TOPICAL REVIEW
Surgery of the Globe and Orbit
Jane Cho, DVM, DACVO
Orbital anatomy and the indications and surgical techniques for a variety of small animal orbital/globe surgical
procedures are discussed. Details of the more common orbital surgical procedures, including ocular eviscera-
tion, intrascleral prosthesis implantation, enucleation, and proptosis repair, are given. Common complications
and postoperative considerations for these procedures are also discussed with an emphasis on the practical
aspects.
© 2008 Elsevier Inc. All rights reserved.
Keywords: orbit, surgery, dog, cat, globe, enucleation, evisceration, exenteration, proptosis, orbitotomy,
orbitectomy
O rbital surgery, particularly enucleation, is a common
procedure in many small animal practices. However,
by virtue of its complex anatomy, difficult exposure, and
tendency to bleed, surgery of the orbit has the potential to be
quite challenging. Proficient knowledge and understanding
of orbital structures is essential to performing surgery that is
both successful for the patient and uncomplicated for the
surgeon. An understanding of orbital anatomy is also impor-
tant for localization and diagnosis of orbital pathology.
The osseous orbit, or bony fossa that contains the globe
and its surrounding soft-tissue structures, is incomplete in
dogs and cats, with the dorsolateral aspect comprised by the
collagenous orbital ligament (Fig. 1A). The bony orbital rim
is made up of the frontal bone (dorsomedially), the maxilla
and lacrimal bone (ventromedially), and the zygomatic bone
(ventrolaterally). The medial bony orbit is defined by the thin
pars orbitalis of the frontal bone; the caudomedial bony orbit
is made up of the sphenoid and palatine (in the dog) bones.1
Just medial and ventral to the orbit are the frontal and max-
illary sinuses. The apex of the orbit is at its caudal aspect and
contains the optic canal and various foramina and fissures
that carry vasculature and nerves into the orbit.2
The soft tissues of the orbit are varied in type (Fig. 1B). The
caudal orbit is made up of the temporalis and masseter mus-
cles, the former of which surrounds and encloses the ramus of
the mandible.3 When the jaw is opened, the vertically ori-
ented ramus of the mandible is pushed up into the caudal
orbit, putting pressure on the orbital soft-tissue structures.
The extraocular muscles originate from the orbital apex (the
four rectus muscles, the dorsal oblique, and the retractor
bulbi) and medial orbit (the ventral oblique) and run rostrally
to insert at their various locations on the globe (Fig. 2A). The
Veterinary Eye Specialists, PLLC, Ardsley, NY.
Address reprint requests to: Jane Cho, DVM, DACVO, Veterinary Eye
Specialists, PLLC, 875 Saw Mill River Road, Ardsley, NY 10502. E-mail:
joc212@yahoo.com.
© 2008 Elsevier Inc. All rights reserved.
1527-3369/06/0604-0171\.00/0
doi:10.1053/j.ctsap.2007.12.004
muscle bellies of the retractor bulbi muscle closely surround
the optic nerve at the posterior pole of the globe4 and often
cannot be directly seen in enucleation surgery until the globe
has been removed. The bony floor of the orbit is incomplete;
the soft-tissue orbital floor is mostly made up of the pterygoid
muscles and the zygomatic salivary gland in the dog and the
infraorbital salivary gland in the cat.1,4 A number of surgi-
cally important nerves and vessels cross these structures, in-
cluding the large maxillary artery and its many branches,
orbital veins, a variable orbital venous plexus, the maxillary
branch of the trigeminal nerve, and the pterygopalatine gan-
glion and nerves.4 The roots of the last three upper teeth
(including the upper carnassial teeth) lie close to the orbital
floor. The nictitans (third eyelid) and its associated gland are
located in the ventromedial orbit, with the base of the nicti-
tans anchored to deeper orbital tissues via a poorly defined
fascial retinaculum. The angularis oculi vein is located super-
ficial and medial to the medial canthal tendon and may be
encountered during dissection of the medial canthus.3
A layer of tough orbital fascia called the endorbita lines
the orbit, completely enclosing the orbital structures,
merging with the periosteum of the orbital rim rostrally
and the dura of the optic nerve caudally2 (Fig. 2B). Leaves
of this fascia line the extraocular muscles, continue on the
globe as Tenon’s capsule between the sclera and conjunc-
tiva, and also split rostrally from the periosteum of the
anterior orbital rim to form a leaf within the eyelids called
the orbital septum. The orbital septum is continuous with
the tarsal plate, helps give the lid structure, and is an
important anatomic structure in enucleation surgery due
to its high tensile strength.5 The area between Tenon’s
capsule and the sclera is the subtenon’s space and is rela-
tively avascular, allowing for surgical dissection with min-
imal hemorrhage.4 Orbital fat lies between the structures
that are enveloped by the orbital fascia and provides cush-
ioning and physical support for the globe. The orbital
lacrimal gland, another important consideration in enucle-
ation, is flat, lobulated, and about 12 to 15 mm wide.3 It
23
24 Topics in Companion Animal Medicine

methods have been pursued first. Referral to a veterinary

ophthalmologist is strongly recommended in any case in
which the diagnosis or best treatment plan is unclear.

Orbital Surgery
From least to most tissue being removed, orbital surgeries
include the following: ocular evisceration, which removes the
tissues within the sclera; transconjunctival, lateral, and trans-
palpebral enucleation, which remove the globe, lid margins,
conjunctiva, lacrimal gland, nictitans, and increasing degrees
of orbital fascia; and exenteration, which removes all the
soft-tissue structures in the orbit including the above as well
as the extraocular muscles and orbital fat. Replacement of a
proptosed globe mainly involves tarsorrhaphy to normalize
the position of the globe. Orbitotomy involves surgically
exposing an area of the orbit, usually while leaving the globe
intact; the much more invasive orbitectomy involves removal
of part of the orbital wall with or without removal of the
globe and other orbital contents.

Ocular Evisceration and Intrascleral Prosthesis

Placement (Fig. 3)
The primary indication for evisceration and intrascleral pros-
thesis placement (ISP) is chronic uncontrollable primary
glaucoma, with the goal being to provide long-term comfort
with minimal long-term medications. Other potential indica-

Figure 1. (A) Gross anatomy of the bones of the orbit. (B)

Gross anatomy of some of the soft tissues around the orbit.

lies dorsolateral to the globe, under the orbital ligament,

and is also surrounded by a layer of fascia.
The conjunctiva, a thin vascular mucosa with a nonkera-
tinized epithelial surface, lines the globe. The conjunctiva
originates at the mucocutaneous junction of the eyelid mar-
gin, lines the posterior eyelid, is reflected back anteriorly at
the fornix, and lines the anterior sclera to attach to the cornea
and sclera at the limbus. In the ventromedial orbit, the con-
junctiva also lines the anterior and posterior surfaces of the
nictitans. Goblet cells that secrete the mucoid portion of the
tear film are present in the conjunctiva, particularly in the
ventromedial fornix.2 Multiple small ductules from the or-
bital lacrimal gland are present in the dorsolateral conjunc-
tiva.2 The locations of these secretory structures are poten-
tially significant in both enucleation and ocular evisceration
surgeries.

Orbital Disease
The clinical signs, differential diagnosis, and diagnostic
methods of orbital disease are beyond the scope of this arti-
cle. For these considerations, the reader is referred to the
many available textbooks and related publications in veteri- Figure 2. (A) Anatomy of the extraocular muscles, left globe.
nary ophthalmology.1,6-9 Removal of the eye should not be (B) Parasagittal view of the structures surrounding the globe,
considered a diagnostic technique unless other diagnostic including the orbital fascia.
Volume 23, Number 1, February 2008 25

Figure 3. Ocular evisceration and prosthesis placement. (A) The dorsal bulbar conjunctiva is incised using tenotomy scissors.
(B) The dorsal sclera is carefully incised with a 64 Beaver or similar blade, revealing the underlying uvea. Ideally, the uvea is
not incised. (C) A lens loop or evisceration spoon is passed between the sclera and uveal tract as far caudally as possible to
separate the two tissues. This step may also be performed using hydrodissection. Care should be taken not to shred the uvea.
(D) The uveal tract is gently pulled from the sclera, teasing to separate the tissues. Additional traction may be needed to pull
the uveal tract from the optic nerve area. (E) After all the uvea has been removed, the scleral shell is flushed with saline, and
an appropriately sized prosthesis is placed with a sphere introducer.

tions include chronic secondary glaucoma, chronic uveitis,
progressive phthisis bulbi, and blinding corneal trauma10—
but only if the above are both noninfectious and nonneoplas-
tic. Globes suspicious for intraocular infection or neoplasia
are generally poor candidates for ISP surgery due to potential
for recurrence.11 Globes undergoing progressive phthisis may
also benefit from ISP surgery, since globe size is maintained.
Eviscerated ocular contents should always be submitted for
histopathologic evaluation, especially when the diagnosis is
not absolutely certain. Other reported contraindications to
26
ISP surgery include corneal ulceration, Kerato conjunctivitis
Sicca (KCS), and severe corneal edema. Corneal disease is a
concern with ISP surgery since the patient retains the ocular
surface, along with any preexisting problems it may have.
Ideally, any corneal disease should be well controlled, normal
tear production should be established, and the cornea should
be free of ulcerative disease, before an ISP is considered.
The main advantage to performing an ISP, compared with
enucleation, is improved cosmesis. Operated eyes can both
blink and move with the fellow eye and thus look much more
normal than enucleated orbits. The implant color is dark
(black or brown), resulting in a final color that resembles the
typically dark color of the eye. The clinician should also
consider that primary glaucoma is typically bilateral in na-
ture, and while some owners strongly resist unilateral enu-
cleation, even more would object to eventual bilateral enu-
cleation. Dogs with bilateral ISPs, on the other hand, can be
quite cosmetic.12 Other surgical options for blind glaucoma-
tous eyes, such as ciliary body ablation (pharmacologic, di-
ode laser photocoagulation), may also be considered depend-
ing on the case. As long as they are comfortable, blind dogs
can adapt well to their vision loss and continue to enjoy a
good quality of life.
Preoperatively, local anesthesia may be considered to im-
prove analgesia. Injections of 2% lidocaine13 (Hospira, Lake
Forest, IL) or 1:4 (v/v) 2% lidocaine:0.5% bupivacaine1
(Hospira) have been used either as a retrobulbar injection or
subconjunctivally. The addition of bupivacaine will increase
the duration of analgesia. Retrobulbar injections may be
given via a subconjunctival or an inferotemporal approach
through the eyelid skin.13 The latter is performed by first
placing a 20° bend midway in a 1.5⬙ 22-g spinal needle. The
needle is pointed just above the lower orbital rim at the
junction of the lateral and middle thirds of the eyelid through
the skin, advanced through the periorbital fascia, and then
tilted slightly dorsally and medially toward the orbital apex
about 1 to 2 cm. Epinephrine may be included in the injection
to improve hemostasis, but heart rate should be monitored as
tachycardia may result. Inherent risks of retrobulbar injec-
tions are potentially significant and include globe perforation,
direct damage to the optic nerve, IV injection, retrobulbar
hemorrhage, extraocular muscle myopathy, and intrathecal
injection (which may lead to seizures or cardiorespiratory
arrest).13,14
Routine perioperative medications, anesthesia, and sur-
gery site preparations are made according to surgeon prefer-
ence. Elevation of the chin on a towel roll may improve
airway positioning, and care should be taken by all members
of the surgery staff to prepare the correct eye for surgery.
Dilute (1:25) povidone iodine solution (Purdue Products LP,
Stamford, CT; not soapy scrub) may be used to both scrub
the periocular skin surface as well as to flush the ocular
surface. The ocular surface should then be flushed well with
sterile saline to remove excess povidone iodine as well as
mucus and clipped hairs. Once the patient is draped, the
tongue is inaccessible to the anesthetist, and palpebral re-
flexes and jaw tone cannot be used to assess anesthetic
Topics in Companion Animal Medicine
depth. Anesthetic monitoring arrangements should be made
accordingly.
The limbal diameter of the other, presumably normal, eye
is measured to identify the size implant needed (generally
about 2 mm larger than the horizontal corneal diameter of
the normal eye, often 18-20 mm in dogs) (Jardon Eye Pros-
thetics Inc., Southfield, MI). The implant should be gas ster-
ilized before use. The patient is placed in sternal recumbency
position with the eye to be operated well-exposed, and the
area clipped, prepped, and draped. A lid speculum is placed,
and a lateral canthotomy may be performed if exposure to
the dorsal sclera is inadequate. One or two stay sutures of 4-0
or 5-0 silk (Ethicon, Johnson & Johnson, Mexico) are placed
in the limbal conjunctiva and tagged with small hemostats.
The dorsal bulbar conjunctiva is incised with tenotomy scis-
sors, parallel to the limbus, 3 to 5 mm from the limbus and 12
to 15 mm long. A similar incision is made in the sclera with a
64 Beaver blade, electrocautery unit, or other cutting instru-
ment. The incision is made carefully so as to incise only the
sclera and not the thin vascular uvea that lies beneath. When
dark brown is seen at the bottom of the incision, the uvea has
been reached. Blunt dissection of the uvea from the overlying
sclera is performed using hydrodissection with a 19-g Bishop
cannula and balanced salt solution, or with a lens loop or
evisceration spoon. Traction may be gently applied to the
uveal tract with a small hemostat, and care should be taken to
keep the uvea intact as it is thin and often friable. Some
bleeding is to be expected during dissection due to the vascu-
lar nature of the uveal tract. Ideally, the uvea, lens, and retina
are removed together in a single rounded mass and placed in
formalin for histopathologic evaluation. Any additional bits
of uvea left in the sclera may be removed with gauze, lens
loop, forceps, or an evisceration spoon, leaving the sclera
clean and nonbleeding. The orbit interior then flushed well
with sterile saline. The sterilized silicone prosthesis is then
rinsed in saline and placed into the sclera using a Carter
sphere introducer. The scleral incision may have to be length-
ened with a tenotomy scissor before sphere placement to
prevent tearing of the sclera during the delivery of the pros-
thetic. The sclera is closed with 5-0 polyglactin (Vicryl, John-
son & Johnson, Mexico) (interrupted or continuous), and the
conjunctiva is closed with 6-0 polyglactin in a continuous
pattern. The canthotomy, if made, is closed with 5-0 poly-
glactin in a figure-eight pattern (Fig. 7E) to prevent suture
irritation of the cornea. An optional temporary lateral tar-
sorrhaphy suture may be placed to reduce swelling, to be
removed in 7 to 10 days.
Postoperative Care Following Ocular
Evisceration and ISP Placement
A hard plastic Elizabethan collar should be placed to re-
duce the risk of self-trauma. Soft cloth barrier collars and
“donut” and other types of restraining neck devices are not
recommended as these do not protect the surgery site. Rou-
tine pain medications (such as buprenexorphine (Hospira),
fentanyl (Alza Corp., Mountain View, CA), or tramadol
Volume 23, Number 1, February 2008
(Caraco Pharmaceutical Lab, Detroit, MI)) and NSAIDS
(carprofen (Pfizer Animal Health, Exton, PA) or meloxicam
(Boehringer Ingelheim Vetmedica Inc., St Joseph, MO) for
dogs, meloxicam for cats) may be given perioperatively as
needed. Topical and oral antibiotics are given for 10 to 14
days, and topical 5% NaCl (Ocusoft Inc., Richmond, TX)
drops may be given for several days if chemosis is excessive.
Warm damp compresses may help in reducing postoperative
swelling and keeping the area clean. Diffuse hyphema is often
immediately present, which becomes black within 1 to 2
days. Over the following 4 to 6 weeks, extensive corneal
vascularization is typically seen, followed by fading of the
corneal vessels to ultimately leave a diffuse gray or pearly
color. The sclera eventually shrinks around the prosthesis
and resolves any preexisting buphthalmos.
Should histopathologic results suggest neoplasia or a septic
process, enucleation should be considered, as full resolution
of such intraocular conditions with evisceration is not com-
mon.11 Histopathologic reports consistent with primary
glaucoma may suggest the need for antiglaucoma prophy-
laxis in the normal fellow eye. Medical therapy typically
increases the length of time such eyes will retain vision,15 but,
in general, the long-term prognosis for vision in dogs with
primary glaucoma is guarded to poor.
Complications Following Ocular Evisceration
and ISP Placement
Medically significant complications are not common after
ISP in properly chosen cases.12,16,17 While ISP eyes are of
course blind, corneal injury in these eyes is surprisingly rare.
The most common problems seen following ISP surgery in-
clude KCS, corneal ulceration, and corneal hypesthesia. Pe-
riodic monitoring of the tear production after surgery may be
warranted, and KCS is treated in a routine fashion if it oc-
curs. The cause for corneal hypesthesia may have more to do
with the presurgical condition of the eye than with the sur-
gery, as chronic glaucoma with buphthalmos has been di-
rectly associated with reduced corneal sensation.18
Enucleation
Enucleation is probably the most common orbital surgical
procedure performed in small animal practice. Common in-
dications for enucleation include irreparable corneal ⫾ in-
traocular injury, unmanageable endophthalmitis, intraocular
neoplasia, severe proptosis, and intractable uveitis. An addi-
tional indication might include painful end-stage glaucoma,
although this can also be treated with globe-sparing proce-
dures (see intrascleral prosthesis, above). All other options
should be considered before enucleation is performed, par-
ticularly for sighted- or potentially sighted eyes. However,
under the right circumstances, enucleation can provide a
rapid resolution to chronic painful eye disease, at the same
time eliminating the need for topical medications in the af-
fected eye.
Several techniques for enucleation of dogs and cats have
27
been described in the veterinary literature. Transconjuncti-
val, transpalpebral, and lateral techniques have all been used,
and various modifications have been noted as well. The tech-
nique chosen in any particular case should reflect the patho-
logic circumstances of the eye to be removed, patient anat-
omy, and surgeon’s preference. With all techniques, excessive
traction on the globe and optic nerve is to be avoided, par-
ticularly in cats. Traction on the optic chiasm during enucle-
ation has been reported, leading to permanent postoperative
blindness in the remaining eye.19 Once exposed, ligation or
cautery of the nasolacrimal openings in the surgery site may
be considered in brachycephalic dogs. Histopathologic eval-
uation of the globe and any other removed contents of con-
cern should always be performed.
The transconjunctival enucleation technique is perhaps the
most commonly used (Fig. 4). Advantages to this approach
are reduced orbital tissue loss (and thus reduced postopera-
tive orbital sinking) and reduced intraoperative bleeding
compared with other methods. However, this technique may
not be ideal for infectious conditions of the anterior segment,
such as severely infected corneal ulceration. The sterile sur-
gical site may easily be exposed to the contaminated ocular
surface, allowing for possible spread of infectious agents into
the orbit. This situation is exacerbated when the cornea is
ruptured, since intraoperative pressure on the globe may ex-
pel infected material from the eye. In such cases, transpalpe-
bral enucleation may be a better choice, particularly in dogs.
Perioperative and anesthetic concerns may be addressed as
discussed above with ISP surgery. Typically, transconjuncti-
val enucleation starts with a wide lateral canthotomy to im-
prove exposure, performed with a heavy scissor. The area to
be cut may be clamped with a straight hemostat before cut-
ting to reduce hemorrhage. A lid speculum is placed. Next, a
peritomy (360° bulbar conjunctival incision) around the lim-
bus is performed with small blunt scissors, such as Stevens
tenotomy or small Metzenbaum scissors. Curved Metzen-
baum scissors are then used to bluntly dissect under the bul-
bar conjunctiva in the subtenon’s space to expose the ex-
traocular muscle tendons. The tendons are incised with
scissors close to the globe; small hemostats may be used to
clamp these areas before cutting to reduce hemorrhage. The
ability to freely rotate the globe almost 360° indicates that at
least the recti and oblique muscles have been cut. The tissues
of the posterior pole of the globe, containing the optic nerve,
retractor bulbi muscle bellies, and associated vasculature,
should be clamped with a curved hemostat. The hemostat
may be left in place if space allows, or more typically, it must
be removed, before the stalk is blindly incised with curved
Metzenbaum or enucleation (more strongly curved) scissors
several millimeters posterior to the globe. Care should be
taken to transect the optic nerve and not cut the posterior
sclera. Bleeding from the orbit may be controlled with pres-
sure, gauze, hemostatic clamps, electrocautery, and/or cal-
cium alginate.20,21 Ligation of vessels and/or the optic nerve,
while theoretically possible, is technically difficult and may
not be necessary.22 The orbital lacrimal gland can also be
removed at this point (although various authors leave this
28 Topics in Companion Animal Medicine

Figure 4. Transconjunctival enucleation, left eye. (A) A lateral canthotomy is performed with heavy scissors. (B) A 360°
peritomy (conjunctival incision) is performed with tenotomy scissors. (C) The extraocular muscle attachments are identified
and incised close to the sclera. The muscles may be clamped before incision to reduce bleeding. (D) The optic nerve and
retractor bulbi muscles are clamped with a curved hemostat and then incised. (E) The nictitans and all associated conjunctiva
are sharply excised. (F) The lid margins are sharply excised before the orbit is closed.

step out4,6). The lid speculum is removed, and the base of the
nictitans is then broadly incised; clamping before cutting may
again reduce hemorrhage. The whole nictitans, including the
cartilage and gland at the base, should be removed. The eye-
lid margins are also removed with a heavy straight scissor,
starting at the lateral canthotomy. Several millimeters of lid
margin tissue should be removed in this process, so that the
smooth hairless lid margin is fully excised and the skin edges
will close without excessive dead space or tension. The me-
dial canthal area tends to be closely adherent to its deeper
attachments, and sharp dissection is sometimes required.
Large vessels are sometimes encountered in this area. The
orbit may be copiously flushed at this point with sterile
saline.
A variation of subconjunctival enucleation improves the
access to the posterior pole of the globe and thus may reduce
traction on the optic nerve. In this technique,23 a lateral can-
thotomy is performed, and the lid margins and nictitans are
then removed. The remainder of the globe dissection pro-
ceeds as for subconjunctival enucleation as above. With the
lid margins and nictitans out of the way from the start, ad-
ditional surgical space is available around the globe. A study
of 25 dogs and 10 cats operated with this technique noted no
additional complications over other procedures.23
Volume 23, Number 1, February 2008
To improve postoperative cosmesis following enucleation,
several techniques have been employed, including orbital
mesh placement, sphere implantation, a combination of the
two, and tissue reconstruction. Placing an orbital meshwork
is simple and does not require special supplies; a taut contin-
uous pattern of 3-0 to 5-0 monofilament nonabsorbable su-
ture (such as nylon; Ethilon) is simply placed with bites 2 to
4 mm apart in the periosteum of the anterior orbital rim. The
meshwork may be placed both horizontally and vertically in
orientation.1 All gauze that has been placed in the orbit
should be removed before the final bites are placed. Dead
space is thus left in the orbit, although postoperative prob-
lems associated with this have not been reported to the au-
thor’s knowledge. Solid implants of methyl methacrylate, or
more commonly silicone, have also been placed in the orbit to
fill its volume. Spherical implant sizes of 16 to 22 mm diam-
eter are typically used for dogs and cats, with brachycephalic
breeds generally tending to require smaller implants and doli-
chocephalic breeds requiring larger ones. Implants should be
gas sterilized and rinsed just before use. Removal of the an-
terior 25% of a solid silicone sphere (such as those used for
ISP surgery above) has been advocated before the implant is
placed into the orbit, with the flat side facing forward.24 The
implant may then be retained in position with an overlying
mesh on the orbital rim as just described. Alternatively, scar-
ifying the sphere has also been used to improve retention.21
The complication rate with orbital prostheses is low, but
complications include sphere extrusion (in some cases result-
ing in a second surgery to remove the implant), orbital cellu-
litis/foreign body reaction, orbital fluid accumulation, and
displacement of the implant into the subcutaneous facial
area.5,10,16 Complications with implant placement are more
likely to occur in cats than in dogs. Tissue reconstruction
techniques including the use of flaps of orbital periosteum25
or rotated sections of temporalis muscle26 have also been
used. Orbital volume augmentation techniques are not nec-
essary for successful enucleation surgery and may even be
contraindicated in cases of suspected infection of the orbit.
Postoperatively, allowing for long hair growth over the enu-
cleated orbit may also improve cosmesis in longhaired
breeds.
Once the globe and nictitans have been removed, closure
of the remaining bulbar conjunctiva (the site of the original
peritomy) with a continuous suture of 4-0 absorbable suture
has been described.4,24 Orbital bleeding is said to be con-
tained by this method, although intact epithelial surfaces in-
cluding secretory surfaces are also left in the orbit. Post-
enucleation cysts are a potential complication that require a
second surgery.6,24 To avoid this possibility, all palpebral and
bulbar conjunctival tissues should be simply trimmed away
with scissors before closure of the lids.1
The lids are then closed in three layers. The orbital septum,
within the eyelid (discernible mainly by its strength in hold-
ing a needle or suture), is closed with 3-0 to 5-0 absorbable
suture in either a simple interrupted or a continuous pattern;
the subcutaneous tissues are closed with 3-0 to 5-0 absorb-
able suture in a simple continuous pattern; and the skin is
29
closed with either 3-0 to 5-0 nylon simple interrupted skin
sutures or 4-0 to 5-0 absorbable simple continuous subder-
mal sutures.
A second technique for enucleation is the lateral ap-
proach27 (Fig. 5). Advantages of the lateral approach include
somewhat better visualization of retrobulbar tissues before
the globe has been removed, especially in those with deep
orbits; improved confinement of the ocular surface from the
sterile surgical site; and retention of more orbital tissue than
with the transpalpebral technique. Disadvantages compared
with the transconjunctival technique include the loss of more
orbital tissue, and potentially increased bleeding (since much
of the dissection occurs more superficially than the sub-
tenon’s space).
The lateral enucleation also starts with a wide lateral can-
thotomy made with a straight heavy scissor such as a Mayo.
The cut surface of each lid is then bluntly dissected into an
anterior skin-orbicularis oculi layer and a posterior tarsocon-
junctival layer using a curved Metzenbaum scissor. Blunt
dissection is continued medially until the medial canthus is
reached. The scissor is then removed, and one blade of the
scissor is replaced in the subcutaneous pocket just created to
allow the anterior layer to be cut parallel to the lid margin as
close to the medial canthus as possible. The lids are closed
with either Allis tissue forceps or a 3-0 or 4-0 simple contin-
uous suture with ends left long. The lateral aspect of the
forceps or suture is used to gently retract and rotate the
dissected orbital contents medially. Blunt and sharp dissec-
tion of the tissues around the lateral globe is performed,
clamping and then incising extraocular muscles close to their
attachments on the globe. The tissues of the posterior pole of
the globe are clamped with a hemostat; the hemostat is re-
moved, and the tissues are transected several millimeters pos-
terior to the globe. The globe is rolled out of the orbit from
lateral to medial, and the remaining extraocular muscles, the
medial canthal tendon, and the attachments of the medial
canthus to the orbit are transected from posterior to anterior.
The nictitans is then removed, and any remaining conjunc-
tiva is trimmed away. Again, hemostasis may be controlled
via a variety of methods as above, and the orbit may be
flushed. Orbital prosthetic and lid closure considerations are
then the same as for transconjunctival enucleation above.
The transpalpebral enucleation technique takes the level of
dissection slightly further external to the globe (Fig. 6). The
main advantage of this technique compared with the other
methods of enucleation is the superior confinement of the
ocular surface from the surgery site, particularly important
when infection or neoplasia is present on the surface. Disad-
vantages include increased bleeding and increased traction
on the optic nerve, a particular concern in cats and deep-
orbited dogs.
Transpalpebral enucleation starts with closure of the eye-
lids. The anterior skin-orbicularis layer of the eyelids is cir-
cumferentially incised parallel to and 4 to 5 mm from the lid
margins with a no. 15 Bard Parker scalpel using a Jaeger lid
plate or tongue depressor for support. The depth of the for-
nices can be estimated by the depth of the lid plate in this step,
30 Topics in Companion Animal Medicine

Figure 5. Lateral approach to enucleation, left eye. (A) A lateral canthotomy is performed with heavy scissors. (B) The lid tissues
are separated with a curved Metzenbaum scissor to the medial canthus into an anterior skin-orbicularis layer and a posterior
tarsoconjunctival layer. (C) The skin-orbicularis layer is incised. (D) The palpebral fissure is closed and the extraocular muscle
attachments are identified and incised close to the sclera, starting with the lateral aspect and continuing posteriorly. The muscles
may be clamped before incision. (E) The optic nerve and retractor bulbi muscles are clamped and then incised. (F) The medially
located extraocular muscles are similarly incised. (G) The nictitans and all associated conjunctiva are sharply excised.

allowing for more accurate dissection around the globe dur-
ing dissection. The lids are sutured closed with a simple con-
tinuous suture with the ends left long, or closed with Allis
tissue forceps, which may be used for traction. The instru-
ments used so far may at this point be removed from the
instrument tray to further reduce the risk of contamination
from the ocular surface. From the initial skin incisions, the
subcutaneous tissues are bluntly dissected with a small
curved Metzenbaum scissor around the globe. The goal is to
keep the plane of dissection outside of the conjunctival sac
Volume 23, Number 1, February 2008 31

Figure 6. Transpalpebral enucleation, left eye. (A) A sharp incision is made around the palpebral fissure through the skin. A
lid plate or tongue depressor may be used behind the lids for support. (B) The lid margins are sutured together and the ends
are left long to allow for traction. An Allis tissue forceps or similar instrument may also be used for this purpose. (C and D)
The subcutaneous tissues are dissected to identify the extraocular muscle attachments, which are isolated and incised close to
the sclera. The muscles may be clamped before incision to reduce bleeding. (E) The optic nerve and retractor bulbi muscles
are clamped with a curved hemostat and then incised.

(ie, posterior to the conjunctival fornix). The medial and
lateral canthal tendons are cut with scissors to free up the
canthal areas. Blunt dissection continues posteriorly, dissect-
ing external to the lacrimal gland, and the extraocular mus-
cles are clamped before they are incised close to their inser-
tions on the globe. Free rotation of the dissected sac indicates
that most of the attachments of the globe have been freed.
The tissues at the posterior pole of the globe are also
clamped; the hemostat is removed, and the stalk is incised
several millimeters posterior to the globe. The globe, lid mar-
gins, orbital lacrimal gland, conjunctiva, and nictitans are
removed together. The orbit may then be flushed and the lids
closed as described above for transconjunctival enucleation.
If contamination of the surgery site is a possible issue, the
cosmetic benefits of prosthetic placement should be weighed
against the possibility of introducing foreign material into a
potentially infected space.
Postoperative Care Following Enucleation
As discussed above under ISP surgery, routine oral antibi-
otics, pain medications, and anti-inflammatory medications are
32
used, and a hard plastic Elizabethan collar is placed to prevent
self-trauma. Cold compresses immediately after surgery may be
used if significant postoperative swelling or hemorrhage are
noted. Pressure bandages on the surgical site typically are diffi-
cult to maintain and are not efficacious. Owners should be
advised that mild ipsilateral epistaxis may be seen soon after
surgery as blood from the orbit drains into the nasolacrimal
duct.
Complications Following Enucleation
As with all types of surgery, bleeding and infection are
potential postoperative complications; the risk of these
may be reduced with meticulous surgical technique. Swell-
ing within the orbit caused by accumulation of air (orbital
emphysema) or lacrimal secretions may also occur weeks
to months following surgery.28,29 Ultrasonography, needle
aspiration, radiographs, and other imaging modalities
may help in the differential diagnosis. Orbital emphysema
is more likely to occur in brachycephalic dogs than in other
breeds, theorized to occur due to retrograde movement of
air through a patent nasolacrimal system during expira-
tion. This condition may sometimes self-resolve, although
repeated air accumulation should be treated surgically by
ligating the proximal nasolacrimal duct in the orbit. Scle-
rosing agents (tetracycline) into the orbit followed by pres-
sure wraps may be of additional help. Postoperative fluid
secretions in the orbit may be due to lacrimal and/or con-
junctival remnant secretion,6,24 and again removal of the
secreting tissue should be performed. Imaging modalities
and radiographic contrast studies may aid in identifying
the extent of such cystic structures. Cystic structures
should be left intact (and not aspirated or drained) before
dissection to improve visualization of natural borders and
allow for complete removal. Loss of orbital implants is an
uncommon problem (more common in cats) and has been
reported to be associated with inadequate closure of the
surgery site, trauma, and fluid accumulation around the
implant.5,10 Such complications have not been reported to
occur with mesh implants to the author’s knowledge.
Exenteration
The main indication for exenteration is orbital disease ex-
tending outside of the globe but limited to the soft tissues in
the orbit that cannot be resolved by other means. Examples
of such etiologies include neoplasia or infection involving
both globe and orbit, diffuse severe trauma involving both
globe and orbit, and penetrating globe injury involving the
orbit (eg, migrating foreign bodies such as wood or porcu-
pine quills). Ideally, the extent of the pathology should not
include or traverse the orbital wall, since exenteration would
not be expected to resolve such a lesion. Depending on the
location of the pathology in question, orbitotomy might be a
consideration for some of these conditions if removal of all
the orbital tissues is not required.
Topics in Companion Animal Medicine
Exenteration is performed similar to transpalpebral enu-
cleation. Placing the patient in lateral recumbency may aid in
improving exposure. The area is clipped and surgically
prepped, and the lids are closed as for transpalpebral enucle-
ation. The skin is incised in a wider circumference than with
enucleation, at or near the width of the orbital rim. Dissec-
tion into deeper tissues is performed with blunt dissection.
The lateral and medial canthal tendons are identified and
sharply incised. Extraocular muscles are identified and in-
cised close to their attachments to the orbit. Electrocautery
and/or ligation of large vessels may be required to control
hemostasis. The orbital lacrimal gland is excised from under
the lateral orbital ligament. Blunt dissection is continued to
the apex of the orbit, which ideally is then clamped with
curved hemostats before it is sharply excised with scissors.
The clamped tissues may or may not be ligated before the
orbit is flushed with sterile saline. An orbital implant may be
considered if no neoplastic or infected material is present in
the orbit, with larger sized implants used for exenteration
than enucleation. The orbit is then closed as described above;
care should be taken to close the wound with no tension. If
the surgical defect is too large to be closed routinely, recon-
structive procedures such as a caudal auricular axial pattern
flap may be used to cover the surgical wound, though two of
four patients required a second surgery in one study.30
Proptosis
Proptosis occurs when the globe is made to protrude anterior to
the orbit, causing entrapment of the lid margins behind the
anterior half of the globe. Typically this occurs due to trauma,
occurring with a major head injury such as a dog fight or car
accident. The more shallow the orbits, the less traumatic force
needed to cause proptosis. Thus, proptosis occurs much more
frequently in brachycephalic dogs, but in these breeds, less in-
jury is required to cause proptosis. Restraint of a struggling
brachycephalic dog may iatrogenically cause proptosis.31 Con-
versely, significant force is required to cause proptosis in doli-
chocephalic dog breeds and most all cats, with a commensu-
rately high degree of damage to the eye and head as well.
Proptosis causes stretching or tearing of the extraocular mus-
cles, the optic nerve, and all vessels and nerves supplying the
globe. In addition to the vascular embarrassment, corneal
drying rapidly occurs. Once the globe is proptosed, lid muscle
spasm and swelling of the orbital tissues exacerbates the condi-
tion. Hyphema, retrobulbar hemorrhage, and orbital rim frac-
tures can also accompany proptosis.
Should veterinary advice for an animal with proptosis be
sought on the phone, the owner should be advised to keep the
cornea moist with sterile saline, lubricating gel (KY jelly,
artificial tear gel), or any other lubricant (mineral oil, petro-
leum jelly, ophthalmic ointments without steroids). In many
cases the animal will not allow topical treatments to be ap-
plied, but an attempt should be at least made. The animal
should be kept without food and water and self-trauma
should be prevented. Immediate medical care should be
sought.
Volume 23, Number 1, February 2008
When a patient presents with proptosis, a physical exam-
ination should be done first to rule out significant systemic
injuries, such as shock or pneumothorax, which should be
treated accordingly first. Bite wounds, orbital rim fractures,
and other head injuries should be identified. The globe
should be rapidly evaluated to determine if it is to be re-
placed. If the optic nerve is torn, the posterior pole of the
globe is clearly visible, or a large perforation of the eye wall is
present (sometimes only indicated by marked hypotony),
enucleation should be performed since the prognosis for
globe salvage is grave. If three or more extraocular muscles
are torn (typically leading to marked dorsolateral strabis-
mus), the orbit is fractured, or the pupil is not visible due to
diffuse hyphema, the prognosis for saving vision is poor,32
although the globe itself may still be salvageable. Pupil size
itself is not necessarily a good predictor of vision progno-
sis,1,32 as it is determined by multiple factors. Positive prog-
nostic indicators include a brachycephalic dog signalment (as
opposed to dolichocephalic dog or any cat), intact direct and
consensual pupillary light reflexes, intact vision (as indicated
by tracking of a thrown cotton ball or head retraction when
the eye is menaced— blinking will not occur in proptosis), a
normal fundus appearance, and short duration of proptosis
before treatment. The overall prognosis for vision in pro-
ptosed globes is guarded to poor. The prognosis for globe
salvage in properly chosen cases is good; the degree of even-
tual ocular cosmesis is variable.
If the globe is to be replaced, this should be done as soon as
possible (Fig. 7). The cornea should be kept lubricated until
reduction can be performed. Once the animal is determined
to be stable enough to undergo anesthesia, general anesthesia
is induced. A perioperative dose of either methylprednisolone
sodium succinate (SoluMedrol®; Pharmacia & Upjohn Co.,
Kalamazoo, MI) 7 to 15 mg/lb IV, prednisolone sodium suc-
cinate (SoluDeltaCortef®; Pharmacia & Upjohn Co.) 7 to 15
mg/lb IV, or flunixin meglumine (Banamine®; IVX Animal
Health, St Joseph, MO) 0.1 mg/lb IV should be given to
reduce orbital inflammation and swelling. This dose of sys-
temic anti-inflammatory medication may be given even if
corneal ulceration is present. Perioperative antibiotics (cefa-
zolin or ampicillin 10 mg/lb IV; Fort Dodge Animal Health,
Fort Dodge, IA) should also be given. The periocular area is
clipped, prepped with dilute povidone iodine solution, and
flushed. A wide lateral canthotomy may be made with a
straight blunt-ended scissor to improve access and lid laxity if
needed. The cornea is lubricated with sterile ophthalmic oint-
ment. The entrapment of the lid margins is reduced with a
strabismus hook or atraumatic forceps. Two to four partial
thickness temporary tarsorrhaphy sutures of 4-0 nylon are
placed but not tied, leaving the area of the medial canthus
open. Care is taken to allow the sutures to exit the lid margins
so that sutures will not touch the cornea even after they
loosen. The ends of the preplaced sutures are then grasped
with a hemostat, which is pulled anteriorly while gentle pos-
terior pressure is placed on the lubricated globe with a
smooth BP blade handle, a Jaeger lid place, or the cut finger
of a surgical glove. The sutures are tied with one end left long;
33
stents may be used if the sutures are excessively tight. Some
have also advocated tying the tarsorrhaphy sutures in a bow
for ease of opening and retying, but this may not be neces-
sary. If the patient is normally very exophthalmic, a perma-
nent lateral tarsorrhaphy may be performed in both eyes by
excising a short length of lid margin laterally and closing this
as a routine canthotomy. The canthotomy is closed with 5-0
polyglactin in two layers and a figure-eight suture to avoid
suture– corneal contact. Significant exophthalmos usually
persists even after the proptosed globe has been reduced and
the tarsorraphy sutures have been placed.
Postoperatively, topical medications are applied through
the medial opening in the palpebral fissure. Triple antibiotic
ointment without steroids QID, 1% atropine ointment BID,
oral antibiotics, and oral prednisone (0.25-0.5 mg/lb BID for
5 to 7 days, then taper) should be used, and an Elizabethan
collar placed. To reduce swelling, cold compresses may be
used postoperatively for the first day, and then warm com-
presses used three to four times a day for several more days if
the patient allows it.33 A tarsorrhaphy suture is removed
from medial to lateral every 5 to 7 days. The owner should be
instructed to monitor for excessive active blepharospasm,
mucopurulent discharge, and ocular discomfort, and to re-
check if any of these are seen. The sutures may need to be
removed to reevaluate the eye if it becomes increasingly pain-
ful. Short-term complications that would require treatment
include corneal ulceration secondary to suture irritation and
infectious keratitis. Long-term complications after proptosis
include blindness and strabismus (very common), corneal
scarring, KCS, lagophthalmos, corneal hypesthesia, and
phthisis bulbi.32 Postproptosis strabismus reportedly im-
proves over 6 to 9 months in many cases and often does not
require repair,34 although surgical options do exist if the
condition persists and is problematic.7
Orbitotomy
When an orbital lesion is present but the globe is otherwise
normal, an orbitotomy may be considered for diagnostic
and/or therapeutic purposes. Indications for orbitotomy
include excision, exploration, and/or biopsy of focal or-
bital conditions including neoplasia, cysts, abscesses not
related to tooth roots, foreign bodies, and other unidenti-
fied masses.
Location and anatomic extent of orbital lesions should be
identified before surgery can be planned. History, detailed
physical examination, and various imaging modalities (in-
cluding radiographs, ultrasonography with Doppler, mag-
netic resonance imaging, computed tomography, angiogra-
phy) should be used to determine whether the mass is
intraconal or extraconal (inside or outside the periorbita),
where the mass is in the orbit and in relation to the globe,
whether or not the mass is attached to the globe, and a rea-
sonable differential diagnosis list. Details of the workup of
orbital masses and disease are beyond the scope of this article
but are well-documented elsewhere.1,6,7 The presence of bony
lysis, extraorbital extension, and systemic metastasis should
34 Topics in Companion Animal Medicine

Figure 7. Replacement of a proptosed globe. (A) A lateral canthotomy is often helpful to increase lid laxity, making lid
reduction easier. (B) After the lid margins are pulled from their entrapped position, several partial thickness tarsorrhaphy
sutures are placed but not tied. No sutures are placed in the medial aspect of the palpebral fissure. (C) The sutures are grasped
all together and pulled anteriorly, while the globe is pushed posteriorly with a lid plate or similar broad object. The lid plate
may also be placed behind the sutures. (D) The sutures are tied. No suture should have any contact with the cornea. (E) The
canthotomy is closed routinely. A figure-eight suture is used at the canthus.

also be determined before any surgery is attempted. These
data together help the clinician determine an appropriate
treatment plan, expectations for resectability, the best surgi-
cal approach, and the overall prognosis. Most tumors of the
orbit are malignant and are associated with a poor long-term
prognosis. Orbitotomy is not necessarily ideal for all orbital
masses,35 and in some cases, alternate therapy is much more
likely to be successful.36
Masses in the anterior orbit may be approached by
transconjunctival orbitotomy, a technique similar to the ap-
proach to transconjunctival enucleation, or transpalpebral
orbitotomy, where an incision is made in the skin parallel to
the lid margin and into the orbit.1,4 Dorsomedial orbital
masses may be accessed with a dorsal orbitotomy ap-
proach,37 although nerve damage and lagophthalmos may
result due to the extensive dissection needed. For intraconal
Volume 23, Number 1, February 2008 35

Figure 8. Transoral drainage of an orbital abscess. (A) A small, shallow incision is made in the oral mucosa, often behind and
slightly medial to the last upper carnassial tooth. (B) A blunt probe or small closed hemostat is gently forced through the incision
and into the retrobulbar space, allowing for laboratory sampling and frank abscess drainage (which is not always seen).

or lateral extraconal masses, lateral orbitotomy with or with-
out transection of the lateral orbital ligament may be used.1,4
Even greater exposure of the retrobulbar area can be
achieved with lateral orbitotomy and zygomatic arch resec-
tion, which involves osteotomy of the zygomatic arch in two
places so that it can be reflected from the orbital space.38-40
Not all orbital masses can be reached while preserving the
globe, and exenteration may be the only means to achieve
complete removal of a mass, a fact that might only be discov-
ered intraoperatively.4 Detailed knowledge of orbital anat-
omy is required for successful orbitotomy, and referral to a
specialist veterinary ophthalmologist or surgeon is strongly
recommended if these techniques are being considered.
Orbital Abscess Drainage (Fig. 8)
Abscesses may form posterior to the globe, commonly due
to local spread of infection from diseased tooth roots, but
also due to migrating foreign bodies, penetrating oral mu-
cosal injury, and possibly hematogenously. Abscesses
should be distinguished from orbital cellulitis, which is
characterized by a more diffuse inflammation of the retro-
bulbar tissues without discernible fluid pockets. Clinical
signs of orbital abscessation include rapid-onset exoph-
thalmos, elevation of the nictitans, lagophthalmos, lid er-
ythema, conjunctival hyperemia, chemosis, pain on open-
ing the mouth or on globe retropulsion, and swelling and
36
erythema of the oral mucosa behind the last upper molar.
Fever, lethargy, anorexia, leukocytosis, and local lymph-
adenopathy are also often seen. Orbital ultrasonography
may reveal heterogeneous or hypoechoic structures, a cav-
itary lesion, or even a mass effect.41
Broad-spectrum systemic antibiotic therapy (such as
amoxicillin/clavulanic acid (Clavamox, GlaxoSmithKline,
Research Triangle Park, NC), enrofloxacin (Baytril, Bayer
HealthCare LLC, Shawnee Mission, KS), metronidazole
(Pliva Inc., East Hanover, NJ), and/or clindamycin (IVX An-
imal Health)), with or without anti-inflammatory medica-
tions should be instituted when an orbital abscess/cellulitis is
suspected. While in some cases medical therapy alone effects
improvement, drainage of an orbital abscess should be con-
sidered when the disease progresses despite medical therapy
or a distinct abscess has been identified on imaging. If the
abscess originates from a tooth root as suggested by dental
radiographs, drainage can be established via extraction of the
tooth. If not associated with apical dental disease, drainage is
established through the oral mucosa.
For transoral orbitotomy to establish drainage, the ani-
mal is anesthetized and the head placed on a wet table or
towels. The mouth is opened with a speculum and the area
behind the upper molars is prepped with dilute povidone-
iodine and flushed with sterile saline. The area in the
throat around the endotracheal tube may be gently packed
with large dry gauze squares to prevent drainage of fluids
into the esophagus and trachea (these must always be re-
moved at the end of the procedure). A shallow ½⬙-long
incision is made with a no. 15 BP blade through the oral
mucosa. If an area of focal mucosal erythema and swelling
(like an abscess coming to a head) is seen, the incision is
made in this area; otherwise, this incision is made caudal
and slightly medial to the last upper tooth. A sterile blunt-
ended probe or small nontoothed hemostats are gently
forced through the soft tissues toward the retrobulbar or-
bit. If fluid drainage is not seen with gentle probing, the
jaws of the small hemostats may be gently opened, but not
closed, in the retrobulbar space.1 Care should be taken to
not damage the numerous vessels and nerves coursing
across the orbital floor. Samples should be taken directly
from the deeply probed areas for aerobic and anaerobic
culture/sensitivity and for gram staining. Drainage of
frank abscess fluid is not always seen. Either way, the
pocket is then flushed with sterile saline or 0.05% chlor-
hexidine in sterile water delivered by a 12 mL syringe. The
incision is left open to allow for drainage. Oral antibiotics
and anti-inflammatory medications are continued until
retrobulbar swelling resolves, and ophthalmic lubricants
are used if lagophthalmos is present.
Orbitectomy
Orbitectomy involves removal of part of the orbital wall with
(total orbitectomy) or without (partial orbitectomy) removal
of the orbital contents, in the interest of more completely
removing disease that has extended beyond the orbital
Topics in Companion Animal Medicine
walls.42 As such, orbitectomy is an invasive procedure that
may require surgery into the nasal sinuses, the bones of the
jaws and head, and/or the oral and cranial cavities. This more
radical surgery results in a much greater loss of tissue than
enucleation or exenteration, with associated facial defor-
mity, possible loss of function, and other complications. In
some cases, the surgery may be followed by appropriate che-
motherapy. If this surgery is being considered, referral to a
specialist veterinary ophthalmologist or surgeon is strongly
recommended.
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