Prolapsed Nictitating Gland in Bulldog

RE: Prolapsed Nictitating Gland in Bulldog

John Flynn — Thu, 20 Aug 2015 07:36:07 GMT

M[quote user="Gerry Henry"]Wossa Morgan Pocket when its at home then ?[/quote]

Ms Morgan wrote the paper that I think was referred to earlier in the thread with follow up on a small number of dogs that either had the gland left prolapsed, where it was fully excised or where it was tucked into a "pocket" made in the third eyelid - I think there's a brief description of this technique posted earlier in thread also.

RE: Prolapsed Nictitating Gland in Bulldog

Gerry Henry — Wed, 19 Aug 2015 14:02:59 GMT

Wossa Morgan Pocket when its at home then ?

RE: Prolapsed Nictitating Gland in Bulldog

Nicola Cole — Thu, 13 Aug 2015 20:50:08 GMT

Many thanks for all the helpful replies. the owner is very dedicated so they will go with what is recommended.

RE: Prolapsed Nictitating Gland in Bulldog

grumpyoldman — Wed, 12 Aug 2015 21:10:36 GMT

[quote user="David Mills"]There was a research abstract presented on this at BSAVA this year, only 10 dogs, half of which were bulldogs, none of which showed ocular or tear changes. Short follow up,[/quote]

very short follow up , 1-2 months ,not 1-5 years ? and that is the problem after 2-3 litters they are sold on as "pets" or handed over to bull dog rescue ,so there is no follow up.

RE: Prolapsed Nictitating Gland in Bulldog

grumpyoldman — Wed, 12 Aug 2015 19:09:41 GMT

Its a lot better with a loupe head light and 6-0 vicryl ,when creating the potential space go deep to the limbus and anchor the gland to the sclera with a 4-0 vicryl ,its less likely to pop up while your suturing . leave your knots on the outside of the 3rd eyelid and try and leave a rim of 5-7 mm of conjunctiva between the limbus and your incision , also mobilise the gland really well and try to stay 5-7 mm away from the edge of the 3rd eye lid. then dex and maxitrol until you can see your vicryl knots have dissolved .

Never met a bulldog owner i liked ,they are all after something for nothing, and intrinsically dim ,the cherry eye is interfering with their business plan so getting some one to hack it out before they sell it is not a problem, as the KCS 3 years later will not bother them too much, and many of them will have snuffed it with something else before KCS develops. I have had them ask me to do morgan pockets intra-section so that the puppy purchasers did not notice when visiting the bitch .

RE: Prolapsed Nictitating Gland in Bulldog

Gerry Henry — Mon, 10 Aug 2015 13:05:18 GMT

The tie down tec IMHO is the best with fewer relapses; approach to the rim of the orbit can be improved by making a semi circular incision below the eye at the level of the rim, make sure you get a good bite; BTW what sutures did you use? I only use monofil nylon 2metric, absorbables won't hold.

RE: Prolapsed Nictitating Gland in Bulldog

David Mills — Mon, 10 Aug 2015 09:59:06 GMT

There was a research abstract presented on this at BSAVA this year, only 10 dogs, half of which were bulldogs, none of which showed ocular or tear changes. Short follow up, but agree with John on this re different aetiologies of KCS and prolapsed glands. Suspect it is another of those veterinary dogmas, file under ACP in Boxers, mammary tumours etc etc

Abstract here (think its open access):

http://www.vin.com/members/cms/project/defaultadv1.aspx?pId=11452&meta=Generic&catId=36372&id=6671842&ind=1

RE: Prolapsed Nictitating Gland in Bulldog

Will McMullan — Mon, 10 Aug 2015 08:49:44 GMT

Wise words John, and fair points about the anaesthetic risks and learning curve. We have lots of bulldogs on our books and thankfully most owners are reasonably well informed and prepared to listen to us on things like cherry eye. I've only had one ask to have it excised and she didn't put up a fight when I said no.

RE: Prolapsed Nictitating Gland in Bulldog

John Flynn — Sun, 09 Aug 2015 19:53:41 GMT

[quote user="Sarah Mark"]A couple of years ago, I was reported to the RCVS by an irate owner, for refusing to excise a prolapsed gland in a Lhasa Apso puppy.[/quote]

One potential tip when challenged to do a procedure that you consider to be largely cosmetic or unwarranted etc, but avoid a confrontation is to advise the client that it's not a procedure you would recommend, politely list your reasons, and then humbly advise that as you've never performed the procedure you wouldn't feel competent to do so and if they wish to proceed then it may be necessary to find a vet with experience and competence in this procedure. If you don't know of any vets with "competence" in this procedure, then you can simply advise them of this and suggest they ring round and you can forward the notes if they find a vet more capable than yourself. Wording your refusal in a "humbly knowing my limitations" manner might make an owner less likely to complain to your regulator, and, if they do, might make your defence simpler.

RE: Prolapsed Nictitating Gland in Bulldog

John Flynn — Sun, 09 Aug 2015 19:42:03 GMT

[quote user="Will McMullan"]I get what people are saying about the possibly low chance of causing dry eye in breeds not necessarily already prone to it, but I feel that Bulldogs in particular have so many problems already that I don't want to contribute to another so will always refuse to excise the gland. The pocket technique is quick and simple once you've done a few, so there isn't even that big a difference in anaesthetic time or surgical cost.[/quote]

I totally see your perspective, Will. I have treated a vanishingly small number of bulldogs period, and none for cherry eye that I remember off-hand, but I regularly offer surgeries with guarantee of salvage at no further cost where chances of success are very high.

Bulldogs are notoriously unhealthy and I would consider an increased risk of clinical ocular problems that may require the regular application of artificial tears a pretty minor point in the average bulldog's overall health.

Additionally, Bulldogs have a significantly increased anaesthetic risk and I think that a procedure which can be guaranteed not to require a second anaesthetic (the excision of a nictitans gland that is inflammed and casuing ocular irritation) may be preferred by some to a procedure that could require a second anaesthetic due to failure (even if salvage would be done at no further cost).

Finally, as with most procedures, there is a learning curve and I'd suggest that chnaces of failure on your first couple of cases could be as high as 50% depending on case selection.

RE: Prolapsed Nictitating Gland in Bulldog

Sarah Mark — Sun, 09 Aug 2015 13:14:46 GMT

I wish!

The whole thing took months to conclude, including RCVS visiting the owners.

RE: Prolapsed Nictitating Gland in Bulldog

Hannah Wynne Richards — Sun, 09 Aug 2015 11:36:29 GMT

I hope PIC had the sense to write back "No case to answer"

Wynne

RE: Prolapsed Nictitating Gland in Bulldog

Sarah Mark — Sun, 09 Aug 2015 10:44:01 GMT

A couple of years ago, I was reported to the RCVS by an irate owner, for refusing to excise a prolapsed gland in a Lhasa Apso puppy.

RE: Prolapsed Nictitating Gland in Bulldog

Will McMullan — Sun, 09 Aug 2015 09:57:22 GMT

I get what people are saying about the possibly low chance of causing dry eye in breeds not necessarily already prone to it, but I feel that Bulldogs in particular have so many problems already that I don't want to contribute to another so will always refuse to excise the gland. The pocket technique is quick and simple once you've done a few, so there isn't even that big a difference in anaesthetic time or surgical cost.

RE: Prolapsed Nictitating Gland in Bulldog

Robin Grimmer — Fri, 07 Aug 2015 17:58:38 GMT

There are some videos of the op on Youtube. The latest BSAVA Opthalmology book has some good illustrations I believe. I thought I had one coming in this evening but seems to have cancelled! I did the suturing to the periosteum technique once and was quite fiddly and invasive. The pocket technique sounds good, would like to try it. I did snip a few off as a new grad in the 90s. They did ok as far as I remember, but maybe I wasn't around years later to see if they got dry eye!

RE: Prolapsed Nictitating Gland in Bulldog

Robin Grimmer — Fri, 07 Aug 2015 17:57:30 GMT

There are some videos of the op on Youtube. The latest BSAVA Opthalmology book has some good illustrations I believe.

RE: Prolapsed Nictitating Gland in Bulldog

John Flynn — Thu, 06 Aug 2015 22:52:59 GMT

Hi Nicola,

My personal take on this recurring issue.

If you think it is negligent to amputate a fractured leg that could be repaired with a 95% success rate, but will require some post-operative care and a 100% guarantee of success cannot be made, then you may find you consider it unacceptable to excise a prolapsed third eyelid gland.

If you are wholly unconvinced that the clinical outcomes from partial excision of such a gland are actually as terrible as some suggest, especially in a breed that is not prone to develop actual KCS (an autoimmune condition the presence/absence of which is not influenced by the presence/absence of a nictitans gland when I last checked), but have explained in simple terms the theory behind a general reluctance to excise such a gland as a first-line approach and the implications of potential reduced tear production, then I think it is more than reasonable.

Finally, you must be convinced that the prolapsed gland is either causing, or likely to cause, a clinical issue in order to excise it - otherwise this would be a (albeit quick and simple) cosmetic procedure, and as such not ethical to me.

That would be an excellent paper selection for Michael's suggested journal club if only it were open access My take based purely on that abstract (unless there are more studies?) would be that the evidence is weak that exicsing part of a prolapsed third eyelid gland is a significant problem, so I'd not be too dogmatic with those whose experience suggests it not to have been a problem in their experience - they may well be correct - who knows? Certainly I'm guessing that regular bulldog fanatics see these cases much more frequently than I do, so I would listen to their experiences before dismissing them.

Re surgical technique for pocketing technique: I'm sure others will share more useful insights, but what has worked for me (and haven't done one for years now so typing off memory!):

Use couple of stay sutures anchored with tiny hemostats to evert the third eyelid.

Use sharp corneal scissors or similar and mini toothed forceps to make non-connecting incisions through inside of third eyelid conjunctiva above and below gland in long section.

Use small iris scissors or similar to blunt dissect to 'open' the pocket up in direction towards eyeball.

Select some small, soft braided suture and begin on outer surface of third eyelid at one end of where incisions almost meet and make knot on outer third eyelid (thick enough bite that won't pull thorugh).

Go through and then do simple continuous thorugh inner third eyelid conjunctiva so gland gets tucked in between. Pull suture to appose conjunctiva at each bite (rather than trying to place all and then just pull the end in hope will all tighten evenly) and aim to appose conjunctiva hiding gland rather than pulling as tight as you can (which will lead to a sort of concertina-effect and excessive tension -> breakdown.

Once you get to the other end, go through the third eyelid and tie a KNOT on outer third eyelid, then go back through and repeat the process going backwards along the suture line you just completed (thus giving 2 lines of suture apposing the conjunctiva edges).

Finally go through to outer third eyelid again and place your final (third) knot.

Use chloramphenicol 6 times daily or equivalent for a week or two afterwards, a buster collar and oral NSAIDs

(avoid steroids after surery, but use topical steroids beforehand to reduce inflammation in gland for couple of weeks if needed).

I think success is very dependent on technique, and like most things practice makes perfect. Overtight suture line with lack of space in "pocket" for the gland probably biggest issue.

I have certainly shaved a bit of the end off the gland to make it fit in before. Of course, purists have cited the same claim as against partial excision in the first place that the ducts come out of the edge you are excising and therefore any excision makes the gland defunct - I'm far from convinced of the clinical effect here.

Given that presumably no specialist (the folks we should be listening to who see a pile of these cases rather than the sporadic ones i see) has excised too many glands since that publication a lot of years back, there probably aren't many out there who can make personal comment other than what is said in that paper and the skewed population of referrals they see of KCS in patients that happen to have had a gland excised (without knowing how common gland excision really is).

Certainly could be a relatively simple retrospective VetSurgeon study to put together to see what incidence of CLINICAL ocular problems was, perhaps stratified by breed if enough cases, over a 5 to 10 year period of cases where third eyelid glands were excised, partially-excised or replaced by the pocket-technique or another technique. I'm confident that a better paper than the one cited would not be difficult with sufficient access to clinical records and a decent number of VetSurgeon collaborators...

RE: Prolapsed Nictitating Gland in Bulldog

Nicola Cole — Thu, 06 Aug 2015 21:52:36 GMT

Sorry to resurrect an old thread. Anyone with a good description of how to do the pocketing technique? Is success very dependent on how tight/or not, the suture is (Ie. The more you do, the more likely it is to stay in)? I haven't had to do a cherry eye for years....Do most people point blank refuse the snipping technique now or will people still do it with a signed disclaimer from owner?

Re: Prolapsed Nictitating Gland in Bulldog

Chris Barker — Tue, 26 Jun 2012 11:26:52 GMT

With profoundly enlarged prolapsed glands I have used the common sense 1st opinion compromise approach... Removed half the gland and then tunnel buried the remaining part Anecdotal I know but seemed successful in the two cases I tried, hopefully leaving enough active gland behind which hopefully can repair/hypertrophy as necesary

Re: Prolapsed Nictitating Gland in Bulldog

Alice Courtney — Tue, 26 Jun 2012 09:01:02 GMT

Yes, Bob, I think this is where the bulldog breeders' experience comes from, and I guess their point is that they have had plenty of dogs with excised glands that did NOT get KCS, so they do not perceive there to be a problem with it. Fair enough. But still, times change and at the moment perhaps there is still a fine (perceived at least by owners/breeders) line between 'doing it the old way because it works for most dogs, and is more convenient to the owner', and risking a chance of KCS, vs. doing it the 'new way', with a small chance of failure, because nowadays we think we should try to preserve functional body-parts (except reproductive ones! ).

The suggestion to use steroid eyedrops to reduce swelling pre-op is useful, thanks.

Re: Prolapsed Nictitating Gland in Bulldog

Rajat — Mon, 25 Jun 2012 18:48:57 GMT

I think each GA carries the same risk and the risk is not cumulative. Not to say one shouldn't be super careful with each bulldog GA. IMHO, the best use of the pulse oximeter is in the bulldog recovering from GA post extubation!

I cannot say I have seen many failures with pocketing probably around 5-8%.

Re: Prolapsed Nictitating Gland in Bulldog

bob lehner — Mon, 25 Jun 2012 18:45:12 GMT

In the 'bad old days' I'm afraid I used to snip off bulldog n.g.s quite happily - and never encountered a problem (Yes I know that's not e.b.m).

Then people started doing the periosteal tie down method - and most that I heard of failed - several times on occasion.

Then the pocket technique came along - better, but still prone to failure.

Repeat g.a.s on bulldogs not ideal

.Don't know what the answer is.

Re: Prolapsed Nictitating Gland in Bulldog

Charlotte Marshall — Mon, 25 Jun 2012 18:17:43 GMT

Although I quite agree that replacement is best I have seen quite a few dogs which have had the glands excised and I think a rate of 48% developing KCS seems very high. I certainly have not noticed a high incidence of KCS in these animals. I might have to see if I can get our database to give me some information out of curiosity now!

Re: Prolapsed Nictitating Gland in Bulldog

Hannah Wynne Richards — Mon, 25 Jun 2012 15:15:07 GMT

Maybe they've got shares in Anadin!!!!!!!!!!!!!!!!

Wynne

Re: Prolapsed Nictitating Gland in Bulldog

Rajat — Mon, 25 Jun 2012 14:54:51 GMT

Just saw your post after writing mine- and agree with Hannah- good riddance. These kind of clients are pure headache material.