2/19/14. Garret Pachtinger, VMD, DACVECC. COO, VetGirl. Justine A. Lee, DVM, DACVECC, DABT CEO, VetGirl. Shelby Reinstein DVM, MS, DACVO
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1 Shelby Reinstein, DVM, MS, DACVO Garret Pachtinger, VMD, DACVECC COO, VetGirl Justine A. Lee, DVM, DACVECC, DABT CEO, VetGirl Shelby Reinstein DVM, MS, DACVO! ed to you 48 hours after the webinar! Active participation = no quiz! Watching video later, must complete quiz! / contact with ANY questions! garret@vetgirlontherun.com! justine@vetgirlontherun.com 1
2 ! Squinting, pawing, swelling! Tearing, discharge, redness! Changes in vision! Systemic signs, concurrent diseases! Duration / Progression / Current meds! Distance exam Pupil size / symmetry, facial symmetry Globe position / size! Neuro-ophthalmic exam Menace response, dazzle & palpebral reflexes PLRs! Initial diagnostic tests Schirmer tear test, fluorescein stain, tonometry! Eyelids! Conjunctiva! Sclera! Cornea! Anterior chamber! PC: Squinting, red right eye! LN: 1 week ago! Prog: Tearing, red at first, now hazy! Syst: Decreased appetite this morning! Distance exam: Moderate blepharospasm Moderate mucopurulent discharge! Neuro-Ophthalmic exam + menace OU + dazzle, palpebral OU + PLR OU (miosis OD)! Diagnostics STT: > 15 mm/min OD, 12 mm/min OS Flu stain: Pos OD, Neg OS Tonometry: 8 mmhg OD, 14 mmhg OS! Moderate to severe conjunctival hyperemia! Moderate, diffuse corneal edema! 6 mm, circular, lateral paraxial corneal ulcer! Surrounding cornea mushy! Anterior chamber, lens clear 2
3 ! Problem List Corneal ulcer OD Reflex uveitis OD " Low IOP, miotic pupil! Underlying cause?! Classify the ulcer Simple / Infected / Indolent Depth - referral for surgery?! Causes Eyelid abnormalities Trauma Dry eye (KCS) Corneal degeneration Spontaneous / Indolent! Simple Superficial Lack of vascularization! Infected Corneal edema Cellular infiltrate ANY depth Uveitis, hypopyon! Indolent Loose epithelial lip! Culture Aerobic, rarely fungal Topical anesthetic " Avoid eyelids, conjunctiva Fine tip culturettes easiest! Cytology Corneal integrity? Collect after culture Blunt edge of a No. 15 Blade! Simple, superficial Topical antibiotic q8h " NeoPolyGram, Tobramycin Atropine q12-24h Oral anti-inflammatory E-collar! Recheck: days! Infected / melting 1. Topical Antibiotics Ofloxacin q4h x 24-48h Cefazolin q4h x 24-48h " 60 mg/ml 2. Topical Anti-collagenase Serum q2h x 24h, then q4h 3. Atropine q12 4. Oral Anti-inflammatories 5. Oral Antibiotics Doxycycline Recheck 2-3 days 3
4 ! Surgical Referral Deepening despite meds Descemetocele Rupture / Iris Prolapse! Superficial Excellent, minimal scarring Eliminate underlying cause! Infected Excellent for globe Vision depends " Scarring variable / location " Uveitis / cataract / synechia! PC: Eye color change! LN: Never really normal Much thinner / small than littermate Not very active, sleeps a lot! Prog: Red, tearing yellow iris turned red! Syst: Poor appetite, occassional vomiting, diarrhea! Distance exam: Mild blepharospasm Mild epiphora, crusted discharge! Neuro-Ophthalmic exam Inconsistent menace OU + dazzle, palpebral OU Sluggish PLRs OU (resting miosis)! Diagnostics STT: not performed Flu stain: Neg OU Tonometry: 4 mmhg OD, 5 mmhg OS! Moderate conjunctival hyperemia! Moderate, diffuse corneal edema Severe keratic precipitates! Anterior chamber flare (3+)! Iris hyperemia (rubeosis irides)! Multifocal posterior synechia Dyscoric pupils! Lens normal! Vitreous / retina cloudy! Problem List Decreased vision OU Low IOP OU Miosis / dyscoria OU Aqueous flare / KPs OU! Dx: Severe uveitis OU 4
5 ! Breakdown of BOB (blood-ocular barriers) Anterior, posterior, pan-uveitis! Leakage of proteins, cells Aqueous flare Keratic precipitates Hypopyon / Hyphema Subretinal exudates! Hallmarks Low IOP Miosis Aqueous flare Corneal edema! Primary ocular disease Corneal ulceration (reflex) Cataracts (lens-induced) Idiopathic Intraocular neoplasia! Systemic disease Infectious Immune-mediated Metabolic Neoplastic/Paraneoplastic! CBC / Serum chemistry! Imaging: CXR / AUS! Infectious diseases Dog " Tick serology, fungal, Leptospira Cat " FeLV/FIV, FeCV, Toxoplasma, fungal, Bartonella! Anti-inflammatory Topical (Pred acetate, NeoPolyDex) " 4-6 times daily Oral NSAIDs, steroids Subconjunctival steroids! Atropine q12-24h! Antibiotics Doxycycline vs. targeted! Treatment of underlying disease! Sequelae Synechiae (posterior) Cataracts Lens luxation Secondary glaucoma Phthisis bulbi! Cleo Pred acetate q4, atropine q12 CBC: Inflammatory leukogram Chemistry: Hyperglobulinemia (8.7 gm/dl) Serology: FeLV/FIV, Toxo, Crypto negative / FeCV positive! PC: Painful right eye! LN: Last night at bedtime! Prog: Maybe tearing x 2 days! Syst: Decreased appetite this morning 5
6 ! Distance exam: Moderate blepharospasm OD Moderate epiphora, elevated 3 rd eyelid OD! Neuro-Ophthalmic exam Menace: Neg OD, Pos OS PLRs: Neg OD (mydriatic), Pos OS " Positive consensual PLR from OD " OS Positive dazzle OU! Severe conjunctival hyperemia & episcleral injection! Moderate, diffuse corneal edema! Anterior chamber normal! Dilated pupil, no PLR! Lens / vitreous normal! Fundic exam: ONH pallor ONH cupping! Diagnostics STT: not performed Flu stain: Neg OU Tonometry: 64 mmhg OD, 17 mmhg OS! Problem List Blind OD Elevated IOP OD! Dx: Glaucoma! Primary Glaucoma Inherited malformation of drainage angle " Goniodysgenesis " Affects both eyes / one eye spikes first Breed predisposition Top 5 " Cocker, Bassett, Chow, Shar-Pei, Boston Terrier Middle aged females! Classify the glaucoma Acute vs. Chronic Primary vs. Secondary! Secondary Glaucoma Obstruction or narrowing of drainage angle " Chronic anterior uveitis " Hyphema " Intraocular neoplasia " Anterior lens luxation " Phacomorphic (swollen, diabetic cataract)! Pain Squinting, tearing, enophthalmos, elevated 3 rd eyelid! Vision loss / negative menace! Mydriasis / negative direct PLR! Episcleral injection! Diffuse corneal edema! Cupped ONH 6
7 ! Acute (<24-48 hours) Vision salvageable Emergency treatment Acute Chronic Dazzle reflex Present Absent Consenual PLR Positive Negative Globe size Normal Buphthalmos Cornea Edema Edema, Haab s striae! Chronic (weeks months) Permanent blindness Controlling IOP for comfort only Lens - Sub / Luxation Retina Cupped ONH Retinal degeneration! Reduction of IOP Vitreal dehyration - Mannitol Improved outflow - Latanoprost Reduced production Dorzolamide / timolol! Treat underlying conditions! Prolong normal IOP in contralateral eye! Vitreous dehydration - Mannitol 20% 1-2 g/kg IV over mins " Withhold water! 30 mins, duration 4-5 h " Recheck 45 mins Can repeat, monitor electrolytes! Prostaglandin analogs - Latanoprost (Xalatan ) Induces miosis opens ICA " Dogs only - cats lack uveal PGF 2α receptors Contraindications " Anterior lens luxation " Severe uveitis 3 drops, 15 mins apart " Recheck IOP, pupil size! Anterior chamber paracentesis Acute glaucoma " Non-responsive to mannitol, latanoprost Procedure " Sedation, propofol, general anesthesia " Topical anesthesia, dilute betadine solution prep " 30 ga. or insulin needle no syringe " lateral limbus, careful of iris, lens, endothelium " Allow ~ 3-5 drops of AH to flow out no suction! Desired IOP = TLTM 15 mmhg 7
8 ! Carbonic anhydase inhibitors Safe / effective in all types of glaucoma " Reduce aqueous humor production Methazolamide " Dogs: mg/kg PO q8-12h " Side effects " GI, hypokalemia, metabolic acidosis cats very susceptible Dorzolamide, Brinzolamide " Topical, q8h " Similar IOP reduction to systemic CAIs (~25%) " Side effects " Irritation / hypersensitivity in some dogs, salivation in cats! Beta-blockers Safe / effective in all types of glaucoma " Reduce aqueous humor production Timolol maleate 0.5% " Topical, q12h " Supplemental to other medications " Prophylaxis for contralateral eye " Contraindications " Cardiovascular disease, asthma (cats) Dorzolamide / Timolol combo (Cosopt )! Chronic anterior uveitis! Hyphema! Intraocular neoplasia! Anterior lens luxation! Phacomorphic As for uveitis *NO atropine! Referral: surgical lens removal! Classify the glaucoma Acute vs. Chronic " History / normal last night " Consensual PLR & dazzle reflex " Normal globe size / lens position " Cupped ONH, otherwise normal retina Primary vs. Secondary " SIGNALMENT " No evidence of uveitis, etc! Start topical meds Latanoprost & Timolol/Dorzolamide " Latanoprost given 3 times, 15 mins apart! Place IVC for mannitol 1 g/kg slowly over 30 mins! IOP / pupil size recheck (pre: mins: mins: 28 mm Hg " Edema / discomfort resolving " Pupil miotic! Timolol/Dorzolamide OD q8h! NeoPolyDex OD q8h! Carprofen 2.2 mg/kg PO q12h x 7 days! Recheck IOP: hours! Instruct owners on Latanoprost use! Timolol q12h OS prophylaxis Referral for gonioscopy? 8
9 ! PC: Left eye injury! LN: Earlier today! Prog: Acutely dog park! Syst: Healthy, UTD on vaccines! Distance exam: Severe blepharospasm OS Moderate epiphora, elevated 3 rd eyelid OS! Neuro-Ophthalmic exam Menace: Pos OD, Neg OS PLRs: Pos OD, difficult to assess OS " Consensual present OS " OD Positive dazzle OU! Diagnostics STT: not performed Flu stain: Neg OU Tonometry: 19 mmhg OD, 72 mmhg OS! Severe conjunctival hyperemia & episcleral injection! Moderate, diffuse corneal edema Focal, axial dense edema! Anterior chamber hazy Iris appears far away / out of focus / dilated Lens present in front of iris! Vitreous / retina not visible! Problem List: Blind / Elevated IOP OS Lens displaced into anterior chamber OS! Dx: Anterior lens luxation, 2 glaucoma! Classify the lens luxation Primary vs. Secondary Duration of glaucoma?! Primary Inherited zonular protein weakness " Terriers, Shar Pei, Chinese Crested " 3-6 years old, bilateral disease! Signs of elevated IOP Axial dense edema w/ lens contact! Iridodonesis / Phacodonesis! Secondary Zonular degeneration / tearing " Trauma " Chronic uveitis, chronic cataract " Chronic glaucoma (buphthalmia)! Physical obstruction of angle 9
10 ! Acute, anterior lens luxation Referral for emergency surgery Initiate IOP reduction " Timolol/Dorzolamide " Mannitol " No latanoprost! Latanoprost prophylaxis " Evidence of lens instability in other eye?! Secondary lens luxation Chronic intraocular inflammation " Topical steroids / oral anti-inflammatories " As for uveitis Direction matters " Anterior glaucoma may develop " Posterior Latanoprost for miosis Treatment depends on visual potential " Chronic cataract w/ acute anterior luxation " Anterior luxation w/ chronic glaucoma! Primary vs. Secondary luxation Signalment Non-cataractous lens! Acute vs. Chronic glaucoma History Consensual PLR, dazzle reflex Normal globe size! Emergency intracapsular lens extraction! PC: Fight w/ housemate dog! LN: Prior to fight! Prog: Was holding eye shut, now open more! Syst: Chronic cruciate rupture / Rimadyl! PE: Abrasion on ear, small puncture on head! Distance exam: Mild blepharospasm OS Moderate epiphora, elevated 3 rd eyelid OS! Neuro-Ophthalmic exam Menace: Pos OD, Inconsistent OS PLRs: Pos OD, Miotic OS Positive dazzle OU! Diagnostics STT: > 15 mm/min OU Flu stain: Neg OU Tonometry: 12 mmhg OD, 5 mmhg OS! Moderate conjunctival hyperemia! Mild, diffuse corneal edema! Anterior chamber Hazy red, obvious blood! Miotic pupil! Lens / vitreous / retina not visible 10
11 ! Problem List Decreased vision OS Hyphema OS Low IOP, miosis OS! Dx: Traumatic hyphema / uveitis OS R/O retinal detachment! Hemo-eyeball! Causes Trauma Tumor Toxin / coagulopathy Retinal detachment! Focal vs. Diffuse! Acute vs. Chronic! Bleeding elsewhere? Subconjunctival / Orbit / Vitreous / Retina! Uveitis Corneal edema Iris color change Miotic pupil, low IOP! Posterior segment disease Mydriatic pupil Neg consensual PLR, dazzle! Ocular ultrasound Evaluate uvea / posterior segment Tumor / clot / retinal detachment! Bloodwork Red cells / platelets Coagulation testing Renal / thyroid disease (cats)! Blood pressure! Imaging CXR / AUS! Anti-inflammatories Topical: Prednisolone acetate 1% / NeoPolyDex q4-6h Oral: Steroids / NSAIDs! Atropine q12-24h Posterior synechia form quickly Caution w/ diffuse hyphema " Tropicamide q8h! Underlying conditions Systemic hypertension / renal disease Intraocular neoplasia! Secondary glaucoma! Posterior synechia! Cataract! Phthisis bulbi 11
12 ! Pred acetate 1% q4h! Atropine 1% q12h! Continue Rimadyl PO! Recheck: 7-10 days Assessment of vision / posterior segment Normalization of IOP Resolution of hyphema 1. Corneal ulcers 2. Uveitis 3. Glaucoma 4. Lens Luxation 5. Hyphema Dr. Justine Lee! March 20-21, 2014: SCAVMA Student Symposium, Fort Collins, CO! March 23, 2014: American Animal Hospital Association, Nashville, TN.! April 1, 2014: Connecticut Veterinary Medical Association, Hartford, CT.! April 22-24, 2014: Russian Veterinary Conference, Moscow, Russia Dr. Garret Pachtinger March 1-2, 2014: ContinuEd Hawaii Veterinary Symposium, Kahola Coast, Hawaii March 5, 2014: North Carolina Academy of Small Animal Medicine August 16-18, 2014: Pennsylvania Veterinary Medical Association Keystone Veterinary Conference in Hershey, PA September 24-28, 2014: Southwest Veterinary Symposium, Ft. Worth, Texas 12
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