Veterinary Ophthalmology (2012) 15, 2, 123–127 DOI:10.1111/j.1463-5224.2011.00945.

CASE REPORT

Everted third eyelid cartilage in a cat: a case report and literature

review
David Williams,* Sheldon Middleton† and Adele Caldwell‡
*Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES UK; †Acorn House Veterinary Practice, Linnet Way,
Bedford MK41 7HN, UK; and ‡Ark House Veterinary Clinic, 22 Hockliffe Street, Leighton Buzzard LU7 1HJ, UK

Address communications to: Abstract

D. Williams An 8-year-old neutered female British Blue cat was presented with a presumed
Tel.: 07939 074682
diagnosis of a prolapsed nictitans gland and associated ocular irritation and epiphora.
Fax: 01223 232977 However, during surgery, the apparent nictitans gland protrusion was determined to
e-mail: dlw33@cam.ac.uk be an everted cartilage of the nictitating membrane. The scrolled portion of the
cartilage was removed through an incision through the conjunctiva on the bulbar
aspect of the third eyelid, as previously described in the dog. This operation resolved
the ocular irritation occurring, and the third eyelid returned to its anatomically
correct position.
Key Words: cat, eversion, nictitating membrane, surgery

INTRODUCTION CASE REPORT

Third eyelid pathology reported in the cat has included pro-
trusion in Horner’s syndrome,1,2 protrusion associated with
dehydration,3 and protrusion in Torovirus infection.4 Con-
junctivitis regularly involves the nictitating membrane.
Neoplastic changes reported have included conjunctival
squamous cell carcinoma,5 lymphoma,6 mast cell tumor,7
hemangiosarcoma,8 fibrosarcoma,9 and adenocarcinoma.10
Prolapse of the gland of the third eyelid is less common in
the cat than in the dog but has been reported in several pub-
lications,11–13 particularly being seen in the Burmese
breed.14,15 Scrolling of the third eyelid cartilage has also
been noted in one report concurrent with gland prolapse in
the Burmese14 and has been reported anecdotally as being
rare in the cat,16,17 but surgical repair does not appear, until
now, to have been documented in the domestic cat.18,19
Here, we report a case of everted third eyelid cartilage in a
cat and its correction using a technique similar to that
employed in the equivalent condition in the dog.20,21 Two
principle methods of removal involve dissection of the
scrolled portion of cartilage through a bulbar approach and
a palpebral approach. The former, in the dog as least, has
the advantage that dissection is easier with less adhesion of
the cartilage to overlying conjunctiva, but the latter may be
beneficial in reducing the possibility of traumatic corneal
scarring in the postoperative period.
An 8-year-old female neutered British Blue cat was referred
with a presumptive diagnosis of prolapsed nictitans gland
and associated ocular irritation and epiphora (Fig. 1). The
condition had been present for 3 weeks without a previous
history of trauma or other ocular pathology. The Schirmer
tear test in the unaffected eye was 14 mm/min, while in the
affected eye, it reached 26 mm/min with a significantly
increased tear lake.
On closer examination under general anesthesia, the pro-
truding mass was found to be an everted third eyelid carti-
lage rather than prolapsed glandular tissue. The adjoining
conjunctiva was seen to be pleated (Fig. 2), demonstrating
that the everted cartilage was causing protrusion of the third
eyelid conjunctiva away from the ocular surface, on which it
would normally follow the curvature of the ocular surface.
On everting the third eyelid, the scrolled cartilage could
clearly be seen (Fig. 3).
The cartilage was partly removed through an incision in
the bulbar conjunctival surface, initially attempting to sepa-
rate the conjunctiva from the underlying cartilage as is read-
ily achieved in the dog. In this cat, however, the conjunctiva
was considerably more adherent to the underlying cartilage
than these authors have previously experienced during simi-
lar surgeries in the dog. As the conjunctiva of the palpebral
surface of the third eyelid was much less adherent to the

 2011 American College of Veterinary Ophthalmologists

124 w i l l i a m s , m i d d l e t o n a n d c a l d w e l l
Figure 1. Appearance at presentation.
Figure 2. Pleated conjunctiva next to the third eyelid elevated from
the ocular surface by the everted cartilage.
Figure 3. The everted cartilage demarcated by arrows.
 2011 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 15, 123–127
Figure 4. Dissection of cartilage from underlying conjunctiva.
Figure 5. Undermining of cartilage appendix prior to complete
removal.
cartilage, it was separated with ease, and the scrolled portion
of the cartilage and the overlying conjunctiva of the bulbar
side were removed together (Figs 4–6).
The everted portion of cartilage, once removed, was
indeed seen to be scrolled in an analogous manner to that
seen in the dog (Figs 7 and 8). The third eyelid returned to

Figure 6. Removal of cartilage appendix.
Figure 7. The everted cartilage ex vivo.
Figure 8. Histological image of cartilage: fixation has uncurled the cartilage. Line = 100 lm.
 2011 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 15, 123–127
everted third eyelid cartilage in a cat 125
Figure 9. The eye restored to normal appearance immediately post-
operatively.
its anatomically correct position after removal of the
deformed section of cartilage (Fig. 9), and the irritation
resolved henceforth. No suturing of the conjunctiva was
attempted, and the animal was discharged with topical
gentamicin antibiotic in a hypromellose base (Clinagel;
CEVA, Chesham, UK). No complications were noted on
re-examination 10 days later nor in the period following
surgery, now reaching 8-month follow-up.
DISCUSSION
The nictitating membrane, a prominent semilunar fold of
conjunctiva at the medial canthus, is supported by a T-
shaped cartilage described anatomically22 and histologically
in several species. The cartilage in the cat comprises, as
described by Schlegel et al., ‘an appendix which is broader in
the proximal end as compared to the dog…[and] initially has
a paddle-like shape, becomes thinner over a small distance
and extends to a triangular plate in the distal direction’. The
cartilage of dog and cat are compared in Fig. 10, these taken
with kind acknowledgement from Schlegel et al.’s mono-
graph.22 These workers concluded that the cartilage in the
126 w i l l i a m s , m i d d l e t o n a n d c a l d w e l l
(a) (b)
Figure 10. Nictitating membrane cartilages of (a) the dog and (b) the
cat, from the study of Schlegel et al. The cartilage of the third eyelid: a
comparative macroscopical and histological study in domestic animals.
Annals of Anatomy 2001; 183: 165–169, with kind permission.
cat was elastic, with fibers originating from adjacent connec-
tive tissue and continuing into the perichondrium.
Leibrich23 reported the cartilage to be hyaline in horses
and pigs and elastic in cats, while other researchers consid-
ered the cartilage to be elastic in horses, pigs, and cats.24,25
Others considered it to have a mixed character in pigs and
cats with some elastic and some hyaline components.26
These anatomical and histological differences between cat
and dog third eyelid cartilages may explain the lack of
reports of everted or scrolled cartilage in the cat compared
with the numerous papers describing third eyelid cartilage
eversion or scrolling in the dog.16–19 Nevertheless, apart
from the considerable adhesion between the bulbar conjunc-
tiva and the cartilage, which somewhat complicated removal
of the cartilage in this report, the everted cartilage described
in this cat and its removal were very similar to those in the
dog in all other respects. However, as a single case, the
authors are aware that the findings here may not be repli-
cated in other cases of the condition in cats.
The function of the third eyelid in the companion animals
has been described as protecting the globe, clearing debris
from the ocular surface27 and providing a sizeable propor-
tion of the ocular tear film through the nictitans gland.28
The third eyelid can be removed if necessary because of
tumor or trauma without marked deterioration of the ocular
surface in the majority of cases in the dog or cat, although
removal of the nictitans gland is reported to predispose to
keratoconjunctivitis sicca in the dog. Removal of the everted
third eyelid cartilage in the dog appears to have little effect
on the animal’s ocular surface health even though the stiff-
ness of the third eyelid, and thus potentially its efficacy at
clearing debris from the tear film, may be to some degree
diminished. No deleterious effects were noted postopera-
tively in this cat with up to 8-month follow-up, and the ani-
mal’s affected eye was returned to normality.
A number of different techniques for restoration of the
anatomical position of the scrolled or everted nictating mem-
brane have been reported, from undertaking a third eyelid
flap for 10–14 days,19 resection of the nictating membrane
margin and cartilage,19 radical resection of nictating mem-
brane cartilage and gland,21 and cartilage transplant.29 The
most commonly used technique in the dog, as here in the cat,
is resection of the deformed section of cartilage, the only dif-
 2011 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 15, 123–127
ference between surgeons being whether the cartilage is
approached from the palpebral or bulbar aspects of the third
eyelid. The bulbar aspect provides in most cases an easier dis-
section of the cartilage from the conjunctiva and so has been
preferred in previous cases by the current authors. Stades
et al.30 in their pictorial representation suggest that corneal
damage may occur from resulting scarring if approach
through the bulbar aspect is chosen, although in over 50 cor-
rective surgeries in the dog, we have not found this to be a
problem because suturing of the conjunctival incision is not
necessary (D.L. Williams, unpublished observations). In the
case reported herein, an approach from the palpebral aspect
was found more beneficial than from the bulbar, and thus,
risk of possible corneal damage was avoided in any case.
While restoration of the third eyelid is relatively straight-
forward, questions regarding the etiopathogenesis of carti-
lage scrolling are much more difficult to answer. Martin19
suggested that abnormal differential growth of the anterior
and posterior portions of the cartilage results in cartilage in-
or out-turning. The fact that fixation straightened the carti-
lage in this cat suggests that it is a tension across the depth of
the cartilage rather than an anatomical abnormal growth
that resulted in scrolling/eversion of the nictitating mem-
brane, but clearly, this is a subject requiring further investi-
gation in both the cat and the dog.
CONCLUSION
This case report documents scrolling of the third eyelid car-
tilage in a cat and the surgical correction of this condition.
Removal of the deformed portion of cartilage resolves the
deformation while still allowing full function of the nictitat-
ing membrane.
REFERENCES
1. Van den Broek AHM. Horner’s syndrome in cats and dogs: a
review. Journal of Small Animal Practice 1987; 28: 929–940.
2. Kern TJ, Aromando MC, Erb HN. Horner’s syndrome in dogs
and cats: 100 cases (1975–1985). Journal of the American Veterinary
Medical Association 1989; 195: 369–373.
3. Nasisse MP, Guy JS, Stevens JB et al. Clinical and laboratory
findings in chronic conjunctivitis in cats: 91 cases (1983–1991).
Journal of the American Veterinary Medical Association 1993; 203:
834–837.
4. Muir P, Harbour DA, Gruffydd-Jones TJ et al. A clinical and
microbiological study of cats with protruding nictitating mem-
branes and diarrhoea: isolation of a novel virus. Veterinary Record
1990; 127: 324–330.
5. Buyukmihci N. Fibrosarcoma of the nictitating membrane in a
cat. Journal of the American Veterinary Medical Association 1975;
167: 934–935.
6. Williams LW, Gelatt KN, Gwin RM. Ophthalmic neoplasms in
the cat. Journal of the American Animal Hospital Association 1981;
17: 999–1008.
7. Larocca RD. Eosinophilic conjunctivitis, herpes virus and mast
cell tumor of the third eyelid in a cat. Veterinary Ophthalmology
2000; 3: 221–225.

8. Multari D, Vascellari M, Mutinelli F. Hemangiosarcoma of the
third eyelid in a cat. Veterinary Ophthalmology 2002; 5: 273–276.
9. Peiffer RL, Simons KB. Ocular Tumors in Animals and Humans.
Iowa State Press, Ames, Iowa, 2002.
10. Komaromy AM, Ramsey DT, Render JA et al. Primary adeno-
carcinoma of the gland of the nictitating membrane in a cat.
Journal of the American Animal Hospital Association 1997; 33:
333–336.
11. Schoofs SH. Prolapse of the gland of the third eyelid in a cat: a
case report and literature review. Journal of the American Animal
Hospital Association 1999; 35: 240–242.
12. Chahory S, Crasta M, Trio S et al. Three cases of prolapse of
the nictitans gland in cats. Veterinary Ophthalmology 2004; 7:
417–419.
13. Albert RA, Garrett PD, Whitley RD et al. Surgical correction of
everted third eyelid in two cats. Journal of the American Veterinary
Medical Association 1982; 180: 763–766.
14. Koch SA. Congenital ophthalmic abnormalities in the Burmese
cat. Journal of the American Veterinary Medical Association 1979;
174: 90–91.
15. Christmas R. Surgical correction of congenital ocular and nasal
dermoids and third eyelid gland prolapse in related Burmese
kittens. Canadian Veterinary Journal 1992; 33: 265–266.
16. Gelatt KN, Gelatt JP. Small Animal Ophthalmic Surgery. Vol. 1:
Extraocular Procedures. Elsevier science, Oxford, 1994; 146–147.
17. Stades F. Ophthalmology for the General practitioner. Schlutersche,
Hannover, Germany, 1998; 9.
18. Gelatt KN. Eversion of the nictitating membranes. Veterinary
Medicine Small Animal Clinician 1970; 65: 674–675.
19. Martin CL. Everted membrana nictitans in German Shorthaired
Pointers. Journal of the American Veterinary Medical Association
1970; 157: 1229–1232.
 2011 American College of Veterinary Ophthalmologists, Veterinary Ophthalmology, 15, 123–127
everted third eyelid cartilage in a cat 127
20. Gelatt KN. Surgical correction of everted nictitating membrane
in the dog. Veterinary Medicine Small Animal Clinician 1972; 67:
291–292.
21. Kuhns EL. Correction of eversion of the membrana nictitans in
the dog. Veterinary Medicine Small Animal Clinician 1977; 72:
411–417.
22. Schlegel T, Brehm H, Amselgruber WM. The cartilage of the
third eyelid: a comparative macroscopical and histological study
in domestic animals. Annals of Anatomy 2001; 183: 165–169.
23. Liebrich HG. Funkionelle histologie der hausaugtiere. Schattauer,
Stuttgart, New York, NY, 1990; 314.
24. Trautmann A, Fiebiger J. Lehrbuch der Histo- logic und verglei-
chenden mikroskopischen. Anatomie der Hausaügetiere, 1931; 15:
1–153.
25. Grau H, Walter P. Grundriss der histology und vergleichenden mikro-
skopischen anatomie. Paul Parey, Berlin, Hamburg, Germany, 1967;
148–149.
26. Czuberka R. Uber den blinzknorpel eineger saugetiere. Dissertation,
Tierarzliche Hochschule, Wein, 1923.
27. Samuelson DA. Ophthalmic anatomy. In: Veterinary Ophthalmol-
ogy IV, Vol. 1. (ed. Gelatt KN) Blackwell Publishing, Ames Iowa,
2007; 46.
28. Saito A, Izumisawa Y, Yamashita K et al. The effect of third
eyelid gland removal on the ocular surface of dogs. Veterinary
Ophthalmology 2001; 4: 13–18.
29. Petruccio C. Surgical correction of the prominent third eyelid in
the dog. Californian Veterinarian 1981; 35: 24–27.
30. Stades F, Wyman M, Boevé MH et al. Chapter 8: conjunctiva
and nictitating membrane. In: Ophthalmology for the Veterinary
Practitioner, 2nd edn. (eds Stades FC, Wyman M, Boeve MH,
Neumann W, Spiess B), Schlütersche Verlagsgesellschaft mbH &
Co. KG, Hannover, Germany, 2007, 105–123.