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Supplied by Intervet/Schering-Plough Animal Health Advertising Feature 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.