TUGAS MATA KULIAH

ILMU BEDAH KHUSUS VETERINER

TEKNIK OPERASI EKSTIRPATIO BULBUS OCULI

Oleh:
Octo Berkat Gea 1509005093
Katarina Kewa Ujan 1509005094
Stefanus Andre Gunawan 1509005095
I Kadek Toto Sugita 1509005097
Archie Leander Maslim 1509005098

LABORATORIUM BEDAH VETERINER

FAKULTAS KEDOKTERAN HEWAN

UNIVERSITAS UDAYANA

TAHUN 2018

i
 RINGKASAN

Ekstirpasi disebut juga enukleasi bulbus oculi, namun terdapat perbedaan

pada komponen mata yang akan di bedah untuk di angkat, pada ekstirpasi bulbus
oculi komponen mata yang akan di bedah akan dilakukan pengangkatan pada
seluruh komponen mata, dimana ekstirpasi tidak bertujuan sebagai bedah
kosmetik, sedangkan enukleasi bulbus oculi bertujuan untuk bedah kosmetik.
Ekstirpasi biasanya dilakukan untuk kasus di mana upaya sebelumnya untuk
mengendalikan proses patologis okular dengan terapi medis dan / atau bedah gagal
dilakukan. Pada perawatan post operasi, langkah utama yang dapat dilakukan
adalah melindungi luka jahitan operasi untuk melindungi dari infeksi, dan
pemberian antibiotika.

ii
 SUMMARY

Common ecstasy is also called enucleation of the bulbus oculi, but there is
a difference in the component of the eye that will be in surgery to excise, the
extravagant bulbus oculi component of the eye will be surgical remove of all the
components of the eye. Extirpation not aimed as cosmetic surgery, while enukleasi
bulbus oculi aims for cosmetic surgery. Extirpation is done for cases where
previous attempts to control ocular pathologic processes with medical and / or
surgical therapy fail. In postoperative care, the main step that can be done is to
protect the surgical suture to protect from infection, and antibiotics.

iii
 KATA PENGANTAR

Puji syukur penulis panjatkan kehadirat Tuhan Yang Maha Esa atas
segala rahmatNYA sehingga penulis dapat membuat paper ini hingga selesai.
Tidak lupa penulis juga mengucapkan banyak terimakasih atas bantuan dari
pihak yang telah berkontribusi dengan memberikan sumbangan baik materi
maupun pikirannya.
Dan harapan kami semoga makalah ini dapat menambah pengetahuan
dan pengalaman bagi para pembaca, Untuk ke depannya dapat memperbaiki
bentuk maupun menambah isi paper agar menjadi lebih baik lagi.
Karena keterbatasan pengetahuan maupun pengalaman, penulis
menyadari bahwa masih banyak kekurangan dalam paper ini, Oleh karena itu
penulis sangat mengharapkan saran dan kritik yang bersifat membangun dari
pembaca demi kesempurnaan paper ini.

Denpasar, 2 Sepetember 2018

Penulis

iv
 DAFTAR ISI

HALAMAN JUDUL................................................................................................ i
RINGKASAN/SUMMARY ................................................................................... ii
KATA PENGANTAR ........................................................................................... iv
DAFTAR ISI ............................................................................................................v
DAFTAR GAMBAR ............................................................................................. vi
DAFTAR LAMPIRAN ......................................................................................... vii
BAB I PENDAHULUAN ........................................................................................1
1.1 Latar Belakang .......................................................................................1
1.2 Tujuan Penulisan ....................................................................................2
1.3 Manfaat Penulisan ..................................................................................2
BAB II TINJAUAN PUSTAKA..............................................................................3
2.1 Definisi ...................................................................................................3
2.2 Teknis Operasi........................................................................................4
2.3 Perawatan Post Operasi ..........................................................................4
BAB III PEMBAHASAN ........................................................................................5
3.1 Premedikasi ............................................................................................5
3.2 Prosedur Operasi ....................................................................................5
3.3 Pasca Operasi .........................................................................................8
BAB IV PENUTUP ...............................................................................................10
4.1 Kesimpulan...........................................................................................10
4.2 Saran .....................................................................................................10
DAFTAR PUSTAKA ............................................................................................11

v
 DAFTAR GAMBAR

Gambar 1. a. sterilisasi dengan iodine, b. pembersihan fonix konjungtiva..5

Gambar 2. Pembuatan sayatan .....................................................................6

Gambar 3. Konjungtiva bulbar ditahan dengan foceps ................................7

Gambar 4. Diseksi mata menggunakan gunting...........................................7

Gambar 5. Pemotongan saraf optic ..............................................................8

Gambar 6. Penjahitan tepi kelopak mata luar...............................................8

vi
 DAFTAR LAMPIRAN

Lampiran 1. Ilmu Bedah Veteriner dan Teknik Operasi ................................

Lampiran 2. A Comparison of Thiopental, Propofol, and Diazepam-

Ketamine Anesthesia for Evaluation of Laryngeal Function in Dogs
Premedicated With Butorphanol-Glycopyrrolate ...........................................

Lampiran 3. Subconjunctival Enucleation Surgery in Dogs & Cats ..............

Lampiran 4. Ophthalmology for the Veterinary Practitioner .........................

vii
 BAB I

PENDAHULUAN

1.1 Latar Belakang

Mata merupakan organ penting dalam tubuh mahkluk hidup. Pada

hewan penyakit serta kelainan pada mata pun sering terjadi. Penyakit mata
yang sering terjadi pada hewan antara lain seperti katarak, tumor, iritasi atau
bahkan luka akibat perkelahian antara hewan lainnya. hal ini menyebabkan
kerugian ekonomi yang besar bagi pemilik dan sering dijumpai dalam profesi
dokter hewan. Selain penanganan juga dapat dilakukan dengan operasi atau
pembedahan. Dalam dunia veteriner biasa disebut dengan Operasi Ekstirpatio
Bulbus Oculi .

Operasi Ekstirpatio merupakan operasi untuk pengambilan atau

pengangkatan dan pembuangan bola mata dari cavum orbital. Teknik operasi
ekstirpatio lebih sering digunakan untuk membuang mata yang buta dan sakit
yang tidak dapat disembuhkan melalui pengobatan. Enukleasi pada kondisi
yang tepat biasanya digunakan sebagai alternatif untuk mengatasi rasa sakit
konstan, euthanasia dan untuk menghilangkan metastasis neoplasia.

Abnormalitas yang sering ditemukan pada kelopak mata adalah

etropion ( melekuknya tepi palpebrae ke arah bola mata), ektropion
(melekuknya tepi palpebrae bawah ke arah luar), trichiasis (penyimpangan
abnormal dari silia sehingga akan bergesekan dengan kornea atau
konjunctiva), distichiasis dan coloboma (tidak adanya kelopak mata). Etropion
dapat disebabkan secara kongenital atau dapatan selama hidup.

Indikasi dari ekstirpatio adalah terjadinya peningkatan tekanan

intraokular yang dihasilkan oleh glaukoma yang tidak dapat disembuhkan
dengan pengobatan. Seperti Neoplasma okular dan periocular yang berpotensi
menyebabkan kesakitan intraokular atau metastasis, trauma yang parah yang
dihasilkan oleh luka perforasi pada mata atau kerusakan pada lensa dan yang
lainnya. Abnormalitas pada bola mata dapat dihasilkan oleh pengaruh lokal
ataupun pengaruh sistemik. Perubahan atau kelainan bola mata diawali oleh

1
kelainan secra unilateral kemudian dapat berubah menjadi bilateral. Selain itu,
kelainan yang sering ditemukan adalah keratitis yang derajatnya bervariasi
dari kekaburan penglihatan ringan pada kasus ringan ataupun kasus akut.

1.2 Tujuan Penulisan

Tujuan dari penulisan makalah ini ialah, mengetahui apa maksud dan
bagaiman teknik Operasi Ekstirpatio Bulbus Oculi serta bagaimana prosedur
dan tatalaksana terapi post operasinya. Hal-hal ini dapat diperlukan nantinya
sebagai referensi pengetahuan di dunia kedokteran hewan.

1.3 Manfaat Penulisan

Dalam penulisan makalah ini diharapkan para mahasiswa dapat

mengerti, mengetahui manfaat dan kegunaan Operasi Ekstirpatio Bulbus
Oculi. Serta mengetahui bagaimana tata cara pelaksaan Operasi Ekstirpatio
Bulbus Oculi.

2
 BAB II

TINJAUAN PUSTAKA

2.1 Definisi

Exterpatio bulbus oculi intoto adalah tindakan operasi untuk

pengeluaran seluruh oculi bola mata dari cavum orbita. Bila penyebabnya
tumor, maka selain bola mata juga sebanyak mungkin jaringan otot yang sakit
dibuang, termasuk sedikit jaringan otot yang sehat. Apabila penyebabnya
proses traumatis maka bola mata dapat diambil dan ditinggalkan jaringannya
sebanyak mungkin agar kesembuhan cepat terjadi dan mata tidak terlalu
cekung. Sebelum bola mata dipotong, pada bagian pangkalnya perlu diligasi
agar tidak terjadi perdarahan

Extirpatio bulbus oculi intoto merupakan suatu tindakan pengambilan

seluruh komponen bola mata dari cavum orbital. Meskipun operasi ini disebut
enucleation dari mata tetapi perbedaan antara extirpation bulbus oculi dengan
enucleation bulbus oculi adalah terletak pada komponen mata yang diambil
atau di angkat, untuk extirpation bulbus oculi seluruh komponen yang ada di
bola mata itu diambil seluruhnya dan tindakan extirpatio bulbus oculi ini tidak
mementingkan nilai estetika, akan tetapi pada kasus enucleasi bulbus oculi ini
masih mementingkan nilai estetika dari hewan yang di operasi.

Exteirpatio bulbul oculi biasanya dilakukan pada hewan yang

mengalami traumatis, berkelahi atau karena penyakit, sehingga mata tidak
dapat berfungsi secara normal dan harus dilakukan pengangkatan agar tidak
terjadi infeksi. Penyakit pada mata biasanya menyebabkan perubahan di
sekitar kulit, misalnya dermatitis periorbital, yang disebabkan oleh adanya
discharge pada kondisi konjunctivitis, keratokonjunctivitis, atau rhinitis.
Beberapa gejala yang menyertai kelainan pada mata adalah keluarnya mata,
kesakitan pada mata, lapisan di atas mata, mata berkabut, mata keras atau
lunak, iritasi pada kelopak mata, mata menonjol atau terbenam, pergerakan
mata abnormal, dan perubahan warna pada mata.

3
 Kesakitan pada mata biasanya berkaitan dengan sekresi air mata yang
berlebihan dan penglihatan yang terganggu. Kondisi ini menyebabkan hewan
cenderung menggaruk pada bagian mata yang sakit. Kondisi lain adalah
dicirikan oleh adanya penonjolan membran nictitan yang merupakan respon
terhadap kesakitan. Penyebab umum dari kesakitan pada mata adalah
perlukaan di kornea dan penyakit-penyakit di bagian mata yang lebih dalam,
termasuk masalah gangguan penglihatan seperti glaucoma dan uveitis.
Lapisan di atas permukaan mata biasanya berbentuk opaque atau lapisan
putih. Apabila penyebab proses traumatis maka bola mata dapat diambil dan
ditinggalkan jaringannya sebanyak mungkin agar kesembuhan cepat terjadi
dan mata tidak terlalu cekung. Sebelum bola mata dipotong pada bagian
pangkalnya perlu dilakukan diligasi agar tidak terjadi pendarahan.

2.2 Teknik Operasi

Extirpatio bulbus oculi dapat dilakukan dengan pengangkatan seluruh

komponen bola mata dari cavum orbital. Teknik operasi dapat dilakukan
dengan pengangkatan atau pengambilan bola mata secara keseluruhan.

2.3 Perawatan Post Operasi

Pada perawatan post operasi, langkah pertama yang dapat dilakukan

adalah melindungi luka jahitan operasi. Antibiotik oral bisa diberikan selama
beberapa hari untuk mencegah terjadinya infeksi sekunder.

4
 BAB III

PEMBAHASAN

3.1 Premedikasi

Premedikasi adalah pemberian obat (± 1-2 jam) sebelum induksi

anestesia dengan tujuan untuk melancarkan induksi, rumatan (durasi), dan
bangun (pemulihan) anestesia. Premedikasi diberikan sebelum memberikan
anestesi umum atau local pada hewan yang dapat mempengaruhi fase anestesi
(induksi, durasi, pemulihan). Premedikasi sering disebut sebagai preanesthetic
atau preoperative medication. Kebanyakan obat premedikasi diberikan hanya
secara injeksi, terutama intramuscular atau subkutan, dan intravena.

Pemberian premedikasi adalah memberikan suatu bahan atau obat

beberapa waktu sebelum pemberian anestesi yang sebenarnya dengan maksud
dan tujuan adalah : agar induksi anestesi berjalan baik (smooth) dan aman
(safe); mengurangi jumlah (dosis) zat aktif anestesi, dengan demikian
mengurangi efek buruk baik farmakologis maupun ekonomis dan mencapai
stadium anestesi yang lebih stabil.

Premedikasi diperlukan sebagai tahap awal setiap prosedur operasi

untuk menidurkan hewan dengan lebih efisien waktu. Obat anestesi injeksi
sebagian besar digunakan pada situasi di mana induksi cepat. Anestesi sebagai
indikasi utama, dan beberapa agen cocok untuk perawatan anestesi. Faktor
penting untuk indikasi agen ini meliputi onset tindakan, durasi efek anestesi,
rute pemberian, dan respons kardiorespirasi (Laredo, 2015). Premedikasi
menggunakan butorphanol dapat digunakan ditinjau dari keamanan efek
sedative dan kecenderungan depresi respirasi yang lebih rendah (Gross dkk,
2002).

3.2 Prosedur Operasi

Prosedur oprasi Extirpatio bulbus oculi antara lain:
i. Cukur rambut dari sekitar mata sebelum memposisikan kepala.
Kemudian tempatkan posisi operator di lateral, dengan kepala hewan
diposisikan dan distabilkan. Setelah memposisikan, persiapkan area

5
 untuk operasi dengan antiseptik seperti iodine (A). Fornix konjungtiva
harus sterilkan terlebih dahulu dengan larutan iodine encer untuk
mensterilkan daerah tersebut dan kemudian dengan mencuci mata
untuk menghilangkan semua rambut yang dipotong (B). Tutupi kepala
dan tubuh dengan tirai steril.

(Gambar 1. A; sterilisasi dengan iodine, b; pembersihan fonix

konjungtiva)

ii. Buat sayatan canthotomi lateral 1- 2 cm dengan gunting Mayo atau

pisau pisau bedah nomor 15. Sebelum memotong, klem sayatan ini
dengan hemostat atau sisipkan insisi dengan 1/100 epinefrin subkutan
untuk mengendalikan perdarahan. Kelopak mata ketiga bisa diangkat
saat ini dengan gunting Mayo setelah menjepit pangkalnya dengan
hemostat.

(Gambar 2. Pembuatan sayatan)

6
iii. Tahan konjungtiva bulbar yang menempel pada limbus dengan
forceps. Gunakan gunting untuk membuat sayatan 360º sedalam 3
sampai 4 mm dari limbus sampai sklera.

(Gambar 3. Konjungtiva bulbar ditahan dengan foceps)

iv. Lanjutkan diseksi mata dengan menggunakan gunting di dinding

skleral sampai mencapai bagian belakang bola mata. Selama
pembedahan. Otot konjungtiva dan ekstraokular dipotong dari bola
mata selama pembedahan (panah) dan tertinggal di orbit. Kelenjar
lakrimal superior bisa dilepas dengan bola mata. Pada saat incici pada
sekitar kelopak mata akan ter jadi perdarahan pada daerah tersebut.
Untuk mengontrol perdarahan pada daerah tersebut dapat dilakukan
pengontrolan dengan baik dengan sistem ligase atau penekanan.

(Gambar 4. Diseksi mata menggunakan gunting)

v. Begitu mata benar-benar bebas dan dapat diputar dengan hati-hati,

Potonglah saraf optik setelah menjepit dari sisi lateral.

7
 (Gambar 5. Pemotongan saraf optik)

vi. Semua bekuan darah pada rongga orbita dikeluaran dari rongga.
Setelah itu kasa yang berada pada rongga orbita di ambil dan
memberikan kasa dengan ukuran 70-80 cm dengan diberikan antiseptic
lotion dimasukkan kedalam rongga orbital. Setelah itu tepi luar dari
kelopak mata dijahit dengan interrupted suture untuk menutup luka
dan sisakan sebgian kecil kasa menjulur keluar menuju bagian dalam
canthus atau kantong mata.

(Gambar 6. Penjahitan tepi kelopak mata luar)

3.3 Pasca Operasi

Pada perawatan post operasi, langkah pertama yang dapat dilakukan
adalah melindungi luka jahitan operasi. Bisa dilakukan penutupan dengan kasa
atau pembalutan di area operasi. Untuk mencegah pasien menggaruk jahitan,
bisa dipasangkan Elizabeth Collar. Antibiotik oral bisa dilakukan dengan
pemberian ampisilin dan selanjutnya dapat dilakukan pemberian ampicilin

8
sirup per oral selama beberapa hari untuk mencegah terjadinya infeksi
sekunder. Selain itu juga dapat diberikan salep mata pada luka bekas jahitan
agar luka cepat kering. Perawatan hewan yang telah dilakukan tindakan
extirpation bulbus oculi setelah operasi pada hari pertama dan ke dua dapat
dilakukan dengan penekanan pada daerah mata yang di operasi, hal ini
bertujuan untuk mengurangi terjadinya akumulasi cairan yang dapat
menghambat kesembuhan dan kemudian kondisi fisiknya juga perlu diamati.
Pelepasan draine dapat dilakukan 12 hari pasca operasi.

9
 BAB IV

PENUTUP

4.1 Kesimpulan

Exterpatio bulbus oculi intoto adalah tindakan operasi untuk

pengeluaran seluruh oculi bola mata dari cavum orbita. Bila penyebabnya
tumor, maka selain bola mata juga sebanyak mungkin jaringan otot yang sakit
dibuang, termasuk sedikit jaringan otot yang sehat. Apabila penyebabnya
proses traumatis maka bola mata dapat diambil dan ditinggalkan jaringannya
sebanyak mungkin agar kesembuhan cepat terjadi dan mata tidak terlalu
cekung. Sebelum bola mata dipotong, pada bagian pangkalnya perlu diligasi
agar tidak terjadi perdarahan.

Pada perawatan post operasi, langkah utama yang dapat dilakukan

adalah melindungi luka jahitan operasi untuk melindungi dari infeksi, dan
pemberian antibiotika.

4.2 Saran

Pembedahan Ekstirpatio Bulbus Oculi memiliki tingkat kesulitan yang

tinggi dan sangat beresiko bagi pasien. Oleh sebab itu teknik operasi ini perlu
diperhatikan dengan baik dan benar.

10
 DAFTAR PUSTAKA

Gross, Marjorie E, dkk. 2015. A Comparison of Thiopental, Propofol, and

Diazepam-Ketamine Anesthesia for Evaluation of Laryngeal Function
in Dogs Premedicated With Butorphanol-Glycopyrrolate. JOURNAL
of the American Animal Hospital Association, Vol. 38.
Krohne S.G. 2009. Subconjunctival Enucleation Surgery in Dogs & Cats. NAVC
clinician’s brief.
Laredo, Francisco. 2015. Injectable Anesthetic. Clinician’s Brief.
Stades, Frans C. 2007. Ophthalmology for the Veterinary Practitioner. Germany:
Schütersche.
Sudisma, I.G.N. 2016. Ilmu Bedah Veteriner dan Teknik Operasi. Denpasar :
Penerbit Plawa Sari.

11
 A Comparison of Thiopental, Propofol,
and Diazepam-Ketamine Anesthesia
for Evaluation of Laryngeal Function
in Dogs Premedicated With
Butorphanol-Glycopyrrolate
Thiopental, propofol, and diazepam-ketamine were compared for evaluation of laryngeal function
in dogs. There was no significant difference among the three protocols in time to observation of
normal function after drug administration or in the occurrence of swallowing, laryngospasm, or
breathing. Jaw tone was significantly greater with diazepam-ketamine. Exposure of the larynx
was excellent in five dogs and moderate in three dogs, each receiving thiopental or propofol.
Exposure was excellent in one dog, moderate in six dogs, and poor in one dog receiving
diazepam-ketamine. Exposure of the larynx for laryngeal function evaluation is more readily
accomplished with thiopental or propofol than with diazepam-ketamine.
J Am Anim Hosp Assoc 2002;38:503-506.

Marjorie E. Gross, DVM, MS, Introduction

Diplomate ACVA In a dog with normal laryngeal function, the arytenoid cartilages of the
larynx abduct during inhalation and passively relax during exhalation.
John R. Dodam, DVM, PhD,
Diplomate ACVA Laryngeal paralysis results in arytenoid cartilages that are displaced
medially and ventrally, remaining in a paramedian location during
Eric R. Pope, DVM, MS, inhalation. Laryngeal paralysis usually manifests as inspiratory stridor,
Diplomate ACVS respiratory distress, or exercise intolerance. Clinical diagnosis of laryn-
geal paralysis in dogs is usually made by evaluating arytenoid cartilage
Brent D. Jones, DVM abduction during inhalation using laryngoscopy under light anesthe-
sia.1-3 Deeper levels of anesthesia will result in a loss of the laryngeal
reflex4 and will make the larynx appear to be paralyzed,1,2 so an anes-
thetic protocol that allows easy visualization while preserving the laryn-
O geal reflex is essential.
Thiopental,1,2,5 propofol,2 and diazepam-ketamine have been used to
provide light anesthesia for evaluation of laryngeal function. The objec-
tive of this study was to compare these three anesthetic protocols to
determine which would be most appropriate for assessing laryngeal
function.

Materials and Methods

From the Departments of Veterinary Medicine
and Surgery (Gross, Dodam, Pope, Jones)
and Veterinary Biosciences (Dodam),
College of Veterinary Medicine,
University of Missouri,
Columbia, Missouri 65211.
JOURNAL of the American Animal Hospital Association
Animals
Eight healthy, female dogs between 2 and 6 years of age were studied.
Prior to assignment to this study, the dogs received a physical examina-
tion, were treated for internal and external parasites, were vaccinated,
checked for heartworms, and received permanent identification mark-
ings (ear tattoo). Dogs weighed an average of 18.4 kg (range, 15.3 to
20.9 kg). Food was withheld for 12 hours prior to the study.
Experimental Protocol
Each dog was anesthetized once with each of three anesthetic protocols
(thiopental,a propofol,b diazepam-ketaminec), with a 24-hour period
503
504 JOURNAL of the American Animal Hospital Association
between each anesthetic administration. The order of drug
administration was determined by random assignment to one
of six schedules: thiopental, propofol, diazepam-ketamine;
thiopental, diazepam-ketamine, propofol; propofol, thiopen-
tal, diazepam-ketamine; diazepam-ketamine, propofol,
thiopental; diazepam-ketamine, thiopental, propofol; and
propofol, diazepam-ketamine, thiopental.
After intravenous (IV) catheter placement, butorphanol
(0.5 mg/kg body weight) and glycopyrrolate (0.01 mg/kg
body weight) were administered IV 5 minutes prior to
administration of the designated anesthetic protocol.
Thiopental (20 mg/kg body weight, calculated dose), propo-
fol (6 mg/kg body weight, calculated dose), or diazepam (0.5
mg/kg body weight, calculated dose) and ketamine (10
mg/kg body weight, calculated dose) were administered IV
until the mouth could be gently pulled open for examination
(“to effect”). Anesthetic drug doses were selected based on
doses commonly administered to induce anesthesia in clini-
cal patients at the University of Missouri Veterinary Medical
Teaching Hospital. Thiopental was administered as a bolus
for the first 50% of the volume, and the remainder titrated to
effect. Propofol was administered slowly over 1 minute to
effect. Diazepam and ketamine were mixed in the same
syringe and administered slowly over 1 minute to effect. The
same individual administered anesthesia for all dogs and
anesthetic protocols. The amount of drug administered for
adequate laryngeal exposure was recorded. Dogs were placed
in sternal recumbency with the head elevated to the level of
normal carriage. The mouth was held open by grasping the
upper jaw in one hand and pulling the tongue forward and
down between the lower canine teeth using the other hand.
The blade of the laryngoscope was directed into the orophar-
ynx, with the tip of the blade positioned under the tip of the
epiglottis and angled ventrally to expose the arytenoid carti-
lages. Assessment of laryngeal function was made as soon
after the mouth was opened and visualization of the larynx
was possible, and it was performed for all dogs by the same
individual, who was blinded to the anesthetic protocol. Time
in seconds from drug administration to observation of ary-
tenoid abduction was recorded. Jaw tone was graded from 0
(no jaw tone, easy to open) to 3 (excessive jaw tone, difficult
to open). Breathing, swallowing, and laryngospasm were
graded as present (score of 1) or absent (score of 0). Overall
exposure of the larynx for observation of function was
graded as excellent (i.e., mouth easily opened, arytenoid car-
tilages readily visualized with no swallowing or tongue
movement), moderate (i.e., some jaw tone present when
opening mouth, some swallowing or tongue movement dur-
ing visualization of arytenoid cartilages), or poor (i.e., mouth
difficult to open, arytenoid cartilages difficult to visualize
due to swallowing or tongue movement). Laryngeal function
was designated as normal (i.e., abduction during inhalation)
or abnormal (i.e., no abduction during inhalation).
Statistical Analysis
A two-way analysis of variance (ANOVA) was used in the
analysis of time to normal function (i.e., abduction). Vari-
November/December 2002, Vol. 38
ability between animals was accounted for as a blocking
variable. Cochran’s Q test was used to test for differences in
the proportion of positive responses for breathing, swallow-
ing, and laryngospasm with each drug protocol. Friedman’s
test was used to evaluate differences in jaw tone. A P value
of <0.05 was considered significant for all of the above
analyses.
Results
Normal laryngeal function was observed in all dogs. Mean
time in seconds from drug administration to observation of
normal function (i.e., arytenoid abduction) was 51.9±36.3
seconds (mean±standard deviation [SD]) for thiopental,
37.8±24.0 seconds for propofol, and 26.3±7.9 seconds for
diazepam-ketamine, and did not differ significantly among
the three protocols. Mean percentage of total calculated
drug administered was 51.9±5.3% (10.4±1.1 mg/kg body
weight) for thiopental; 60.1±13.2% (3.6±0.8 mg/kg body
weight) for propofol; and 55.9±10.9% (0.3±0.1 and 5.6±1.1
mg/kg body weight, respectively) for diazepam-ketamine.
One dog experienced apnea after both the thiopental and
propofol injections and would breathe only when the ary-
tenoids were stimulated with a cotton-tipped swab. Swal-
lowing occurred in two dogs receiving thiopental, one dog
receiving propofol, and five dogs receiving diazepam-keta-
mine. Laryngospasm occurred in one dog receiving propo-
fol and one dog receiving diazepam-ketamine [see Table].
No significant differences occurred among the three drug
protocols for the occurrence of swallowing, laryngospasm,
or breathing.
Jaw tone was absent in five dogs receiving thiopental,
seven dogs receiving propofol, and one dog receiving
diazepam-ketamine; slight in two dogs receiving thiopental;
moderate in one dog receiving thiopental, one dog receiving
propofol, and six dogs receiving diazepam-ketamine; and
strong in one dog receiving diazepam-ketamine [see Table].
There was no significant difference between thiopental and
propofol in the amount of jaw tone present after injection.
However, the amount of jaw tone present after diazepam-
ketamine injection was significantly increased when com-
pared with both thiopental and propofol. Exposure of the
larynx was graded as excellent in five dogs receiving
thiopental (62.5%), in five dogs receiving propofol (62.5%),
and in one dog receiving diazepam-ketamine (12.5%).
Exposure was graded as moderate in three dogs receiving
thiopental (37.5%), in three dogs receiving propofol
(37.5%), and in six dogs receiving diazepam-ketamine
(75%). One dog receiving diazepam-ketamine (12.5%) was
scored as having poor exposure of the larynx [see Table].
Discussion
Disease or injury involving the caudal laryngeal or recurrent
laryngeal nerves or the cricoarytenoideus dorsalis muscle
could result in laryngeal paralysis. Laryngeal paralysis may
be congenital6,7 or more commonly may be acquired.
Acquired idiopathic laryngeal paralysis usually occurs in
older, large-breed dogs, but may be observed in a variety of
November/December 2002, Vol. 38 Anesthesia for Evaluation of Laryngeal Function 505

Table

Subjective Scoring of Responses During Laryngeal Examination in Dogs

When Comparing Three Anesthetic Protocols

Number of Dogs

Thiopental Propofol Diazepam-Ketamine

Response

Breathing*
0 1 1 0
1 7 7 8

Swallowing*
0 6 7 3
1 2 1 5

Laryngospasm*
0 8 7 7
1 0 1 1

Jaw Tone†
0 5 7 1
1 2 0 0
2 1 1 6
3 0 0 1

Exposure Score

Excellent 5 5 1
Moderate 3 3 6
Poor 0 0 1

* 0=absent; 1=present
† 0=absent; 1=slight; 2=moderate; 3=strong

sizes and breeds of dogs.5 Laryngeal paralysis may be par-
tial or complete, and unilateral or bilateral, with the severity
of clinical signs directly related to degree of paralysis. Con-
sequently, dogs with unilateral laryngeal paralysis may
have no clinical signs unless they are working or extremely
athletic dogs.8,9 Laryngeal paralysis may be the earliest evi-
dence of a generalized neuropathy or myopathy,9-12 and
possible association with hypothyroidism has been sug-
gested.13 The larynx is in a relatively protected position in
the dog, but laryngeal paralysis may be trauma induced,
may occur as a postsurgical complication, or may be the
result of pressure from space-occupying lesions, such as
abscesses or tumors.1,5
Adduction of the arytenoid cartilages after exhalation
when the epiglottis has been stimulated is referred to as the
laryngeal reflex.4 The laryngeal reflex serves as an endpoint
when assessing the level of anesthesia for evaluation of
laryngeal function. Deeper levels of anesthesia, such as
used to facilitate intubation, will result in loss of this reflex
and will make the larynx appear to be paralyzed. To avoid
inappropriate diagnosis of laryngeal paralysis, an anesthetic
protocol that allows visualization while preserving the
laryngeal reflex is essential. The three protocols investi-
gated in this study have the benefit of being administered
by titrating “to effect,” which may allow greater control
over depth of anesthesia and make them uniquely suitable
for assessing laryngeal function.
Before attempting to evaluate laryngeal function, the
evaluator should become familiar not only with the
anatomy and function of the larynx, but also with the drugs
used to provide anesthesia for exposure of the arytenoid
cartilages. Thiopental,1,2,5 propofol,l,2 and diazepam-keta-
mine are anesthetic protocols that have been commonly
used to provide light anesthesia for evaluation of laryngeal
function. Thiopental is an ultrashort-acting thiobarbiturate
that is widely used for induction of anesthesia in dogs. It is
506 JOURNAL of the American Animal Hospital Association
typically titrated IV to effect,14 which allows some control
over the level of anesthesia that is achieved. Consciousness
is regained primarily due to rapid redistribution of the drug.
Propofol is an alkyl phenol in an emulsion formulation that
is used for induction and maintenance of anesthesia in dogs.
It is administered slowly to effect IV. Recovery from propo-
fol is due to rapid redistribution as well as to rapid metabo-
lism, with both hepatic and extrahepatic metabolism occur-
ring.15 Diazepam is a benzodiazepine sedative-hypnotic
that has muscle relaxant and anticonvulsant properties. It is
commonly combined with ketamine, a dissociative anes-
thetic, to relieve muscle rigidity and prevent seizure-like
activity associated with dissociatives in dogs.16 Ketamine
and diazepam are metabolized by the liver, although a per-
centage of ketamine is excreted unchanged in urine, and
some metabolites of diazepam may be active. Some pharyn-
geal reflexes are preserved with this combination, which
may make visualization of the larynx difficult.
The time from initial drug administration to observation
of normal function was not significantly different among
the three drug protocols in this study. However, laryn-
gospasm occurred more frequently, and jaw tone was sig-
nificantly increased with the diazepam-ketamine protocol.
Consequently, overall exposure was more readily accom-
plished with thiopental or propofol when compared with
diazepam-ketamine.
Deep inspiration is essential for accurate evaluation of
laryngeal function. In this study, spontaneous breathing was
preserved in all but one dog. Arytenoid activity can be very
difficult to evaluate during shallow breathing or apnea and
should be correlated with the phase of the respiratory cycle.
Paralyzed arytenoid cartilages may actually be pushed out-
ward during exhalation and give the appearance of abduc-
tion, or they may paradoxically be sucked inward due to the
negative pressure generated during inhalation, giving the
impression of adduction.2 This emphasizes the need for as
light an anesthetic level as possible while still allowing
exposure for evaluation. In a preliminary study, it was
determined that light anesthesia was difficult to achieve and
maintain without premedication.d However, because many
of the patients undergoing laryngeal examination are also in
some degree of respiratory distress, a very mild sedative
with minimal respiratory depression would be desirable. In
the present study, premedication with butorphanol was
selected based on its mild sedative effects and minimal
depression of respiration. Certainly, the doses of anesthetic
drugs and the character of the laryngeal examination may
differ if butorphanol were omitted from the protocol.
In this study, laryngeal function in normal dogs was
determined while comparing three different anesthetic pro-
tocols. It may be convenient to infer from this study that
anesthetic protocols that facilitate recognition of the pres-
ence or absence of normal arytenoid function would also be
appropriate for evaluation of subtle changes in function.
However, determining the appropriateness of these proto-
cols for evaluating subtle changes in arytenoid function is
beyond the intent and scope of this study.
November/December 2002, Vol. 38
Conclusion
Normal laryngeal function was observable with the three
protocols investigated in this study. However, the overall
exposure score indicates that visualization of the larynx in
dogs premedicated with butorphanol is more readily
accomplished with thiopental (10.4±1.1 mg/kg body
weight) or propofol (3.6±0.8 mg/kg body weight) when
compared with diazepam-ketamine (0.3±0.1 mg/kg body
weight and 5.6±1.1 mg/kg body weight, respectively).
a Pentothal; Abbott Laboratories, North Chicago, IL
b Rapinovet; Schering-Plough Animal Health Corp., Union, NJ
c Abbott Laboratories, North Chicago, IL
Ketaject; Phoenix Pharmaceutical, Inc., St. Joseph, MO
d Gross ME, Dodam JR. Personal communication.
Acknowledgment
The authors acknowledge the generosity of Mallinckrodt-
Shering (presently Shering-Plough) in donating propofol
for this study.
References
11. Greenfield CL. Canine laryngeal paralysis. Comp Cont Ed Pract Vet
1987;9:1011-1020.
12. LaHue TR. Laryngeal paralysis. Seminars in Vet Med and Surg (Sm
Anim) 1995;10:94-100.
13. Smith MM. Diagosing laryngeal paralysis. J Am Anim Hosp Assoc
2000;36:383-384.
14. Turner DM, Ilkiw JE. Potency of rapidly acting barbiturates in dogs,
using inhibition of the laryngeal reflex as the end point. Am J Vet Res
1990;51:595-597.
15. Gaber CE, Amis TC, LeCouteur RA. Laryngeal paralysis in dogs: a
review of 23 cases. J Am Vet Med Assoc 1985;186:377-380.
16. Venker-van Haagen AJ, Hartman W, Goedegebuure SA. Spontaneous
laryngeal paralysis in young bouviers. J Am Anim Hosp Assoc
1978;14:714-720.
17. O’Brien JA, Hendriks J. Inherited laryngeal paralysis: analysis in the
husky cross. Vet Quart 1986;8:301-302.
18. O’Brien JA, Harvey CE. Disease of the upper airway. In: Ettinger SJ,
ed. Textbook of veterinary internal medicine – diseases of the dog and
cat. Vol. 1. Philadelphia: WB Saunders, 1975:587-598.
19. Lane JG. Canine laryngeal surgery. Vet Ann 1978;18:239-250.
10. Wykes PM. Canine laryngeal diseases. Part I: anatomy and disease
syndromes. Comp Cont Ed Pract Vet 1983;5:8-13.
11. Reinke JD, Suter PF. Laryngeal paralysis in a dog. J Am Vet Med
Assoc 1978;172:714-716.
12. O’Brien JA, Harvey CE, Kelly AM, et al. Neurogenic atrophy of the
laryngeal muscles of the dog. J Sm Anim Pract 1973;14:521-532.
13. Harvey HJ, Irby NL, Watrous BJ. Laryngeal paralysis in hypothyroid
dogs. In: Kirk RW, ed. Current veterinary therapy VIII, small animal
practice. Philadelphia: WB Saunders, 1983:694-697.
14. Thurmon JC, Tranquilli WJ, Benson GJ, eds. Lumb and Jones’ veteri-
nary anesthesia. 3rd ed. Baltimore: Williams and Wilkins, 1996:223-
225.
15. Thurmon JC, Tranquilli WJ, Benson GJ. Lumb and Jones’ veterinary
anesthesia. 3rd ed. Baltimore: Williams and Wilkins, 1996:232-233.
16. Lin HC. Dissociative anesthetics. In: Thurmon JC, Tranquilli WJ,
Benson GJ, eds. Lumb and Jones’ veterinary anesthesia. 3rd ed. Balti-
more: Williams and Wilkins, 1996:244-251.
Topics in Medicine and Surgery

Enucleation of Exotic Pets

Bradford J. Holmberg, DVM, PhD, Dip. ACVO

Abstract
Enucleation is often the final option when considering ocular treatment for an
exotic pet patient. There are many considerations when performing the surgical
procedure to remove the eye. It is incumbent on the surgeon to be familiar with the
anatomy of the individual species’ globe and orbit to reduce hemorrhage, optic
nerve trauma, and postsurgical complications. This review of enucleation proce-
dures will focus on ocular anatomical differences and techniques that should be
used to maximize surgical success. Copyright 2007 Elsevier Inc. All rights reserved.

Key words: exotic pets; small mammal; enucleation; ocular; avian

E
nucleation involves the surgical removal of
the globe along with a short segment of the
optic nerve. The eyelids, third eyelid, conjunc-
tiva, and lacrimal gland(s) are also excised, except in
the rare instance in which an ocular prosthesis (such
as a corneoscleral shell) is fitted. Although cosmesis
is enhanced with a prosthesis, the availability, cost,
and necessity for frequent cleaning prohibit custom-
ary usage. In small mammals, normal grooming be-
havior would likely dislodge the prosthesis and allow
contamination of the orbit, especially because of
their usual habitat consisting of straw or shavings.
Therefore, removal of the globe and adnexa fol-
lowed by closure of the surgical wound are recom-
mended to prevent secondary complications.
Enucleation is usually reserved for cases in which
previous attempts to control an ocular pathologic
process with medical and/or surgical therapy have
failed. It is the treatment of choice for a permanently
blind, painful eye regardless of the cause. Indica-
tions for enucleation include intraocular neoplasia,
diffuse surface ocular neoplasia, perforating corneal
and scleral injuries resulting in loss of ocular con-
tents, intractable intraocular inflammation (e.g.,
uveitis, endophthalmitis, panophthalmitis), unman-
ageable glaucoma, and chronic ocular pain. An ad-
ditional indication is palliation for chronic exposure
secondary to severe exophthalmos. The small size of
the orbit and difficulty accessing the retrobulbar
space make orbital surgery for these cases challeng-
ing. Removal of the eye not only provides comfort,
but also an avenue to address the orbital disease.
Before surgery, knowledge of the relevant ocular
and orbital anatomy is imperative. Ocular anatomy is
similar among species, with all having an outer fibrous
tunic (cornea and sclera), middle vascular tunic
(uvea), inner nervous tunic (retina), and internal op-
tical media (aqueous humor, lens, vitreous). The sclera
of birds and reptiles contains cartilage posterior to the
equator and ossicles in the ciliary region. These in-
crease structural rigidity and, in the bird, contribute to
the tubular shape of the eye. The avian eye fits snuggly
within the shallow orbit, making periocular dissection
difficult. This combination of scleral ossicles, tubular
shape, and shallow orbit in birds necessitates modifica-
tion of routine enucleation techniques. Another
unique feature found in many small mammals (e.g.,
rabbits, ferrets, chinchilla, rats, mice) is the presence of
a large vascular sinus or plexus within the orbit. In the
From the Veterinary Medical Teaching Hospital, University of
California, Davis, CA 95616 USA.
Address correspondence to: Bradford J. Holmberg, Veterinary
Referral Centre, 48 Notch Road, Little Falls, NJ 07424. E-mail:
dvm4eyes@yahoo.com
© 2007 Elsevier Inc. All rights reserved.
1557-5063/07/1602-$30.00
doi:10.1053/j.jepm.2007.03.011

88 Journal of Exotic Pet Medicine, Vol 16, No 2 (April), 2007: pp 88-94

Enucleation of Exotic Pets
rabbit, the venous sinus extends from the globe equa-
tor to the orbital apex and drains posteriorly to the
pterygoid and cavernous sinuses. Laceration of the
sinus during surgery results in significant hemorrhage
and may lead to exsanguination if adequate hemostasis
is not achieved.
Surgical Preparation and Instruments
The planned surgical field should be prepared in a
fashion such that the normal bacterial flora are de-
creased without damaging the skin to reduce the risk
of postoperative infection. The hair or feathers should
be clipped or plucked at least 1 cm around the eyelid
margins. Because of the thin, fragile nature of the skin
of many small mammals, clipping must be done with
extreme care to prevent tears or lacerations. The eyelid
margins and conjunctival fornices are cleansed with
dilute betadine (1:50) solution (Betadine solution; The
Purdue Frederick Co., Stamford, CT USA). Dilute be-
tadine is safe for the ocular surface unlike chlorhexi-
dine (Nolvasan Solution; Fort Dodge/Wyeth, Madison,
NJ USA), which can cause severe corneal cell toxicity.1
Surgical preparation is facilitated by sterile, cotton-
tipped applicators and flushing with a 21-gauge can-
nula. After aseptic preparation of the site, the surgical
field is then draped. Clear plastic, adhesive drapes
(VSP Surgical Drapes; Veterinary Specialty Products,
Inc., Mission, KS USA) are preferred over cloth or
disposable 4-quarter drapes. These transparent drapes
are conforming, inexpensive, and disposable. More
importantly, with the small size of many exotic pets,
they allow the anesthetist to continue monitoring the
patient.2
The small eye of most exotic pets necessitates the
use of magnification and delicate surgical instru-
ments. Several methods of magnification are avail-
able. Loupes are most commonly used, and a mag-
nification of 3.5⫻ is adequate for most ophthalmic
procedures. An operating microscope provides supe-
rior magnification, but with some reduction in depth
and size of the surgical field. It is only necessary for
surgery on eyes with a horizontal corneal diameter of
less than 5 mm. A typical microsurgical pack for
enucleation should include at least the following
instruments: Bishop-Harmon toothed tissue forceps,
Barraquer pediatric eyelid speculum, conjunctival
fixation forceps, Westcott tenotomy scissors, Stevens
tenotomy scissors, mosquito hemostatic forceps, #15
and #11 Bard-Parker scalpel blades and handle, mi-
crosurgical needle driver (Troutman or similar),
Derf needle driver (for rabbits and larger birds),
bulldog clamp or serrefine, and a silicon bulb sy-
ringe and cannula.
89
Because of the extensive vascular network within the
retrobulbar space of many small mammals and their
small total blood volume, hemostasis is critical during
surgery. Three useful sponges include cotton-tipped
applicators, Weck-cel sponges (Medtronic Solan, Jack-
sonville, FL USA), and dental sponges. These sponges
absorb up to 0.1, 0.3, and 3.0 mL of blood, respectively,
and should be counted and used for estimation of
blood loss. Other mechanisms to achieve hemostasis
include the use of handheld thermal cautery, bipolar
radiosurgery (Ellman, Inc., Oceanside, NY USA), and
carbon dioxide laser energy. However, these modalities
are not sufficient for hemostasis of the large-diameter
retrobulbar sinus of small mammals. If the sinus is
ruptured, it cannot be ligated. The orbit should be
packed with dental sponges, and direct pressure
should be applied for at least 5 minutes. Many times
this is not adequate, and hemorrhage continues. Pack-
ing the orbit with an absorbable gelatin sponge (Gel-
foam; Pharmacia & UpJohn Co., Kalamazoo, MI USA)
or oxidized regenerated cellulose (Surgicel; Biosense
Webster, Inc., Diamond Bar, CA USA) may aid in
hemostasis. Some surgeons will wrap a piece of throm-
bin-soaked Gelfoam with Surgicel (a “hemostatic
taco”) to promote hemostasis.2 These agents can be left
in the orbit and not only promote clot formation but
also provide a matrix to which the clot can adhere.
Rapid and tight closure of the subcutaneous tissue and
orbital fascia will also aid in hemostasis.
Appropriate suture for closure of an enucleation
site in exotic pets should be minimally reactive, dis-
courage bacterial binding, and have good tensile
strength.3 Monofilament suture, such as poligleca-
prone 25 (Monocryl; Novartis Animal Health, Inc.,
Basel, Switzerland), is well tolerated, has good han-
dling characteristics, and maintains 65% of its tensile
strength for 1 week. Braided or multifilament suture
is contraindicated for subcutaneous closure of the
enucleation site because it may prolong and pro-
mote inflammation while also serving as a potential
nidus for bacterial growth.
Surgical Technique
The 3 surgical techniques described for enucleation
are the transconjunctival, transpalpebral, and lateral
approach.4 The transpalpebral and lateral ap-
proaches are associated with a reduced chance of
leaving neoplastic or infectious material from the
globe or adnexa within the orbit. However, because
of the inherent risks of hemorrhage in exotic pets,
the transconjunctival enucleation is usually pre-
ferred. The unique anatomy of the bird eye requires
90 Holmberg

Figure 1. Transconjunctival enucleation technique in a rabbit. (1) An eyelid speculum is placed, and a lateral canthotomy is performed. (2)
A peritomy is performed with tenotomy scissors. (3) The extraocular muscle attachments are transected at their insertions to the sclera. (4)
After transection of all extraocular muscle attachments, the optic nerve and associated vessels are clamped, and the globe is removed. (5)
The eyelids are removed by cutting from the lateral canthus toward the medial canthus. (6) The eyelids and conjunctiva have been removed.
Note that the third eyelid is still in place. Closure of the subcutaneous tissue/orbital fascia is begun before removal of the third eyelid.

modifications of this technique and will be described
separately.
An eyelid speculum is placed in all animals with
palpebral fissures large enough to accommodate
one. In animals whose palpebral fissure is less than
10 mm (measured from the medial to lateral can-
thus), a horizontal mattress suture with 6-0 silk can
be placed in the upper and lower eyelids. The free
ends of the suture are clamped with a Dieffenbach
serrefine or bulldog clamp and can be used to re-
tract the eyelids. A lateral canthotomy is then per-
formed to increase visualization of the globe (Fig
1-1). A mosquito hemostatic forcep is clamped along
the lateral canthus before performing the incision.
The forcep is removed, and a #15 scalpel blade is
used to incise within the crushed area. The globe is
grasped with conjunctival fixation forceps next to
the limbus, and a 360° peritomy (circumferential
incision through the conjunctival attachment to the
limbus) is performed approximately 2 mm caudal to
the limbus with either Westcott or Stevens tenotomy
scissors (Fig 1-2). The 2-mm rim of bulbar conjunc-
tiva is intentionally left to provide an area to grasp
the globe and manipulate it during further dissec-
tion. Blunt dissection with tenotomy scissors is then
performed through Tenon’s fascia to the level of
sclera and caudal to the insertion of the extraocular
muscles. To incise the extraocular muscles, the teno-
tomy scissors should be opened, the lower jaw slid
under the muscle, and gentle anterior pressure ap-
plied (Figs 1-3). This ensures the incision is made
through the muscle insertion, not the muscle belly,
thereby decreasing intraoperative hemorrhage. The
globe can be rotated to facilitate transection of all
rectii and oblique muscles. The retractor bulbi mus-
cles are then transected in a similar fashion, at their
attachment close to the sclera. Once all muscle at-
tachments are released, the globe should rotate
freely in the orbit. The globe is then rotated medially
to facilitate access to the optic nerve from the lateral
side. Clamping blood vessels coursing with the optic
nerve (ciliary arteries, branches of the external oph-
thalmic artery) must be done carefully, because an-
terior traction of the nerve can lead to pressure at
the optic chiasm and permanent damage to the
contralateral nerve. A mosquito hemostatic forcep
can be used in larger exotic species such as rabbits
(Fig 1-4). In most other species, a dedicated pair of
lockable microsurgical needle drivers can be used.
The optic nerve is incised with tenotomy scissors
proximal to the clamp, and the globe is removed.
Care must be taken not to cut the posterior sclera,
especially in animals with septic endophthalmitis or
an intraocular tumor, because this can permit con-
tamination of the orbit. If the posterior sclera is
ruptured, the orbit should be copiously lavaged with
dilute (1:50) betadine solution. Because of the
Enucleation of Exotic Pets
threat of significant hemorrhage, the clamp is left in
place during the removal of the adnexa.
After removal of the globe, the eyelids, conjunc-
tiva, and third eyelid are removed. Failure to com-
pletely remove these structures and their associated
glands can result in cyst formation postoperatively. A
mosquito hemostatic forcep is placed 2 mm caudal
to the upper and lower eyelid margins and clamped
for 15 seconds to aid in hemostasis. The eyelids are
then incised with Metezenbaum or Mayo scissors
from the lateral aspect toward the medial canthus
(Fig 1-5). The incisions are joined at the medial
canthus with a #15 scalpel blade, being careful not to
incise the medial angular vein that courses superfi-
cial and medial to the orbital rim. Most of the pal-
pebral conjunctiva will also be excised during this
part of the procedure. However, careful inspection
of the remaining orbital tissue should be performed,
and any remaining conjunctiva should be excised
(Fig 1-6).
In this author’s experience, significant hemor-
rhage can commonly be encountered during re-
moval of the third eyelid. Therefore, before remov-
ing the third eyelid and its associated glands (gland
of the third eyelid and Harderian gland), closure of
the surgical wound is begun. This permits more
rapid closure of the surgical wound and aids hemo-
stasis. Remaining Tenon’s fascia, orbital septum, and
extraocular muscles are apposed in a simple contin-
uous pattern with 5-0 to 6-0 absorbable monofila-
ment sutures. The medial aspect is left open to allow
access to the third eyelid. The third eyelid is then
grasped, anteriorly displaced, and removed by care-
ful dissection with tenotomy scissors, sometimes aug-
mented with thermal cautery. Use of a carbon diox-
ide laser has not achieved the desired vessel coagu-
lation and has resulted in significant hemorrhage.
After removal of the third eyelid, any hemorrhage is
controlled by means of direct pressure with dental
sponges or cotton-tipped applicators. However, if
the orbital sinus has been lacerated, direct pressure
will not be sufficient to achieve hemostasis, and pack-
ing the orbit with the hemostatic aids mentioned
above will be necessary to decrease hemorrhage and
provide a matrix to allow clot formation. Suturing is
then completed. Because skin sutures are not always
well tolerated in exotic pets, the skin should be
apposed with an intradermal/subcuticular pattern,
making sure the knots are buried (Fig 2).
Two techniques have been described for the enu-
cleation of birds.5 Raptors with an extensive external
ear opening, such as owls, can be enucleated with a
transaural approach.5 With this technique, the globe
can be removed intact, which aids histological anal-
91
Figure 2. Postoperative appearance after enucleation of the left eye
of a rabbit. Notice the lack of skin sutures.
ysis. In birds without this anatomic configuration,
the transaural technique is not appropriate, and a
globe-collapsing technique is recommended to facil-
itate globe removal (Fig 3) . Unfortunately, this tech-
nique somewhat compromises histological examina-
tion.
The globe-collapsing technique for enucleation
of birds is similar to the subconjunctival enucleation
of small mammals. After aseptic preparation of the
surgery site, a wire eyelid speculum (or stay sutures,
depending on the size of the globe) is placed under
the eyelids and third eyelid to increase exposure. A
lateral canthotomy and peritomy are performed as
described above (Figs 3-1 and 2). Blunt dissection is
then performed to the level of the sclera, caudal to
the limbus 360° around the globe. Insertions of the
extraocular muscles are transected as they are en-
countered. Because of the tubular shape of the
globe, the presence of scleral ossicles, and the fact
that anterior traction on the globe should be
avoided, further caudal dissection is often not possi-
ble. Therefore, a full-thickness limbal incision is
made throughout the dorsal 180° of the globe (Fig
3-3). Manipulation of the globe is facilitated by
placement of a stay suture through the cornea at the
12 o’clock position. Aqueous humor will egress
through this limbal incision. Globe collapse is fur-
ther enhanced by making an incision through the
sclera, perpendicular to the limbus and parallel to
the scleral ossicles (Fig 3-4). The ossicles are then
incised with Metezenbaum scissors. To prevent sig-
92 Holmberg

Figure 3. Globe-collapsing procedure for enucleation. (1) An eyelid speculum is placed and a lateral canthotomy is performed to increase
exposure. A peritomy is performed to the level of sclera. (2) A full-thickness, 180° limbal incision is made dorsally and a stay suture is placed
to facilitate manipulation of the globe. (3) Further caudal dissection is performed, and insertions of extraocular muscles are transected. (4)
The sclera and its associated ossicles are transected, sparing the underlying uvea. (5) Forceps are used to collapse the globe and overlap the
sclera ossicles, increasing visualization of the posterior aspect of the globe to permit further dissection and clamping of the optic nerve. (6)
After globe removal, the conjunctiva and third eyelid are removed and the skin is closed. Reprinted with permission.5

nificant hemorrhage, only the sclera and ossicles are
incised; the uvea should be left intact. This incision
allows the surgeon to overlap the ossicles and in-
crease visualization of the posterior globe (Fig 3-5).
Dissection medial to the globe can damage the frag-
ile interorbital bony septum. The optic nerve and
associated vessels are then clamped, and the globe is
removed. Access to the retrobulbar space is en-
hanced with the globe-collapsing procedure, and
clamping or possible ligation of the optic nerve and
vessels is feasible. The anesthetist should be alerted
before clamping the optic nerve and vessels because
profound bradycardia may occur because of the ocu-
locardiac reflex. After removal of the globe, the
conjunctiva, third eyelid, and eyelids are removed in
a similar fashion as is used in small mammals. Clo-
sure of the wound is usually performed in 2 layers, a
deep subcutaneous layer and a skin layer (Fig 3-6, Fig
4). Unlike small mammals, birds infrequently dis-
turb their skin sutures.2
Complications
Complications infrequently occur after enucleation.
The most common intraoperative and immediate
postoperative complication is hemorrhage, espe-
cially in species with a large venous sinus or plexus.
Enucleation of Exotic Pets
Figure 4. Postoperative appearance after enucleation of the right
eye of a bird. Notice the presence of skin sutures.
Meticulous surgical technique and attention to he-
mostasis usually prevent this from being a life-threat-
ening complication. Additional complications in-
clude orbital infection, suture line abscesses, wound
dehiscence, and orbital cyst formation. Infection of
the orbit may be secondary to intraoperative rupture
of a septic globe, failure to follow aseptic technique,
or due to systemic septicemia. Prophylactic periop-
erative and postoperative therapy with a broad-spec-
trum antibiotic may decrease the prevalence of or-
bital infection after enucleation. Dehiscence of the
wound is usually secondary to a local inflammatory
reaction associated with infection or excessive
grooming by the animal. Closure in 3 layers may
prevent the likelihood of dehiscence. Likewise, su-
ture line abscesses usually occur with the use of
braided suture or contamination of the suture line
by environmental factors. Cyst formation within the
orbit has been noted secondary to continued secre-
tions from the conjunctival epithelium and/or lacri-
mal glands (orbital lacrimal gland, gland of the third
eyelid, Harderian gland). Cyst formation is mini-
mized by careful inspection of the surgery site before
closure to ensure all conjunctival epithelium and
glandular tissue have been removed.
Rare complications include orbital emphysema
and contralateral blindness. If the nasolacrimal duct
remains patent after surgery, air may be forced
through the duct and into the orbit because of in-
creased intranasal air pressure resulting in accumu-
lation of air within the orbit.6 Treatment involves
opening the surgical incision, locating the opening
to the nasolacrimal duct, and closing it with either
suture or thermal cautery. Although extremely rare,
enucleation may result in blindness of the contralat-
eral eye. Excessive manipulation of the globe during
93
surgery may result in tractional forces on the optic
chiasm, damaging chiasmal axons. This is most com-
mon in animals with a small orbit and a short dis-
tance between the posterior globe and chiasm. In
these animals, a hemostat should not be placed pos-
terior to the globe before removing the eye because
this can cause enough anterior traction to injure the
chiasm. Either no clamp or a smaller clamp such as
a lockable microsurgical needle driver should be
used.
Postoperative Care
The goal of postoperative care is to ensure patient
comfort and prevent potential complications. Post-
operatively, animals should be placed in a warm,
quiet, dim, nonstressful environment with easy ac-
cess to both food and water.7 Sufficient ventilation
and proper sanitation are necessary, with particular
attention to environmental temperature and humid-
ity (specifics depend on species). The animal’s hab-
itat may also need to be changed to prevent second-
ary contamination of the surgical wound. For in-
stance, rodents may be housed on artificial turf after
enucleation instead of shavings.
Determination of the degree of surgical pain in
exotic pets is difficult. Some indications of pain in-
clude anorexia, decreased grooming/preening activ-
ity, and alterations in normal behaviors (explora-
tion, social interactions, and so forth).8,9 Analgesia
for both small mammals and birds should start be-
fore surgery, so-called preemptive analgesia. Treat-
ing before a noxious stimulus prevents hypersensiti-
zation of pain receptors and may reduce the amount
of inhalant anesthesia necessary to maintain a surgi-
cal plane.8 Multimodal analgesia involving the use of
several classes of medications is more effective at
controlling postoperative pain. Butorphanol (1-3
mg/kg intramuscularly, Torbugesic-SA; Fort Dodge
Animal Health, Fort Dodge, IA USA) is a good an-
algesic for birds, because they have a greater popu-
lation of versus opioid receptors.9 Long-term
analgesia can be accomplished with oral nonsteroi-
dal antiinflammatory drugs such as meloxicam (0.1
mg/kg by mouth every 24 hours, Metacam; Boehr-
inger Inglelheim Vetmedica, Inc., St. Joseph, MO
USA) or carprofen (2-4 mg/kg by mouth twice per
day, Rimadyl; Pfizer Animal Health, New York, NY
USA).9 The response of small mammals to both
opiates and nonsteroidal antiinflammatory drugs
varies among species, with some animals such as
ferrets more sensitive to their effects. Doses for these
drugs are available in the literature8,9 and should be
researched before surgery.
94
Conclusion
Enucleation is the most commonly performed oph-
thalmic procedure in veterinary medicine. In exotic
pets, a transconjunctival approach is recommended
to enhance visualization and prevent secondary com-
plications. This technique is modified in birds to
account for the presence of scleral ossicles, tubular
shape of the eye, and tight fit of the globe in the
orbit. Complications are rare, especially if intraoper-
ative hemorrhage is limited.
References
1. Green K, Livingston V, Bowman K, et al: Chlorhexi-
dine effects on corneal epithelium and endothelium.
Arch Ophthalmol 98:1273, 1980
Holmberg
2. Bennett RA: Preparation and equipment useful for
surgery in small exotic pets. Vet Clin North Am (Ex-
otic Anim Pract) 3:563-585, 2000
3. Mullen HS: Nonreproductive surgery in small mam-
mals. Vet Clin North Am (Exotic Anim Pract) 3:629-
645, 2000
4. Ramsey DT, Fox DB: Surgery of the orbit. Vet Clin
North Am (Sm Anim Pract) 27:1215-1264, 1997
5. Murphy CJ, Brooks DE, Kern TJ, et al: Enucleation in
birds of prey. J Am Vet Med Assoc 183:1234-1237, 1983
6. Martin CL: A complication of ocular enucleation in
the dog: orbital emphysema. Vet Med Small Anim
Clin 66:986-989, 1971
7. Pollock C: Postoperative management of the exotic
animal patient. Vet Clin North Am (Exotic Anim
Pract) 5:183-212, 2002
8. Flecknell PA: Analgesia of small mammals. Vet Clin
North Am (Exotic Anim Pract) 4:47-56, 2001
9. Paul-Murphy J, Ludders JW: Avian analgesia. Vet Clin
North Am (Exotic Anim Pract) 4:35-46, 2001
procedures pro OPHTHALMOLOGY

Sheryl G. Krohne, DVM, MS, Diplomate ACVO, Purdue University

Subconjunctival Enucleation Surgery

in Dogs & Cats

E
nucleation surgery, a common procedure
in small animal practice, is indicated
when an eye is painful or infected and
vision can’t be saved. However, enucleation
should not be used in place of a correct diag-
nosis or treatment for ocular disease.

Indications
• End-stage glaucoma
• Severe corneal or scleral laceration with
loss of intraocular contents
• Phthisical eye with discharge accumulating
in the conjunctival sac
• Unresponsive painful dry eye with corneal
scarring (accompanied by owner’s inability
to pursue other treatment options)
• Severe proptosis with extraocular muscle 1
avulsion
• Progressive intraocular tumors not involv- In eyes blinded from glaucoma (not caused by
ing the sclera neoplasia) or traumatic loss of intraocular
• Blinding unresponsive infectious or inflam- contents, evisceration and placement of an
matory uveitis, with or without hyphema intrascleral prosthesis is an alternative to enu-
(Figure 1) cleation. Owners who prefer an intrascleral
prosthesis should be referred to an ophthal-
Alternative Techniques mology practice for this procedure. However,
Eyes that have been irreversibly damaged many owners prefer enucleation to intrascleral
from severe panophthalmitis or a retrobulbar prosthesis because it involves less postopera-
abscess, or that have an extensive or invasive tive care.
intraocular tumor, should be removed by using
an exenteration or transpalpebral technique,
not simple subconjunctival enucleation. c o n t i n u e s

p ro ce d u re s p ro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N AV C c l i n i c i a n’s b r i e f . n ove m b e r . 2 0 0 9 . . . . . 2 7
procedures pro CONTINUED

STEP BY STEP SUBCONJUNCTIVAL ENUCLEATION

What You Will Need

• General surgery pack, vacuum pack
for positioning the head, standard
surgery room and anesthesia equip-
ment, & adjustable-height chair
(seated position for ocular procedures
increases surgeon’s hand stability)
A B
• Jar of 10% neutral buffered formalin Clip hair from around the eye before positioning the head. Then place the animal in
(10 parts formalin:1 part eye tissue).
This volume is needed to adequately 1 lateral recumbency, with the head positioned and stabilized. Adjust the surgeon’s
chair or stool so that the surgeon’s arms and hands are supported comfortably, and
fix the eye for histopathology.
set the overhead light position so that all ocular structures are well illuminated.
• 3/0 or 4/0 absorbable suture
(such as PDS* II, Monocryl mono-
filament or Vicryl braided suture; After positioning, prepare the area for surgery by using a mild surgical scrub and solution (eye
ethicon.novartis.us) on a cutting (FS- damage from a scrub is not a concern if the eye and conjunctiva will be removed at enucle-
2) needle. Monofilament sutures have ation) (A). The conjunctival fornix should be flushed first with dilute povidone-iodine solution to
less tissue drag and are sterilize the area and then with eye wash to remove all clipped hairs (B). Cover the head and
preferred for this use. Skin sutures
should be 2/0 to 4/0 (depending on body with sterile drapes.
animal size) nonabsorbable suture
(such as Ethilon or Prolene; ethicon.
novartis.us) on a cutting needle. PROCEDURE PEARL
• Surgical clippers, 4 × 4 sponges, mild Using a vacuum pack (to position the head)
surgical scrub, water and eye wash for and tying the endotracheal tube behind the
rinsing, dilute 1:25 povidone-iodine head or to the lower jaw allows the head to
solution for final surgical preparation
be positioned at any convenient angle dur-
of the skin, and cotton-tipped applica-
tors to clean and prepare the conjunc- ing surgery. (It is critical to ensure that the
tival sac with the solution tongue is not inadvertently clamped if the
tube is tied to the lower jaw.) Using a wired
• Injectable 1/1000 epinephrine diluted
to 1/10,000 (using saline) in a 6-mL tube to prevent the tube lumen from col-
syringe to be used as a subcutaneous lapsing is helpful but not necessary.
injection or irrigation to control hem-
orrhage
• Optional: Electrocautery with a cut-
ting tip for the eyelid margin and
Make a 1- to 2-cm lateral
cautery tip for controlling hemor-
rhage. A tonsil snare attachment is
useful, if available, for removing the
2 canthotomy incision with
Mayo scissors or a #15
eye at the optic nerve. scalpel blade for exposure. Before cut-
ting, clamp this incision with a hemo-
stat or inject the incision with 1/10,000
epinephrine subcutaneously to control
hemorrhage. The third eyelid may be
removed at this time with Mayo scis-
sors (or electrocautery scalpel) after
clamping the base with hemostats.

2 8 . . . . . N AV C c l i n i c i a n’s b r i e f . n ove m b e r . 2 0 0 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p ro ce d u re s p ro
 PROCEDURE PEARL
In cats, to help maneuver and
elevate the eye from the orbit,
remove approximately 1 mL or
more of aqueous humor by
paracentesis to reduce the size
of the globe at the start of the
enucleation procedure.

Hold the bulbar conjunctiva

3 attached to the limbus with a
toothed tissue forceps. Use curved
tenotomy or small Metzenbaum scissors to
make a 360º incision 3 to 4 mm back from the
limbus and down to the level of the sclera.

A B
Once the eye is completely free and can be gently rotated (but not too aggressively,
5 especially in the cat), cut the optic nerve after clamping from the lateral side for 3
minutes with curved Kelly or mosquito forceps (A). Cutting with Metzenbaum scissors
(rather than a blade) helps control hemorrhage (B); alternatively, remove the eye by cutting with
a tonsil snare wire attached to the electrocautery unit. With the latter, little to no hemorrhage
Continue blunt and sharp dissection occurs after the globe is removed. Slight hemorrhage can be controlled with the coagulation
4 around the eye by using the scissors
against the scleral wall until reach-
cautery tip.

ing the back of the globe. During dissection, Pack the orbit with 4 × 4 sponges
the globe is held by the conjunctiva that
remains at the limbus. The conjunctiva and
6 and apply light pressure for several
minutes to facilitate clotting and
extraocular muscles are cut from the globe minimize postoperative hemorrhage. The
during the dissection (arrow ) and are left in deepest sponges may be left in place while
the orbit. The superior lacrimal gland may be the lacrimal gland and eyelid margins are
removed with the globe or left in place. removed. Only a 2-mm stump of optic nerve
on the back of the globe should remain after
While cutting around the globe, apply as little removal if the globe has not been retracted
tension as possible while elevating the eye too aggressively. Place the eye in a formalin
from the orbit. This precaution is especially PROCEDURE PEARL container as soon as it is removed for submis-
important and more difficult to avoid in the Making a small atraumatic slit or injecting sion to a histopathology laboratory.
cat. The opposite eye may be blinded from formalin through the posterior sclera
mechanical or ischemic damage to the chiasm allows formalin to penetrate the eye and
fix the retina before autolysis occurs.
if traction or twisting occurs to the optic nerve
of the eye being removed. c o n t i n u e s

p ro ce d u re s p ro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N AV C c l i n i c i a n’s b r i e f . n ove m b e r . 2 0 0 9 . . . . . 2 9
procedures pro CONTINUED

Remove the eyelid margins

7 (4–5 mm from edge, includ-
ing the pigmented margin
and all skin edges) with Metzenbaum
or Mayo scissors (shown ) or the elec-
trocautery scalpel. The latter greatly
reduces the possibility of postoperative
hemorrhage from the cut skin margins.
Carefully remove all medial canthus
skin and the medial caruncle at the
conjunctival margin so that a tract into the orbit does not remain. In this area, bluntly dissect
A
under the skin to avoid the angularis oculi vein, which can be a significant source of hemorrhage.

A B B
Trim the remaining conjunctiva from the orbit (A). Remove the superior lacrimal gland
8 if it has not been removed with the globe (B). Doing so prevents production of aque-
ous tears in the orbit after wound closure.

Assess hemorrhage
9 again—it is optimum
to have a dry orbit that
can be inspected before closing
sutures are placed. Most postop-
erative complications result from C
postoperative orbital hemorrhage.
If bleeding continues from the
It is ideal to place 2 layers of
stump of the optic nerve after the
sponges are removed, place liga- 10 sutures using 3/0 or 4/0 absorbable
sutures in a simple continuous pat-
tures around the nerve and the
tern with buried knots. The first layer closes
ciliary vessels.
the orbital muscle and fat, and the second
layer is a subcutaneous suture line (A).
Monofilament or braided synthetic sutures are
preferred for subcutaneous layers because of
longer tissue life and knot security; however,
chromic gut may be adequate in noncontami-
nated surgeries.
See Aids & Resources, back page, for references, contacts, and appendices.
Article archived on cliniciansbrief.com Before completely closing the first suture line,
inspect the orbit for sponges and hemorrhage
one last time. If the orbit has been irrigated

3 0 . . . . . N AV C c l i n i c i a n’s b r i e f . n ove m b e r . 2 0 0 9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p ro ce d u re s p ro
with dilute antibiotic solution (diluted 1/10 for the specificity of the diagnosis), most state
povidone-iodine solution is excellent for this veterinary laboratories have adequate ocular
purpose), aspirate it before inspecting the pathology services available for a modest
orbit and tying the suture (B). Close the eyelid charge. It could be a useful continuing educa-
incision with a 2/0 to 4/0 nonabsorbable sim- tion tool for the veterinarian to absorb the
ple continuous suture pattern or interrupted cost of this diagnostic service (if necessary) in
sutures (C). order to confirm the clinical diagnosis made
before the eye was removed.
Submit
11 removed
globe for
Postoperative Care
Postoperative pressure or protective bandages
histopath- are rarely necessary; however, if hemorrhage
ology to rule occurs, a bandage is an excellent way to apply
out neopla- pressure after the incision is closed. See Aids
sia or an & Resources for bandage placement tech-
unexpected niques. An Elizabethan collar is useful to pre-
intraocular vent postoperative trauma to the surgery site.
infection,
which could I prefer to keep patients in the hospital for
have sys- one night to monitor for hemorrhage. Owners
temic implications. If an owner can’t afford often have emotional difficulties with enucle-
the cost of histopathologic evaluation by a ation surgery, and postoperative bleeding
veterinary ophthalmic pathologist (preferred from a bruised and clipped surgery site at
home the night after surgery can be a very
bad experience. Owners should be warned
about postoperative appearance or even
shown pictures of what it will look like before
they are reunited with their pet at discharge.
Postoperative analgesia can be used in the
hospital (nonsteroidal antiinflammatory drugs,
fentanyl, morphine) as needed, and patients
can be released the next day with oral anal-
gesic medications (carprofen, deracoxib,
tepoxalin, or meloxicam in dogs; meloxicam in
cats) for 3 to 5 days. Systemic antibiotics are
recommended to prevent intraocular infection.
Reevaluation 5 to 6 days after surgery and
suture removal 12 to 14 days postoperatively
are recommended. ■
Acknowledgment
The author wishes to thank Dr. Martin Coster
and Sam Royer for providing the surgical pic-
tures and also Dr. Pam Mouser for providing
the pathology photo for this article.
 Frans C. Stades
Milton Wyman · Michael H. Boevé · Willy Neumann · Bernhard Spiess

Ophthalmology for

Ophthalmology for the Veterinary Practitioner

Recognized as a standard work, this new, completely
revised and expanded edition contains:

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• The latest drugs, diagnostic and
therapeutic methods
• Step-by-step surgical procedures
• First-class color photographs and instructive

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drawings to illustrate symptoms and techniques

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