01:08:10

Common Misconceptions in Veterinary Ophthalmology

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Robin Stanley, BVSc. Hons., MANZCVSc (Surgery), FANZCVSc (Ophthalmology) VetScope 2020-01-08

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Common Misconceptions in Veterinary Ophthalmology
Robin G Stanley, Jane Whitley Matt Sanders, Heather Kaese
Animal Eye Care, Melbourne

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The Animal Eye Care Team
• Robin Stanley – Veterinary Eye Specialist
• Jane Whitley – Professional Interest Practitioner in Ophthalmology
• Matt Sanders- Resident in Veterinary Ophthalmology
• Heather Kaese - Veterinary Eye Specialist

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The Animal Eye Care Team
• Nicole T
• Nicole R
• Mari
• Danijela
• Michelle
• Jayde
• Sierra
• Harriet
• Ellie

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No need to worry about the Breed

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No need to worry about the Breed

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Consider the Breed
- Breed predisposition is very important in veterinary ophthalmology
- Most of the eye problems – apart from trauma are breed related
- Always check the breed predisposition lists in all pure bred dogs and their primary crosses

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Eye diseases that occur by breed

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PRA – progressive retinal atrophy
- Labradors
- Australian Cattle Dogs
- Poodles
- Cocker Spaniels

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Eye Diseases by Breed

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Lens Luxation
- Terriers
- Terriers
- Terriers
- Terriers
- Australian Cattle Dogs

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STT Schirmer Tear Tests are overrated
They take at least 2 minutes of my valuable time!!

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STT Schirmer Tear Tests are overrated

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STT – Schirmer tear tests are underused
- Many cases referred to us have not had a STT done
- Do a STT is all cases of
– Conjunctival Disease
– Corneal Disease
– And Ocular Discharge
– watery and mucky

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Dry eye is commonly overlooked
- Dry eye treatment is more successful when treated early.
- Do a STT with chronic conjunctivitis cases as allergic conjunctivitis can lead to dry eye.

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Why do a STT here?

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Use NSAIDs in ocular trauma, severe uveitis cases, hyphaema cases

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We lose most eyes to uveitis
- Uveitis in ocular trauma cases is usually severe
- Use oral prednisolone in most cases
– Prednisolone
- 1mg/kg BID for 3 to 5 days then
- 1mg/kg SID for 5 to 7 days then
- 1mg/kg EOD then slowly reduce
– Consider subconjunctival depot cortisone injections in severe cases

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Use oral cortisone and topical cortisone eg Prednefrin Forte

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Amacin
is a good choice in these cases

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Amacin
is a good choice in these cases

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Amacin
- A useful ointment for acute bacterial conjunctivitis
- Not potent enough for uveitis, ocular trauma cases
- Use potent cortisone drops eg Prednefrin Forte or Maxidex eye drops for uveitis cases

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Don’t bother with a PLR It’s too basic

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Don’t bother with a PLR

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PLRs can be very useful
- Do PLRs on every eye case you see

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Small pupil suggests Uveitis

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Image

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The Consensual/Indirect PLR is one of the most useful tests in Ophthalmology

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Yes!
The Consensual/Indirect PLR is one of the most useful tests in Ophthalmology

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Image

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Image

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Use the largest possible suture in cherry eyes and eyelid surgery

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Use the largest possible suture in cherry eyes and eyelid surgery

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Cherry eye surgery
- Larger, abrasive suture (eg. PDS) will rub on the cornea and cause deep corneal ulcers
- Use 6/0 vicryl – soft, fine, absorbable
- Continuous pattern for closing incision with pocket technique
- Tie knots on the palpebral surface

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Eyelid surgery
- Entropion surgery, eyelid tumour removals
- Use soft, fine, absorbable suture – eg. 6/0 Vicryl or 5/0 Maxon
- If corneal ulcer and blepharospasm – consider placing lateral TT suture at same time as entropion correction

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Useful suture materials for eye surgery
- 6/0 Vicryl – cherry eyes, eyelid surgery
- 5/0 Maxon – entropion, eyelid tumour removals
- 4/0 nylon – Temporary tarsorrhaphy, third eyelid flaps

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Large dogs are really easy to do cherry eye surgery

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Large dogs are really hard to do cherry eye surgery

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Large dogs are really HARD to do cherry eye surgery
- Commonly have BOTH cherry eye and third eyelid cartilage eversion –WARN OWNERS!
- Saint Bernards, Great Danes, German Shepherds, Newfoundlands
- Need to replace prolapsed third eyelid gland and assess cartilage
- Bend in cartilage must be corrected
- Consider referral in these cases

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Topical NSAIDs - use on an ulcer

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Topical NSAIDs - use NEVER on an ulcer

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Topical NSAIDs - use on an ulcer – NO!
- Significantly delays epithelialization – slows healing
- Risk of stromal melting +/- corneal perforation
- Only use topical anti-inflammatory drops on eyes with an intact epithelium

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Indications for topical NSAID drops Voltaren or Acular eye drops
- Lens induced uveitis – cataracts
- Vascular keratitis – reduce vascularization/fibrosis once an ulcer has healed
- Uveitis in cats
- Post-operative inflammation after cataract surgery

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Treatment for corneal ulcers
- Prophylactic topical antibiotic
- Oral NSAIDs
- Doxycycline - may help with healing by inhibiting MMPs.
- +/- Additional pain relief eg. gabapentin or oral buprenorphine

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- Indolent ulcers = superficial ulcers will require cotton tip debridement +/- anterior stromal procedure e.g. Grid keratotomy or diamond burr debridement to encourage healing
- Third eyelid flap alone will not speed up healing

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Once ulcer has epithelialised!
- Use topical NSAID to reduce vascularization/fibrosis

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Older dogs - white spots => lipidosis, not a problem!

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Older dogs - white spots => lipidosis, not a problem!

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Causes of corneal lipid deposits
- Corneal lipid dystrophy
– Inherited – CKCS, shelties, beagles, huskies, rough
collie
– No inflammation (no blood vessels)
– Non-responsive to treatment
– Topical anti-inflammatories will EXACERBATE

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Causes of corneal lipid deposits
- Corneal Degeneration
– Secondary to pathologic changes in cornea
• Ocular disease or systemic disease
– Opacities consist of lipid, cholesterol or calcium
• Preceded by keratitis, vascularisation
– Vascularisation is hallmark clinical feature of CD
– Presence of Calcium delays healing

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Corneal degeneration
- May be secondary to systemic disease - altered lipid metabolism
– General physical exam!
– +/- diagnostic tests

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Age related Lipid + Calcium

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Corneal lipidosis/degeneration
- Topical anti-inflammatories may worsen degeneration
– Don’t use topical NSAIDs or corticosteroids
– Decrease vascularization => can’t clear the lipid
– Will attract/bind calcium
- Fragile deposits can crumble – leaving deep corneal defect or corneal perforation => requires CCT graft!

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Image

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Corneal degeneration/lipid keratopathy treatment
- Treat underlying cause
- Low fat diet eg. Hills w/d
- Optimmune or Tacrolimus 0.02% drops BID- TID
- If ulcerated, or calcium preventing healing
– can use diamond burr to remove the gritty
material

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Image

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Indolent Ulcers in Cats must be gridded

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Indolent Ulcers in Cats must never be gridded

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Gridded Feline corneas will form corneal sequestrums

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Superficial Ulcers in cats are usually viral
TRUE

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Feline superficial Ulcers - viral
- Topical anti-virals
– Aciclovir – Zovirax eye ointment – human – Cidofovir eye drops – compounded
- Oral Famciclovir 40-90mg/kg BID
- Doxycycline 5 mg/kg BID

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Feline superficial Ulcers - viral
- Oral meloxicam
- Hylo-Forte these eyes can go dry for up to 6 weeks after infection
- Reduce stress

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Conjunctivitis in cats = doxycycline deficiency
True

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Older cats get iris pigment changes so do not worry

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Older cats get iris pigment changes so do not worry

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Iris Pigment in Older Cats

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Iris Pigment – be concerned
- Growing quickly
- Darker black lesions
- Distorted pupil – tumour is growing through the posterior iris epithelium
- Increased IOP – intraocular pressure

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This old cat has good vision so no need to do a fundus examination

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This old cat has good vision so no need to do a fundus examination in ALL older Cats

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Most older cats have hypertension You can see changes in the fundus way before systemic signs of hypertension

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Small Haemorrhages

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Image

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Image

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Image

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Serum Heals All Ulcers

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No – Serum only helps with Malacia

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Serum and Ulcer Treatment
- Indolent Ulcers
– Need debridement
– +/- Linear Grid Keratotomy
– +/- Superficial Keratectomy
- Topical Prophylactic Antibiotic
- Oral NSAID
- Pain Control
- Prevent Self Trauma

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Serum and Ulcer Treatment
- Infected Ulcers
– Antibiotics
- Systemic
- Topical
– Anti-inflammatories
– Pain Control
– Prevent Self Trauma
– Hygiene

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Malacic /Melting Corneal Ulcer
- Release of Collagenases/Proteases
– Bacteria
– White blood cells
– Corneal stromal cells
- Breakdown > Repair
- Common in Brachycephalic
- In Cats – Burmese seem to be over-represented

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Serum and Ulcer Treatment
- Malacic/Melting Ulcers
– Topical Antibiotics
- Ofloxacin/Chloramphenicol
- Frequently during the first hour/24 hours
– Systemic Antibiotics
- Doxycycline 5mg/kg bid
- Cephalexin 25mg/kg
- Enrofloxacin 5mg/kg
– Systemic Anti-inflammatory
– Pain Control
– Prevent Self Trauma
– Hygiene
–Oh yes – SERUM WILL HELP

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Latanoprost: First Choice for Glaucoma

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Latanoprost – Not a First Line of Defense Drug

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No - Complicates Glaucoma Secondary to Lens Luxation

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Latanoprost – Not in cases of Lens Luxation
- Causes Pupillary Constriction
– Can trap the lens in Anterior Chamber
– Can trap the lens in Pupil
- Pupillary Block Glaucoma
– Aqueous can not get from behind the iris to the drainage angle
- If you are not sure – Don’t risk it!
You can always call Animal Eye Care

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No – Complicates Glaucoma Secondary to Uveitis

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Latanoprost – Not in cases of Uveitis
- Latanoprost = Prostaglandin Analog
– Can Increase inflammation
– Resulting in Higher Pressures

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Glaucoma - First Line of Defense Brinzolamide and Dorzolamide

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Recheck IOP in 1-2 Weeks After starting Anti-Glaucoma Treatment

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No Recheck the pressures in 90 minutes

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Thanks for attending
Animal Eye Care
181 Darling Rd
East Malvern, 3145, Victoria
Phone (03) 9563 6488
www.animaleyecare.com.au

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