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Keratoconjunctivitis Sicca (KCS)

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Keratoconjunctivitis Sicca (KCS) Vision Matters A Focus on Keratoconjunctivitis Sicca (KCS) Brought to you by Bayer Keratoconjunctivitis sicca (KCS): The normal tear film explained The normal tear film (also called Ocular conditions account for about ten percent of canine consultations in first opinion Recent research into tear film dynamics 1 practice ; this means if twenty dogs come into your surgery in a day, two of them are likely the precorneal tear film) consists suggests that the three component to be presenting with an eye condition. of three major components: layers are not well defined, and that there is a possible fourth layer of glycocalyx With owners increasingly doing their own research before visiting their vet, it is vital to have in-depth that extends from the corneal epithelium.5,6 knowledge of commonly seen conditions. This report focuses on keratoconjunctivitis sicca (KCS), Mucous layer – produced by conjunctival also known as dry eye, a condition where early recognition can have a significant impact on prognosis. goblet cells, and also by the epithelial The aqueous layer of the tear film is 98.2% water cells of the cornea and conjunctiva “and 1.8% solids, including immunoglobulins“ (IgA, IgG, IgM), lysozyme, lactoferrin, Aqueous layer – produced by the lacrimal 7,8 and nictitans glands transferrin, ceruloplasmin and glycoproteins. Without a normal aqueous layer, the corneal Lipid layer – produced by meibomian surface is at risk from bacterial infection, glands in the eyelid margin hypoxia, toxic tissue metabolite accumulation and excessive degradation. 5% 20% 46% The tear film plays a vital role 46% of dog owners in maintaining ocular health: ...and up to 20% of in a recent survey Dry eye affects predisposed breeds3 were not aware that • Lubricates the cornea, 2 nearly 5% of all dogs their pet could suffer eyelids and conjunctiva from dry eye4 • Provides oxygen and nutrients (e.g. glucose and electrolytes) to the cornea; vital due to its avascular nature • Removes metabolic by-products (carbon dioxide and lactic acid) • Aids removal of irritants • Allows white blood cells to access the cornea and conjunctiva • Plays a role in local immune defence of ocular surface Look out for useful hints and tips from Chris Dixon BVSc All three components are CertVOphthal MRCVS throughout this report: vital for ocular health. Chris Dixon is an ophthalmologist at Veterinary Vision, an “ Immune-mediated KCS “ophthalmology referral practice in Cumbria. Chris graduated from results in a reduction of the the University of Bristol and spent several years in mixed practice, aqueous component only. before deciding to focus on ophthalmology; he was awarded a certificate in ophthalmology in 2011. Chris has a particular interest in ocular micro-surgery and topographical analysis of the cornea. Case study photography courtesy of Veterinary Vision 2 Brought to you by Bayer 3 Aetiology of KCS: Clinical signs of KCS: Acute onset, conjunctival Acute: hyperaemia, mucopurulent Most common cause discharge and periocular crusting Immune- KCS can present acutely, Affects the lacrimal and nictitans glands but this is less common mediated More common in certain breeds than a chronic presentation • Very painful For example: • +/- Corneal ulceration – likely to rapidly Acute onset, Hypothyroidism9 deteriorate if left untreated (may lead mucopurulent discharge Systemic to stromal malacia or globe rupture) diseases Diabetes mellitus9 Hyperadrenocorticism9 Sulphonamides Chronic – Early Stages: Drug Topical and systemic atropine Low grade, uncontrolled chronic KCS. induced Following sedation/GA KCS usually presents In the first picture, conjunctival (reduces tear production for at least 24 hours)10 as a chronic condition hyperaemia is evident along with a • Often subtle signs initially mucoid discharge. In the second Hypoplasia or aplasia of the lacrimal gland • Conjunctival hyperaemia of the two, neovascularisation Usually unilateral of the cornea can be seen. • Intermittent mucoid/ Congenital Dogs present with severe corneal dryness mucopurulent discharge Usually in miniature breeds Uncommon Chronic – Later Stages: Removal of nictitans gland or third eyelid Iatrogenic • Worsening conjunctival Densely pigmented cornea, likely hyperaemia to have diminished visual acuity. • +/-Corneal ulceration- often small and may rapidly worsen Loss of parasympathetic innervation to the lacrimal gland (CN VII) • Pain – photophobia and blepharospasm Chronic, uncontrolled KCS. Loss of sensory innervation • Increasing, persistent Corneal pigmentation and Neurogenic to the ocular surface (CN V) mucopurulent discharge scarring. Note that the camera Idiopathic or as a result of inner • Corneal vascularisation and pigmentation flash reflection is not sharp, ear disease/trauma/neoplasia which is indicative of an “ irregular corneal surface. KCS can commonly Infectious E.g. Distemper be misdiagnosed causes as bacterial conjunctivitis due to the persistent mucopurulent ocular discharge. Prolapsed nictitans gland “ Other Trauma to the orbit affecting the tear glands 4 Brought to you by Bayer 5 Diagnosis: Interpreting STT results KCS is diagnosed by performing a Schirmer Tear Test (STT); STT-1 Reading Interpretation there are two types: STT-1 and STT-2. <5mm/min Severe KCS – commence treatment 6-10mm/min Mild/Moderate KCS – commence treatment 11-14mm/min Interpret alongside clinical signs – STT-1: STT-2: STT-1 readings re-test in 3 weeks (or sooner if necessary) should be interpreted Most commonly performed Local anaesthetic used in conjunction with 15mm/min Normal tear film quantity Measures basal tear the clinical appearance, and No local anaesthetic used production only readings may be falsely high“ in painful eyes. Always Measures reflex and Performed in order to compare the STT-1 readings Key Points to Consider basal tear production eliminate the reflex tear “between the eyes and Always perform the test on both eyes, component, which can be STT-2 readings are useful in painful eyes consider performing an even when there is unilateral disease: STT-2 to eliminate the reflex usually half the STT-1 tear component. A sore eye may have a normal reading, as a readings and a normal result of ocular pain and increased tearing, dog will record 7mm/min. whilst the other eye may have a low reading Both eyes should be tested so suggestive of underlying KCS. Equally an that an accurate comparison can be made. ulcerated eye with a borderline reading would “ Case Example: be of concern as a much higher result would Tear film quantity has be expected due to reflex tearing. been found to vary during Consider a dog with KCS that has a superficial ulcer daylight hours (<2mm/min), in one eye. This eye may have an increase in reflex Any red or ulcerated and reaches peak production tearing due to the pain caused by the ulcer. eye should have at night.12 Despite having KCS, an STT-1 result from this eye may an STT performed (unless deep The application of most show a normal or borderline reading, as an increase topical medications prior in reflex tears contributes to a falsely high result. ulceration is present and the integrity of to assessment may falsely By performing an STT-2 in this patient, the reflex tear the cornea is fragile). increase STT readings, but component is eliminated. STT-2 readings are usually lower readings can also “ half that of STT-1 readings. In any case where KCS is Superficial ulcer of the occur if the dog has been suspected it is important ventral cornea. The flash prescribed topical atropine. to assess both eyes for reflection on the cornea It is therefore important evidence of corneal is not sharp, indicating to document baseline ulceration; especially where that the cornea is dry STT-1 readings prior to the To perform an STT-2: discharge is present, which in the unstained image. use of atropine. Performing a Schirmer Tear Test • Apply a drop of topical local anaesthetic may obscure an underlying This dog had superficial to the eye (e.g. 0.5% Proxymetacaine) ulcer. Discharge should be corneal ulceration To perform an STT-1: removed very gently secondary to KCS. • After approximately one minute, gently • Bend the STT strip at the notch whilst still in the dry the conjunctival sac with a sterile to avoid exacerbating a packet (if the strips are touched on the corneal cotton bud or bacteriology swab pre-existing ulcer. contact area they will not be sterile and the “ If you suspect KCS, but obtain a normal STT • The STT paper strip can then “ grease from fingers may compromise the result) be applied for one minute reading, advise the owner to have a repeat check in a few weeks. • Place the short section of the bent strip It is important to perform any STT over 60 into the lateral half of the lower eyelid seconds, as it has been shown that the paper Predisposed breeds should have regular STTs • Ensure there is contact with the corneal strips do not absorb the tears in a linear carried out – at vaccinations and check ups. 11 surface to cause reflex tear production fashion. Timing over 15 or 30 seconds may therefore provide false results. • Measure for a full minute 6 Brought to you by Bayer 7 Treatment: In addition to treating the underlying condition, it is really important to look for and treat any secondary complications, e.g. bacterial infections or corneal ulceration. Artificial Tears/Tear Supplements All cases with a When considering suspected secondary • Only supplemental and should not be viewed a tear replacement Infected mid-stromal ulcer bacterial infection as a replacement for treatment targeting therapy for a patient, secondary to KCS. It is crucial should be treated with “ the underlying cause I will always use a long- to assess dogs with KCS for the a topical antimicrobial acting product, as it is often • Essential component in the management presence of ulceration so that preparation. An ocular swab not practical to apply topical of KCS to keep eyes lubricated management can be initiated may provide additional therapy at a high frequency.
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