Visiting Vet: Little Horatio

Proptosis is more common than you might think.

Little Horatio, a 10-year-old Chihuahua mix, recently came to summer on the Vineyard, happily sharing his home with two other dogs and two cats. Everyone was getting along splendidly until Saturday afternoon, when a brief squabble occurred between Horatio and one of his considerably larger canine companions over a chewy treat. Big Dog snapped at Little Dog. He probably just meant it as a warning, but ended up biting Horatio’s head. Two things ensued. A puncture wound on Horatio’s forehead … and proptosis of his right eye. Stop reading now if you’re squeamish. That’s right. Horatio’s eyeball popped out.

Proptosis is defined as the sudden expulsion of the eyeball globe from the socket, protruding past the eyelids. It is a condition that can occur with minimal trauma in certain breeds, especially those with short, flat faces like Pekingese or pugs. These dogs have naturally shallow eye sockets, and eyeballs that already bulge a bit. The most common cause is, like with Horatio, a big-dog-little-dog altercation, but proptosis can also sometimes occur simply as a result of forcefully restraining a bug-eyed dog. In other words, some unfortunate veterinarian, trying too hard to wrestle an anxious pug to clip toenails or draw blood, can end up with a patient with a dangling eyeball, and a very upset owner.

I was out doing errands when my husband called. I’ll admit I was cranky. “What?” I snapped. “I’m in the middle of … ” My ever-patient husband interrupted to say that Horatio was in my waiting room, with his eye popped out. That shut me up. “Thanks for calling,” I said contritely. “Have them sit tight. I’m on my way.”

Horatio seemed stable except for the proptosis. The eyeball was extremely swollen, and there was an area puffed up with hemorrhage under the surface, where I suspect one of Big Dog’s teeth had landed. I immediately rummaged through my supplies to locate a bottle of 50 percent dextrose, i.e., sterile sugar water. I squirted some directly over the globe, then soaked a gauze pad and had my assistant, who had kindly come to help, hold the compress on the eye. This helps reduce swelling, using osmotic pressure to draw fluid out of the globe and surrounding tissues.

“We need to anesthetize Horatio and see if we can save his eye,” I began. Faced with a proptosis, the first decision (after confirming the patient is otherwise stable) is whether to try to replace the globe, or go straight to nucleation, i.e., removing the eye. If there is any chance of putting the eyeball back in place, it’s usually worth trying … and the sooner the better. If the optic nerve is intact, some dogs may retain sight in the affected eye, but even if they end up blind in that eye, saving the globe gives a better cosmetic result. The eye can always be removed later if necessary.

Once Horatio was snoozing, I checked for corneal damage, continued to compress with dextrose, lubricated the globe, and gently tried to work it back into the socket. It’s hard to explain, but the eyelids, now sitting behind the eyeball, make it difficult to squeeze the swollen globe back in. Picture the eyelids are a small buttonhole, and the eyeball a large swollen round button that doesn’t fit through that buttonhole. I had to do a lateral canthotomy. That’s a fancy way of saying I enlarged the buttonhole with a small incision at the outer corner of the eyelid.

Sometimes these eyes pop back in fairly easily. Not this time … but eventually I got the globe back in the socket. Now to make sure it stayed there. Using the flat back of a scalpel handle, my assistant gently kept pressure on the eyeball, holding it in, while I preplaced a series of sutures to draw the eyelids together. Often a small piece of rubber tubing or elastic is incorporated into the suture line to reduce tension. I tried to do so, but the degree and location of the swelling made it too difficult for me to simultaneously reduce the globe, include the tubing, and place the stitches. Pulling the sutures slowly closed, the eyelids were now sewn together temporarily to work as both a barrier keeping the globe in, and a bandage, keeping the eye protected. Ideally, we like to leave a little opening at the corner so owners can instill medication under the lids, but Horatio’s membranes were so swollen in that area, I was afraid they might squeeze through, like toothpaste from a tube. I opted to close right down to the corner. Once the swelling abates in a few days, I may remove the corner stitch to facilitate topical treatment of the eye.

Horatio went home with antibiotics, multiple pain medications, eye ointment, and an Elizabethan collar to prevent him from rubbing his eye. By the morning after surgery, his family reported good pain control, and that he had eaten breakfast. We will check him frequently. If all continues to go well, we will begin removing sutures in a week or two. This is usually done sequentially over a period of time, starting with just the middle sutures. Then we can assess if he has function. With or without vision, there are other possible complications, including infection, recurrence of proptosis, loss of eye mobility, loss of tear production, or continued pain, all of which may indicate removal of the eye to preserve his quality of life.

The prognosis varies depending on degree and type of trauma, and how quickly surgical correction can occur. I had offered Horatio’s family the option of going to a board-certified veterinary surgeon off-Island, but also advised that time was of the essence. Let’s hope early intervention has saved his eye, maybe even his vision on that side. As for Big Dog, I suspect he is contrite, and did not intend to cause such grievous injury to his little pal, but from now on, Big Dog and Little Dog will get their treats separately, and supervised.