornea and tracheon, but definitely an anatomical problem that we have to resolve.

And another way to look at roon if I go back to mechanisms is really if you think about it, ectropion is due to an elongated eyelid. Look at this picture and you'll get And a feeling for what I mean by an elongated eyelid. Obviously, if this dog had an eyelid with a proper length, it would sit here.

Because it is elongated, it falls down and it is averted and it exposes the quantum tidal sack. Normal eyelid length should be 33 to 35 millimetres. This guy probably has 15 millimetre of lower eyelid length, and that's why it falls out.

We call it macrolepharone or urlephone. How do we correct the tropeion? Well, we want to restore the eyelid to its proper length to about 33/35 millimetres.

So, if it is a slight tropeon, we, it is more such as this guy here, it is most easily corrected by the wedge, resection, the wedge resection. Shown here we make an incision shaped in in the shape of a triangle again using a jagger literally to protect the cornea and giving us tension and something to cut against then you remove the piece of Of eyelid, full thickness and then you have to suture the defect you have created and again prior to surgery, you measure the desired eyelid length so you know how much eyelid to remove. Suturing is done in two layers in this case.

The first layer is the tarsoonjung I layer. Again, I remind you of the eyelid anatomy, so I'm talking the first suture is placed to oppose the. Inner two layer, the tarza plate and the quantum tiva and this was suture with a 5 odd or smaller absorbable suture.

You can do a horizontal mattress with a buried suture for acquisitioning and just continue with simply interrupted or continuous. Nothing fancy about the inner layer of the two except the fact that you have very fine suture material. The second layer is where it gets a bit trickier.

Second layer, I mean, we are now suturing the outer two layers, the skin and the muscle layer. And here suture. Placement is critical because you want to achieve perfect alignment of the eyelid margin.

And in order to do that, we have what we call a figure of 8 suture that you can see here, but I'll go through the steps. Basically you go in through the skin on one side, come out the stroma, come out the muscle on the same side, through the stroma or the muscle on the opposite side of the incision. Out through the eyelid margin right through the my boing gland opening.

I'll come back to that in a minute. On this side, look to the my boing gland opening on the contralateral side. Out through, sorry about my mouse here, out through the muscle, through the muscle of the opposite side and out of the skin, and you have created a figure of 8 which if done properly, will create a perfectly alignment.

And when I say if done properly, what it means is that this should be parallel to this, the needle passing through the muscle. On this side should parallel the needle passage on the other side. And most critical of them all is the fact that these two are on equal distance on both sides of the incision.

And to help to make sure that you're on equal at equal distances on both sides of the incision, use the my boing gland openings. That's another reason we have myboming gland openings. It's not just To secrete my bomium.

It's also to help us properly place sutures when doing eyelid surgery. You want to actually count my boing gland openings on both sides of the incision and make sure that the suture passes through equal distance, equidistant my boing land openings on both sides. Here are a couple of examples showing you what happens if you don't do it properly.

So, here the suture on the right side passed through the my bombing land opening and the suture on the left side did not, it's right at the margin and this is the result and misalignment along this axis of the eyelid. Here on this example, we have the suture passing through the 2nd or my boing land opening on this side, but the 3rd on the other side, and we have this kind of. Malignment.

So I think this is something I always stress to my interns and my residents. If you're not happy with the alignment of the sutures, take out the suture and pass it again and again and again until you have perfect alignment, perfect figure of weight, giving you perfect eyelid alignment. So this first suture is critical, then the rest are simple interrupted and another trick I like doing is showing here, cut very, very long sutures for the figure of 8 and all subsequent sutures and then grab all of these long suture ends with your last suture shown here.

So you use last suture not just place it here but also to grasp the ends of these sutures. Come in contact with the cornea and the ocular surface and again, this is what it looks like. Here we are doing the wedge resection, removing full thickness eyelid in the shape of a triangle and suturing nice eyelid alignment here, margin alignment here, and again, the last suture is used to grasp.

Sutures. I would make a note, a small digression here and note that this is also the technique that we use to repair eyelid laceration. Here we are seeing an eye lacerated eyelid, huge laceration going extending all the way out here.

This has also been repaired by a figure of 8, giving. This nice alignment here. Another point make when talking about eyelid laceration is please make this your first suture because we care about eyelid margin alignment and then you can feel the rest of the defects using simply interrupted.

There may be misalign. And later, we don't care about this. I know that other soft tissue surgeons approaching other lacerated tissue would place their first suture here because they're worried about misalignment and gaps here.

We don't care about gaps here. We care about alignment of the eyelid margin. So that's how we repair a mild case of tropeon just with a simple wedge resection.

If we have a more moderate case, then we need other techniques and the two that are most commonly used are what we call the V2 Y the plasty. Here we have a dog with an obvious. We make a triangle in a shape of a V following undermining and then we start suturing, turning the V into a Y as shown here, so you first place a few sutures.

In a straight line making the base or the vertical part of the Y, the height of the Y is the amount of the aversion that we are going to correct plus 2 millimetres and then completing the suturing with a V turning a V8 into the two arms of the Y. Sorry, so we've turned a V into a Y and removed the excess skin. So that's one technique and a second technique and actually one that is probably more commonly used is the modified modified, sorry, KuniManovsky technique.

Shown here, the advantage of this technique as opposed to the other techniques, technique I've shown you is that we do not involve the eyelid margin as we did here. We do not split the eyelid margin. We make our first incision here about a couple of millimetres away.

We split the eyelids again into two layers, the outer skin and mass layer. This picture has been flipped on purpose because we're looking at the eye out of it, so we split the skin and muscle layer as an outer layer. We have the tarsus and the conjunctiva as an inner layer and what we are doing here is removing the piece from the.

Inner arsal conjuncti layer at the centre of the ectropion and an equal piece of skin and muscle quite a distance at the edge of the incision here and then we suture. The advantage of this is that we don't place all of the tension just at one spot. This incision involves only two layers.

The tarsal and conjunctiva, this incision would include the skin and the muscle, so not all of the tension has been placed here. We've still got intact skin and muscle here, and that would, probably give us a better chance of success rate. So that's what we would use for a more severe case of ectropia.

Unfortunately, as I said, many ectropions are, or most ectropions are really, hereditary. And it means that sometimes we are faced with even more severe cases that can't be repaired with a modified conimanovski technique, and I'm talking mainly about giant breeds like the San Bernards and the Great Danes and other dogs that present with what we. Call a pagoda eye or a diamond eye simply based on this presentation which involves an entropion of the central portion of the lower lid and there is also a notch in the centre of the upper eyelid and entropeon in the lateral and medial parts of the eyelids.

So we've got A severe entropion, notching of the low of the leads and entropion at both ends at both natural and medial ends and . This presents more of a challenge to repair because actually we are not looking just at a simple entropion entropin combination at this breed at this breeds, in addition to having the elongated upper and lower lids that cause the pagoda eye, they also suffer these dogs also suffer from a weakened lateral palpibral ligament. That gives the eyes its overall shape.

So just repairing the extent of the just measuring IV length and repairing the ectropion. Oh So these guys, you also have to address the problem of the lateral febrile ligament, and there are various techniques out there. Again, I refer you to various textbooks, .

That address this problem and as you can see in each and every of the techniques that have developed here, we are recreating a lateral ligament by placing non-absorbable sutures here. Likewise, we are doing it here. Likewise we're doing it here.

So lots of various techniques, not just to repair the ectropion but also to lend it lateral support restoring. Unfortunately, even that is not enough sometimes cause that's when we, cause we have a special case when we come to these breeds, when we come to deal with the sharpes and the chows and the. Problem of not really entropion ectropion, it's really a problem of excessive facial falls in reeds, because if you think about it, eyelids, the function of the upper eyelid is really to, keep facial skin away from the eyes, and these guys simply have so much facial skin, so much, such heavy eyebrows that The upper eyelid simply collapses.

It cannot bear the weight of all these skin, of all these folds and therefore it's more problem of excessive facial faults in these dogs. And to help us deal with these breeds, we have what is called the studies procedure again named after Franz Stus from Utrecht, it's also called the cline, a clown eyebrow procedure which is shown here. The first critical step in this procedure is to make your incision 0.5 millimetre from the eyelid margin.

We're not talking 2 to 2.5 millimetres as we're talking about the hot Celsius previously. We make it right and The eyelid margin, so it would be right at this point between the cilia, between the eyelash and the myboming glands.

So we want to avoid the myboin gland openings but remove all the follicles so the incision would be right here or right here. Again, another drawing that is shown here. And then you create a clown eyebrow by removing a huge crescent of skin as I'll show you in a minute, but again, going back to the critical placement of the first incision, this is probably too far from the eyelid margin because we've left all these.

Hair here and I will explain in a minute you realise why it's important. This is a perfectly placed incision. We've removed all the hairs, but we have preserved the myboin gland, my boing glands and their openings.

And then the, so this is the first critical step in the status technique to deal with sharp pains and chaos, and the second critical step is that we do not suture one edge of the incision to the other as we did in hot celsius. We suture this upper incision to the tarsal plate. Remember I showed you the tarsal.

Plate here we suture it to the car plate which is about 456 millimetres from the lead margin. That's where we place the sutures as you can see here, leaving us with this exposed tissue and the reason we're leaving this tissue exposed is simply to allow it to heal by secondary intention healing or by secondary granulation. You'll get extra retraction of the eyelid margin pulling all sutures, all hairs, sorry, away from the ocular surface.

So we really did two things here. Number one, we've created the hairless area, and number 2, we have allowed secondary intention healing, pulling eyelid margins, cilia and eyelashes or any remaining eyelashes away from the ocular surface. So again, Here is the first incision right at the edge.

Second incision may be 2345 centimetres away and then you suture the second incision to the base of the arsen plate for 5 millimetres from the high margins using absorbable sutures, and this is what the final appearance of the dog would look like, not that we Also fix the lower lid here, but this is what the dog would look like at the end of the surgery, and you can understand why it is called a clown clown eyebrow procedure. It certainly looks like a clown. And obviously, as it says here, we have to warn the owners about post-op appearance because if you send the dog home like that without discussing it with the owners first.

You will have, you'll be looking at very angry owners who will be certain that you forgot to suture the dog's skin. You did not forget to suture it. The sutures are all here.

This tissue is both for the secondary intention healing, and this is a final result. Here is a chow before surgery. Here is the same child 3 weeks after surgery, you can see.

Number one, as I said, we've created the hairless area here because we've removed all skin here. This is all secondary intention healing, and you can see how the eyelid margin has been lifted by the secondary healing and all future hairs will be facing away from the eyelid margin. Unfortunately, we have even more severe cases sometimes in Sharpes.

It's really a breed where I say that, you know, it is sold by according to how many square metres of skin it has, so lots and lots of. Folds this would be very expensive if you go by this case, by this formula here, even a studies technique will not be helpful and we have to perform what is called a retidectomy. You can retidectomy, removing all of the redundant facial skin, maybe 20 centimetres or more, sometimes even more 30 or 40 centimetres.

You can see the outline here with the surgical pen of. How much skin we are going to remove, so we're really doing a face lift and then we are have to anchor the redundant folds, to the periosteum using special, special sutures, meshwork, etc. Etc.

Again, I refer you to text for more details. And again, this is what it would look like. Another picture showing you how much of the skin we have removed in these dogs.

But again, I started out by talking about entropion ectropion. This is not really entropy ectropion. Excuse me, we are looking more at excessive facial faults and tracheasis, natural hair coming in contact with the eyes.

So we've got tracheosis in these sharp pes and in these chows. We also really have tracheosis in the brackets of 5 breeds. I'm talking about breeds like Pekings and the Shih Tzu and the pugs and the Boston Terrier where we've got normal air coming in contact with the eyes and I'm talking most commonly about the nasal folds, .

Obviously, it look, you can see the nasal fold coming in contact with the cornea of these guys, and as you know, it causes chronic keratitis, inflammation. You can see the extensive pigmentation on these guys, irritation, etc. Etc.

Etc. And we look at these pictures, obviously it is very tempting to think that, gosh, I'm just going to remove this. Skin folds, the nasal folds, and all will be well and yes, it may be done.

It's a very simple technique, grab the nasal fold, cut it, suture it, and problem and you've removed the skin fold, but really it's a very simplistic approach because in this bracket cephalic breeds nasal. Folds are really one component of what we call a bracket cephalic breeds. They have, as I mentioned earlier, a medial entropion in the lower eyelid.

It causes epiphera. They have obviously shallow orbit. All of these brackycephalic breeds present with the so-called exopthalmos, very susceptible to traumatic prolapse, pigmentary teratitis that you can see here, Kunal, they have.

Fear production problems. So really, describing all of their problems to just to this nasal fold is simplistic and therefore we need a surgical technique that addresses all of these problems and we do that with what's called a medial or nasal canopplasty that involves shortening both of the upper and lower eyelids. Decreasing substantially the palpy fissure.

People are always worried what happens to the laron punctas if I decrease the fissure by that much. I'll show you in a minute. We remove the caruncle, we correct the entropion, so all of the problems mentioned in the other slide have to be addressed.

And again going back to the punktas, here they are. I'm cannulating them. I am taking scissors and I am cutting the cannuliqueli sounds drastic.

Yes, I'm sacrificing my punkta, but actually they with a cutting of the scissors, they will be transposed to a new location, so the new punktas will be here and here and that. Will allow me to safely remove as much skin as I need shown here at the bottom and if done properly, the results are wonderful. Here is a pug before surgery.

Here it is 4 years after surgery. Note the decrease in palpibrile opening. The entropy has also been resolved.

The decreasing palpibrol opening helps you spread the tears, tear feels better. It prevents traumatic collapse of the globe and with topical cyclosporin acrolimus on, treatment, you can see how corneal clarity was restored in this dog. Right One topic I want to cover because we're running out of time is eyelid tumours.

If there are small tumours, they are removed with a wedge resection that I mentioned earlier. And when I say small tumours, anywhere up to 25 to 30% of ID glands may be removed with a wedge resection and the closure that we described earlier. However, if you try removing larger amounts of eyelids, you will cause entropion, unless you, use plas our plastic techniques in order to make up for the lost tissue.

And here two of them are shown, two ways to restore or two techniques to restore the eyelid that you removed anything above 30%. 1 is what we call the house inverted triangle. We are removing a large tumour here on the upper eyelid.

Measure how much eyelid length you have removed and create an equidistant triangle here at the end, this length equals the amount of eyelid you have removed and then suture point C to B as shown here and if you suture C to B, you will have extended the length of the upper eyelid by A to B, which equals the amount of eyelid length you have removed. So that's The other is what we call the H+ T sliding graph. Shown here, here we are removing first the tumour with by removing a rectangle.

So here is a, here used to be a tumour and we make extend our incisions down, making it an age, we move to skin triangles that are called the barrows triangles in order to allow you to Slide the skin upwards and then two figure of 8 sutures on both sides in order to restore perfect eyelid alignment. Here is a cat with squamous cell carcinoma and here it is the result after we've done an H+ T on the cat sliding the skin in order to fill up the effect. However, obviously sometimes even that is not enough.

Sometimes you'd have huge tumours. How about this guy, a cat with what we call apocrine hydrocystoma. Actually, that's not a surgical case.

This is repaired medically or chemically, I should say. But it gives you an idea that sometimes tumours are too large, even for an H + T. And again, I refer you to textbooks for some of the repair techniques.

Maybe this you slide a graph from the lip. Cale gives you actually a very nice mcutaneous junction if you think about it, or you slide a graph from the lower lead to fill a defect in the upper lid. This would be a two-step procedure, but it will recreate the graph.

Post-operative care in all of these cases. Whether you're talking about entropion, entropion, studies technique or whatever, in all these cases, please, please, please don't forget an Elizabethan colour which should stay in place 2 or 3 days after suture removal, remove in silk sutures 10 days, nylon sutures, which I rarely use 14 days afterwards. Topical antibiotics, sometimes systemic antibiotics, analgesia, and most importantly, wait.

Do not be quick to judge your results and, admit failure. There will be contraction that lasts up to 6 weeks. So wait, wait, wait before you decide that you need to go into another surgery.

. I'm going to skip through these pictures to give you time for questions. I can't see you, so I always bring my own thank you slides. I really be glad to take your questions.

Oh, Ron, that's brilliant. I've never seen a slide like that at the end. I am sitting here smiling from ear to ear.

That is brilliant. But not as good as your presentation. That was absolutely unbelievable.

Thank you so much. Thank you, Bruce. Thank you everyone for your nice applause.

there was one question that came in, which I answered in the text format, for you was, to repeat the concentrations of the 2% cyclosporin and the 0.1% tacrolimus. Do you know if there are any commercial preparations available or do they need to be compounded?

Tacrolimus is compounded. We don't have commercial preparations. Cyclosporin, there is a commercial preparation in an ointment form.

It's called Optimune OPT immune, and it's, one second here, 0.2%, sacrosporin ointment made by sharing cloud. Excellent, thank you.

We do have comments coming through of applause and that's coming through saying excellent, thank you so much. What a wonderful speaker, brilliant presentation. Please can you book him again?

Thank you so much. That was absolutely brilliant. So although the audience.

Can't clap for you. They are sending verbal verbal thanks to you. Thank you.

I'm just scrolls that are coming through at the moment and everything that is coming through is all thank you. We don't have any other questions. I think I'll just repeat your, please enter the monkey survey in order to put your comments and suggestions into writing.

Exactly. And give us some more ideas that you want on ophthalmology and I'm sure that we can twist Ron's arm to come back again because as as everybody in the comments section is agreeing, that was an absolutely unbelievable presentation. We have got one question from Catherine which has come through.

Catherine asks, are there any tips for corneal sequestration due to entropion? OK, corn sequesttrum is a disease we see only in cats, . I'm not, it, histologically we're talking about corneal necrosis.

We see a pathognomonic brown or black stain on the feline cornea, . And that's really pathognomonic because we don't have pathological pigmentation of the feline cornea like we do in dogs and the picture I showed you in dogs. You bring up a very, a couple of very interesting questions, Katherine.

Number one, what causes sequestering cats, and yes, it could be irritation. By entropion, but then I would suspect that in this case maybe the entropion is actually secondary to the sestrum. We get very little inherited entropions in.

It may be tastic, probably rather than hereditary. I think the sequetrum was actually their first. Due to herpes involvement, inflammation, exposed ocular surface in the bracketallic breath, and yes, you would have to address both problems, so probably a superficial curatectomy with a conjunctial flap or an amniotic membrane if needed, for the cornea and then a simple hot cells is repair for the entroa.

Both would have to be addressed. OK. Maybe what we need to do is get you back to talk about corneal defects and repair of corneal defects and conjunctival flaps and all those sorts of brilliant, brilliant one.

Sue has posed a question. She says very mundane, but is there anything that really removes tear staining from dogs? Thank you, Sue.

OK, OK, there are all sorts of, products you can buy on the internet that claim to remove it. I won't mention any names for risk of offending someone. None of them are really based on, any scientific proof.

And my favourite story in this regard, I was at an, and the huge veterinary meeting once and, I walked up to one guy who was selling, one of the vendors who was selling one of these products and he said, Ah, maybe now I'm finally going to understand how it works. And I go up to the guy and I say, would you please explain to me how it works? And he starts talking and after about 10 seconds, he stops and says, excuse me, what are you, where do you work in?

And I say, I'm a veterinary ophthalmologist, who looks at me and says, Oh, you're an ophthalmologist, sorry, I can't explain it to you. So I think that says it all about those products that you found on the internet. Anecdotal reports of metronidazole or tetracycline, people say they might help, because of, antibacterial effect, but again, no one demonstrated the actual mechanism.

I think really the best way to go about it is to repair the nasal entropy of the lower lid with that causes it or the nasal duct dysfunction that causes it. And then let it grow naturally. Yes, to be honest, it's really just a cosmetic problem.

Mark has come up with a lovely question. He says that he uses viral rape on a lot of his eyelid surgery. Any comments on the suture material?

No, I, that, that's a very, again, I would also be a good choice. Thank you very much for that comment. Again, I stay away from nylon if possible, just because it may irritate the cornea if it comes in contact with it.

So via a silk or vil would be two very good choices. Yes. Thank you for the, for reminding me.

Francesca asks, what is the best position for the patient to be placed in while performing eyelid surgery? Well, it really depends, I, I, for eyelid surgery, I always have them externally, cause I want the To see the lead margin so externally for me and then obviously you need cushions for the, to support the face in the correct line, in the correct position. Excellent.

Last question comes through from Katherine again. What is your opinion of using intradermal sutures rather than simple interrupted for eyelid surgery? I think you're making your life more complicated, than it should be.

simple interrupted usually will do the trick unless you know, it's some wild thing that you can't remove sutures, in which case you'd probably use yryl, . I, I, I don't see the advantage in that. I'm sorry.

Excellent. Well, folks, that's the end of this fabulous webinar, Ron. There are so many comments and your picture of applause is literally echoed by all the comments that have come through of thank you so much and absolutely brilliant.

Thank you everyone for attending and thank you, Bruce for Sharing and I hope to see you again sometime in the future. Feline ocular surfaces. Right folks, that's it for tonight and I promised you an awesome webinar and we got it.

To Dawn in the background, my controller for making everything happen seamlessly. Thank you so much. And for me it's good night.