Equine Eyelid Disease

Caryn E. Plummer, DVM

The most common eyelid disorders of horses include traumatic insults, anatomic malalignment problems, inammatory lesions, and neoplasms. These eyelid conditions are discussed in this article with particular attention paid to practical diagnostic and therapeutic options. Surgical treatment for eyelid lacerations, entropion, ectropion, and temporary tarsorrhaphies are described. Causes and treatments for blepharitis and neoplastic diseases, especially sarcoids, are included. Clin Tech Equine Pract 4:95-105 2005 Elsevier Inc. All rights reserved. KEYWORDS eyelid, laceration, entropion, blepharitis, habronemiasis, sarcoid

he equine eyelid consists of four major layers: the outermost typical haired skin, muscle, tarsal plate and stroma, and the innermost palpebral conjunctiva. The dorsal and ventral folds of skin of each lid are continuous with the facial skin. Underlying subcutaneous tissue is irregular and devoid of fat and blends with the striated orbicularis oculi muscle deep to it. The tarsal plate is an area of dense connective tissue which lends rigidity to the eyelid margins. A number of glandular structures within the tarsus and at the eyelid margin, including the meibomian glands and the glands of Zeis and Moll, contribute to the preocular tear lm or function to lubricate the edges of the lids. Stiff tactile vibrissae are present along the base of the lower eyelid and at the base of the upper eyelid medially. The free edges of the dorsal and ventral lids meet to form the palpebral ssure which should t close to the globe except at the medial canthus, where the lacrimal caruncle protrudes. The eyelids function to protect and exclude light from the eyes, spread the tear lm over and remove foreign material from the anterior surface of the globe, contribute to the production of the tear lm, and facilitate its drainage through the nasolacrimal apparatus. Evaluation of the eyelids should include examination of the cutaneous, marginal, and conjunctival surfaces of both the upper and lower lids of the patient. Before any sort of sedation, regional nerve blocks, or topical anesthesia, it is important to perform a preliminary examination of the eyelids of the equine patient, paying particular attention to eyelid function, conformation, and neurologic reexes. Acquiring a detailed history of duration, changes in appearance, previous therapies, and responses is also crucial as these can guide your diagnostic and treatment

plans, as well as your prognosis. The lids should hug the globe snuggly while being freely mobile, and should be capable of performing a complete blink action covering the entire cornea. The shape, position, and condition of the eyelid margins, the relative size of the palpebral ssure compared with the globe, the symmetry of the two eyes, and the effectiveness and frequency of the blink response are important to assess.1 The position of the eyelids may be assessed by considering the angle of the cilia (eyelashes) in relation to the globe. The eyelashes are normally positioned almost perpendicular to the corneal surface. Cilia which are directed even subtly downward may indicate lid disease or deformity or that the patient is experiencing ocular pain or discomfort. The neurologic reexes of the eyelids to evaluate include the menace response, which tests the visual response to a stimulus and the eyelids ability to respond with movement (cranial nerves 2 and 7), and the palpebral and corneal reexes (cranial nerves 5 and 7). If the menace response is negative, the next step is to assess the palpebral reex by touching the eyelids or their tactile vibrissae. The afferent pathway of the palpebral reex provides sensory information that elicits the blink motor response. In other words, this reex helps assess whether the eyelids are capable of movement or blinking in response to the visual or sensory stimulus.1 The corneal reex evaluates the sensitivity of the cornea rather than that of the eyelid skin and is performed by slightly touching the cornea with a wisp of cotton. A positive response is a blink.

Trauma
Traumatic Eyelid Lacerations
The horse often exhibits quick movements of the head in response to fear or play situations, with trauma to the eyelids often a sequela. Any sort of eyelid trauma necessitates a full ophthalmic examination because of the potential for additional damage to the globe or orbit. Corneal ulcerations, 95

Department of Small Animal Clinical Sciences, Comparative Ophthalmology, University of Florida, College of Veterinary Medicine, Gainesville, FL. Address reprint requests to: Dr. Caryn E. Plummer, Department of Small Animal Clinical Sciences, Comparative Ophthalmology, University of Florida, College of Veterinary Medicine, PO Box 100126, Gainesville, FL 32610. E-mail: PlummerC@mail.vetmed.u.edu

1534-7516/05/$-see front matter 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.ctep.2005.03.004

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Eyelid Laceration Repair

It is wise to consider culturing a traumatic eyelid wound of any long-standing duration before cleaning and suturing the defect. Thorough ushing of the affected area with saline and a dilute povidine/iodine (2%) solution followed by minimal debridement of any wound margins or lid pedicles should be performed. The eyelids have a rich vascular supply and generally do not require removal of tissue of questionable viability. Even desiccated, avulsed eyelids are capable of recanalization by blood vessels following a repair.2 For this reason and because of the concern for exposure keratitis, it is imperative that eyelid tissue tags and pedicles not be amputated, and instead replaced to as normal an anatomical position as possible (Fig. 2). 1. It is crucial to accurately appose the lid margin, and this should be the rst step taken in the repair.2 A gureeight suture is placed on the eyelid margin that allows for knot placement away from the globe (Fig. 3). 2. The remainder of the defect is closed in two layers: a deep layer in the palpebral conjunctiva with 4-0 to 6-0

Figure 1 Sensory innervation of the eyelids of the horse. These regions will be temporarily desensitized by blocking the specic nerves as described in the text. A block between the auricolupalpebral and palpebral nerves will facilitate examination and repair procedures by temporarily limiting motor function of the lids.

globe perforation, uveitis, periorbital fractures, and orbital cellulitis or abscessation can accompany eyelid trauma. Lacerations of the eyelids should be repaired promptly to prevent lid deformities, infections, and exposure-induced damage to the cornea.2 Depending on the extent of the lid injury, surgery to repair an eyelid laceration may be performed with sedation and local anesthesia alone, or for severe lesions with the animal under general anesthesia.2,3 Akinesia and anesthesia of the eyelids can be achieved by injecting 2% lidocaine regionally to affect either motor or sensory innervation of the eyelids (Fig. 1). An auriculopalpebral motor nerve block will limit the movement of the lids (specically the function of the orbicularis oculi muscle), and is performed by injecting 1 to 2 mL 1% lidocaine through a 25-gauge, 5/8-inch needle where the auriculopalpebral branch of the facial nerve is palpable as it crosses over the dorsal aspect of the zygomatic arch.1,4,5 There are several different sensory blocks that may be employed depending on the location of the eyelid lesion to be addressed. The central two-thirds of the upper eyelid is innervated by the frontal or supraorbital nerve, and is blocked by injecting 2 mL of 2% lidocaine into the supraorbital foramen. This foramen can be identied as a small depression in the supraorbital process of the frontal bone, medial to its most narrow aspect.1,4,5 The lateral upper eyelid and lateral canthus are innervated by the lacrimal nerve, and can be blocked with a line block along the lateral third of the dorsal orbital rim.1,4,5 A block of the zygomatic nerve will anesthetize the lateral lower lid and is achieved with a line block along the ventrolateral orbital rim.1,4,5 The medial canthal region is innervated by the infratrochlear nerve and is desensitized by injecting anesthetic through the bony notch on the dorsal rim of the orbit near the medial canthus.1,4,5

Figure 2 Upper eyelid laceration before repair (A) and after (B).

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Figure 3 Eyelid laceration repair. (A) The wound is cleansed and minimally debrided. (B) A gure-8 suture at the eyelid margin will allow for alignment of the eyelid margin, which is critical to an effective repair. (C) A two-layer closure is performed if possible. The deep layer should start at the eyelid margin as well and proceed distally from it. (D) Simple interrupted skin sutures nish the closure.

absorbable suture material in a simple interrupted or simple continuous pattern starting at the eyelid margin, and a supercial layer through the skin with 4-0 to 5-0 nonabsorbable suture in a simple interrupted pattern (Fig. 4).6-8 Any suture tags that appear capable of irritating the cornea should be incorporated into the knot of the next suture distal to the lid margin. Sutures are usually left in place for 7 to 10 days; however, if there is tension on a repair, the sutures should remain longer to ensure adequate time for healing. The more extensive wounds and lacerations, especially those with tissue loss, are best repaired with the patient under general anesthesia and may require sophisticated blepharoplastic procedures. Lacerations near the medial canthus may involve the nasolacrimal apparatus and affect tear drainage. The integrity of the duct should be tested by close examination and the passage of uorescein sodium dye through the nasolacrimal duct. If the nasolacrimal canaliculus is damaged, surgical repair is denitely warranted.2,8,9 Any lacerations of the nictitating membrane should be promptly and carefully repaired as well. Excision of the nictitans should only occur if the damage to this structure is severe or if it is affected by a neoplasm. Administration of topical and systemic antibiotics, systemic analgesia/antiinammatory drugs, and tetanus toxoid are the mainstays of postoperative medical care. Protection of the cornea is absolutely imperative if the lids are swollen or compromised in such a way that the cornea is perpetually exposed. Frequent administration of topical articial tear replacement ointment may be sufcient in such cases, while others may need a tarsorrhaphy.

Temporary Tarsorrhaphy
A temporary tarsorrhaphy is achieved by placing one or more (depending on whether the tarsorrhaphy is to be partial or complete) horizontal mattress sutures of 3-0 to 5-0 nonabFigure 4 Lower eyelid laceration before repair (A) and after (B).

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Figure 5 Temporary tarsorrhaphy. (A) All of the horizontal mattress sutures that are to be employed are preplaced before securing any one individual suture. (B) It is important to make the suture depth only partial thickness to prevent damage to the underlying cornea. Sutures should exit at the level of the meibomian gland openings. (C) Stents reduce tension on the eyelid tissue once the sutures are tied.

sorbable material partial thickness along the eyelid margin to distribute tension and avoid contact with the cornea (Fig. 5). The use of stents (rubber bands, IV tubing, buttons) is advisable to prevent the suture from cutting into the eyelid. The medial canthus is usually left open to facilitate drainage and medication administration. While the wound is healing, it is important to prevent further damage (usually self-inicted) to the repair site. A hard-cup hood or thick head bumper may be necessary to prevent rubbing of the area. Fly masks are often critical to keep the wound free of unwanted visitors during the healing process. Alternatively, a y repellant ointment may be applied adjacent to the surgical site.

Entropion and Other Anatomical Malalignment Problems

Entropion is the inward rolling of the eyelid margin, which may allow eyelid hair to contact and irritate the cornea. Clinical signs include excessive tearing and blepharospasm, and variable amounts of keratitis and conjunctivitis. Entropion is most often seen in young foals, and may be either hereditary or acquired (Fig. 6). Since many cases of foal entropion are secondary to ocular irritation, systemic diseases (especially those resulting in dehydration or loss of periorbital tissue or fat), or disproportionate growth and since the growing foal has a dynamic conformation, surgical correction is not recommended until maturity is reached. In the meantime, ocular lubricants and sometimes temporary eversion of the offending eyelid with vertical mattress sutures or staples may be necessary. Entropion may also be from spasms of the orbicularis oculi muscle due to chronic, irreversible ocular irritation, or may be cicatricial due to previous eyelid trauma (scarring). If surgical therapy is indicated, it is absolutely critical that the extent of required correction be determined with the animal awake. Topical anesthetics and a local nerve block will facilitate differentiation between any primary anatomic component of the entropion and any secondary contribution of spasm. The goal of surgical correction of entropion should be slight undercorrection because overcorrection can cause problems more signicant than the initial complaint.

Blunt Trauma-Induced Blepharitis

Blunt trauma may not necessarily result in an actual laceration, but may alternatively result in blepharoedema and hematomas of the eyelids due to the lack of dermal fatty tissue in this region. Lid swelling is treated with ice-packing and systemic antiinammatory drugs, such as unixin meglumine. Again, if eyelid function is impaired, measures must be taken to protect the cornea. Small eyelid punctures may cause an infectious blepharitis or eyelid abscesses or cellulitis.9 Eyelid abscesses are addressed by rst obtaining samples of exudates for culture and sensitivity and then administering systemic antibiotics and antiinammatories. Cytologic examination and Gram stain of samples from the affected area may guide empiric therapy while culture results are pending. Warm compresses are usually helpful. Some wounds will require surgical debridement or the placement of drains. Foreign bodies are another source of traumatic insult. Any patient presenting for epiphora, conjunctivitis/chemosis, blepharitis/blepharospasm, or corneal damage (especially recurrent or refractory lesions) should have a thorough search for foreign objects, paying particular attention to the conjunctival fornix and the area posterior to the nictitating membrane. Removal of a foreign body and appropriate supportive care should be instituted when a foreign body is discovered. Even seemingly minor traumatic insults can result in cicatricial entropion and ectropion that may need surgical attention. It is important to be vigilant and inform owners of this possibility.

Modied Hotz-Celsus Procedure

1. The modied Hotz-Celsus procedure is particularly useful for dealing with most entropion conditions in the adult horse.2,8 This procedure should not be done in foals. The procedure is simple and involves removing a crescent-shaped piece of skin and orbicularis muscle (Fig. 7).8,10 The initial incision is made with a No. 15 scalpel blade 2 mm from the eyelid margin, its length dependent on the amount of eyelid margin involved.

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Figure 6 Lower eyelid entropion in a foal.

2. A second elliptical incision made parallel to the rst joins the two ends of the rst incision. 3. A Jaeger lid plate inserted into the conjunctival fornix will stabilize the skin for these incisions. The width of the piece of tissue to be excised will have been previ-

ously determined while examining the awake horse for the amount of eversion necessary for a correction. 4. After the skin is incised to the depth of the orbicularis oculi muscle, the skin and a portion of this muscle are undermined and excised with scissors.

Figure 7 Modied Hotz-Celsus procedure for treatment of entropion. (A) An elliptical strip of skin and orbicularis oculi muscle is incised with a Bard-Parker No.15 scalpel blade and then carefully elevated and excised with scissors. (B) The wound is closed in one layer. The rst suture should be placed in the center of the defect. (C) Simple interrupted nonabsorbable sutures are used in the repair and are left in place 10 to 14 days.

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Figure 8 Y-to-V entropion repair. (A) The arms of the Y-shaped incision will extend slightly beyond the extent of the cicatricial lesion. (B) Once the incision is made with a scalpel, the scar tissue should be excised with scissors. (C) The eyelid margin is everted when the V-shaped ap that results is sutured into the Y-shaped incision, resulting in a V-shaped nal closure.

5. The defect is then closed using 4-0 to 6-0 nonabsorbable suture material in a simple interrupted pattern. The rst suture placed should be the central suture, which will separate the wound into two equal halves. This insures even closure. 6. The suture ends adjacent to the cornea are trimmed short to avoid irritation of the cornea. The sutures are left in place for 10 to 14 days.

base of the Y ultimately resulting in a V-shaped skin closure. 4. Simple interrupted sutures of 4-0 to 6-0 nonabsorable material are utilized here as well.6,10,11

Ectropion and the V-to-Y Repair

Ectropion is an outward rolling of the eyelid margin and, when present in the horse, is most frequently a consequence of cicatrix formation involving the eyelid or periorbital region. The increased exposure of the conjunctiva and cornea and the potential problems resulting from that are what makes it necessary to correct an ectropion. The favored repair is the reverse of the focal repair for entropion. In the case of ectropion, a V-to-Y plasty procedure is performed (Fig. 9).8 1. A V-shaped skin incision is made to encompass the extent of the affected area. 2. Its skin ap is undermined and the underlying scar tissue is excised. 3. The ap is then advanced toward the eyelid margin and

Y-to-V Entropion Repair

In cases in which a focal lesion, usually a cicatrix, is the cause of the entropion, a Y-to-V repair may be advantageous (Fig. 8).8 1. In this procedure, a Y-shaped incision is made such that the arms of the Y span the length of the offending lesion. The height is determined by the extent of the eversion necessary. 2. The skin is undermined and the cicatricial tissue is dissected free with scissors. 3. The central point of the Y is then sutured to the distal

Figure 9 V-to-Y ectropion repair. (A) The arms of the V-shaped incision will again encompass the extent of the lesion. (B) Once the incision is made, the resulting skin ap is elevated and scar tissue is excised. This should allow for the skin ap to be advanced toward the eyelid margin, relieving tension and returning the eyelid margin to its normal position. (C) To keep the eyelid margin in its proper position, the wound is closed in a Y-shaped pattern.

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Figure 10 Brush-re induced blepharitis in an adult horse.

closed so that the tension on the lid is relieved and a Y-shaped closure results.6,8,10

may manifest as blepharitis. Lymphoma has been associated with lid and conjunctival swelling.14

Blepharitis
Blepharitis can be the result of a traumatic event, an infectious agent, an immune-mediated process, or a neoplasm (Fig. 10). Cytology and culture, and potentially skin scraping, of any persistently inamed eyelid is recommended. While primary bacterial blepharitis is rare in the horse, secondary infections due to a wound, foreign body, or even a subpalpebral lavage system are not uncommon. Removal of the foreign body if indicated, wound cleansing, hot-packing, and systemic antibiotics are the preferred treatment regime. Dermatophytes such as Trichophyton or Microsporum spp can be responsible for blepharitis as well, either primarily or secondarily.2,12 Topical administration of miconazole 2% ointment is usually sufcient for dermatophytosis unless the horse has a generalized immune-suppressive condition.2,12 Other more aggressive fungal infections have been reported to cause blepharitis in the horse, and these usually require systemic administration of antifungal agents. Immune responses that may result in blepharitis include allergic reactions, both acute and chronic, drug reactions, eosinophilic granulomas, solar irritation, and the pemphigoid diseases. Biopsy and histopathologic examination will be essential for these diagnoses and treatment will be aimed at modulating the immune response. Tumors with aggressive inammatory components such as squamous cell carcinomas

Parasitic Blepharitis
Probably one of the most common causes of blepharitis in the horse is local infection with a parasitic organism. Habronema organisms are common residents of the equine stomach. Larval habronema stages (specically the infective L3) passed in the horses feces and ingested by an intermediate host (usually a house or stable y) can be deposited in wounds or on adnexal structures.2,8,11 Nodular or ulcerative periocular granulomas and stulous tracts with a gritty, yellow exudate of necrotic mineralized tissue can be found with habronemiasis.8,11 The medial canthus is the most frequent site of invasion, but habronemiasis can affect any portion of the eyelids, conjunctiva, nasolacrimal apparatus, or nictitating membrane (Fig. 11). Signs are most common in the summer months. Much of the inammatory response is due to an immune-mediated hypersensitivity to the offending organism.2 Eosinophils and mast cells abound in cytologic samples of these lesions. Treatment involves removing or destroying the organisms, alleviating the inammation, and eliminating any secondary infections present. Fly control is crucial. Multifocal lesions can most easily be treated with systemic administration of ivermectin (200 g/kg PO or 0.02 mg/kg IM) and topical use of an antibiotic-corticosteroid ointment (as long as no corneal ulceration is present).2,8 A mixture of 135 g of nitrofurazone ointment, 30 mL of 90% dimethyl sulfoxide

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Figure 11 A lesion typical of eyelid habronemiasis.

(DMSO), 30 mL of 0.2% dexamethasone, and 30 mL of 12.3% oral trichlorfon has been suggested for topical use on solitary lesions.8 Alternatively, oral diethylcarbamazine (6 mg/kg for 21 days) may be effective.8 Surgical removal of granulomatous lesions may hasten recovery, but care must be taken to preserve sufcient eyelid tissue for proper functioning of the lids. Intralesional corticosteroids, such as triamcinolone, may help reduce the size of the granulomas by helping to control the hypersensitivity reaction to the organism.2 Other organisms to keep on the differential list include the normally commensual nematode Thelazia, which can cause mild lid swelling and dacryocystitis, Demodex, which can cause meibomianitis, alopecia, and dermatitis, and Onchocerca.11

their propensity to occur in gray-colored animals. Arabians and Percherons may also have an increased risk for melanomas.2 Treatment for these tumors is surgical excision followed by cryotherapy. Since the different kinds of tumors have different behaviors and prognoses, it is important to obtain a denitive diagnosis with either ne-needle-aspirate and cytology or, preferably, with histopathology. Also, not infrequently will inammatory lesions masquerade as neoplasms (eg, Habronemiasis granulomas), which is another strong argument in favor of performing a histopathologic examination.

Sarcoids
Sarcoids are the most common cutaneous tumors and the second most frequently recognized periocular tumors in horses. They generally have a low metastatic potential, but are frequently locally invasive. Sarcoids are broblastic neoplasms that are sometimes a challenge to diagnose and treat, particularly when they appear in the periocular region because they can be unpredictable in their behavior and responses. They occur in several clinical forms ranging from areas of alopecia or altered character of the hair alone (occult) to alopecia with thickening, hyperkeratosis, aking, and sometimes skin ulceration (verrucuous) to nodular with variable overlying skin involvement (nodular) (Fig. 12) to a rm, proliferative, eshy mass with ulceration (broblastic) (Table 1).15,16 Intermediate and mixed forms also exist, as do subtypes within each form. Unfortunately, the clinical appearance is not reliable in determining future behavior and the various types may transform over time. Some sarcoids are

Neoplasia
The most common eyelid tumor in the horse by far is squamous cell carcinoma, which will be addressed fully in a separate chapter of this publication. Sarcoids are the next most frequent tumor of the periocular region of the horse. Numerous other tumor types are of low incidence and include bromas, brosarcomas, schwannomas, basal cell carcinomas, lymphomas, adenocarcinomas, hemangiosacromas, plasmacytomas, mast cell tumors, papillomas, and melanomas.13 Among the more rare neoplasms, papillomas are observed in relatively immature animals and are the result of the bodys reaction to a papovavirus.12 Most papillomas are self-limiting and regress spontaneously, but an occasional persistent lesion may require surgical removal, cryotherapy, or autogenous vaccination. Melanomas also warrant note because of

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103 tumor cells, it is important to undertake this procedure with a plan for prompt subsequent treatment and only after warning the owner that the tumor may grow rapidly and aggressively after the biopsy is taken.19 Differential diagnoses for sarcoid include fungal dermatitis, dermatophilus, granulation tissue, granulomas including habronemiasis or onchocerciasis and foreign body reactions, papillomas, melanomas, squamous cell carcinomas or other neoplastic lesions, and scarring, depending on the clinical appearance.16,18 Treatment for these tumors can be performed with several different modalities, but the goal of therapy is to remove as much, if not all, of the tumor as possible, either by physical or mechanical surgical removal, by immunologic destruction, or by a combination thereof. Options include benign neglect, surgical excision with wide margins (at least 1-2 cm of normal tissue is ideal), cryotherapy, chemotherapy, immunotherapy, and radiation therapy (Tables 2 & 3).2,8,15,16,18 Many of the treatment methods performed elsewhere on the body are impossible or impractical for periocular sarcoids. Surgical excision alone (either conventionally or if performed by laser ablation) has a recurrence rate of as high or higher than 50%, due at least in part to the difculty of excising all affected tissue without compromise to lid and adnexal function in the horse.8,15,16 Combination therapy is therefore commonly employed, particularly with large lesions, where debulking is performed, followed by some other modality, such as immunotherapy with BCG or cryotherapy, especially if histologic evaluation suggests incomplete resection. Ancillary treatments could include any of the above-mentioned treatment options. Cryotherapy alone can be effective for smaller lesions and has success rates of up to 75%.8,21 It is relatively easy, quick, and inexpensive to perform and can be repeated, but when unsuccessful in achieving remission frequently results in the proliferation of the aggressive broblastic form that may be refractory to treatment (Fig. 13).15 Intralesional chemotherapy with either cisplatin (1 mg/cm3 of 3.33 mg/mL solution once every 2 weeks for 4-5 treatments), an alkylating agent that binds to DNA and inhibits replication, or 5-uoruracil (50 mg/mL in a 1:1 ratio of oil every 1-2 weeks for 4-5 treatments), an antimetabolite, in sesame oil have had variable successes of up to 80%.2,18,22 Cisplatin is much more expensive than 5-FU, but it may also be more effective. These two intralesional drugs may be appropriate when other modalities of treatment are not possible. Probably the most promising methods of treatment are immunotherapy, especially in conjunction with surgical excision, and radiation therapy. Radiation therapy is very expensive, but

Figure 12 A nodular sarcoid on the upper eyelid of a horse.

extremely aggressive and resistant or refractory to treatment, while others regress spontaneously. While they do not metastasize, they can be locally aggressive and tend to have a relatively high rate of recurrence, especially when surgical methods of treatment leave residual tumor cells in place. The mean age for the onset of clinical signs associated with sarcoids is between 3 and 7 years of age.18 Quarter Horses, Appaloosas, Arabians, and Thoroughbreds are reported to have the highest risk, while Standardbreds and Lippizaners have the lowest.17 It is believed that genetic predisposition, as well as the potential induction or inuence of a viral agent (bovine papillomavirus types 1 and 2 have been implicated), may play a role in the development of these tumors.17,19 The presence of ies is considered a risk factor for the development of sarcoid because ies are believed to be capable of directly translocating sarcoid cells to open wounds or to the medial canthal region of horses.17 Diagnosis depends on an index of clinical suspicion and biopsy results. Since biopsy or surgical trauma (or any trauma at all for that matter) may induce proliferation and expression of virus and resultant

Table 1 Types of Sarcoids Type of Sarcoid Occult Verrucose Nodular Type A Nodular Type B Fibroblastic Type A Fibroblastic Type B Mixed Malignant Description Area of alopecia or altered hair, small sub-epidermal, miliary nodules/plaques Alopecic, thickened area with hyperkeratosis and extensive aking, some ulceration Subcutaneous nodule with no epidermal involvement Subcutaneous nodule with varying involvement of overlying skin Fleshy, ulcerated appearance; pedunculated, limited base palpable within skin Fleshy, ulcerated appearance; broad-base, with thickening beyond obvious margins Characteristics of two or more of the other dened types Unusual; aggressive nodules, cords of palpable tumor, extensive inltration, variable ulceration

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Table 2 Sarcoid Treatment Regimes Agent Cryotherapy Cisplatin 3.33 mg/mL 5-FU 50 mg/mL in 1:1 sesame oil BCG Table 3 Sarcoid Therapy Treatment Modality Benign neglect Surgical excision Cryotherapy Chemotherapy Immunotherapy (BCG) Radiation Overall Success Rate Variable <50% Up to 75% Up to 80% 69100% Nearly 100% Dose Three quick freeze/slow thaw cycles 1 mg/cm3 1 mL/cm3 1 mL/cm3

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Frequency May be repeated Q 2 weeks 45 treatments Q 12 weeks 45 treatments Q 24 weeks 39 treatments

Types that are Non-responsive to or Unsuitable for this Therapy All types eventually need treatment of some form or euthanasia Extensive lesions, achievable margins <2 cm, without adjunctive therapy Large or deep lesions Occult, verrucose Occult, verrucose

has the best outcomes with long-term success rates approaching 100%.15,16,20 Interstitial brachytherapy (gamma radiation) with iridium-192 or gold-198, wherein radioactive implants are placed within the offending masses and left for 10 to 14 days, delivers a large dose of radiation to a focal area with little affect on surrounding tissues. It has limited availability in private practice, however, and is restricted to certied operators and approved facilities. Beta radiation with strontium-90 is less effective in large masses because its penetration is limited to 1 to 2 mm.15,16 Immunotherapy with Bacillus Calmette-Guerin cell wall extracts stimulates a nonspecic immune response that can result in regression of sarcoids. It is most effective for the nodular (Fig. 12) and broblastic forms of sarcoid (Fig. 13); occult and verrucuous forms tend to respond poorly.15 Therapy consists of intralesional (rather than perilesional) injection of the product to the point of saturation of the tumor (usually 1 mL/cm3).2,16 The procedure is repeated every 2 to 4 weeks for 3 to 9 treatments in the same location.16,23 It is very important to

note that as a consequence of the immune reaction that is generated by the BCG, each subsequent injection carries with it the likelihood of a faster and more intense local inammatory response, and the possibility of anaphylaxis (rare but possible).23 For these reasons, it is recommended that the patient be prophylactically pretreated with unixin meglumine (1.1 mg/kg IV) and diphenhydramine HCL (1.0 mg/kg IV) before administration of BCG.2,8,15,16,18 With each additional injection, more local inammation should be present and progress to the point where necrosis, ulceration, and regression are usually evident after the third injection. The inammation should be allowed to subside before additional injections are performed.8 Treatment is discontinued if no response is seen after the fourth injection.18 Tumor regression may occur slowly over several months. For the nodular and broblastic forms of sarcoid, success rates of immunomodulating therapy with BCG range from 69% to 100% (Table 3).15,16,17,24 Other forms of treatment including hyperthermia and topical application of 5-uoruracil or idoxuridine have been attempted with only marginal to poor successes.8,15 The overall prognosis for equine periocular sarcoids is guarded. Cases that carry the worst prognosis are those that have been previously treated unsuccessfully.15

References
1. Carastro SM: Equine ocular anatomy and ophthalmic examination. Vet Clin North Am Equine Pract 20:285-299, 2004 2. Lassaline ME: Emergency treatment of ocular trauma, in Robinson NE (ed): Current Therapy in Equine Practice 5. St. Louis, MO, Saunders, 2003, pp 461-467 3. Brooks DE: Equine ophthalmology, in Gelatt KN (ed): Veterinary Ophthalmology (ed 3). Baltimore, MD, Lippincott, Williams & Wilkins, 1999, pp 1053-1116 4. Strubbe DT: Ophthalmic examination and diagnosic procedures, in Gelatt KN (ed): Veterinary Ophthalmology (ed 3). Baltimore, MD, Lippincott, Williams & Wilkins, 1999, pp 427-466 5. Thurmon JC, Tranquilli WJ, Benson GJ (eds): Lumbs and Jones Veterinary Anesthesia (ed 3). Baltimore, MD, Lippincott, Williams & Wilkins, 1996, pp 448-451 6. Severin GA: Eyelids, in Severins Veterinary Ophthalmology Notes (ed 3). Fort Collins, CO, 1996, pp 151-206 7. Severin GA: Principles of ocular surgery, in Severins Veterinary Ophthalmology Notes (ed 3). Fort Collins, CO, 1996, pp 139-150 8. Miller TR: Eyelids, in Auer JA (ed): Equine Surgery. Philadelphia, PA, WB Saunders, 1992, pp 599-619

Figure 13 An ulcerated broblastic sarcoid (the most aggressive form) on the upper eyelid of a horse.

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