Key Takeaways from a lecture by Dr Elizabeth Giuliano at Zoomies 2026

This lecture provides a comprehensive update on the ocular challenges facing brachycephalic breeds, with particular emphasis on the French Bulldog, whose meteoric rise in popularity has brought a corresponding surge in ophthalmological problems. We explore the evolving understanding of dry eye disease in these breeds, practical approaches to common conditions including prolapsed gland of the nictitans and indolent ulcers, and the latest research on treatment outcomes. Throughout, the emphasis is on practical clinical pearls that can be implemented immediately, from diagnostic techniques to surgical considerations.

1. The Brachycephalic Predisposition: A Matter of Anatomy and Sensation

Brachycephalic breeds have upwards of 2.7 times greater odds of presenting with corneal ulcers, and those ulcers are more likely to be complicated. This stems from their characteristic shallow orbits, breed-related exophthalmos, macro palpebral fissures, lagophthalmos (incomplete eyelid closure), and medial lower lid entropion. Critically, brachycephalic dogs have reduced corneal sensation, with sensitivity 50-93% lower than mesocephalic or dolichocephalic breeds. This means they do not blink as frequently and may not register corneal injury, allowing problems to progress unnoticed. The result is a breed population uniquely vulnerable to recurrent erosions, impaired wound healing, and infections, with comorbidities such as diabetes or prior ocular surgery further compounding these risks.

2. Rethinking Dry Eye: The Importance of Evaporative Disease

Our understanding of keratoconjunctivitis sicca (KCS) has fundamentally changed. Traditional aqueous-deficient dry eye, diagnosed by Schirmer tear test (STT) values below 15 mm/minute, represents only part of the picture. 

Qualitative or evaporative dry eye disease, resulting from deficiencies in the lipid or mucin layers of the tear film, is now recognised as a widespread condition in brachycephalic breeds. French Bulldogs in particular show shortened tear film breakup time, reduced lipid layer thickness, and paradoxically, normal or even elevated STT values. This occurs because the cornea registers evaporation and triggers a reflex increase in aqueous tear production. Consequently, a normal Schirmer tear test does not rule out dry eye disease in these patients. The clinical implication is that reliance on STT alone will miss the diagnosis, and lubrication should be considered a fundamental component of preventive care.

3. Lubrication: The Cornerstone of Management

Every brachycephalic dog, regardless of age or presenting complaint, should be on regular ocular lubrication. The recommendation is to start from eight weeks of age, ideally with a preservative-free product containing hyaluronic acid (hyaluronate), which acts as a mucinomimetic and substitutes for deficient mucin production. Twice-daily application is ideal, but if owners can only manage once daily, bedtime application is most important because tear evaporation occurs during sleep. Preservative-free drops are preferred as they never harm the ocular surface. Ointments can be easier to administer if warmed: closing the cap tightly and running the tube under hot water for 10-30 seconds liquefies the product so it emerges as a drop rather than a sticky ribbon. Practical advice includes training puppies to accept eye drops as part of early socialisation, using positive reinforcement so the dog willingly lines up for its treatment.

4. Prolapsed Gland of the Nictitans (Cherry Eye): Surgical Pearls

Brachycephalic breeds have 6.71 times the odds of developing prolapsed gland of the nictitans compared with mesocephalic breeds. The gland contributes 30-50% of basal tear production, so surgical replacement rather than excision is essential. For first-time offenders, the Morgan pocket technique preserves normal third eyelid movement. Key practical tips include:

• Use 6-0 Vicryl on a tapered needle (rather than cutting) for better tissue purchase
• Place knots on the anterior surface of the third eyelid
• Warn owners of approximately 20% recurrence rate
• Add a temporary medial tarsorrhaphy to reduce swelling, protect healing, and hide the surgical site from the owner’s view

For refractory cases, a permanent pocket technique (fixing the gland to the orbital rim) is reserved for eyes where the third eyelid will never need to move again. Excellent surgical videos are available online, demonstrating how smoothly this procedure can be performed with proper technique.

5. Indolent Ulcers (SCCEDs): Diagnosis and Treatment

Spontaneous chronic corneal epithelial defects (SCCEDs, or indolent ulcers) are characterised by chronicity, superficiality, and a characteristic fluorescein pattern where stain leaks under a lip of redundant epithelium. The underlying problem is epithelial inability to adhere to the stroma due to an acellular hyalinisation zone, not infection. French Bulldogs develop these ulcers at a younger age, experience longer healing times, and have higher complication rates than other breeds.

Treatment involves a stepwise approach:

1. Pre-procedure: Administer topical atropine and phenylephrine before starting to address reflex uveitis and to dilate the pupil; phenylephrine also blanches conjunctival hyperaemia, reassuring owners
2. Dry Q-tip debridement: Use sterile, dry Q-tips (not moistened) and apply firm pressure – if epithelium can be wiped off, it was meant to come off; this alone heals approximately 50% of cases
3. Grid keratotomy or Diamond Burr debridement: For those that do not heal, these procedures create channels through the dysfunctional stroma to allow epithelial adhesion. For Diamond Burr, the medium-grit (3.5 mm) tungsten carbide bur is recommended, not the micro-bur which risks globe perforation. A slow, deliberate technique is essential, and with proper cleaning, the bur can be reused approximately 100 times
4. Post-procedure: E-collar is essential. Oral NSAIDs and gabapentin (more effective than tramadol) keep patients comfortable and compliant. Topical antibiotics are used to prevent secondary infection (systemic doxycycline is an alternative). Atropine is usually given in the clinic rather than dispensed for home use

Crucially, grid keratotomy should never be performed in cats (risk of corneal sequestrum), horses, or in infected ulcers. Third eyelid flaps are not recommended for indolent ulcers because they prevent medication delivery, hinder monitoring, and cause friction from the lymphoid follicles on the back of the third eyelid. Contact lenses have largely replaced this approach, though placement can be fussy and is best performed under sedation with topical anaesthesia.

6. Pigmentary Keratitis: Surgical and Medical Management

Pigmentary keratitis is more severe in pugs than French Bulldogs, though all brachycephalic breeds are at risk. Research demonstrates that medial canthoplasty combined with topical immunomodulatory therapy (cyclosporine or tacrolimus) provides superior long-term control compared with topical therapy alone. For advanced cases, adjunctive corneal cryotherapy can remove pigment initially, though recurrence over time is common and owners should be warned. The simplified medial canthoplasty technique, documented in a study of over 1,000 eyes, involves incising the canaliculi to allow medial canthal closure beyond the puncta (previously thought impossible), combined with elliptical incisions to evert the lower eyelid. This approach addresses the underlying entropion and trichiasis driving pigment deposition.

7. Clinical Pearls for Everyday Practice

Several practical takeaways apply across all brachycephalic ocular conditions:

• Magnification is essential: Without magnification, subtle diagnostic features are missed. Use head-mounted loupes (even inexpensive chemist’s loops) and separate the viewing axis from the illumination axis by approximately 30 degrees to gain depth perception. The direct ophthalmoscope can be held 2-3 cm from the eye and viewed from the side, rather than peering through the eyepiece
• Fluorescein staining patterns: The classic SCCED pattern shows stain pooling under a redundant epithelial lip. A neovascular response indicates the ulcer has been present for at least one week (three-day lag time, then 1 mm/day growth)
• Schirmer tear test interpretation: In an ulcerated eye, pain-induced reflex tearing may give a normal result while the contralateral eye reveals true aqueous deficiency. Always test both eyes and never rely on the STT alone to rule out dry eye disease
• Serum therapy: Though one study questioned its efficacy, serum remains useful in clinical practice for its anti-collagenase properties and growth factors. When using serum alongside antibiotic drops, separate administration by 20 minutes as serum can bind to antibiotics
• Third eyelid flap limitations: Apart from corneal hydrops, corneal transplants, and difficult-to-medicate species (e.g. cattle), third eyelid flaps have limited utility. They prevent medication delivery, obscure monitoring, and create friction on the compromised cornea
• Follow-up and prevention: Any dog that has suffered one SCCED ulcer is at increased risk for recurrence in either eye. After healing, recommend lifelong lubrication. For all brachycephalic patients, lubrication should begin from the time they join their household

Conclusion

The lecture concludes with a sobering note: French Bulldogs and other brachycephalic breeds represent human-driven anatomical extremes that carry significant welfare implications. As clinicians, our role is to recognise these challenges, implement preventive strategies, and offer evidence-based treatments that improve quality of life for these popular but predisposed patients.