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Hyphema. Part II. Diagnosis and Treatment

Hyphema. Part II. Diagnosis and Treatment

University of Pennsylvania ScholarlyCommons

Departmental Papers (Vet) School of Veterinary Medicine

1-1-2000

Hyphema. Part II. Diagnosis and Treatment

András M. Komáromy

David T. Ramsey

Dennis E. Brooks

Cynthia C. Ramsey

Maria E. Kallberg

See next page for additional authors

Follow this and additional works at: https://repository.upenn.edu/vet_papers

Part of the Eye Diseases Commons, Commons, and the Veterinary Medicine Commons

Recommended Citation Komáromy, A. M., Ramsey, D. T., Brooks, D. E., Ramsey, C. C., Kallberg, M. E., & Andrew, S. E. (2000). . Part II. Diagnosis and Treatment. Compendium on Continuing Education for the Practicing Veterinarian, 22 (1), 74-79, 96-. Retrieved from https://repository.upenn.edu/vet_papers/52

Dr. Komáromy was affiliated with the University of Pennsylvania from 2003-2012. Part I can be found at http://repository.upenn.edu/vet_papers/51/

This paper is posted at ScholarlyCommons. https://repository.upenn.edu/vet_papers/52 For more information, please contact [email protected]. Hyphema. Part II. Diagnosis and Treatment

Abstract The clinical appearance of hyphema is variable and is influenced by the volume of blood and the amount of time erythrocytes are present in the anterior chamber. When hyphema is evident, a complete history should be obtained and a thorough physical examination performed to direct the initial selection of diagnostic tests. Secondary complications of hyphema include , synechiae, formation, blood-staining of the , and blindness. Frequent measurement of is recommended. The two primary management issues in animals with hyphema are prevention of secondary hemorrhage (by treating the underlying disease) and control of secondary glaucoma.

Disciplines Eye Diseases | Medicine and Health Sciences | Ophthalmology | Veterinary Medicine

Comments Dr. Komáromy was affiliated with the University of Pennsylvania from 2003-2012.

Part I can be found at http://repository.upenn.edu/vet_papers/51/

Author(s) András M. Komáromy, David T. Ramsey, Dennis E. Brooks, Cynthia C. Ramsey, Maria E. Kallberg, and Stacy E. Andrew

This journal article is available at ScholarlyCommons: https://repository.upenn.edu/vet_papers/52 Vol. 22, No.1 January 2000

reclll ofa ic di : CE Article #4 (1.5 contact hours) Refereed Peer Review TI is PI [ clini diffe Hyphema. Part II. exan coag take Diagnosis and Treatment* whe l FOCAL POINT med lar tJ Hyphema is frequently associated Un iversiry of Florida Michi ga n Stare 0niversiry also with iridocyclitis and generally Andras M. Komaromy, Dr.med.vet. David T. Ramsey, DVM pher implies severe intraocular or Dennis E. Brooks, DVM, PhD Cynthia C. Ramsey, DVM, MS systemic disease. PH~ Maria E. Kallberg, DVM TI an aJ Stacy E. Andrew, DVM KEY FACTS not I ed e The prognosis for animals with ABSTRACT: The clinical appearance of hyphemais variable and is influenced by the volume of e1im hyphema depends in large part blood and the amount of time erythrocytes are present in the anterior chamber. When hyphe­ pruc on the identification of underlying ma is evident, a complete history should be obtained and a thorough physical examination that diseases; institution of proper performed to direct the initial selection of diagnostic tests. Secondary complications of hyphe­ ocul treatment; and careful , long-term ma include glaucoma, synechiae, cataract formation , blood-staining of the cornea, and blind­ 109 : follow-up, p. 74. ness . Frequent measurement of intraocular pressure is recommended. The two primary man­ unn , agement issues in animals with hyphema are prevention of secondary hemorrhage (by ougr treating the underlying di.sease) and control of secondary glaucoma. Athorough ophthalmic and amll systemic diagnostic evaluation tect should be performed when art I of this two-part presentation reviewed the pathophysiologic mecha­ syste hyphema is present, p. 75 . nisms that most frequently result in hyphema in animals; this article cov­ orrh Pers diagnostic and treatment considerations. The prognosis for animals bran The two primary management with hyphema depends on identifYing the underlying cause; initiating proper muo issues in animals with hyphema treatment; and careful, long-term follow-up. sa) ( are preventing secondary sent hemorrhage (i.e., rebleeding) HISTORY tope and controlling secondary When hyphema is evident, a complete history should be obtained and a thor~ Intrd glaucoma, 77. ough physica.l examination performed to direct the ,initial selection of appropriate I diagnostic tests. Recent health and vaccination statlls should also be ascertained. hypl Frequent measurement of Trauma or ingestion of toxins (e.g., todenticide) should be consid­ Abd, intraocular pressure is required ered if an animal has access to the outdoors regardless of whether a traumatic in­ tion in patients with hyphema, p. 78. cident or rodenticide ingestion was witnessed by the owner. Living in or travel to veal regiom in which enzootic infectious disease (e.g., ehrlichiosis, Rocky Mountain a th: spotted fever) is common should alert clinicians to consider infectious agents as a rhag potential cause of hyphema. Recent drug administration or past illness may be men' important factors in determining the cause of hyphema. A recent history of ab­ tivel) normal vision or behavior before the onset of hyphema may signifY preexisting or intr. underlying ocular (e .g., iridocyclitis, glaucoma, ) or central shou nervous system (e.g., hemorrhage, retrobu1bar optic neuriris) disease. Hisrory of iden!

*Parr I of this [Wo-parr presentation appeared in the November 1999 (Vol. 21 >No. 11 ) OPH issue of Compendium. Tf: Compendium January 2000 Small Animal/Exotics 75

recurrent hyphema is suggestive detailed ophthalmic examina­ of a persistent ocular or system­ tion of both the anterior and ic disease. posterior segments of the af­ The time at which hyphema fected and contralateral eye. In­ is first observed may also assist direct pupillary light response clinicians in developing a list of allows the evaluation of retinal

I differential considerations. For function, even with a blood­ example, hyphema from anti­ filled anterior chamber, as long coagulant rodenticide toxicity as the contralateral is vis­ takes 5 to 7 days to develop, ible. Iridocyclitis manifests as whereas hemorrhage occurs im­ , corneal edema, mediately in patients with ocu­ , and hyporony. Glauco­ lar trauma. Ocular neoplasia may Figure 1A ma and retinal detachment are also cause an acute onset of hy­ generally associated with a my­ phema. 2 driatic pupil. When hyphema 3 is aruibutable to a systemic dis­ PHYSICAL EXAMINATION ease process, the contralateral The physical examination of eye may also have clinical sigll:s an animal with hyphema should suggestive of the disease. Fun­ not be limited only ro the affect­ 1 duscopic examination allows ed eye. \Vhen trauma has been direct visualization of delicate eliminated as a likely cause, the vascular structures (retinal and prudent approach is ro assume choroidal vasculature) and cen­ that a serious sight-threatening tral nervous tissue ( ocular disease or life-rhreaten­ head, ). Ocular signs sug­ ing systemic disease is present gestive of systemic vasculitis are until proven otherwise. A thor- Figure 1B frequently detected during ex­ ough and detailed physical ex­ Figure 1-Photograph (A) and photomicrograph (B) amination of the fundus. amination is indicated to de­ showing inrrastromal hemorrhage of rhe iris (1) in a Depending on the cause and tect any underlying evidence of dog (cornea (2J, anterior chamber (3J, posrerior cham­ severity of blood-ocular barrier systemic disease. Petechial hem­ ber (4j). (Hematoxylin & eosin srain; original magni­ breakdown and the presence of orrhages of the mucous mem­ ficarion, x40) iridocyclitis, aqueous flare (pre­ branes (i.e., , oral dominantly proteins), hypopy­ mucosa, preputial/vulvar m uco­ on, or hyphema may appear in sa) or skin are frequently pre­ the anterior chamber. The clin­ sent along with thrombocy­ ical appearance of hyphema is topenia or thrombocytopathy. influenced by the volume of Intrastromal hemorrhage of the erythrocytes in the anterior iris may also be present before chamber and by how long they hyphema occurs (Figure 1). have been present and may dif­ Abdominal and thoracic palpa­ fer substantially from case to tion and auscultation may re­ case. The term complete or to­ veal physical signs suggestive of tal h),phema is used to describe a third-compartment hemor- hemorrhage filling the entire rhage or vital organ involve- Figure 2-Complere (toral) hyphema in a dog. anterior chamber and is usually memo Unless trauma is defmi- a result of acute fulminant or tively identified as the cause of recurrent hemorrhage (Figure 2). , every cat with hyphema Complete hyphema obstructs the examiner's ability to should have its arterial blood pressure measured to visualize intraocular structures. identify systemic hyperrension. 1 The blood in a complete hyphema may change color from red to black as a result of altered aqueous dynam­ OPHTHALMIC EXAMINATION ics, indicating the cessation of aqueous circulation.2 If The physical examination should always include a hemorrhage was initially minimal and transitory, hy-

I RI DOCYC LlTI S FUNDUSCOPIC EXAMINATION . COMPLETE HYPHEMA 76 Small Animal/Exotics Compendium January 2000

phema is light red in appear­ currently (e.g., bone-marrow dis­ TREA ance. This type of hyphema may ease). If bone-marrow disease is Prir develop a shallow line of demar­ suspected based on CBC results, ma 111 cation (i.e. , gravity line) when aspiration cytology with or with­ bleedi erythrocytes settle due to gravity out core biopsy is indicated. 4 treati l in a homogeneous layer in the Serum biochemical profile and glauc< ventral anterior chamber (Figure urinalysis may help identify such amon l 3). Extensive or persistent hem­ underlying abnormalities as liver from I orrhageinto the anterior cham­ disease, renal insufficiency, or hy­ ber appears bright red in color peradrenocorticism. and may occlude both the pupil Indications for selecting more and iris. Complete hyphema at­ specific diagnostic tests are de­ tributable to transient hemor­ termined by history, physical ex- rhage that has been present for 3.mination findings, and initial Irido at least 5 to 7 days appears dark diagnostic test results. Evalua­ red or bluish-black and is re­ tion for infectious diseases should ferred to as eight-baff hyphema Figure 3-Hyphema wirh gravity line. Eryrhrocytes be performed if suggested by ge­ (Figure 4) ..1 Decreased oxygena­ sertle due (0 gravity in a homogeneous layer in rhe ographic location, travel history, tion of erythrocytes in the ante­ ventral anterior chamber. or exposure to other risk factors. rior chamber is reflected by the Toxoplasma gondii, feline dark color. 2 Chronic active hy­ virus (FeLV), feline immuno­ phema may appear light or dark deficiency virus (FIV), and FIP red or bluish-black, depending infection and possibly systemic on when the last active hemor­ fungal diseases should be consid­ rhage occurred. Occlusion of the ered when hyphema is evident ,in pupil by hyphema may cause a a cat. 5 The seroprevalence of T relative pupillary block that in­ gondii in cats with iridocyclitis hibits aqueous circulation to the was reported to be as high as anterior chamber, resulting in 78.5%.5 However, serologic evi­ subsequent elevated intraocular dence of infection by T gondii, pressure (lOP). FeLV, FIV, or FIP does not nec­ There are definitive circum­ Figure 4-Dark red or bluish-black appearance of essarily correlate with clinical stances thac determine when eighr-ball hyphema. disease induced by these causa­ ------rive agents.' When a systemic blood in the anterior chamber Bloo( mayor may not clot. Hyphema disorder is suspected, a 4 caused by trauma, vasculitis (e.g., feline infectious peri­ coagulat,ion profile should be completed. Secor tonitis [FIP]), or iridocycliris may clot, whereas hyphe­ Sampling of aqueous humor to determine local in­ rna attributable to immune-mediated thrombocytope­ traocular antibody production is not ,indicated in pa­ nia or toxicity generally will not dot. '! tients with hyphema because the sample will be con­ Hyphema attributable to (new vascular taminated with systemic blood. When hyphema proliferation of the iris), intraocular neoplasia, or con­ prevents visualization of intraocular structures, genital ocular anomalies may occasionally clot." transcorneal B-mode ultrasound (7.5- to 12-MHz transducer) is indicated to determine whether retinal EXPANDED DATABASE detachment or intraocular tumors are present or to Laboratory tests should be performed based on find­ identify other oCLIlar lesions (e.g., luxated , intraoc­ ings from the history and physical examination. A di­ ular foreign body).G Skull radiographs, computed to­ rect blood smear permits rapid estimation of mography, or magnetic resonance imaging may also re­ and megathrombocyte numbers and the detection of veal an intraocular foreign body, depending on the erythrocyte and leukocyte involvement (e.g., presence type or composite. When a metallic intraocular foreign of schistocyrosis or Haemobartonella). , leuko­ body is suspected, magnetic resonance imaging should cytes, and erythrocytes should be evaluated by a com­ be avoided and computed tomography performed. ·See rl bUnd plete blood count (CBC); the three cell lines may be af­ Retinal function can be evaluated using electroretinog­ lV= fected individually (e.g., ) or con- raphy.7 il

EIGHT-BALL HYPHEMA INFECTIOUS DISEASES IMAGING TECHNIQUES Compendium January 2000 Small Animal/Exotics 77

TREATMENT rna treatment is management of the iridocyclitis that is Primary management issues in animals with hyphe­ frequently present. Erythrocytes exit the anterior cham­ rna include preventing secondary hemorrhage (i.e., re­ ber primarily through the iridocorneal dra,inage angle. bleeding) by (1) treating the underlying disease, (2) The iris produces enough fibrinolytic enzymes in most treating iridocyclitis, and (3) controlling secondary instances to prevent blood from cloning so that it can glaucoma (Table I). There is considerable variation more easily exit the anterior chamber via the aqueous among specific treatment regimens to eliminate blood humor outflow pathways. Uncomplicated hyphema from the anterior chamber, bur the hallmark of hyphe­ should resolve within 7 to 21 days.3 Hyphema that

TABLE I Treatment of Hyphema".IJ Disorder Drug Class Drug Frequency/Dose Iridocyclitis)' Topical parasympatholytics Atropine 1% (use ointment 1-4 times daily in cats) Topical corticosteroids Prednisolone acetate suspension 4-6 times daily 1%, dexamethasone solution 0.1 % Dexamethasone ointment 0.05% 3-4 times daily Topical NSAIDs Flurbiprofen 0.03%, suprofen 1%, 4 times daily indomethacin 1%, diclofenac 0.1 % y temic corticosteroids Prednisone 1-2 mg/kg/day in divided doses Systemic NSAIDs Dogs: 10-15 mg/kg PO 2-3 times daily Cats: 80 mg PO every 48-72 hr Flunixin meglumine Dogs: 0.25-0.5 mg/kg IV, single dose Carprofen Dogs: 2 mg/kg PO t\vice daily

Blood or fibrin clot\9 Fibrinolytics Tissue plasminogen activator 25-75 flg intracamerally

11 Secondary glaucoma' O. Systemic carbonic Dichlorphenamide Dogs: 2-4 mg/kg PO anhydrase inhibitors 2-3 times daily Cats: 1 mg/kg PO 2-3 times daily Methazolamide 2-4 mg/kg PO 2-3 times daily Topical carbonic Dorzo lamide 3% 3 times daily anhydrase inhibitors Topical sympathomimetic Epinephrine 1%, 2-3 times daily drugs dipivefrin HCI 0.1 % Topical sympatholytic T imolol maleate 0. 5% 2-3 times daily drugs Osmotic agents 0.5-1.0 g/kg IV

"See rexr for derails. "Underlying diseases should be rreared firsr in cases ofhyphema. IV = inrravenously; PO =orally. 78 Small Animal/Exotics Compendium January 2000

continues to bleed may indicate that the underlying when injected within 48 hours of clot formation, but it clea disease is still present. Surgical removal of a blood clot can also be effective tn dissolving clots of longer dura­ If tl with or without is discussed in the human tion.' However, tPA injections may also induce hyphe­ 101 2 12 medicalliterature • and is rarely necessary in human or rna or result in more severe hyphema from dissolution oft veterinary patients. of a blood clot when given within 24 hours of the ini­ onc Prevention of a posterior synechiae and iris bombe is tial hemorrhage or when recurrent bleeding is Iikely..19 Intr achieved with the use of topical parasympatholytics Surgical intervention and concurrent systemic and er h (e.g., atropine) to dilate the pupil and topical cortico­ topical treatment with antibiotics should be considered steroids to suppress anrerior (Table I). In addi­ when hyphema results from penetrating ocular tion to prevenring synechiae, topical atropine (a topical or blunt trauma with eyeball rupture. Restricted exer­ 1. mydriatic and cycloplegic drug) also relieves some pain cise or even cage rest is recommended to prevent re­ 2. associated with spasm of the ciliary musculature and bleeding. Animals with hyphema may need to be hos­ helps to stabilize the blood-aqueous barrier. I.I- 1> If an pitalized for close monitoring of possible secondary increase in lOP is noted after the initiation of mydriat­ hemorrhages and elevation of rOp. lOP should be mea­ ic treatment, atropine should be discontinued immedi­ sured at least daily during the hospital stay a'nd fre­ 3. 12 ately and glaucoma treatment initiated.' quently after discharge. ,IG We do not recommend Topical use of parasympathomimetic drugs (e.g., pi­ Schiotz tonometry in animals with weakened locarpine) to treat hyphema has been advocated to con­ caused by penetrating trauma. 4. tract the ciliary musde, which hypothetically facilitates If secondary glaucoma develops due to anterior or drainage of blood from the anrerior chamber through posterior synechiae of the iris, treatment can be at­ 5. the iridocorneal angle. I !; Parasympathomimetic drugs tempted (e.g., intracameral tPA and antiglaucoma also cause miosis, which increases iris surface area, drugs) but the prognosis to save vision is poor. When 6. thereby hypothetically exposing iris surface fibri­ the eyeball is irreversibly blind or painful from sec­ nolysins to the clot and blood in the anrerior cham­ ondary glaucoma, enucleation should be performed. 7. ber. 1(. We do not recommend using topical parasympa­ Medical treatment of secondary glaucoma consists of a thomimetic drugs to treat hyphema; they dilate iris combination of systemic or topical carbonic anhydrase blood vessels and increase iridal intravascular pressure, inhibitors, topical sympathomimetic drugs, and sympa­ 8. which may exacerbate hyphema. Because these drugs tholytic drugs (Table I). Osmotic agents are less effec­ induce miosis, the risk of posterior synechiae forma­ tive with a leaky blood-ocular barrier. Because of the tion, iris bombe, and peripheral anrerior synechiae for­ risk of posterior synechiae, parasympathomimetic drugs 9, mation is increased. (e.g., ) are contraindicated. Nonspecific reduction of ocular to pre­ 10. serve the transparency and function of ocular structures COMPLICATIONS and stabilize the blood-aqueous barrier can be achieved Mild hyphema may resolve without significant se­

with topical corticosteroids andlor NSAIDs (Table quelae. The main complications of persistent hyphema I 1. I I). Ll.1 7 Topical corticosteroids are contraindicated when are increased lOP, peripheral anterior and posterior corneal ulceration is present. Systemic administration synechiae, development of , and an increased of NSAIDs can further decrease inflammation but risk of corneal bllood staining attributable to endothe­ 12. I 12 should also be used very cautiously because of their in­ lial damage and breaks in Descemet's membrane. If an \3, terference with platelet function. Systemic cortico­ underlying disease persists and hemorrhage is recurrent, steroids (e.g., prednisone, prednisolone) should be used of the eyeball () and blindness are cautiously and only when systemic infectious disease usually the long-term results. 14, has been ruled out or is being treated concurrently. Sys­ temic immunosuppressive doses of corticosteroids and PROGNOSIS

systemic carbonic anhydrase inhibitors may help to Prognosis for vision in geriatric dogs with hyphema 15 . 1 reattach in patients w·ith exudative detach­ secondary to retinal disease is grave, 20 In cases of unex­ ments. IH.l~ plained, unresponsive, or recurring hyphema, the diag­ Although the use of anrifibrinolytic agents in the nosis must be reassessed. Prognosis is grave for any hy­ 16, 1 managemenr of hyphema is conrroversial, intracameral phema in which an unknown underlying systemic 17. \ injection of tissue plasminogen activator (tPA) to in­ disease persists. In such cases, enucleation is recom­ duce fibrinolysis can be performed to reverse a pupil­ mended if the lOP rises to leve'ls that cause pain. When lary block when the iris is adhered to the lens by a intraocular neoplasia is known or strongly suspected as blood or fibrin clot (Table I)..1.~. 12 tPA is most effective the cause for hyphema, the affected eye should be enu­ 18.

PARASYMPATHOMIMETIC DRUGS TISSUE PLASMINOGEN ACTIVATOR . SURGICAL INTERVENTION cleared and submiued for histopathologic evaluation. l car, and monkey eyes. Normarive dara and enhancemenr by If the underlying cause is nonrecurring or treated and manniro l and acera zolamide. Invest Ophthalmol Vi,. Sc i 33(6): 1879- 1882, 1992. lOP does nor increase, an accurate prognosis for return 19. Andrew SE, Abrams KL, Brooks D E, Kuhilis PS: Clinical of the eye to cosmetic and visual normalcy can be made features of sreroid responsi ve rerinal derachmenrs in twenry­ once resorption of the hemorrhage allows a complete rwo dogs. Prog Vet Comp OphrhaLmoI7(2):82-87, 1997. intraocular examination..' It is difficult to predict wheth­ 20. Nelms SR, Nasisse MP, D avidson MG, Kirschner SE: H y­ er hyphema will resorb. phema associared wi rh rer inal disease in dogs: 17 cases (1 986-199 1), jAVMA 202(8): 1289-1 292, 1993. REFERENCES I. Henik RA: Sysremic hyperrension and irs managemem. Vet C!in North Alii SmaIL Anim Pract27(6): 1355-1372, 1997. About the Authors 2. Fo lberg R, Parrish RK: G laucoma following trauma, in Tas­ Drs. Komaromy, Brooks, Kallberg, and Andrew are affili­ man W , Jaeger EA (cds) : Duane's Ophthalmology, Clil1iCtlI ated with the Department of Small Animal Clinical Sci­ Volume 3, CD-ROM Edition. Hagersrown, MD, Lippincon­ ences, College of Veterinary Medicine, University of Flori­ Raven, 1998. da, Gainesville, Florida. Drs. David and Cynthia Ramsey 3. Collins BK, Moore CP: Diseases and surgery of rhe canine are affiliated with the Department of Small Animal Clinical amerior , in Gelan KN (cd): Veteril1fl1)' Ophthalmology, ed 3. Baltimore, Lippincorr Williams & Wilkins, 1999, pp Sciences, College of Veterinary Medicine, Michigan State 755-795. University, East Lansing, Michigan. Drs. David Ramsey, 4. Hackner SG: Approach ro rhe diagnosis of bleeding disor­ Brooks, and Andrew are Diplomates of the American Col­ ders. Compend Co ntin Educ Pract Vet 17(3):33 1-349, 1995. lege of Veterinary Ophthalmologists. Dr. Cynthia Ramsey 5. Chavkin MJ, Lappin MR, Powell Cc, er al: Se roepidemio­ is a Diplomate of the American College of Veterinary In­ logic and clinical observarions of 93 cases of uveiris in cars. Prog Vet Comp OphthalmoI2(l):29-36, 1992. ternal Medicine and thwAmerican College of Veterinary 6. Williams J, Wilkie DA: Ulrrasonography of rhe eye. Com­Emergency Medicine and Critical Care. pend Contin Educ Pract Vet 18(6):667-676, 1996. 7. Komaromy AM , Smirh PJ, Brooks DE: Elecrrorerinography in dogs and cars. Parr If. Technique, imerprerari on, and in­ ARTICLE #4 CE TEST dicarions. Compend Contin Ec!lI e Pract Vet 20(3):355-366, The article you have read qualifies for 1.5 con­ 1998. 8. Wilkie DA: Uvea, in Bi rchard SJ, Sherding RG (eds): Saun­tact hours of C ontinuing Education Credit from ders ManuaL of SmaLl Animal Practice. Philadelphia, WB the Auburn University College of Veterinary Saunders Co, 1994, pp 1213-1216. M edici ne. Choose only the onl! best answer to each <). Marrin C, Kaswan R, Grarzek A, er al: Ocular use of ri ss ue of the following questions; then mark your an­ plasminogen acrivaror in companion animals. Prog Vet Comp swers on the test form inserted in Compendium. OphthalmoI3(l):29-36,1993. 10. Wilkie DA: G laucoma, in Birchard SJ, Sherding RG (eds): Saunders ManuaL ofSma!! Animal Practice. Philadelphia, WB 1. The dark red or bluish-black color of eight-ball hyphe­ Saunders Co, 1994, pp 121 7-1222. ma indicates decreased 1I. Gelan KN , Brooks DE: The canine , in Gelarr a. oxygenation of the animal. KN (ed): Veterinary Ophrhalmology, ed 3. Balrimore, Lippin­ b. ocular b:lood flow. corr Williams & Wilkins, 1999, pp 70 1-754. 12. GortSch JD: H yphema: Diagnosis and managemenr. Retina e. oxygenarion oferythrocytes in rhe antnior chamber. 10(S uppl 1):S65-S7 1, 1990. d. none of the above 13. Bisrner S: Allergic- and immunologic-mediared diseases of 2. Which of the following must be considered 111 cats rhe eye and adncxae. Vet Clin North Am Small Anim Pract with intraocular hemorrhage? 24(4):7 ll-734, 1994. a. 14. Swan KC, Harr WM: A compararive srudy of rhe effecrs of FIr mec holyl, doryl, eserine, pilocarpine, arropine, and epineph­ b, sysremic rine on rhe blood-aqucous barrier. A m j Ophtha/mol 23( 12): e. T gondii l311-1319, 1940. d, all of the ahove 15. Van Alphen GWHM, Macri FJ: Enrrance of fluorescein inro 3. Sampling of aqueous humor from an eye with hyphe­ aqueous humor of cat eye. Arch OphthaLmoI75(2):247-253, m<1 to derermine intraocular antibody producrion 15 1<)66. 16. W imton SM: Ocular emergencies. Ver CLin North Am Small not indicared because A nim P/'tlct 11(1):59-76, 1981. a. rhere is no inrraocular anribody producrion, 17. Ward DA, Ferguson DC, Ward SL, er al: Comparison of rhe h. the aqueous humor is conraminared wirh antibod­ blood-aqueous barrier stabilizing effecrs of sreroidal and non­ ies from sysremic circularion, sreroidal anti-inflammatory agenrs in rh e dog. Prog Vet c. possible complicarions (e.g., a dramaric drop in lOP). Comp OplnhaLmoI2(3): 11 7-124, 1992. d, Sampling of aqueous humor is indicared in eyes 18. Ki m M, Marmor MF: Reri nal adJles ive force in living rabbir, with hyphema. (COil Tin lies on page 90) 96 " Compendium January 2000

Hyphema (r:u lllinuedfro/1l.page 79) Index to Advertisers 4. When hyphema is presenr, a complete hisrory should include questions regardi ng Small Animal :l. geographic location of res idencelrravel history. Haye r Agri cultu re Di vision An ima l Hca lr h b. recent adminis tratio n of medica ti on. Acivanragc 43 O ro mal Pl us 15 c. pas t illnesseslrecenr . Classic M ed ical Supply d. all of th e above h r:'lsoli ll d Eguip menr ...... 59 Fo rr D odge Animal H ealth 5. In an eye with hyphema, the condition of the re[Ina DUramllJ1 C' V~ l cc i n cs ...... Co\'r r 4 can be assessed with Pain NlJn:1gCnlcllt f-acr Sheer ...... In se rt rnnov'Hive Ve[crina ry Dict's a. indirect pupillary light res po nse (if the contralateral I.imircd In grcdic nr Diets ...... " .. ,...... 4- 5 pupil is vis ible). \X'cstc rn Vere rin ary Conrerence Symposium " ...... 60 Mark ~i l o r rL~ Insritut(' b. transcorneal B-mode ultrasound. Small Animnl Clinicnl lVutrition .. " ...... 34 c. electro retinography. lVlt rck Pu hlishing Group d. all of the above Mack Veterinary Mallual CD-ROM...... 53 N:trure's Form lib H C;'l lrh Prod ucts 6. ______is not caused by topical atro pine. I.iquid Herha l Remedies ...... 16 NOV;lrtis :l. Clomicalm .. , ...... " ...... Co'er 2- 1 b. Progr::l!n ...... 26--27 c. Mios is N utraln:·LX L~ lborJ l or i (' s Coscquin...... 6 d. Stab iliza tion of the blood-aqueous barrier Pfizer Animall-lcalrh .0 ughG uard B, Va nguard 5/B. N3.,aGuard-IJ ...... 8 7. Use of topical corticosteroids is contraindicated in pa­ Revolurion...... "6~ .li 7, 48 tiems with Zeni quin...... 22- 23 . 28 . . . Schcri nu- Pl ollgh An ima l H ealth a. antenor UV CltlS. c. . G;.exy P a~vo ...... 67 b. cataract. d. conjunc[Ivltls. Orb", ...... 31.32- 33 Synhioric..') 8. How fas t does uncomplicated hyphema generally resolve? . Wi rn.s. HW ...... 11 a. 1 day c. 3 months Ve{e~:~h ~~~~~~l~~ ~ ,~,~,~ ~~. ~.l, ~ . , ...... •...... •••. ...Cover 3 b. 7 to 2 1 days d. 6 monrhs Ve{crin:l ry Prodllcr.s Labo ramri t's Fle:xl;S Plll .~ ...... 71 9. is not a complication of hyphema. a. Equine b. G laucoma Fo[[ Dodge An imal Health c. Anteri or and posterior sy nechiae of the iris Pinnacle l. N ...... 80 d. Corneal blood staining Ve[sn eam CD-Eq uis ...... 85 lO . should nor be used to trea t iridocyclitis.

OCTOBER 1999 QUIZ ANSWERS

ARTICU i #1 ;tRTICLE #5 Renal Effect.'; of Nonste roidal Ant iinflammatory Drugs-S. D. Fo rrester. A Practilio ne r s Guide In Nccrop, y- E. A. Sartil/ . 1. S. Spalla. T. L Halhcock G. C. Troy I . b 2. a 3. c 4. d 5. d I. c 2. d 3. b 4. 5. a 6. d 7. d 8. a 9. e 10. d 6. c 7. <1 8. b 9. 10.d ARTICLE #6 ARTlCLH#2 Diagnosing Equin e P rotozoal M yclol! llcephaliti s: Complica[ing Fac[ors­ Ac ute: T horaco lumbar Disk Extrusi on in Dogs. Part (-R. /II!. Jerrol1l. B. C. Bell I:. W. G. C"ner. T. Tobill e. lV. f.)(')r n· l. d 2. a 3. b 4. 5. a I . h . 2. 1. J 4. 5. c 6. e 7. d ~ b 9. 10 . 6. h 7. c R. J 9. e 10. a ARTICLE #7 ItRl"ICLE #3 Agric ul[ unll Economics fo r Vetcrin arians: Marketing Becf Cow Herds- The Avian Re.."Ip iralOry S y s l ~ nl -S. L O/'{H Z: R. L. La rson, V. L. Pierce I. a 2. e 3. 4. d 5. b I. d 2. e 3. e 4. a 5. e 6. e 7. d R. a 9. h 10. a 6. a 7. b 8. d 9. a 10. c

ARTICLE #4 ARTICLE #8 Basic fl lepharo plasly Techlliqll cs-H. L. Hamilron. R. D. Whilley. Cryplosporidiox i,- G. L S",kklJ. 1. D. \I{/n B Oe llill~. fi. Ridlev. D. Van )\1elre. S'. t\. M('u (l{ ~h l il1. S. F. Swoilll R. Falkner I. b 2. d 3. d 4. 5. a I. d 2. a 3. d 4. d 5. e 6. d 7. b 8. e 9. a 10. c 6. d 7. b 8. d 9. a 10. d

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