Ophthalmology Review Flashcards

Question

# ophthalmic exam (rankin) Jones Test

Answer 1

* Evaluates patency of nasolacrimal system * Apply fluorescein stain to ocular surface rinse * Hold nose down and examine nostrils * Examine oral cavity * Normal passage \< 5 min

Answer 2

* Tear quality assessment * Moisten strip with saline and apply to cornea * Do NOT rinse * Blink eyelids * Hold lids open and monitor for “dry spots” * Normal tear break up time \>20 seconds

Answer 3

* Aqueous humor leakage * Corneal lacerations * Ruptured ulcers * Surgical incisions * Apply fluorescein * Do NOT rinse * If leaking aqueous humor will create a “river”

Answer 4

* Measures intraocular pressure * Normal 15-25 mmHg * Applanation * Tono-Pen® * Induction impact * Tonovet ®

Answer 5

* Conjunctival hyperemia * Extensive branching * Extraocular disease * Episcleral Injection * Radial pattern from limbus * Dark red * Intraocular disease * Subconjunctival hemorrhage * Difuse red * Trauma/bleeding disorder

Answer 6

* Fluorescein stain * Schirmer tear test * don't do for deep ulcer * Intraocular pressure * don't do for deep ulcer * +/- Conjunctival cytology * +/- Aerobic culture and sensitivity

Answer 7

* Rarely infectious!!!!!! * Usually secondary to other abnormalities * Entropion, ectropion, trichiasis, eyelid tumors… * Tear film abnormalities-keratoconjunctivitis sicca (KCS) * Irritants-chemicals, dust, smoke…. * Bacteria can frequently be cultured at low numbers from NORMAL conjunctiva * *Staphylococcus , Streptococcus , Cornyebacterium , and Bacillus spp.*

Answer 8

* Treat the underlying cause * Broad spectrum topical antibiotic QID * Topical corticosteroids (hydrocortisone) * Fluorescein negative!!! * If no response to therapy * _Re-evaluate diagnosis_

Answer 9

* Typically seen in young dogs * Lymphoid follicles bulbar surface of the nictitans * Etiology-immune mediated, allergic, chronic irritation…. * Treatment-topical steroids +/- topical antihistamines (olopatadine)

Answer 10

* Usually infectious!!! * Do NOT use topical steroids! * Feline herpesvirus 1 FHV-1 * Chlamydia * Mycoplasma * Calicivirus * Eosinophilic conjunctivitis

Answer 11

* Most common cause of feline conjunctivitis * Seroprevalance up to 97% of cats * \>80% of cats that recover are carriers * Approximately ½ of the carriers shed under normal conditions * Corneal ulcers/keratitis * Latency occurs in trigeminal ganglion * URI * Kittens most susceptible * Short lived in the environment \<18hrs * Virus is inactivated by most disinfectants * Sneezing carriers the virus approximately 4 feet ## Footnote **DON'T USE TOPICAL STEROIDS IN CATS**

Answer 12

* _Clinical signs!!!!_ * Conjunctival cytology * Intranuclear inclusions, PMNs * PCR - sensitive and specific * IFA - insensitive * Fluor. stain may cause false + * Serology (serum neutralization titer) insensitive * Virus isolation * Definitive dx for acute infection * Insensitive for chronic infection

Answer 13

* Most recover in 10-21 days * Which cases should you treat? * _Moderate to severe conjunctivitis_ * _Corneal disease_

Answer 14

* Topical and systemic antiviral medications * Oral lysine * Decrease stress

Answer 15

* Cidofovir 0.5% solution * Compounding pharmacy * 2 times daily * Idoxuridine 0.1% solution * Compounding pharmacy * 4-8 times daily * Trifluridine 1% solution * Refrigerated * Topically irritating * 4-8 times daily

Answer 16

* Famciclovir * BID * NOT the same as valacyclovir! * Lysine * BID * Give with food

Answer 17

Continue therapy for at least 1 week after resolution of clinical signs

Answer 18

* URI in young cats * Chemosis usually begins unilaterally then bilateral * Follicles with chronicity

Answer 19

* Cytology * Intracytoplasmic inclusion bodies * Days 3-14 * PCR

Answer 20

* Oral medication * \*\*Doxycycline (kittens over 4 weeks of age) * Esophageal stricture * Azithromycin * Pradofloxacin * Treat for at least a month * Ideally at least 2 weeks beyond resolution of clinical signs * Topical medications QID * In addition to oral therapy * Tetracycline ( Terramycin ®) * Erythromycin * Recurrence common * Zoonotic - rarely

Answer 21

* Mycoplasma felis and M. gatae * Opportunistic * Conjunctival pseudomembranes * Diagnosis * Cytology-small cytoplasmic basophilic inclusion bodies * Culture in special media * PCR test for M. felis * Pathogenicity * Questionable * Isolated from normal cats

Answer 22

* Topical medications QID * Tetracycline ( Terramycin ®) * Fluoroquinolones * Oral medication * Doxycycline (kittens over 4 weeks of age) * Esophageal stricture * Pradofloxacin * Duration of therapy * At least 2 weeks

Answer 23

* URI * Oral and nasal ulceration * Polyarthritis * Low pathogenicity for conjunctiva * Topical antivirals are ineffective * RNA virus * Supportive care

Answer 24

* Chronic superficial keratitis * Most common * _German Shepherds_ * Greyhounds * Dobermans * Pigment and vascularization * Starts _laterally_ * Higher altitudes * Bilateral disease * NONPAINFUL!!!!!! * Atypical pannus * Third eyelid * Depigmented and follicles

Answer 25

* Life long treatment!!!! * Treat aggressively initially then taper * Topical steroids * Prednisolone acetate 1% * Neopolydex (0.1% dexamethasone) * 3-4 times daily * Topical cyclosporine A or tacrolimus * Taper medications * Control with CSA or tacrolimus

Answer 26

* Blepharospasm * Rubbing * Epiphora * Elevated third eyelid * “Red * Reflex uveitis * Miosis , aqueous flare, hypopyon, fibrin, photophobia

Answer 27

* Examine eyelids and conjunctiva * Palpebral reflex * STT * Fluorescein staining * Examine posterior TEL * Cytology * Culture and sensitivity

Answer 28

* Corneal blood vessels * 3-5 days to begin to grow * ~1mm/day * Is it superficial or deep?

Answer 29

* Depth * Corneal malacia * Cellular infiltrate * Pain * Purulent ocular discharge * Hypopyon

Answer 30

* If greater than 50% depth or severe infection: * Surgical therapy recommended: Conjunctival graft, corneoconjunctival transposition, corneal transplant, amnionic memebrane graft referral

Answer 31

Do NOT place a third eyelid flap…it only covers up the cornea and prevents you from observing the ulcer…

Answer 32

* Broad spectrum antibiotic * Neomycin/bacitracin/polymyxin B ointment Neomycin/bacitracin/ gramacidin solution * Tobramycin ophthalmic solution * Treat T-QID * Mydriatic therapy * Treat “reflex uveitis” * Topical 1% atropine (SID or BID) * Do not use if decreased tear production or glaucoma * Drops vs. ointment? * Hypersalivation (especially in cats) * Analgesic/anti-inflammatory therapy * DO NOT **_EVER_** USE TOPICAL STEROIDS OR TOPICAL NONSTEROIDAL MEDICATIONS * Delay corneal wound healing * Predispose to infection * Potentiate enzymatic destruction of the cornea * Systemic NSAIDS * Analgesic therapy * Codeine * Tramadol * Prevent self trauma * Elizabethan collar!!!!

Answer 33

* Recheck in 5-7 days * If the ulcer has not healed * Change the diagnosis…not the antibiotic!!! * If the ulcer has not resolved * Underlying cause * Ulcer is infected * Indolent ulcer

Answer 34

* Antimicrobials - based on culture/sensitivity * Antimicrobials - based on cytology * Cocci - cefazolin 5%,chloramphenicol * Rods - ofloxacin, gentamicin, tobramycin * Use q 1-2 hrs initially and decrease as infection resolves * Use drops if the ulcer is deep or if perforation is a possibility…the petrolatum vehicle in ointments causes severe inflammation inside the eye * Anticollagenase agents * Decrease stromal melting * Serum/plasma * Autologous/ homogolous /heterologous * Treat q 1-2 hrs initially * Keep refrigerated for up to 2 weeks * Others: EDTA, N-acetylcysteine , ilmostat , tetracycline antibiotics * Topical atropine1% SID or BID * Oral antibiotics * Clavamox or enrofloxacin * Oral anti-inflammatory/analgesics * ELIZABETHAN COLLAR AND RESTRICT ACTIVITY! * Recheck in 24 hours

Answer 35

* Spontaneous chronic corneal epithelial defect * BOXERS * Middle/older age dogs * Chronic * Epithelial lip * Fluorescein ‘leaking’

Answer 36

* _Remove loose epithelium_ * Topical anesthetic * Dilute providone-iodine soln. * Sterile eyewash * Debride with sterile cotton tipped applicator * ~4 0% will heal * Need to remove ALL loose epithelium * Usually need to go several millimeters past fluorescein positive area * Grid / diamond burr keratotomy **(NOT IN CATS)** * ~85 90% success rate

Answer 37

* Topical broad spectrum antibiotic T QID * Topical atropine 1% (SID to BID) * Elizabethan collar * Oral analgesics/NSAIDS if needed

Answer 38

– American Cocker Spaniel – Basset Hound – Chow Chow – Shar Pei – Boston Terrier – Fox Terrier, Wire – Norwegian Elkhound – Siberian Husky (43 breeds)

Answer 39

– Blepharospasm – Nictitating membrane protrusion – Red eye – Cloudy eye – Mydriasis – Decreased vision

Answer 40

– Red eye (episcleral injection) – Corneal edema (blue) – Mydriasis – Lens subluxation/luxation – Painful!!! (blepharospasm) – Buphthalmia – Retinal and optic nerve changes – Decreased vision

Answer 41

* Breed related * **Always** bilateral * “Good” eye will be lost in median of 8 months * With prophylactic therapy, median time to onset of glaucoma is 31 months

Answer 42

– Less than 24 hours old – Potential for vision?

Answer 43

– \>\>24 hours old – Buphthalmia (big, blue…..

Answer 44

* Goals – Save or regain, and maintain vision – Achieve and maintain comfort * Control of intraocular pressure – Target “safe” level – Avoid progressive optic nerve and retinal damage with associated visual deficits

Answer 45

Treat aggressively if chance for vision!!! Referral * Emergency treatment – Topical prostaglandin analogues - Latanoprost 0.005% (Xalatan®) - Travaprost 0.004% ( Travatan ®) – Topical carbonic anhydrase inhibitors - Dorzolamide 2% ( Trusopt ®) - Brinzolamide 1% ( Azopt ®) – Beta blocker - Timolol 0.5 & 0.25% - Betaxolol 0.5% * Hyperosmotic agents – Dehydrate vitreous – Last about 6-10 hours – IV mannitol - Dosed at 1-2 grams/kg - Administered slowly over 20 30 minutes – Glycerin - 1-2 g/kg orally - May produce emesis – Withhold water for 4 hours * Contraindications – Renal disease – Cardiovascular disease – Dehydration – Diabetes (glycerin) – Other debilitating disease * Ophthalmologist referral * Maintenance therapy – Latanoprost 0.005% q12 to 24 hr – Dorzolamide 2% q6 to 8 hr – Timolol 0.5% q12 hr * \*\*Treat the “normal – Timolol 0.5% q12 hr * Frequent IOP checks for monitoring of BOTH eyes – 1 day, 3-5 days, then weekly, monthly, q2 to 3 months

Answer 46

* Irreversibly blind (duration \>72 hours) * Buphthalmic (big, blue…blind) – Except puppies * Absent dazzle reflex * Absent consensual PLR to fellow eye * Palliative procedure – Enucleation – Evisceration – Chemical ablation

Answer 47

* Topical prostaglandin derivatives * PGF2α derivatives – Latanaprost 0.005% (Xalatan®) – Travoprost 0.004% ( Travatan ®) – Increase uveoscleral outflow – Species specific - Causes miosis but does not lower IOP in cats - Ineffective in horses – Used SID (in evening) or twice daily * Carbonic anhydrase inhibitors – Dorzolamide 2% ( Trusopt ®) – Brinzolamide 1% ( Azopt ®) – TID to QID treatment – Decrease aqueous humor production – May be topically irritating - Dorzolamide pH 5.6 vs brinzolamide pH 7.5 – Oral CAI rarely used due to systemic side effects * Sympatholytic agents (adrenergic antagonists) Beta blockers – 0.25% & 0.5% Timolol (ß1 and ß2), Betaxolol (ß1)BID – Inhibits ß receptors on ciliary epithelium – Decrease aqueous humor production – May also increase aqueous humor outflow – Mild miosis – Potential adverse effects - Bradycardia - Exacerbation of asthma in cats - Mild decrease in tear production * Cholinergic miotics _– Direct-acting parasympathomimetic agent_ ▪ 2% pilocarpine _– Indirect-acting parasympathomimetic agent:_ ▪ 0.25% or 0.125% demecarium bromide (compounded) – Increase aqueous humor outflow – Usually not effective alone – Contraindicated in uveitis and anterior lens luxation – I do _NOT_ recommend using topical pilocarpine (too irritating!) – Demecarium bromide for prophylactic therapy SID ▪ Often administered with topical steroid SID

Answer 48

Treat the underlying problem! – Lens luxation - refer for surgery if still visual – Uveitis - treat the inflammation – Intraocular neoplasia - enucleation? – Hyphema - determine cause of hyphema

Answer 49

Increase aqueous humor drainage Decrease aqueous humor production

Answer 50

* Gonioimplants – Tube in AC drains fluid to subconjunctival space – Fibrosis leads to early failure * Filtering procedures: – Creating holes in iris, sclera, ciliary body – Low success rate in veterinary patients

Answer 51

* Destruction of ciliary body – Cyclophotocoagulation-diode or YAG laser - Transcleral - Endolaser * Both - postoperative pressure spike, cataract formation, inflammation * Can perform both cyclophotocoagulation and gonioimplant at the same time…increase “success” rate to 58% visual in 1 year

Answer 52

Corneal ulcers – Geographic – Dendritic – Stromal keratitis

Answer 53

* **CLINICAL SIGNS!!!!** * If it is a cat and it has a corneal ulcer…. * Conjunctival cytology * Intranuclear inclusions, neutrophils * PCR – sensitive and specific * IFA - insensitive * Fluoroescein stain may cause false positive * Serology (serum neutralization titer) - insensitive * Virus isolation * Definitive dx for acute infection * Insensitive for chronic infection

Answer 54

* Cidofovir 0.5% solution * Compounding pharmacy * 2 times daily * Idoxuridine 0.1% solution * Compounding pharmacy * 4-6 times daily * Trifluridine 1% solution * Viroptic® and generic * Refrigerated * Topically irritating to most patients * Topical antibiotic- to prevent bacterial infection

Answer 55

* Famciclovir * 250 mg or 125 mg tablets (Famvir ®) * 30-40 mg/kg B-TID po * Do NOT use valacyclovir * Lysine * 250 mg po BID in kittens * 500 mg po BID adult cats * Give with food

Answer 56

* Globe rupture * Symblepharon

Answer 57

Generally older cats (\>10years) Present with dilated pupils or vision loss

Answer 58

* Idiopathic – 20% * Chronic kidney disease – 19% to 65%of cats * Hyperthyroidism – 10% to 20% * Diabetes mellitus * Primary aldosteronism * Pheochromocytoma * Chronic anemia

Answer 59

* Diagnostics – Systolic blood pressure \> 160 mmHg – CBC/chemistry panel/UA/T4 * Treatment – Treat underlying condition – Antihypertensive medication - Amlodipine (0.18-0.22mg/kg PO SID, 0.625mg PO SID) - Goal BP \< 150 mmHg * Prognosis for vision?

Answer 60

* Acute retinal degeneration * 1997 label dosing changed from 2.5mg/kg BID to 5-20mg/kg as a split or single dose * May occur even at recommended dose (2.5mg/kg BID) * Especially in cats with impaired drug metabolism (renal/hepatic dz.) * IV administration of enrofloxacin may increase risk of retinal toxicity * In most cases the blindness is permanent * Use enrofloxacin if no other alternative * Use only the lowest dose/shortest amount of time

Answer 61

* Most common feline primary intraocular tumor * Malignant melanocytic neoplasm * Slow, progressive, often multifocal areas of pigmentation of the iris * Secondary glaucoma from involvement of the iridocorneal angle

Answer 62

* Monitor for progression – Photos or drawings in the medical record – Recheck at 2-4 months intervals * Diode laser ablation??? * Enculeation – Thoracic radiographs – Abdominal US

Answer 63

**• Exophthalmos** • Enophthalmos • Strabismus **• Elevated third eyelid** • Pain on palpation of periorbital area • Pain on opening mouth • Exposure keratitis

Answer 64

* Normal sized globe displaced anteriorly/rostrally within the orbit * Due to increased orbital volume * Numerous causes * **Neoplasia, abscess/cellulitis**, hemorrhage, vascular anomaly, mucocoele, cyst, myositis, etc.

Answer 65

_proptosis_ (an eye that is protruding outside the orbit, usually due to trauma) _exophthalmos_ (an eye that is pushed forward relative to its normal position, but is still in the orbit) _buphthalmos_ (an enlarged, glaucomatic globe)

Answer 66

* Normal sized globe displaced posteriorly/caudally within the orbit * Due to globe retraction, decreased orbital volume or pressure anterior to the equator of the globe * Numerous causes * **Pain**, muscle wasting, loss of orbital fat, **Horner’s syndrome**, orbital fractures, dehydration, extraocular muscle fibrosis, adnexal neoplasia

Answer 67

* Inflammation of the orbital tissues +/- abscess * Signalment and history • Young animal, acute onset, compatible history (“stick chewer”) • Possibly hyporexic or decreased chewing/aversion to hard food * Clinical signs and findings • Exophthalmos +/- lagophthalmos • Elevated third eyelid • Injected conjunctival and episcleral vessels • Resistant to retropulsion +/- painful • Pain on periorbital palpation, yelps when mouth opened! • Febrile

Answer 68

* Immune-mediated inflammation targeting temporalis, masseter, and pterygoid muscles * Type 2M myofibers * Breed predisposition: * Golden and Labrador Retrievers * German Shepherds * Weimeraners * Clinical signs: * Acute onset bilateral exophthalmos, painful and restrictive jaw movements, fever, lethargy, anorexia * Diagnosis: 2M antibody test, compatible clinical signs * Treatment: systemic immunosuppression

Answer 69

* Origin • Primary from any orbital tissue • Invasion from adjacent structures • Metastasize from distant site * Signalment and history • Generally older patients • Slowly progressive changes * Clinical findings • Unilateral exophthalmos • Elevated third eyelid • Decreased retropulsion • Scleral indentation on fundic exam • Usually **NOT PAINFUL**

Answer 70

* Diagnostics * Complete physical exam * Thoracic radiographs (met check) * Orbital ultrasound * CT/MRI for lesion localization and surgical planning * FNA/biopsy of lesion * Treatment * Orbitotomy and mass excision (Referral) * Exenteration or radical orbitectomy * +/- Radiation therapy and/or chemotherapy * Enucleation or exenteration may also be performed as a palliative measure * Euthanasia if advanced disease * Prognosis * Guarded to poor * Survival time increases with early diagnosis and surgical therapy * Less than 1 year in dogs, ~ 1 month in cats

Answer 71

* Think **inflammatory** disease… • If younger animal • If painful • If rapid onset • If febrile * Think **neoplasia**… • If older animal • If slow onset * If bilateral…think myositis or multicentric neoplasia (lymphosarcoma) * But not all patients read the textbooks!!

Answer 72

* Globe moves anterior and eyelids become “trapped” behind equator * True ophthalmic emergency!!! * Caused by trauma * HBC, dog fight, kicked by horse * Degree of trauma needed to cause proptosis varies * Most common in brachycephalic dogs * Shallow orbit and large palpebral fissure * Minimal trauma needed (even exam restraint can be a cause!) * Prognosis very poor in horses, cats, and dolicocephalic dogs * Severe trauma necessary

Answer 73

* Ocular lubricant & E-collar * KY Jelly, artificial tears, eyewash, Vaseline, cooking oil, etc. * Complete physical exam – assess for other injuries * Complete eye exam * Decide whether to enucleate or surgically reposition eye * 3 enucleation criteria: * 3 or more EOMs torn * Optic nerve transsected * Globe (cornea and/or sclera) ruptured

Answer 74

Globe replacement * General anesthesia * Prep * Keep eye lubricated! * Carefully clip eyelid hair * Cleanse area with dilute betadine solution * ~1:50 dilution: 5 ml 5% betadine in 250 ml saline * Not betadine scrub or chlorhexidine – toxic to cornea

Answer 75

* Medications • Oral antibiotic • Oral NSAID • Topical antibiotic • Topical atropine • Pain meds as needed * E-collar * Keep area clean * Rechecks • Remove sutures in 2-3 weeks • Staged removal?

Answer 76

* When in doubt, replace the globe • You can always take it out, but you can never put it back! * Prognosis • Good in general if brachycephalic and minor trauma • Guarded for vision with intraocular hemorrhage • Pupil size is not an indicator of prognosis • But if direct or consensual PLR present, prognosis is good • Vision prognosis varies (~20% have some vision) • Better prognosis for saving globe • Many owners value globe for cosmesis

Answer 77

* Assess and treat the whole animal * Keep eye moist! * Rapid globe replacement if possible * When in doubt, replace the globe!

Answer 78

* Surgical removal of globe, third eyelid & gland * +/- silicone orbital prosthesis

Answer 79

* Removal of intraocular contents and placement of a silicone prosthesis in corneo-scleral shell * Contraindicated in cases of neoplasia/infection

Answer 80

* Removal of globe and all orbital contents * Generally performed for orbital neoplasia

Answer 81

* **Indications: surface ocular infection or neoplasia** * Suture eyelids closed * Incise skin around lids and dissect down to sclera, then work posterior

Answer 82

* Remove globe and all orbital soft tissues • VS. enucleation (fat/muscle left behind in orbit) • Transpalpebral approach • Routine skin closure * Used in cases of extensive neoplasia * Submit tissues for histopathology

Answer 83

* Clinical signs of orbital disease: * **Exophthalmos** * **Third eyelid elevation** * Orbital inflammation **(abscess/cellulitis) occurs in young dogs, is acute & painful, and results in fever, leukocytosis** * Orbital neoplasia **occurs in older dogs, is non-painful and slowly progressive** * Ocular proptosis **is a true ophthalmic emergency** * **When in doubt, always attempt replacement with tarsorrhaphy** * Enucleation **involves complete removal of globe and adnexa** * Evisceration **is a cosmetic alternative to enucleation** * Exenteration **is necessary in cases of advanced orbital neoplasia**

Answer 84

• _Entropion_ – inversion of the eyelid margin • _Ectropion_ – eversion of the eyelid margin • Combination of entropion and ectropion – “diamond eye” – Bloodhound, Clumber Spaniel, St. Bernard, Great Dane, etc.

Answer 85

• Clinical signs – Pain and squinting (blepharospasm) – Excessive tearing (epiphora) • Corneal sequelae – Ulceration – Vascularization – Pigmentation – Fibrosis

Answer 86

* _Anatomic entropion_ * Young dogs * Breed-related • Shar Peis, Retrievers, Chow Chows * _Spastic entropion_ * Lid spasm associated with pain (foreign body, corneal ulcer, etc.) * Vicious cycle! * \*Evaluated by use of topical anesthetic * _Cicatricial entropion_ * Less common * Associated with previous surgery, trauma, or chronic inflammation of eyelids

Answer 87

Eyelid tacking – Young animals and spastic entropion – Non-absorbable Lembert-type (interrupted) sutures – Leave in for 3 weeks .…or longer – Replace as necessary

Answer 88

• Anatomic (in mature animals) • Hotz-Celsus procedure – How much skin to remove??

Answer 89

– Normal facial hairs that contact the cornea/conjunctiva – Ex. **Entropion**, Nasal folds, Medial caruncle

Answer 90

– Hairs emerge from Meibomian gland openings – Sometimes cause problems

Answer 91

– Hairs emerge through the palpebral conjunctiva – Very commonly cause problems (i.e., ulcers!)

Answer 92

* Nasal fold trichiasis – Nasal fold excision * Medial canthal trichiasis or caruncular hair – Medial canthoplasty or local cryotherapy * Entropion – Temporary or permanent surgical correction

Answer 93

en bloc excision +/- cryotherapy

Answer 94

* _Hordeolum (stye)_ – **painful** suppurative infection of eyelid glands of Zeis or Moll * _Chalazion_ – firm, **non-painful** swelling of Meibomian gland caused by accumulation of lipid secretions and granulomatous reaction

Answer 95

* More common in older animals * **Canine – ~80% of eyelid tumors are benign** * *• Meibomian gland adenoma most common** * **Feline – most are malignant** * *• SCC** * Equine – SCC most common, sarcoid second * Bovine – SCC * Therapeutic goal – destroy tumor while preserving eyelid function and cosmesis

Answer 96

* Primary/anatomic entropion **requires permanent surgical correction in adult animals** * Spastic entropion should be treated with **temporary correction** * Entropion is the most important example of **trichiasis** * *– Others include nasal fold, facial hair, lacrimal caruncle** * Distichiasis and ectopic cilium represent **cilia abnormalities arising from the Meibomian glands** * *– Ectopic cilia are more likely to lead to corneal ulceration** * Dogs are most commonly affected by **benign Meibomian gland adenomas** * Eyelid tumors in cats are more often **malignant (squamous cell carcinoma)**

Answer 97

* \*Quantitative = KCS – Keratoconjunctivitis sicca – Decreased aqueous tear production * Qualitative – Disorder of mucin or lipid tear components – Causes tear film instability * Result in desiccation and inflammation of the ocular surface

Answer 98

* Tear stimulation – lacrimostimulants * Tear replacement – lacrimomimetics * +/- supplemental therapy – Secondary bacterial infections * Client education – Must use medications as often as directed – May take a month or more to see STT improvement – Tear stimulant therapy is _lifelong_! * Parotid duct transposition surgery option

Answer 99

* Cyclosporine A * Optimmune® 0.2% ointment * *Compounded* 1% or 2% drops or ointment * Tacrolimus * *Compounded* 0.02% or 0.03% formulations * 10-100 times more potent than CsA in vitro * T cell inhibitors with anti-inflammatory, anti-pigment, and possibly anti-fibrotic effects * Use BID _for life_! * _Reputable compounding pharmacy is important_ * Cholinergic agent (Pilocarpine) * Indicated in cases of neurogenic KCS resulting from parasympathetic denervation * Dilute topical (0.125%, compounded) or _very careful_ oral dosing * Warn owners of side effects! * **S**alivation * **L**acrimation (desired!) * **U**rination * **D**efecation

Answer 100

• Tear replacements or _substitutes_ • Many OTC products – Choose one with increased viscosity (not ‘rewetting drops’) • Use 4-6 times daily+ – While tear production is decreased – Ointments can be used before bedtime

Answer 101

* Saliva is used to lubricate the cornea in place of tears * Recommended if medical therapy fails • Must give adequate time for medical therapy response * Frequent small meals fed post-op to stimulate salivation * Complications possible • Mineral deposition • Moist dermatitis • Sialolith/sialocele * Most still need medications post-op

Answer 102

* Abnormality in mucin or lipid layer of tear film * Clinical signs * Conjunctival hyperemia and dull appearance to the corneal surface * Keratitis consisting of variable pigmentation, edema, multifocal areas of fluorescein stippling or erosions * With normal STT * Marginal blepharitis, meibomianitis, chalazion * Both cause and clinical sign * Corneal ulcers possible (but less likely) * Signs may be _subtle_

Answer 103

* Normal aqueous production (STT 15-25 mm/min) * Lipid deficiency * Inspect Meibomian glands/secretions * Mucin deficiency * \*\*Tear film breakup time\*\* * Apply fluorescein dye * Normal * \>20 sec dogs * \>17 sec cats

Answer 104

* Clinical signs * Mucopurulent discharge, epiphora, swelling or draining fistulas in medial canthal region * Typically **no blepharospasm**, minimal conjunctival hyperemia * Usually secondary to foreign bodies but rarely find them * Treatment: repeated NL flushing, topical antibiotic + steroid solution * May require surgery if FB is identified Purulent discharge from lower lacrimal punctum

Answer 105

* KCS is the most commonly diagnosed tear film abnormality in **dogs** * Major third eyelid abnormalities include **prolapsed NM gland and scrolled cartilage** * When epiphora is diagnosed, **increased production vs. inadequate drainage must be determined** * Dacryocystitis is **an uncommon problem, generally resulting in purulent ocular discharge without blepharospasm**

Answer 106

* Treat cause if known (Specific) * In most cases the cause is not known…. (Symptommatic) Goals of therapy 1. Decrease inflammation 2. Relieve pain 3. Prevent complications of uveitis

Answer 107

* Common clinical signs of anterior uveitis: **– Aqueous flare, miosis, hypotony** * Inactive posterior uveitis = **chorioretinal scars (tapetal hyperreflectivity)** * There are many possible causes of uveitis in small animals – Most common diagnosis = **idiopathic** * Treatment goals for uveitis include **decreasing inflammation, relieving pain, and preventing complications/sequelae**

Answer 108

• Cataract = opacity in the lens or capsule • Classification – Etiology – Age of onset – Location in lens – Stage of development • Patient with a cataract should have a normal PLR and dazzle reflex!

Answer 109

* The optimal stage for cataract surgery is **immature (vision impairment but no LIU)** * Cataracts are **opacities that block light**, but nuclear sclerosis is **an expected aging change that causes hardening of the central lens (decreased accommodation)** * Anterior lens luxation is **an ophthalmic emergency** * Lens subluxation and posterior luxation are often managed medically with **miotics**

Answer 110

– _Bilateral_ -- progressive loss of vision--blindness – _Decreased night vision_ (nyctalopia) usually first sign – Progressive decrease in PLR – Larger than normal resting pupil size • Owner will sometimes report increase in “eye shine” – Cataract formation in very late stages

Answer 111

• SARDS-_acute_ photoreceptor death • Usually middle aged to older dogs; female overrepresented • All breeds affected • Associated clinical signs – May have ‘Cushing’s-like’ signs for weeks or months _prior to_ vision loss

Answer 112

– _Acute_ vision loss – Variable PLR • Chromatic PLR • Red light – • Blue light + – Fundic exam **• NORMAL initially** • Chronic cases – Retinal degeneration

Answer 113

* Diagnosis: * Electroretinogram (ERG) * May have elevated ALP, or other Cushing’s-like changes on blood work; less commonly diagnosed with Cushing’s via traditional screening tests * No proven treatment-permanent blindness * Emphasize quality of life as blind pet

Answer 114

* _Retinal tear_ present which allows liquefied vitreous to enter subretinal space * Primary **ocular disorder** (previous cataract surgery, inherited vitreal degeneration, etc.)

Answer 115

* Remains attached at ora ciliaris retinae & optic disc * Serous sub-retinal fluid-bullous retinal detachment * Exudative retinal detachments-inflammatory or exudative sub-retinal fluid * **Systemic disease**

Answer 116

• Depends on type of sub-retinal fluid/material • Exudate (cloudy or discolored, yellow) – Same as chorioretinitis (i.e., posterior uveitis) → suspect systemic infection • Transudate (clear) – A.k.a. bullous **– \*Hypertension** – Hypoproteinemia – Idiopathic (steroid responsive?) • Dog specific

Answer 117

* Always perform **a systemic work-up** in animals with non-rhegmatogenous retinal detachments – CBC/chemistry panel/urinalysis – Blood pressure – Chest radiographs – Titers/antigen tests if any suspicion of infectious cause

Answer 118

• Only appropriate for rhegmatogenous detachments • Laser retinopexy – 2 rows of burns around detachment to create adhesions – Prophylactic vs. barrier • Retinal reattachment

Answer 119

* = Optic neuritis * Unilateral or bilateral * Can involve any segment of optic nerve (intraocular vs. retrobulbar) * Associated with sudden blindness, fixed and dilated pupils

Answer 120

• CBC, chemistry panel, urinalysis • Titers/antigen tests for infectious organisms • Chest radiographs • MRI or CT scan • CSF tap \*Think of optic neuritis as a **neurologic disease!**\*

Answer 121

* Referral? * Treat primary cause * Systemic steroids (immunosuppressive dose) * Oral antibiotics (empiric) * Prognosis for vision = _poor_

Answer 122

* 3 hallmark signs of retinal degeneration: * *– Tapetal hyperreflectivity** * *– Retinal vessel attenuation** * *– Optic disc pallor** * SARDS results in **sudden blindness with a normal ophthalmic exam (ERG needed to definitively diagnose)** * Rhegmatogenous retinal detachments are due to **primary ocular disease** * Non-rhegmatogenous retinal detachments are due to **systemic disease** * Optic neuritis is **a neurologic disease!**