Download The Red, The Cloudy, The Painful

The Good The Bad, The Ugly
The Cloudy The Red, The Painful
The Cloudy, The Red, The
Painful
Cornea
Uvea
Glaucoma
Lens
David A. Wilkie DVM, MS,
Diplomate ACVO
Professor
The Ohio State University
[email protected]
Diagnostic Tools
! 
! 
! 
Cornea Epithelium
! 
0.5-0.6 mm
Corneal endothelium
=
Diffuse Edema
Corneal epithelium
=
Focal Edema
8-15 cell layers thick
7 day
turnover
Cornea
What is cloudy?
!  Cornea, aqueous, lens?
What is red?
!  Conjunctiva, cornea, aqueous, iris?
Where is the pain?
!  Extraocular, intraocular?
Focal Edema
Flourescein stain
Diffuse edema from loss of the
corneal endothelium
Uveitis
Glaucoma
Lens Luxation
Primary dystrophy
Boston
Chihuahua
1
Siberian husky-glaucoma
Terrier – anterior lens luxation
Ulcerative Keratitis
! 
Ascertain the etiology of the lesion.
WHY?
Erlichiosis - uveitis
! 
Ascertain the etiology of the lesion.
Examine the eye for:
!  eyelid abnormality
Entropion
! 
! 
Primary endothelial dystrophy
Ulcerative Keratitis
! 
Ulcerative Keratitis
Trichiasis
Ulcerative Keratitis
Ulcerative Keratitis
Ascertain the etiology of the lesion
!  Examine the eye for:
!  eyelid abnormality
!  abherent hair
!  foreign body
Ascertain the etiology of the lesion.
!  Examine the eye for:
!  eyelid abnormality
!  abherent hair
! 
! 
Ectopic cilia
Ulcerative Keratitis
! 
! 
Ascertain the etiology of the lesion.
Examine the eye for:
KCS
!  eyelid abnormality
!  abherent hair
!  foreign body
!  tear deficiency
!  STT
Most ulcers are simple and heal in 24-72
hours, often DESPITE what the Veterinarian
does
When they fail to do so:
!  Did I miss the etiology?
!  Is it infected?
!  Have I done a culture/cytology?
!  What drugs are being used?
!  Is it time to discuss surgery?
Ulcerative Keratitis
Ulcerative Keratitis
! 
! 
Ascertain the etiology of the lesion.
Examine the eye for:
!  eyelid abnormality
!  abherent hair
!  foreign body
!  tear deficiency
!  infectious causes
! 
Complete history
!  duration
!  previous therapy
(especially corticosteroids)
!  TBUT
2
Ulcer
Superficial Corneal Ulcer
! 
Erosion
! 
Superficial
! 
Midstromal
X
X
Deep
Generally extremely painful
Heal within 72 hours when the cause has
been removed
If the ulcer has not resolved in 3 to 5 days:
!  cause is still present
!  ulcer is infected
!  indolent ulcer
is present
Descemetocoele
Indolent Ulcer
Indolent Ulcer
Failure of attachment
Indolent Ulcer
! 
Indolent Ulcer
Hallmark features:
!  Superficial
!  Nonpainful to mildly painful
!  Loose or redundent epithelial
borders
!  Usually middle aged to older dogs
!  Chronic in nature
!  Predisposed breeds - boxers
Indolent Ulcer
Debride
3
Debride
! 
Grid Keratotomy
Algerbrush diamond burr
Diamond Burr Debridement
! 
Outcome
!  Debridement
- 63% healed after single
procedure
! 
25% healed at 1st postop visit
!  GK
! 
- 85% healed after single procedure
75% healed at 1st postop visit
Algerbrush; Alger Equipment Company, Lago
Vista, TX, USA
3.5mm, medium grit tip
Courtesy Dr Enry Garcia, University of Colorado
https://www.youtube.com/watch?v=W2ndvDx_1SE
Indolent Ulcer
Indolent Ulcer
! 
! 
Treatment:
!  Client
education is essential
loose, redundant epithelium
!  Gently break the basement membrane with
25g needle (Grid keratotomy)
!  Diamond burr
!  Topical tetracycline - 50% reduced time to
heal (oral doxy also works)
!  Recheck every 7-14 days
!  Remove
Treatment:
!  ± Contact lens:
!  15mm diameter, thin,
soft bandage lens
!  >8mm base curve
!  Acrivet
!  ± Antibiotics
4
Indolent Ulcer
Placing the Acrivet ® Contact Lens
Adult cat - herpes
Herpes felis
Acrivet, Inc.
9067 South 1300 West
Salt Lake City, UT 84088
USA
! 
! 
classic dendritic
ulcer
no URT signs
70% of cats infected with herpes virus
will become carriers
!  recurrent conjunctivitis/keratitis
!  stress and immunosuppression will
predispose to recurrence
!  FeLV
!  FIV
!  Other
! 
Herpes felis
! 
Treatment:
!  Antiviral agents topically
! Idoxuridine - Stoxil, Herplex
! Trifluorothymidine - Viroptic
! q2-4 hr
!  Cidofovir 0.5%
! Q12 hr
Herpes felis
! 
Herpes felis
! 
Treatment
!  Antivirals - Systemic
!  Famciclovir
Diagnosis:
!  History - previous stress?
Herpes felis
! 
Treatment:
!  L-lysine, 250-500 mg/day PO
!  Variable
doses listed
mg/cat divided daily
data suggests 40 mg/kg PO
!  90 mg/kg PO TID
!  65
!  New
5
Midstromal Corneal Ulcer
! 
! 
! 
! 
Managed medically
Associated anterior uveitis
Cytology
Culture/Sensitivity
Midstromal Corneal Ulcer
! 
Treatment:
!  Topical antibiotics
!  Broad spectrum, every 2-6 hours
!  Neomycin-bacitracin-polymyxin
!  Gentamicin -poor choice
!  Ciprofloxacin
!  Levofloxacin
!  Gatifloxacin
Midstromal Corneal Ulcer
! 
Treatment:
!  Surgery if progressive
! 
! 
! 
Desmetocoele
Melting/collagenase ulcer
Acute eruptive keratopathy
!  feline
Treatment:
!  As for deep ulcers, but more
aggressive
!  Antibiotics are administered every 1-2
hours
!  Ofloxacin
!  Levofloxacin
!  Gatifloxacin
!  Anticollagense
!  Serum
!  Tetracycline - topical, systemic
!  +/- Surgery
Treatment:
!  1% Atropine
! as needed to dilate the pupil, but
not more than 4x/day
! Usually q24-24hr
Melting Corneal Ulcer
! 
! 
Enzymatic breakdown of the cornea
Sterile or Infected
Melting Corneal Ulcer
Surgery may be indicated
!  Debridement of the melting portion
always indicated
! 
Deep/Desmetocele Corneal
Ulcer
Melting Corneal Ulcer
! 
Midstromal Corneal Ulcer
! 
! 
Fluorescein negative centrally
6
Superficial Keratectomy
! 
! 
Superficial Keratectomy
Superficial Keratectomy
Thickness of the normal canine cornea is
0.4-0.7mm
#64 Beaver blade/Desmarres corneal
dissector
Avoid tension in this direction
Lamellar dissection
0.12mm Colibri
Conjunctival Graft
Superficial Keratectomy
http://youtu.be/vB0P3lJmvXU
Conjunctival Pedicle Graft
http://youtu.be/qC2Amv5RW-k
Conjunctival Pedicle Graft
http://youtu.be/IRzC3lHRdps
7
Corneal-Conjunctival Graft
http://youtu.be/NvwnZhGpK6M
Siberian husky-glaucoma
Erlichiosis - uveitis
Corneal endothelial dystrophy
Terrier – anterior lens luxation
Primary endothelial dystrophy
Endothelial Dystrophy Keratoleptynsis
Treatment
-hyperosmotics
-conj graft
-fresh transplant
http://youtu.be/qX4kSgXu3gw
8
Cat Claw
Non Perforating
Corneal Trauma
! 
Cat Claw
Perforating
Perforation /
Laceration
!  Sharp Corneal
Trauma
!  Blunt Corneal
Trauma
Seidel Test
Magnification
Epinephrine
Viscoelastic
8-0 to 9-0 suture
Microsurgical instruments
Seidel Test
Cat Claw
Perforating with
Lens capsule tear
Positive Seidel Test - Canine
Cat Claw
Perforating with
Iris prolapse
Phacoanaphylaxis
9
Blunt vs Sharp
Blunt trauma
So what do you think?
Prognosis?
The Cloudy, The Red, The Painful
The eye is the “window” to
systemic information
Uveitis
Vitreous echo-hemorrhage
Posterior scleral rupture
The eye has the highest blood
flow by weight of any organ
Uveitis
Anterior Uveitis
! 
! 
Clinical Signs
!  Anterior
!  Posterior
Miosis
Anterior Uveitis
! 
! 
Miosis
Flare
10
Anterior Uveitis
! 
! 
! 
Anterior Uveitis
Miosis
Flare
Redness
! 
! 
! 
! 
Miosis
Flare
Redness
Photophobia
Anterior Uveitis
! 
! 
! 
! 
! 
Anterior Uveitis
! 
! 
! 
! 
! 
! 
Anterior Uveitis
Miosis
Flare
Redness
Photophobia
Pain
Keratic precipitates
! 
! 
! 
! 
! 
! 
! 
Posterior Uveitis
! 
Anterior Uveitis
Anterior Uveitis
! 
Miosis
Flare
Redness
Photophobia
Pain
Keratic precipitates
Hypotony
! 
Etiologies
!  The etiologies of anterior uveitis can
be either ocular or systemic.
Ocular
Ocular Etiologies
!  There are only 4 main ocular
causes, rule them out first
Miosis
Flare
Redness
Photophobia
Pain
Chorioretinitis
!  Hemorrhage
!  Vaculitis
!  Edema
!  Transudate
!  Exudate
Anterior Uveitis
! 
Ocular:
!  Corneal
ulceration
Systemic
Uveitis
11
Anterior Uveitis
Anterior Uveitis
Anterior Uveitis
! 
! 
! 
Ocular:
!  Corneal
ulceration
!  Lens-induced
Ocular:
!  Corneal
ulceration
!  Lens-induced
!  Ocular trauma
Ocular:
!  Corneal
ulceration
!  Lens-induced
!  Ocular trauma
!  Neoplasia
! 
Ocular Oncology
Anterior Uveitis
! 
primary
Neoplasia
! 
Primary vs secondary
Primary - intraocular
Secondary - intraocular
Melanoma
Lymphosarcoma
Adenoma/Adenocarcinoma
Carcinoma
Spindle cell sarcoma - cat
Sarcoma
COPLOW - Comparative Ocular Pathology Laboratory of Wisconsin
Anterior Uveitis
Anterior Uveitis
! 
! 
Etiologies
!  The etiologies of anterior uveitis can
be either ocular or systemic.
X
Ocular
Systemic
Uveitis
Bacteremia
Septicemia
Viremia
Mycotic
Metastatic neoplasia
Autoimmune
Systemic Etiologies:
!  Bacteremia, viremia, or septicemia
!  Systemic mycoses
!  Autoimmune
!  Metastatic neoplasia
!  A complete physical examination is
therefore essential.
Uveitis
12
Uveo-Dermatologic Syndrome
Canine Uveitis
Canine Uveitis
Idiopathic / Immune-mediated (58%)
Neoplasia (24.5%)
!  Systemic infectious disease (17.5%)
! 
! 
! 
Massa KL, et al. Causes of uveitis in dogs:
102 Cases (1989-2000) Veterinary Ophthalmology
Systemic infectious disease (17.5%)
!  Younger (mean 2.1 yrs), Male
!  No breed
Massa KL, et al. Causes of uveitis in dogs:
102 Cases (1989-2000) Veterinary Ophthalmology
Systemic Infectious Disease
Systemic Infectious Disease
Systemic Infectious Disease
•  Ehrlichia canis (39%)
•  Ehrlichia canis (39%)
•  Blastomycosis dermatitidis (28%)
•  Ehrlichia canis (39%)
•  Blastomycosis dermatitidis (28%)
•  RMSF
Massa KL, et al. Causes of uveitis in dogs:
102 Cases (1989-2000) Veterinary Ophthalmology
Systemic Infectious Disease
Systemic Infectious Disease
•  Ehrlichia canis (39%)
•  Blastomycosis dermatitidis (28%)
•  RMSF
•  Dirofilaria immitis
•  Ehrlichia canis (39%)
•  Blastomycosis dermatitidis (28%)
•  RMSF
•  Dirofilaria immitis
•  Lyme disease
13
Canine Uveitis
! 
Neoplasia (24.5%)
!  Seen in older dogs (mean 7.5 years)
Lymphosarcoma
Canine Neoplastic Uveitis
! 
! 
! 
Lymphosarcoma (68%)
Undifferentiated sarcoma
Metastatic carcinoma
Canine Neoplastic Uveitis
Feline Uveitis
Canine Neoplastic Uveitis
Multiple Myeloma
Histiocytic Sarcoma
! 
! 
! 
Crypto
Feline Infectious Disease
•  FELV (12%)
•  FIP (5-19%)
•  Toxo (5-75%)
•  FIV (13-21%)
•  Crypto (2%)
•  Bartonella
Idiopathic / Immune-mediated (33-58%)
Neoplasia (13-23%)
Systemic infectious disease (24-83%)
Anterior Uveitis - systemic
FIP
Toxo
Cat may have more than
one of these
FIP
! 
Diagnostic Tests
!  History - Duration, progression of disease
!  Physical examination
!  Complete blood count
!  WBC count, Differential
!  Platlet count
FeLV
FIV
14
Anterior Uveitis
! 
Diagnostic Tests
!  Biochemical profile
!  Serology
!  Radiology
!  Ultrasound
!  Cytology/Histopathology
Anterior Uveitis
! 
The Cloudy, The Red, The Painful
Serology – REMEMBER CO-INFECTIONS
!  Blasto, Histo, Crypto
!  RMSF, Erlichia canis/platys, Lymes, ICH,
Distemper
!  FeLV, FIV
!  Toxo - request IgG, IgM, and Toxo antigen
tests
!  Bartonella
!  Leishmania
Sequelae of Anterior Uveitis
Anterior &/or posterior synechia
Cataract
!  Glaucoma
!  Blindness
!  Phthisis bulbi
! 
! 
Glaucoma
! 
Is the glaucoma primary or secondary?
Glaucoma
! 
! 
Is the glaucoma primary or secondary?
Is it acute or chronic?
Glaucoma
Acute
Chronic
Glaucoma
Intraocular Pressure
Determination
! 
Applanation Tonometry
There are 3 specific ways to determine
intraocular pressure:
!  Indentation tonometry
!  Applanation tonometry
!  Rebound tonometry
Tonovet
-Rebound
Tonometry
Transducer tip
15
Primary Glaucoma
! 
! 
Not associated with
any other ocular
disease
No antecedent
cause
Primary Glaucoma
! 
! 
! 
! 
! 
! 
Primary Glaucoma
! 
! 
! 
predisposed to bilateral involvement
bilateral involvement is 50% within 2 years
unaffected eye requires preventive therapy
!  IOP monitoring
!  Prophylactic Rx
This is generally seen in predisposed breeds:
Poodle, Basset hound, Beagle, Afghan
American & English Cocker Spaniel
English Springer Spaniel
Artic breeds - Husky, Elkhound, Samoyed, etc.
Shar-Pei, Chow Chow, Dalmation, Bouvier, Other
Primary Glaucoma
! 
! 
Secondary Glaucoma
! 
The result of some other event in the
eye which results in a decrease in
aqueous humor access to the drainage
angle or a decrease in outflow
Secondary Glaucoma
! 
Etiologies
!  Anterior lens
luxation
! 
Etiologies
!  Anterior lens
luxation
!  Uveitis
Lens Instability
!  Genetic
!  Gene
Testing
for PLL identified at University of
Missouri and AHT
!  Simple recessive trait
!  Homozygous affected luxated by 4-8 yr
predisposed to bilateral involvement
bilateral involvement is 50% within 2
years
Secondary Glaucoma
16
K9 Blasto, uveitis, glaucoma
Hypermature cataract, Lens-induced uveitis, Secondary glaucoma
Secondary Glaucoma
! 
Etiologies - PIFM
!  Pre-iridal fibrovascular membrane
!  Uveitis
#1
!  Intraocular
!  Retinal
Neoplasia
Detachment
Why does this
happen?
PIFM
Normal Iris
Acute Primary Glaucoma
! 
PIFM
! 
" Chronic uveitis
" Intraocular neoplasia
" Retinal detachment/
degeneration
Glaucoma
PIFM’s
Acute Glaucoma
! 
Treatment
!  Personal preference:
!  Latanoprost
!  Mannitol
if
latanoprost
ineffective
!  Topical and Systemic
CAI
!  Referral
These patients are
true medical &/or
surgical
emergencies
Hours make the
difference between
seeing and being
blind
Acute Glaucoma
! 
Treatment
!  Prostaglandins
!  Latanoprost
0.005% (Xalatan)
Miosis
for Sx
17
Acute Glaucoma
! 
Treatment
!  Surgical Therapy
!  Cyclophotoabalation
TSCP
Success at 1 year:
Canine: 50-60%
Equine: >80%
Success at 1 year:
Canine: >80%
Chronic Glaucoma
! 
! 
Normal Canine
These are not
emergencies as is
the case with the
acute patient
Treatment
! 
! 
! 
Prosthesis
Enucleation
Pharmacologic
ablation
Chronic Glaucoma Canine
18
Chronic Glaucoma
Normal Canine
! 
Treatment
!  Eviseration with Prosthesis
!  Remove
internal contents of the globe
a 19mm silicone sphere
!  Cornea will vascularize over the next 2-4
weeks.
!  Insert
Chronic Glaucoma Canine
K9 Intrascleral Prosthesis
K9 ISP 1 week post-op
K9 ISP 2 week post-op
http://youtu.be/lF0bOb42oNs
K9 ISP 10 week post-op
K9 ISP 1 year post-op
K9 ISP OD, enucleation OS 1 yr post-op
19
The Cloudy, The Red, The Painful
Etiology of Cataracts
Cataract
Hereditary
Metabolic
!  Inflammatory
!  Traumatic
!  Toxic
!  Nutritional
!  Radiation
!  Electric
! 
! 
Cataract - location
! 
Location
!  Capsular
!  Cortical
! 
Age of onset
!  Congenital
! 
Canine
! 
Location
!  Capsular
!  Cortical
!  Nuclear
! 
Progression
!  Incipient
Location
!  Capsular
Feline
Cataract - location
Cataract
!  at
Cataract - location
Cataract - location
! 
Location
!  Capsular
!  Cortical
!  Nuclear
!  Equatorial
Cataract - severity
birth
!  Developmental
!  <
6yr
!  Senile
!  >6-9yr
20
Cataract - severity
! 
Cataract
Equatorial vacuoles - immature
Progression
!  Incipient
!  Immature
Cataract
Cataract - severity
Posterior cortical - immature
! 
Progression
!  Incipient
!  Immature
!  Mature
! 
Progression
!  Incipient
!  Immature
!  Mature
!  Hypermature
Cataract
Cataract - severity
Mature cataract
Hypermature
J. Mould
21
Hypermature
Mature
Hypermature cataract with LIU
Hypermature
Hypermature
Hypermature with Retinal detachment
J. Mould
Lens induced uveitis with secondary glaucoma
Lens induced uveitis
Ocular Ultrasound
Normal eye 10 mHz
Anterior Chamber
Cataract Surgery
Iris
Lens
! 
Vitreous
EOM
Ultrasound
!  Vitreous Degeneration
!  Immature
- 2%
- 7%
!  Hypermature - 20%
!  Mature
22
Cataract Surgery
Vitreous
degeneration
! 
Cataract
Ultrasound
!  Retinal Detachment
!  Immature
- 2%
- 5%
!  Hypermature - 12-15%
Vitreous degeneration
!  Mature
Cataract
Retinal
detachment
Cataract
Retinal
detachment
Retinal
detachment
When to Refer?
! 
! 
! 
Referral should be
done early
We no longer wait
for a mature “ripe”
cataract
Refer early
immature and all
cataracts that are
progressive
1 Year - old Dog
Phaco -8 sec, 50ml
! 
! 
! 
Phaco – lowest complication rate
Anti-inflammatory – 4X complication rate
No therapy – 255X complication rate
23
AcriVet 60V IOL
Emmetropia
2 yr post op IOL’s
Aphakia -14D
Questions?
24