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NEU2 > Small animal ophthalmology > Flashcards

Small animal ophthalmology Flashcards

Conjunctivitis and keratoconjunctivitis sicca, feline ophthalmology

1
Q

Describe the anatomy of the conjunctiva

A
  • Thin transparent pink mucous membrane
  • Starts at limbus and covers globe (bulbar conjunctiva) and lines inner aspects of upper/lower eyelids (palpebral conjunctiva)
  • Space formed called conjunctival sac
  • Lines both sides of third eyelid
  • Fornix is the “u-turn” of conjunctiva
  • Freely mobile apart from attachments at the limbus and eyelid margin
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2
Q

Describe the physiology of the conjunctiva

A
  • Rich vascular supply to allow rapid healing
  • Sparse nerve supply
  • Provides the only lymphatic drainage of the eye
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3
Q

Describe the appearance of the CALT

A
  • Conjunctival associated lymphoid tissue

- Appears as little follicles, roughened areas of conjunctiva

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4
Q

Describe the nervous supply of the conjunctiva

A
  • Supplied by CNV ophthalmic brnach
  • Easy to anaesthetise with topical anaesthetic
  • Facilitates minor surgery e.g. conjunctival biopsy
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5
Q

Describe the common clinical signs of acute conjunctivitis

A
  • Uni or bilateral
  • Hyperaemia (conjunctival redness)
  • Chemosis
  • Swelling or thickening
  • Mild irritation e.g. mild blepharospasm
  • Discharge (lacrimation)
  • Pruritus may be seen in allergic conjunctivitis and may lead to self trauma
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6
Q

Describe the potential appearance of discharge in conjunctivitis

A
  • Mucoid
  • Purulent
  • Mucopurulent
  • Haemorrhagic
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7
Q

Describe mucinosis in Shar Pei dogs

A
  • Mimics chemosis but is normal for breed

- Muzzle also looks swollen

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8
Q

Describe medial canthal pocket syndrome

A
  • Normal variation in dolicephalic breeds
  • Have naturally deep set eyes
  • Mucus accumulates at medial canthus, should be flushed away naturally but does not occur properly in these breeds
  • No treatment indicated, can flush with contact lens solution every few days
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9
Q

Describe the clinical signs of chronic conjunctivitis

A
  • Hyperaemia, discharge etc. as for acute
  • Thickening (squamous metaplasia of epithelium)
  • Hyperpigmentation
  • Follicular hyperplasia
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10
Q

Describe what is meant by follicular hyperplasia

A
  • Nodule like structure representing lymphoid tissue
  • Most obvious on posterior third eyelid and in conjunctival fornices
  • Follicular conjunctivitis common in young dogs, may need treatment but often resolves spontaneously
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11
Q

List the potential aetiological agents of canine conjunctivitis

A
  • Infectious
  • Non-infectious
  • Extension from local disease
  • Secondary to another ocular disease
  • Secondary to systemic disease
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12
Q

Describe infectious conjunctivitis in dogs

A
  • Primary infectious uncommon
  • Secondary bacterial very common e.g. dry eye, abnormal eyelid conformation, often by commensal G+ve e/g/ Staph, Strep.
  • Viral infection v. uncommon e.g. canine herpesvirus-1
  • Parasitic uncommon e.g. Thelazia more common in dogs imported from eastern Europe
  • Fungal rare in UK
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13
Q

Describe the common sign of bacterial conjunctivitis

A

Purulent discharge

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14
Q

List the common underlying causes for conjunctivitis in dogs

A
  • Eyelid problem e.g. entropion, ectropion
  • Eyelash problem e.g. distichia, ectopic cilia
  • Tear film problem e.g. dry eye
  • Tear duct infection (dacryocystitis)
  • Trauma e.g FB, laceration
  • Allergic e.g. atopic dermatitis
  • Irritants e.g. smoke sand, neomycin
  • Ligneuous conjunctivitis in Doberman
  • Radiation induced
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15
Q

What is entropion and how is it treated?

A
  • Inturned eyelid
  • Surgical treatment
  • Removal of elliptical piece of skin
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16
Q

Describe ectropion as a cause of conjunctivitis

A
  • Everted eyelid margin
  • Common in St Bernards, eyelids too big
  • “Normal” in many breeds
  • If marked, can accumulate debris in sac which predisposes to infection and conjunctivitis
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17
Q

Describe distichiasis as a cause of conjunctivitis

A
  • Extra eyelashes
  • Often incidental finding but can cause conjunctivitis
  • Unlikely to be causing conjunctivitis if found at 5yo, more likely to be the cause if found at 1yo
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18
Q

Give examples of how conjunctivitis may be an extension from local ocular disease

A
  • Blepharitis eyelid inflammation)
  • Lacrimal disease e.g. cherry eye
  • Orbital disease e.g. retrobulbar abscess
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19
Q

Give examples of diseases that may have conjunctival involvement

A
  • Anaemia
  • Jaundice
  • Coagulopathy
  • Neoplasia e.g. lymphoma
  • Auto-immune disease
  • Systemic hypertension
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20
Q

List the breeds that are predisposed to cherry eye

A
  • Bulldog
  • Lhasa Apso
  • Shih Tzu
  • Mastiff breeds
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21
Q

Explain why excision is not recommended as the treatment for cherry eye

A
  • Third eyelid gland produces 1/3rd of tear volume

- Breeds predisposed to cherry eye also predisposed to dry eye

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22
Q

List the potential causes of keratoconjunctivitis sicca

A
  • Most common: immune mediated destruction of lacrimal tissue, stopping fluid production
  • Congenital: lacrimal gland aplasia/hypoplasia
  • Neurogenic: uniateral, dry eye/dry nose
  • Toxic: sulphonamide drugs
  • Endocrine disease: diabetes mellitus, hypothyroidism
  • Iatrogenic: removal of TEG, some drugs
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23
Q

List the breeds that are predisposed to KCS

A
  • WHWT
  • Pug
  • Shih Tzu
  • Bulldog
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24
Q

Describe the typical presentation of KCS

A
  • Young dog
  • Bilateral
  • Progressive
  • Recurrent conjunctivitis that improves with any topical therapy as anything lubricates eye
  • Conjunctivitis
  • Sticky discharge
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25
Q

How is KCS diagnosed?

A
  • Shirmer tear test

- Clinical signs

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26
Q

Describe the treatment of KCS

A
  • Lifelong therapy
  • Tear substitutes
  • Tear stimulations (lacrimogenic) e.g. ciclosporin 0.2% (Optimmune)
  • Broad spectrum topical antibiotic to treat secondary Staph infection
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27
Q

What is the main difference between feline and canine conjunctivitis?

A

Canine usually not infectious, feline usually infectious

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28
Q

List the potential aetiologies of feline conjunctivitis

A
  • Infectious
  • Non-infectious
  • Extension from local disease
  • Secondary to another ocular disease
  • Secondary to systemic disease
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29
Q

List the 5 primary agents of feline infectious conjunctivitis

A
  • Chlamydophila felis (bacterium)
  • Feline herpesvirus 1
  • Feline calicivirus
  • Mycoplasma felis
  • Bordatella bronchiseptica
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30
Q

Describe the presentation and treatment of feline calicivirus

A
  • TYpically upper respiratory disease, oral ulceration, polyarthritis
  • Generally do not test and treat for it as a cause of conjunctivitis
  • Anti-viral treatment ineffective
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31
Q

Describe Mycoplasma spp. as a cause of conjunctivitis in cats

A
  • Also found in normal cats
  • Diagnosis by PCR
  • Topical antibiotic e.g. tetracyclines (Doxycycline)
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32
Q

Describe Bordetella bronchiseptica as a cause of conjunctivitis in cats

A
  • G-ve bacterium
  • Affects respiratory tract of cats (and dogs) and rare zoonosis
  • Diagnosis: culture and/or PCR
  • Treatment: doxycycline
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33
Q

What 3 causes of conjunctivitis are treated by doxycycline in the cat

A
  • Chlamydophila
  • Mycoplasma
  • Bordetella
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34
Q

Describe the clinical signs of chlamydial conjunctivitis in cats

A
  • Unilateral conjunctivitis, becomes bilateral within a few days
  • Chemosis often marked, hyperaemia
  • No corneal signs, no corneal ulcer
  • Absent or mild upper respiratory disease
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35
Q

Describe the diagnosis of chlamydial conjunctivitis in cats

A
  • Clinical signs
  • Conjunctival swab for PCR
  • Culture superseded by PCR, lots of false negatives
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36
Q

Describe the treatment of chlamydial conjunctivitis in cats

A
  • Systemic treatment indicated as organism affects resp, GI and repro tract
  • Doxycyline antibiotic (5mg/kg BID or 10mg/kg SID for 3 weeks)
  • Treat all in contacts with doxy as well
  • Amoxyclav good for pregnant queens or kittens
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37
Q

What is the main side effect of doxycycline in cats?

A

Discolouration of teeth and oesophagitis

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38
Q

Describe the clinical signs of FHV-1 in kittens and youung cats

A
  • Bilateral conjunctivitis in conjunction with upper resp signs (cat flu)
  • +/- corneal ulceration
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39
Q

Describe the clinical signs of FHV-1 in adult cats

A
  • Unilateral ocular discharge with mild conjunctivitis
  • History of previous upper resp infection
  • Wide range of other conditions e.g. sequestrum entropion, eosinophilic keratitis
  • Dendritic corneal ulcer (linear ulcer) pathognomic if seen
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40
Q

How can chlamydial and herpes conjunctivitis be distinguished from one another in cats?

A

Herpes causes coneal diseas, non in chlamydial

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41
Q

Describe the diagnosis of FHV-1

A
  • History and clinical signs most important
  • Conjunctival swab for PCR test
  • NB PCR will also detect FHV-1 vaccine so less useful in vaccinted cats
42
Q

Describe the occurrence of FHV-1 conjunctivitis

A
  • FHV is an alphavirus that becomes latent and reactivates under stress
  • Hides in trigeminal ganglion on one side, leads to unilateral conjunctivitis
43
Q

Describe the treatment of herpes conjunctivitis in cats

A
  • Nursing: cleaning eyes, nutrition, rehydration is main treatment
  • Antibiotics to prevent/treat secondary bacteria infection (broad spec)
  • Topical for eyes e.g. fusidic acid, chloramphenicol
  • Systemic for resp involvement e.g. amoxyclav
  • Antivirals are ineffective but can use topical ganciclovir or systemic famcyclovir in cases of persistent ulcers, pain and severe ocular signs
44
Q

Describe the main topical ophthalmic antibiotic treatments used in dogs

A
  • Fusidic acid (Isathal): first choice, treats G+ve common in conjunctivitis i.e. staphs and streps
  • Chloramphenicol drops/ointment: broad spec
  • Other antibiotics based on culture and sensitivity
45
Q

Name the layers of the cornea from superficial to deep

A
  • Epithelium
  • Basement membrane
  • Stroma
  • Descemet’s membrane
  • Endothelium
46
Q

Explain why superficial corneal lesions are more painful than deep lesions

A

Nerve endings present in the epithelium and stroma, not further down

47
Q

Describe the pathophysiology of corneal oedema

A
  • Collagen fibrils have specific anatomical structure and arrangement which allows light rays to pass through
  • Increased water content distorts collagen fibrils which creates opacity
  • Occurs when barrier layers (epithelium and/or endothelium) are breached/dysfunctional
48
Q

Describe the pathophysiology of corneal vascularisation

A
  • Superficial or deep in-growth of blood vessels

- Promotes healing, but can increase scarring

49
Q

Describe the pathophysiology of corneal pigmentation

A
  • Non-specific response to corneal insult

- Can reduce vision

50
Q

Describe the process of healing in the corneal epithelium

A
  • Cells slide rapidly across defect within hours to days
  • Mitosis increases, reduce size of defect
  • Good at healing
  • Cells present develop micropodia and walk across cornea
  • Rarely requires treatment, antibiotics may be needed only to prevent secondary infeciton
51
Q

How long does it take for the whole cornea to epithelialise and what is the importance of this?

A

Takes 7 days - if an ulcer is not improved within a week, then this indicates an underling problem

52
Q

Describe the process of stromal healing

A
  • Only starts once defect is covered by epithelial layer
  • Regeneration from fibroblasts (weeks) and filled in with collagen
  • Vascularisation from limbus at a rate of ~1mm/day
  • Blood vessels slowly resorbed
53
Q

Describe the healing of descemet’s membrane

A
  • Elastic, limited ability to repair

- will scar over and bridge the defect, but takes time

54
Q

Describe the healing of the corneal endothelium

A

Very poor ability to repair

55
Q

List the potential causes of corneal ulceration

A
  • Trauma
  • Tear film production
  • Adnexal conditions
  • Primary corneal disease
  • Infection
  • Neurological disease
56
Q

Give conditions of tear film production that may lead to corneal ulceration

A
  • Dry eye (quantitative, common in dogs)

- Qualitative tear film problem (uncommon)

57
Q

Describe the typical appearance of corneal ulcers secondary to dry eye

A

Circular, punched out appearance, deteriorate rapidly, can be quite deep

58
Q

List adnexal conditions that may lead to corneal ulcers

A
  • Eylids: entropion, ectropion, eyelid margin mass, trauma
  • Eyelashes: distichiasis, ectopic cilia
  • Conformation: trichiasis (normal skin hairs contacting eye), lagophthalmos in brachy breeds
59
Q

Give a primary corneal disease that leads to ulcers

A

Spontaneous chronic corneal epithelial defect (SCCED)

60
Q

Give examples of infectious causes of corneal ulcers

A
  • Usually secondary to trauma
  • Bacterial keratitis
  • Fungal keratitis
61
Q

Give examples of neurological diseases that may lead to the development of corneal ulcers

A
  • Neuroparalytic keratitis

- Nerotrophic keratitis

62
Q

Describe neuroparalytic keratitis

A
  • Facial nerve paralysis
  • Unable to blink so surface of eye dry and exposed
  • May be due to ear disease/surgery e.g. TECA
63
Q

Describe neurotrophic keratitis

A
  • Reduced or absent corneal sensation
  • Trigeminal nerve problem
  • Can blink but no sensation of cornea
  • Uncommon, may be due to head trauma e.g. RTA
64
Q

Describe corneal ulcers in brachycephalic breeds

A
  • Very common
  • Always potentially serious
  • Ability to deteriorate rapidly
  • Conformation predisposes to corneal disease: shallow orbit = prominent globe, reduced blinking and poor distributionof tear film as a result of prominent globe, medial lower entropion, nasal fold trichiasis
65
Q

Give examples of breed typical conditions that predispose for corneal ulcers

A
  • Persian cat medial lower entropion: normal for breed, some cope well, others rub and get corneal ulcers in that area
  • Pekingese nasal fold trichiasis: prominent nasal fold rubs on medial corner of eye causing ulcer
66
Q

Describe the clinical signs of corneal ulcers

A
  • Increased lacrimation
  • Blepharospasm
  • Photophobia
  • Conjunctival hyperaemia
  • Ocular discharge
  • Corneal oedema
  • Reflex uveitis
67
Q

What is reflex uveitis?

A

Reflex contraction of the pupil in response to corneal injury, mediated by substance P, requires treatment

68
Q

List the parts of the routine ophthalmic exam that are relevant to the diagnosis of corneal ulcerations

A
  • Careful examination of both eyes
  • Direct observation
  • Palpebral and corneal reflex
  • ST
  • Flourescein dye
  • Corneal cytology
  • Corneal culture and sensitivity
69
Q

Name the different types of corneal ulcer

A
  • Superficial
  • Stromal
  • Desmetocoele
  • Indolent
  • Corneal facette
70
Q

Describe the characteristics of superficial ulcers

A
  • Epithelial loss only
  • Acute onset
  • Painful
  • Sharp distinct borders
  • Minimal corneal inflammatory response
  • +/- reflex uveitis
71
Q

Describe the treatment of superficial corneal ulcers

A
  • Identify and treat underlying cause
  • Prevent secondary infection by using topical antibiotics e.g. fusidic acid q12h, chloramphenicol q8h
  • Analgesia e.g. systemic NSAIDs
  • Atropine drops (single application)
  • Buster collar if rubbing eye
  • Recheck in 3-5 days, would expect healing in this time, check 1-2 days in brachy
72
Q

Describe the characteristics of stromal corneal ulcers

A
  • Loss of epithelium and stroma
  • Acute or chronic, superficial or deep
  • Fluorescein stains walls and floor of ulcer
  • Deep are complex
  • Surrounding stroma can be normal or diseased, indicated by Purkinje reflex
  • Anterior uveitis common
73
Q

Describe the characteristics of indolent ulcers

A
  • Specific type of superficial
  • Non-healing ulcer
  • SCCED/Boxer ulcer
  • Can affect any breed but common in boxers
  • Typically unilateral, can be bi and recurrent
  • Epithelial loss only
  • Indistinct, irregular border which becomes under-run with fluorescein dye
  • Usually minimal inflamm response but variable
74
Q

Explain how indolent corneal ulcers develop

A

Epithelium grows back, but does not adhere to the underlying stroma

75
Q

Outline the surgical management of indolent corneal ulcers

A
  • Debridement
  • Keratotomy or keratectomy
  • Either only debride, or debride + keratotomy/tectomy
  • All surgical options in conjunction with medical treatment
  • 85% heal within 2 weeks with debridement and grid keratotomy
76
Q

Describe the medical treatment of indolent corneal ulcers

A
  • Similar to that for simple superficial
  • Prevent secondary infectionwith fusidic acid, chloramphenicol or topical or systemic tetracycline
  • Analgesia e.g. systemic NSAIDs, tramadol
  • Atropine drops, 1-2 doses usually enough
  • +/- contact lens bandage
  • Buster collar
77
Q

Which types of ulcers are classed as complex?

A
  • Deep stromal
  • Melting ulcer
  • Desmetocoele
78
Q

Describe the characteristics of desmetocoeles

A
  • Acute or chronic
  • Complete stromal loss down to Descemet’s membrane
  • Walls of ulcer usually obvious
  • Descemet’s membrane does not stain with fluorescein so walls stained but floor black/clear
  • Ophthalmic emergency, high risk of rupture
79
Q

Describe the treatment of a desmetocoele

A
  • Intensive medical therapy following general principles: antibiotics, analgesia, atropine
  • Prompt surgery to provide tectonic support to prevent corneal perforation
80
Q

What is a melting ulcer?

A

A deep stromal ulcer, aka keratomalacia

81
Q

Describe the appearance of a melting ulcer

A
  • Acute, painful
  • Copious gelatinous discharge
  • Marked corneal oedema
  • Marked anterior uveitis (pain, miosis, hypopyon, low IOP)
  • Size and position variable
  • Edges ill-defined, rounded, soft
  • Can progress rapidly and perforate within hours
82
Q

Explain the pathogenesis of a melting ulcer

A
  • Proteinases and collagenases break down corneal stroma
  • These may be of corneal origin: epithelial cells, stromal fibroblasts, WBCs
  • Or bacterial infection: Pseudomonas spp, beta-haemolytic Streptococcus spp.
83
Q

Describe the treatment of deep ulcers

A
  • Similar treatment as simple superficial but more intensive
  • Analgesia: NSAIDs, tramadol
  • Topical atropine to effect e.g. once daily
  • Consider corneal support with contact lens, glue, or graft
  • Buster collar
  • Monitor closely +/- hospitalise
84
Q

Outline the diagnostics for complex ulcers

A
  • Corneal cytology: scrape margin of ulcer
  • Corneal swab: bacterial culture and sensitivity, fungal culture, swab margin not base
  • Care as sampling may cause corneal perforation
85
Q

Describe the specific topical treatment of melting ulcers

A
  • Assume infected until proven otherwise
  • Topical steroids cause local immune suppression and potential collagenase activity, should not be used
  • Anticollagenase therapy applied q1-2h for 24h then gradually reduce
  • Serum/plasma, serum better
  • Na+/L+ EDTA solution
86
Q

Explain the use of Na+/L+ EDTA solution in the treatment of melting ulcers

A

Chelates zinc and calcium and therefore inhibits MMPs of bacteria

87
Q

Discuss the use of N-acetyl-L-cysteine in the treatment of melting ulcers

A

In vitro good but in vivo can be useful but also can cause necrosis

88
Q

Explain the use of serum in the treatment of melting ulcers

A
  • Alpha2 macroglobulin and alpha1 antitrypsin
  • Most broad spectrum of treatment options
  • Does have epitheliotropic properties so can be used for indolent ulcers
  • Good at stopping enzyme action and stopping melting
89
Q

Describe the production and use of serum for the treatment of melting ulcers

A
  • Take blood from animal and put into plain tubes
  • Stand and allow to clot, then spin in centrifuge
  • Draw off serum
  • Can be used directly in eye or stored in syringe or dropper bottle for 3 days
  • Can use serum from one species in another, but tend to avoid using cat’s serum for one another due to risk of FeLV
90
Q

Describe the treatment of indolent ulcers in cats

A
  • Gentle debridement and contact lens
  • Do not use keratotomy and phenol
  • Keratotomy will lead to formation of sequestrum
91
Q

Describe the method for debridement of corneal ulcers

A
  • Use sterile swab
  • Apply gentle pressure and remove loose epithelium
  • May look like too much removed but only abnormal epithelium can be removed
  • Ulcer will appear large
92
Q

Describe the method for keratotomy

A
  • Debride first
  • Use 25-27G needle, bevel up
  • Hold needle parallel to corneal surface and drag across, do not push
  • Create cross-hatch of superficial lines 1mm apart
  • Clear cornea to clear cornea i.e. treat entire debrided area +1-2mm into surrounding normal cornea
  • Need to expose normal protein in stroma
93
Q

Briefly outline keratectomy in the treatment of ulcers

A
  • Specialist technique using scalpel, requires microscope

- 100% success rate

94
Q

In what conditions is

debridement and grid keratotomy indicated?

A

ONLY in superficial ulcers with non-adherent epithelium, contraindicated in all other types

95
Q

Outline the surgical treatment of complex ulceers

A
  • Conjunctival grafts from same eye, stitch into position
  • Provide immediate tectonic support
  • Provide blood supply
  • Several types
  • Best performed with magnification and microinstrumentation
  • Once healed, can trim pedicle so only have circular scar
96
Q

Describe transposition grafts in the treatment of corneal ulcers

A
  • Sliding advancement of cornea
  • Move peripheral cornea to cover the ulcer
  • Will come with conjunctiva and see paler opaque region of the conjunctiva over the iris
97
Q

List the conditions commonly affecting the feline eye

A
  • Trauma
  • Conjunctivitis
  • Herpes keratitis
  • Eosinophilic (proliferative) keratitis
  • Corneal sequestrum
  • Diffuse iris melanoma
  • Uveitis
98
Q

What are common causes of trauma in the feline eye?

A
  • Cat claw injuries
  • RTA
  • Blunt trauma to eye
99
Q

Describe the common appearance of cat claw injuries to the eye

A
  • Laceration of superficial cornea
  • Small puncture wounds +/- bleeding in anterior chamber
  • historical wounds may have iris adhesions to lens giving unusual shapes
100
Q

Outline RTAs as a cause of traumatic injury to the feline eye

A
  • Cranial trauma
  • Can lead to ocular proctosis (requires a lot of force as globe protected by rim of orbit and ocular ligament, easier in brachy)
  • Proctosed globe usually associated with brain or head injury which requires more attention than the eye
  • May require enucleation if cannot be replaced

NEU2 (23 decks)

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