Reducing Cherry Eye Recurrence: Common Surgical Mistakes and Clinical Tips

Few postoperative complications are as frustrating as recurrent cherry eye. After careful surgery and an apparently uneventful recovery, seeing the gland prolapse again can leave both veterinarians and owners questioning what went wrong. However, recurrence is rarely the result of a single factor. Current evidence suggests that successful outcomes depend on appropriate case selection, meticulous surgical technique, careful postoperative management, and recognition of breed-related anatomical and genetic predispositions^1,2,3. 

Understanding the common reasons for recurrence can help veterinarians improve long-term surgical success while setting realistic expectations for owners. 

Mistake 1: Waiting too long before surgery 

One of the most common clinical errors occurs before the patient reaches the operating table. 

Dogs with recently prolapsed glands generally have healthier tissue, making surgical repositioning easier and reducing postoperative complications. In contrast, prolonged prolapse exposes the gland to desiccation, inflammation, and repeated trauma, leading to oedema and fibrosis that make repositioning more challenging^1,2. 

Medical therapy may temporarily reduce inflammation, but it rarely provides permanent resolution. Veterinarians should therefore emphasise that topical medications are supportive rather than curative and should not replace timely surgical intervention. 

Clinical tip: Encourage owners to pursue surgery early, particularly in young dogs, before chronic tissue changes develop. 

Mistake 2: Inadequate preoperative assessment 

Successful surgery begins with a complete ophthalmic examination. 

Before scheduling surgery, clinicians should routinely evaluate: 

• Duration of prolapse 

• Corneal integrity using fluorescein staining 

• Tear production with the Schirmer Tear Test (STT) 

• Severity of conjunctival inflammation 

• Presence of bilateral disease 

Establishing baseline tear production is particularly valuable for monitoring postoperative gland function and identifying dogs at risk of developing keratoconjunctivitis sicca¹. 

Failure to identify concurrent ocular disease may complicate both surgery and recovery. 

Mistake 3: Poor tissue handling during surgery 

The Morgan's Pocket Technique remains the preferred gland-preserving procedure for most uncomplicated cases because it restores the gland to its physiological position while preserving tear production¹. Nevertheless, even the best technique can fail if tissue handling is poor. 

Common intraoperative mistakes include: 

• Creating a conjunctival pocket that is too small. 

• Applying excessive suture tension. 

• Leaving part of the gland exposed. 

• Excessive manipulation causing tissue trauma. 

• Poor suture placement leading to corneal irritation. 

• Inadequate haemostasis that increases postoperative inflammation. 

A prospective study evaluating Morgan's Pocket Technique reported an overall 94.1% success rate, demonstrating that meticulous surgical execution can produce excellent long-term outcomes². 

Clinical tip: Handle the gland as gently as possible. Excessive manipulation contributes to postoperative oedema and may compromise gland viability. 

Mistake 4: Underestimating postoperative care 

The surgery is only one component of successful treatment. 

Postoperative management should include: 

• Elizabethan collar for 10–14 days. 

• Appropriate topical antibiotic therapy when indicated. 

• Lubricating eye drops to improve ocular comfort. 

• Systemic anti-inflammatory medication based on individual clinical findings. 

• Restricted activity during early healing. 

• Scheduled re-examinations to confirm gland stability. 

Owners should also be reassured that mild conjunctival swelling during the first few postoperative days is expected and should not immediately be interpreted as recurrence². 

Clear discharge instructions improve compliance and reduce avoidable complications. 

Mistake 5: Assuming every recurrence is preventable 

Perhaps the most important lesson from recent research is that not every recurrence reflects poor surgical technique. 

A genome-wide association study identified the FGF4L1 retrogene insertion as a significant genetic risk factor for cherry eye, supporting the theory that inherited connective tissue weakness contributes to gland instability³. Earlier pedigree studies similarly demonstrated that the condition has a complex hereditary basis rather than a simple mode of inheritance⁴. 

Consequently, breeds such as Bulldogs, French Bulldogs, Beagles, American Cocker Spaniels, Shih Tzus, and Lhasa Apsos may remain predisposed to recurrence despite technically successful surgery. 

When recurrence occurs in these patients, clinicians should explain that the underlying connective tissue abnormality—not necessarily the surgery itself—may have contributed to the outcome. 

Practical strategies for improving long-term success 

Veterinarians can minimise recurrence by adopting a systematic approach: 

• Recommend early surgery whenever possible. 

• Preserve the gland rather than excising it. 

• Perform a complete preoperative ophthalmic assessment. 

• Use meticulous, atraumatic surgical technique. 

• Reinforce owner compliance with postoperative care. 

• Monitor tear production and evaluate the contralateral eye during follow-up visits. 

• Counsel owners of predisposed breeds about the possibility of future recurrence or bilateral disease. 

Combining these measures improves not only surgical success but also long-term ocular health. 

Clinical Pearl 

Cherry eye recurrence is rarely caused by a single mistake. Successful outcomes depend on recognising that surgery, biology, genetics, and owner compliance all contribute to long-term gland stability. A technically sound procedure combined with early intervention and structured follow-up offers the best chance of preserving both the gland and the patient's tear production. 

References (Vancouver) 

1. White C, Brennan ML. An evidence-based rapid review of surgical techniques for correction of prolapsed nictitans glands in dogs. Vet Sci. 2018;5(3):75. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6163435/ 

2. Deveci MZ, İşler CT, Yurtal Z, Altuğ ME, Kırgız Ö. Evaluation of Morgan's pocket technique in the treatment of nictitans gland prolapse in dogs. Turkish Journal of Veterinary & Animal Sciences. 2020;44(3):521–527. Available from: https://journals.tubitak.gov.tr/cgi/viewcontent.cgi?article=1191&context=veterinary 

3. Freyer J, Labadie JD, Huff JT, et al. Association of FGF4L1 Retrogene Insertion with Prolapsed Gland of the Nictitans (Cherry Eye) in Dogs. Genes. 2024;15(2):198. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10887708/ 

4. O'Neill DG, Church DB, McGreevy PD, et al. Investigating the inheritance of prolapsed nictitating membrane glands in a large canine pedigree. Canine Genetics and Epidemiology. 2015;2:7. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4361898/