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How to Insert and Manage a SubpalpebralLavage System

Ann E. Dwyer, DVM

Author’s address: Genesee Valley Equine Clinic PLLC, 925 Chili Scottsville Road, Scottsville, NY14546; e-mail: [email protected]. © 2013 AAEP.

1. Introduction

A subpalpebral lavage system (SPL) is an ophthal-mic catheter that delivers topical liquid medicationonto the surface of the equine cornea. The systemconsists of a long silicone tube that passes throughthe upper or lower eyelid and is secured to the facialskin. The tubing, which is woven through themane and draped along the crest of the neck, ends ina closed port that is secured to the mane. Medica-tion is injected into the port and pushed through thetube by an air bolus or by additional medications toreach the tear film.

An SPL is an essential tool for treating seriousequine ocular conditions such as corneal lacerations,deep ulcers that are infected or melting, or severeuveitis.1 Management of these ocular problems re-quires multiple treatments per day and may extendfor several weeks. SPL medication is deliveredwithout the handler touching the face or periocularregion; therefore, treatment of fractious or painfuleyes is simplified. An SPL makes therapy as easyas possible for the caretakers and ensures that allmedication reaches the tear film to medicate thecornea. The use of an SPL is mandatory in anyglobe that is at risk for rupture caused by tectonicinstability of the cornea or sclera.

The use of an SPL is not limited to the hospitalsetting. Practitioners can place SPLs and trainfarm personnel to implement treatment in the field.SPLs can be used on any size of horse and have beenused to treat neonates and foals as well as adults.The use of an SPL increases the safety and efficacyof topical therapy, improves compliance, and re-duces caretaker fatigue in complex, multidrug treat-ment plans.

2. Materials and Methods

Commercial SPL kits are available through two vet-erinary manufacturers.a This author prefers kitsthat provide a solid 12-gauge insertion trochar thatis swaged onto the silicone tubing.b The kits offer achoice of a straight or angled insertion trochar; prac-titioners who use a gloved finger as a guide to slipthe trochar beneath the lid may favor the angledversion. The kits are sold in 36- and 60-inchlengths with a single 5F lumen diameter. The 60-inch kit is most versatile because the longer tubesare suitable for large horses and can be shortened toaccommodate small patients. The 36-inch tubesmay be too short for use in some horses.

The following checklist summarizes all items theauthor commonly uses to facilitate restraint, seda-

164 2013 � Vol. 59 � AAEP PROCEEDINGS

HOW-TO SESSION: OPHTHALMOLOGY

NOTES

tion, and site preparation and to secure the tube andconstruct a durable injection port:

● SPL Kit, 60 inches● Sterile gloves (for trochar insertion)● Topical bottle of 2% povidone iodine solution

and gauze 4 � 4 gauze pads (to clean theperiocular region)

● Proparacaine or tetracaine topical ophthalmicsolution (to numb the corneal surface)

● Mepivicaine or lidocaine injectable (for block-ing the eyelid)

● Several 3-mL syringes● Detomidine (for sedation)● Small rubber bands (to braid the mane)● A roll of duct tape (to make butterfly tabs for

securing the tubing)● A roll of white adhesive tape (to make mane

braids snug and create the base for the injec-tion port)

● 20-gauge, 1.25-inch catheter (to create injec-tion port)

● Male catheter cap (to create the injection port)● Wooden tongue depressor● Nonabsorbable suture (1–0 to 1 diameter, to

secure the tube to the skin)● Olsen-Hegar needle holders, 6 inches long (for

tube suturing)

SPL treatment plans require a large quantityof tuberculin (1-mL) syringes and 25-gauge, five-eighths–needles. These may be dispensed in boxquantities. A selection of colored tape rolls will aidin labeling different medication syringes.

InstallationThe clinician should ensure that the horse is re-strained in a clean, wind-free, well-lit, quiet area.Placement of an SPL is not difficult, but it carries arisk to the patient because insertion involves briefpassage of a sharp trochar over the corneal surface.The clinician must insist that barn activity be keptto a minimum when the trochar insertion takesplace. All necessary items should be placed on aclean, elevated surface. Folding tables sold for doggrooming make handy equipment stages in thefield.c

The owner or veterinary assistant should braidthe mane and forelock into a series of “pigtails” thatwill serve as guides to secure the tubing to the crestof the neck. Because the tubing may be maintainedfor several weeks, it is helpful to secure the top andbottom of each pigtail with a wrap of adhesive tapeso the braids do not loosen.

Insertion is safest when the horse’s mandible issupported on a solid object (stacked bales, oil drum,recycling bin, etc). Stocks are helpful if they areavailable. The horse should be sedated heavilywith the use of detomidine at a dose of 0.02 to0.04 mg/kg. Deep sedation will cause the horse torest the mandible on the support material, and the

handler will only have to lightly brace the headwhile standing on the opposite side to the affectedeye (Fig. 1).

The periorbital region is cleaned with a 1:50 pov-idone iodine/saline solution. The target area fortrochar insertion is blocked with local infiltration ofmepivicaine or lidocaine. If the tube is intended forthe upper eyelid, an auriculopalpebral and supra-orbital block should be performed. One milliliter oftopical anesthetic is drawn up into a tuberculin or3-mL syringe and sprayed onto the corneal surfacewith the use of the hub of a broken-off 25-gaugeneedle as a spraying device.

The SPL tube can be inserted into either the up-per eyelid or the lower eyelid (Fig. 2A,B). Someclinicians think that the use of the dorsotemporalfornix of the upper lid provides beneficial “waterfalleffect” in which the medication cascades over theocular surface. Others argue that insertionthrough the ventronasal cul-de-sac of the lower lidprovides protection against iatrogenic ulceration be-cause the nictitans is a barrier if the tube footplatemigrates in from the conjunctiva. There is goodevidence to support that a lower-lid SPL is an effec-tive and safe choice.2 Ultimately, the choice willdepend on clinician preference, patient tempera-ment, and location of the lesion. Securing the tubeto the face can be done in a linear pattern fromupper eyelid insertion sites. If the lower lid is used,the tube must be secured to the face in a J-shapedpattern.

The following steps (Fig. 3A–D) describe the in-sertion process once the mane is braided, the horse

Fig. 1. A wheeled recycling bin or other stationary prop is usedto support the horse’s mandible for safe SPL insertion.

AAEP PROCEEDINGS � Vol. 59 � 2013 165


Fig. 2. A, SPLs can be inserted into the upper or lower lid. This system was inserted into the upper eyelid. B, This SPL wasinserted into the lower eyelid.

Fig. 3. A, SPL insertion: A gloved finger is used to probe the depths of the fornix and test the horse’s reaction. B, The trochar iscarefully pushed through the palpebral conjunctiva and eyelid. C, The SPL tubing is pulled through the eyelid. D, The tubingfootplate is pulled under the lid. Care must be taken to align the angle of the footplate with the angle of the palpebral conjunctiva.Photo courtesy of University of Illinois Comparative Ophthalmology Service, Amber Labelle, DVM, DACVO.



is sedated and blocked, and topical anesthetic isapplied to the cornea:

(1) A gloved finger or a blunt sterile probe (cot-ton-tipped wooden swab or the hollow inser-tion tube provided with the SPL kit) into thedeepest palpebral reflection is used to testthe eyelid block and tolerance of instrumentsat the site. Additional sedation and/or an-esthetic is indicated if the horse reacts (Fig.3A).

(2) With the use of either a gloved finger or thehollow insertion tube as a guide, the trocharpoint is then carefully advanced to the targetpuncture site adjacent to the orbital rim.The trochar tip is pushed through the lid skin(Fig. 3B). The trochar and tube are thenpulled through the eyelid until the disc-shapedfootplate of the SPL tube rests against the pal-pebral conjunctiva. Care is taken to ensurethat the oblique angle of the footplate matchesthe slant of the eyelid conjunctiva and thatthe footplate is snug against the mucosa(Fig. 3C,D).

(3) The section of the tubing that exits the eyelidand traverses to the forelock is sutured to thefacial skin (Fig. 4A). The author makes twoto four half-inch wide “butterfly” wings out ofduct tape or adhesive tape and fastens thefirst wing to the tubing at the eyelid skin exithole. Other wings are taped to the tubing atappropriate intervals toward the ear. Thewings are then sutured to the skin with theuse of four simple interrupted sutures per

wing. Alternatively, the tubing can be lacedthrough the plastic U-shaped guides pro-vided with the SPL kit, and the guides can besutured to the skin in a similar pattern.

(4) The trocar is used to pull the tubing throughthe base of the forelock braid and then weavethe tubing through the mane braids, with theuse of a consistent “under-over” or “over-un-der” pattern of inserting the trochar into thecenter of the braid base (Fig. 4B). A stoutbraid near the withers is selected as the an-chor for the injection port. When this braidis reached, the trochar is capped for safetybefore assembly of the port.

(5) The tubing is cut near the withers. The un-used portion may be saved for future repairs.

(6) A 1.25-inch, 20-gauge catheter is carefullythreaded into the lumen of the open tubingwith the use of the catheter stylet (with thesharp tip pulled back slightly into the cathe-ter lumen) as a probe to aid in the sleevingprocess (Fig. 5A). The stylet is removed,and a standard male catheter cap is twistedonto the catheter hub.

(7) The injection port is secured to the manebraid as described below.

The author prefers to cut a wooden tongue depres-sor in half and use two folded 4 � 4 gauze squares asa “bed” for the capped injection port, leaving a halfinch of tongue depressor extending beyond the placewhere the cap rests (Fig. 5B). Adhesive tape iswound around the tubing, catheter, and gauze toseat the catheter firmly, leaving only the injection

Fig. 4. A, Adhesive or duct tape wings are folded over the tubing and sutured to the facial skin. B, The SPL trochar is used to weavethe tubing through the mane.



port exposed. Tape wings are then used to securethe “braced” injection port to the anchoring braid.In some cases, tape wings are then sutured to thebraid twists to further ensure that the port is wellattached to the mane braid. Care taken with se-curing the port should ensure that the braid will notunravel with normal stable activity, even if the de-vice remains in place for several weeks. A heavyplastic bag can be taped over the injection assemblyto keep it clean.

Neonates and very young foals must undergoshort-term general anesthesia or heavy sedation toinduce lateral recumbency for safe insertion of anSPL, but all other steps in the process remain thesame. Very young foals will not have enough maneto make braids, but adhesive tape can be wrappedaround short mane hairs to create a series of tuftsthat will serve the same purpose. The injectionport assembly may need to be sewn to the skin(Fig. 6). Some clinicians slip a section of widestockinette over the head and neck of the foal toprotect the tubing from damage. Holes can be cutin the stockinette to provide openings for the eyes.

A series of tape butterfly guides must be suturedclose to the crest of the neck to secure an SPL in anadult horse that has had the mane shaved off(roached).

Use of an SPL to Deliver Ocular MedicationTreatment involves injection of medication into thetubing cap. The tongue depressor support taped tothe mane braid makes a secure handle to access theinjection cap. Medication that has been drawn up

into a tuberculin syringe is injected through a 25-gauge, five-eighths–inch needle (Fig. 7). Most med-ication is dosed at a volume of 0.2 mL. Some verycostly medications are dosed at a volume of 0.1 mL.d

The medication is then “pushed” toward the eye by a

Fig. 5. A, The 20-gauge, 1.25-inch catheter is inserted into the SPL tubing near the withers to create the injection port. B, Theinjection port is closed with a male catheter cap. The tubing end and port are braced with a few pieces of gauze and a tongue depressorand taped and sutured to the anchoring mane braid.

Fig. 6. Tufts of mane can be used as a channel for SPL tubing inyoung foals. Two injection ports were secured to the skin of thisfoal’s neck.



second injection of air. The air injection should bedone slowly to minimize discomfort and reducewashout. A volume of 1.5 to 2.0 mL of air is suffi-cient to push the medication beyond the footplate,where it then mixes with the tear film. Most horseswill react with a slight head shake when the medi-cation exits the tube.

Almost all SPL medication schedules require thatmultiple drugs, which may include mydriatics, anti-biotics, anti-fungals, anti-inflammatories and anti-collagenases, are given several times a day. Mostclinicians advise that each drug be given separately,with an interval of a few minutes before the nextproduct is injected. Definitive research has notbeen performed to determine if “stacking” medica-tion in a tube (injecting several products one afteranother and then using the air bolus to propel all ofthem at once to the eye) is as effective as individualinjections, but a large volume (�0.4 mL) of liquidthat reaches the eye all at once may spill out ontothe face. Alternately, the SPL line can be loadedwith medication, and each individual dose then maybe administered at 5-minute intervals so that only0.2 mL of medication is administered to the ocularsurface with each dose.

Battery-powered, single-use infusion pumps de-signed to deliver continuous ocular medications intoan SPL are commercially available.e These pumpshave a 10-mL fluid reservoir that can be filled withliquid topical medication. They can be ordered inflow rates that vary from 0.06 mL per hour (10-mLreservoir is slowly discharged over 7 days) to 1.0 mLper hour (the entire reservoir is discharged in 10hours). “T” and “W” adaptors that allow more than

one pump to be hooked to the same SPL are avail-able from the manufacturer. It is important to fol-low the directions when filling the reservoir andsecuring the discs to the SPL port because thepumping assembly relies on the intake of a smallvolume of air into the device to deflate the reservoir.Care must be taken to ensure that the air intakevalve is not obstructed. The disc bladder should bechecked periodically to ensure that the medicationreservoir bag is deflating on schedule. When thedisc is empty, it can be disconnected from the SPLand replaced with a new disc.

The author has used these pumps a few times infractious horses and in situations in which manualtreatment was not practical. Some clinicians havereported good success with these devices. It is im-portant to consider the effect of ambient tempera-ture on drug stability when using such devicesbecause some drugs may not remain stable withprolonged exposure to room temperature.

Maintenance

The SPL catheter cap should be cleaned daily withapplication of an alcohol wipe. Catheter caps arechanged at 3- to 7-day intervals in hospitalized pa-tients. Cases handled in the field may undergocap changes at veterinary recheck appointments.Some clinicians advise running a small amount(1 mL) of 1:50 povidone iodine/saline solutionthrough the tube several times a week as an anti-septic, then flushing the tube lumen with air beforethe next scheduled medication application. Exper-imental evidence suggests that colonization of theSPL system by bacteria is uncommon; thus, the need

Fig. 8. The SPL footplate is removed by use of the adjacentsection of tubing as a “pole” to push the disc away from theconjunctiva.

Fig. 7. Medication is injected into the SPL through a 25-gauge,five-eighths–inch needle attached to a tuberculin syringe. Theinjection port has been covered with a plastic bag.



for lavage with an antiseptic solution is uncon-firmed.3 The tube suspension arrangement (braids,sutured tape wings) may require rebraiding, resutur-ing, or new tape application.

Removal

SPL tubes are easily removed in the standing,sedated horse by cutting the tubing a few centime-ters away from the fornix or cul-de-sac exit site and

removing all wings or guides that attach the cutsection to the face. The tubing that remains at-tached to the footplate can be used as a “pole” topush the footplate away from the conjunctiva andinto the fornix space (Fig. 8). A gloved finger isused to fish the footplate and short length of tubingout of the fornix and remove it.

Occasionally, the footplate will remain buriedin the conjunctival tissues. In these instances,

Fig. 9. A, SPL repair: The 20-gauge, 1.25-inch catheter is threaded halfway into one end of the broken tubing. The catheter styletis then removed. B, The hub of the catheter is cut off. C, The other end of the broken SPL tubing is carefully “shimmied” onto theremaining length of catheter until the two ends meet. D, The spliced tubing section is wrapped with tape, then sutured with aseparate tape wing to the horse’s skin.



sometimes the attached tubing can be used to pullthe footplate out through the skin exit hole. Alter-natively, the exit site in the eyelid skin can be infil-trated with a small amount of local anesthetic, anda simple cutdown surgery can be performed aroundthe tubing stump to retrieve the footplate and asso-ciated remnant.

3. Results

Both veterinary ophthalmologists and generalequine practitioners rely on these devices to treattheir most difficult cases, and properly installed sys-tems usually work very well in both hospital andfield situations. SPL tubes have been left in pa-tients for as long as 10 to 12 weeks. Treatmentregimens range from multiple medications injectedon an hourly basis for initial treatment of seriousproblems to treatment that is delivered just a fewtimes a day for issues nearing resolution. The useof SPLs to deliver targeted treatment for seriousequine ocular problems has preserved vision andsaved thousands of eyes.

ComplicationsAlthough SPLs are managed in most horses withoutproblems, complications do occur in some patients.The two major issues are iatrogenic corneal ulcer-ation from footplate irritation and lack of patencycaused by damage to the tube lumen (breakage ordevelopment of small punctures).

Corneal ulceration occasionally occurs after anSPL is placed in the upper lid if the device is notinserted deep in the fornix and the footplate rubsagainst the cornea. It can also occur if the footplateis not snug against the conjunctiva. Removal andreplacement of the SPL is necessary to stop furthermechanical irritation. A new SPL should be placedand firmly secured to avoid SPL-associated cornealtrauma. The second SPL is often placed in theventronasal aspect of the lower lid because at thissite, the nictitans provides a protective barrier be-tween the footplate and the cornea. Ulcers associ-ated with lavage tube irritation are often very slowto heal; choice of treatment medication is dependenton analysis of cytology and culture of the ulcer bed.

Although the silicone tubing of an SPL is quitestrong, it can break or develop leaks if the horsesnags it on an object. Breaks will be obvious, butleaks may not be noticed immediately. The persontreating the horse should be suspicious that thesystem is not working if a horse stops reacting whenenough of an air bolus is injected to push medicationinto the tear film—the lack of a reaction may indi-cate that the medication is leaking out of the tubebefore it reaches the globe surface.

A simple method to check for patency is to tear offa small piece of a fluorescein dye strip and mix itwith saline solution. One to 2 mL of the dyed salineis then flushed through the tube. The tear film willturn green as the dye/saline mixture exits the eyelidif the tube is patent. If the tube is leaking, the tear

film will remain clear, but the dyed saline mixturewill leak from the damaged part of the tube.

SPL tubing that breaks or tears near the witherscan be repaired by simply shortening the tube.The open end of the tube is flushed with a quantityof 1:50 betadine/saline antiseptic, and a new cathe-ter and cap are inserted. An injection port assem-bly is created as described above and taped andsutured to a more proximal braid.

SPL tubing that breaks near the ear or above theeyelid can be repaired with the use of a 20-gaugecatheter as a splice to connect the two separatedends (Fig. 9A–D). The catheter is inserted into oneend of the broken tubing, with the stylet retractedslightly back into the catheter lumen. The tubingis “shimmied” over half of the catheter length.The stylet is then removed, and the hub of the cath-eter is cut off. Half the Teflon catheter is exposedbeyond the section that is sleeved with one end ofthe broken SPL tubing. The other end of the SPLtubing is then carefully pushed over the exposedcatheter. This is somewhat difficult without theuse of a stylet but can be done with a light touch anda little patience. When both of the broken ends ofsilicone tubing meet in the center of the cathetertubing, a small piece of white tape is wound aroundthe junction to secure the splice. Patency of thespliced segment is tested with a saline flush, whichshould pass through the catheter lumen. The sec-tion of spliced tubing is then secured to the face orneck crest with a sutured tape wing.

4. Discussion

Horses diagnosed with deep stromal or melting ul-cers and stromal abscesses usually require an SPLto deliver the intense treatment that is required tosave the eye and preserve vision. Horses with con-ditions such as severe uveitis or indolent ulcers mayalso benefit from an SPL when the problem is verypainful or requires prolonged therapy. Many ofthese cases can be handled effectively in the field.However, some cases are best referred—even whena practitioner has the skills to insert an SPL, opti-mum outcome may only be realized with specialistevaluation and hospitalization. Practitioners mustconsider several factors beyond the simple mechan-ics of installing an SPL when making clinical deci-sions on a problem eye. Serious infections andmelting ulcers can quickly progress and threatenvision and ocular integrity; therefore, it is importantthat the treatment plan is based on a comprehensiveexamination and appropriate diagnostic testing.Practitioners who install SPLs must have skills andexperience in assessing such cases and a broadknowledge of rational therapy choices.

SPL insertion is not inexpensive; the kit materialsand sedation are costly, and the process of placingand securing the tube is somewhat time-consuming.Owners who bring their horses to a referral facilityare prepared for significant expense and readily givepermission for SPL placement. However, the first



veterinarian who sees the case usually does the as-sessment at the home stable. In these settings,owners are often unwilling to authorize tube place-ment because of the expense and the idea of “a tubein the eyelid.” A common response when an SPL isadvised is, “Let me just try to treat this myself for afew days.”

That approach may be acceptable for a simpleshallow corneal ulcer in a cooperative horse, butwhenever a serious vision-threatening condition isdiagnosed, the veterinarian must act as a strongadvocate for the horse and recommend immediateSPL insertion. Corneal infections and deep stro-mal defects respond best if intense treatment is in-stituted right after initial diagnostics are completed,and an SPL is the key element for safe administra-tion of effective therapy. Owners who decline tubeplacement often change their minds several dayslater when the treatments are not reaching the eyeconsistently, the horse has become unmanageable,and they are exhausted from trying to comply withthe rigorous treatment schedule. At this point, thetotal management cost may actually increase be-cause of progression of disease in the face of ineffec-tive treatment, or it may be too late to initiateeffective therapy.

Another element to consider in managing seriousocular problems in an ambulatory setting is thatthere must be sufficient manpower to carry out theprescribed treatment schedule; treatment may needto be delivered through the SPL six to 12 times perday. If the desired schedule cannot be delivered atthe home barn, referral to a full-service hospital

should be encouraged. If referral is not an option,the clinician should stress that having the tube inplace is only as useful as the number of times it isused to actually treat the horse.

The author has installed and managed SPLs for avariety of problems in horses of all breeds and ages.Although some of these patients were hospitalized,the majority were treated on the farm (Fig. 10).Stall rest was usually prescribed during the earlyphase of treatment, but horses that had an SPL inplace for several weeks were usually allowed turn-out, and some were ridden lightly.

Several simple strategies can be recommended tokeep an SPL intact, clean, and protected at home:

● Securing each tape wing on the face with foursutures helps ensure that the wing will stay inplace for several weeks when veterinary over-sight is infrequent.

● White adhesive tape wraps around the base ofeach mane braid to help the braids stay tightand keep the SPL tubing close to the crest.

● A plastic bag taped over the injection port as-sembly keeps the port clean and protected,especially if the catheter cap comes off thecatheter. Treatment injections can be donedirectly through the plastic bag wall, and thebag can be replaced as needed.

● Fly masks provide helpful covers to protect theperiocular region and cover the tubing that isexposed on the face. The author rarely useshoods with hard plastic cups but advises flymasks for the majority of patients.

● Stretchy nylon hoods that cover the head andneck (known as “sleazy sleepwear,” made by avariety of manufacturers) may also protect theSPL from stable or pasture trauma.

● Stalls and paddocks should be inspected forany hooks, nails, or other elements that mightsnare the tubing: all such items should be

Fig. 10. Horses can be successfully treated on the farm with theuse of aids such as fly masks and/or neck covers to protect theSPL.

Fig. 11. Colored tape is an effective way to label medicationsyringes and help caretakers keep track of treatments.



removed or taped over. J-shaped hooks at thebase of bucket handles should be taped up.

● Solitary turnout is best because pasture matesmay pull at SPL elements and damage them.

Even though the technical process of injectingmedication through an SPL is simple, many horsesare still difficult to treat because of their tempera-ment or ocular pain. A multidose medication sched-ule can also be confusing. Several “practice tips” arelisted below to help caretakers or technicians managethe treatment plan:

● Medication syringes can be labeled with a thinstrip of colored tape for easy distinction of dif-ferent products (Fig. 11).

● A blank “treatment spreadsheet” that is laidout in grid form with spaces for up to six medi-cations should be issued to the caretaker.This can be stored on the ambulatory computerand emailed or pre-printed. A checkbox sys-tem will clarify multidrug treatment regimensand keep track of compliance.

● Horses that react strongly when medicationcontacts the tear film may become more coop-erative if a small treat (sliced carrot, pepper-mint, gingersnap) is given before and after theprocess.

● Caretaker “burnout” is a threat to successfultherapy. Time spent explaining possible con-sequences of treatment lapses pays off.

● Digital photography is an invaluable owner ed-ucation and compliance aid.4 Sharing imageswith caretakers will inspire the caretakers tocontinue with a challenging medication sched-ule, particularly if sequential images demon-strate positive progress.

Finally, clinicians must make good decisions onwhen to remove the SPL. Generally, all surfaceocular problems must be treated until the cornealsurface has epithelialized and the stromal bed hasbegun to fibrose. Recheck visits with careful exam-ination of the cornea, coupled with administration ofsurface ocular stains, will be required to assess thestatus of healing. However, a clinician may wantto stop therapy but still may be uncertain aboutwhether the condition is truly healed. In thesecases, the tube may simply be left in place for anadditional 5 to 7 days. If the condition remainsstable, the tube then can be removed, but if there areany negative developments, the SPL is in place andcan be used again for further treatment.

5. Conclusions

Lavage systems are essential tools for the manage-ment of serious ocular disease because they providean easy, safe means to deliver ocular medications inpatients with painful ocular problems. Rationalmedication selection for individual cases dependson the results of a thorough ocular examination cou-pled with appropriate diagnostics and any indicatedstall-side ocular therapy or procedures. Clinicianswho use SPLs to treat major ocular problems inambulatory practice must have strong skills inophthalmic examination and have a thorough un-derstanding of corneal disease and ophthalmicpharmacology. Caretakers who use SPLs to delivercomplex treatment schedules must dedicate suffi-cient time to deliver the treatment schedule asprescribed.

Horses tolerate SPLs very well, and the systemsmay be maintained for months if necessary. Themost common complication noted is external traumato the tube that causes leaks or breaks. Lavagetubing that breaks or develops a hole can be re-paired by shortening or splicing the tubing. La-vage system damage from pasture, stall, or patienttrauma can be minimized by the use of suture andtape to secure the system to the patient and byexternal head and neck covers such as fly masks andhoods.

Insertion of an SPL is a simple technique that allequine practitioners can master. This report hasoutlined numerous tips for installation and manage-ment of SPLs that can be implemented in both hos-pital and ambulatory settings.

References and Footnotes1. Sweeney CR, Russell GE, Complications associated with use

of a one hole subpalpebral lavage system in horses: 150cases (1977–1996). J Am Vet Med Assoc 1997:211:1271–1274.

2. Giuliano EA, Maggs DJ, Moore CP, et al. Inferomedialplacement of a single-entry subpalpebral lavage tube fortreatment of equine eye disease. Vet Ophthalmol 2000;3:153–156.

3. Jacobi S, Townsend WM, Bolin CA. Proliferation of Strep-tococcus zooepidemicus and Pseudomonas aeruginosa withina simulated subpalpebral lavage flushed with equine serum.Vet Ophthalmol 2009;12:343–9.

4. Dwyer, AE. How to take digital photographs of equine eyesin practice, in Proceedings. Am Assoc Equine Pract 2010;228–237.

aMila International, Erlanger, KY 41018, and Jorgensen Lab-oratories, Loveland, CO 80538.

bMila International, Erlanger, KY 41018, http://milainternational.com.

cChampagne Pet Products, Southampton, MA 01073.dDr Brian Gilger, Personal communication.eInfu-Disk, Mila International, Erlanger, KY 41018.



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