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What’s your
diagnosis?
By Claire
Pointing, BSc BVetMed MRCVS
Companion Animal Veterinary Advisor
Describe the changes in each of the everyday presentations below,
construct a differential diagnosis list for each and fill in the most
likely diagnosis below
This image shows conjunctivitis and inflammation of the third
eyelid (nictitating membrane). Mucopurulent discharge is
present in the medial canthus and along the lower eyelid.
Corneal light reflection (also known as the Purkinje reflex) has
lost it’s usual sharp appearance the edges are blurred.
Neovascularisation is apparent, most obviously across
the centre of the cornea. The cornea has an opaque
‘blue’ appearance – this is corneal oedema, and is
often associated with neovascularisation and ulceration.
Conjunctivitis is seen in the medial canthus.
Diagnosis: .......................................................................................................
Diagnosis: .......................................................................................................
A central corneal ulcer is present and is associated with
surrounding corneal oedema. Neovascularisation is seen on
the dorsal aspect of the cornea, extending from the limbus.
‘Stringy’ mucopurulent discharge is seen across the cornea,
building in the medial canthus. Conjunctivitis is apparent and
the third eyelid is also inflamed with a degree of chemosis.
A profuse mucopurulent discharge is seen across
the cornea, forming a ‘string’ across the centre.
Neovascularisation is present and especially obvious to the
dorsocentral aspect of the cornea. Hyperpigmentation is
apparent towards the lateral canthus.
Diagnosis: .......................................................................................................
Diagnosis: .......................................................................................................
This pictures shows a descemetocoele – a very deep ulcer
where only the innermost layer of the cornea (Descemet’s
membrane) remains. This deep ulcer does not stain with
fluorescein and should be treated as an ocular emergency.
Treatment usually involves surgery. This eye also shows
neovascularisation extending from the limbus.
There is severe hyperpigmentation of the entire cornea.
Injected scleral vessels are also apparent to the medial
limbus. The light reflex is also very blurred and the ocular
surface appears dry.
Diagnosis: .......................................................................................................
Diagnosis: .......................................................................................................
In fact, all of these dogs have
keratoconjunctivitis sicca
(KCS), otherwise known as
Dry-Eye. The appearance of
KCS can be very varied and
not all dogs present with the
classic ‘textbook’ appearance.
There are approximately 8 million
dogs in the UK,1 and the disease
has an incidence of 4.6% of the
total canine population2 - therefore
368,000 dogs are estimated to have
KCS in the UK. This figure rises to
8.3% of predisposed breeds which
includes West Highland White
Terriers, Cavalier King Charles
Spaniels, Shih Tzus and Cocker
Spaniels. However, the condition
is thought to be significantly
underdiagnosed. Intervet/ScheringPlough Animal Health calculates
that only 11% of estimated cases
are treated with Optimmune, the
treatment of choice.
KCS should be considered
during all corneal examinations
as delayed diagnosis worsens
long-term prognosis for ocular
health and vision. This is because
more lacrimal tissue has been
destroyed by the autoimmune
process causing KCS and
more deleterious secondary
changes to the eye such as
hyperpigmentation will have
developed over time.
except where a descemetocoele
is present, as this could lead
to corneal perforation. Typical
secondary changes which
should raise the suspicion of KCS
include:
• Conjunctivitis
(especially if >2 bouts in 12 months)
• Neovascularisation
• Mucopurulent discharge
(especially a ‘string’ across the centre
of the eye)
The sooner the condition is
diagnosed and correct treatment
started, the better the outcome.
KCS is also painful – early
diagnosis and treatment is
therefore important on welfare
grounds.
Specialist ophthalmologists
recommend all dogs with sore
eyes should all have a Schirmer
Tear Test (STT) performed,
Tips for STT
• Test both eyes – results are often different
• Perform the STT before other liquids are applied to the
eye e.g. fluorescein
• Eyes can be open or shut
• Read the results immediately at 60 seconds
1. www.pfma.org
2. Pierce V & Williams D, Determination of Schirmer Tear Test values in 1000 dogs. BSAVA Abstract 2006
3. Fuller RJ Characterisation of Tears Induced by Cyclosporine Veterinary Applications in Ophthalmic Disease.
Minutes of ESVO-ECVO meeting
4. Data on File Ref IPOSOS-RSL J.0174U03.180800
Optimmune® contains 0.2% ciclosporin w/w. Legal category POM-V
intervet/Schering-Plough Animal Health, Walton Manor, Walton, Milton Keynes MK7 7AJ
• Hyperpigmentation
• Corneal ulceration
(especially if central and slow to heal)
• Corneal oedema
Regular testing of predisposed
breeds is also valuable and can
avoid delayed diagnosis.
Optimmune is the treatment
of choice for KCS as it is the
only product which controls the
underlying disease process
and treats clinical signs. Most
specialist ophthalmologists
recommend Optimmune first line
for the treatment of KCS.
Natural tears are essential for
ocular health as they have many
vital functions which cannot be
replicated by tear replacement
products e.g. defensive,
nutritional. Optimmune stimulates
natural tear production – work has
shown that protein components
of tears e.g. secretory
Key Points
• Appearance of KCS is very variable
• STT all dogs with sore eyes*
• Early diagnosis and treatment with Optimmune gives the
best prognosis
*except where a descemetocoele is present
immunoglobulin A (sIgA) increase
along with the aqueous phase of
the tear film.3
Optimmune should be started
as soon as KCS is diagnosed to
limit lacrimal gland destruction
and development of undesirable
secondary changes as much
as possible. When assessing
progress, remember that an
increase in tear production is
usually seen within 10 days but
can take 6 weeks for the full
effect.
Owners must be aware that
KCS requires lifelong treatment,
and that Optimmune also treats
parts of the eye they cannot
see. It is not uncommon for an
owner to stop treatment when the
eye looks better, but within 24
hours the autoimmune process
resumes and tear production is
reduced. UK Market Research
has shown that 50% of owners
expected a cure for dry-eye and
average duration of treatment
with Optimmune is just 6 weeks4
which adversely affects long-term
prognosis for ocular health.
The prognosis for KCS
is determined by prompt
recognition and treatment
choice. Early diagnosis
and lifelong treatment with
Optimmune will give the
best outcome.
For more information on KCS or
Optimmune, please contact your
local Intervet/Schering-Plough
Animal Health territory manager or
call 01908 685685.
Photos courtesy of the Animal
Health Trust.