Veterinary Medicine - Ophthalmology Flashcards
Name the 3 layers of the tear film and where they’re produced
Oily layer - Meibomian glands
Aqueous layer - Lacrimal glands: 2\3 produced in the upper eyelid, 1\3 in the 3rd Eyelid
Mucin layer - Goblet cells in the conjunctiva
Name common causes for third eyelid to be elevated and whether we expect unilateral or bilateral elevation
Retrobulbar disease (Abscess, Neoplasia) - unilateral
Dehydration Cachexia (Bilateral)
Pain (Unilateral if local pathology, can be also bilateral)
Define the limbus
Where 3 tissues meet: Sclera, Conjunctiva and Cornea
What are the 2 functions of the ciliary bodies?
Hold the lens
Produce the aqueous humor
Which of the retinal blood vessels disappear first in retinal degeneration
Retinal arterioles
What is the function of the tapetum
Improves night vision
Hyperreflective is indicative of..?
Retinal thinning (e.g. due to retinal atrophy, retinal scarring)
Hyporeflective retina is indicative of..?
Retinal edema (Inflammation)
Blue-colored tapetum can be seen in…?
Young puppies (2 months of age)
Retinal pigmented epithelium - dark color might suggest..? Mildly transparent (Can partially see choroidal blood vessels)..? Completely see-through (Choroidal blood vessels completely visible)..?
Dark - Dark densely colored fur.
Mildly transparent - Brighter fur color (e.g. light brown).
Transparent - Albino
What are 2 differences in the cat’s optic disc and retinal blood vessels
Optic disc is not myelinated (at least portion visible in fundoscopy)
All blood vessels start at the edge of the optic disc and not cross it (as opposed to the retinal veins which do cross in dogs)
Entropion - Clinical signs
Blepharospasm
Enophathalmus
Epiphora
Eyelid discoloration
Conjunctivitis
Corneal ulcers (Which can also lead to 2nd Uveitis)
Entropion - Why does it cause epiphora in small brachycephalic breeds?
Due to the eyelid caving in and blocking the puncta which drains the tears into the lacrimal duct. Can also be due to pain as with all breeds
Entropion - What are the 2 components of every entropion? how to differentiate between them?
Anatomic
Spastic (due to pain)
Local anesthetics
What breeds are predisposed to combined entropion-ectropion (“Diamond-shape”)?
Giant breeds
Define distichiasis
Cilia originating from the Meibomian gland
Define trichiasis
Normal eyelid cilia that turn 180 degrees towards the eye
Define ectopic cilia
Ectopic cilia that originates from the inner eyelid (upper eyelid) at 90 degrees towards the eye
Ectopic Cilia - Where is the only location it can be found at
Upper eyelid (On the inside)
Define “Stye” and how do you treat it?
Meibomitis and subsequent obstruction of the Meibomian gland.
Burst it manually -> Warm compress -> local antibiotics
Post-operative care for eyelid operations
Elizabethan collar
Systemic antibiotics
Systemic analgesia
*Systemic - because we don’t want owners to come into contact with the area that was operated on
3 DDs for “Red eye”
Conjunctivitis
Uveitis
Glaucoma
Causes for conjunctivitis in dogs
Mechanical irritation (Eyelid abnormalities such as Entropion, Distichiasis, Ectopic cilia etc., Foreign body)
Infectious diseases (e.g. Distemper, Leishmaniasis)
KCS
Allergies
Insect bites
Conjunctivitis in dogs - Treatment
Treat underlying cause (!)
Local antibiotics
Local anti-inflammatory treatment (NSAIDs\Steroids)
Causes for conjunctivitis in cats
Herpes
Chlamydia
Causes for 3rd eyelid elevation (Bilateral)
Dehydration
Cachexia
Haws syndrome (cats)
What are the 3 elements of Horner’s syndrome
Lowered upper eyelid
3rd Eyelid elevation
Miotic pupil
Define “Cherry eye”
Prolapse of the tear gland on the medial side of the 3rd eyelid
What is the most common cause for Keratoconjunctivitis sicca (KCS) in dogs
Primary - Autoimmune disease
Keratoconjunctivitis sicca (KCS) - Causes
Autoimmune disease (Most common)
Neurogenic KCS (Along with Xeromycteria Facial paralysis) - due to otitis interna
Infectious diseases (e.g. Leishmaniasis, Distemper, FHV)
Endocrine (e.g. Hypothyroidism, DM)
Drugs (e.g. TMS (irreversible), Atropine (reversible), Anesthesia)
Ocular causes: Blepharoconjunctivitis, Removal of tear glands (Inappropriate treatment of “Cherry eye”)
Keratoconjunctivitis sicca (KCS) - Infectious causes (dogs and cats)
Leishmaniasis
Canine distemper virus
Feline herpes virus
Keratoconjunctivitis sicca (KCS) - Diagnosis
Schirmer tear test
Schirmer tear test - What are the reference intervals for normal, abnormal
<5 mm\min - KCS
5 - 15 mm\min - Suspicious
> 15 mm\min - Normal
Keratoconjunctivitis sicca (KCS) - Treatment
Clean secretions
Artificial tears
Local antibiotics if indicated. Immunosuppression: 1st Line: Cyclosporine A (Excellent) 2nd Line: Tacrolimus
*In neurogenic cases - Pilocarpine (Parasympathomimetic agent)
Parotid duct transposition (Surgical)
Tear-film breakup time test - Used to diagnose what? What is the deficiency?
Qualitative KCS
Mucin layer (Produced by the goblet cells in the bulbar conjunctiva)
2 General Causes for Epiphora
Excess production (e.g. due to irritation, Pain, foreign body, Eyelid abnormalities)
Drainage block
Epiphora due to drainage block - Common causes
Congenital (e.g. Imperforate puncta, Micropuncta)
Dacryocystitis
Entropion
Tear stain syndrome - Common breeds (Dogs and cats)
Brachycephalic dogs and cats, Miniature dogs
Tear stain syndrome - Common cause in affected breeds (Dogs and cats)
Brachycephalic and miniature dogs - Entropion causes corneal irritation and medial entropion also causes blockage of the nasolacrimal duct
Brachycephalic cats - Congenital abnormal kinking of nasolacrimal duct
Epiphora - Diagnosis
Full ophthalmic exam to look for causes for excessive tear production
Nasolacrimal duct blockage:
-Florecin flushing (“Jones test”).
-Cannulation through the upper puncta (diagnostic and possibly also curative)
Corneal ulcers - What are the 2 types of vascularizations that occur in order to facilitate repair? What are their origins?
Superficial (Conjunctiva)
Deep (Ciliary bodies)
What other pathology can always accompany corneal ulcers and should require consideration and prophylactic treatment?
Anterior uveitis
Corneal ulcers - Epithelial defect - Usually doesn’t stain with florecin (Which only stains exposed stroma). How can you stain it and what is a common cause for epithelial defects in certain animals?
Rose Bengal
FHV in cats
Corneal ulcers - Desmatocoel - How would it appear with florecin staining
Only the periphery of the ulcer is stained while the center remains black (no stroma left)
Corneal ulcers - Treatment
Treat underlying cause
Local Systemic antibiotics (Depending on severity)
Inhibit proteolysis in melting ulcers (Local: Tetracycline\Serum\Plasma)
Treat 2nd uveitis: NSAIDs, Atropine.
Elizabethan collar
Contact lenses
For deep and severe ulcers: Surgical intervention (e.g. Conjunctival flap)
Why is Atropine indicated in uveitis (2nd to corneal ulcers or otherwise) - 2 reasons
Analgesia (Iridial spasms are painful)
Mydriasis (to prevent glaucoma 2nd to uveitis)
A Corneal ulcer has not started healing after 2 days of treatment. What are your next diagnostic steps
C&S (Pseudomonas? Chlamydia?)
Cytology (Bacteria? Fungus?)
Check for Boxer ulcers
2 Possible sequelas to Persistent Pupillary Membrane
Focal cataract if PPM attaches to the lens
Corneal opacity and edema if PPM attaches to the cornea
3 Common causes for diffuse corneal edema (“Blue Eye”)
Glaucoma
Anterior uveitis
Anterior lens luxation
Lipid keratopathy - How does it Look Like? What are the general causes & common DDs
Arcus Lipidosis - Crescent moon shape on the periphery of the cornea
Hypertriglyceridemia\Hypercholesterolemia: Cushing’s disease, Hypothyroidism, DM, Pancreatitis
Corneal degeneration - Causes
Ocular Inflammation (e.g. Uveitis, Keratitis)
Systemic hypercalcemia
Hypophosphatemia
Hypervitaminosis D
Uremia
Pannus - Predisposed breeds
German shepherd
Belgian Malinois
Pannus - Treatment
Reduce UV exposure
Topical steroids
Cyclosporine\Tacrolimus
Superficial Keratectomy
Anterior uveitis - causes in dogs (Bilateral)
Infectious diseases (e.g. Leishmaniasis, Ehrlichiosis, Leptospirosis, Toxoplasmosis, Canine adenovirus, Distemper, Blastomycosis, Histoplasmosis).
Idiopathic - Most common cause (~50% of cases)
Anterior Uveitis - Common causes (Unilateral)
2nd to Corneal ulcers
Trauma
Neoplasia
2nd to Cataract (Lens-induced uveitis)
Anterior Uveitis - Clinical signs
Blepharospasm
3rd Eyelid elevation (Pain)
Miosis
Conjunctival hyperemia
Corneal edema (“Blue Eye”)
Congested iris
Aqueous flare
Hypopyon, Hyphema, Fibrin, Keratic\Phakic precipitates
Posterior synechia
Anterior Uveitis - Possible complications
Iris bombe
Glaucoma
Cataract (In cats)
Anterior Uveitis - Treatment
Treat underlying cause (!!)
NSAIDs\Steroids (Depending if 2nd to corneal ulcer) - Local\Systemic (Depending on severity)
Atropine (Mydriasis, Analgesia)
Tissue Plasminogen Activator (TPA) for preventing\dissolving fibrin adhesions
Hyphema - Causes
Trauma
Uveitis
Coagulopathies (Thrombocytopenia, Thrombocytopathy, Decrease in coagulation factors)
Hypertension
Hyperviscosity Syndrome
Neoplasia
Hyphema - Treatment
Same as Uveitis: Treat the primary Issue!
Mydriatics
NSAIDs\Steroids
“Red eye” + “Blue eye” - Causes
Glaucoma
Uveitis
Normal IOP in dogs
15-25 mmHg
Which 2 animals have a relatively high amount of unconventional drainage of aqueous humor?
Horses
Cats
What are the 2 Main Differences between Primary and Secondary Glaucoma?
1) Primary - Both eyes are predisposed (might first manifest unilaterally and later become bilateral).
Secondary - Mainly unilateral disease
2) Primary - Life-long treatment.
Secondary - Treat underlying cause and glaucoma resolves
Primary Glaucoma - How long does it usually take for a unilateral presentation to become bilateral?
6-10 months
Secondary Glaucoma - Causes (Explain the mechanisms)
Lens luxation:
1) Anterior - Lens blocks the drainage directly)
2) Posterior - The Vitreal body bulges out and blocks the drainage.
Uveitis:
1) Inflammatory infiltrate and debris accumulates and blocks the drainage
2) Posterior Synechia
Neoplasia
Glaucoma - Diagnosis
Tonometry (Measures IOP)
Gonioscopy (Examine both eyes!)
Glaucoma - Clinical signs
Fixed dilated pupil (due to retinal damage or damage to the pupillary constrictor muscle)
Buphthalmus
Pain
Episcleral injection (“Red eye”)
Corneal edema (“Blue eye”)
Striate Keratopathy
Lens luxation
Retinal atrophy
Glaucoma - Low IOP in end stage glaucoma - How can that be possible?
High IOP eventually destroys the ciliary body which produces the aqueous humor - leading to a drop in IOP
Glaucoma - When a dog presents with a unilateral presentation - What is the most important thing to remember
If it is suspected to be primary - don’t forget to treat the other eye as well!
Glaucoma - Treatment (Medical)
*Mannitol (In acute crisis)
PGF2a analogues (Increases unconventional drainage)
Carbonic Anhydrase Inhibitors (Inhibits production of aqueous humor)
Beta blocker (Decreases blood flow to the eye)
Pilocarpine (Parasympathomimetic - Opens the Angle)
Which is worse - Exophthalmos or Proptosis?
Proptosis
The eye’s equator is beyond the equator of the orbit
Proptosis (Prolapse) - Which has a worse prognosis - Dog or Cat
Cat
Proptosis (Prolapse) - Which has a worse prognosis - Brachycephalic or non-brachycephalic breeds?
Non-brachycephalic
Proptosis (Prolapse) - What is the surgical procedure performed in cases of lateral strabismus
Medial Canthoplasty
Proptosis (Prolapse) - First aid until reaching the vet
Keep the globe wet with Vaseline\Wet towel
What is the gold standard for diagnosing the cause for Exophthalmos?
Imaging - US CT
What is the gold standard for diagnosing Buphthalmus?
Tonometry (IOP Measurement)
Exophthalmos - 2 Main causes
Retrobulbar abscess
Retrobulbar neoplasia
Ocular Retropulsion - A technique used to differentiate between which 2 pathologies? Explain the possible results of the test
Exophthalmos and Buphthalmus (Glaucoma)
If the eye is successfully pushed back -> Buphthalmus
If not -> Exophthalmos - due to a retrobulbar mass
Retrobulbar Abscess - 2 Main causes
Foreign body
Oro-Ocular fistula
Exophthalmos - Acute and painful = ? (AbscessNeoplasia)
Retrobulbar abscess
Exophthalmos - Chronic and not painful = ? (AbscessNeoplasia)
Retrobulbar neoplasia
Cataract - What endocrine disease causes cataract in dogs?
Diabetes Mellitus
Cataract- What are the 4 stages of cataract
Incipient - Focal opacity
Immature - Involves most of the lens but Tapetal reflection can still be seen
Mature - Lens is completely opaque
Hypermature - Lens starts to break down
Cataract - At which stage of maturity does Lens-induced uveitis usually starts?
Mature
Cataract - In which stage of maturity is it best to operate on?
Immature
Cataract - What disease is closely genetically linked to hereditary cataract
Progressive Retinal Atrophy
Cataract - What are the 4 considerations before performing cataract surgery
1) Maturity stage (Best - Immature)
2) Retinal function (Verify with ERG)
3) Concurrent diseases (e.g. Lens-induced uveitis, DM)
4) Owner compliance (Post-op care for Lens-induced uveitis)
Cataract - What are the main complications for untreated cataract (Also untreated post-op cataract)
Uveitis -> Glaucoma -> Phthisis Bulbi
Lens-luxation - Causes
Hereditary
Trauma
Age
Uveitis
Glaucoma
Anterior Lens Luxation - 3 Prominent clinical signs\Complications
Acute pain
Corneal edema
Glaucoma (Posterior lens luxation can also cause it if vitreous bulges out)
*Glaucoma can either be a complication of lens luxation or the cause of it.
Lens Luxation - What is a good prophylactic treatment for lens sub luxation. Why?
PGF2a analogue (e.g. Latanoprost)
Causes miosis (In addition to increasing unconventional draining) - So that if the lens ultimately luxates - it will luxate posteriorly (which is the better outcome)
What are the 3 characteristics of hereditary retinal disease
Chronic progressive onset
Loss of night vision first
No additional neurological\systemic clinical signs
What are the 3 characteristics of secondary\acquired retinal disease
Acute onset
No difference between night\day vision
Additional neurological\systemic clinical signs
If the funduspupil can not be visualized (e.g. Hyphema) - What 2 tests (part of the ophthalmic exam) assist in assessing retinal function
PLR (Consensual)
Dazzle reflex
Positive PLRDazzle reflex = The animal can see (TF)
False
1) Theses are sub-cortical reflexes and said animal can still have cortical blindness
2) Very minimal amount of light is required for positive results
Arrange in the proper order of execution when performing an ophthalmic exam: IOP Measurement, STT, PLR, Tropicamide Administration. Explain the reasoning
1) STT
2) IOP
3) PLR
4) Tropicamide - Might affect the other 3, so administer last. 15 Minutes later - perform a fundic exam.
The blind patient - Normal ophthalmic exam + Normal PLR (Location + Causes)
Cortical lesion (e.g. MUE, Neoplasia, Infections)
The blind patient - Abnormal ophthalmic exam + Normal PLR (Locations + Causes)
Eyelids to Retina (e.g. Corneal edema, Anterior uveitis, Hypopyon, Hyphema, Cataract, Retinal degeneration, Chorioretinitis)
The blind patient - Abnormal ophthalmic exam + Lack of PLR (Locations + Causes)
Retina (e.g. Glaucoma, Retinal detachment, Proximal optic neuritis)
The blind patient - Normal ophthalmic exam + Lack of PLR (Locations + Causes)
Diseases affecting the proximal tract and optic chiasma
Distal optic neuritis
SARDS
Retinal hemorrhage - Causes
Thrombocytopenia
Thrombocytopathy
Decrease in coagulation factors
Hypertension
Hyperviscosity syndrome
Posterior uveitis
Trauma
Posterior Uveitis (Chorioretinitis) - What mainly causes it in the dog (Name the category of causes). What are the common causes in cats (Specific diseases)
Dog - Infectious diseases
Cat - FIV, FeLV, FIP, Toxoplasmosis, Idiopathic
Posterior Uveitis (Chorioretinitis) - Possible complication
Retinal bleeding edema => Retinal detachment => Blindness
Posterior Uveitis (Chorioretinitis) - Treatment
Treat underlying cause!
If not possible - Systemic NSAIDs\Steroids
Retinal Detachment - Pathogenesis (3)
1) Accumulation of sub-retinal fluid (Exudate Edema Bleeding)
2) Tractional detachment (e.g. Anterior lens-luxation, Chorioretinitis)
3) Rhegmatogenous detachment - Hole in retina + Liquification of the vitreous = the vitreous pours into the hole and detaches the retina. Hereditary disease found in certain breeds such as Shih-Tzu, Whippet)
Retinal Detachment - PLR Result
Negative - Fixed dilated pupil
Consensual PLR - No response either
Retinal Detachment - Diagnosis
Fundus exam
US
SARDS - Name the acronym
Sudden Acquired Retinal Degeneration Syndrome
SARDS - Signalment and what endocrine it mimics
Middle-age to old female dogs
Over-weight
Generally <15kg
Cushing’s disease
SARDS - Ophthalmological findings. ERG results
Fixed dilated pupil
Negative menace response
Negative PLR (Direct and consensual)
In the acute stage - no additional abnormalities in the ocular exam. With time - signs of retinal degeneration (tapetal hyperreflectivity, vascular attenuation, and atrophy of the optic nerve).
Negative ERG (standard one. Positive response to blue light).
4 DDs for acute blindness and fixed, dilated pupils
Glaucoma
Retinal detachment
SARDS
Optic neuritis
Distal optic neuritis & SARDS - What are the common findings in an ophthalmic examination? How to differentiate between the two?
Normal eye and lack of PLR (Fixed, dilated pupil).
ERG: SARDS - Negative. Optic neuritis - Positive
Optic neuritis - Treatment
Treat underlying cause (e.g. Infectious diseases, Neurological diseases etc.)
Systemic NSAIDs\Steroids
Progressive Retinal Atrophy - Diagnosis (4 Elements)
1) History: Progressive onset, Loss of night vision (Nyctalopia) => Loss of daytime vision => Blindness
2) Ophthalmic exam: Hyperreflective retina, Retinal vasculature attenuation, Optic nerve atrophy, Dilated pupils (Positive PLR or diminished)
3) ERG
4) Genetic Testing
Progressive Retinal Atrophy - Diagnosis (Gold standard)
ERG
Cats - Most common eyelid pathology
Squamous cell carcinoma
Neonatal Ophthalmia in kittens - Treatment
Manually open eyelids
Flush
Topical antibiotics
Artificial tears
What is Haws syndrome? Treatment?
Idiopathic elevation of both 3rd eyelids in cats
Not necessary - Self-limiting
3 DDs for bilateral elevation of both eyelids in cats
Dehydration
Weight loss
Haws syndrome
Main cause of KCS in cats
FHV-1
KCS in Cats - Pathogenesis (4)
FHV-1 Does the following:
1) Damages the tear glands
2) Scarring of the draining ducts of the tear glands
3) Damages the corneal Trigeminal sensory nerve => Less blinking
4) Destroys conjunctival goblet cells => Loss of mucin layer (Qualitative KCS)
KCS in Cats - Treatment
Artificial tears
FHV-1 - Clinical Signs
Conjunctivitis
Keratitis
Corneal ulcers
Symblepharon
Sequestrum
Rhinitis
Stomatitis
Stromal keratitis (In recurrent disease)
Eosinophilic Keratopathy - Major DD to..?
Squamous cell carcinoma
Hypertensive Retinopathy - 2 Most common causes in cats
CKD
Hyperthyroidism
Hypertensive Retinopathy - Treatment of choice
Amlodipine
Hypertensive Retinopathy - Prognosis
Good. 60% of eyes regain menace response due to retinal reattachment. 50% of them in 3 weeks, 25% in 2 months
Anterior uveitis - causes in cats (Bilateral)
FIV
FeLV
FIP
Toxoplasmosis
Proptosis (Prolapse) - Prognostic indicators
Animal (Cats worse than dogs)
Breed (Non-brachycephalic worse than brachycephalic)
Number of damaged extra-ocular muscles (Prognosis worsens as more muscles are involved)
Additional ocular damage\Pathologies (e.g. Hyphema, Lens luxation, Retinal detachment)
Additional extra-ocular trauma (e.g. head trauma)
SARDS - What is a special tool that can help achieve diagnosis?
Chromatic PLR: No response to red light - but blue light does induce a response
What is the name of the tool that can assist in checking if the irido-corneal angle is open or closed?
Goniolens
Glaucoma - Clinical signs
Lethargy (Painful)
Conjunctival hypermia
Corneal edema
Mydriasis
Striated keratopathy
Buphthalmus
Fixed-dilated pupil, Absent-menace response, Lens-luxation
Glaucoma - What is the Most Useful drug in Acute Glaucoma?
Latanoprost (PGF2a)
Glaucoma - What does striations signify? What is the prognosis to the vision?
Chronic glaucoma
Poor - Vision most likely gone
Glaucoma - What is the preferred long term medical treatment composed of?
PGF2a (e.g. latanoprost)
Beta Blocker (e.g. Timolol)
Carbonic Anhydrase Inhibitor
Glaucoma - Medical treatment is starting to fail. What are your surgical options?
cyclophotocoagulation laser treatment
Aqueous humor shunt
Prosthesis
Enucleation
Glaucoma - Why is prophylactic treatment in the non-affected eye important in primary glaucoma?
You can buy more time for the 2nd Eye - 8 months => 2.5 years
Cataracts - What are the 3 main categories by which we classify cataracts?
Etiology: Genetic / Diabetes / Inflammatory
Location: Capsular / Cortical / Nuclear
Degree of Maturity: Incipient / Immature / Mature / Hypermature
Cataracts - Possible sequalas
Lens-induced uveitis
Glaucoma
Lens luxation
Retinal detachment
Cataracts - 3 Main pre-op evaluations needed
ERG (Primary PRA)
US (Evaluate retina and lens)
Blood work (DM / Pre-anesthesia)
Cataract - Post op treatment & what to monitor
Topical steroids
Systemic NSAIDs
Topical AB
Monitor: Fundic exam (Retinal Detachment) | IOP (Uveitis)
What is the best drug to use when wanting to perform a Fundic exam (mydriatic)? What do we need to check before using it?
Tropicamide
Full ophthalmic exam to check for: Glaucoma (IOP)
Lens (Sub)Luxation
Uveitis (IOP)
KCS (STT).
All of these can be affected or caused by Tropicamide
What is the name of a specific retinal structure that cats use to hyper focus their vision? Where is it located? What is the cause for retinal degeneration that originates from that location?
Area Centralis
Temporal aide of the optic disc
Taurine deficiency
What is the one pathognomonic finding on the retina in SARDS that you might find if you are very lucky?
Arteriolar Boxcarring (Strictures)
Undulating KCS - What is the Common Breed and what is the defining mark of the disease?
WHWT
“Mountain response” to Tacrolimus / Cyclosporine - Ever-changing STT results
What is unique about KCS in German shepherds?
No pathological signs! no pigment / vasculature / corneal ulcers.
Just low STT and tear production
Response to treatment is poor
What is the PLR Response in SARDS (2 Parts)
Normal white light - Positive PLR But slow
Blue light - Positive
Red - Negative