Eye Problem - Third eyelid up, Horner's Syndrome


Question: Hi Dr. Mike, I searched your site for third eye problems and I am interested in Haw's syndrome. I have a cat that seems healthy in all ways except that for the past several days he has had both his third eyes one third the way up. He jumps and plays, eats great, and there is no discharge or obvious irritation to the eyes and no light sensitivity. I am just wondering if there are any infections or treatable causes that would only have this symptom. Haw's seems the likey cause, but there is no treatment except tincture of time I understand. What causes the Sympathetic nerve irritation? The other two cats (they are all close and sleep together) are unaffected. I must find a new Vet in my area since my own closed her practice recently. I am just wondering if I need to find a new Vet fast or do some watchful waiting. I found a site belonging to http://www.eyevet.ca/ a Vet ophthamologist, but not much else on Haw's. Thanks much. Dr. Debbie

Answer: Dr. Debbie-

Haw's syndrome, bilateral elevation of the third eyelids that is not due to dehydration, is thought to be caused by a problem with the autonomic nervous system. It can occur in conjunction with gastrointestinal disease, especially tapeworms and possibly other GI parasites, and has been linked to a torovirus by some researchers (Papasouliotis 1996) due to finding this virus in cats with chronic diarrhea and elevation of the third eyelids. In this article the authors state that Haw's syndrome may persist for as long as six months and that there is no effective treatment.

Since cats do eventually recover, the lack of a treatment doesn't seem as important as it might otherwise. Supposedly, putting phenylephrine drops in the eyes will cause the third eyelids to return to normal positioning in cats with Haw's syndrome but I have never actually tried this to see if it works. If tapeworms are contributing to the problem deworming may resolve it and is probably worth considering as a diagnostic test since tapeworms can be hard to find if segments are not being passed at the present time.

Chlamydiosis and herpes virus infection are sometimes associated with bilateral elevation of the third eyelids but they usually have obvious ocular signs associated with them, as well.

Bilateral Horner's syndrome sometimes occurs, but this should produce miotic pupils on both sides. It may be hard to discern that this is present. Horner's syndrome occurs due to damage to the recurrent laryngeal nerve, anywhere along its path, which includes the chest, the neck, the brain and the local eye area. As long as there isn't a space occupying lesion in the chest, Horner's syndrome is often a temporary problem in cats, too.

I guess the good news is that this problem is highly likely to resolve and the bad news is that it might take a while and there usually isn't any way to speed up the process unless you luck out and your cat responds to deworming for tapeworms. Some cats are supposed to respond to metronidazole therapy, too. This is probably also due to decreasing gastrointestinal parasites like giardia or response from other GI problems like inflammatory bowel disease.

Mike Richards, DVM 8/20/2001

Horner's or Haw's syndrome - third eyelid up

Q: My niece has a cat, female, spayed, about 1 year old. Her kitten is in very good health. She romps and plays despite her problem. Her problem is this: She has cotinuous "Haws" Her third eyelid is always partially closed over her eye, about half way. Because of this she bumps into things. She does have very small eyes for a cat. Is there any type of eye drops that we could use to make the third eyelid go back in place? I myself have had cats for over 20 years, and never saw this problem. I had one male nueter cat to live for 21 years! I now have 4! Any Ideas or suggestions would be most helpful. I love your internet page, I always "paws" to read it! Respectfully

A: Is this a recent change or has the third eyelid always been "up"? The third eyelids appear when the eye to retracts into the socket for any reason. It is not consciously raised or dropped by the cat, it just pops up when the eye is pulled back into the socket and disappears when the eye is in its normal position. So the only really good way to get it to disappear is to figure out why is is showing.

Pain in the eye, dehydration and Horner's syndrome (usually occurs in one eye only) are common causes of one or both third eyelids showing. There is a condition in which the third eyelids suddenly "appear" and stay up for four to six weeks and then usually spontaneously "disappear" again. This is commonly called "Haw's syndrome". I think that the theory is that this is caused by some sort of irritation of the sympathetic nervous system but I am not sure if this is the most recent explanation. Tetanus can cause third eyelid protrusion but has many other signs associated with it. The conformation of the cat's head and eyes can sometimes lead to this problem and if the cat's eyes are truly small in relation to the size of the orbit, this may be a factor.

If this is Haw's syndrome it should respond to instillation of topical ophthalmic epinephrine drops (1%) into the eye. Usually the third eyelids will retract after a few minutes and stay down for a while. Putting the drops in frequently is a conceivable treatment but most people chose to ignore this and hope it will go away since it usually does.

Mike Richards, DVM

Third eyelid and Horner's Syndrome

Q: Dear Doctor: I noticed last night that my 1 1/2 neutered cat's third eyelid appeared. His eyes looked squinty and dark. He has very large eyes and this seemed to be a dramatic change from just the day before. I am concerned because last week I discovered a bump near his arm. I had just had him into the vet and had him "fixed" and had all of his vaccinations made current. When I took him in regarding this bump they informed me that he had an allergic reaction to the vaccination. I called my Doctor tonight and he told me to take him into emergency. I did and the vet said he was normal. I am concerned, however, because I do not know if the third eyelid suddenly appears. The only reason I had concern is because the emergency vet said that he was running a fever and that being in the cat carrier could cause this. In the other times that I took him in the carrier he never had a fever (at least the vet never mentioned this to me). I am not second quessing the emergency doctor, however, his eyes do not look "normal". Am I just overreacting and does the appearance of the third eyelid suddenly appear such as this did? If you have a moment to respond please do. Thanks. Twigxter

A: Twigxter- I am assuming that only one third eyelid is visible. This happens when there is damage to the cornea causing eye pain and when Horner's syndrome is present.

There is a form of Horner's syndrome that occurs for unknown reasons and lasts 3 to 6 weeks then resolves. If your cat is better by now it is probably safe to assume this was the case. If the problem persists ask your vet about Horner's syndrome and ask him or her to recheck your cat.

Mike Richards, DVM

Last edited 01/30/05

Haw's syndrome or third eyelid problems


Michael Richards, D.V.M. co-owns a small animal general veterinary practice in rural tidewater Virginia. Dr. Richards graduated from Iowa State University's College of Veterinary Medicine in 1979, and has been in private practice ever since. Dr. Richards has been the director of the PetCare Forum...