Download comparative veterinary ophthalmology

COMPARATIVE VETERINARY
OPHTHALMOLOGY
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VOLK
The Ophthalmic History and
Examination
Clinical Problem
The First Step in solving ANY Problem is to:
DEFINE THE PROBLEM
• Solving of a patients Clinical Problem
– In ophthalmology, almost 99% of the
information collected and utilized in making
the initial tentative diagnosis which will direct
the subsequent diagnostic and therapeutic plan
is based on:
The clinicians OBSERVATIONS
THE OPHTHALMIC EXAMINATION FLOW
CHART
GOAL = SOLVE THE PATIENT’S PROBLEM
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*Signalment
*Primary complaint
*History
*Ophthalmic Examination
*Special Diagnostic Tests
Problem List
Differential Diagnosis
Diagnosis
Therapy
* Key Defining Information
Prognosis
Re-examination plan
Signalment
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Species
Breed
Age
Sex
Coat Color
Altered or not
Primary Complaint
History
What led you to believe your animal has
an eye problem?
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*
*
*
*
Loss of Vision
Eye discharge
Peculiar color of eye(s)
Veterinarian noted problem
Other, explain
History
How long has this problem been present?
Which eye(s) is (are) affected?
RIGHT LEFT BOTH
Has the character of the eye(s) changed since
you first noticed it? YES NO UNK
If yes, how?
Have you treated the eye(s)? YES NO UNK
If yes, how, and with what?
History
How well do you believe your animal sees?
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*
*
Excellent
Poor in regard to moving objects
Poor on all occasions
Poor in regard to stationary objects Poor especially in dim light or dark
Poor when turning to the right
Poor especially in bright light
Poor when turning to the left Poor in regard to near objects
Poor when jumping or climbing down Poor in regard to far objects
Poor when jumping or climbing up
History
Do you think your animal sees well in familiar
surroundings?
YES NO UNK
Strange surroundings?
YES NO UNK
Has your animal had any other eye problems?
NO YES UNK
If YES, what type?
History
Has your animal experienced seizures, loss of balance,
weakness, in coordination or personality change?
NO YES UNK
Is your animal receiving medication?
NO YES UNK
If YES, what?
Do you have other animals?
NO YES
If YES, do they have eye problems? NO YES
If YES, what type?
Do you know your animal's dam or sire?
NO YES UNK
History
If YES, do either of them have eye problems? NO YES
UNK
13. Is your animal consuming water and food normally?
YES NO UNK
14. Is you animal urinating more frequently than normal?
YES NO UNK
15. Has your animal had previous or present illness? NO
YES UNK
16. Has your animal been exposed to house or farm
chemicals (cleaners, agricultural, industrial or
automotive chemicals) or building supplies? NO YES
UNK
Ophthalmic Examination
KNOWING:
CHIEF COMPLAINT
SIGNALMENT
and
PERFORMANCE OF A GOOD
MEDICAL HISTORY
WILL GREATLY HELP DIRECT
AND REFINE YOUR
OPHTHALMIC EXAMINATION
THIS WILL RESULT IN AN
ACCURATE
PROBLEM LIST and DIAGNOSIS
CHIEF COMPLAINT
SIGNALMENT
+
HISTORY
Focus
OPHTHALMIC EXAM
PROBLEM LIST
ACCURATE DIAGNOSIS
Examination Environment
The examination environment is important and can
greatly influence the examination results. In an
environment that is too distractive and bright, a
complete careful examination can not be done;
especially in an animal that is unruly.
Small animals are best examined on a table with a
non-slip surface. Unruly cats can be placed in a cat
bag for the examination. For large animals, try to
locate a non-confined area that is away from the
general activity, which provides adequate lighting
that can be reduced when necessary.
Vision Testing
• Menace Response
• Cotton Balls
• Maze Testing
Menace Response
• This is a response and
it is learned.
• The endpoint is a
blink.
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Cotton Balls
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Maze Testing
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Video provided by
Sinisa Grozdanic D.V.M., Ph.D. Iowa State University
Gross Evaluation of the Head
• Symmetry
– Compare one side with the other
Gross Evaluation of the Head
• Step back and compare the palpebral
fissures for their size, symmetry, position
of the upper eyelid cilia and the general
eyelid form, as well as characterization of
any ocular discharge.
• Ocular discharge if present should be
characterized as serous, mucoid, purulent,
hemorrhagic, seromucoid, mucopurulent, or
serosanguinous.
Gross Evaluation of the Head
– The position of the upper eyelid cilia normally should be
directed nearly perpendicular -semivertical to the
corneal surface. Subtle ptosis or drooping of the eyelid
without noticeable narrowing of the fissure would be
detected by observing more ventrally directed cilia.
Horner's syndrome: sympathetic denervation (ptosis,
miosis, enophthalmia, prolapsed third eyelid) can be due
to pre or post ganglionic sympathetic denervation.
Pupillary symmetry
Pupillary symmetry can be evaluated by viewing the animal
head on from about 6 feet through a direct
ophthalmoscope set a 0 diopters and stimulating a tapetal
reflection (eye shine).
Room Light
Dim Light
Reflexes and Neurological
Responses
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Palpebral Reflex
Corneal Reflex
Dazzle Reflex
Pupillary Light Reflex
Reflexes and Neurological
Responses Video on the left shows a
• Palpebral Reflex
clinical example of the
technique as well as clinical
patient with a CN 5 lesion.
Left eye Normal palpebral
reflex
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Right eye Abnormal
CN 5 Lesion
Tests CN 5 and CN 7
Notice that the lack of
sensation is only in the
temporal upper lid not nasal
so if only the nasal area was
stimulated the CN5 lesion
would have been missed!!!
Reflexes and Neurological
Responses
• Corneal Reflex
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Tests Ophthalmic branch of CN 5
(corneal sensation), CN 7 (closer of the
eyelids) and CN 6 (retraction of globe).
Note: A sterile cotton tipped applicator can
be used to gently touch the cornea.
Alternatively a simpler method is to just
pay attention to the reaction of the eye to
the placement of the Schirmer Tear Test
Strip.
Reflexes and Neurological
Responses
Dazzle Reflex
- not a vision test
- tests continuity of
retina, optic nerve
Reflexes and Neurological
Responses
The Pupillary Light Reflex is not a vision test.
MUST USE A BRIGHT FOCAL LIGHT
CATARACTS WILL NOT BLOCK A PLR
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A bright light used to stimulate direct PLR and ideally a second
person then observes the fellow pupil with a weak dim light in
most species, since it is hard to see the fellow pupil in just room
light.
Drawing by M. Wyman
Representative PLR Diagram taken from Kathleen B. Digre, M.D. ﾊ ﾊ DEPARTMENTS OF NEUROLOGY AND OPHTHALMOLOGY UNIVERSITY OF UTAH MEDICAL CENTER
PALPATION
Orbital zone and Orbital rim
Feel for topographical changes
characterize them:
hard or soft, moveable or fixed, sensitive or insensitive and
orbital or extra-orbital swellings/masses.
OPEN the MOUTH
Last Upper Molar
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Pterygopalantine Fossa
Sewing Needle Foreign Body
Close Gross Evaluation
Eyelids
Conjunctiva
Third Eyelid
Cornea
Anterior Chamber
Iris
Lens
Vitreous and fundus:
Indirect and Direct ophthalmoscopic exam
Eyelids
Optivisor or Loupe
Otoscope Head without cone (5x
magnification)
Conjunctiva
Third Eyelid
The third eyelid is covered with the
palpebral conjunctiva which has bulbar and
palpebral surfaces and the obvious gross
feature is that the bulbar surface has a
cluster of lymph follicles. Examine the
anterior surface simply by retropulsing the
globe.
Cornea
Evaluate the cornea briefly for its clarity
and surface characteristics (smooth,
uniform and glistening normally).
Anterior Chamber
Lens
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For Info.
About slit light
Anterior Chamber
Slit Lights
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Iris
Edilon Hand Held Slit Light - Excellent!!
Lens
DIRECT OPHTHALMOSCOPE
EXAMINE AT AN ARMS LENGTH
SET AT 0 DIOPTERS
LOOK FOR OPACITIES IN THE LENS
Step One
LOCALIZE LENS OPACITIES
Step Two
Vitreous and Fundus
• Indirect Ophthalmoscopic Exam
• Direct Ophthalmoscopic Exam
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Direct Ophthalmoscope tid bits
• One diopter of change = movement of 0.2
mm in the cat, 0.3mm in the dog, 0.7 mm in
the ox, and about 1.3 mm in the horse.
Special Diagnostic Tests
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Schirmer Tear Test
Culture
Fluorescein
Eyelid Eversion
Nasolacrimal Flush
Schirmer Tear Test
Schirmer tear test
values
Normal – 15 – 25 mm/60
sec
Marginal – 10 – 15 mm/60
sec
Low <10 mm/60 sec
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Culture
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Fluorescein
Note: If an Immunofluorescent
Antibody Test (IFA for Herpes or
Chlamydia) is planned in a cat, do not
apply Fluorescein before doing the
conjunctival scraping. Fluorescein will
cause a false positive test result to
occur. Fluorescein may affect the
IFA result for up to 7 - 10 days.
Tonometry
Tonopen
PREFERRED INSTRUMENT
Schiotz
Not Preferred unless all that
is available
Burdock Pappus Fiber
Foreign Body
Eyelid Eversion
Adson 1 x 2
Retropulsion to prolapse
Third Eyelid for Inspection
Muscle Hook Eversion
Double Eversion
Muscle Hook
Topical Anesthesia (PROPARACAINE)
Grasping below margin
to inspect bulbar surface
Conjunctival Scraping
Nasolacrimal Flush
Gonioscopy
Ocular Ultrasound
Electroretinogram
At the completion of the exam:
• Make a list of all of the problems that
were identified.
• This list can be as unrefined (red eye) or
refined (anterior uveitis) as you can at this
point.
• Create the Temporary Problem List
Temporary Problem List
1
2
3
4
5
Try to Group Problem
“Refine” Problem List
• For Example:
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Conjunctival hyperemia
Serous ocular discharge
Aqueous Flare
Miosis
Enophthalmia with prolapse of the third eyelid
• Group to: ANTERIOR UVEITIS
Initial Differential Diagnosis
For Each Problem
•
For Example: There are at least twelve possible
reasons for the Red Eye
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Blepharitis
Cherry Eye
Conjunctivitis
Corneal Hemorrhage
Episcleritis
Glaucoma
Hyphema
Iris Hemorrhage
Intraocular Neoplasia
Keratitis
Subconjunctival Hemorrhage
Uveitis
Clinical Diagnosis
• The Tentative Clinical Diagnosis is based
upon the findings in the previous steps.
– Combination of the
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Signalment
Primary Complaint
History
Ophthalmic Examination
• A Final Diagnosis can be made initially or
after subsequent diagnostic tests have
been performed.
Therapy
• The therapy of course depends on the diagnosis
– Many times there are pending laboratory test or other
diagnostic procedures and the exact clinical diagnosis
can not be made yet. However the patient needs some
form of therapy started immediately.
– The decision of what therapy to initially institute is
based on the findings up to this point. One must be
cautious and avoid therapies that could cause harm if
given in the face of a condition where that therapy
was contraindicated.
Prognosis
• Depends on severity of the problems.
• Depends on accuracy of diagnosis.
• Depends on the diagnosis; some disorders
are more serious than others.
Re-examination Plan
• Hospitalize
• Send home on treatment
– Re-examine 24 hours to 7 days
• Depending on the severity and what the diagnosis is.
Key Points to Consider During
General Physical Examination
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SIGNALMENT
PRIMARY COMPLAINT
HISTORY
GROSS APPEARANCE OF THE
HEAD
SYMMETRY
RED EYE ?
CLARITY OF THE OCULAR MEDIA
MONOCULAR INDIRECT
OPHTHALMIC EXAMINATION
COMPARATIVE VETERINARY
OPHTHALMOLOGY