All Rounds notes and Pretest Notes Flashcards
Uveal tract anatomy
Anterior part is ciliary body and iris-blood aqueous barrier
Posterior part is the choroid including tapetum lucidum - a blood retinal barrier
what is it called when there is posterior uveitis
choroiditis
What is main function of the ciliary body?
aqueous humor production, gives cornea its general shape and can change pupil size (moreso in humans than in animals)
Choroid function
provides blood supply to retina
Main infectious cause for uveitis in dogs is ____ and is ___ in horses
Blastomycosis; leptospirosis
causes of uveitis
any source of inflammation occurring
Parasites, trauma, lens lux, ulcers, neoplastic, autoimmune, perforation of globe, etc. etc.
epiphora means
discharge
ciliary flush means
360 degree of invasion of vessels around the cornea, red
episcleral injection
severe redness of the sclera
corneal edema
enlarged/swollen, cloudy cornea
infected ulcer of the cornea is called….
Cornel malacia (horses get corneal abscesses but usually dogs and cats do not, they get corneal malacia)
normal IOP
10-25mmHg
Low usually means uveitis– will also have miotic pupil (small)
increased usually means glaucoma- will usually have larger pupil (meiosis)
Atropine does what in a uveitis case?
we give atropine to help stop the spasming of the iris sphincter muscles (which IS PAINFUL),it also decreases the iridocorneal angle (so avoid in glaucoma cases) and decreases secretions (so avoid in KCS cases)
What does aqueous flare mean?
breakdown of blood-aqueous barrier causing floating debris within the anterior chamber, indicates inflammation, “fog in headlights” look
Usually a slam-dunk for anterior uveitis
Hypopyon meaning
accumulation of WBC
Hyphema meaning
accumulation of RBC
what do you think if p has uveitis but has HIGH IOP?
Likely getting glaucoma secondary to severe uveitis
Hyperemia
iris reddening and inflamed
Dyscoria
Pupil is an abn shape
Synechia posterior
iris to lens
synechia anterior
iris to cornea (whereas iris to lens is posterior synechia)
Persistent pupillary membrane vs synechia
PPM is from middle of area to cornea but usually does NOT affect pupil shape unlike synechia which does have abn pupil shape (dyscoria)
Uveitis in horses and cats often leads to…..
Cataracts (whereas dogs usually have cataracts secondary to genetics or DM which then causes the uveitis so other way around)
What is panuveitis
just like how pancytopenia is all WBC, RBC, and platelets low, panuveitis is inflammation of both the anterior and posterior segments!!!!!
Aqueous flare of the anterior segment and retinal detachment in the posterior segment in a p is usually what?
Panuveitis
Uveo-dermatologic syndrome
The uveodermatologic syndrome (UDS) is a rare, immune-mediated, hereditary disease in dogs which has ophthalmic and dermatologic manifestations, seen in dark pigmented dogs that lose some hair on their face esp around muzzle and eyes and also have uveal eye changes
usually diagnose with skin biopsies I think and tx is steroids
looks similar to lupus erythematous but LE is moreso on the nasal phylum and UDS is moreso on the philtrum, under the nose and around the bridge of the muzzle and eyes
Do not use ____ in KCS
Atropine (bc will dry the eye out even more since atropine dries secretions)
do not use ___ in glaucoma
Atropine because will further decreases iridocorneal angle and further increase the IOP
never use ___ in eye ulcer cases
steroids- will delay healing and further suppress the immune system and allow the bacteria and such to get further into the eye
Which of the following are side effects that may be seen with most chemotherapy drugs?
Bone marrow suppression (esp. neutrophils and sometimes even thrombocytopenia which is decreased platelets), GI upset also occurs
Chose the correct statement regarding prednisone use in canine lymphoma patients
It is useful in a palliative setting and is used also in conjunction with some chemotherapy protocols
prolonged pred use prior to chem can make the chemotherapy less effective T/F
True!!
BY which route is a carcinoma MOST likely to mets?
Lymphatics
Sarcomas spread via which route?
Hematogenously spread
carcinomas spread mostly via ____
lymphatics
round cell tumors spread via…
blood (hematogenously) and lymphatics
Clinicians determine stage or grade
STAGE
Grade is done by a ____
Pathologist
Why are conservative excisional biopsies contraindicated for ISS?
bc they are unlikely to remove all of the tumor and make make subsequent re-cut surgery extremely challenging
What are the margins rec. for removal of ISS?
5 cm laterally, 2 fascial planes deep
For both dogs and cats, the risk of what tumor type is increased with each heat cycle, and what is the protective effect?
for both dogs and cats, the risk of mammary tumor formation increases with each heat cycle, and the protect effect of spaying is negligible if spay is performed after the second estrus (approximately 2 years of age)
You recently removed a mast cell tumor from the lateral body wall of a dog, and re reviewing the histopathology report. Which of these scenarios is paired with a correct assessment?
Grade 3/high grade, clean wide margins. This tumor has a high risk of mets, and post op chemotherapy should be strongly considered
What is a SE of dogs tx with Doxorubicin?
Cumulative cardiotoxicity
9 year old FS Cocker Spaniel presents for generalized lymph node enlargement. On abdominal ultrasound, the spleen has a “honeycomb” appearance. The dog is quiet and depressed during the exam, and the owners report she has not been eating well recently. Results of a CBC and serum chemistry are unremarkable. Cytologies of the spleen and right popliteal lymph node both return as high grade lymphoma. What is this dog’s most likely stage and substage
Substage 4b
The prognosis for lymphoma can be influenced by a variety of factors relating to the patient or their disease. Which of the following is NOT considered to be a STRONG negative prognostic indicator for dogs with lymphoma?
Being female; being female is a WEAK positive prognostic indicator in some studies
What is the most impt prognostic indicator for canine dermal MCT?
Tumor grade
What are some prognostic indicators of canine dermal MCT?
Tumor grade, anatomic location- mm, mucocutaneous jxn, pinnae, muzzle, digits, preputial/scrotal, and GI all have BAD prognosis, BUT conjunctival MCT seems to have non aggressive (good prognosis) behavior, mitotic count, stage, grade, skin ulceration or now, and breed (Shar Peis and Mastiffs seem to get worse forms whereas Brachycephalic have better prognosis)– which is good bc they are the poster children for MCT and are very predisposed.
Which of the following is NOT one of the 4 classic diagnostic criteria for canine multiple myeloma?
Bleeding diathesis– abn bleeding can be seen with MM, but its not one of the 4 diagnostic criteria– which are bone marrow suppression, lytic bone lesions, monoclonal gammopathy, and bence jones proteinuria
A 10 year old female spayed terrier mix presents to you for a 2 week hx of hematuria and stranguria. On ultrasound, you think you see a mass in the bladder trigone. You are therefore highly suspicious of a transitional cell carcinoma and wish to confirm the diagnosis. Which of the following methods of diagnosis is MOST likely to result in widespread tumor seeding?
Cystotomy and sx biopsy
Whats the most impt initial therapy for a cat with ISS?
Radical sx excision
In a lightly pigmented, short-haired cat, what cutaneous tumor is induced by exposure to UV light?
SCC
What tumor types in dogs are induced by UV-light?
Canine SCC and dermal hemangiosarcoma (HSA)
DO cats seem to grow dermal HSA with sun exposure like in dogs?
Nope
In which of the following anatomic areas of a dog is a melanoma most likely to be benign?
Haired skin
A cat presents to you for halitosis and ptyalism and on exam you identify an oral mass. What is the mass most likely to be?
SCC
An approximately 8 year old female spayed cat is presented to you for a mammary mass. She was adopted from a shelter two years ago, spay was performed at the time of adoption. On exam today, there is a 2 cm mass in the left 6th mammary gland. The remainder of the physical exam is unremarkable. Punch biopsy of the mass diagnoses a mammary carcinoma. Which of the following treatment plans will maximize the chance of a good long-term prognosis for this cat?
In cats, the standard care is bilateral chain mastectomy followed by chemotherapy.
A 10 year old Collie is assessed at your clinic for unilateral epistaxis of one month duration. Physical exam is unremarkable except for reduced air flow through the right nostril. The dog’s PCV is 30% and TP is 5.6 g/dl. The platelet count is 200,000/ul and PT/PTT are at the high end of the normal range. What is the most likely cause of this dog’s epistaxis?
Nasal Adenocarcinoma
A cat is presented to your clinic with a cutaneous mass that is 4 mm in diameter. Cytology of the mass shows cells with a round nucleus and abundant purple cytoplasmic granules. Which of the following is the most likely diagnosis?
MCT
What are the layers of cornea in order from outside to inside?
Epithelium, stroma, Descemet’s membrane, and endothelium
which of the following are two procedures used for spontaneous chronic corneal epithelial defects (SCCEDs)?
Diamond bur debridement, grid keratotomy
which of the following organisms is associated with Keratomalacia (melting cornea)?
Pseudomonas
Which of the following are the two most common breeds predisposed to superficial keratitis (pannus)?
GSD and Greyhounds
What type of ulcer is commonly seen with feline herpesvirus?
Dendritic
You have a 7 year old FS Bassett Hound that presents for acute blindness. On ophthalmic examination, you note corneal edema, a midrange pupil, trace aqueous flare, and an elevated third eyelid. What is most likely the diagnosis?
Acute glaucoma
what do you run on a patient with acute aqueous hyphemia?
CBC, coags, 4Dx
what is the most appropriate term for the earliest/smallest stage of a cataract???
Incipient
What breed is most likely to get anterior lens luxation?
Terriers
This is an eye ER situation
what is the most common cause of cataracts in horses and cats?
Uveitis
what is the ophthalmic term for when the iris is stuck down onto the lens?
Posterior synechia
What is the retinal vasculature pattern of the dog and the cat?
Holangiotic
The rabbit is Meragiotic
Horseis proangotic
Vessels go through the optic disc in cats but not in dogs
What describes the directional term for most accurately describing the location of the tapetum?
Superior
A 7 year old lab presents for “cloudy eyes” and has had progressive night blindness over the past 6 months. What is the most likely diagnosis for the cause of the night blindness (nyctolopia)?
Progressive retinal atrophy (PRA)
What retinal disease may sometimes be associated with PU/PD, polyphagia, and sudden blindness?
Sudden acquired retinal degeneration syndrome (SARDS)
a cat presents with a complete retinal detachment. What are the best diagnostics out of the following options to do after your initial ophthalmic examination to determine the underlying cause?
A chem panel, systemic BP and thyroid panel
How long does topical cyclosporine (Optimmune) take to start working usually?
4-6 weeks!!!!!!!
What type of drug is Latanoprost???
Prostaglandin analog
What is C/I for dilating the eye?
Retinal detachment
What is NOT a CS of anterior uveitis? What is???
Miosis is NOT; the CS are mydriasis, decreased IOP, and aqueous flare
What is the most common bacterial organism associated with recurrent uveitis?
Leptospirosis
What is the most common eyelid tumor in a dog?
Meibomian gland adenoma
cats and humans atopic dermatitis is similar in location/presentation T/F
True!!
What is the most common assoc. of miliary dermatitis in cats but IS DEFINIETLY NOT the only cause?
Flea allergy dermatitis (FAD)
what is the most pruritic of the 3 eosinophilic granuloma complex?
The eosinophilic plaque
what is feline atopic skin syndrome?
Allergic SKIN (only skin) disease associated with environmental allergens
whereas feline atopic syndrome (FAS) is skin, GI, and respiratory signs
Bravecto is useful against Demodex gatoi in cats T/F
True!!!
allergic dermatitis in dogs and cats are with Ig____ formation against _____ allergens
IgE against environmental allergens
T/F feline and canine atopy can be genetic
True!!!! but needs more research
signs of pruritus in cats–
over grooming, hair pulling – both of those result in alopecia, excoriations common and can also have otitis externa
What is NOT A differential for a pustule lesion?
Discoid lupus erythematosusor pyoderma (usually from Staphylococcus infections).
What are the 3 causes of infectious folliculitis in the dog? What do these rule outs commonly require as far as diagnosis is concerned?
Bacterial, demodex, dermatophytosis
These differentials all require scrape, pluck, and smear for cytology
What is the correct spelling of the word used to describe an unpleasant sensation that provokes the desire to scratch?
P R U R I T U S
What parasite is NOT zoonotic
Demodex gatoi
What is the minimum proper length of abx therapy for superficial bacterial pyoderma?
21 days
What is the best way to choose the best diet for a diet elimination trial?
dietary hx
What is Apoquel’s MOA?
inhibits Janus Kinase
Which cytokine does cytopoint target and neutralize?
IL-31
Which is NOT considered a primary cause of otitis externa?
Bacterial infection
Which antibiotic is considered a 2nd tier choice for treatment of canine bacterial pyoderma, and ideally would be prescribed based on a culture and susceptibility test?
Chloramphenicol
what is the best way to diagnose canine atopic dermatitis?
Clinical diagnosis- exclude other possibilities
a 4-month old severely pruritic dog presents to you for treatment. You eliminate the possibility of skin infections and do not think the history and clinical signs suggest scabies. What would be the safest and most appropriate treatment for this puppy’s itching?
Cytopoint
Cytopoint can safely be used in cats T/F
Falseeee
What is the most reliable way to diagnose Malassezia dermatitis?
Cytology
T/F Canine juvenile cellulitis (puppy strangles) is caused by an infections
Falseee
It is immune mediated and is seen in certain breeds like Irish setters and Golden Retrivers so there is a hereditary component to it
The definition of an acantholytic cell is _____
Acantholytic Cells
These keratinocytes have lost their intercellular connections deeper in the epidermis and are usually found in animals with immune-mediated disease, such as pemphigus. Occasionally, severe bacterial infections and dermatophytosis can cause these cells to develop.
what is the maximum time period needed for proper diet elimination trial when trying to diagnose a dog with a cutaneous adverse reaction to food (food allergy)?
8-12 weeks
Which of the following parasite is NOT contagious?
Demodex canis
The most common trigger for erythema multiforme in dogs and cats is…
drug reaction
What term fits with the following definition- a Small, circumscribed elevation of the epidermis that is filled with purulent material
papule
What is the reservoir for Trichophyton mentagrophytes?
Rodents
What is the reservoir for Microsporum canis?
Cats
What is the reservoir for Microsporum gypseum?
Soil
when discussing allergic dermatitis and pruritic threshold, which of the following describes the concept known as the summation effect?
Summary of all factors that can contribute to itching, including allergic and non allergic factors
What is the most common cause of feline miliary dermatitis?
allergic skin disease
What is the circulating life cycle of a neutrophil?
6-8 hours
What cells are turning over quickly and therefore are affected by chemotherapy?
Bone marrow (chemo causes myelosuppression) and GI cells
Alkalizing agent chemo drug used for B lymphomas commonly is _____ what is the SE you need to be aware of?
Cyclophosphamide; SE is it can cause a sterile hemorrhagic cystitis (will have pollakiuria- frequent, small amount of voiding, hematuria, and present just like they have a UTI)
the sterile hemorrhagic cystitis is reversible if you d/c the drug, replace the drug with another alkalizing agent chemo like Chlorambucil which is well tolerated
why do we not reach for it first? can be very expensive and cyclophosphamide still works better
Chlorambucil
Alkalizing agent, first line for small cell GI lymphoma in cats, leukemia, urethral carcinomas, and second choice for lymphoma if cyclophosphamide caused sterile hemorrhagic cystitis
CCNU
Alkalizing agent, used with MCT when Vinblastine is on back order/not available, and used as a rescue agent for lymphoma, main SE are hepatotoxicity (can respond well with Denamarin supplementation), and can generate a thrombocytopenia, and can cross the BBB so if you have intracranial neoplasia this may be a good choice (especially if it is intracranial lymphoma)
most concerned with neutropenia when using CCNU
T cell lymphoma ____ protocol
LOPP protocol
B cell lymphoma _____ protocol
CHOPP
What is the preferred tx for insulinomas?
diazoxide and streptozotocin and chemo (vincristine)
Why do we use abx with chemo patients? What abx do we use?
Doxorubicin and Mitoxantrone
Yes, Doxorubicin is technically an antibiotic but it is also classified/used as a chemotherapy drug and causes a lot of free radicals/oxidative damage
Doxorubicin SE
Vesicant so will cause radical damage around the vessel if escaped the vessel and may cause so much damage that the patient would even need an amputation. Also, can cause a cardiotoxicity in dogs at larger doses/cumulative doses, it will decrease contractility so in dogs with DCM already, you cannot use bc contractility would already be low and you would use mitoxantrone because it is not cardiotoxic
Do ecg and echo before putting p on Doxorubicin
Is mitoxantrone a vesicant like Doxorubicin?
No
Antidote type of drug for Doxorubicin is what? Why use it?
Droxyzine which is used if Doxorubicin is accidentally given outside of the vein
What drugs MOA is to stop the tubules in cellular division from ripping apart the chromosomes so they have no other choice but to go under apoptosis?
VINKAALKALOIDS
Vincristine (can CURE TVT), also used for other cancers like lymphoma, leukemia, and sarcomas, also use for immune mediated thrombocytopenia (IMHA)— can cause immediate release of some platelets from the bone marrow and they can stop the formation of tubulin within platelets so the platelets cannot stick to everything like they are doing with IMHA so there are more platelets that are inactive and are free in circulation
Platelets circulate inactive so they do not stick to everything, but once activated they contain a ton of tubulin to grow arms and stick to things
Vincalkaloids
Vincristine, Vinblastine, some others that we did not go over
both vesicants and used for lymphomas and can cause of peripheral neuropathy
Do not use vincristine with MDR-1 mutation dogs!!!!!
Antimetabolite drugs
Throwing something in DNA to prevent it from being able to replicate by falsely inserting a nucleotide
Examples are:
5-FU which will cross the BBB and can cause a significant neurotoxicity in cats SO DO NOT USE IT IN CATS
Also, Cytosar which is used also in neuro, crosses the BBB and is fairly well-tolerated
Tanovea- new canine only lymphoma drug, active ingredient is rabacfosadine which is a compound that accumulates in lymphoid tissues, especially rapidly dividing lymphoma cells. Once inside the cell, this medication inhibits DNA synthesis, interrupts cell division, and induces cell death.
Platin agents
Carboplatin is the main one we use, usually the p will NADIR at about 7 days but with carboplatin, the NADIR may be random throughout the protocol
Cisplatin- makes cats go splat- causes fatal pulmonary edema in cats and they will die quickly; can also cause acute GI side effects as well as renal failure
L-spar
L-asparaginase- destroys all asparagine in the patient, give it to zap the lymphoma, but do not keep giving it because will eventually become less effective
Biggest SE is can cause anaphylaxis bc the body will amount an immune response to the drug because the body sees it as foreign
Short lived, saved for patients who really need to zap the lymphoma
Palladia
Not actively trying to kill cancer cells, but rather functions to bind on the growth factor to tell it to not grow
What species has a more myelinated optic nerve head/aka optic disk?
In dogs, they are more myelinated so are paler/white
In the _____ (species) the eye vessels cross the optic disc/optic nerve head whereas in the _____ (species) they do not.
Dog; cats
Atapetal fundus
Red or orange to pale gray reflection from the fundus to reflection of the choroidal vessels
Squirrels, birds, light colored dogs with blue eyes
Do not be scared, looks like pink to red so do not assume it is hemorrhage
will still have normal vessels, optic nerve disc may be harder to visualize because blends in with the overall color of the tapetum so not as obvious with color contrast
Progressive retinal atrophy (PRA)–
Sudden night blindness first and then day time vision affected
the rods are impt for night time vision and cones are impt for day time vision, so with this condition the rods are affected first
Inherited process, hx will be like “p losing vision at night but fine in the day time or in the light”
Age of onset is very broad
Can also happen in cats but is rare..
Signs of PRA on the ophthalmic examination
hyperreflective of tapetum (and is very thin), reduced to absent PLRs, retinal vessel attenuation (can hardly see the vessels), optic n./optic disc atrophy, +/- cataracts
can do electroretinography (ERG) but is not very variable because if we see the following signs and the hx matches then we are over 99% sure we know it is PRA so do not want to waste owner’s money
Is there genetic testing for testing for genetic PRA?
yes
What is optic neuritis?
inflammation of the optic nerve
it tells you there is another underlying cause of it (neoplasia, trauma, infectious, immune mediated, idiopathic etc.)
they will have bilateral mydriasis (very large pupils) with no PLR/menance/ etc. will have normal ERG because retina is not the problem, but the nerve itself is the problem, do full PE and look for infection and offer MRI and CSF tap if all normal on PE and infectious testing
pupils are fixed and dilated and may or may not have changes of the tapetum
prognosis for the vision to return to normal is guarded to poor even with Tx
what is an ERG electroretinogram?
Like ECG but for the eye, testing the retina to see if the retina is functioning, tests action potentials within the retina of the eye
optic nerve atrophy notes:
will be dark since myelin decreased to absent and optic nerve will be smaller and gray/darker than normal
Causes are usually Glaucoma, PRA, orbital disease
Sudden acquired retinal degeneration syndrome (SARDS)
Sudden loss of vision, over weeks to months with variable degree of vision and PLR, initial absence of ophthalmoscopic lesions but further down with chronicity of the disease will have retinal degeneration seen on the fundic examination
SARDS signalment overrepresented
Middle aged, overweight female, +/- PUD/PD, mini schnauzers, britany spaniels, dachshunds, poodles, looks like they have cushing’s with hx (and may have it! test for it if necessary!), unknown cause and unsure why it looks/coincides with cushing’s disease
Normal vs SARDS ERG
Normal is a normal peaked waveform and SARDs is a flat line on ERG because retina is no longer functional at all anymore so no signal/action potential generated
Currently no tx for SARDs and we are unsure what causes it……
Chorioretinitis
And How to tell the difference between active and inactive lesions:
infectious sequala lesions, usually something systemically infectious causes it; active lesions have unclear boarders and inactive lesions have sharp borders (scarring of the chorioretinal space)
Tx is to tx the underlying cause
Inactive is usually gray and paler with well defined margins
How to tell between inactive and active chorioretinitis/retinal scarring?
inactive has sharp borders and active lesions have splotchy. splattered borders
retinal detachment
multiple causes:
Can be infectious/uveitis, trauma, neoplasia, hypertension
how to tx hypertensive retinopathy
ID and tx underlying causes (CBC chem UA BP), calcium channel blockers, systemic AND topical steroids to prevent secondary uveitis
Where do TCC mets first and most commonly?
carcinoma so goes to lymphatics and goes to sublumbar LN and remember CARCINOMAS can mets to the bone and form metastatic carcinomas of the bone and TCC will mets to the vertebrae
TCC signs with neuro signs also means likely….
Has TCC that met to the vertebrae because it has metastatic carcinoma onto the vertebrae (can even happen without urinary signs)
Oliguria
abn small amounts of urine
Pollakiuria
frequently trying to urinate
Breeds overrep for TCC
Scottish terriers (Scotties) and Shetland sheepdogs (shelties)
How to do traumatic catheterization if you do not want to do FNA?
pass red rubber urinary catheter, suck all the urine out, place the holes at the end of the urinary catheter to the sides of the tumor and suck back a lot with neg pressure to try to get some of the cells of the urinary tumor to exfoliate into the holes of the urinary catheter and put on slide and examine
“Field effect”
Carcinomas are made of epithelial cells that are not firmly attached so they will float around like a snow globe and can seed that way, which is called the field effect
TOC for TCC’s? What is the MST?
Piroxicam (COX-2 inhibitor) and vinblastine (first choice), or Mito or Carboplatin; 9 months
can you throw any COX-2 inhibitor to a carcinoma in a last ditch effort for carcinoma patients?
yup, may not work but worth the try. Can use any COX-2 inhibitor as long as the p will tolerate it, most studies have been done on Piroxicam but can use others as long as the p tolerates it well.
What is the retinal vascular pattern of the dog and cats?
Holoangiotic
what is the retinal vascular pattern of the horse?
Porangiotic – they do not have a lot of vessels in their retinas
What dog breed is predisposed to anterior lens luxations?
Small Terriers jack russel terriers
You have a 7 year old FS basset hound presenting for acute blindness. What are two clinical signs that you would expect to see with acute primary angle closure glaucoma in this breed?
Increased IOP more than 25mmHg and mydriases/buopthalmous/ mid range pupil, may also have third eyelid elevation
What are two contraindications for using atropine or a similar drug to dilate the eye?
Anterior lens luxation, glaucoma, retinal detachment
What drug do you use to decrease IOP?
Latanoprost because it’s a prostaglandin analog, it constricts the pupil and lowers IOP (one of the strongest glaucoma drugs **ONLY to use in PRIMARY glaucoma that is truly hereditary glaucoma in dogs). It is nicknamed “uveitis in a bottle”
one bacterial organism known to cause keratomalacia- aka melting corneal ulcer?
Pseudomonas is the most common but strep and others can do it also
A dog has normal direct PLR and normal consensual PLR from right to left, but has no direct PLR in the left eye with no consensual PLR from left to right. Where is this lesion?
There is a retinal/optic nerve issue- this is pre-chiasmal because anything before the optic chiasm crosses is just innervating one eye but if it crosses the optic chiasm then both eyes are affected
Who is predisposed to pannus (two breeds to list):
GSD is the most common and second most common is Greyhounds
What is the most common eyelid tumor in horses, cows, and cats?
SCC
§ What is the most common eyelid tumor in the dog?
MGA is the most common
What are some causes of cataract formation?
Dog most common is genetics, second most common is secondary to DM
Cats and horses is secondary to uveitis most common or secondary to trauma
what are some diagnostics you would perform for hyphema? What is Hyphema?
Hyphema is blood and the anterior chamber and you should perform:
Blood pressure, coag panel, medicine work up basically
What is the most likely systemic disease associated with complete retinal detachment in a cat?
Systemic hypertension– usually from chronic kidney disease and/or hyperthyroidism
What retinal diseases may sometimes be associated with pu/pd, obese patients, polyphagia?
SARDs aka sudden acquired retinal degeneration, can become acutely blind, no TX at all, usually presents like it has Cushing’s disease
What are the common causes of red eye?
There are seven of them that we discussed
Uveitis, trauma, glaucoma, KCS, corneal ulceration, conjunctivitis, immune mediated episcleritis where the body attacks the scleral tissue and eye becomes red and inflammed
Where is the tapetum located anatomically?
Superior
What are two differentials for pigments spots on a cat’s iris?
Melanosis (great prognosis) and melanoma
What are the four stages of a cataract?
○ Incipient <15%
○ Incomplete or immature is 15%-99%
○ Mature is 100%
○ Hypermature is more than 100% and is worse severity
Signs for Horner’s Syndrome and how to test for it—>
Prolapsed 3rd eyelid, miosis (small pupil), ptosis (drooping of the eyelid), enophthalmos
Give phenylephrine to test what order it is in, like level of the ear or not and if it is in the ear then should respond within 30 minutes
What type of tonometer is the tonopen?
Applanation
What type of tonometer is tonovet?
Rebound tonometer
What are the uveal structures?
iris, ciliary body, choroid
what is the choroid
layer of blood vessels between the sclera and the retina
Histiocytic sarcoma vs histiocytoma notes
Solitary histiocytomas can under spontaneous disappear within 6 weeks and multiple histiocytomas within 10 months. Histiocytic sarcomas are malignant (cancerous) soft tissue sarcomas that arise from histiocytic cells (eg macrophages and dendritic cells) which are a part of the immune system
Spontaneous chronic corneal epithelial defects (SCCEDs) aka ____ ____ aka ____ ___
Boxer ulcers; indolent ulcers
grid keratotomy notes
Use 25 G needle, you should not be able to see the scratches onto the epithelium with the naked eye, success rate is approximately 80%
Tx of non-healing ulcers in cats
usually secondary to feline herpesvirus-1 infection, do cotton swab debridement or keratectomy DO NOT do grid keratotomies because it may predispose the, to sequestrum formation (we are still unsure whether or not to use diamond burr in cats)
corneal sequestrum (in cats specifically) characteristics:
stromal collagen degradation, accumulation of brown pigment, tx is surgical keratectomy with graft if needed
what is the number one SE with cyclosporin in cats and dogs?
GI upset
Why is it called HemangioSARCOMA and not carcinoma because carcinoma is the endothelium, lining of the blood vessels?
Because HSA is sarcoma of the connective tissues around the blood vessels, NOT the lining of the blood vessels (endothelial cells)
pulmonary edema is inside of the lungs
pleural effusion is outside of the lungs
Why do you have some resp. signs with HSA of the right heart?
because there will be pericardial effusion and cardiac tamponade (which is a medical or traumatic emergency that happens when enough fluid accumulates in the pericardial sac compressing the heart and leading to a decrease in cardiac output and shock)
The definition of an acantholytic cell is ______
A keratinocyte that has lost its normal cohesion and is round in shape
Is demodex canis contagious???
Nopeee
The most common trigger for erythema multiforme in dogs and cats is what???
Drug reaction
What is the most common cause of feline miliary dermatitis?
Allergic skin disease
What are some of the major differences b/w canine & feline lymphoma?
feline LSA is usually low-grade, immunotype doesn’t effect prognosis, peripheral lymphadenopathy is rare, & cats have bimodal age distribution
What are risk factors for feline lymphoma?
retrovirus infection (FeLV/FIV),
male cats,
siamese/oriental breeds,
cigarette smoke,
chronic inflammation
Which chemo drugs are vesicants?
tanovea,
vincristine (all vinca alkaloids)
mustargen - severe,
doxorubicin - severe
What unique toxicity is associated with Tanovea?
grade 5 pulmonary fibrosis
avoid in Westies or any dog w/ known/suspected pulm fibrosis. Monitor w/ serial thoracic rads
What is the most important diagnostic test for SARDS?
ERG - will be a flat line
8 yr NM lab presents for sudden decrease in vision and has trouble navigating outside at night. On PE you note absent menance, weak dazzle/PLRs, and an immature cataract OU. What is your presumptive dx?
PRA
5yr FS dachshund presents for acute blindness. She’s unable to navigate around her house & is bumping into walls. She has been PU/PD for several weeks and you note she is rather chunky. PE reveals absent menace, positive PLRs, and she fails a maze test. What is your presumptive dx & what test will you run to confirm it?
SARDs, if you do a ERG you will see a flatline and that will be confirmatory
5yr NM Terrier mix presents for being acutely blind this AM, acting lethargic, & not wanting to play with his fav toy. On PE there is absent menace OU, incomplete PLRs, a faint dazzle, and he fails a maze test. You perform an ERG and it’s normal. What is your dx?
Optic Neuritis
this is an ER
What 2 C/S that are associated with acute glaumoa are NOT associated with other causes of red eye very often?
midrange pupil,
sluggish PLR
What is the most common cause of secondary glaucoma?
Uveitis
What is the most common c/s associated w/ anterior vs posterior uveitits?
anterior= aqueous flare
posterior = retinal detachment
How does the time of spaying a dog affect their risk of mammary carcinoma?
0.5% risk if spayed before 1st heat cycle
8% risk if spayed before 2nd heat cycle,
26% risk if spayed before 3rd heat cycle
What glands are commonly invovled in canine mammary carcinoma?
4th and 5th
What is a sentinel lymph node?
first lymph node to which cancer cells are most likely to spread from a primary tumor
Where do the canine cranial mammary glands drain?
Axillary +/- sternal LN’s
Where do the canine 3rd mammary glands drain?
axillary, inguinal, +/- medial iliac LN
Where do the canine caudal mammary glands drain?
inguinal +/- medial iliac LN
What makes inflammatory mammary carcinoma different?
diffusely affects entire chain/inguinal area w/ erythema, edema, heat/swelling & has a MST 30-60d
How does time of spay affect the risk of feline mammary carcinoma?
<6mo = 91% reduction in risk,
>2y = no reduction in risk
T/F: Majority of canine mammary tumors are malignant, while only half of feline mammary tumors are malignant.
FALSE - 50% canine are malignant, 85-95% feline are malignant
What is the TOC for canine vs feline mammary tumors?
canine = surgery
feline = bilateral chain mastectomy + chemo
A Lab presents for a dental and your tech finds a smooth, well-marginated tumor on the gum line. You tell the tech this is most likely benign and arises from _________.
periodontal lig
acanthomatous ameloblastoma (epulis)
What are risk factors for feline oral SCC?
flea collars,
high consumption canned food/tuna,
cigarette smoke
What is the tx of choice for feline SCC?
sx + radiation
*considered chemo-resistant
What drugs can be used to stimulate tear production?
cyclosporine & tacrolimus
What drugs can be used for tear support?
sodium hyaluronic acid & methylcellulose
What are common reasons for a non healing ulcer?
exposure, infection, FB, herpes, KCS, distichia/ectopic cilia, chemicals
How do you know a corneal infection is present preventing healing of an ulcer?
stromal loss, corneal malacia, hypopyon/corneal cellular infiltrate, purulent discharge
How do you know a corneal infection is present preventing healing of an ulcer?
stromal loss, corneal malacia, hypopyon/corneal cellular infiltrate, purulent discharge
What is the most common cause of cataract formation in horses & cats?
Uveitis
What breed is most likely to get an anterior lens luxation?
Jack Russel Terrier
a three year old Cocker Spaniel named Chloe presents for their annual vaccinations. While there, the owner mentions that Chloe seems really anxious at night in the backyard. You ask him to explain further and he says that Chloe will not wander far from him in the dark. Then once Chloe wanders away, she seems unable to find her way back to the house. Yesterday, she even ran into a pole in the yard.
During ophthalmic exam you notice very sluggish PLRs and the tapetum is very, very reflective.
What would you diagnose this dog with? What treatment should you start?
Progressive Retinal Atrophy (PRA)
no treatment exists
A poodle breeder calls to consult about breeding two of her show-winning poodles. She is worried about progressive retinal atrophy (PRA) and asks if she is able to predict what, if any, puppies would be affected with this condition?
perform a blood screening/genetic test on the parents
perform an animal eye certification (OFA)
A 12 year old chihuahua named Wally comes into the clinic after being dropped by his 8 year old human-sister. Wally was dropped two days ago and its unclear how he hit the ground. The sister said he fell on his chest and face. The owner said he seemed pretty normal for a day or so, but now he isn’t able to catch his treats anymore. Once the owner noticed this, she felt she should bring Wally into the vet, just to make sure he is ok.
On ophthalmic exam, Wally fails his maze test and his pupils are fixed and VERY dilated. What condition should you suspect Wally has?
Optic neuritis secondary to trauma
optic neuritis is a clinical symptom from another disease process. What disease processes can cause a secondary optic neuritis?
infectious disease
inflammation (GME or CNS reticulosis)
neoplasia
trauma
idiopathic (50%)
how does optic nerve atrophy look during a direct ophthalmic exam?
what conditions can cause optic nerve atrophy?
the optic nerve loses myelin and appears grey to white in color
glaucoma, PRA, orbital disease, optic neuritis
Ellie, a 8 year old obese female Dachshund, comes into an emergency clinic on a Saturday night. Her owner is in a panic and explains Ellie has become acutely blind.
You perform an ophthalmic exam and realize the owner is right. Ellie is completely blind clinically. However, her fundus looks completely normal during direct ophthalmoscopy.
What condition should you suspect?
Sudden Acquired Retinal Degeneration Syndrome (SARDS)
feline allergic disease
-feline disease of presumed allergic etiology have some comparable to canine atopic dermatitis
feline atopic syndrome
-allergic dermatitis associated with environmental allergens, food allergy, and asthma that may be associated with IgE antibodies
feline atopic syndrome reaction patterns
-miliary dermatitis
-self inflicted alopecia/hypotrichosis
-eosinophilic granuloma complex
most common bacteria seen with secondary infections in cats
-staph pseudointermedius
treatment of feline atopic syndrome
-steroids
-atopica for cats
-apoquel off label
Allergen specific immunotherapy in cats
-only therapy that targets the immune system to alter response to allergens
contributing factors for atopic dermatitis
-bacterial infections
-malassezia dermatitis
-concurrent allergic skin diseases
-psychogenic factors
age of onset of atopic dermatitis
-4 months to 7 years
-breed predilection and familial history
allergy testing
-not a tool for diagnosing atopic dermatitis
-used to identify allergens for immunotherapy
diagnosis of atopic dermatitis
-clinical diagnosis with characteristic clinical signs
when should intradermal testing be done
-duration of clinical signs over 3-4 months
-seasons becoming longer or symptoms worsening
-recurrent otitis and/or recurrent infections
-owner desires
considerations for intradermal testing
-animal should be at least 1 year old so that it is exposed to all seasons
-do not do if skin is really bad
-consider if the owners want to pursue allergen specific immunotherapy
A mixed breed dog named Lola presents for her routine bloodwork one week post chemotherapy session. The owner reports she behaves normally at home and has been doing well.
However, her bloodwork shows neutropenia and thrombocytopenia. What adverse effect does this reflect?
bone marrow suppression
T/F: sensitivity to one chemotherapy drug does NOT predict sensitivity to another
True
A four year old Collie named Ollie is visiting for his first round of Vincristine to treat his B-cell lymphoma. What special considerations should you take into account considering his breed, diagnosis, and drug?
breeds affected with MDR-1/ ABCB1 mutation have the inability to appropriately process and excrete some chemotherapies, including Vincristine, Vinblastine, Vinorelbine, and Doxorubicin
other breeds affected: whippet, Australian Shepard, sheepdog, windhound
A golden retriever named Champ comes into the clinic 1 week after receiving his first dosage of Vincristine at MSU-CVM. His owner reports that Champ has a normal energy level and the chemo hasn’t slowed him down at all! He is eating and drinking normally. His temperature was normal. However, when you take a look at his CBC, his neutrophils were at 900.
How would you handle this situation?
broad spectrum oral ABX (cefpodoximine) for 5-7 days
send home
avoid dog parks, groomers, etc until neutrophil count recovers
A boxer named Zazu visits your clinic 4 days post doxorubicin administration as treatment for his lymphoma. His owner is extremely concerned, because Zazu is lethargic, off food, and has intermittent diarrhea. During his physical exam, you see that he has a 104 F.
How would you handle this situation?
fever or other clinical signs, plus neutropenia, is a reason to hospitalize
aseptic catheter placement for IV fluids and ABX
pantoprazole or omeprazole
discharge decision should be based on patient condition, NOT CBC
average hospital stay is 3-5 days
an owner calls and informs you that their dog, Zazu, requires a CBC 1 week following his last chemotherapy treatment. His chemo-discharge says that Zazu should receive a CBC 7 days following his chemotherapy, but his owner is unable to get him into the clinic that day. He can either come 1 day early or 1 day late, which would be better?
better to check early than late
one day early or one day late can make a huge difference
T/F: if your clinic is unable to receive same day results for neutrophils for chemo patients, you can check granulocytes instead
TUREE
A young GSP named Sam comes back from his hunting bootcamp (approximately 8 weeks) and his owner noticed Sam seems slightly lethargic, but otherwise normal. The owner is concerned maybe he contracted something while at boot camp, espeically because the bootcamp workers forgot to give Sam his monthly preventatives.
On physical exam, you notice generalized lymphadenopathy. What are your rule outs for generalized lymphadenopathy in the South East?
what additional differentials would you include if you were NOT in the South East?
Ehrlichia
Blastomycosis
Lymphoma
Salmon poisoning (west coast, usually very ill)
leishmania
a dog with generalized lymphadenopathy usually does NOT have
A non-specific bacterial infection DO NOT just throw some abx at it
when would it be inappropriate to prescribe a dog with lymphoma prednisone?
you don’t have a confirmed diagnosis / there are more tests you want to run
it’s going to be more than a few days before patient starts chemo
prolonged pred use makes future chemo less effective
when would it be appropriate to prescribe a dog with lymphoma prednisone?
you have a confirmed diagnosis / any other diagnostic testing has been completed
patient will NOT get chemo
patient starts chemo in a few days
T/F: dogs commonly have peripheral lymphadenopathy when they are diagnosed with lymphoma, while cats do not
TRUE
in cats with lymphoma, peripheral lymphadenopathy is uncommon to rare
what are risk factors for feline lymphoma?
Retrovirus
Male cats
Siamese/oriental breeds
cigarette smoke
chronic inflammation
what is the treatment of choice for feline nasal lymphoma?
radiation (median survival time 1.5-3 years)
what drug class are vincristine and vinblastine?
anti-miotics
what drug class is carboplatin?
Platinum Analogs
What drug class are cyclophosphamide, chlorambucil, and CCNU?
Alkylating agents
what drug class are doxorubicin and mitoxantrone?
Topoisomerase II inhibitors, technically abx
when is tanovea contraindicated?
West highland terriers
grade 5 pulmonary fibrosis
what is the MOA of vinca alkaloids?
inhibits microtubules formation
what chemo drug is a vesicant and causes peripheral neuropathy?
Vincristine
by which route are round cell tumors MOST likely to metastasize?
via blood
by which route is carcinoma MOST likely to metastasize?
Lymphatics
a 9 year old FS Cocker Spaniel presents for generalized lymph node enlargement. On abdominal ultrasound, the spleen has a “honeycomb” appearance. The dog is quiet and depressed during the exam, and the owner reports she has not been eating well recently. Results of a CBC and serum chemistry are unremarkable. Cytologies of the spleen and right popliteal lymph node both return as high grade lymphoma.
What stage is this?
Stage 4b
what is the most important initial therapy for a cat that has been diagnosed with an injection site (vaccine-associated) sarcoma?
Radical sx excision
what anatomic areas of a dog is melanoma most likely to be aggressive?
anal gland
maxillary gingiva
nail bed/digit
an approximately 8 year old female spayed cat is presented to you for a mammary mass. She was adopted from a shelter two years ago, spay was performed at the time of adoption. On exam today, there is a 2 cm mass in the left 6th mammary gland. the remainder of the physical exam is unremarkable. Punch biopsy of the mass diagnoses a mammary carcinoma. Which of the following treatment plans will maximize the chance of a good long-term prognosis for this cat?
bilateral chain mastectomy, followed by chemotherapy
a 10 year old Collie is assessed at your clinic for unilateral epistaxis of of one month duration. Physical exam is unremarkable except for reduced air flow through right nostril. The dog’s PCV is 30% and TP is 5.6 g/dl. the platelet count is 200,000/ul and PT/PTT are at the high end of the normal range. What is the most likely cause of this dog’s epistaxis?
Nasal Adenocarcinoma
a cat is presented to your clinic with a cutaneous mass that is 4 mm in diameter. Cytology of the mass shows cells with a round nucleus and abundant purple cytoplasmic granules. What is the most likely diagnosis?
Mast cell tumor
All causes of hypertension in digs and cats
Hyperthyroidism, hyperaldosteronism, chronic kidney disease, HCM =in cats
Basically any endocrine disease = Dogs
a dog comes into the clinic and fails the maze test horribly. You suspect he may be blind, but has normal PLRs. What do you make of this?
he is blind
animals with cortical disease can have normal PLRs
T/F: eyes with negative PLRs can be visual
True!!!
define the following terms:
Emmetropia:
myopia:
hyeropia:
emmetropia: normally focused, light accurately focuses on the retina
myopia: nearsightedness, light focused in front of the retina
hyperopia: farsightedness, rays of light focused behind the retina
what breeds of dogs are predisposed to SARDS?
mini schnauzers
Brittany spaniels
Dachshund
poodles
mixed breeds
what are the causes of canine chorioretinitis?
distemper, fungi, autoimmune
what are the causes of feline chorioretinitis?
FIP, FeLV, Toxoplasmosis, fungi
what are the underlying causes of secondary hypertensive retinopathy?
renal failure
hyperthyroidism
high-salt diet
atherosclerosis
HCM
catsway more frequently than in dogs
How can you differentiate persistent pupillary membranes and synechia in a young animal?
PPM = persistent pupillary membrane, congenital abnormality, the iris is still circular/normal shaped
synechia = pupillary margins adhering to cornea, this often changes the shape of the iris
atropine
mydriatic agent
reduce pain and risk of synechia
don’t use in cases of KCS-induced ulcer or glaucoma
Where does the herpes virus lay dormant?
Trigeminal ganglion
what can cause a false-negative during fluorescein staining?
indolent ulcer
stain is not concentrated enough
corneal edema
epithelialized deep stromal ulcer
descemetocele
what can cause false-positives during fluorescein staining?
mucous
touch stain strip to cornea instead of sclera
where your Schirmer tear test touched cornea
a young golden named Tucker presents for a corneal ulcer. His owner said they have recently gotten a new kitten and the two have been rough-housing.
How should you treat this uncomplicated corneal ulcer?
E-collar
Atropine 1-2x daily until dilation occurs
Systemic NSAID (Carprofen)
Topical ABX 2-3x daily (NeoPolyBac)
recheck in 5-7 days
what are common reasons for non-healing ulcers in dogs?
canine herpes virus
endothelial degeneration (bullae)
cholesterol/calcium degeneration
distichia & ectopic cillia
KCS
SCEEDS
what are common reasons for non-healing ulcers in cats?
feline herpesvirus
corneal sequestrum
what are common reasons for non-healing ulcers in dogs and cats?
exposure
neurotrophic keratitis
progressive infections
foreign bodies
chemical induced
shampoos
what is the common clinical presentation of a corneal infection?
stromal loss
corneal malacia
hypopyon
corneal cellular infiltrate
purulent discharge
what are the criteria for a chronic, non-healing ulcer that should be sent to a referral center?
perforated
greater than 50% stromal loss
progressive despite aggressive medial management
what are the three ways oral antibiotics reach the cornea?
corneal blood vessels
tear film
aqueous humor
A Doberman named Maverick comes into the clinic for chronic eye irritation. You notice several hairs growing from the conjunctiva and irritating the eye. What condition is this and how should you treat it?
ectopic cillia
use punch biopsy (not full thickness)
remove punch fully with tenotomy scissors and Bishop Harmon forceps
leave open - no sutures
a bulldog puppy named Uga comes into the clinic because both of his eyes seems chronically irritated. It appears the lower eyelids of both eyes are turned or tucked inward toward the globe and irritating it. What condition is this and how should you treat it?
entropion
need permanent surgical repair
a middle-aged bulldog named Uga was previously diagnosed with entropion and had a corrective surgery to remedy the problem. However, the resection left Uga unable to close his eye completely. What condition does this create and how should it be treated?
exposure keratitis
treat like KCS > cyclosporine, tacrolimus, refresh PM
what is the mechanism of action of glaucoma?
blockage of aqueous humor outflow pathway >
intraocular pressure increases ( >25 mmHg) >
continously increased IOP causes damage to retinal ganglion > damages optic nerve >
blindness
a middle-aged Poodle named Dolly comes into the clinic because her eyes look “like they hurt” and she is very lethargic.
On exam, you notice that her eyes are diffusely red and blepharosparmic and she has a midrange pupil with a sluggish PLR. His intraocular pressure in her right eye was 84 mmHg, but her left eye is normal.
What condition do you suspect Dolly has?
acute canine glaucoma / “Canine Primary Glaucoma”
primary angle closure glaucoma (PACG) aka “Canine Primary Glaucoma” in dogs is a bilateral disease, so the other eye will likely develop a pressure spike at some time. It rarely presents in both eyes at the same time.
how can you treat primary glaucoma in canines?
- latanoprost
- dorzolamide
- timolol
what is the mechanism of action of Latanoprost?
increases aqueous humor outflow
strongest drug we have against glaucoma, ONLY to be used in primary glaucoma
does NOT work in cats
prostaglandin analog
what is the mechanism of action of Timolol?
prophylactic use that can lower IOP slightly
should NEVER be used alone in a glaucomatous eye
what are the vision sparing procedures for glaucoma?
what are the salvage procedures?
placement of valve or shunt
cyclophotocoagulation
enucleation
evisceration and prosthesis
how can you differentiate between nuclear sclerosis and a cataract on physical exam?
you will be able to obtain tapetal reflection without interreference with retro illumination
you will NOT be able to obtain tapetal reflection with cataracts
what is the classification system of cataracts?
classification is based on opacity, location, underlying etiology, and age of onset
incipient <15%
immature 15-99%
mature 100% (lack tapetal reflection)
hypermature - resorption/break down occurs
what are common causes of cataracts?
hereditary/genetic (labs)
trauma
nutritional (taurine deficiency in cats)
diabetic development
secondary to uveitis and its sequelae
T/F: cataract development implies poor management of diabetes
FALSE
blindness can occur regardless
what are the treatment options for cataracts?
surgery is the only option
phacoemulsification
extracapsular lens extraction (ECLE)
intracapsular lens extraction (ICLE)
what are the two categories of lens-induced uveitis?
phacolytic: leakage of lens proteins through intact capsule into aqueous
phacoclastic: rupture of lens capsule
how do you treat lens-induced uveitis?
same principles as uveitis
treat underlying conditions and topical steroids (if no corneal perforation)
how would you treat anterior lens luxation?
intracapsular lens extraction (gold standard)
transcorneal lens reduction/ couching with long term latanoprost treatment
what are the layers of the cornea in order from outside to inside?
epithelium
stroma
Descemet’s membrane
endothelium
which of the following are 2 procedures that can be used for spontaneous chronic corneal epithelial defects (SCCEDs)?
diamond burr debridement
grid/superficial keratotomy
what organism is commonly associated with keratomalacia (melting of the cornea)?
pseudomonas
which of the following are the 2 most common breeds predisposed to chronic superficial keratitis (pannus)?
German Shepard, greyhound
you have a 7 year old female spayed Basset Hound present for acute blindness. On ophthalmic examination, you note cornea edema, a fixed midrange pupil, trace aqueous flare, and an elevated third eyelid. What is the most likely diagnosis?
acute glaucoma
a 4 year old male neutered lab presents to you for “blood in the eye”. You diagnose hyhema. After performing Schirmer tear test, IOP, and fluorescein stain, what other diagnose test would be most appropriate next steps?
CBC, coags, Snap 4Dx
