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How to place a 3rd eyelid flap into a dog or cat | VETgirl Veterinary Continuing Education Videos

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In this VETgirl online veterinary continuing education video, we discuss the use and placement of a 3rd eyelid flap in your veterinary patient. A third eyelid flap is an easy and quick procedure, and is a very good option for certain cases. The 3rd eyelid can serve as tectonic support and protection for severe, melting corneal ulcers or large corneal perforations when a conjunctival graft is not possible. Additionally, it is a less invasive and less expensive option for eyes which were previously blind or for owners with financial limitations.

The patient is placed under general anesthesia and the periocular area is clipped about 2 inches around. Dilute betadine solution (not scrub!) is used to clean the eyelids and under the eyelids, using sterile Q-tips and 3x3s gauze pads. The choice of suture will depend upon the size of the patient, but most often VETgirl will use 3-0 to 5-0 Ethilon. A stent is necessary and can be cut from a sterile red rubber catheter, IV line, or extension set tubing.

The suture is first passed through the stent – it is important to pass the needle through each wall of the tubing, and NOT through the lumen of the tubing – this will keep the knot off of the eyelid skin. Using small forceps, such as Bishop Harmons or Brown Adsons, the upper eyelid is grasped and the dorsolateral fornix is visualized. The needle is passed into the fornix, making sure to be as far into the fornix as possible so that the 3rd eyelid will cover the entire globe. Grasping the 3rd eyelid, the needle is passed from the ANTERIOR aspect posteriorally, around the T-shaped cartilage, and then back out the anterior surface. All attempts should be made not to penetrate the posterior surface with the needle, to prevent suture rub, however VETgirl knows this isn’t easy. If a small amount of suture is showing on the posterior 3rd eyelid, it shouldn’t be a problem as long as the flap is pulled far enough into the fornix! After the suture has hooked the 3rd eyelid cartilage, it is again passed into the fornix and out the upper eyelid skin. The entry and exit points on the skin should be about 8-10 mm apart – and this distance should be mimicked in the stent. Finally, the suture is passed through the stent, and a knot is tied. There should be sufficient tension on the suture to pull the 3rd eyelid fully into the fornix, but not enough to cause the stent to indent into the eyelid deeply.

VETgirl’s tip: the eyelids are likely swollen due to the ulceration, so you should expect some loosening of the suture. The flap is generally left in place for 3-4 weeks, and VETgirl doesn’t recommend taking them down before that unless the patient seems uncomfortable. Topical medications (antibiotics, atropine) should be used in drop form, to allow them to penetrate through and around the flap. And, as always, a hard plastic E-collar is essential!! When in doubt, consult with a board-certified veterinary ophthalmologist!

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